Chronic Venous Insufficiency: Diagnosis and Medical Management Patrick Alguire, MD, FACP
Chronic Venous Insufficiency: Diagnosis and Medical Management
Patrick Alguire, MD, FACP
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Disclosures
None
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Learning Objectives
Make the clinical diagnosis of chronic venous insufficiency
Recognize common complications of chronic venous insufficiency
Manage chronic venous insufficiency and its early complications
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Introduction
CVI is the most common vascular disorder
Associated with chronic disability, diminished quality of life, and high health care costs
Varicose veins in the absence of skin changes are not indicative of CVI
Coon WW, Willis PW III, Keller JB. Venous thromboembolism and other venous disease in the Tecumseh Community Health Study. Circulation. 1973;58:839–46
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Risk Factors
Increased age
Increased BMI
Female gender
Prior deep venous thrombosis (may not be recalled)
Family history of venous disease
Smoking
History of lower extremity trauma
Pregnancy Brand FN, et al. The epidemiology of varicose veins: the Framingham Study. Am J Prev Med. 1988 Mar-Apr;4(2):96-101
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Co-Morbid Conditions
Comorbid conditions can contribute to diagnostic difficulty and management complexity
• PAD
• Coronary artery disease
• Heart failure
• Diabetes
• Arthritis Coon WW, Willis PW III, Keller JB. Venous thromboembolism and other venous disease in the Tecumseh Community Health Study. Circulation. 1973;58:839–46
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Symptoms
Limb discomfort
• Worse with standing or with feet dependent
• Improves with leg elevation or walking
Itching
Numbness and tingling Chiesa R, et al. Chronic venous disorders: correlation between visible signs, symptoms, and presence of functional disease. J Vasc Surg 2007; 46:322
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Clinical Findings
Vein abnormalities
Edema
Skin discoloration
Lipodermatosclerosis
Ulcers
Stasis dermatitis Abbade LP, et al. A. Venous ulcer: clinical characteristics and risk factors. Int J Dermatol. 2011 Apr;50(4):405-11
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Venous Findings
Telangiectasias • Confluence of dilated intradermal venules <1 mm
in diameter Reticular veins • Dilated, bluish subdermal veins, 1-3 mm in
diameter, tortuous Varicose veins • Subcutaneous dilated, tortuous veins >3 mm in
diameter Eklof B, et al. Updated terminology of chronic venous disorders: the VEIN-TERM transatlantic interdisciplinary consensus document. J Vasc Surg. 2009 Feb;49(2):498-501
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Edema
Dependent ankle edema
• Progress over time to include the calf region
• May be present only at the end of the day but eventually is persistent
• Often unilateral (particularly early)
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CVI-Related Edema
Venous abnormalities present
Hyperpigmentation present
Subsides with recumbency (chronic lymphatic obstruction does not)
Normal CVP
Poor or adverse response to diuretics
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Skin Discoloration
Hemosiderin deposition
Most prominent at the medial ankle
Can evolve to involve foot and lower leg
May predispose to lipodermatosclerosis
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Lipodermatosclerosis
Fibrosing panniculitis of the subcutaneous tissue
Firm area of induration at medial ankle
Entire leg can become circumferentially involved
May imped venous and lymphatic flow
Prone to repeated bouts of cellulitis
Morton LM, Phillips TJ. Venous eczema and lipodermatosclerosis. Semin Cutan Med Surg. 2013 Sep;32(3):169-76
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Venous ulceration
CVI is the most common cause of leg ulcers
Medial ankle
Multiple or single
Painful, shallow, exudative with a granulation base
Can extend circumferentially around the leg Abbade LP, et al. A. Venous ulcer: clinical characteristics and risk factors. Int J Dermatol. 2011 Apr;50(4):405-11
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Other Ulcers
Arterial ulcers • Painful, punched out or stellate
• Pale or black or yellow eschar
• Surrounding skin is red and taut
• Common on the foot over pressure points
• Other signs of arterial insufficiency
Neuropathic foot ulcers • Areas of increased pressure at sites of bony prominences
• Surrounded by a thick hyperkeratosis with undermined borders
• Ulcer is usually insensate
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Stasis Dermatitis
Common and early complication of CVI
Inflammatory process causing an eczematous rash
• Itching, erythema, inflammatory papules, scaling, weeping, erosions, and crusting
Excoriations from itching
Acute stasis dermatitis often mistaken for cellulitis
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Contact Dermatitis
Common in CVI and difficult to diagnosis
• Redness, pruritus, and vesicle or bullae formation
• Mimics stasis dermatitis and cellulitis
Most commonly characterized by failure to improve on appropriate therapy
May be associated with eczematous rashes on other parts of the body
Kulozik M, Powell SM, Cherry G, Ryan TJ. Contact sensitivity in community-based leg ulcer patients. Clin Exp Dermatol. 1988 Mar;13(2):82-4
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Pathophysiology
Venous hypertension
• Obstruction to venous flow
• Dysfunction of venous valves
• Failure of the "venous pump"
Increased venous pressure is directed to the superficial system
Tretbar LL. Deep veins. Dermatol Surg. 1995 Jan;21(1):47-51
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Effects of Venous Hypertension
Pressures can reach 60 to 90 mm Hg • Endothelial damage • Altered vessel anatomy • Valvular damage
Microcirculation abnormalities • Tissue hypoxia • Leaky capillaries • Fibrin deposition • Leukocyte activation
Stücker M, et al. Cutaneous microcirculation in skin lesions associated with chronic venous insufficiency. Dermatol Surg. 1995 Oct;21(10):877-82
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Leukocyte Activation
