- Clinical science
The most common chronic venous diseases are varicose veins (affecting approx. 23% of the US population) and chronic venous insufficiency (CVI), which affects 2–5% of the population. The condition is most often caused by increased venous pressure due to malfunctioning valves in the veins. Elevated venous pressure results in fluid accumulation in the lower extremities, leading to alterations in the skin and veins. Depending on the severity of hemodynamic changes, clinical manifestations may include superficial tortuous veins, edema, skin changes (e.g., stasis dermatitis), and ulcer formation. Diagnosis is established based on duplex ultrasonography. In complicated cases, magnetic resonance venography (MRV) may be performed as well. Treatment may be conservative (e.g., compression stockings) or involve ablation therapies (e.g., sclerotherapy, surgical excision).
Risk factors for chronic venous disease
- Elevated venous pressure (see “Risk factors” above) → incompetence of venous valves (superficial or deep veins)→ reflux of blood into superficial veins and back into the extremity → further elevation of venous pressure → formation of varicose veins
Chronic venous insufficiency
- Varicose veins → extravasation of protein and leukocytes → release of free radicals → damage to capillary basement membrane → leakage of plasma proteins → edema formation → ↓ oxygen supply → tissue hypoperfusion and hypoxia → inflammation and atrophy → possibly ulcer formation
Chief complaints: generalized or localized pain, lower extremity discomfort/cramping, and limb swelling
- Worsened by heat
- Worse while standing, relieved by walking and raising of legs
- Occurs in ∼ 50% of affected individuals
- Pruritus, tingling, and numbness
- Edema formation (may be unilateral) that starts in the ankle and may involve the calf later in the disease course (in about half of affected individuals)
- Telangiectasias (esp. in women)
- Yellow-brown or red-brown skin pigmentation of the medial ankle; later of the foot and possibly lower leg
- Paraplantar varicose veins
- Lipodermatosclerosis: Localized chronic inflammation and fibrosis of skin and subcutaneous tissues of lower leg
The diagnosis of varicose veins is based on history and clinical findings; . Imaging is only used in the diagnosis of CVI.
Test of choice: duplex ultrasonography
- Presence of venous reflux confirms diagnosis of CVI
- Examine patency of deep vein
- Examine sufficiency of superficial and perforating veins
General treatment principles
- Elimination of the reflux pathways (via conservative, interventional, or surgical treatment options) → long-term normalization of hemodynamics → prevention/slowing of CVI progression
- Superficial disease with no correctable cause of reflux
- Postoperative period
- Symptomatic venous disease with correctable cause of reflux
- In case of complications such as bleeding, ulcers, or recurrent superficial thrombophlebitis (also see “Complications” below)
- Technique: vein ablation therapies
- Definition: Chronic defects of the skin that do not heal spontaneously
- Etiology: usually caused by chronic venous insufficiency
- Clinical features
- ABI) to exclude (
- Evaluate patients for
- Biopsies should be performed in any nonischemic wound that fails to improve after 3 months of treatment.
- Culture if wound appears infected
- See also “Diagnostics” above.
- Diabetic foot wounds ()
- Ulcerated skin tumors (e.g., )
- Prognosis: recurrence rate as high as 40% depending on the initial size of the ulcer
We list the most important complications. The selection is not exhaustive.