Clinical presentation includes increasing leg pain, fatigue, and heaviness with prolonged standing, associated with dilated tortuous veins.
More severe cases exhibit progressive skin changes, venous stasis dermatitis, lipodermatosclerosis, and frank ulceration.
Underlying venous insufficiency is most efficiently documented, localized, and graded by duplex ultrasound.
Conservative treatment requires graded compression.
Open surgical or endovenous treatment options may be used in highly selected cases.
Venous ulceration and bleeding are recognized complications.
Chronic venous insufficiency (CVI) refers to functional changes that may occur in the lower extremity due to persistent elevation of venous pressures. This most commonly results from venous reflux due to faulty valve function developing as a long-term sequela of deep vein thrombosis (DVT) and recanalization, and may also develop due to primary valvular incompetence without previous episode(s) of DVT. The term CVI is usually reserved for more advanced disease involving edema, skin changes, or frank ulcers.
History and exam
Key diagnostic factors
- corona phlebectatica (malleolar flare or ankle flare)
- ankle swelling
- hyperpigmentation (brawny edema)
- atrophie blanche
- leg ulcers
Other diagnostic factors
- leg fatigue, aching, and/or discomfort
- heavy legs
- leg cramps
- reticular veins
- dilated tortuous veins
- dry and scaly skin
- skin burning and itching
- unilateral leg swelling
- increasing age
- family history
- deep vein thrombosis
- orthostatic occupation
- female sex
- obesity (waist circumference)
- ligamentous laxity
1st investigations to order
- duplex ultrasound
Investigations to consider
- ascending phlebography
- CT venography
- magnetic resonance venography
- CT abdomen and pelvis
- intravascular ultrasound
- air plethysmography
all symptomatic patients
Joseph L. Mills Sr, MD
Professor and Chief
Division of Vascular Surgery and Endovascular Therapy
Michael E. DeBakey Department of Surgery
Baylor College of Medicine
JLM declares that he has no competing interests.
David G. Armstrong, DPM, MD, PhD
Professor of Surgery
Director of Southern Arizona Limb Salvage Alliance (SALSA)
Department of Surgery
University of Arizona College of Medicine
DGA declares that he has no competing interests.
Raouf A. Khalil, MD, PhD
Division of Vascular Surgery
Brigham and Women's Hospital
RAK has received NIH research funds greater than 6 figures USD. RAK has no other competing interests.
Paul Tisi, MBBS, MS, FRCSEd
Medical Director/Consultant Vascular Surgeon
PT declares that he has no competing interests.
Mark D. Iafrati, MD
Chief of Vascular Surgery
Tufts Medical Center
MDI is the author of a study referenced in this monograph.
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