• Clinical science

Chronic venous disease

Abstract

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 (e.g., dysplastic venous veins in Klippel-Trénaunay-Weber syndrome)[1]

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
      • Painful, indurated, and hardened skin
      • Atrophie blanche: White, coin- to palm-sized atrophic plaques due to absent capillaries in the fibrotic tissue.
  • Chronic venous disease of the lower extremity may be classified according to the CEAP classification.

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
  • Magnetic resonance venography (MRV)
    • Better sensitivity and specificity
    • Typically used in complicated cases, when duplex ultrasonography is inconclusive
    • Visualizes venous anatomy and depicts venous reflux and/or obstruction
  • Venous plethysmography: noninvasive measurement of the velocity of venous recovery (while exercising) via infrared light

References:[1][2]

Venous function tests

  • General
    • Venous function tests have largely been replaced by duplex ultrasonography, which provides more conclusive results.
    • Concept: assessment of the patency and function of the venous valves
  • Trendelenburg test: examines the function of superficial and perforating venous valves
    • Procedure
      1. The patient should be in a supine position and his/her legs are elevated → Because of gravity, the veins empty (possibly additional pressure until completely empty).
      2. A tourniquet is applied to compress the superficial veins (great saphenous vein).
      3. The leg is lowered (patient should stand) → In normally functioning perforating veins, the superficial veins are not filled as the blood flows from the superficial to the perforating veins.
      4. Trendelenburg I positive: If stasis is present, there is rapid filling from the deep to superficial venous system → insufficient perforating veins
      5. Trendelenburg II positive: After stasis removal, there is rapid filling within the superficial venous system → insufficient superficial venous valves (truncal varicose veins)
  • Perthes test: assesses deep venous patency
    • Indication: examine operability before varicose vein surgery
    • Procedure
      1. The patient should be in a standing position. A tourniquet is applied to compress the superficial vein (great saphenous vein).
      2. The patient should walk for several minutes, allowing the blood to flow through the deep venous system up to the heart via venous muscle pumps.
        • Normal findings: no filling of the varices as the blood flows in the direction of the heart
        • Positive finding: excessive filling of the varices, as the volume of blood is unable to flow through the obstructed deep veins

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

Further complications

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

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