Chronic Venous Insufficiency

Chronic venous disease is a spectrum of disorders characterized by venous dilation and/or abnormal vein function in the lower extremities resulting from venous hypertension Hypertension Hypertension, or high blood pressure, is a common disease that manifests as elevated systemic arterial pressures. Hypertension is most often asymptomatic and is found incidentally as part of a routine physical examination or during triage for an unrelated medical encounter. Hypertension. “Chronic venous insufficiency” refers to the more severe forms of chronic venous disease. Skin Skin The skin, also referred to as the integumentary system, is the largest organ of the body. The skin is primarily composed of the epidermis (outer layer) and dermis (deep layer). The epidermis is primarily composed of keratinocytes that undergo rapid turnover, while the dermis contains dense layers of connective tissue. Structure and Function of the Skin changes typically distinguish chronic venous insufficiency from milder forms of venous disease (like varicose veins Veins Veins are tubular collections of cells, which transport deoxygenated blood and waste from the capillary beds back to the heart. Veins are classified into 3 types: small veins/venules, medium veins, and large veins. Each type contains 3 primary layers: tunica intima, tunica media, and tunica adventitia. Veins) and include skin pigmentation, stasis dermatitis, lipodermatosclerosis, and eventually, the development of ulcers. Diagnosis is usually based on physical exam findings alone, although venous duplex ultrasonography can provide additional information about the etiology, location, and extent of disease. The mainstay of management is compression therapy. A variety of surgical options also exist, including ablation, sclerotherapy, and valve repair. Venous ulcers are common as the disease progresses and are often very difficult to treat.

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Overview

Definition

Chronic venous disease is a spectrum of disorders characterized by venous dilation and/or abnormal vein function in the lower extremities resulting from venous hypertension Hypertension Hypertension, or high blood pressure, is a common disease that manifests as elevated systemic arterial pressures. Hypertension is most often asymptomatic and is found incidentally as part of a routine physical examination or during triage for an unrelated medical encounter. Hypertension.

Epidemiology

  • Females > males
  • Lifetime incidence of chronic venous disease: up to 50% of individuals
  • Lifetime incidence of chronic venous insufficiency:
    • Up to 40% of women 
    • Up to 17% of men 
    • Incidence ↑ with age

Etiology

  • Chronic venous hypertension Hypertension Hypertension, or high blood pressure, is a common disease that manifests as elevated systemic arterial pressures. Hypertension is most often asymptomatic and is found incidentally as part of a routine physical examination or during triage for an unrelated medical encounter. Hypertension
  • Causes of venous hypertension Hypertension Hypertension, or high blood pressure, is a common disease that manifests as elevated systemic arterial pressures. Hypertension is most often asymptomatic and is found incidentally as part of a routine physical examination or during triage for an unrelated medical encounter. Hypertension:
    • Obstruction: usually deep vein thrombosis Deep vein thrombosis Deep vein thrombosis (DVT) usually occurs in the deep veins of the lower extremities. The affected veins include the femoral, popliteal, iliofemoral, and pelvic veins. Proximal DVT is more likely to cause a pulmonary embolism (PE) and is generally considered more serious. Deep Vein Thrombosis ( DVT DVT Deep vein thrombosis (DVT) usually occurs in the deep veins of the lower extremities. The affected veins include the femoral, popliteal, iliofemoral, and pelvic veins. Proximal DVT is more likely to cause a pulmonary embolism (PE) and is generally considered more serious. Deep Vein Thrombosis)
    • Reflux (retrograde venous blood flow):
      • Usually due to valve incompetence
      • Valve incompetence may develop after obstruction.
  • Primary disease: symptomatic presentation without a precipitating event (70%)
  • Secondary disease: develops after obstruction due to DVT DVT Deep vein thrombosis (DVT) usually occurs in the deep veins of the lower extremities. The affected veins include the femoral, popliteal, iliofemoral, and pelvic veins. Proximal DVT is more likely to cause a pulmonary embolism (PE) and is generally considered more serious. Deep Vein Thrombosis (30%)
  • Risk factors for chronic venous insufficiency:
    • ↑ Age
    • ↑ BMI
    • Family history of venous disease
    • Laxity of ligaments (hernias, flat feet)
    • Prolonged standing
    • Smoking
    • Prior DVT DVT Deep vein thrombosis (DVT) usually occurs in the deep veins of the lower extremities. The affected veins include the femoral, popliteal, iliofemoral, and pelvic veins. Proximal DVT is more likely to cause a pulmonary embolism (PE) and is generally considered more serious. Deep Vein Thrombosis
    • Klippel–Trenaunay syndrome
    • ↑ Estrogen states, including pregnancy Pregnancy Pregnancy is the time period between fertilization of an oocyte and delivery of a fetus approximately 9 months later. The 1st sign of pregnancy is typically a missed menstrual period, after which, pregnancy should be confirmed clinically based on a positive β-hCG test (typically a qualitative urine test) and pelvic ultrasound. Pregnancy: Diagnosis, Maternal Physiology, and Routine Care

