CHRONIC VENOUS DISEASE OVERVIEW

Chronic venous disease is a common disorder that affects the veins of the legs. Normally, these veins carry blood from the legs to the heart. Normal veins have a series of valves that open and close to direct blood flow from the surface of the legs to the deep veins and back to the heart; the valves also control the pressure in veins and capillaries on the legs' surface.

If the valves within the veins fail to work properly, blood can flow backwards in the veins and pool in the legs. The pooled blood can increase pressure in the veins. This can cause problems that are mild (leg heaviness, aching, dilated or unsightly veins) or severe (swelling, skin color changes, rashes on the legs, recurrent skin infections and chronic ulcers). People who develop these symptoms are said to have chronic venous insufficiency.

CHRONIC VENOUS DISEASE CAUSES

There are several conditions than can cause the valves and veins to work improperly:

• Any problem that increases pressure in the veins in the legs can stretch the veins. This can damage the valves, which leads to even higher pressures and worsened vein function.
• A clot in a vein will block blood flow back through the vein, which can increase pressures, often permanently damaging the vein or valves even after the clot has dissolved.
• Leg injury or surgery can damage the veins or valves.
• Increased body weight (eg, pregnancy, obesity) can increase pressure in the veins of the legs, and this can damage the veins and valves.
• The muscles in the legs play an important role in the circulation of blood, acting as a pump. Standing or sitting for prolonged periods without walking can decrease the movement of blood out of the legs and lead to increased pressures in the veins and pooling of blood.

CHRONIC VENOUS DISEASE SYMPTOMS

Chronic venous disease can cause painless widened veins, skin irritation, skin discoloration, itching, swelling, and skin ulcers. The legs may feel heavy, tired, or achy, usually at the end of the day or after prolonged standing. (See "Clinical evaluation of lower extremity chronic venous disease".)

Dilated veins — The most frequent feature of venous disease is widening (dilation) of the veins. Dilated veins may appear as thin blue flares (picture 1) to much wider veins that appear as twisted and raised areas on the skin, which are called varicose veins (picture 2).

Edema — Long-standing venous insufficiency can cause swelling (edema) in the ankles and lower legs (picture 3). Mild edema may only be found at the end of the day or it may be present all the time. The area around the ankle bones is often the first place that swelling is seen.

However, edema can develop in people with other conditions, so this problem should be evaluated to determine the cause. (See "Patient information: Edema (swelling) (Beyond the Basics)".)

Skin changes — Pooling of blood and increased pressure in the veins can cause the skin to become red, and over several years, the skin may become tan or a reddish-brown color. The skin changes are initially noticeable around the ankle, but frequently occur over the shins and on the foot.

The skin can also develop a type of inflammation that can cause itching, dryness, oozing fluid, scaling, open sores from scratching, and crusting or scabbing. Some people develop an area of intensely painful skin that turns red or brown, hard, and scar-like. This can occur suddenly or may develop after many years.

Venous ulcers — Skin ulcers caused by chronic venous insufficiency are called venous ulcers. These are usually located low on the inner ankle. Venous ulcers can occur higher on the leg after an injury, but rarely higher than the knee. More than one ulcer may occur at a time. Venous ulcers are usually tender to touch, shallow, have a red appearance at the bottom, and occasionally ooze.

Venous ulcers can recur or may not heal for months or years.

CHRONIC VENOUS INSUFFICIENCY DIAGNOSIS

You may be diagnosed with chronic venous disease or chronic venous insufficiency based upon your symptoms, including varicose veins, swelling in the legs, skin changes, or skin ulcers. Further testing (ultrasound) is often performed to look at vein valve function to identify if the problem is located in the superficial veins or the deep veins. (See "Diagnostic evaluation of chronic venous insufficiency".)

CHRONIC VENOUS DISEASE MANAGEMENT

Treatment of chronic venous insufficiency tries to reduce symptoms, edema (swelling), treat thickened, hardened tissues, and heal ulcers. (See "Medical management of lower extremity chronic venous disease".)

Leg elevation — Simple elevation of the legs above heart level for 30 minutes three or four times per day can reduce edema and improve blood flow in the veins. Improving blood flow can speed healing of venous ulcers.

Leg elevation alone may be the only treatment needed for people with mild venous disease, although additional treatments are usually needed in more severe cases. However, it may not be practical for some people to elevate their legs several times per day.

