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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 venous thrombosis of the leg develop postphlebitic syndrome

PREVENTION

  • Prevention of venous thrombosis is key to ...

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