History

Fact Explanation
Occurs in the superficial venous system Venous insufficiency syndromes are more common due to valve incompetence in the superficial venous system but can also occur in the deep venous system as well. Congenital absence of venous valves, venous incompetence due to thrombosis, varicose veins can contribute to the development of chronic peripheral venous insufficiency. These disorders are more common in developed countries than in developing countries and increases with age and more common in women than in men. [1] [3] [4] [5]
Aching, Burning, Throbbing pain in the legs [1] [3] [4] [5] Prolonged standing and exercise cause hypertension in the venous system in muscles of the leg results in these symptoms. Pain caused by venous insufficiency is usually reduced with walking or elevating the legs. [1] [3] [4] [5]
Swelling of the legs [1] [3] [4] [5] Damage to capillary basement membranes by white blood cells causes leg oedema. [1] [3] [4] [5]
Heaviness of the legs, Cramping [1] [3] [4] [5] Prolonged standing and exercise cause hypertension in the venous system in muscles of the leg results in these symptoms. [1] [3] [4] [5]
Itching of the legs [2] [6] [7] Due to release of various mediators due to increased capillary permeability cause eczematous changes in the skin. [2] [6] [7]
Nonhealing ulcers in the legs [2] [6] [7] Medial malleolus area is the common place for venous ulcers because venous pressure is maximal here. [2] [6] [7]
Skin changes in the legs/ Poor cosmetic appearance [2] [6] [7] As a result of deposition of hemosiderin from the red blood cells which migrate from capillaries, reddish or brown skin discoloration is seen[2] [6] [7]
References
  1. GOLDSTEIN E. J. C., WEINGARTEN M. S.. State-of-the-Art Treatment of Chronic Venous Disease. Clinical Infectious Diseases [online] 2001 March, 32(6):949-954 [viewed 28 August 2014] Available from: doi:10.1086/319360
  2. THOMAS HESS CATHY. Checklist for Factors Affecting Wound Healing. Advances in Skin & Wound Care [online] 2011 April [viewed 28 August 2014] Available from: doi:10.1097/01.ASW.0000396300.04173.ec
  3. EBERHARDT R. T.. Chronic Venous Insufficiency. Circulation [online] 2005 May, 111(18):2398-2409 [viewed 28 August 2014] Available from: doi:10.1161/01.CIR.0000164199.72440.08
  4. KELLER E. C., TOMECKI K. J., CHADI ALRAIES M.. Distinguishing cellulitis from its mimics. Cleveland Clinic Journal of Medicine [online] December, 79(8):547-552 [viewed 28 August 2014] Available from: doi:10.3949/ccjm.79a.11121
  5. EVANS C. J., FOWKES F. G., RUCKLEY C. V., LEE A. J.. Prevalence of varicose veins and chronic venous insufficiency in men and women in the general population: Edinburgh Vein Study. Journal of Epidemiology & Community Health [online] 1999 March, 53(3):149-153 [viewed 28 August 2014] Available from: doi:10.1136/jech.53.3.149
  6. AGALE SHUBHANGI VINAYAK. Chronic Leg Ulcers: Epidemiology, Aetiopathogenesis, and Management. Ulcers [online] 2013 December, 2013:1-9 [viewed 28 August 2014] Available from: doi:10.1155/2013/413604
  7. THOMAS HESS CATHY. Venous Dermatitis Checklist. Advances in Skin & Wound Care [online] 2011 February [viewed 28 August 2014] Available from: doi:10.1097/01.ASW.0000394035.87647.38