Exercises — Foot and ankle exercises are often recommended to reduce symptoms. Pointing the toes and feet down and up several times throughout the day can help to pump blood up into the legs. This may be especially helpful for people who sit or stand for long periods.

Compression therapy — Most experts consider compression therapy to be an essential treatment for chronic venous disease [1,2]. Compression stockings are suggested for anyone with chronic venous disease. People with more severe symptoms, such as severe edema, skin changes, or skin ulcers often need treatment with compression bandages.

Compression stockings — Compression stockings gently compress the legs, which may improve blood flow in the veins by preventing backward flow through the veins of the legs.

Effective compression stockings apply the greatest amount pressure at the ankle and gradually decrease the pressure up the leg. These stockings are available with varying degrees of compression.

• Stockings with small amounts of compression can be purchased at pharmacies and surgical supply stores without a prescription.
• People with moderate to severe disease, those on their feet a lot, and those with ulcers usually require prescription stockings. A healthcare provider may take measurements for stockings, or may write a prescription for stockings and then have a surgical supply or specialty store take the necessary measurements.

Stockings are available in several heights, including knee-high, thigh-high, and pantyhose. Knee-high stockings are sufficient for most patients. Some stockings can cause skin irritation or pain, although proper measurement and fitting of the stockings can reduce the risk of discomfort.

The following are tips for using compression stockings (table 1 and figure 1A-C).

Intermittent pneumatic compression pumps — Standard compression stockings may be less effective or difficult to use if you are very overweight or have a lot of edema. An alternative approach is the use of intermittent pneumatic compression (IPC) pumps [3].

These devices consist of flexible plastic sleeves that encircle the lower leg; periodically the air chambers inflate and compress the leg, and then deflate. These are generally used for four hours per day.

Similar to compression stockings, IPC pumps may be painful for some people.

Compression bandages — People with severe symptoms, like severe edema, skin changes and ulcers may need to be treated with compression bandages. These are multilayer wraps placed on the leg by an experienced nurse or physician after any ulcers are covered.

The bandages are usually changed once or twice a week and must stay dry. A cast bag or other plastic bag can be placed over the compression bandage while showering to keep it dry. The bandages should be removed and replaced if they become wet, either from water or from wound drainage.

Dressings — Ulcers are usually covered with special dressings before putting on compression stockings or compression bandages. Dressings are used to absorb fluid oozing out of the wound, reduce pain, control odor, remove dead or infected cells, and help new skin cells to grow.

Several types of dressings may be required for a venous ulcer.

Medications — A variety of medications have been used for chronic venous disease and venous ulcers.

• Diuretics (water pills) remove fluid from the body but are usually not very useful with chronic venous disease. Venous disease is caused by a problem in the veins of the legs rather than an overload of fluid throughout the body. Patients with severe edema (swelling) may sometimes benefit from a few days of diuretics. (See "Patient information: Edema (swelling) (Beyond the Basics)".)
• Aspirin (300 to 325 mg/day) may speed the healing of ulcers.
• Antibiotics are only recommended when there is an infection.
• Horse chestnut seed extract reduces swelling and leg size in people with chronic venous insufficiency. It may be recommended for people who cannot tolerate compression therapy, usually at a dose of 300 mg twice daily. Horse chestnut seed extract is available as a dietary supplement and does not require a prescription. However, its production is not regulated, and the dose may vary from one pill or bottle to another.
• Hydroxyethylrutoside is a prescription medication available in Europe that can reduce leg volume, swelling, and other symptoms.
• Stasis dermatitis (irritation of skin resulting from swelling, pooled blood and increased pressure in the veins) usually responds to moisturizers. Sometimes, a steroid cream or ointment is needed to help with itching.
  
  Other creams and ointments (eg, triple antibiotic ointments like Neosporin), anti-itch products, and scented lotions should be avoided because there is a risk of developing an allergic rash (contact dermatitis) from these products.

Treatment of contact dermatitis — Contact dermatitis is a skin reaction that occurs when an irritating or allergy-producing substance touches the skin. The reaction may occur on the legs or other areas of the body. Contact dermatitis is common in people with chronic venous disease treated with topical therapy. Treatment of contact dermatitis is discussed separately. (See "Patient information: Contact dermatitis (including latex dermatitis) (Beyond the Basics)".)

