chronic venous insufficiency Flashcards
A 76-year-old man comes to the office due to leg discomfort. He describes intermittent swelling and heaviness in both legs over the past year. Medical history is significant for hypertension, hyperlipidemia, benign prostatic hyperplasia, and degenerative joint disease of both knees. The patient is retired and frequently volunteers as a hospital greeter. Vital signs are within normal limits. Estimated jugular venous pressure is normal. Cardiopulmonary examination reveals normal lung and heart sounds. The left lower extremity is shown in the exhibit; there are similar findings in the right lower extremity. Peripheral pulses are full and symmetric. Results of recent laboratory studies, including complete blood count, complete metabolic panel and urine electrolytes, were within normal limits. Which of the following is the most appropriate next step in management of this patient?
CVI is a condition where the venous valves in the lower extremities become incompetent, leading to venous hypertension, venous stasis, and pooling of blood. Most patients with symptomatic lower extremity varicose veins should be treated initially with conservative measures such as leg elevation and compression stockings. Varicose veins are superficial veins that have become visible, palpable, dilated, and tortuous; they are most commonly seen on the lower leg or medial thigh. Varicose veins develop due to chronic venous hypertension and may appear alone or alongside other signs of chronic venous insufficiency (CVI). Many patients with varicose veins are asymptomatic. Others report leg cramping, heaviness, fatigue, and swelling, with symptoms that are generally worse in the evening or after prolonged standing. Treatment of varicose veins is aimed at alleviating symptoms, although some patients seek treatment for cosmetic improvement. Most patients with symptomatic varicose veins should be treated initially with conservative measures such as leg elevation (when possible) and continuous compression therapy. Graduated compression stockings counteract the elevated venous hydrostatic pressure that is present in CVI, improve venous return from the legs, and often improve patients’ symptoms.
What are common causes of chronic venous insufficiency?
Prolonged standing, obesity, pregnancy, deep vein thrombosis (DVT), and aging.
What are common symptoms of chronic venous insufficiency?
Leg discomfort (e.g., heaviness, cramping), swelling, fatigue, and symptoms that worsen in the evening or after prolonged standing.
What are the common physical exam findings in CVI?
Dilated, tortuous varicose veins, leg edema, skin changes (e.g., hyperpigmentation, stasis dermatitis), and venous ulcers, particularly near the medial malleolus.
How is chronic venous insufficiency diagnosed?
Primarily a clinical diagnosis, but venous duplex ultrasonography can be used to confirm valve incompetence and rule out other conditions.
What is the initial management for chronic venous insufficiency?
Conservative measures such as leg elevation, exercise, and graduated compression stockings. Compression therapy should be avoided or used with caution in patients with comorbid arterial insufficiency.
When are interventional therapies indicated in CVI?
For patients with persistent symptoms despite conservative measures, interventional options include injection sclerotherapy, endovenous ablation, or surgical ligation and stripping.
What complications can arise from untreated chronic venous insufficiency?
Venous ulcers, lipodermatosclerosis, recurrent cellulitis, and chronic leg swelling.
Why should compression stockings be used cautiously in patients with arterial insufficiency?
Compression stockings can worsen blood flow in patients with arterial disease and should be avoided in severe peripheral arterial disease (PAD).
What are common sites for venous ulcers in CVI?
Venous ulcers typically occur near the medial malleolus.
What lifestyle modifications can help prevent chronic venous insufficiency?
Weight loss, regular exercise, avoiding prolonged standing, and leg elevation during rest.
