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Venous Insufficiency of the Lower Limbs

Essentials

  • Common disease with no known causal treatment
  • Superficial venous insufficiency is the most common form. Varicose veins are the most common visible sign of superficial venous insufficiency but not all patients have them.
  • Deep venous insufficiency is less frequent and often results from deep venous thrombosis.
  • Colour Doppler duplex ultrasound is the diagnostic method of first choice and absolutely indispensable when planning any procedures.
  • Intravenous treatments on an outpatient basis are suitable for most patients. Long-term results of thermal ablation are better than those of foam sclerotherapy.

Epidemiology

  • Superficial venous insufficiency occurs in about 30-40% of adults in Western countries.
  • As many as 80% of the working-age population have minor subcutaneous venectasia and/or telangiectasia.
  • Risk factors include ageing, female sex, history of pregnancies and family history.
  • Varicose veins often emerge or worsen during pregnancy.

Aetiology

  • The fundamental causes and mechanisms of venous insufficiency are unknown.
  • Chronic venous insufficiency leads to venous hypertension in the limb, which may be due to
    • venous valve insufficiency
    • venous outflow obstruction (permanent obstruction in the deep venous system)
    • muscle dysfunction (insufficient physical activity, stiff ankle joint, calf muscle dysfunction)
    • increased intra-abdominal pressure (obesity).
  • An important factor raising venous pressure is venous reflux.
  • Prolonged venous hypertension may cause skin changes in the leg and ankle area and a venous leg ulcer.
    • This may damage the lymphatic system, leading to secondary insufficiency of the lymphatic system and mixed oedema.
  • Deep vein insufficiency which is most often a consequence of deep venous thrombosis (postthrombotic syndrome), causes on average more troublesome symptoms than insufficiency in the superficial veins.

Symptoms, findings and examination

  • The most common symptoms and findings are:
    • Swelling of the lower limbs (often becoming worse in the course of the day)
    • Aching
    • Feelings of heaviness and tightness
    • Itching
    • Visible varicose veins
    • Leg ulcer
  • Find out any history of (superficial or deep) vein thrombosis or venous surgery.
  • The clinical examination should be performed with the patient standing. Look for
    • Telangiectasia, varicose veins and their extent (there are not necessarily any visible varicose veins)
    • Swelling
    • Skin changes associated with venous insufficiency (pictures 1 2 3
      • Hyperpigmentation, usually on the lower medial aspect of the shin
      • Scaly rash, varicose eczema
      • Lipodermatosclerosis, or induration of the subcutaneous tissue, may be palpable on the shin, causing a constriction leading to an inverted champagne bottle appearance.
    • Active or healed ulcer (picture 4)
      • Most venous ulcers are situated close to the medial malleolus but some can be seen around the lateral malleolus.
      • A venous leg ulcer never occurs in the foot or toe area.
      • There may be an underlying disturbance of both the arterial and the venous circulation and, particularly in patients with diabetes, also neuropathy.
  • The CEAP classification and classification of the degree of disability are used for clinical severity assessment; see TablesT1 and T2.
  • It is essential to differentiate between uncomplicated (clinical categories C2-3) and complicated (C4-6) venous disease.
  • Arterial circulation should be examined: limb temperature, peripheral pulses and, as necessary, the ankle-brachial index (ABI, see Doppler Stethoscopy in Diagnostics) should be measured for differential diagnosis at least in the elderly and in people with diabetes Lower Limb Ischaemia.
  • Venous ultrasonography done by the doctor in specialized care deciding on the procedure is the diagnostic method of first choice and indispensable when planning any procedures.

Assessment of the severity of venous disease. Source: Current Care Guideline on Venous insufficiency of the lower limb, 2016.

Uncomplicated venous disease (C0-3)
Clinical category C0Normal findings, nothing suggestive of venous disease
Clinical category C1Telangiectasia or intradermal reticular veins
Clinical category C2Varicose veins, no swelling, no skin changes ascribed to venous disease
Clinical category C3Varicose veins, swelling, no skin lesions ascribed to venous disease
Complicated venous disease (C4-6)
Clinical category C4Skin changes ascribed to venous disease: hyperpigmentation, eczema, lipodermatosclerosis
Clinical category C5Skin changes ascribed to venous disease and healed venous ulcer
Clinical category C6Skin changes ascribed to venous disease and active venous ulcer

Assessment of the clinical disability category of venous disease. Source: Current Care Guideline on Venous insufficiency of the lower limb, 2016.

