Chapter 30: Lower Extremity Venous Disease

INTRODUCTION

Lower extremity venous disease is extremely common, with varicose veins remaining the most frequently encountered venous condition followed by chronic venous insufficiency.^1,2 The two conditions often occur together, but each condition may also be present clinically without the other. Lower extremity venous disease comprises a clinical spectrum ranging from completely asymptomatic telangiectasias to symptomatic varicose veins to debilitating venous ulcers.^1,2 The most frequently encountered symptoms associated with varicose veins include leg swelling, pain, itching, nocturnal cramping, and leg heaviness. Patients with chronic venous insufficiency often present with leg edema, skin hyperpigmentation, stasis dermatitis of the skin involving the ankles, fibrosis of the subcutaneous fat (lipodermatosclerosis), and ulceration.^1,2 Lower extremity venous ulceration remains a significant worldwide health problem resulting in significant morbidity.^1,2

Deep venous thrombosis (DVT) of the lower extremities is another highly prevalent venous condition encountered by health care providers of all disciplines.³ Much has been published regarding venous thromboembolic disease^4,5,6,7,8; therefore, the content of this chapter is limited to the intrinsic venous disorders of the lower extremities.

EPIDEMIOLOGY

Prevalence estimates of lower extremity venous disease vary widely by geographic location, with the highest reported rates observed in Western countries. The variability in estimates is likely attributable to population differences in risk factor distribution, methods of measurement, variability in diagnosis, and disease definition.^1,2,9,10 The prevalence of lower extremity varicose veins is estimated to be as high as 56% in men and 73% in women.^9,10 The prevalence of chronic venous insufficiency is estimated to be as high as 17% in men and 40% in women.¹⁰ Lower extremity venous ulceration has been reported to occur in approximately 0.3% to 1% of the adult population worldwide.^9,11

Risk factors associated with the development of lower extremity venous disease are listed in Table 30-1. Family history, female gender, age, and pregnancy have been well established as risk factors for developing varicose veins.^9,10 These risk factors have also been shown to contribute to the development of chronic venous insufficiency.^9,10 Regarding the development of venous ulceration, in addition to the risk factors shown in Table 30-1, history of lower extremity phlebitis, lower extremity trauma, DVT, and congestive heart failure have been shown to be associated with the development of venous ulceration.¹¹

Chronic venous insufficiency with venous ulceration is extremely prevalent in the United States ...