Examination

Fact Explanation
Oedema [1] [5] [7] Damage to capillary basement membranes by white blood cells causes leg oedema and also could be due to deep venous thrombosis [DVT]) . [1] [5] [7]
Hyperpigmentation and Venous dermatitis such as erythema and scaling, atrophic blanche (white scarring at the site of previous ulcerations with a paucity of capillaries) [2] [3] [4] [5] Deposited hemosiderin from red blood cells and byproducts of melanin and erythrocyte breakdown can result in this appearance of the skin. Over time, lipodermatosclerosis of the limb can develop in which there's replacement of the skin and subcutaneous tissue by fibrous scarring. [2] [3] [4] [5]
Cellulitis changes [6] recurrent cellulitis is a common sequelae of venous insufficiency and is due to venous stasis and predisposition to ulcer formation [6]
Ulceration [2] [3] [4] [5] [8] Non healing ulcers on the medial part of the ankle mostly around medial malleolus are likely due to venous stasis. [2] [3] [4] [5] [8]
Dilated tortuous veins (Varicose veins) [1] [5] [7] Varicose veins can be a contributory factor therefore dilated, tortous veins can be seen [1] [5] [7]
Positive Trendelenburg test [1] [5] [7] When patient is lying down, the leg is elevated and veins are emptied. Sapheno-femoral (S-F) junction is then obliterated and the patient is asked to stand up. If veins are filled, the incompetence is below the S-F junction and if not above the S-F junction. This is mainly done to determine level clinicallly [1] [5] [7]
Tenderness over the dilated veins [1] [5] [7] Palpation also may reveal tenderness of the dilated veins indicating superficial thrombophlebitis which develops as a complication. [1] [5] [7]
Perthes test [9] The Perthes test is performed with the patient in the standing position with a tourniquet postioned below the knee. The patient is asked to repeatedly stand on tip toes and relax. If there's pain, it indicates acute deep vein thrombosis. [9]
References
  1. GOLDSTEIN E. J. C., WEINGARTEN M. S.. State-of-the-Art Treatment of Chronic Venous Disease. Clinical Infectious Diseases [online] 2001 March, 32(6):949-954 [viewed 28 August 2014] Available from: doi:10.1086/319360
  2. SIMON DA, DIX FP, MCCOLLUM CN. Management of venous leg ulcers BMJ [online] 2004 Jun 5, 328(7452):1358-1362 [viewed 28 August 2014] Available from: doi:10.1136/bmj.328.7452.1358
  3. THOMAS HESS CATHY. Venous Dermatitis Checklist. Advances in Skin & Wound Care [online] 2011 February [viewed 28 August 2014] Available from: doi:10.1097/01.ASW.0000394035.87647.38
  4. THOMAS HESS CATHY. Checklist for Factors Affecting Wound Healing. Advances in Skin & Wound Care [online] 2011 April [viewed 28 August 2014] Available from: doi:10.1097/01.ASW.0000396300.04173.ec
  5. EBERHARDT R. T.. Chronic Venous Insufficiency. Circulation [online] 2005 May, 111(18):2398-2409 [viewed 28 August 2014] Available from: doi:10.1161/01.CIR.0000164199.72440.08
  6. KELLER E. C., TOMECKI K. J., CHADI ALRAIES M.. Distinguishing cellulitis from its mimics. Cleveland Clinic Journal of Medicine [online] December, 79(8):547-552 [viewed 28 August 2014] Available from: doi:10.3949/ccjm.79a.11121
  7. EVANS C. J., FOWKES F. G., RUCKLEY C. V., LEE A. J.. Prevalence of varicose veins and chronic venous insufficiency in men and women in the general population: Edinburgh Vein Study. Journal of Epidemiology & Community Health [online] 1999 March, 53(3):149-153 [viewed 28 August 2014] Available from: doi:10.1136/jech.53.3.149
  8. AGALE SHUBHANGI VINAYAK. Chronic Leg Ulcers: Epidemiology, Aetiopathogenesis, and Management. Ulcers [online] 2013 December, 2013:1-9 [viewed 28 August 2014] Available from: doi:10.1155/2013/413604
  9. KRISHNAN S, NICHOLLS SC. Chronic Venous Insufficiency: Clinical Assessment and Patient Selection Semin Intervent Radiol [online] 2005 Sep, 22(3):169-177 [viewed 28 August 2014] Available from: doi:10.1055/s-2005-921961

