Chronic venous disease

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).

• 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

• Prevalence
  • CVI affects 2–6% of women and ∼ 2% of men. ^[1]
  • Varicose veins affect approx. 23% of individuals in the US. ^[2]
• Sex: ♀ > ♂ (∼ 2:1)

Epidemiological data refers to the US, unless otherwise specified.

Risk factors for chronic venous disease include the following:

• Increasing age; and female sex
• Family history of venous disease
• Ligamentous laxity
• Sedentary lifestyle and prolonged standing
• Obesity
• Pregnancy
• Smoking
• Prior thrombosis (postthrombotic syndrome)
• Prior extremity trauma
• Congenital abnormalities

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: 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
  • 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
    • RBC breakdown leads to hemosiderin release → accumulation in the dermis → skin pigmentation
    • May lead to stasis dermatitis; a scaly, pruritic rash
  • Paraplantar varicose veins
  • Lipodermatosclerosis: Localized chronic inflammation and fibrosis of skin and subcutaneous tissues of lower leg ^[3]
    • Painful, indurated, and hardened skin
    • Atrophie blanche: White, coin- to palm-sized atrophic plaques due to absent capillaries in the fibrotic tissue.
• Physical examination
  • Trendelenburg test: examines the function of superficial and perforating venous valves
    • Procedure
      1. The patient should be in a supine position with their legs elevated.
      2. A tourniquet is applied to compress the superficial veins (mainly the great saphenous vein).
      3. The leg is lowered (patient should stand).
    • Interpretation
      • Normal: No filling of the superficial veins as blood flows from the superficial to the perforating veins.
      • Trendelenburg I positive: If stasis is present, there is rapid filling from the deep to superficial venous system (insufficient perforating veins)
      • Trendelenburg II positive: After stasis removal, there is rapid filling within the superficial venous system (insufficient superficial venous valves)
  • 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 (mainly the great saphenous vein).
      2. The patient should walk for several minutes.
    • Interpretation
      • Normal: no filling of varices
      • Positive: excessive filling of the varices (blood is unable to flow through the obstructed deep veins)

Varicose veins and chronic venous insufficiency are diagnosed based on history and clinical findings. Imaging is only used when a clinical diagnosis of CVI cannot be established and/or conservative management has failed.

• 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

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 ^[4]

• 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 ^[4]

• 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

Venous ulcers ^[5]

• 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
  • Ankle-brachial index (ABI) to exclude peripheral artery disease
  • Evaluate patients for diabetes mellitus
  • 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.
• Treatment
  • Treat underlying disease (see “Treatment” above)
  • Topical wound treatment : debridement, skin care, wound dressings
  • Systemic antibiotics in signs of infection (see cellulitis and erysipelas)
  • Skin graft in large or refractory ulcers
• Differential diagnosis
  • Arterial ulcer
  • Diabetic foot wounds (Malum perforans)
  • Pyoderma gangrenosum
  • Vasculitis
  • Ulcerated skin tumors (e.g., basal cell carcinoma)
• Prognosis: recurrence rate as high as 40% depending on the initial size of the ulcer

Differential diagnosis of foot ulcers

Further complications

• Vein hemorrhage
• Superficial thrombophlebitis
• Deep vein thrombosis

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