Pathophysiology

Venous hypertension Hypertension Hypertension, or high blood pressure, is a common disease that manifests as elevated systemic arterial pressures. Hypertension is most often asymptomatic and is found incidentally as part of a routine physical examination or during triage for an unrelated medical encounter. Hypertension

  • DVT DVT Deep vein thrombosis (DVT) usually occurs in the deep veins of the lower extremities. The affected veins include the femoral, popliteal, iliofemoral, and pelvic veins. Proximal DVT is more likely to cause a pulmonary embolism (PE) and is generally considered more serious. Deep Vein Thrombosis (obstruction) and/or primary valve incompetence (reflux) can cause: 
    • ↑ venous pressure in deep veins Veins Veins are tubular collections of cells, which transport deoxygenated blood and waste from the capillary beds back to the heart. Veins are classified into 3 types: small veins/venules, medium veins, and large veins. Each type contains 3 primary layers: tunica intima, tunica media, and tunica adventitia. Veins 
    • ↑ pressure in perforating veins Veins Veins are tubular collections of cells, which transport deoxygenated blood and waste from the capillary beds back to the heart. Veins are classified into 3 types: small veins/venules, medium veins, and large veins. Each type contains 3 primary layers: tunica intima, tunica media, and tunica adventitia. Veins 
    • ↑ pressure in superficial veins Veins Veins are tubular collections of cells, which transport deoxygenated blood and waste from the capillary beds back to the heart. Veins are classified into 3 types: small veins/venules, medium veins, and large veins. Each type contains 3 primary layers: tunica intima, tunica media, and tunica adventitia. Veins 
  • Endothelial dysfunction of vein walls ensues from DVT DVT Deep vein thrombosis (DVT) usually occurs in the deep veins of the lower extremities. The affected veins include the femoral, popliteal, iliofemoral, and pelvic veins. Proximal DVT is more likely to cause a pulmonary embolism (PE) and is generally considered more serious. Deep Vein Thrombosis.
  • Chronic inflammation Inflammation Inflammation is a complex set of responses to infection and injury involving leukocytes as the principal cellular mediators in the body's defense against pathogenic organisms. Inflammation is also seen as a response to tissue injury in the process of wound healing. The 5 cardinal signs of inflammation are pain, heat, redness, swelling, and loss of function. Inflammation of vein walls leads to eventual remodeling of those vein walls:
    • ↑ Type 1 collagen
    • ↓ Type 3 collagen
    • ↓ Smooth muscle cells 
    • Degradation of the extracellular matrix
    • ↑ Proteinases lead to increased permeability.
  • Severe wall dysfunction increases the risk of DVT DVT Deep vein thrombosis (DVT) usually occurs in the deep veins of the lower extremities. The affected veins include the femoral, popliteal, iliofemoral, and pelvic veins. Proximal DVT is more likely to cause a pulmonary embolism (PE) and is generally considered more serious. Deep Vein Thrombosis due to: 
    • Inability to properly move blood forward (stagnation)
    • Chronic inflammation Inflammation Inflammation is a complex set of responses to infection and injury involving leukocytes as the principal cellular mediators in the body's defense against pathogenic organisms. Inflammation is also seen as a response to tissue injury in the process of wound healing. The 5 cardinal signs of inflammation are pain, heat, redness, swelling, and loss of function. Inflammation/endothelial damage
Varicose veins

Varicose veins Veins Veins are tubular collections of cells, which transport deoxygenated blood and waste from the capillary beds back to the heart. Veins are classified into 3 types: small veins/venules, medium veins, and large veins. Each type contains 3 primary layers: tunica intima, tunica media, and tunica adventitia. Veins

Image: “Varicose veins Veins Veins are tubular collections of cells, which transport deoxygenated blood and waste from the capillary beds back to the heart. Veins are classified into 3 types: small veins/venules, medium veins, and large veins. Each type contains 3 primary layers: tunica intima, tunica media, and tunica adventitia. Veins” by National Heart Lung and Blood Institute. License: Public Domain

Skin Skin The skin, also referred to as the integumentary system, is the largest organ of the body. The skin is primarily composed of the epidermis (outer layer) and dermis (deep layer). The epidermis is primarily composed of keratinocytes that undergo rapid turnover, while the dermis contains dense layers of connective tissue. Structure and Function of the Skin and soft tissue changes