Disability classSymptoms
0No symptoms of venous disease
1Symptoms of venous disease, no need for regular compression therapy
2Symptoms of venous disease, cannot work without compression therapy
3Symptoms of venous disease, cannot work even with compression therapy

Differential diagnosis

  • Other conditions producing lower limb symptoms to be considered in differential diagnosis:
  • In differential diagnosis of swelling, conditions such as cardiac insufficiency must be considered; see article on leg oedema Leg Oedema.
  • If there are no clinical findings suggestive of venous insufficiency apart from swelling, the swelling is unlikely to be due to venous insufficiency.

TreatmentCompression Stockings and Surgery for Varicose Veins in Patients Without Venous Ulceration, Horse Chestnut Seed Extract for Chronic Venous Insufficiency, Phlebotonics for Venous Insufficiency, Compression for Venous Leg Ulcers, Compression Stockings in Standing Workers

  • The aim is to alleviate symptoms and prevent the emergence of complications (bleeding of the varices, superficial or deep venous thrombosis, leg ulcer).

Compression therapy

  • Compression therapy is used to support the function of the calf muscle pump and to compensate for the reflux.
  • A compression class 2 knee stocking is usually sufficient (pressure at ankle level 30-40 mmHg). Stockings should be replaced 2-3 times a year.
  • Support bandages are a secondary alternative if use of compression stockings is not possible in patients with ulcers, for example.
  • Compression stockings should be worn with caution if the patient is suspected of having impaired arterial circulation. Claudication is not a contraindication for compression therapy but critical ischaemia of the lower limb is.
    • An ABI of > 0.8 is considered safe for compression therapy.
    • If the ABI is < 0.5, no compression should be used.
    • Already when the ABI is < 0.9, treatment should be performed with caution.
      • Symptoms of ischaemia should be discussed and the limb should be monitored.
      • An ulcer requires assessment by a vascular surgeon.
  • In symptomatic, uncomplicated (C2-3) venous disease, compression therapy will alleviate the symptoms and benefit some patients but will probably not prevent varicose veins from getting worse.
  • In complicated (C4-6) venous disease, compression therapy is important, and even after invasive treatment compression can be used to reduce the risk of recurring ulceration.

Invasive treatment

  • Complicated (categories C4-6) superficial venous disease should always be treated invasively.
  • Consider invasive treatment in patients with milder disease (C2-3) but numerous symptoms and significant superficial venous insufficiency.
  • Consider invasive treatment in patients with repeated episodes of thrombophlebitis or a single extensive thrombophlebitis, or bleeding varicose veins.
  • Invasive treatment of deep veins should be separately considered in patients with complicated (C4-6) venous disease with significant underlying flow obstruction.
  • Invasive treatment should be planned individually depending on the clinical status and based on colour Doppler examination.
    • Today, the first-line treatment is intravenous thermal ablation.
    • The results of open surgery and thermal ablation are equally good. In 5-year follow-up, the results remain good in more than 85% of patients.
    • Foam sclerotherapy is associated with far more cases of recurring disease.

Intravenous treatment Sclerotherapy for Varicose Veins, Interventions for Great Saphenous Vein Incompetence

