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