VEIN ABLATION TREATMENTS

Vein ablation treatments are treatments designed to destroy superficial veins with abnormal valve function. These treatments are usually reserved for people with symptoms that do not respond to the treatments described above. Veins are destroyed in one of three ways:

Sclerotherapy — Sclerotherapy is a chemical ablation in which a substance is injected into the vein, causing the vein to collapse. This procedure is done in an office setting. (See "Liquid and foam sclerotherapy techniques for the treatment of lower extremity veins".)

Radiofrequency or laser ablation — Radiofrequency and laser ablation involve putting a special device into the abnormal vein. High energy is applied, which destroys the vein from the inside. The vein is not removed but it no longer functions. These procedures can be done with minimal anesthesia (no incisions) and are often performed in an office setting. (See "Clinical evaluation of lower extremity chronic venous disease".)

Vein ligation/stripping — Vein ligation or stripping are surgical procedures requiring anesthesia. Veins are removed with many small incisions.

Compression stockings are generally recommended following these ablation procedures (see 'Compression stockings' above).

SUMMARY

• Chronic venous disease is a problem that affects the veins of the legs. Normally, the leg veins carry blood back to the heart. In people with chronic venous disease, the veins do not work as well. This can cause blood to collect in the lower legs and feet.
• People with chronic venous disease often complain of legs that feel heavy, tired, or achy. These problems are more common at the end of the day or after standing for long periods. The lower feet and ankles may also become swollen.
• People who have chronic venous disease can develop more severe problems like skin infections, skin color changes, rashes, or sores that do not heal. These infections and sores can be difficult to treat, and sometimes require months or years to heal.
• The goal of treatment is to improve symptoms, reduce swelling and prevent skin infections.
• Treatments for swelling include propping up the legs when possible, wearing stockings that gently compress the ankles and lower legs, and performing foot and ankle exercises.
• Treatments for skin ulceration include special coverings for the area and antibiotics if there is an infection. Some people will need compression bandages to help ulcers heal.
• Antibiotic ointments or salves that are rubbed on the skin, anti-itch creams, and scented lotions are not recommended because these products can cause an allergic rash.
• Vein ablation treatments (sclerotherapy, laser or radiofrequency ablation or surgical stripping) can be considered in patients who have symptoms that not respond medical management.

WHERE TO GET MORE INFORMATION

Your healthcare provider is the best source of information for questions and concerns related to your medical problem.

This article will be updated as needed on our web site (www.uptodate.com/patients). Related topics for patients, as well as selected articles written for healthcare professionals, are also available. Some of the most relevant are listed below.

Patient level information — UpToDate offers two types of patient education materials.

The Basics — The Basics patient education pieces answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials.

Patient information: Deep vein thrombosis (blood clots in the legs) (The Basics)
Patient information: Swelling (The Basics)
Patient information: Varicose veins and other vein disease in the legs (The Basics)
Patient information: Pulmonary embolism (blood clot in the lungs) (The Basics)
Patient information: Doppler ultrasound (The Basics)
Patient information: Superficial phlebitis (The Basics)
Patient information: Vein ablation (The Basics)

Beyond the Basics — Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are best for patients who want in-depth information and are comfortable with some medical jargon.

Patient information: Edema (swelling) (Beyond the Basics)
Patient information: Contact dermatitis (including latex dermatitis) (Beyond the Basics)

Professional level information — Professional level articles are designed to keep doctors and other health professionals up-to-date on the latest medical findings. These articles are thorough, long, and complex, and they contain multiple references to the research on which they are based. Professional level articles are best for people who are comfortable with a lot of medical terminology and who want to read the same materials their doctors are reading.

Classification of lower extremity chronic venous disorders
Clinical evaluation of lower extremity chronic venous disease
Diagnostic evaluation of chronic venous insufficiency
Medical management of lower extremity chronic venous disease
Pathophysiology of chronic venous disease
Post-thrombotic (postphlebitic) syndrome
Liquid and foam sclerotherapy techniques for the treatment of lower extremity veins

The following organizations also provide reliable health information.

• National Library of Medicine

     (www.nlm.nih.gov/medlineplus/healthtopics.html)

• National Heart, Lung, and Blood Institute

     (www.nhlbi.nih.gov/)

• American Venous Forum

     (www.veinforum.org/patients.aspx)

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