venous obstruction &/or venous valve incompetence results in venous hypertension in the legs which causes:
capillary leak and pitting oedema
fibrin deposition, erythrocyte and leukocyte sequestration, thrombocytosis, and inflammation which result in hyperpigmentation and subcutaneous fibrosis
impaired oxygenation of the skin and subcutaneous tissues
superficial veins such as the saphenous veins, their accessory veins and communicating veins
the great saphenous vein drains into the deep venous system via the femoral vein at the saphenofemoral junction and also through both calf and thigh perforating veins
deep veins which include:
intramuscular veins such as the gastrocnemial and soleal veins
intermuscular veins such as the popliteal veins and crural veins (paired anterior tibial, posterior tibial and peroneal veins), the femoral vein, deep femoral vein and common femoral vein
perforating veins - these connect the superficial veins to the deep veins (in contrast “communicating veins” connect veins to a vein of the same system eg. deep to deep)
pathophysiology:
the contraction of the calf muscles combined with the one way venous valves combine to pump blood from the superficial veins into the deep veins
damage to the venous valves results in reflux or retrograde venous flow back into the superficial system which becomes dilated and tortuous and thus varicose_veins
venous obstruction such as thrombosis or local pressure forces blood to be diverted and also can cause venous dilatation and secondary valve incompetence from the dilated veins
disease progression and increasing severity of symptoms appear to be related to the extent of venous valvular incompetence
vulval varicosities
the veins draining the female external genitalia do not have valves and thus may become varicose
pelvic compression and pelvic vein compression combined with venodilatory effects of high progesterone levels is a common cause in pregnancy
incompetent saphenofemoral junction cause 50% as the great saphenous vein drains the superficial and deep external pudendal veins and posteromedial tributaries
terminology and staging of chronic venous disorders
no visible or palpable signs of venous disease (C0)
normal venous findings
telangiectasias/reticular veins (C1)
telangiectasia or “spider veins” are a confluence of dilated intradermal venules <1 mm in diameter
reticular veins are dilated, usually tortuous, abnormal bluish subdermal veins, 1 to 3 mm in diameter
varicose veins (C2)
varicose_veins are subcutaneous dilated veins 3 mm or greater in size
pitting oedema (C3)
pigmentation or eczema (C4a)
lipodermatosclerosis (C4b)
localized chronic inflammation and fibrosis of the skin and subcutaneous tissues of the lower leg
risk for varicose_veins was 90% when both parents were affected, 25% for men and 62% for women when one parent was affected, and 20% if neither parent had varicose veins
elevation of the feet to at least heart level for 30 minutes three or four times per day improves cutaneous microcirculation and reduces oedema in patients with chronic venous disease
elevation of the feet below the level of the heart, such as in a lounge chair, is ineffective and should be avoided
walking and calf exercises
daily walking and simple ankle flexion exercises while seated can be very helpful
compression stockings
ulcer healing rates are increased when compression therapy is used compared to no compression therapy with healing rates approaching 97% being possible in compliant patients
patients with varicose_veins should have a trial of minimum of three months of conservative therapy using compression stockings prior to considering venous ablation therapy
only have a role in acute cellulitis as they otherwise just increase risk of resistant organisms in the ulcer and risk otehr adverse effects
consider use if:
acute increased pain, swelling, redness, tenderness with spreading erythema
rapid increase in size of ulcer
fever
wound swabs are not helpful as chronic leg ulcers are contaminated with a variety of organisms
pentoxifylline
appears to increase healing of ulcers but side effects are common
stanozolol
stanozolol is a fibrinolytic anabolic steroid which appears to reduce area of lipodermatosclerosis and hasten healing of ulcers
escin (horse chestnut seed extract)
appears to improve symptoms and healing
hydroxyethylrutoside
appears to be effective at reducing leg volume, edema, and symptoms of chronic venous insufficiency but may not have much benefit for healing of leg ulcers