II. Risk Factors

  1. Obesity
  2. Congestive Heart Failure
  3. Diabetes Mellitus
  4. Advanced age
  5. Female gender
  6. Family History of Varicose Veins
  7. Deep Vein Thrombosis
  8. Superficial Thrombophlebitis
  9. Prior leg injury
  10. Prolonged standing or sitting

III. Pathophysiology

  1. Chronic Venous Disease is a spectrum of related conditions resulting from venous Hypertension and venous reflux
    1. Early findings include Telangiectasia or reticular veins
    2. Next, Varicose Veins and edema develop
    3. Chronic stasis changes follow with pigmentation, Lipodermatosclerosis, and ultimately Venous Stasis Ulcers
  2. Venous Reflux
    1. Normal Venous valves prevent backflow
      1. Valves prevent Distal to Proximal vein backflow
      2. Valves prevent Superficial to Deep vein backflow
    2. Incompetent valves allow backflow when legs relax
      1. Results in distal venous Hypertension
      2. Primary etiology for Chronic Venous Insufficiency
    3. Venous Hypertension Causes
      1. Valve dysfunction
      2. Venous outflow obstruction
      3. Arteriovenous Malformation
      4. Calf Muscle pump failure

IV. Symptoms and Signs

  1. See CEAP Chronic Venous Disease Classification
  2. Initial Changes
    1. Telangiectasias or Spider Veins (<1 mm diameter)
    2. Reticular veins (1-3 mm diameter)
    3. Varicose Veins (3 mm or more in diameter, with patient standing)
  3. Next
    1. Pedal edema
  4. Next
    1. Tan or reddish brown Skin Color changes
    2. Weeping, Eczematous or excoriated skin
  5. Later Changes
    1. Lipodermatosclerosis or atrophie blanche
      1. Induration at medial ankle to mid-leg
  6. Advanced Changes
    1. Brawny Edema above and below fibrotic area
    2. Ulcerations

V. Complications

  1. Venous Stasis Ulcers
    1. More common in older women
    2. Chronic and often recurrent
  2. Postphlebitic Syndrome
    1. Chronic Leg Edema
    2. Lipodermatosclerosis (see signs above)
    3. Deep Venous Thrombosis
    4. Superficial Thrombophlebitis
    5. Pigmentation
    6. Ulceration
  3. Overlying Skin Changes
    1. Eczema
    2. Cellulitis and other secondary infection

VI. Diagnosis

  1. Duplex Ultrasound (B-Mode and Directional Pulse)
    1. Can accurately assess venous reflux
    2. Can also be used to assess Arterial Insufficiency
      1. With Ultrasound ankle/brachial index (See below)
  2. Descending Venography
    1. Not as accurate as Duplex scanning

VII. Management

  1. Confirm No Arterial Insufficiency
    1. Assess before managing Venous Insufficiency
    2. Ankle-Brachial Index
      1. Blood Pressure measurement
      2. Doppler Ultrasound measurement
  2. General measures
    1. Take regular walks
      1. Leg Muscle activity promotes better venous return
    2. Avoid prolonged standing in one place
    3. Elevate Legs above Heart
      1. Perform 30 minutes each 3-4 times daily
      2. Elevate the foot of the bed to raise legs overnight
    4. Graduated Compression Stockings (Jobst Stockings)
  3. Intermittent Pneumatic Compression Pumps
    1. Indications
      1. Obesity
      2. Moderate to Severe edema
    2. Contraindications
      1. Uncompensated Congestive Heart Failure
  4. Diuretics
    1. Short term use
    2. Indications: Severe edema

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Related Studies

Ontology: Venous Insufficiency (C0042485)

