Chronic venous disease

Last updated: June 24, 2022

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Chronic venous disease (also referred to as chronic venous disorders) is an umbrella term for a variety of clinical manifestations caused by chronically increased venous pressure in the lower extremities. Manifestations are categorized according to the CEAP classification of chronic venous disorders. Depending on the severity of hemodynamic dysfunction, manifestations can include superficial dilated veins (including varicose veins), peripheral edema, skin changes (e.g., stasis dermatitis), and venous ulcers. Diagnosis is based on clinical features and duplex ultrasonography, which shows vascular reflux and/or obstruction. Advanced diagnostic studies, such as magnetic resonance venography (MRV), may be indicated for certain patients. Treatment is aimed at reducing underlying venous hypertension. Lifestyle changes and localized vascular compression therapy are indicated for all patients. Surgical intervention is additionally recommended for patients with advanced or refractory disease. Surgical procedures are typically minimally invasive (e.g., endovenous ablation), although vein removal or valvuloplasty may be required. Phlebotonic supplements, most of which are available as nutritional supplements in the US, may help relieve symptoms such as pain and the sensation of heaviness.

  • Venous insufficiency: disturbance in venous outflow; may be congenital (e.g., congenital absence of valves, Klippel-Trenaunay syndrome) or acquired (e.g., valvular injury secondary to deep vein thrombosis) [1]
  • Chronic venous disease/disorders (CVD): a spectrum of disorders caused by venous dysfunction; ranges from telangiectasia to venous ulceration
    • Chronic venous insufficiency (CVI): advanced CVD including edema, skin changes, and venous ulceration
    • Varicose veins: a type of CVD characterized by cylindrical dilation; (diameter > 3 mm) and tortuosity of superficial veins

The terms CVD and CVI are sometimes used interchangeably in literature because the pathophysiology is similar. However, most guideline definitions limit the term CVI to more advanced disease. [2][3][4]

Epidemiological data refers to the US, unless otherwise specified.

Risk factors for CVD include the following: : [4]

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

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

Features of venous hypertension

Tourniquet tests for varicose veins

Bedside tourniquet tests may help determine the site of venous insufficiency, but imaging is required for diagnostic confirmation. [2][4]

  • CVD is classified using the CEAP classification system. [9]
    • C: clinical signs, ranked in severity from C0–C6
    • E: etiology; may be congenital (Ec), primary (Ep), or secondary (Es) , or ranked as unidentified (En)
    • A: anatomy; involves the superficial veins (As), perforators (Ap), or deep veins (Ad), or is ranked as unidentified (An)
    • P: pathophysiology; caused by reflux (Pr), obstruction (Po), or both (Pr,o), or is ranked as unidentified (Pn)
  • The clinical component of CEAP is often used alone in primary care as it does not require venous studies. [10]
Clinical component of CEAP classification [9]
Clinical features
CEAP class C0
  • No visible or palpable signs of disease
CEAP class C1
CEAP class C2
CEAP class C3
CEAP class C4
CEAP class C5
CEAP class C6

CVI is equivalent to CEAP classes C3 and above. [2][3]

Approach

Venous duplex ultrasound [2][4]

Additional studies [2][3]

Not routinely required; consider in complications, diagnostic uncertainty, or planned interventions.

Laboratory studies

Venous plethysmography (venous function test)

  • A noninvasive test used to assess venous blood flow and detect reflux and/or obstruction
  • Indications include quantification of reflux or obstruction if duplex US findings are unclear. [2][3][12]

Further imaging

  • Abdominal/pelvic US: Consider as initial study for suspected suprainguinal venous obstruction. [3]
  • CT or MR venography: Consider if duplex US is inconclusive and before planned intervention for suprainguinal venous obstruction. [2][3]
  • Invasive imaging (e.g., contrast venography, intravascular ultrasound): Consider if CT/MRV is inconclusive or inadequate. [3]

Differential diagnosis of leg ulcers
Venous ulcer Arterial ulcer Malum perforans
Location
  • Gaiter region (above the ankle)
Mechanism
  • Vessel occlusion leads to tissue ischemia.
  • Diabetic microvasculopathy and neuropathy leads to impaired tissue sustenance.
Wound features
  • Punched-out appearance
  • No exudation
Pain
  • Mild
  • Severe
  • Absent
Additional features

The differential diagnoses listed here are not exhaustive.