  • The increase in venous hypertension Hypertension Hypertension, or high blood pressure, is a common disease that manifests as elevated systemic arterial pressures. Hypertension is most often asymptomatic and is found incidentally as part of a routine physical examination or during triage for an unrelated medical encounter. Hypertension is combined with increased vessel permeability.
  • This leads to efflux of blood components into the subcutaneous space:
    • Fluid → edema Edema Edema is a condition in which excess serous fluid accumulates in the body cavity or interstitial space of connective tissues. Edema is a symptom observed in several medical conditions. It can be categorized into 2 types, namely, peripheral (in the extremities) and internal (in an organ or body cavity). Edema → ↑ pressure in the extremity, which may lead to:
      • Necrosis
      • Impaired lymph drainage → further fluid accumulation and impaired waste removal
    • RBCs (which break down) → hemosiderin deposits → skin pigmentation
    • Proteinases → cutaneous ulcers
    • WBCs → cytokine release → subcutaneous fibrosis (lipodermatosclerosis) → ↓ capillaries Capillaries Capillaries are the primary structures in the circulatory system that allow the exchange of gas, nutrients, and other materials between the blood and the extracellular fluid (ECF). Capillaries are the smallest of the blood vessels. Because a capillary diameter is so small, only 1 RBC may pass through at a time. Capillaries in these areas:
      • White plaques (atrophie blanche) 
      • ↓ Blood flow → poor healing and ischemia/necrosis

Clinical Presentation

Spectrum of chronic venous disease

  • Asymptomatic venous dilation
  • Mild disease:
    • Telangiectasias
    • Reticular veins Veins Veins are tubular collections of cells, which transport deoxygenated blood and waste from the capillary beds back to the heart. Veins are classified into 3 types: small veins/venules, medium veins, and large veins. Each type contains 3 primary layers: tunica intima, tunica media, and tunica adventitia. Veins
    • Varicose veins Veins Veins are tubular collections of cells, which transport deoxygenated blood and waste from the capillary beds back to the heart. Veins are classified into 3 types: small veins/venules, medium veins, and large veins. Each type contains 3 primary layers: tunica intima, tunica media, and tunica adventitia. Veins
    • Mild dependent ankle edema Edema Edema is a condition in which excess serous fluid accumulates in the body cavity or interstitial space of connective tissues. Edema is a symptom observed in several medical conditions. It can be categorized into 2 types, namely, peripheral (in the extremities) and internal (in an organ or body cavity). Edema
  • Severe disease (chronic venous insufficiency):
    • Significant edema Edema Edema is a condition in which excess serous fluid accumulates in the body cavity or interstitial space of connective tissues. Edema is a symptom observed in several medical conditions. It can be categorized into 2 types, namely, peripheral (in the extremities) and internal (in an organ or body cavity). Edema
    • Skin Skin The skin, also referred to as the integumentary system, is the largest organ of the body. The skin is primarily composed of the epidermis (outer layer) and dermis (deep layer). The epidermis is primarily composed of keratinocytes that undergo rapid turnover, while the dermis contains dense layers of connective tissue. Structure and Function of the Skin changes 
    • Ulcers

Presenting symptoms

  • Dependent pitting edema Edema Edema is a condition in which excess serous fluid accumulates in the body cavity or interstitial space of connective tissues. Edema is a symptom observed in several medical conditions. It can be categorized into 2 types, namely, peripheral (in the extremities) and internal (in an organ or body cavity). Edema 
  • Lower extremity pain Pain Pain has accompanied humans since they first existed, first lamented as the curse of existence and later understood as an adaptive mechanism that ensures survival. Pain is the most common symptomatic complaint and the main reason why people seek medical care. Physiology of Pain or discomfort: 
    • Often described as “heavy legs,” throbbing, aching, or cramping
    • Worse with standing
    • In contrast to peripheral artery disease Peripheral artery disease Peripheral artery disease (PAD) is obstruction of the arterial lumen resulting in decreased blood flow to the distal limbs. The disease can be a result of atherosclerosis or thrombosis. Patients may be asymptomatic or have progressive claudication, skin discoloration, ischemic ulcers, or gangrene. Peripheral Artery Disease (PAD), pain Pain Pain has accompanied humans since they first existed, first lamented as the curse of existence and later understood as an adaptive mechanism that ensures survival. Pain is the most common symptomatic complaint and the main reason why people seek medical care. Physiology of Pain improves with:
      • Leg Leg The lower leg, or just "leg" in anatomical terms, is the part of the lower limb between the knee and the ankle joint. The bony structure is composed of the tibia and fibula bones, and the muscles of the leg are grouped into the anterior, lateral, and posterior compartments by extensions of fascia. Leg elevation
      • Walking
  • Numbness or tingling
  • Pruritus
  • Visible tortuous veins Veins Veins are tubular collections of cells, which transport deoxygenated blood and waste from the capillary beds back to the heart. Veins are classified into 3 types: small veins/venules, medium veins, and large veins. Each type contains 3 primary layers: tunica intima, tunica media, and tunica adventitia. Veins:
    • Telangiectasias: dilated intradermal venules < 1 mm
    • Reticular veins Veins Veins are tubular collections of cells, which transport deoxygenated blood and waste from the capillary beds back to the heart. Veins are classified into 3 types: small veins/venules, medium veins, and large veins. Each type contains 3 primary layers: tunica intima, tunica media, and tunica adventitia. Veins: dilated subdermal veins Veins Veins are tubular collections of cells, which transport deoxygenated blood and waste from the capillary beds back to the heart. Veins are classified into 3 types: small veins/venules, medium veins, and large veins. Each type contains 3 primary layers: tunica intima, tunica media, and tunica adventitia. Veins, 1–3 mm in diameter 
    • Varicose veins Veins Veins are tubular collections of cells, which transport deoxygenated blood and waste from the capillary beds back to the heart. Veins are classified into 3 types: small veins/venules, medium veins, and large veins. Each type contains 3 primary layers: tunica intima, tunica media, and tunica adventitia. Veins: dilated subcutaneous veins Veins Veins are tubular collections of cells, which transport deoxygenated blood and waste from the capillary beds back to the heart. Veins are classified into 3 types: small veins/venules, medium veins, and large veins. Each type contains 3 primary layers: tunica intima, tunica media, and tunica adventitia. Veins > 3 mm in diameter
  • Skin Skin The skin, also referred to as the integumentary system, is the largest organ of the body. The skin is primarily composed of the epidermis (outer layer) and dermis (deep layer). The epidermis is primarily composed of keratinocytes that undergo rapid turnover, while the dermis contains dense layers of connective tissue. Structure and Function of the Skin changes:
    • Brown or blue-gray discoloration of the skin from hemosiderin deposits
    • Stasis dermatitis (eczematous rash) characterized by:
      • Erythema
      • Scaling
      • Weeping
      • Erosions
      • Crusting
    • Lipodermatosclerosis: 
      • Firm, indurated areas
      • Skin Skin The skin, also referred to as the integumentary system, is the largest organ of the body. The skin is primarily composed of the epidermis (outer layer) and dermis (deep layer). The epidermis is primarily composed of keratinocytes that undergo rapid turnover, while the dermis contains dense layers of connective tissue. Structure and Function of the Skin is tacked down to the subcutaneous tissue (subcutaneous fibrosis).
      • Most common at the medial ankle
      • May form a constrictive band around the extremity
    • Atrophie blanche: 
      • Atrophic white plaques with red punctate dots or telangiectasias
      • Circular or stellate
      • Surrounded by hyperpigmentation
    • Ulcers: commonly over the medial malleolus

