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  • • Chronic venous insufficiency (CVI) caused by chronic elevation in venous pressure

    • 3 factors

    • 1. Calf muscle pump dysfunction

      2. Valvular reflux

      3. Outflow obstruction

    • Venous outflow obstruction results in "venous claudication" pain during exercise

    • Valvular incompetence

    • -Congenital or secondary to phlebitis

      -Varicose veins

      -Deep venous thrombosis (DVT)

    • Venous stasis changes centered in "gaiter areas" around ankles: commonly affected perforator veins, region of sparse soft-tissue support

    • Local inflammation, hemosiderin deposits, leakage of plasma fluid results in fibrosis and ulceration

    • Isolated saphenous vein incompetence & DVT can lead to chronic venous stasis changes

    • May-Thurner syndrome: Compression of left iliac vein by right iliac artery causing venous stasis, CVI

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Epidemiology

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  • • Venous reflux demonstrable in 17% of extremities 1 wk after thrombosis and in 66% 1-year after thrombosis

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Symptoms and Signs

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  • • First symptom usually ankle and calf edema, worse at end of day, improves with leg elevation

    • Involvement of foot and toes suggests lymphedema

    • Long-lasting disease:

    • -Stasis dermatitis

      -Hyperpigmentation

      -Brawny induration

    • Venous stasis ulcers: Large, painless, irregular, located in medial or lateral gaiter area

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Imaging Findings

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  • Duplex US: Can identify location of incompetent perforating veins, does not assess calf muscle function/proximal obstruction

    Venography

    • -Determines functional outflow obstruction

      -Descending phlebography tests valves and identifies reflux

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  • Air plethysmography: Quantitative assessments of venous reflux, calf muscle pump function, overall venous function; can be used to differentiate superficial from deep veins

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Rule Out

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  • • Lymphedema: Nonpitting edema of foot and toes

    • Acute DVT

    • Congestive heart failure, chronic liver disease, chronic kidney disease

    • Arterial insufficiency: Ulcer location is more distal and painful

    • Erythema nodosum

    • Fungal infections

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  • • Physical exam

    • Duplex US

    • Occasional venography to define valve function

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  • • Incurable disease

    • Conservative: Leg elevation, graduated compression stockings, exercise

    • Venous ulcers improve with leg elevation, compression, and wound care

    • Unna's boot or occlusive wound dressing can be used for compression

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Surgery

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  • • 2 categories of procedures

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Antireflux Procedures

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  • • Perforating vein ligation: Incompetent perforating veins

    • Valvuloplasty, venous segment transposition, valvular transplantation; popliteal vein valve may be most important valve for CVI

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Bypass Operations for Obstruction

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  • • Palma procedure: Cross-femoral bypass with contralateral proximal saphenous vein; can use prosthetic material

    • May-Thurner syndrome: Angioplasty and stenting

    • Superficial vein occlusion: May-Husni procedure = saphenopopliteal bypass (75% improvement)

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Indications

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  • • Nonhealing ulcers

    • Disabling symptoms

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Prognosis

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  • • Perforator ligation surgery: Ulcer recurrence 15-20%

    • Difficult patient population

    • At best, surgical results show 70% improvement in symptoms

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References

Gohel MS et al: Randomized clinical trial of compression ...

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