Differential Diagnoses

Fact Explanation
Cellulitis [1] [2] [3] This is a spreading inflammation of the skin and subcutaneous tissues, due to an acute infection following a breach in the skin [1] [2] [3]
Deep Vein Thrombosis [1] [3] [5] Acute thrombotic occlusion of a deep vein results in pain, swelling of a unilateral limb and this should be immediately managed as it may give rise to pulmonary embolism. [1] [3] [5]
Basal Cell Carcinoma or squamous cell carcinoma [1] [3] [6] [7] Basal cell carcinoma (BCC) arises from basal cells and squamous cell carcinoma arises from epidermal keratinocytes. A long-standing venous ulcer can transform in to a basal cell carcinoma or squamous cell carcinoma. [1] [3] [6] [7]
Systemic diseases causing ankle oedema [1] [3] [12] Cardiac failure, renal failure, liver failure can result in bilateral pitting ankle oedema due to fluid retention. [1] [3] [12]
Klippel-Trenaunay-Weber Syndrome [1] [3] [9] Klippel-Trenaunay syndrome (KTS) is a cause for a gigantic limb. It has vascular malformation of the capillaries, veins, and lymphatics, and limb hypertrophy. [1] [3] [9]
Ankle swelling as side effect of a medication [1] [3] [8] sometimes certain medication such as calcium channel blockers, nonsteroidal antiinflammatory agents, and oral hypoglycemic agents can cause ankle swelling [1] [3] [8]
lymphedema [1] [3] [10] This causes non pitting oedema. It causes fluid retention and tissue oedema [1] [3] [10]
Contact Dermatitis (Allergic) [1] [3] [11] This usually seen in the legs due to allergies for certain foot wear with erythematous scaly papules with pruritis. [1] [3] [11]
References
  1. EBERHARDT R. T.. Chronic Venous Insufficiency. Circulation [online] 2005 May, 111(18):2398-2409 [viewed 28 August 2014] Available from: doi:10.1161/01.CIR.0000164199.72440.08
  2. KELLER E. C., TOMECKI K. J., CHADI ALRAIES M.. Distinguishing cellulitis from its mimics. Cleveland Clinic Journal of Medicine [online] December, 79(8):547-552 [viewed 28 August 2014] Available from: doi:10.3949/ccjm.79a.11121
  3. EVANS C. J., FOWKES F. G., RUCKLEY C. V., LEE A. J.. Prevalence of varicose veins and chronic venous insufficiency in men and women in the general population: Edinburgh Vein Study. Journal of Epidemiology & Community Health [online] 1999 March, 53(3):149-153 [viewed 28 August 2014] Available from: doi:10.1136/jech.53.3.149
  4. AGALE SHUBHANGI VINAYAK. Chronic Leg Ulcers: Epidemiology, Aetiopathogenesis, and Management. Ulcers [online] 2013 December, 2013:1-9 [viewed 28 August 2014] Available from: doi:10.1155/2013/413604
  5. GOLDHABER S. Z.. Pulmonary Embolism and Deep Vein Thrombosis. [online] 2002 September, 106(12):1436-1438 [viewed 28 August 2014] Available from: doi:10.1161/01.CIR.0000031167.64088.F6
  6. KASPER MARIA, JAKS VILJAR, HOHL DANIEL, TOFTGåRD RUNE. Basal cell carcinoma — molecular biology and potential new therapies. J. Clin. Invest. [online] 2012 February, 122(2):455-463 [viewed 28 August 2014] Available from: doi:10.1172/JCI58779
  7. GURUDUTT VIVEK V., GENDEN ERIC M.. Cutaneous Squamous Cell Carcinoma of the Head and Neck. Journal of Skin Cancer [online] 2011 December, 2011:1-10 [viewed 28 August 2014] Available from: doi:10.1155/2011/502723
  8. PEDRINELLI R., DELL OMO G., MELILLO E., MARIANI M.. Amlodipine, Enalapril, and Dependent Leg Edema in Essential Hypertension. Hypertension [online] 2000 February, 35(2):621-625 [viewed 28 August 2014] Available from: doi:10.1161/01.HYP.35.2.621
  9. SAMO SALIH, SHERID MUHAMMED, HUSEIN HUSEIN, SULAIMAN SAMIAN, YUNGBLUTH MARGARET, VAINDER JOHN A.. Klippel-Trenaunay Syndrome Causing Life-Threatening GI Bleeding: A Case Report and Review of the Literature. Case Reports in Gastrointestinal Medicine [online] 2013 December, 2013:1-6 [viewed 28 August 2014] Available from: doi:10.1155/2013/813653
  10. MOFFATT C.J., FRANKS P.J., DOHERTY D.C., WILLIAMS A.F., BADGER C., JEFFS E., BOSANQUET N., MORTIMER P.S.. Lymphoedema: an underestimated health problem. QJM [online] December, 96(10):731-738 [viewed 28 August 2014] Available from: doi:10.1093/qjmed/hcg126
  11. SASSEVILLE DENIS. Occupational Contact Dermatitis. Array [online] 2008 December [viewed 28 August 2014] Available from: doi:10.1186/1710-1492-4-2-59
  12. ELY J. W., OSHEROFF J. A., CHAMBLISS M. L., EBELL M. H.. Approach to Leg Edema of Unclear Etiology. The Journal of the American Board of Family Medicine [online] 2006 March, 19(2):148-160 [viewed 28 August 2014] Available from: doi:10.3122/jabfm.19.2.148