Definition (MSH) Impaired venous blood flow or venous return (venous stasis), usually caused by inadequate venous valves. Venous insufficiency often occurs in the legs, and is associated with EDEMA and sometimes with VENOUS STASIS ULCERS at the ankle.
Concepts Disease or Syndrome (T047)
MSH D014689
ICD9 459.81
SnomedCT 20696009
English Insufficiencies, Venous, Venous Insufficiencies, Insufficiency, Venous, Venous insufficiency, Venous (peripheral) insufficiency, unspecified, venous insufficiency (diagnosis), venous insufficiency, Venous insufficiency NOS, Venous Insufficiency [Disease/Finding], peripheral venous insufficiency, Insufficiency;venous, insufficiency venous, Venous Insufficiency, Peripheral venous insufficiency (disorder), Peripheral venous insufficiency, insufficiency; venous, venous; insufficiency, Peripheral venous insufficiency, NOS, Peripheral venous insufficiency, unspecified, Venous insufficiency, unspecified
Dutch veneuze (perifere) insufficiëntie, niet-gespecificeerd, insufficiëntie; veneus, veneus; insufficiëntie, veneuze insufficiëntie, Insufficiëntie, veneuze, Veneuze insufficiëntie
French Insuffisance veineuse (périphérique), non précisée, Insuffisance veineuse
German Veneninsuffizienz (peripher), unspezifisch, Veneninsuffizienz
Italian Insufficienza (periferica) venosa non specificata, Insufficienza venosa
Portuguese Insuficiência venosa (periférica) NE, Insuficiência venal, Insuficiência Venosa
Spanish Insuficiencia venosa (periférica) no especificada, insuficiencia venosa periférica (trastorno), insuficiencia venosa periférica, Insuficiencia venosa, Insuficiencia Venosa
Japanese 静脈(末梢)不全、詳細不明, 静脈不全, ジョウミャクマッショウフゼンショウサイフメイ, ジョウミャクフゼン
Swedish Venös insufficiens
Finnish Laskimoiden vajaatoiminta
Czech žilní nedostatečnost, Žilní insuficience, Žilní (periferní) nedostatečnost, blíže neurčená, žilní insuficience, venózní insuficience
Polish Niewydolność żylna
Hungarian Venás (peripheriás) elégtelenség, nem meghatározott, Venás elégtelenség
Norwegian Venøs insuffisiens

Ontology: Lipodermatosclerosis (C0406500)

Definition (SCTSPA) Disminución de la circunferencia de la pierna debida a ulceración recurrente y necrosis adiposa que produce pérdida del tejido subcutáneo en un paciente con estasis venosa
Definition (SNOMEDCT_US) A decrease in lower leg circumference due to recurrent ulceration and fat necrosis causing loss of subcutaneous tissue in a patient with venous stasis disease
Definition (SNOMEDCT_US) A decrease in lower leg circumference due to recurrent ulceration and fat necrosis causing loss of subcutaneous tissue in a patient with venous stasis disease
Concepts Disease or Syndrome (T047)
MSH C537026
SnomedCT 95335006, 201301003, 201306008, 410016009
English Post-phlebitic liposclerosis, Acute lipodermatosclerosis, Lipodermatosclerosis, lipodermatosclerosis, lipodermatosclerosis (diagnosis), Lipodermatosclerosis, NOS, Lipodermatosclerosis (disorder)
Dutch lipodermatosclerose
French Lipodermatosclérose
German Lipodermatosklerose
Italian Lipodermatosclerosi
Portuguese Lipodermatosclerose
Spanish Lipodermatoesclerosis, lipodermatosclerosis (trastorno), lipodermatosclerosis, lipodermatoesclerosis (trastorno), lipodermatoesclerosis
Japanese 脂肪皮膚硬化症, シボウヒフコウカショウ
Czech Lipodermatoskleróza
Hungarian Lipodermatosclerosis

Ontology: Chronic venous insufficiency (C1306557)

Concepts Disease or Syndrome (T047)
ICD10 I87.2
SnomedCT 195516009, 20696009
English Chronic venous insuffic.NOS, Venous insufficiency (chronic) (peripheral), chronic peripheral venous insufficiency, chronic peripheral venous insufficiency (diagnosis), Venous insufficiency (chronic)(peripheral), chronic insufficiency venou, chronic venous insufficiency, Chronic venous insufficiency, Chronic venous insufficiency NOS (disorder), Chronic venous insufficiency, NOS, Chronic venous insufficiency NOS
Dutch chronische veneuze insufficiëntie, Veneuze insufficiëntie (chronisch)(perifeer)
French Insuffisance veineuse chronique
German chronisch venoese Insuffizienz, Venoese Insuffizienz (chronisch) (peripher)
Italian Insufficienza venosa cronica
Portuguese Insuficiência venosa crónica
Spanish Insuficiencia venosa crónica, insuficiencia venosa crónica, SAI (trastorno), insuficiencia venosa crónica, SAI, insuficiencia venosa crónica
Japanese 慢性静脈機能不全, マンセイジョウミャクキノウフゼン
Czech Chronická venózní nedostatečnost
Korean 정맥기능부전(만성)(말초성)
Hungarian Chronikus venás elégtelenség