Diagnosis and Classification

Physical exam

Lower extremity appearance:

  • Edema 
  • Visible or palpable tortuous superficial veins Veins Veins are tubular collections of cells, which transport deoxygenated blood and waste from the capillary beds back to the heart. Veins are classified into 3 types: small veins/venules, medium veins, and large veins. Each type contains 3 primary layers: tunica intima, tunica media, and tunica adventitia. Veins
  • Characteristic skin changes
  • +/– Ulcers

Venous refilling time:

  • Observe the time it takes for visible veins Veins Veins are tubular collections of cells, which transport deoxygenated blood and waste from the capillary beds back to the heart. Veins are classified into 3 types: small veins/venules, medium veins, and large veins. Each type contains 3 primary layers: tunica intima, tunica media, and tunica adventitia. Veins to distend after patient stands from a seated position.
  • Refilling time of 20–40 or < 20 seconds is abnormal.

Ankle–brachial index:

  • Ankle–brachial index = ratio of blood pressure of the ankle to blood pressure of the arm Arm The arm, or "upper arm" in common usage, is the region of the upper limb that extends from the shoulder to the elbow joint and connects inferiorly to the forearm through the cubital fossa. It is divided into 2 fascial compartments (anterior and posterior). Arm 
  • Ankle–brachial index ≤ 0.9 → PAD
  • Important: Compression therapy (standard in venous insufficiency) is contraindicated in PAD.

Imaging

Duplex ultrasonography:

  • 1st-line test to:
    • Confirm the diagnosis (if in question)
    • Determine the etiology
    • Rule out a DVT DVT Deep vein thrombosis (DVT) usually occurs in the deep veins of the lower extremities. The affected veins include the femoral, popliteal, iliofemoral, and pelvic veins. Proximal DVT is more likely to cause a pulmonary embolism (PE) and is generally considered more serious. Deep Vein Thrombosis
    • Assess the severity of deep vein disease
    • Localize affected anatomy
  • Combines: 
    • B-mode imaging of deep and superficial veins Veins Veins are tubular collections of cells, which transport deoxygenated blood and waste from the capillary beds back to the heart. Veins are classified into 3 types: small veins/venules, medium veins, and large veins. Each type contains 3 primary layers: tunica intima, tunica media, and tunica adventitia. Veins
    • Doppler assessment of blood flow
  • Obstruction shows: 
    • Absence of blood flow
    • Noncompressible veins Veins Veins are tubular collections of cells, which transport deoxygenated blood and waste from the capillary beds back to the heart. Veins are classified into 3 types: small veins/venules, medium veins, and large veins. Each type contains 3 primary layers: tunica intima, tunica media, and tunica adventitia. Veins
  • Reflux shows: 
    • Reversal of blood flow
    • > 0.5 second in the superficial and perforator veins Veins Veins are tubular collections of cells, which transport deoxygenated blood and waste from the capillary beds back to the heart. Veins are classified into 3 types: small veins/venules, medium veins, and large veins. Each type contains 3 primary layers: tunica intima, tunica media, and tunica adventitia. Veins
    • > 1 second in deep veins Veins Veins are tubular collections of cells, which transport deoxygenated blood and waste from the capillary beds back to the heart. Veins are classified into 3 types: small veins/venules, medium veins, and large veins. Each type contains 3 primary layers: tunica intima, tunica media, and tunica adventitia. Veins