Investigations - for Diagnosis

Fact Explanation
Full blood count [2] [7] This is to exclude cellulitis which has a high white cell count and in Klippel-Trénaunay-Weber (KTW) syndrome patients develop thrombocytopenia. [2] [7]
Estimated GFR, Serum creatinine, Blood urea nitrogen [1] To exclude any renal dysfunction which causes bilateral ankle oedema and is one of the differential diagnosis. [1]
Liver function tests [1] To exclude any liver failure which causes bilateral ankle oedema and is one of the differential diagnosis. [1]
2D Echocardiography [1] To exclude any heart failure which causes bilateral ankle oedema and is one of the differential diagnosis. [1]
Serum D-dimer level [3] [4] [5] [6] This is particularly elevated in deep vein thrombosis and may help in excluding this. [3] [4] [5] [6]
hand-held continuous -wave Doppler ultrasound [8] The Doppler probe is positioned at 45°over the vein. It can help to detect the retrograde flow in the veins due to incompetent veins. [9]
Duplex ultrasonography [3] [4] [5] [6] [8] This is the investigation of choice or gold standard test for the evaluation of venous insufficiency syndromes. This is very sensitive and specific [3] [4] [5] [6] [8]
Venography [3] [4] [5] [6] [8] Direct contrast venography is an invasive procedure. Magnetic resonance venography (MRV) is considered as the most sensitive and specific test. But duplex scanning has replaced most of these tests. [3] [4] [5] [6] [8]
Photoplethysmography [3] [4] [5] [6] [8] Capillary filling during exercise is assessed using infra red light and if increased capillary filling is obtained this means venous reflux due to incompetent veins. [3] [4] [5] [6] [8]
Physiologic tests of venous function [3] [4] [5] [6] [8] Maximum venous outflow (MVO), Venous refilling time (VRT) and the calf muscle pump ejection fraction (MPEF) are the tests used. [3] [4] [5] [6] [8]
Ambulatory Venous Pressure (AVP) [3] [4] [5] [6] [8] The technique involves insertion of a needle into the pedal vein with connection to a pressure transducer. The pressure is determined at rest and after exercise is performed. AVP has been shown to be valuable in assessing the severity and clinical outcomes in CVI. [3] [4] [5] [6] [8]
liquid crystal Thermography [3] [4] [5] [8] This has a high sensitivity and specificity and since it uses a simplified method since recent times, it can be used as a screening test to localize incompetent perforators. Immediately after a tiptoe exercise demonstrates incompetent perforating veins as “hot spots.” [3] [4] [5] [8]
References
  1. ELY J. W., OSHEROFF J. A., CHAMBLISS M. L., EBELL M. H.. Approach to Leg Edema of Unclear Etiology. The Journal of the American Board of Family Medicine [online] 2006 March, 19(2):148-160 [viewed 28 August 2014] Available from: doi:10.3122/jabfm.19.2.148
  2. KELLER E. C., TOMECKI K. J., CHADI ALRAIES M.. Distinguishing cellulitis from its mimics. Cleveland Clinic Journal of Medicine [online] December, 79(8):547-552 [viewed 28 August 2014] Available from: doi:10.3949/ccjm.79a.11121
  3. GOLDSTEIN E. J. C., WEINGARTEN M. S.. State-of-the-Art Treatment of Chronic Venous Disease. Clinical Infectious Diseases [online] 2001 March, 32(6):949-954 [viewed 28 August 2014] Available from: doi:10.1086/319360
  4. NICOLAIDES A. N.. Investigation of Chronic Venous Insufficiency : A Consensus Statement. Circulation [online] 2000 November, 102(20):e126-e163 [viewed 28 August 2014] Available from: doi:10.1161/01.CIR.102.20.e126
  5. EBERHARDT R. T.. Chronic Venous Insufficiency. Circulation [online] 2005 May, 111(18):2398-2409 [viewed 28 August 2014] Available from: doi:10.1161/01.CIR.0000164199.72440.08
  6. EVANS C. J., FOWKES F. G., RUCKLEY C. V., LEE A. J.. Prevalence of varicose veins and chronic venous insufficiency in men and women in the general population: Edinburgh Vein Study. Journal of Epidemiology & Community Health [online] 1999 March, 53(3):149-153 [viewed 28 August 2014] Available from: doi:10.1136/jech.53.3.149
  7. SAMO SALIH, SHERID MUHAMMED, HUSEIN HUSEIN, SULAIMAN SAMIAN, YUNGBLUTH MARGARET, VAINDER JOHN A.. Klippel-Trenaunay Syndrome Causing Life-Threatening GI Bleeding: A Case Report and Review of the Literature. Case Reports in Gastrointestinal Medicine [online] 2013 December, 2013:1-6 [viewed 28 August 2014] Available from: doi:10.1155/2013/813653
  8. KRISHNAN S, NICHOLLS SC. Chronic Venous Insufficiency: Clinical Assessment and Patient Selection Semin Intervent Radiol [online] 2005 Sep, 22(3):169-177 [viewed 28 August 2014] Available from: doi:10.1055/s-2005-921961

