Chronic Venous Insufficiency (CVI)
Biggest cause of CVI is varicose veins!
Epidemiology-One quarter to a third of all adults in western world have
varicose veins
USA-80 million; estimates of the prevalence 7-60% of adults; Best point
estimate is 30%
1 million-venous ulceration due to venous incompetence of superficial
system
100,000 disabled
Pathogenesis of venous insufficiency
-most often secondary to DVT, although history of phlebitis is not obtainable
in 25% of patients. Other causes: leg trauma, varicose veins, DVT,
pregnancies, immobilization
CVI is chronic elevation in venous pressure; normally can hold large volume
changes that can occur with exercise; when valves in the deep or perforating
veins are destroyed as in thrombophlebitis, valvular reflux and bidirectional
flow result in high ambulatory venous pressures. Damage to any component
of the calf muscle pump can cause dysfunction of the pump, thus leading to
superficial varicosities, edema, fibrosis of the subq tissue and skin,
hyperpigmentation, and later, dermatitis and ulceration.
Symptoms: characterized by progressive edema of the leg that begins at the
ankle and calf and is accompanied by dull aching discomfort. Symptoms are
prolonged with standing.
Aching
Heaviness
Leg-tiredness
Cramps
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Itching
Burning
Restless legs
Signs: Go to the following website for pictures of common findings:
http://www.veinclinics.com/cme/skin-findings.html
-Skin changes: hyperpigmentation-hemoglobin deposited in the tissues
is digested, but the iron remains in the dermis as hemosiderin and produces
a brown or brown-red pigmentation in skin surrounding ulcer
Edema-unlike the edema associated with salt-retaining conditions such
as heart failure and nephrotic syndrome, the edema that precedes venous
ulcer formation accumulates under high pressure, creating tissue damage
that is tender.
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Stasis Dermatitis-DeGowin-increased venous and capillary pressures
leads to inflammation, edema, subcutaneous fibrosis, and skin atrophy with
hemosiderin staining. Often mistaken for cellulitis. With chronic disease, the
subcutaneous tissues become fibrotic and the edema no longer pits
(brawny edema). The skin becomes thin and easily injured.
Lipodermatosclerosis-“Champagne bottle” appearance- leg assumes
the shape of an inverted champagne bottle – wide at knee narrow at the
ankle)
http://dermatlas.med.jhmi.edu/derm/IndexDisplay.cfm?ImageID=12364244
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Eczema to ulceration
Ulceration
Review case study of Mr. Crabbe:
http://www.worldwidewounds.com/2005/november/Doherty/Encouragepatient-Involvement-Mgt-Lymphovenous.html
Review website for pictures of ulcers:
http://www.bmj.com/cgi/content/full/320/7249/1589
Differential diagnosis
HF
CRF
Lymphedema-associated with brawny thickening in the subq tissue that does
not respond to elevation; edemia is particularly prominent on the dorsum of
the feet, and in the toes (sausage toe); varicosities are absent, often history
of recurrent cellulitis
Acute DVT-need tests
Other conditions: automimmune disorders, arterial insufficiency, sickle cell
anemia,
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Comparison-Table, p. 442, Adult Guidelines
Comparison of 3 common types of leg ulcers
Venous
Arterial
Neuro/DM
Location
Lesion features
Surrounding skin
Palpation findings
Gaiter area of legwill break
down/medial leg
Shallow, partial
thickness with
irregular
borders/shaggy
Hyperpigmented,
thickened, with
dermatitis-stasis
changes
Non-pitting, tight
edema; peripheral
pulses may be
normal
Pressure sites/toes,
heels, foot
Punched-out, eschar
(blackened if
necrotic)
Pressure
sites/plantar, arches
heels, toes
Punched-out
Hair low, not
hyperpigmented,
atrophic
Hair loss, not
hyperpigmented,
callus
Peripheral pulses
decreased, capillary
refill time increased
Altered sensation
with touch, vibration,
peripheral pulses
decreased
History-Review Dunphy, 411-415
Physical Examination-Have patient stand or dangle leg to evaluate for
edema’ examine groin to the ankle; Inspect and palpate for varicose and
telangiectatic veins; Check the medial and lateral ankle regions for skin
changes suggestive of chronic venous insufficiency; Inspect the abdomen for
enlarged superficial veins if ilio-femoral thrombosis is suspected
Pulses
Look for ulcers
Diagnostics-not needed for intact skin and normal pulses;
Order ABI to assess for arterial disease
MRI if ulcer and suggestive of osteomyelitis
Labs to rule out autoimmune/blood disorders
Treatment-Referral
Arterial ulcers and neuropathic/DM are referred
Pentoxifylline treatment-drug/drug interactions, consideration?
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If ulcer present use the Rule of 6, see below
Do not use TEDS, not enough pressure.
Compression Strength
8-15mm
15-20mm
20-30mm
30-40mm
40-50, 50-60 mm
Indications
Leg fatigue, mild swelling, stylish
Mild aching, swelling, stylish
Requires prescription-Aching, pain,
swelling, mild varicose veins
Requires prescription-Aching, pain,
swelling, varicose veins, post-ulcer
Requires prescription-Recurrent
ulceration, lymphedema
Procedures
Compression Therapy
Leg Elevation
Sclerotherapy
Ambulatory Phlebectomy
http://www.veindirectory.org/content/surgical_methods.asp
Endovenous Ablation with Laser or Radiofrequency-video
Subfascial Endoscopic Perforator Surgery (SEPS)
Transilluminated Power Phlebectomy
Surgical Stripping
Combination of Procedures
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