Cross-sectional venography with CT or MRI:

  • Used to evaluate the deep venous system poorly accessible by ultrasound (e.g., infrainguinal area)
  • Consider in patients with normal or equivocal ultrasound

Catheter-based (invasive) venography:

  • Gold standard test
  • Rarely needed to make diagnosis
  • Used prior to more invasive intervention

Clinical, etiologic, anatomic, and pathophysiologic (CEAP) classification of chronic venous disease

  • Clinical signs: 
    • C0: no visible or palpable disease
    • C1: telangiectasias and reticular veins Veins Veins are tubular collections of cells, which transport deoxygenated blood and waste from the capillary beds back to the heart. Veins are classified into 3 types: small veins/venules, medium veins, and large veins. Each type contains 3 primary layers: tunica intima, tunica media, and tunica adventitia. Veins
    • C2: varicose veins Veins Veins are tubular collections of cells, which transport deoxygenated blood and waste from the capillary beds back to the heart. Veins are classified into 3 types: small veins/venules, medium veins, and large veins. Each type contains 3 primary layers: tunica intima, tunica media, and tunica adventitia. Veins
    • C3: edema Edema Edema is a condition in which excess serous fluid accumulates in the body cavity or interstitial space of connective tissues. Edema is a symptom observed in several medical conditions. It can be categorized into 2 types, namely, peripheral (in the extremities) and internal (in an organ or body cavity). Edema
    • C4: skin changes 
      • C4a: pigmentation or stasis dermatitis (eczematous rash)
      • C4b: lipodermatosclerosis
    • C5: healed ulcer
    • C6: active ulcer
    • C6R: recurrent active ulcer
  • Etiologic signs:
    • Ep: primary causes, usually degeneration of valves leading to reflux
    • Es: secondary causes, usually DVT DVT Deep vein thrombosis (DVT) usually occurs in the deep veins of the lower extremities. The affected veins include the femoral, popliteal, iliofemoral, and pelvic veins. Proximal DVT is more likely to cause a pulmonary embolism (PE) and is generally considered more serious. Deep Vein Thrombosis or trauma
    • Ec: congenital causes
  • Anatomic signs:
    • As: superficial veins Veins Veins are tubular collections of cells, which transport deoxygenated blood and waste from the capillary beds back to the heart. Veins are classified into 3 types: small veins/venules, medium veins, and large veins. Each type contains 3 primary layers: tunica intima, tunica media, and tunica adventitia. Veins (within the subcutaneous tissue)
    • Ad: deep veins Veins Veins are tubular collections of cells, which transport deoxygenated blood and waste from the capillary beds back to the heart. Veins are classified into 3 types: small veins/venules, medium veins, and large veins. Each type contains 3 primary layers: tunica intima, tunica media, and tunica adventitia. Veins (within the muscle compartments bound by fascia)
    • Ap: perforating veins Veins Veins are tubular collections of cells, which transport deoxygenated blood and waste from the capillary beds back to the heart. Veins are classified into 3 types: small veins/venules, medium veins, and large veins. Each type contains 3 primary layers: tunica intima, tunica media, and tunica adventitia. Veins ( veins Veins Veins are tubular collections of cells, which transport deoxygenated blood and waste from the capillary beds back to the heart. Veins are classified into 3 types: small veins/venules, medium veins, and large veins. Each type contains 3 primary layers: tunica intima, tunica media, and tunica adventitia. Veins that connect superficial to deep veins Veins Veins are tubular collections of cells, which transport deoxygenated blood and waste from the capillary beds back to the heart. Veins are classified into 3 types: small veins/venules, medium veins, and large veins. Each type contains 3 primary layers: tunica intima, tunica media, and tunica adventitia. Veins by traversing the muscular fascia)
  • Pathophysiologic signs:
    • Pr: venous reflux (retrograde flow)
    • Po: venous obstruction (thrombosis)
    • Pr,o: both reflux and obstruction
Exemplary photographs for a spectrum of clinical manifestations of chronic venous disease