Investigations - Fitness for Management

Fact Explanation
Full blood count [1] [2] To assess the platelet count, hemoglobin count prior to surgery [1] [2]
Coagulation studies [1] [2] To exclude any coagulopathy prior to surgery [1] [2]
Blood urea nitrogen [1] [2] Renal function tests- Serum Creatinine, To exclude any renal dysfunction prior to anesthesia [1] [2]
Ankle brachial pressure measurement [3] Before compression therapy is commenced, exclusion of significant peripheral arterial disease is essential. Compression therapy is deemed safe in patients with an ankle-brachial pressure index greater than 0.8. However, reduced compression is advised when the ankle-brachial pressure index is 0.5–0.8 [3]
References
  1. KUMAR A, SRIVASTAVA U. Role of routine laboratory investigations in preoperative evaluation J Anaesthesiol Clin Pharmacol [online] 2011, 27(2):174-179 [viewed 28 August 2014] Available from: doi:10.4103/0970-9185.81824
  2. SHULMAN M. A., THOMPSON B. R.. I. Not fit for a haircut ... how should we assess fitness and stratify risk for surgery?. British Journal of Anaesthesia [online] December, 112(6):955-957 [viewed 28 August 2014] Available from: doi:10.1093/bja/aeu003
  3. NICOLAIDES A. N.. Investigation of Chronic Venous Insufficiency : A Consensus Statement. Circulation [online] 2000 November, 102(20):e126-e163 [viewed 28 August 2014] Available from: doi:10.1161/01.CIR.102.20.e126

Investigations - Followup

Fact Explanation
Duplex scanning [1] [2] [3] [4] This is quick, cheap, and noninvasive and can show the location and specific venous system with valvular incompetence. This is important in following up the patient to assess the response to therapy. [1] [2] [3] [4]
References
  1. NICOLAIDES A. N.. Investigation of Chronic Venous Insufficiency : A Consensus Statement. Circulation [online] 2000 November, 102(20):e126-e163 [viewed 28 August 2014] Available from: doi:10.1161/01.CIR.102.20.e126
  2. GOLDSTEIN E. J. C., WEINGARTEN M. S.. State-of-the-Art Treatment of Chronic Venous Disease. Clinical Infectious Diseases [online] 2001 March, 32(6):949-954 [viewed 28 August 2014] Available from: doi:10.1086/319360
  3. EBERHARDT R. T.. Chronic Venous Insufficiency. Circulation [online] 2005 May, 111(18):2398-2409 [viewed 28 August 2014] Available from: doi:10.1161/01.CIR.0000164199.72440.08
  4. KRISHNAN S, NICHOLLS SC. Chronic Venous Insufficiency: Clinical Assessment and Patient Selection Semin Intervent Radiol [online] 2005 Sep, 22(3):169-177 [viewed 28 August 2014] Available from: doi:10.1055/s-2005-921961

