Venous Insufficiency, Chronic

• • 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

Epidemiology

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

Symptoms and Signs

• • 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

Imaging Findings

• • 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

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

Rule Out

• • 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

• • Physical exam

  • Duplex US

  • Occasional venography to define valve function

• • 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

Surgery

• • 2 categories of procedures

Antireflux Procedures

• • Perforating vein ligation: Incompetent perforating veins

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

Bypass Operations for Obstruction

• • 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)

Indications

• • Nonhealing ulcers

  • Disabling symptoms

Prognosis

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

  • Difficult patient population

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

References