CHAPTER SUMMARY AND CENTRAL ILLUSTRATION
This chapter reviews the pathophysiology and treatment of peripheral venous disease. The anatomy of the venous system is central to the diagnosis and management of acute and chronic venous disease (see Fuster and Hurst’s Central Illustration). Both intrinsic and extrinsic risk factors may contribute to venous thrombosis in the deep veins, calf veins, or superficial veins. Duplex ultrasonography is useful for diagnosis in most cases; computed tomography or magnetic resonance venography may be considered to evaluate pelvic vein thrombosis or outflow obstruction. Catheter-based venography is reserved for planned treatment. The cornerstone of medical therapy for venous thrombosis is anticoagulation. Advanced therapies such as inferior vena cava filter or catheter-directed thrombolysis and thrombectomy may be considered in specialized cases. Prior venous thrombosis is a risk factor for chronic venous disease, as well as family history, age, sex, parity, and obesity. Candidacy for advanced therapies may be assessed by duplex ultrasonography to quantify the extent of insufficiency and anatomy. Compression therapy is central to management of chronic venous disease; in refractory cases, endovenous ablation, vein stripping, or other surgical techniques may be considered. Venous ulcers require additional attention beyond compression to skin care, infection control, and assessment of arterial perfusion, which may be compromised in up to 26% of patients.
eFig 56-01 Chapter 56: Diagnosis and Management of Diseases of the Peripheral Venous System
The lower extremity venous system includes the deep, superficial, and perforating veins that work in concert to return blood to the heart (Fig. 56–1).1 Unlike the arterial system, the venous system is low resistant and must overcome gravitational and hydrostatic pressure forces to achieve blood return to the heart. The venules and veins have very thin walls and low resting basal tone, which allows for enormous distensibility. As a result, small changes in hydrostatic forces, central pressure, and/or external forces result in changes of the vein diameter. Venous blood flow is reliant upon muscular leg contraction, historically referred to as “the peripheral heart,”2 as well as bicuspid venous valves that open and close to prevent backflow; together, muscular leg contraction and venous valves help to overcome hydrostatic forces within the vein itself. Venous disease results due to degeneration and dysfunction of the veins and/or valves, which may occur following an obstruction such as deep vein thrombosis (DVT) or in the setting of increased central pressures as in heart failure. Venous disease is associated with a wide array of clinical manifestations due to complex hemodynamic and anatomic failures. A basic understanding of these complexities is essential in the evaluation, diagnosis, and appropriate treatment of venous disease.
Peripheral venous anatomy.
The veins of the lower ...