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Basics

[Section Outline]

Author:

Bo E.Madsen


Description!!navigator!!

Etiology!!navigator!!

Diagnosis

[Section Outline]

Signs and Symptoms!!navigator!!

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!!navigator!!

The physical exam is essential to the diagnosis

Diagnostic Tests & Interpretation!!navigator!!

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!!navigator!!

Treatment

[Section Outline]

Initial Stabilization/Therapy!!navigator!!

ED Treatment/Procedures!!navigator!!

Medication!!navigator!!

Follow-Up

[Section Outline]

Disposition!!navigator!!

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!!navigator!!

Pearls and Pitfalls

  • Ensure that arterial insufficiency is not the underlying cause before assuming etiology of venous insufficiency:
    • ABI <0.9 (unmodified compression can be used with ABI >0.8)
    • Absence of palpable pulses
    • Severe extremity pain
    • Extremity ulcerations
    • Risk factors for peripheral artery disease
  • Unmodified compression therapy is contraindicated in patients with peripheral vascular disease and ABI <0.8
  • Compression therapy is contraindicated in patients with overlying cellulitis
  • Initial recommendations for isolated chronic venous insufficiency should include trial of compression stockings, exercise, and weight loss if applicable
  • Be aware of concurrent cellulitis vs. chronic skin changes in CVI

Additional Reading

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.

Codes

ICD9

ICD10

SNOMED