Leukocytes aggregate and adhere to the damaged endothelium and become activated • Abnormal vascular permeability and edema
• Proteolytic enzymes facilitate the formation cutaneous ulcers
• TGF-β1 fibrogenic cytokine release increases production of collagen
Extravasated and degraded erythrocytes produce characteristic brown hyperpigmentation
Wilkinson LS, et al. Leukocytes: their role in the etiopathogenesis of skin damage in venous disease. J Vasc Surg. 1993 Apr;17(4):669-75
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Indications for Duplex Ultrasonography
If a clinical diagnosis cannot be established but symptoms are suggestive
Signs of CVI but symptoms are questionably related
Venous ulceration
CVI not responding to standard therapy Labropoulos N, et al. Duplex evaluation of venous insufficiency. Semin Vasc Surg. 2005 Mar;18(1):5-9
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Ankle-Brachial Index
Perform ABI to exclude PAD in patients compatible PAD symptoms
Perform ABI in patients with weak or absent pulses
An ABI ≤0.9 is diagnostic for PAD
An abnormal ABI may influence therapy for CVI
Barnes RW. Noninvasive diagnostic assessment of peripheral vascular disease. Circulation. 1991 Feb;83(2 Suppl):I20-7
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Treatment Goals
Improvement of symptoms
Reduction of edema
Treatment of lipodermatosclerosis
Healing of ulcers Douglas WS, et al. Guidelines for the management of chronic venous leg ulceration. Report of a multidisciplinary workshop. British Association of Dermatologists and the Research Unit of the Royal College of Physicians. Br J Dermatol. 1995 Mar;132(3):446-52
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Treatment Strategy: Reduce Venous Hypertension
Leg elevation
Leg exercises
Compression therapy
Venous surgery
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Leg Elevation
Heart level for 30 minutes 3-4 times per day
Improves cutaneous microcirculation
Reduces edema
Promotes healing of venous ulcers Abu-Own A, et al. Effect of leg elevation on the skin microcirculation in chronic venous insufficiency. J Vasc Surg. 1994 Nov;20(5):705-10.
Myers MB, et al. The effect of edema and external pressure on wound healing. Arch Surg. 1967 Feb;94(2):218-22.
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Exercise
Daily walking
Ankle flexion exercises
• Improvement in venous flow
• Impact on preventing or healing venous ulcers is unknown
Padberg FT Jr, et al. Structured exercise improves calf muscle pump function in chronic venous insufficiency: a randomized trial. J Vasc Surg. 2004 Jan;39(1):79-87
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Static Compression Therapy
Essential component
Rapid symptomatic improvement (observational data)
Evidence-based effectiveness for venous ulcers • Improved ulcer healing rates
• Improve rates of secondary prevention
Hosiery or bandages O'Meara S, et al. Compression for venous leg ulcers. Cochrane Database Syst Rev. 2009 Jan 21;(1):CD000265
Nelson EA, Bell-Syer SE. Compression for preventing recurrence of venous ulcers. Cochrane Database Syst Rev. 2012 Aug 15;8:CD002303.
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Compression Therapy Indications
Edema
Lipodermatosclerosis
Venous ulceration
de Araujo T, et al. Managing the patient with venous ulcers. Ann Intern Med. 2003 Feb 18;138(4):326-34
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Compression Therapy Cautions/Contraindications
Peripheral artery disease
• Contraindicated ABI ≤ 0.6
• Caution 0.6 – 0.9
Acute stasis dermatitis
Acute cellulitis
de Araujo T, et al. Managing the patient with venous ulcers. Ann Intern Med. 2003 Feb 18;138(4):326-34
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Mechanics of Compression Therapy
Creates pressure gradient from distal to proximal
Increases deep venous flow velocity and venous return
Improves lymphatic flow and cutaneous microcirculation
Decreases ambulatory venous pressure Lattimer CR, et al. Quantifying the degree graduated elastic compression stockings enhance venous emptying. Eur J Vasc Endovasc Surg. 2014 Jan;47(1):75-80
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Compression Hosiery
Prescription • The grade of compression, stocking length and type of
stocking
• Five pressure gradients (<20, 20 to 30, 30 to 40, 40 to 50, and >50 mm Hg)
• Minimum pressure 20 to 30 mm Hg for CVI
Lengths • Knee-high (appropriate for most patients)
• Thigh-high
• Chaps (unilateral waist high)
• Pantyhose
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Tips for Compliance
Silk liner
Stockings with a zipper
Leggings with Velcro fastening bands
Donning devices
Lower grade compression stockings (<20 mm Hg) are more beneficial than nothing
Compression stockings can be worn over a simple dressing covering an ulcer
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Inelastic Compression Bandages
Must be applied by trained personnel
Frequency of changing dependent on degree of drainage
Unna boot
• Single component bandage impregnated with zinc oxide that hardens after application
• Relatively inexpensive
• Easy to apply
• Improves healing rates compared with placebo
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Dynamic Compression Therapy
For those who cannot tolerate static compression Plastic air cylinder that encases the lower leg
• Periodically inflates to a preset pressure and then deflates
• Single chamber or multi-chamber
They may increase ulcer healing when compared with no compression • Impact on healing when used instead of or added to
compression stockings/bandages is unclear
Nelson EA, et al. Intermittent pneumatic compression for treating venous leg ulcers. Cochrane Database Syst Rev. 2014 May 12;5:CD001899
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Venoactive Drugs
Escin (horse chestnut seed extract) • HCE reduces leg volume and edema
• Equivalent to compression reducing leg volume and edema
• improves symptoms related compared with placebo
• Available as a dietary supplement
• Safe, well tolerated
Diehm C, et al. Comparison of leg compression stocking and oral horse-chestnut seed extract therapy in patients with chronic venous insufficiency. Lancet. 1996 Feb 3;347(8997):292-4.
