Venous Insufficiency

KEY FEATURES

ESSENTIALS OF DIAGNOSIS

• Pain and swelling of the leg with prolonged standing

• Dilated superficial veins (venous stars, varicose veins)

• Increased skin pigmentation, lipodermatosclerosis

• Ulcerations, usually on the medial aspect of the lower leg

• Duplex ultrasound useful to detect and locate refluxing segments

GENERAL CONSIDERATIONS

• Chronic venous insufficiency is a common problem that occurs more frequently in the legs than the arms

• Venous insufficiency is caused by incompetent venous valves

• With varicose veins alone, the incompetent valves are in the superficial veins

• Deep venous thrombosis damages deep vein valves, leading to the postphlebitic syndrome, which is characterized by:

  • – Chronic swelling and pain of the leg

  • – Varicose veins

  • – Hyperpigmentation (stasis dermatitis)

  • – Ulcerations

CLINICAL PRESENTATION

SYMPTOMS AND SIGNS

• Leg swelling and pain that are exacerbated by prolonged sitting, standing, or vigorous exercise

PHYSICAL EXAM FINDINGS

• Stasis dermatitis of the affected leg

• Venous stars and varicosities

• Edema

• Ulcerations

DIFFERENTIAL DIAGNOSIS

• Deep venous thrombosis

• Phlegmasia cerulea dolens

• Localized lymphedema

• Enlarged inguinal lymph nodes obstructing flow

• Heart failure

DIAGNOSTIC EVALUATION

IMAGING STUDIES

• Doppler ultrasonography with imaging: can localize the refluxing venous segments

• If surgery is considered, contrast CT or magnetic resonance venography is usually done

DIAGNOSTIC PROCEDURES

• Photoplethysmography: uses color change to assess reflow rates in small skin veins after exercise, which are reduced in patients with venous insufficiency

• Direct venous pressure measurements: typically elevated

TREATMENT

CARDIOLOGY REFERRAL

• When heart failure is suspected

HOSPITALIZATION CRITERIA

• For surgery

• For complications

MEDICATIONS

• Graduated compression stockings, leg elevation

• Local wound care for ulcerations

THERAPEUTIC PROCEDURES

• Isolated superficial venous insufficiency can be treated with sclerosis, radiofrequency ablation, or vein stripping

SURGERY

• Deep vein insufficiency can be treated surgically in selected patients

• Plastic surgery or skin grafting may be required with severe ulcers

MONITORING

• Leg circumference during therapy

DIET AND ACTIVITY

• Low-sodium diet

• Restricted activity

ONGOING MANAGEMENT

HOSPITAL DISCHARGE CRITERIA

• After successful surgery

• After resolution of complications

FOLLOW-UP

• Depends on the severity of the problem

COMPLICATIONS

• Cellulitis

• Pulmonary embolus

PROGNOSIS

• About 20% of patients with deep ...