Chronic Peripheral Venous Insufficiency - Clinicals, Diagnosis, and Management

Vascular

Clinicals - History

Fact Explanation
Occurs in the superficial venous system Venous insufficiency syndromes are more common due to valve incompetence in the superficial venous system but can also occur in the deep venous system as well. Congenital absence of venous valves, venous incompetence due to thrombosis, varicose veins can contribute to the development of chronic peripheral venous insufficiency. These disorders are more common in developed countries than in developing countries and increases with age and more common in women than in men. Occurs in the superficial venous system
Venous insufficiency syndromes are more common due to valve incompetence in the superficial venous system but can also occur in the deep venous system as well. Congenital absence of venous valves, venous incompetence due to thrombosis, varicose veins can contribute to the development of chronic peripheral venous insufficiency. These disorders are more common in developed countries than in developing countries and increases with age and more common in women than in men.
Aching, Burning, Throbbing pain in the legs Prolonged standing and exercise cause hypertension in the venous system in muscles of the leg results in these symptoms. Pain caused by venous insufficiency is usually reduced with walking or elevating the legs. Aching, Burning, Throbbing pain in the legs
Prolonged standing and exercise cause hypertension in the venous system in muscles of the leg results in these symptoms. Pain caused by venous insufficiency is usually reduced with walking or elevating the legs.
Swelling of the legs Damage to capillary basement membranes by white blood cells causes leg oedema. Swelling of the legs
Damage to capillary basement membranes by white blood cells causes leg oedema.
Heaviness of the legs, Cramping Prolonged standing and exercise cause hypertension in the venous system in muscles of the leg results in these symptoms. Heaviness of the legs, Cramping
Prolonged standing and exercise cause hypertension in the venous system in muscles of the leg results in these symptoms.
Itching of the legs Due to release of various mediators due to increased capillary permeability cause eczematous changes in the skin. Itching of the legs
Due to release of various mediators due to increased capillary permeability cause eczematous changes in the skin.
Nonhealing ulcers in the legs Medial malleolus area is the common place for venous ulcers because venous pressure is maximal here. Nonhealing ulcers in the legs
Medial malleolus area is the common place for venous ulcers because venous pressure is maximal here.
Skin changes in the legs/ Poor cosmetic appearance As a result of deposition of hemosiderin from the red blood cells which migrate from capillaries, reddish or brown skin discoloration is seen Skin changes in the legs/ Poor cosmetic appearance
As a result of deposition of hemosiderin from the red blood cells which migrate from capillaries, reddish or brown skin discoloration is seen

Clinicals - Examination

Fact Explanation
Oedema Damage to capillary basement membranes by white blood cells causes leg oedema and also could be due to deep venous thrombosis [DVT]) . Oedema
Damage to capillary basement membranes by white blood cells causes leg oedema and also could be due to deep venous thrombosis [DVT]) .
Hyperpigmentation and Venous dermatitis such as erythema and scaling, atrophic blanche (white scarring at the site of previous ulcerations with a paucity of capillaries) Deposited hemosiderin from red blood cells and byproducts of melanin and erythrocyte breakdown can result in this appearance of the skin. Over time, lipodermatosclerosis of the limb can develop in which there's replacement of the skin and subcutaneous tissue by fibrous scarring. Hyperpigmentation and Venous dermatitis such as erythema and scaling, atrophic blanche (white scarring at the site of previous ulcerations with a paucity of capillaries)
Deposited hemosiderin from red blood cells and byproducts of melanin and erythrocyte breakdown can result in this appearance of the skin. Over time, lipodermatosclerosis of the limb can develop in which there's replacement of the skin and subcutaneous tissue by fibrous scarring.
Cellulitis changes recurrent cellulitis is a common sequelae of venous insufficiency and is due to venous stasis and predisposition to ulcer formation Cellulitis changes
recurrent cellulitis is a common sequelae of venous insufficiency and is due to venous stasis and predisposition to ulcer formation
Ulceration Non healing ulcers on the medial part of the ankle mostly around medial malleolus are likely due to venous stasis. Ulceration
Non healing ulcers on the medial part of the ankle mostly around medial malleolus are likely due to venous stasis.
Dilated tortuous veins (Varicose veins) Varicose veins can be a contributory factor therefore dilated, tortous veins can be seen Dilated tortuous veins (Varicose veins)
Varicose veins can be a contributory factor therefore dilated, tortous veins can be seen
Positive Trendelenburg test When patient is lying down, the leg is elevated and veins are emptied. Sapheno-femoral (S-F) junction is then obliterated and the patient is asked to stand up. If veins are filled, the incompetence is below the S-F junction and if not above the S-F junction. This is mainly done to determine level clinicallly Positive Trendelenburg test
When patient is lying down, the leg is elevated and veins are emptied. Sapheno-femoral (S-F) junction is then obliterated and the patient is asked to stand up. If veins are filled, the incompetence is below the S-F junction and if not above the S-F junction. This is mainly done to determine level clinicallly
Tenderness over the dilated veins Palpation also may reveal tenderness of the dilated veins indicating superficial thrombophlebitis which develops as a complication. Tenderness over the dilated veins
Palpation also may reveal tenderness of the dilated veins indicating superficial thrombophlebitis which develops as a complication.
Perthes test The Perthes test is performed with the patient in the standing position with a tourniquet postioned below the knee. The patient is asked to repeatedly stand on tip toes and relax. If there's pain, it indicates acute deep vein thrombosis. Perthes test
The Perthes test is performed with the patient in the standing position with a tourniquet postioned below the knee. The patient is asked to repeatedly stand on tip toes and relax. If there's pain, it indicates acute deep vein thrombosis.

