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Chronic Venous Insufficiency
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Essentials of Diagnosis
Pitting edema.
Skin changes, including hyperpigmentation, lipodermatosclerosis, and varicose veins.
Limb pain with prolonged standing.
Chronic edema resulting in ulcer formation above the medial malleolus.
Venous reflux may be identified on ultrasound imaging.
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General Principles in Older Adults
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From epidemiologic studies, the prevalence of chronic venous insufficiency (CVI) is estimated to be between 5% and 30% in the general population. CVI is more common in women than in men, with a ratio of approximately 3:1. United States expenses related to CVI have been estimated at $1.9 billion to $2.5 billion annually.
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The venous system is made up of deep veins within the subfascial, muscular compartment of the limbs, superficial veins, which are located in the epifascial, subcutaneous compartment and perforator veins, which communicate between the 2 compartments. Normal venous outflow depends on patency of the veins, intact venous valves, and a normal functioning calf muscle pump to return blood from the periphery to the right side of the heart.
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CVI results venous hypertension or sustained venous pressure within the deep or superficial venous system. Venous hypertension may be related to failure of any of the required components: abnormal or damaged venous valves and reflux, venous outflow obstruction either as a result of intrinsic or extrinsic injury, or loss of the normal calf muscle pump. Venous insufficiency may be primary or secondary. Risk factors for CVI include advancing age, obesity, pregnancy, history of lower-extremity injury, and prolong standing or dependency.
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Patients with limited mobility, using walking aids, stroke, or using ankle-foot orthoses will frequently have decreased calf muscle pump and secondary CVI. Patients should always be questioned regarding sleeping habits. Chair or recliner sleeping is common in older adults because of back or joint pain, limited mobility, cardiopulmonary disease, or poor sleep habits.
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Postthrombotic syndrome is 1 form of venous insufficiency related to valve damage or incomplete recanalization of the veins following deep vein thrombosis or phlebitis. Many venous thromboses are asymptomatic and the patient may not be aware of the risk for injury. This can be easily identified using duplex ultrasound.
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Patients with CVI may range from virtually asymptomatic to severe disease with the presence of venous ulceration. The clinical staging is best identified using the CEAP classification (Table 33–1). Symptoms associated with CVI include pain, itching, burning, aching, and heaviness or fatigue of the legs. Symptoms may improve dramatically with leg elevation, essentially relieving the venous hypertension.
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