Investigations - Screening/Staging

Fact Explanation
Duplex scanning [1] [2] [3] [4] It can detect even small reflux in asymptomatic individuals therefore can be used as a screening method. As well as it is quick, cheap, and noninvasive and can show whether reflux is in the deep, superficial, or perforating veins. This also helps in CEAP anatomic classification. [1] [2] [3] [4]
liquid crystal Thermography [1] [2] [3] [4] This has a high sensitivity and specificity so it can be used as a screening test to localize incompetent perforators. Immediately after a tiptoe exercise demonstrates incompetent perforating veins as “hot spots.” [1] [2] [3] [4]
photoplethysmography (PPG) [1] [2] [3] [4] Capillary filling during exerciseis assessed with the use of infra red waves. This can be used as a screening test [1] [2] [3] [4]
Ambulatory Venous Pressure (AVP) [1] [2] [3] [4] This is invasive therefore can not be repeated as a screening test. Correlation of AVP with the grades of reflux defined by descending phlebography in patients with skin changes or ulceration has been tried. [1] [2] [3] [4]
foot volumetry [1] [2] [3] [4] Dynamic foot volumetry is based on the water plethysmographic principle and provides measurement of volume changes of the foot during exercise and may be used as a screening test [1] [2] [3] [4]
References
  1. NICOLAIDES A. N.. Investigation of Chronic Venous Insufficiency : A Consensus Statement. Circulation [online] 2000 November, 102(20):e126-e163 [viewed 28 August 2014] Available from: doi:10.1161/01.CIR.102.20.e126
  2. GOLDSTEIN E. J. C., WEINGARTEN M. S.. State-of-the-Art Treatment of Chronic Venous Disease. Clinical Infectious Diseases [online] 2001 March, 32(6):949-954 [viewed 28 August 2014] Available from: doi:10.1086/319360
  3. EBERHARDT R. T.. Chronic Venous Insufficiency. Circulation [online] 2005 May, 111(18):2398-2409 [viewed 28 August 2014] Available from: doi:10.1161/01.CIR.0000164199.72440.08
  4. KRISHNAN S, NICHOLLS SC. Chronic Venous Insufficiency: Clinical Assessment and Patient Selection Semin Intervent Radiol [online] 2005 Sep, 22(3):169-177 [viewed 28 August 2014] Available from: doi:10.1055/s-2005-921961

Management - General Measures

Fact Explanation
Patient education [1] [2] [3] [5] [6] Patient education plays a major role and should be educated to avoid long periods of standing or sitting, and to elevate legs while sitting and lying down, with legs elevated above the level of your heart and to practice good skin hygiene for the foot to avoid foot ulcers.[1] [2] [3] [5] [6]
Exercise [1] [2] [3] [6] Patient should be educated to exercise regularly. Walking is especially beneficial as well as running, bicycling, and swimming can help. [1] [2] [3] [6]
Diet [1] [2] [3] [6] Patient should undergo dietary restrictions of fat to should lose weight if overweight. [1] [2] [3] [6]
Antibiotics [1] [2] [3] [4] [5] [6] Antibiotics can be given for infections which arise due to venous stasis [1] [2] [3] [4] [5] [6]
Diuretics [3] Oedema associated with venous ulceration is treated with diuretics. Diuretics are very beneficial if combined with compression therapy, and might be ineffective if given alone. [3]
References
  1. KRISHNAN S, NICHOLLS SC. Chronic Venous Insufficiency: Clinical Assessment and Patient Selection Semin Intervent Radiol [online] 2005 Sep, 22(3):169-177 [viewed 28 August 2014] Available from: doi:10.1055/s-2005-921961
  2. NICOLAIDES A. N.. Investigation of Chronic Venous Insufficiency : A Consensus Statement. Circulation [online] 2000 November, 102(20):e126-e163 [viewed 28 August 2014] Available from: doi:10.1161/01.CIR.102.20.e126
  3. GOLDSTEIN E. J. C., WEINGARTEN M. S.. State-of-the-Art Treatment of Chronic Venous Disease. Clinical Infectious Diseases [online] 2001 March, 32(6):949-954 [viewed 28 August 2014] Available from: doi:10.1086/319360
  4. SIMON DA, DIX FP, MCCOLLUM CN. Management of venous leg ulcers BMJ [online] 2004 Jun 5, 328(7452):1358-1362 [viewed 28 August 2014] Available from: doi:10.1136/bmj.328.7452.1358
  5. THOMAS HESS CATHY. Venous Dermatitis Checklist. Advances in Skin & Wound Care [online] 2011 February [viewed 28 August 2014] Available from: doi:10.1097/01.ASW.0000394035.87647.38
  6. EBERHARDT R. T.. Chronic Venous Insufficiency. Circulation [online] 2005 May, 111(18):2398-2409 [viewed 28 August 2014] Available from: doi:10.1161/01.CIR.0000164199.72440.08

