• Clinical science

Chronic venous disease

Summary

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).

Definition

  • Varicose veins: cylindrical extension and dilation of superficial veins; (diameter > 3 mm) with development of knots and tortuous veins
  • Chronic venous insufficiency: increased venous pressure resulting in alterations of the skin and veins

References:[1]

Epidemiology

  • Prevalence:
    • CVI affects 2–5% of individuals in the US.
    • Varicose veins affect approx. 23% of individuals in the US.
  • Peak incidence: CVI
    • : 5th decade
    • : 8th decade
  • Sex: > (∼ 2:1)

References:[1][2][3]

Epidemiological data refers to the US, unless otherwise specified.

Etiology

Risk factors for chronic venous disease

  • Higher age and female sex (see “Epidemiology” above)
  • Family history of venous disease
  • Ligamentous laxity
  • Sedentary lifestyle and prolonged standing
  • Obesity
  • Pregnancy
  • Smoking
  • Prior thrombosis (postthrombotic syndrome)
  • Prior extremity trauma
  • Congenital abnormalities

Pathophysiology

In healthy individuals, blood from the superficial leg veins passes through the perforating veins into the deep veins.

Varicose veins

  • 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

References:[2][3]

Clinical features

  • 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
  • Skin findings
    • 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

References:[2][4][5][6]

Diagnostics

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

References:[1][2]

Treatment

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

Conservative measures

  • Indications
    • Superficial disease with no correctable cause of reflux
    • Postoperative period
  • Measures
    • Compression therapy with compression stockings
    • Frequent elevation of the legs
    • Physical therapy, manual lymphatic drainage
    • Avoid long periods of standing and sitting (with bent legs) and heat

Definite treatment

  • Indications:
    • 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
    • Interventional:
      • First-line: endovenous thermal ablation (laser and radiofrequency)
      • Alternative: chemical ablation (sclerotherapy)
    • Open surgery with partial or complete removal of a vein: only for veins that are not accessible by interventional techniques

References:[1]

Complications

Venous ulcers

  • Definition: Chronic defects of the skin that do not heal spontaneously
  • Etiology: usually caused by chronic venous insufficiency
  • Clinical features
    • Most frequently occur just above the ankle (gaiter region)
    • Shallow ulcer with irregular borders
    • Usually only mild pain, pruritic
    • Symptoms and skin findings of chronic venous disease (see “Clinical features” above)
  • Diagnostics
  • Treatment
  • Differential diagnosis
  • Prognosis: recurrence rate as high as 40% depending on the initial size of the ulcer

Further complications

References:[1][4][7][8]

We list the most important complications. The selection is not exhaustive.