see also:

• venous leg ulcers
• DVT and post-thrombotic syndrome (PTS)
• varicose_veins

• 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
  • formation of chronic venous leg ulcers
• veins of the lower leg are either:
  • 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
  • venous thrombosis may also directly result in damaged venous valves causing DVT and post-thrombotic syndrome (PTS)
  • 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

• 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
• healed venous ulcer (C5)
• active venous ulcer (C6)
  • see venous leg ulcers

• congenital
  • Klippel Trenaunay syndrome, etc
• risk factors
  • genetic
    • 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
  • advancing age
  • obesity
  • pregnancy
  • ligamentous laxity (eg, hernia, flat feet)
  • prolonged standing
  • smoking
  • sedentary lifestyle
  • a-v shunt
  • high oestrogen states
  • DVT and post-thrombotic syndrome (PTS) although only 30% recall a PH of deep venous thrombosis (DVT)
  • trauma to the legs

• leg elevation
  • 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
  • C/I if acute cellulitis or mod/severe peripheral vascular disease (PVD or PAD) is present
    • use of compression therapy in the presence of arterial disease can cause skin necrosis
• intermittent pneumatic compression Rx
  • may be useful in those who cannot tolerate stockings such as morbid obesity, severe oedema and/or lipodermatosclerosis
• multilayered compression bandages
  • useful if there is severe oedema, weeping, eczema or ulceration
• diuretics
  • diuretics have NO role in the treatment of oedema due solely to chronic venous insufficiency
  • diuretics may be used to treat associated conditions which may exacerbate the oedema such as congestive cardiac failure
• aspirin (acetylsalicylic acid)
  • aspirin may accelerate healing of leg ulcers
• antibiotics
  • 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
  • is not recommended for patients with deep venous thrombosis (DVT) as benefits not proven
• sulodexide
  • a glycosaminoglycan which may be useful
• skin care
  • Mx of stasis dermatitis
    • gentle daily washing
    • emollients
    • barrier preparations such as Vaseline
    • topical corticosteroids may be indicated
• see venous leg ulcers for additional Mx of ulcers