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The online version of this article, along with access to discussion threads on NATFs eForum, is available at: www.NATFonline.org/ethrombosis.php (March, 2010) Chronic Venous Insufficiency Authored by, Aman Khurana, MD, Vascular Medicine Fellow and Suman Rathburn MD, MS, Associate Professor of Medicine and Director of Vascular Medicine Program from the University of Oklahoma Health Sciences Center

Abstract:

Chronic Venous Insufficiency (CVI) is a common medical condition but often

overlooked by the medical community. Manifestations of CVI are a result of

longstanding venous hypertension due to chronic venous obstruction or venous

valvular reflux. Most patients present with symptoms of leg heaviness, aching,

cramps, itching, tingling, restless leg, swelling, fatigue, pruritus and skin changes.

Skin changes in the extremities range from dilated veins (small reticular veins,

teleangiectases and varicose veins) to edema, hyperpigmentation, fibrosis and

ulceration. Complications include cellulitis and venous ulcers. Treatment is aimed

at reducing venous pooling, either with conservative measures initially, or with

endovascular interventions if disabling symptoms persist. Compression therapy

using short-stretch bandages and then graded compression garments are the

mainstay of therapy. Skin and wound care is of paramount importance in

preventing more serious complications.

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eDiscussion Points:

1. What is the role of sclerotherapy in the treatment of chronic venous

insufficiency?

2. What is the role of iliac vein angioplasty and stenting in the treatment of

chronic venous insufficiency?

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Chronic Venous Insufficiency (CVI) is an extremely common disease of the

veins of lower extremities affecting 80% of men and 85% of women (1). It is

often underreported and overlooked by patients and doctors. It is estimated

that more than 2.5 million people in United States have CVI and of those,

roughly 20% develop the most troublesome and costly complication, venous

ulceration (2). Risk factors for CVI include age, obesity, pregnancy, phlebitis,

female sex, obesity, pregnancy, prolonged standing, leg trauma and history of

phlebitis or deep venous thrombosis (3).

The veins of lower extremity are divided into the deep and superficial system

connected by perforator veins (4). These veins have series of bicuspid valves

that ensures that blood moves in antegrade direction towards the head.

Incompetent venous valves, venous outflow obstruction and/or muscle pump

dysfunction lead to increased venous pressure resulting in vein dilatation and

turtuosity (5). Longstanding untreated venous hypertension results in dermal

changes associated with CVI.

CVI may be asymptomatic with cosmetically bothersome teleangiectasias and

reticular veins of the lower extremities or patients may complain of leg heaviness,

aching, cramps, itching, tingling, restless legs, swelling, fatigue, pruritus and skin

changes to the lower extremity due to inflammation (6). Patients with

longstanding edema often develop cellulitis, requiring hospitalization if not

recognized and treated early.

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The most common clinical manifestations of CVI are dilated cutaneous veins

such as teleangiectases also know as spider veins, bluish reticular veins and

larger varicose veins. Physical examination may also reveal edema, eczema,

hyperpigmentation of the skin and subcutaneous fibrosis known as

lipodermatosclerosis. Advanced disease may be present as venous ulceration,

commonly seen in the perimalleolar medial ankle (7). The prognosis of venous

ulcers is poor, requiring prolonged intensive wound care in some cases. Despite

aggressive treatment, delayed healing and recurrent ulcers are often seen (7).

The diagnosis of CVI is based upon the clinical history, physical examination for

signs of CVI and use of noninvasive testing to document venous obstruction or

valvular reflux. In 2004, the American Venous Forum updated the diagnostic

classification of chronic venous disease allowing comparison of the clinical

severity of disease (8). This classification is given in Figure 1.

Venous duplex imaging is used to test for reflux in the lower extremity veins and

exclude thrombotic obstruction (9). Plethysmography assesses the effectiveness

of venous emptying in the presence of residual thrombosis and can quantify the

severity of venous reflux (10). Although rarely performed today for diagnostic

purposes, venography may be used to confirm valvular reflux or document iliac

vein obstruction in advance of an endovascular treatment (11).

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The treatment goals for patients with CVI include improvement of symptoms,

reduction in edema and prevention of complications such as cellulitis,

lipodermatosclerosis and venous ulceration. The initial treatment of CVI involves

conservative measures that aim to reduce venous hypertension.

Patients should be encouraged to avoid prolonged standing or sitting that may

exacerbate venous insufficiency. Patients should elevate the feet above their

thighs while sitting and above their heart when supine for 30 min at least three to

four times daily if possible (12). Leg elevation alone is sometimes effective in

relieving symptoms in patients with mild venous disease, but usually does not

provide adequate relief in more advanced disease. Structured exercise to

strengthen calf musculature can have beneficial effects on calf muscle pump

function (13). This can be achieved by a walking regimen or even ankle flexion

exercises while seated.

The use of compressive therapy is an essential component of conservative

treatment of CVI. The objective is to provide external compression to the leg

thereby reducing venous volume, preventing venous distension and reducing

venous wall tension with improvement of calf muscle pump function (14). While

short stretch bandages may be used acutely to reduce edema, graded

compression garments donned daily are used for prevention of swelling long-

term (15).

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Short stretch bandages resist changes in leg circumference, thereby, reinforcing

calf pump function during ambulation, but not during rest. These are used for

moderate to severe edema in CVI patients to reduce swelling prior to fitting

graded compression stockings. Multi-layered bandages may be used for patients

with weeping edema or ulceration. Intermittent pneumatic compression therapy

may be indicated for patients with massive edema, morbid obesity and/or

lipodermatosclerosis to reduce swelling until more durable compression

garments can be fitted. Intermittent pneumatic compression therapy is most

effective when used several hours per day (16).

Elastic graded compressive stockings are available in a variety of lengths and

compression grades. These should be fitted based on limb length and diameter.

The level of tension of the stocking is based on the clinical stage of CVI and

patient tolerance. Class I (20-30 mmHg) is appropriate for patients with CEAP

classes 2-3, Class II (30-40 mmHg) for CEAP classes 4-6 and Class III (40-50

mm Hg) is appropriate for patients with recurrent ulcers (16). Ulcer healing rates

are as high as 93% in patients who undergo structured regimen of compression

therapy (17). Acute infection, severe peripheral arterial disease (ABI

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Cellulitis can develop and progress quickly and requires systemic antibiotics,

often necessitating hospitalization. Statis dermatitis can be treated initially with a

topical steroid such as 0.1% triamcinolone cream; however compression therapy

is required to prevent recurrence (18). With venous ulcers, aggressive wound

care including debridement, local skin care and silver impregnanted dressings

may decrease infectious complications.

The routine use of diuretics to reduce swelling is not recommended. Small doses

may be prescribed for a short duration to reduce massive edema. Patients

should be followed carefully for signs of volume depletion and electrolyte

imbalance (19).

Although not regulated by the FDA in the U.S., the use of over-the-counter herbal

supplements may be effective adjunct treatment in refractory patients.

Saponosides containing horse chestnut extract and flavonoids have been used to

promote vein health, reduce swelling, and promote venous ulcer healing (20, 21).

Further study is needed to document the effectiveness and safety of these

products.

If these conservative measures are not effective, more invasive endovascular

procedures including incompetent perforator ligation, or iliac vein angioplasty and

stenting for relief of venous outflow obstruction, may be helpful in patients with

unrelenting pain or recurrent venous ulcers (22,23).

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12. Xia, ZD, Hu D, Wilson JM et al. How echographic image analysis of venous

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Figure 1 Clinical , Etiologic, Anatomic, Pathophysiologic (CEAP)

Classification of Chronic Venous Insufficiency