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Rheologic Agents
Aspirin
• Improved ulcer healing rates del Río Solá ML, et al. Influence of aspirin therapy in the ulcer associated with chronic venous insufficiency. Ann Vasc Surg. 2012 Jul;26(5):620-9
Stanozolol
• Reduced area of lipodermatosclerosis McMullin GM, et al. Efficacy of fibrinolytic enhancement with stanozolol in the treatment of venous insufficiency. Aust N Z J Surg. 1991 Apr;61(4):306-9
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Rheologic Agents
Pentoxifylline
• Improve ulcer healing rates with or without compression
Jull AB, et al. Pentoxifylline for treating venous leg ulcers. Cochrane Database Syst Rev. 2012 Dec 12;12:CD001733
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Emollients and Barriers
Emollients maintain a skin barrier and lubricate the skin • Limits dryness, itching, and fissuring
Common emollients are petrolatum, mineral oil and dimethicone silicon oil • Vaseline, Aquaphor, Lubriderm, Cetaphil, and Aveeno
Ammonium lactate used when scaling is present • Lac-Hydrin, AmLactin
Topical barriers are used to protect the skin from exudative ulcer drainage • Petrolatum, zinc oxide
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Topical corticosteroids
Stasis dermatitis
• Erythema, inflammation, pruritus, and vesicle formation
Group III or IV topical corticosteroids
• Triamcinolone, fluocinolone, betamethasone
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Systemic Antibiotics
Systemic antibiotics for clinical infection
Empiric treatment
• Target Gram positive (MRSA) and negative organisms, including Pseudomonas
O'Meara S, et. al. Antibiotics and antiseptics for venous leg ulcers. Cochrane Database Syst Rev. 2014 Jan 10;1:CD003557
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Topical Therapy
Little or no evidence for topical therapies
• Antibiotics
• Cadexomer iodine
• Silver sulfadiazine
• Povidone iodine
• Acetic acid
• Hydrogen peroxide
• Enzymatic agents
• Honey
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Ulcer Dressing
Ulcer dressings • Control exudate, maintain moisture, control odor, and
help control pain • Facilitate epithelialization and speeds healing
Options • Semipermeable adhesive films • Simple nonadherent dressings • Paraffin gauze • Hydrogels, hydrocolloids, alginates, • Silver impregnated dressings or foams
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Ulcer Dressing
Specific dressing does not significantly affect ulcer healing when compression therapy used
O'Donnell TF Jr, Lau J. A systematic review of randomized controlled trials of wound dressings for chronic venous ulcer. J Vasc Surg. 2006 Nov;44(5):1118
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Customizing Dressings
Dressings are characterized by their composition and properties • Adherence, absorbency, conformability
Occlusive dressings • Speed reepithelialization, stimulate collagen
synthesis, and encourage angiogenesis
• Decrease infection rates
• Ease of application and reduction of pain
• Can be changed by the patient every five to seven days at home.
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Customized Dressings
Low-adherent gauze dressings
• Daily or more frequent dressing changes
• Drainage and odor can be problematic.
• Inexpensive
Hydrogels and alginate dressings
• Highly absorbent
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Venous Surgery
Persistent ulcers
Recurrent ulcers
Other symptoms unresponsive to medical therapy
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Summary
CVI is a clinical diagnosis (abnormal veins, edema, hyperpigmentation, discoloration, lipodermatosclerosis)
Duplex Doppler and ABI are performed as needed
Leg elevation
Lower extremity exercise Compression improves ulcer healing
Dressings can be customized to meet needs of wound Topical drugs are not useful
ASA, horse chestnut seed extract, pentoxifylline may be helpful
Surgery for selected cases