Approach [2][4][10]

Manage CVD in pregnancy with conservative measures only and reassess for persistent disease at 3–6 months after delivery. [3]

Lifestyle modifications [3][10][16]

  • Frequent elevation of the legs [11]
  • Daily exercise [4][13]
  • Change in footwear [17]
  • Avoidance of:
    • Long periods of standing and sitting
    • Hot temperatures [18]
  • Smoking cessation
  • Management of obesity
  • Emollients to prevent dry skin [19]

Consider referral to physical therapy to increase calf pump activity and help improve mobility. [3]

Venous compression therapy

Indications [2][3][20]

  • Primary treatment modality for:
    • Most patients with symptomatic mild venous disease (CEAP C1 or CEAP C2) or edema
    • Pregnant patients with any stage of CVD
  • Adjunct to interventional therapy: patients with skin changes or ulceration (CEAP C4–C6)

Contraindications [3]

  • PAD with either:
    • ABI < 0.6 (absolute) or < 0.8 (relative) [3][11]
    • Absolute ankle pressure < 60 mm Hg [3][11]
  • Prior peripheral arterial bypass grafting at the site of compression
  • NYHA III and IV congestive heart failure
  • Severe diabetic neuropathy or microangiopathy
  • Allergy to compression bandage materials

Active ulceration is not a contraindication to compression bandages; consult wound care to help manage concurrent wounds with compression dressings.

Avoid compression therapy in significant PAD.

Types of compression [2][3]

  • Graded compression stockings
    • Options include below-the-knee, thigh-high, or waist-high products [21]
    • Can be applied by patients themselves
    • Should be worn long-term all day, every day; adherence is often poor. [22]
    • Elasticity is lost over time; provide two pairs that should be alternated daily and replace after 6–9 months. [4]
  • Elastic or inelastic bandages (e.g., Unna boots)
    • Application of bandages requires trained staff.
    • Multicomponent elastic bandages are the most effective form of compression therapy for venous ulcers. [11]
  • Adjustable compression garments [3]
    • Inelastic material with straps that can be tightened to increase pressure
    • Used as an alternative to compression stockings or bandages
  • Intermittent pneumatic compression device: for refractory edema or as a second-line option for venous ulcers [3][11]

Some individuals (e.g., with obesity or limited mobility) may have difficulty applying compression garments and thus require a donning device or assistance. [13]

Amount of pressure [4]

Recommended pressure for compression dressings in CVD [2][3][11]
Clinical condition Pressure in mm Hg
Varicose veins
  • 15–30
Edema or skin changes
  • 20–40
Postthrombotic syndrome
  • 30–40 [3][11]
Active venous ulceration
  • 40–60 [3]

Interventional procedures

Indications [2][3][23]

Modalities

Management of venous reflux [2][3][23]

Before ablating or stripping superficial veins, confirm the deep veins are patent using duplex US.

Management of venous obstruction [3][23]

  • First-line: endovascular recanalization and stenting
  • Alternative: surgical reconstruction

Phlebotonic supplements [2][10][25]

  • Venoactive drugs that increase tone and/or decrease capillary permeability
  • Consider as an adjunct therapy for patients with pain or edema secondary to CVD. [2][3]
  • Examples include horse chestnut seed extract and micronized purified flavonoid fraction (e.g., diosmiplex). [26]

Phlebotonics may improve some symptoms of CVI, but there is a paucity of evidence on the efficacy and safety of long-term use. [10]

Stasis dermatitis [13][27]

Treatment of stasis dermatitis includes addressing the underlying CVI.

Consider antibiotic therapy for skin and soft tissue infections only if there is strong suspicion for cellulitis. [13][27][30]

Venous ulcers [11][14][31]

To prevent recurrence, compression therapy should be continued after a venous ulcer is healed. [11]

Other complications

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

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