Investigations - Diagnosis

Fact Explanation
Full blood count This is to exclude cellulitis which has a high white cell count and in Klippel-Trénaunay-Weber (KTW) syndrome patients develop thrombocytopenia. Full blood count
This is to exclude cellulitis which has a high white cell count and in Klippel-Trénaunay-Weber (KTW) syndrome patients develop thrombocytopenia.
Estimated GFR, Serum creatinine, Blood urea nitrogen To exclude any renal dysfunction which causes bilateral ankle oedema and is one of the differential diagnosis. Estimated GFR, Serum creatinine, Blood urea nitrogen
To exclude any renal dysfunction which causes bilateral ankle oedema and is one of the differential diagnosis.
Liver function tests To exclude any liver failure which causes bilateral ankle oedema and is one of the differential diagnosis. Liver function tests
To exclude any liver failure which causes bilateral ankle oedema and is one of the differential diagnosis.
2D Echocardiography To exclude any heart failure which causes bilateral ankle oedema and is one of the differential diagnosis. 2D Echocardiography
To exclude any heart failure which causes bilateral ankle oedema and is one of the differential diagnosis.
Serum D-dimer level This is particularly elevated in deep vein thrombosis and may help in excluding this. Serum D-dimer level
This is particularly elevated in deep vein thrombosis and may help in excluding this.
hand-held continuous -wave Doppler ultrasound The Doppler probe is positioned at 45°over the vein. It can help to detect the retrograde flow in the veins due to incompetent veins. hand-held continuous -wave Doppler ultrasound
The Doppler probe is positioned at 45°over the vein. It can help to detect the retrograde flow in the veins due to incompetent veins.
Duplex ultrasonography This is the investigation of choice or gold standard test for the evaluation of venous insufficiency syndromes. This is very sensitive and specific Duplex ultrasonography
This is the investigation of choice or gold standard test for the evaluation of venous insufficiency syndromes. This is very sensitive and specific
Venography Direct contrast venography is an invasive procedure. Magnetic resonance venography (MRV) is considered as the most sensitive and specific test. But duplex scanning has replaced most of these tests. Venography
Direct contrast venography is an invasive procedure. Magnetic resonance venography (MRV) is considered as the most sensitive and specific test. But duplex scanning has replaced most of these tests.
Photoplethysmography Capillary filling during exercise is assessed using infra red light and if increased capillary filling is obtained this means venous reflux due to incompetent veins. Photoplethysmography
Capillary filling during exercise is assessed using infra red light and if increased capillary filling is obtained this means venous reflux due to incompetent veins.
Physiologic tests of venous function Maximum venous outflow (MVO), Venous refilling time (VRT) and the calf muscle pump ejection fraction (MPEF) are the tests used. Physiologic tests of venous function
Maximum venous outflow (MVO), Venous refilling time (VRT) and the calf muscle pump ejection fraction (MPEF) are the tests used.
Ambulatory Venous Pressure (AVP) The technique involves insertion of a needle into the pedal vein with connection to a pressure transducer. The pressure is determined at rest and after exercise is performed. AVP has been shown to be valuable in assessing the severity and clinical outcomes in CVI. Ambulatory Venous Pressure (AVP)
The technique involves insertion of a needle into the pedal vein with connection to a pressure transducer. The pressure is determined at rest and after exercise is performed. AVP has been shown to be valuable in assessing the severity and clinical outcomes in CVI.
liquid crystal Thermography This has a high sensitivity and specificity and since it uses a simplified method since recent times, it can be used as a screening test to localize incompetent perforators. Immediately after a tiptoe exercise demonstrates incompetent perforating veins as “hot spots.” liquid crystal Thermography
This has a high sensitivity and specificity and since it uses a simplified method since recent times, it can be used as a screening test to localize incompetent perforators. Immediately after a tiptoe exercise demonstrates incompetent perforating veins as “hot spots.”

