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Lower Extremity Chronic Venous Disease - Physicians

By Bryan Kramer, MD and Grace Boyle, OMS-II - December 30, 2019

Lower Extremity Chronic Venous Disease - Physicians
Definition: spectrum of lower extremity vein abnormalities that may be morphologic and/or functional in nature that lead to venous dilation 
  • May or may not be symptomatic 
Causes: 
  • Inadequate muscle pumps 
  • Incompetent venous valves (reflux)
  • Venous thrombosis (clotting)
  • Non-thrombotic venous stenosis 
Risk Factors: 
  • Advanced age 
  • Family history of venous disease 
  • Smoking
  • Sedentary lifestyle
  • Lower extremity trauma 
  • Prior venous thrombosis 
  • Pregnancy 
Symptoms and Clinical Signs:  
  • Symptoms: calf pain, leg heaviness and aching, swelling of the calves, muscle cramps, and skin irritation (tightness, dryness, itching) 
  • Clinical signs:
    • Telangiectasias: dilated intradermal and subdermal veins (spider veins)
      • Most prevalent clinical sign
    • Varicose veins: dilated, elongated, tortuous, dilated subcutaneous veins
      • >/= 3 mm in diameter 
      • Often concerning to patients for cosmetic reasons
  • Signs of more advanced disease:
    • Edema (swelling)
    • Skin changes
      • Hyperpigmentation (discoloration) and induration (hardening)
    • Ulceration
Differential:
  • Other causes of edema, skin changes, and non-healing wounds:
    • Heart failure, DVT, cellulitis, lymphedema, medication side effect, diabetes, infection, etc. 
Management:
  • Asymptomatic:
    • Consult patients about cosmetic treatment for telangiectasias and varicose veins
  • Symptomatic:
    • Imaging: venous reflux duplex ultrasound 
      • Confirms the presence of reflux 
        • Treatment based on severity of reflux 
Treatment:
  • Conservative treatment: exercise, leg elevation, compression, and skin care 
  • Varicose veins without axial venous reflux:
    • Sclerotherapy 
    • Phlebectomy 
  • With superficial venous reflux:    
    • Superficial (great saphenous and small saphenous) venous ablation
      • Ablation recommended prior to varicose vein excision 
  • With deep venous reflux:
    • Venogram with angioplasty/stenting
    • Valve repair 
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