Spectrum of chronic venous disease:
Extent of disease can be classified from C1 to C6 on the basis of the following manifestations:
a: spider and reticular veins Veins Veins are tubular collections of cells, which transport deoxygenated blood and waste from the capillary beds back to the heart. Veins are classified into 3 types: small veins/venules, medium veins, and large veins. Each type contains 3 primary layers: tunica intima, tunica media, and tunica adventitia. Veins (C1)
b: varicose veins Veins Veins are tubular collections of cells, which transport deoxygenated blood and waste from the capillary beds back to the heart. Veins are classified into 3 types: small veins/venules, medium veins, and large veins. Each type contains 3 primary layers: tunica intima, tunica media, and tunica adventitia. Veins (C2)
c: edema Edema Edema is a condition in which excess serous fluid accumulates in the body cavity or interstitial space of connective tissues. Edema is a symptom observed in several medical conditions. It can be categorized into 2 types, namely, peripheral (in the extremities) and internal (in an organ or body cavity). Edema and skin pigmentation (C4)
d: lipodermatosclerosis (C4)
e: healed ulcer (C5)
f: active venous ulcer (C6)

Image: “Spectrum of chronic venous disease” by Eva Ellinghaus et al. License: CC BY 4.0

Management

Goals

  • Reduce edema Edema Edema is a condition in which excess serous fluid accumulates in the body cavity or interstitial space of connective tissues. Edema is a symptom observed in several medical conditions. It can be categorized into 2 types, namely, peripheral (in the extremities) and internal (in an organ or body cavity). Edema.
  • Reduce discomfort.
  • Prevent and treat skin manifestations.
  • Heal ulcers.
  • Improve modifiable risk factors.

Conservative (nonsurgical) management

  • Frequent leg elevation (30 minutes, 3–4 times daily)  → improve venous drainage
  • Exercise → improve calf muscle pump
  • Weight loss → ↓ pressure
  • Skin Skin The skin, also referred to as the integumentary system, is the largest organ of the body. The skin is primarily composed of the epidermis (outer layer) and dermis (deep layer). The epidermis is primarily composed of keratinocytes that undergo rapid turnover, while the dermis contains dense layers of connective tissue. Structure and Function of the Skin care:
    • Cleansing
    • Emollients:
      • To maintain skin barrier
      • Prevent dryness and fissuring
      • ↓ Scratching (which can lead to ulcers)
  • Compression therapy (hosiery):
    • Primary initial management technique
    • Contraindicated with coexisting PAD
    • Long-term adherence required
  • Venoactive substances to ↑ venous tone:
    • Used in patients with:
      • Resistant edema Edema Edema is a condition in which excess serous fluid accumulates in the body cavity or interstitial space of connective tissues. Edema is a symptom observed in several medical conditions. It can be categorized into 2 types, namely, peripheral (in the extremities) and internal (in an organ or body cavity). Edema in spite of compression therapy
      • Contraindications to compression therapy
    • Beneficial for treating edema Edema Edema is a condition in which excess serous fluid accumulates in the body cavity or interstitial space of connective tissues. Edema is a symptom observed in several medical conditions. It can be categorized into 2 types, namely, peripheral (in the extremities) and internal (in an organ or body cavity). Edema, but not for ulcer healing
    • Options available in the United States:
      • Escin (horse chestnut seed extract)
      • Micronized purified flavonoid fraction

Ulcer care

  • Debridement: 
    • Removes surrounding necrotic tissue
    • Promotes healthy granulation tissue
    • Enhances reepithelialization
    • ↓ Risk for infection
    • May be done using surgical, enzymatic, or biologic methods
  • Topical agents (most do not improve healing rates):
    • Cadexomer iodine
    • Silver sulfadiazine
    • Avoid topical antiseptics.
  • Systemic antibiotics: only in patients with acute cellulitis Cellulitis Cellulitis is a common infection caused by bacteria that affects the dermis and subcutaneous tissue of the skin. It is frequently caused by Staphylococcus aureus and Streptococcus pyogenes. The skin infection presents as an erythematous and edematous area with warmth and tenderness. Cellulitis or clinically infected ulcer
  • Dressings
  • Medical options for treating resistant ulcers:
    • Stanozolol: an anabolic steroid that stimulates fibrinolysis
    • Pentoxifylline: ↑ microcirculation and tissue oxygenation

Surgical management

Goals:

  • Occlude (or remove) the damaged vessels and restore proper blood flow 
  • Decrease venous hypertension Hypertension Hypertension, or high blood pressure, is a common disease that manifests as elevated systemic arterial pressures. Hypertension is most often asymptomatic and is found incidentally as part of a routine physical examination or during triage for an unrelated medical encounter. Hypertension to reduce edema Edema Edema is a condition in which excess serous fluid accumulates in the body cavity or interstitial space of connective tissues. Edema is a symptom observed in several medical conditions. It can be categorized into 2 types, namely, peripheral (in the extremities) and internal (in an organ or body cavity). Edema and skin effects

Options include:

  • Superficial venous ablation (thermal destruction)
  • Sclerotherapy (injection of toxic substances causing fibrosis and occlusion)
  • Phlebectomy (vein excision)
  • Angioplasty and stenting (relieve obstructions in the deep veins Veins Veins are tubular collections of cells, which transport deoxygenated blood and waste from the capillary beds back to the heart. Veins are classified into 3 types: small veins/venules, medium veins, and large veins. Each type contains 3 primary layers: tunica intima, tunica media, and tunica adventitia. Veins)
  • Valve repair (deep veins Veins Veins are tubular collections of cells, which transport deoxygenated blood and waste from the capillary beds back to the heart. Veins are classified into 3 types: small veins/venules, medium veins, and large veins. Each type contains 3 primary layers: tunica intima, tunica media, and tunica adventitia. Veins)