Management - Specific Treatments

Fact Explanation
Graduated Compression therapy [1] [2] [3] [5] Graded compression stockings provide a high pressure at the ankle level but gradually decreasing pressure at proximal levels. This helps to restore the normal venous flow and also improves venous flow [1] [2] [3] [5]
Wound Care [1] [2] [3] [4] [5] [6] Debridement of necrotic infected tissue is first done, and the wound should be kept moist to promote healing. Saline dressings, Hydrogel dressings are used and moist wound dressings also provide pain relief for these wounds. Skin grafting for wounds also can be done. [1] [2] [3] [4] [5] [6]
Surgical ablative therapy (Vein ligation and stripping) [1] [2] [3] [5] Surgical options should be considered if less invasive treatment options fail. This is also for patients with non healing venous ulcers, low compliance with compression therapy or experience recurrent varicose veins. But deep vein occlusion must be excluded first as it is an absolute contraindication to vein ligation. [1] [2] [3] [5]
Ablative therapy (Sclerotherapy) [1] [2] [3] [5] A sclerosant injection into a vessel causes endothelial destruction and fibrosis. [1] [2] [3] [5]
Endo-vascular laser treatment (EVLT) [1] [2] [3] [5] Laser energy is used for vein destruction. [1] [2] [3] [5]
Radio Frequency Ablation (RFA) [1] [2] [3] [5] high heat causes thermal destruction of the vein. [1] [2] [3] [5]
Subfascial endoscopic perforator surgery (SEPS) [1] [2] [3] [5] This is a minimally invasive surgical technique which is used to treat chronic venous ulcers caused by perforating veins. [1] [2] [3] [5]
Stab evulsion [1] [2] [3] [5] To avoid the damage to saphenous nerve or sural nerve, this is only done in areas above the knee in the great saphenous venous system. The perforators are ligated once the vein is dissected from the underlying tissues. This technique is reserved for CVI in which there are severe symptoms. [1] [2] [3] [5]
Clot lysis in Deep Vein Thrombosis [7] This will be achieved by either Tissue plasminogen activator [TPA] (urokinase) or thrombectomy [7]
Venous by pass grafting [8] Saphenous vein crossover graft is used in ilio-femoral disease. Additionally polytetrafluoroethylene (PTFE) grafts can also be used. [8]
Valvuloplasty [9] [10] [11] External valvuloplasty of the femoral vein when combined with surgical repair of the superficial venous system has shown to improve the hemodynamic status of the lower limbs, and restore valvular function more effectively.[9] [10] [11]
Hemorheologic and venotonic agents [1] [2] [3] [5] Pentoxifylline and Daflon are drugs which are thought to alter the microcirculation in patients and used in various trials. Daflon is a venotonic agent and increases venous tone in patients with abnormal venous elasticity. [1] [2] [3] [5]
References
  1. KRISHNAN S, NICHOLLS SC. Chronic Venous Insufficiency: Clinical Assessment and Patient Selection Semin Intervent Radiol [online] 2005 Sep, 22(3):169-177 [viewed 28 August 2014] Available from: doi:10.1055/s-2005-921961
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