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Chronic venous disease

Last updated: February 11, 2020

Summary

The most common chronic venous diseases are varicose veins (affecting approx. 23% of the US population) and chronic venous insufficiency (CVI), which affects 2–5% of the population. The condition is most often caused by increased venous pressure due to malfunctioning valves in the veins. Elevated venous pressure results in fluid accumulation in the lower extremities, leading to alterations in the skin and veins. Depending on the severity of hemodynamic changes, clinical manifestations may include superficial tortuous veins, edema, skin changes (e.g., stasis dermatitis), and ulcer formation. Diagnosis is established based on duplex ultrasonography. In complicated cases, magnetic resonance venography (MRV) may be performed as well. Treatment may be conservative (e.g., compression stockings) or involve ablation therapies (e.g., sclerotherapy, surgical excision).

Definition

  • Varicose veins: cylindrical extension and dilation of superficial veins (diameter > 3 mm) with development of knots and tortuous veins
  • Chronic venous insufficiency: increased venous pressure resulting in alterations of the skin and veins

References:[1]

Epidemiology

References:[1][2][3]

Epidemiological data refers to the US, unless otherwise specified.

Etiology

Risk factors for chronic venous disease

  • Increasing age and female sex (see “Epidemiology” above)
  • Family history of venous disease
  • Ligamentous laxity
  • Sedentary lifestyle and prolonged standing
  • Obesity
  • Pregnancy
  • Smoking
  • Prior thrombosis; (postthrombotic syndrome)
  • Prior extremity trauma
  • Congenital abnormalities

Pathophysiology

In healthy individuals, blood from the superficial leg veins passes through the perforating veins into the deep veins.

Varicose veins

Chronic venous insufficiency

References:[2][3]

Clinical features

  • Chief complaints: generalized or localized pain, lower extremity discomfort/cramping, and limb swelling
    • Worsened by heat
    • Worse while standing, relieved by walking and raising of legs
    • Occurs in ∼ 50% of affected individuals
  • Pruritus, tingling, and numbness
  • Skin findings

References:[2][4][5][6]

Diagnostics

The diagnosis of varicose veins is based on history and clinical findings; . Imaging is only used in the diagnosis of CVI.

References:[1][2]

Treatment

General treatment principles

  • Elimination of the reflux pathways (via conservative, interventional, or surgical treatment options) → long-term normalization of hemodynamics → prevention/slowing of CVI progression

Conservative measures

Definite treatment

  • Indications:
    • Symptomatic venous disease with correctable cause of reflux
    • In case of complications such as bleeding, ulcers, or recurrent superficial thrombophlebitis (also see “Complications” below)
  • Technique: vein ablation therapies
    • Interventional:
    • Open surgery with partial or complete removal of a vein: only for veins that are not accessible by interventional techniques

References:[1]

Complications

Venous ulcers

Further complications

References:[1][4][7][8]

We list the most important complications. The selection is not exhaustive.

References

  1. Ferri FF. Ferri's Clinical Advisor 2017. Elsevier ; 2016 : p. 1345-1346
  2. Venous Stasis & Arterial Ulcer Comparison. http://www.lhsc.on.ca/Health_Professionals/Wound_Care/venous.htm. Updated: February 1, 2009. Accessed: March 8, 2017.
  3. Alguire PC, Mathes BM, Eidt JF, Mills JL, Collins KA. Clinical manifestations of lower extremity chronic venous disease. In: Post TW, ed. UpToDate. Waltham, MA: UpToDate. https://www.uptodate.com/contents/clinical-manifestations-of-lower-extremity-chronic-venous-disease?source=see_link#H6.Last updated: August 17, 2015. Accessed: December 7, 2016.
  4. Alguire PC, Scovell S, Eidt JF, Mills JR, Collins KA. Overview and management of lower extremity chronic venous disease. In: Post TW, ed. UpToDate. Waltham, MA: UpToDate. https://www.uptodate.com/contents/overview-and-management-of-lower-extremity-chronic-venous-disease?source=machineLearning&search=chronic%20venous%20insufficiency&selectedTitle=1~150§ionRank=1&anchor=H26#H1.Last updated: July 27, 2016. Accessed: December 7, 2016.
  5. Rosh AJ. Superficial Thrombophlebitis. Superficial Thrombophlebitis. New York, NY: WebMD. http://emedicine.medscape.com/article/463256-overview. Updated: July 12, 2016. Accessed: March 8, 2017.
  6. Weiss R, James WD. Venous Insufficiency. Venous Insufficiency. New York, NY: WebMD. http://emedicine.medscape.com/article/1085412-overview#showall. Updated: May 26, 2016. Accessed: December 7, 2016.
  7. Weiss R, James WD. Varicose Veins and Spider Veins. Varicose Veins and Spider Veins. New York, NY: WebMD. http://emedicine.medscape.com/article/1085530-overview#showall. Updated: September 12, 2016. Accessed: December 7, 2016.
  8. Alguire PC, Mathes BM. Pathophysiology of chronic venous disease. In: Post TW, ed. UpToDate. Waltham, MA: UpToDate. https://www.uptodate.com/contents/pathophysiology-of-chronic-venous-disease.Last updated: August 11, 2015. Accessed: March 8, 2017.
  9. Leg ulcers (and disorders of venous insufficiency). http://www.pcds.org.uk/clinical-guidance/leg-ulcers. Updated: October 17, 2016. Accessed: March 8, 2017.
  10. Herold G. Internal Medicine. Herold G ; 2014
  11. Arterial Ulcers. http://www.woundsource.com/patientcondition/arterial-ulcers. Updated: March 8, 2017. Accessed: March 8, 2017.