Investigations - Management

Fact Explanation
Duplex scanning This is quick, cheap, and noninvasive and can show the location and specific venous system with valvular incompetence. This is important in following up the patient to assess the response to therapy. Duplex scanning
This is quick, cheap, and noninvasive and can show the location and specific venous system with valvular incompetence. This is important in following up the patient to assess the response to therapy.
Full blood count To assess the platelet count, hemoglobin count prior to surgery Full blood count
To assess the platelet count, hemoglobin count prior to surgery
Coagulation studies To exclude any coagulopathy prior to surgery Coagulation studies
To exclude any coagulopathy prior to surgery
Blood urea nitrogen Renal function tests- Serum Creatinine, To exclude any renal dysfunction prior to anesthesia Blood urea nitrogen
Renal function tests- Serum Creatinine, To exclude any renal dysfunction prior to anesthesia
Ankle brachial pressure measurement Before compression therapy is commenced, exclusion of significant peripheral arterial disease is essential. Compression therapy is deemed safe in patients with an ankle-brachial pressure index greater than 0.8. However, reduced compression is advised when the ankle-brachial pressure index is 0.5–0.8 Ankle brachial pressure measurement
Before compression therapy is commenced, exclusion of significant peripheral arterial disease is essential. Compression therapy is deemed safe in patients with an ankle-brachial pressure index greater than 0.8. However, reduced compression is advised when the ankle-brachial pressure index is 0.5–0.8
Duplex scanning It can detect even small reflux in asymptomatic individuals therefore can be used as a screening method. As well as it is quick, cheap, and noninvasive and can show whether reflux is in the deep, superficial, or perforating veins. This also helps in CEAP anatomic classification. Duplex scanning
It can detect even small reflux in asymptomatic individuals therefore can be used as a screening method. As well as it is quick, cheap, and noninvasive and can show whether reflux is in the deep, superficial, or perforating veins. This also helps in CEAP anatomic classification.
liquid crystal Thermography This has a high sensitivity and specificity so it can be used as a screening test to localize incompetent perforators. Immediately after a tiptoe exercise demonstrates incompetent perforating veins as “hot spots.” liquid crystal Thermography
This has a high sensitivity and specificity so it can be used as a screening test to localize incompetent perforators. Immediately after a tiptoe exercise demonstrates incompetent perforating veins as “hot spots.”
photoplethysmography (PPG) Capillary filling during exerciseis assessed with the use of infra red waves. This can be used as a screening test photoplethysmography (PPG)
Capillary filling during exerciseis assessed with the use of infra red waves. This can be used as a screening test
Ambulatory Venous Pressure (AVP) This is invasive therefore can not be repeated as a screening test. Correlation of AVP with the grades of reflux defined by descending phlebography in patients with skin changes or ulceration has been tried. Ambulatory Venous Pressure (AVP)
This is invasive therefore can not be repeated as a screening test. Correlation of AVP with the grades of reflux defined by descending phlebography in patients with skin changes or ulceration has been tried.
foot volumetry Dynamic foot volumetry is based on the water plethysmographic principle and provides measurement of volume changes of the foot during exercise and may be used as a screening test foot volumetry
Dynamic foot volumetry is based on the water plethysmographic principle and provides measurement of volume changes of the foot during exercise and may be used as a screening test

Management - Supportive

Fact Explanation
Patient education Patient education plays a major role and should be educated to avoid long periods of standing or sitting, and to elevate legs while sitting and lying down, with legs elevated above the level of your heart and to practice good skin hygiene for the foot to avoid foot ulcers. Patient education
Patient education plays a major role and should be educated to avoid long periods of standing or sitting, and to elevate legs while sitting and lying down, with legs elevated above the level of your heart and to practice good skin hygiene for the foot to avoid foot ulcers.
Exercise Patient should be educated to exercise regularly. Walking is especially beneficial as well as running, bicycling, and swimming can help. Exercise
Patient should be educated to exercise regularly. Walking is especially beneficial as well as running, bicycling, and swimming can help.
Diet Patient should undergo dietary restrictions of fat to should lose weight if overweight. Diet
Patient should undergo dietary restrictions of fat to should lose weight if overweight.
Antibiotics Antibiotics can be given for infections which arise due to venous stasis Antibiotics
Antibiotics can be given for infections which arise due to venous stasis
Diuretics Oedema associated with venous ulceration is treated with diuretics. Diuretics are very beneficial if combined with compression therapy, and might be ineffective if given alone. Diuretics
Oedema associated with venous ulceration is treated with diuretics. Diuretics are very beneficial if combined with compression therapy, and might be ineffective if given alone.