Complications

  • Bleeding from varicose veins Veins Veins are tubular collections of cells, which transport deoxygenated blood and waste from the capillary beds back to the heart. Veins are classified into 3 types: small veins/venules, medium veins, and large veins. Each type contains 3 primary layers: tunica intima, tunica media, and tunica adventitia. Veins
  • DVT DVT Deep vein thrombosis (DVT) usually occurs in the deep veins of the lower extremities. The affected veins include the femoral, popliteal, iliofemoral, and pelvic veins. Proximal DVT is more likely to cause a pulmonary embolism (PE) and is generally considered more serious. Deep Vein Thrombosis
  • Superficial thrombophlebitis:
    • Inflammation within the vein walls → thrombosis
    • Treatment:
      • NSAIDs
      • Compression therapy
  • Cellulitis or infected ulcers:
    • Require treatment with systemic antibiotics and debridement
    • May lead to amputation Amputation An amputation is the separation of a portion of the limb or the entire limb from the body, along with the bone. Amputations are generally indicated for conditions that compromise the viability of the limb or promote the spread of a local process that could manifest systemically. Amputation

Differential Diagnosis

  • Heart failure: clinical syndrome resulting from dysfunction of the cardiac pump that leads to low tissue perfusion and congestion in the venous system: Heart failure can be distinguished from chronic venous insufficiency by the presence of dyspnea Dyspnea Dyspnea is the subjective sensation of breathing discomfort. Dyspnea is a normal manifestation of heavy physical or psychological exertion, but also may be caused by underlying conditions (both pulmonary and extrapulmonary). Dyspnea, jugular venous distention, and an S3 heart sound. Diagnosis is made from a combination of clinical, laboratory, and imaging findings, and management is directed toward medical optimization.
  • Cirrhosis Cirrhosis Cirrhosis is a late stage of hepatic parenchymal necrosis and scarring (fibrosis) most commonly due to hepatitis C infection and alcoholic liver disease. Patients may present with jaundice, ascites, and hepatosplenomegaly. Cirrhosis can also cause complications such as hepatic encephalopathy, portal hypertension, portal vein thrombosis, and hepatorenal syndrome. Cirrhosis: progressive fibrosis and failure of the liver Liver The liver is the largest gland in the human body. The liver is found in the superior right quadrant of the abdomen and weighs approximately 1.5 kilograms. Its main functions are detoxification, metabolism, nutrient storage (e.g., iron and vitamins), synthesis of coagulation factors, formation of bile, filtration, and storage of blood. Liver, which leads to portal hypertension Portal hypertension Portal hypertension is increased pressure in the portal venous system. This increased pressure can lead to splanchnic vasodilation, collateral blood flow through portosystemic anastomoses, and increased hydrostatic pressure. There are a number of etiologies, including cirrhosis, right-sided congestive heart failure, schistosomiasis, portal vein thrombosis, hepatitis, and Budd-Chiari syndrome. Portal Hypertension: Portal hypertension Hypertension Hypertension, or high blood pressure, is a common disease that manifests as elevated systemic arterial pressures. Hypertension is most often asymptomatic and is found incidentally as part of a routine physical examination or during triage for an unrelated medical encounter. Hypertension can cause venous congestion distally, resulting in ascites Ascites Ascites is the pathologic accumulation of fluid within the peritoneal cavity that occurs due to an osmotic and/or hydrostatic pressure imbalance secondary to portal hypertension (cirrhosis, heart failure) or non-portal hypertension (hypoalbuminemia, malignancy, infection). Ascites, gastric and esophageal varices, and peripheral edema Edema Edema is a condition in which excess serous fluid accumulates in the body cavity or interstitial space of connective tissues. Edema is a symptom observed in several medical conditions. It can be categorized into 2 types, namely, peripheral (in the extremities) and internal (in an organ or body cavity). Edema. Telangiectasias are also possible. Symptoms also include jaundice Jaundice Jaundice is the abnormal yellowing of the skin and/or sclera caused by the accumulation of bilirubin. Hyperbilirubinemia is caused by either an increase in bilirubin production or a decrease in the hepatic uptake, conjugation, or excretion of bilirubin. Jaundice, GI bleeding, neurologic symptoms, and coagulation disorders. Management is mostly supportive, with the goal of reducing complications.
  • Nephrotic syndrome Nephrotic syndrome Nephrotic syndrome is characterized by severe proteinuria, hypoalbuminemia, and peripheral edema. In contrast, the nephritic syndromes present with hematuria, variable loss of renal function, and hypertension, although there is sometimes overlap of > 1 glomerular disease in the same individual. Nephrotic Syndrome: Damaged renal podocytes lead to massive proteinuria, which ultimately can result in significant peripheral edema Edema Edema is a condition in which excess serous fluid accumulates in the body cavity or interstitial space of connective tissues. Edema is a symptom observed in several medical conditions. It can be categorized into 2 types, namely, peripheral (in the extremities) and internal (in an organ or body cavity). Edema similar to chronic venous disease. It is also associated with a hypercoagulable Hypercoagulable Hypercoagulable states (also referred to as thrombophilias) are a group of hematologic diseases defined by an increased risk of clot formation (i.e., thrombosis) due to either an increase in procoagulants, a decrease in anticoagulants, or a decrease in fibrinolysis. Hypercoagulable States state due to urinary loss of antithrombin III, so DVTs may develop. Renal biopsy will yield a definitive diagnosis. Management is largely supportive and directed at the underlying cause.
  • PAD: atherosclerosis Atherosclerosis Atherosclerosis is a common form of arterial disease in which lipid deposition forms a plaque in the blood vessel walls. Atherosclerosis is an incurable disease, for which there are clearly defined risk factors that often can be reduced through a change in lifestyle and behavior of the patient. Atherosclerosis leading to decreased blood flow in the peripheral arteries Arteries Arteries are tubular collections of cells that transport oxygenated blood and nutrients from the heart to the tissues of the body. The blood passes through the arteries in order of decreasing luminal diameter, starting in the largest artery (the aorta) and ending in the small arterioles. Arteries are classified into 3 types: large elastic arteries, medium muscular arteries, and small arteries and arterioles. Arteries, commonly in the lower extremities: The atherosclerosis Atherosclerosis Atherosclerosis is a common form of arterial disease in which lipid deposition forms a plaque in the blood vessel walls. Atherosclerosis is an incurable disease, for which there are clearly defined risk factors that often can be reduced through a change in lifestyle and behavior of the patient. Atherosclerosis results in claudication ( pain Pain Pain has accompanied humans since they first existed, first lamented as the curse of existence and later understood as an adaptive mechanism that ensures survival. Pain is the most common symptomatic complaint and the main reason why people seek medical care. Physiology of Pain that is induced by exercise and relieved with rest). The decreased arterial blood flow in PAD may also lead to ulcers secondary to ischemia. Diagnosis is established clinically and supported by vascular imaging. Treatment involves medications and surgical revascularization.
  • Squamous cell carcinoma Squamous cell carcinoma Cutaneous squamous cell carcinoma (cSCC) is caused by malignant proliferation of atypical keratinocytes. This condition is the 2nd most common skin malignancy and usually affects sun-exposed areas of fair-skinned patients. The cancer presents as a firm, erythematous, keratotic plaque or papule. Squamous Cell Carcinoma (SCC): a malignant tumor arising from the epidermal keratinocytes, usually in sun-exposed areas: SCCs can form well-demarcated, scaling, pink plaques that can resemble inflammatory skin changes. Diagnosis is established with a biopsy. SCC can also arise in chronic venous ulcers. The mainstay of treatment is surgical excision.