  • Thermal ablation (radiofrequency and laser therapy) is based on heating the vein wall to shrink the vein and obstruct the lumen.
    • It can be used to treat main trunks of virtually any size.
    • It is the primary means of treating insufficiency of the great and small saphenous veins.
    • The varicose veins themselves must be treated by other means (surgical removal through stab incisions using a tiny hook-like instrument [= hook phlebectomy] or foam sclerotherapy).
    • Alternatively, thermal ablation can be used primarily just to treat the insufficiency of the main trunk, leaving local varicosities untreated, because in many cases such varicosities will shrink spontaneously as soon as the insufficiency has been treated. Varicosities can then be treated 3 to 6 months later, as necessary.
    • Usually done as an outpatient procedure under tumescent anaesthesia (= injecting an anaesthetic-saline-adrenaline solution into the tissue around the vein under ultrasound guidance) with no need for operating theatre conditions.
    • The patient is allowed to walk immediately, and there is no particular need for monitoring.
    • There are fewer problems with recovery and fewer complications than with surgical treatment. Mild symptoms, such as tenderness and bruising, are common.
    • Individual cases of deep vein thrombosis, nerve damage or burn injury have been reported.
    • There is normally little need for sick leave.
  • In sclerotherapy, a liquid or foam injected into the vein causes endothelial damage constricting the vein and leading to occlusive fibrosis.
    • Suitable for the treatment of small venous trunks and varices.
    • Particularly suitable for recurrences after surgical treatment.
    • Carried out at an outpatient clinic, no need for local anaesthesia. The patient should walk immediately after the treatment and can be discharged after very short monitoring.
    • Contraindications include a history of deep vein thrombosis or pulmonary embolism, a diagnosed coagulation disorder, allergy to the sclerosant, pregnancy, lactation, patent foramen ovale (right-to-left shunt), severe migraine and severe lower limb ischaemia.
    • The most common adverse effect is hyperpigmentation that may be persistent or even permanent. Transient thrombi and phlebitis in treated veins are common and may remain painful for weeks or even months. No treatment is needed unless the pain and swelling are severe.
    • The risk of serious complications (deep vein thrombosis, pulmonary embolism, skin necrosis) is small.
    • There is little need for sick leave.

(Open) surgery Tourniquet in Varicose Vein Surgery, Subfascial Endoscopic Perforator Surgery for Venous Leg Ulcer, Chiva Method for the Treatment of Chronic Venous Insufficiency

  • Has decreased considerably with the development of intravenous forms of treatment.
  • Surgical treatment is particularly suitable for large and extensive varices in superficial veins.
  • The operation is based on a map produced by ultrasonography.
  • The defective saphenous vein or its significant collateral is removed by stripping, and local varicosities are resected. Defective perforating veins, particularly those above the calf muscle pump, are often also closed.
  • The most common complications of superficial venous surgery are wound infection, haematomas, superficial sensory nerve damage and damage to the lymphatic system.
  • Sick leave is normally needed for about 2-4 weeks, depending on the extent of surgery and on the patient's job.

Acute care

  • Acutely bleeding varix
    • For first aid, elevate the leg and apply a dressing.
    • Bleeding easily recurs, and specialized care should be consulted (sclerotherapy, other further measures).
  • Superficial phlebitis associated with varicose veins
    • Causes pain, erythema and swelling.
    • For examinations and treatment see article on treatment for superficial thrombophlebitis of the leg Superficial Venous Thrombophlebitis.
    • A patient with extensive phlebitis or recurrent more limited phlebitis should be referred to specialized care for consideration of required procedures.
  • Acute lipodermatosclerosis
    • Symptoms increase within a few days: the leg becomes sore and swells, and the skin becomes erythematous.
    • There may already have been some skin changes (hyperpigmentation and lipodermatosclerosis) on the leg previously.
    • May be confused with erysipelas. However, laboratory values showing inflammation are not elevated and the patient has no general symptoms.
    • Acute lipodermatosclerosis should be treated first by elevating the leg, then by a compression stocking; referral for specialized care may be needed.

Leg ulcer

    References

    • Porter JM, Moneta GL. Reporting standards in venous disease: an update. International Consensus Committee on Chronic Venous Disease. J Vasc Surg 1995;21(4):635-45. [PubMed]
    • Wittens C, Davies AH, Bækgaard N et al. Editor's Choice - Management of Chronic Venous Disease: Clinical Practice Guidelines of the European Society for Vascular Surgery (ESVS). Eur J Vasc Endovasc Surg 2015;49(6):678-737. [PubMed]
    • Gloviczki P, Comerota AJ, Dalsing MC 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(5 Suppl):2S-48S. [PubMed]
    • Rabe E, Partsch H, Hafner J et al. Indications for medical compression stockings in venous and lymphatic disorders: An evidence-based consensus statement. Phlebology 2018;33(3):163-184. [PubMed]
    • Vähäaho S, Halmesmäki K, Albäck A et al. Five-year follow-up of a randomized clinical trial comparing open surgery, foam sclerotherapy and endovenous laser ablation for great saphenous varicose veins. Br J Surg 2018;105(6):686-691. [PubMed]

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