Management - Specific

Fact Explanation
Graduated Compression therapy Graded compression stockings provide a high pressure at the ankle level but gradually decreasing pressure at proximal levels. This helps to restore the normal venous flow and also improves venous flow Graduated Compression therapy
Graded compression stockings provide a high pressure at the ankle level but gradually decreasing pressure at proximal levels. This helps to restore the normal venous flow and also improves venous flow
Wound Care Debridement of necrotic infected tissue is first done, and the wound should be kept moist to promote healing. Saline dressings, Hydrogel dressings are used and moist wound dressings also provide pain relief for these wounds. Skin grafting for wounds also can be done. Wound Care
Debridement of necrotic infected tissue is first done, and the wound should be kept moist to promote healing. Saline dressings, Hydrogel dressings are used and moist wound dressings also provide pain relief for these wounds. Skin grafting for wounds also can be done.
Surgical ablative therapy (Vein ligation and stripping) Surgical options should be considered if less invasive treatment options fail. This is also for patients with non healing venous ulcers, low compliance with compression therapy or experience recurrent varicose veins. But deep vein occlusion must be excluded first as it is an absolute contraindication to vein ligation. Surgical ablative therapy (Vein ligation and stripping)
Surgical options should be considered if less invasive treatment options fail. This is also for patients with non healing venous ulcers, low compliance with compression therapy or experience recurrent varicose veins. But deep vein occlusion must be excluded first as it is an absolute contraindication to vein ligation.
Ablative therapy (Sclerotherapy) A sclerosant injection into a vessel causes endothelial destruction and fibrosis. Ablative therapy (Sclerotherapy)
A sclerosant injection into a vessel causes endothelial destruction and fibrosis.
Endo-vascular laser treatment (EVLT) Laser energy is used for vein destruction. Endo-vascular laser treatment (EVLT)
Laser energy is used for vein destruction.
Radio Frequency Ablation (RFA) high heat causes thermal destruction of the vein. Radio Frequency Ablation (RFA)
high heat causes thermal destruction of the vein.
Subfascial endoscopic perforator surgery (SEPS) This is a minimally invasive surgical technique which is used to treat chronic venous ulcers caused by perforating veins. Subfascial endoscopic perforator surgery (SEPS)
This is a minimally invasive surgical technique which is used to treat chronic venous ulcers caused by perforating veins.
Stab evulsion To avoid the damage to saphenous nerve or sural nerve, this is only done in areas above the knee in the great saphenous venous system. The perforators are ligated once the vein is dissected from the underlying tissues. This technique is reserved for CVI in which there are severe symptoms. Stab evulsion
To avoid the damage to saphenous nerve or sural nerve, this is only done in areas above the knee in the great saphenous venous system. The perforators are ligated once the vein is dissected from the underlying tissues. This technique is reserved for CVI in which there are severe symptoms.
Clot lysis in Deep Vein Thrombosis This will be achieved by either Tissue plasminogen activator [TPA] (urokinase) or thrombectomy Clot lysis in Deep Vein Thrombosis
This will be achieved by either Tissue plasminogen activator [TPA] (urokinase) or thrombectomy
Venous by pass grafting Saphenous vein crossover graft is used in ilio-femoral disease. Additionally polytetrafluoroethylene (PTFE) grafts can also be used. Venous by pass grafting
Saphenous vein crossover graft is used in ilio-femoral disease. Additionally polytetrafluoroethylene (PTFE) grafts can also be used.
Valvuloplasty External valvuloplasty of the femoral vein when combined with surgical repair of the superficial venous system has shown to improve the hemodynamic status of the lower limbs, and restore valvular function more effectively. Valvuloplasty
External valvuloplasty of the femoral vein when combined with surgical repair of the superficial venous system has shown to improve the hemodynamic status of the lower limbs, and restore valvular function more effectively.
Hemorheologic and venotonic agents Pentoxifylline and Daflon are drugs which are thought to alter the microcirculation in patients and used in various trials. Daflon is a venotonic agent and increases venous tone in patients with abnormal venous elasticity. Hemorheologic and venotonic agents
Pentoxifylline and Daflon are drugs which are thought to alter the microcirculation in patients and used in various trials. Daflon is a venotonic agent and increases venous tone in patients with abnormal venous elasticity.

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