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venous stasis; venous hypertension

Etiology: 1) primary varicose veins 2) secondary varicose veins a) obesity b) pregnancy c) prolonged standing or walking 3) postphlebitic syndrome 4) progression of underlying disease - heart failyure Pathology: 1) valvular incompetence with retrograde venous flow 2) increased capillary pressure 3) extrusion of fluid & erythrocytes into the interstitial space 4) ulceration 5) venous stasis dermatitis Genetics: - family history in patients with primary varicose veins Clinical manifestations: 1) unilateral or bilateral leg swelling 2) exacerbated by prolonged standing or other activities that increase swelling of lower extremity 3) superficial thrombosis 4) dependent pitting edema 5) brown discoloration due to hemosiderin deposition, especially medial ankle 6) leg heaviness, tiredness 7) varicose veins or reticular veins 8) loss of ankle dorsiflexion & presence & severity of peripheral neuropathy correlate with venous stasis severity [4] * image [5] Laboratory: - renal function tests - urine protein - urinalysis - serum albumin Radiology: - duplex ultrasound to rule in/out deep vein thrombosis if DVT suspected Complications: - venous stasis ulcer a) due to tissue damage or trauma to the skin b) base of ulcer with granulation tissue c) serosanguineous drainage d) painful - stasis dermatitis - reddish-brown discoloration of the skin with erythema & pruritus - pruritus, eczema - lipodermatosclerosis* * image [5] Management: 1) elevation of extremity 2) gradient elastic stockings of 30-40 mm Hg a) calf-length stockings are generally adequate b) panty hose if entire extremity is involved 3) external pneumatic compression device (evenings) - sequential or single-chamber 4) moisturing cream applied to skin a) prevent dryness b) diminish risk of cellulitis 5) treat stasis dermatitis (pruritus, erythema) - topical glucocorticoids 1st line 5) exercise 6) in patients with chronic venous insufficiency, diuretics should be avoided because fluid mobilization from interstitial space to intravascular space does not predictably occur [1] 7) surgery may be of benefit (see ESCHAR study) [2] - endovenous Nd:YAG laser surgery of saphenous vein [3]

Interactions

disease interactions

Related

ESCHAR study lower extremity edema stasis dermatitis; venous eczema; gravitational dermatitis varicose vein (varix) venous stasis ulcer

Specific

chronic cerebrospinal venous insufficiency (CCSVI)

General

venous disease; venopathy peripheral vascular disease (PVD)

References

  1. Medical Knowledge Self Assessment Program (MKSAP) 11, 15, 16, 18. American College of Physicians, Philadelphia 1998, 2012. 2018. - Medical Knowledge Self Assessment Program (MKSAP) 19 Board Basics. An Enhancement to MKSAP19. American College of Physicians, Philadelphia 2022
  2. Journal Watch 24(14):112, 2004 Barwell JR, Davies CE, Deacon J, Harvey K, Minor J, Sassano A, Taylor M, Usher J, Wakely C, Earnshaw JJ, Heather BP, Mitchell DC, Whyman MR, Poskitt KR. Comparison of surgery and compression with compression alone in chronic venous ulceration (ESCHAR study): randomised controlled trial. Lancet. 2004 Jun 5;363(9424):1854-9. PMID: 15183623
  3. Proebstle TM et al, Endovenous treatment of the great saphenous vein using a 1320 nm Nd:YAG laser causes fewer side effects than using a 940 nm diode laser. Dermatol Surg 2005, 31:1678 PMID: 16336887 - de Medeiros CA & Luccas GC Comparison of endovenous treatment with an 810 nm laser versus conventional stripping of the great saphenous vein in patients with primary varicose veins. Dermatol Surg 2005, 31:1685 PMID: 16336888
  4. Yim E, Vivas A, Maderal A, Kirsner RS. Neuropathy and ankle mobility abnormalities in patients with chronic venous disease. JAMA Dermatol 2014 Apr; 150:385. PMID: 24196260 http://archderm.jamanetwork.com/article.aspx?articleid=1768236
  5. Rashid RM, Barros BS (image) Hidden Heart Disease: 19 Dermatologic Clues You Should Know. Medscape. June 13, 2017. http://reference.medscape.com/slideshow/hidden-heart-disease-6004452
  6. Eberhardt RT, Raffetto JD. Chronic venous insufficiency. Circulation. 2014 Jul 22;130(4):333-46. Review. PMID: 25047584
  7. Barstow C, Kassop D. Cardiovascular disease: chronic venous insufficiency and varicose veins. FP Essent. 2019;479:16-20. PMID: 30995000