Signs and Symptoms
History
- Asymptomatic phase:
- Venous dilation ranging from venous flares to small varicosities
- Symptomatic phase:
- Ankle and calf swelling
- Dull ache/pain in the legs:
- Worsened by prolonged stand ing
- Resolves with leg elevation
- Burning sensation
- Pruritus
- Night cramps
- Varicose veins
- Skin discoloration/hyperpigmentation
- Ulcer formation
- Lipodermatosclerosis
Physical Exam
- Varicose veins
- Ankle- and calf-dependent edema
- Dependent edema of the calf and ankle
- Telangiectasias
- Reticular veins
- Brownish to reddish purple hyperpigmentation
- Stasis dermatitis
- Sclerosis, induration, and atrophy of skin
- Lipodermatosclerosis
- Varicosity bleeding
- Venous ulcers:
- Most often situated over the malleoli or medial portion of calf
- Consider arterial insufficiency in the presence of weak or absent distal pulses
- Bacterial cellulitis:
- Rapidly growing extremity ulcer
- Extremity ulcer with surrounding cellulitis or purulent drainage
- Fever
- Lymphangitis
- Other etiologies than venous insufficiency, proximal to the lower extremity, should be suspected in the following settings:
- History of heart failure or ischemic cardiomyopathy
- History of liver disease
- Peripheral edema and ulcers in the presence of ascites
- Periorbital edema
- Orthopnea
- Positive hepatojugular reflux
- Jugular venous distention
Essential Workup
The physical exam is essential to the diagnosis
Diagnostic Tests & Interpretation
Lab
- Lab tests add little to the physical exam unless other causes need to be excluded
- Cardiac markers, brain natriuretic peptide, albumin, and renal function testing can be sent if considering other causes of peripheral edema
Imaging
- Doppler auscultation (DopA):
- Can assess for arterial Doppler signals to the lower extremities, in an effort to differentiate venous insufficiency from arterial insufficiency when concern exists (weak or nonpalpable pulses, history of peripheral artery disease, decreased ankle-brachial index, extremity ulceration)
- Duplex US (DUS):
- Most common modality to diagnose chronic venous insufficiency
- Uses B-mode grayscale and pulsed Doppler evaluation to determine presence, patency, and direction of venous blood flow in the superficial and deep venous distribution
- Can assess for deep venous thrombosis (DVT), valvular dysfunction/incompetence, and retrograde flow
- Invasive testing:
- Contrast venography
- Intravascular US
- CT/MR venography
- Ambulatory venous pressure monitoring
Diagnostic Procedures/Surgery
Ankle-brachial index:
- Should be measured if arterial insufficiency is suspected
Differential Diagnosis
- Venous valvular incompetence
- DVT
- Arterial insufficiency
- Lymphatic disorders or obstruction
- Soft-tissue infections
- Trauma:
- Compartment syndrome
- Vascular or lymphatic disruption
- Inflammatory response
- Ruptured Baker cyst
- Pyoderma gangrenosum
- Congestive heart failure
- Pulmonary hypertension
- Renal disease:
- Nephrotic syndrome
- Renal failure
- Hepatic disease with ascites
- Vasculitis or autoimmune disorders:
- Polyarteritis
- Hypothyroidism with myxedema
- Systemic lupus erythematosus
- Pregnancy with or without preeclampsia
- Medications (e.g. NSAIDs, calcium channel blockers)
Initial Stabilization/Therapy
- Leg elevation to above the level of the heart
- Control bleeding with direct pressure
- May require limited silver nitrate application or suture placement to effectively control persistent bleeding
ED Treatment/Procedures
- Leg elevation above the level of the heart
- Compression stockings or compression dressing for patients with an ABI >0.8
- Moisture retentive wound dressings applied to ulcers
- Anticoagulants for confirmed DVT
- Antibiotics if signs of infection, specifically cellulitis or infected ulcer
- Aspirin (improves ulcer healing rate)
- Topical steroids for stasis dermatitis
- Antihistamines for pruritus
Medication
Disposition
Admission Criteria
- Acute or severe chronic arterial insufficiency
- Evidence of cellulitis, lymphangitis, or osteomyelitis may require admission, specifically for instances of failed outpatient therapy or immunocompromised
- DVT in the following setting:
- Extensive thrombosis or suspicion for pelvic thrombosis
- Presence of concurrent pulmonary embolism in need of inpatient treatment
- Patients at high risk of significant bleeding with anticoagulation
- Outpatient management with low molecular weight heparin (enoxaparin) and /or close follow-up is not appropriate or available
- Treatment of an underling etiology of lower-extremity swelling other than chronic venous insufficiency or concurrent significant medical comorbidities warrant admission
Discharge Criteria
- Presence of lower-extremity pulses
- Absence of uncontrolled hemorrhage or compartment syndrome
- DVT has been excluded by imaging or patient is low risk (see Well Criteria for DVT)
- No evidence for bacterial cellulitis requiring admission
- Appropriate treatment and follow-up/referral arranged
- Patient has been given instructions for wound care, dressing changes, and the use of compression stockings
Issues for Referral
Patients should be referred to their primary care physician. They should be referred to a vascular surgeon if there is concern for peripheral vascular disease
Follow-up Recommendations
- Home health care or close follow-up with outpatient care provider for ulcer management
- Application of compression stockings
- Immediate surgical procedures are not required for varicose veins
- Vein stripping, vein ligation, sclerotherapy, and endovenous thermal ablation are options for cases refractory to medical management:
- Reduce ulcer recurrence but not necessarily primary ulcer healing rates
- All of these methods cause irreversible venous vascular changes which can result in recurrence of edema and can increase risk for future DVT
- CreagerMA, LoscalzoJ, KasperD, et al. Harrison's Principles of Internal Medicine. 19th ed.McGraw-Hill; 2015:303.
- GloviczkiP, ComerotaAJ, DalsingMC, et al. The care of patients with varicose veins and associated chronic venous diseases: Clinical practice guidelines of the Society for Vascular Surgery and the American Venous Forum . J Vasc Surg. 2011;53:2S-48S.
- MauckKF, AsiN, ElraiyahTA, et al. Comparative systematic review and meta-analysis of compression modalities for the promotion of venous ulcer healing and reducing ulcer recurrence . J Vasc Surg. 2014;60:71S-90S.e1-e2.
- O'DonnellTF , Jr., PassmanMA, MarstonWA, et al. Management of venous leg ulcers: Clinical practice guidelines of the Society for Vascular Surgery (R) and the American Venous Forum . J Vasc Surg. 2014;60:3S-59S.
- SingerAJ, TassiopoulosA, KirsnerRS. Evaluation and management of lower-extremity ulcers . N Engl J Med. 2017;377:1559-1567.
See Also (Topic, Algorithm, Electronic Media Element)
Deep Venous Thrombosis
The authors gratefully acknowledge Cameron R. Wangsgard for his contribution to the previous edition of this chapter.