II. Risk Factors

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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