References

  1. Creager, M. A., Loscalzo, J. (2008). Vascular disorders of the extremities. In Fauci, A. S., Braunwald, E., Kasper, D.L., et al. (Eds.) Harrison’s Internal Medicine (17th ed., p. 1574).
  2. Kabnick, L. S., Scovell, S. (2020). Overview of lower extremity chronic venous disease. In Collins, K. A. (Eds.) UpToDate. Retrieved February 14, 2021, from https://www.uptodate.com/contents/overview-of-lower-extremity-chronic-venous-disease
  3. Mathes, B. M. (2019). Clinical manifestations of lower extremity chronic venous disease. In Collins, K. A. (Ed.) UpToDate. Retrieved February 14, 2021, from https://www.uptodate.com/contents/clinical-manifestations-of-lower-extremity-chronic-venous-disease
  4. Moneta, G. (2020). Classification of lower extremity chronic venous disease. In Collins, K. A. (Ed.) UpToDate. Retrieved February 14, 2021, from https://www.uptodate.com/contents/classification-of-lower-extremity-chronic-venous-disorders
  5. Alguire, P. C., Mathes, B. M. (2019). Diagnostic evaluation of lower extremity chronic venous insufficiency. In Collins, K. A. (Ed.) UpToDate. Retrieved February 14, 2021, from https://www.uptodate.com/contents/diagnostic-evaluation-of-lower-extremity-chronic-venous-insufficiency
  6. Mathes, B. M., Kabnick, L.S., Alguire, P. C. (2021). Medical management of lower extremity chronic venous disease. In Collins, K. A. (Ed.) UpToDate. Retrieved February 14, 2021, from https://www.uptodate.com/contents/medical-management-of-lower-extremity-chronicvenous-disease
  7. Patel, S. (2020). Venous insufficiency. In Surowiec S. (Ed.) StatPearls. Retrieved February 14, 2021, from https://www.statpearls.com/articlelibrary/viewarticle/31060/

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