Chronic venous insufficiency

• Deep veins are more important in the development of chronic venous insufficiency 
• is dues to venous hypertension 
• venous hypertension is due to:

 

1) Venous obstruction eg: DVT – ↓ proximal flow of venous blood + destruction of valves ￫  persistence of venous hypertension even if the thrombosed veins are recanalized.

2) Incompetent venous valves

3) Inadequate muscle contraction

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flow is directed abnormally from the deep to the superficial system

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deep and superficial veins distended with excess volume ￫ anatomic distortion of the vessel wall

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further valvular incompetence

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excess superficial venous pressures (60- 90 mmHg) ￫ producing local tissue anoxia, inflammation, and occasionally necrosis  ￫ subcutaneous fibrosing panniculitis and ulceration

Risk Factors

• Obesity
• Congestive Heart Failure
• Diabetes Mellitus
• Advanced age
• Female gender – pregnancy/multiple pregnancies
• Family History of Varicose Veins

Venous factors

• Incompetent valve in the superficial, perforating, and deep systems

• External compression of veins
  • May–Thurner syndrome – compression of the left common iliac vein by the overlying right common iliac artery
• Deep venous obstruction – Phlebitis
• Previous Deep vein thrombosis (DVT)/postthrombotic syndrome

Impaired calf muscle pump

• Immobility including lack of physical exercise and paralysis
• Joint disease particularly of the ankle
• Obesity
• Prolonged standing or sitting
• Previous leg injury.

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CLINICAL MANIFESTATIONS

Symptoms: 

• no symptoms, or 
• complain of leg fullness
• aching discomfort
• heaviness
• nocturnal leg cramps
• bursting pain upon standing
• pain worse during the menstrual cycle /pregnancy due to increased fluid volume and/or higher circulating levels of estrogen. 

A, Extensive varicose veins involving the thigh and leg. 

B, Hyperpigmentation and severe lipodermatosclerosis with leg edema. Notice healed ulcers in the gaiter region of the medial leg. 

C, Medial malleolar venous ulcers. Notice concomitant eczema and lipodermatosclerotic skin.

Asymptomatic phase

• venous dilation
• Venous flairs
• reticular veins
• small varicose veins
• superficial thrombophlebitis due to sluggish venous flow, or the unsightly nature of the venous flairs and varicosities. 

Pitting Oedema

• is the hallmark of chronic venous insufficiency
• it is present in all but the earliest stages. 
• edema is limited to the lower extremities and is often unilateral (particularly early on),in contrast to edema in generalized edematous states 
• Subsides with recumbency
• Accompanied by varicosities, hyperpigmentation, and the other signs of venous disease. 
• central venous pressure is normal-  excludes heart failure

Skin changes

• a tan or reddish-brown hue to the skin
• derived from the breakdown of red blood cells that have extravasated through damaged capillaries and smaller vessels. 
• Venous stasis dermatitis 
• following the onset of hyperpigmentation. 
• Itching, Weeping, Scaling, Erosions
• Dry, irritated, and heavily crusted skin 🡪 causes pruritus
• Telangiectasia adjacent to perforating veins

 

lipodermatosclerosis 

• due to ↑severity (eg, following severe cases of deep venous thrombosis) 
• fibrosing panniculitis characterized by advanced hyperpigmentation and induration involving most of the leg circumferentially
• In advanced cases of lipodermato- sclerosis, fibrosis binds the skin to the underlying tissue inverted champagne bottle look

• bulbous cork =lymphedematous foot,
• neck of the bottle = lipodermatosclerosis area
• body of the bottle =  edema of the leg

Cellulitis

• Staphylococcal or Streptococcal organisms
• Redness and swelling of the skin surrounding the wound
• Increasing warmth
• Increasing pain
• Increasing wound size
• Increasing purulent discharge from the wound
• Fever

Atrophie blanche 

• caused by avascular fibrotic scars
• predisposed to venous ulceration

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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

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Management

• Confirm No Arterial Insufficiency
  • Assess before managing Venous Insufficiency
  • Ankle-Brachial Index
• General measures
  • Take regular walks
    • Leg Muscle activity promotes better venous return
  • Avoid prolonged standing in one place
  • Elevate Legs above Heart
    • Perform 30 minutes each 3-4 times daily
    • Elevate the foot of the bed to raise legs overnight
• Graduated Compression Stockings (Jobst Stockings)
  • Intermittent Pneumatic Compression Pumps
    • Indications
      • Obesity
      • Moderate to Severe edema
    • Contraindications
      • Uncompensated Congestive Heart Failure
• Diuretics: Short term use, Indications: Severe edema