Background Information

Definitions

Chronic venous insufficiency: functional changes that occur due to persistent venous hypertension.
Varicose veins and venous leg ulcers can occur secondary to chronic venous insufficiency:

• Varicose veins: dilated tortuous superficial veins (most commonly found in the lower limb)
• Venous leg ulcer: a break in the skin which has not healed within 2 weeks, in the presence of venous disease

Clinical Features

Chronic Venous Insufficiency

Symptoms:

• Pain / itching / aching / swelling of the affected leg
• Discomfort after prolonged standing + relieved with leg elevation
• Restless leg and leg cramps (usually nocturnal)

Possible examination findings:

• Varicose veins (defined by ≥3 mm dilated in the upright position)
• Saphena varix (dilatation of the saphenous vein as it drains into the femoral vein in the groin)
• Widespread brown-red hyperpigmentation (from haemosiderin deposition)
• Venous eczema (red scaly and/or flaky skin)
• Lipodermatosclerosis (hardening and narrowing of the distal leg skin, giving an upside-down champagne bottle appearance)
• Atrophie blanche (star-shaped, white, depressed scars with surrounding pigmentation)
• Venous ulcers (usually happen in severe untreated disease) – see below

Venous Ulcer

Site: gaiter area (ankle to mid-calf), most commonly the medial malleolus:

• Painless, or mild pain relieved by elevation
• Irregularly shaped
• Shallow base
• Presence of granulation tissue and exudate

Varicose Veins

Referral Criteria

Refer to secondary care (vascular service) to consider interventional treatment if any of the following:

• Chronic venous insufficiency symptoms (e.g. pain, aching, discomfort, swelling, heaviness, itching)
• Chronic venous insufficiency skin changes (e.g. pigmentation, eczema)
• Superficial vein thrombosis (hard painful superficial vein)
• Presence of venous leg ulcer (active / healed)
• Bleeding varicose vein

If referral is not needed → manage in primary care

Primary Care Management

Offer ALL the following:

• Lifestyle advise
  • If overweight / obese → weight loss
  • Engage in light to moderate physical activity
  • Avoid exacerbating factors (e.g. prolonged standing / sitting)
  • Elevate legs when possible

• Compression stockings, only if arterial insufficiency is excluded by a normal ABPI

Secondary Care (Vascular Service) Management

Perform duplex ultrasound to confirm the diagnosis and plan interventional treatment.

Choice of interventional treatment:

• 1st line: endothermal ablation (radiofrequency / laser ablation)
• 2nd line: ultrasound-guided foam sclerotherapy
• 3rd line: surgery (ligation and stripping)

Only offer compressive stockings if interventional treatment is unsuitable.

Leg Venous Ulcer

Management of Active Leg Venous Ulcer

All patients:

• Wound management by district nurse / tissue viability nurse
  • Wash the affected leg normally in tap water and dry carefully
  • Apply simple non-adherent dressings
• High compression multicomponent bandaging, if arterial insufficiency is excluded by a normal ABPI
  • Offer the strongest compression that they can tolerate
  • Assess for skin complications within 24-48 hours of initiation
  • Replace every 3-6 months
• Repeat duplex ultrasound every 6-12 months

Consider pentoxifylline as an adjunct to aid ulcer healing

Also offer lifestyle advice:

• If overweight / obese → weight loss
• Engage in light to moderate physical activity
• Avoid exacerbating factors (e.g. prolonged standing / sitting)
• Elevate legs when possible

References