Clinical manifestations of lower extremity chronic venous disease
- Patrick C Alguire, MD, FACP
Patrick C Alguire, MD, FACP
- Senior Vice President for Medical Education
- American College of Physicians
- Barbara M Mathes, MD, FACP, FAAD
Barbara M Mathes, MD, FACP, FAAD
- Clinical Associate, Dermatology
- University of Pennsylvania
- Secretary Treasurer
- American Academy of Dermatology
- Section Editors
- John F Eidt, MD
John F Eidt, MD
- Section Editor — Vascular and Endovascular Surgery
- Professor of Surgery, Texas A&M Health Science Center
- Vice Chair of Vascular Surgical Services, Baylor Heart and Vascular Hospital at Dallas
- Joseph L Mills, Sr, MD
Joseph L Mills, Sr, MD
- Section Editor — Vascular and Endovascular Surgery
- Professor and Chief
- Division of Vascular Surgery and Endovascular Therapy
- Baylor College of Medicine
Chronic lower extremity venous disease is the most common vascular disorder . Chronic venous disease refers to the presence of morphological (ie, venous dilation) or functional (eg, venous reflux) abnormalities of long duration and manifested by symptoms and/or signs indicating the need for further investigation or treatment .
Chronic venous disease encompasses the full spectrum of signs and symptoms associated with classes CØ to C6 of the Clinical-Etiology-Anatomy-Pathophysiology (CEAP) classification (table 1), whereas the term "chronic venous insufficiency" is generally restricted to disease of greater severity (ie, classes C4 to C6) . Thus, varicose veins in the absence of skin changes are not indicative of chronic venous insufficiency.
Initial clinical presentation is highly variable with the most common symptoms consisting of lower extremity pain or discomfort. Physical findings include abnormal venous dilation (ie, telangiectasias, reticular veins, varicose veins), edema, inflammation, dermatitis, or ulceration. Chronic venous insufficiency is associated with chronic disability, diminished quality of life, and high health care costs [4-8].
The clinical evaluation of chronic venous disease is reviewed here. The classification, diagnostic evaluation and management of chronic venous disease are discussed elsewhere. (See "Classification of lower extremity chronic venous disorders" and "Overview and management of lower extremity chronic venous disease".)
APPROACH TO THE PATIENT
The diagnosis of chronic lower extremity venous disease is predominantly clinical. Initial evaluation consists of a thorough history and physical examination, with clinical classification of disease severity according to the Clinical-Etiology-Anatomy-Pathophysiology (CEAP) criteria (table 1) . The CEAP classification is helpful in documenting venous disease severity both at initial presentation as well as in documenting changes over time. The CEAP clinical classification is discussed in detail elsewhere. (See "Classification of lower extremity chronic venous disorders" and 'Clinical signs by CEAP category' below.)
- Criqui MH, Jamosmos M, Fronek A, et al. Chronic venous disease in an ethnically diverse population: the San Diego Population Study. Am J Epidemiol 2003; 158:448.
- Porter JM, Moneta GL. Reporting standards in venous disease: an update. International Consensus Committee on Chronic Venous Disease. J Vasc Surg 1995; 21:635.
- Bergan JJ, Schmid-Schönbein GW, Smith PD, et al. Chronic venous disease. N Engl J Med 2006; 355:488.
- Chiesa R, Marone EM, Limoni C, et al. Effect of chronic venous insufficiency on activities of daily living and quality of life: correlation of demographic factors with duplex ultrasonography findings. Angiology 2007; 58:440.
- Tsai S, Dubovoy A, Wainess R, et al. Severe chronic venous insufficiency: magnitude of the problem and consequences. Ann Vasc Surg 2005; 19:705.
- Kaplan RM, Criqui MH, Denenberg JO, et al. Quality of life in patients with chronic venous disease: San Diego population study. J Vasc Surg 2003; 37:1047.
- Duque MI, Yosipovitch G, Chan YH, et al. Itch, pain, and burning sensation are common symptoms in mild to moderate chronic venous insufficiency with an impact on quality of life. J Am Acad Dermatol 2005; 53:504.
- Langer RD, Ho E, Denenberg JO, et al. Relationships between symptoms and venous disease: the San Diego population study. Arch Intern Med 2005; 165:1420.
- Chiesa R, Marone EM, Limoni C, et al. Chronic venous disorders: correlation between visible signs, symptoms, and presence of functional disease. J Vasc Surg 2007; 46:322.
- Asbeutah AM, Asfar SK, Shawa NJ, et al. Is venous reflux a common disease in post-thrombotic patients with unilateral deep vein thrombosis episode? Phlebology 2007; 22:8.
- Yamaki T, Nozaki M. Patterns of venous insufficiency after an acute deep vein thrombosis. J Am Coll Surg 2005; 201:231.
- Labropoulos N, Waggoner T, Sammis W, et al. The effect of venous thrombus location and extent on the development of post-thrombotic signs and symptoms. J Vasc Surg 2008; 48:407.
- Sprague AH, Khalil RA. Inflammatory cytokines in vascular dysfunction and vascular disease. Biochem Pharmacol 2009; 78:539.
- Scott TE, Mendez MV, LaMorte WW, et al. Are varicose veins a marker for susceptibility to coronary heart disease in men? Results from the Normative Aging Study. Ann Vasc Surg 2004; 18:459.
- Mäkivaara LA, Ahti TM, Luukkaala T, et al. Persons with varicose veins have a high subsequent incidence of arterial disease: a population-based study in Tampere, Finland. Angiology 2007; 58:704.
- Kurz X, Lamping DL, Kahn SR, et al. Do varicose veins affect quality of life? Results of an international population-based study. J Vasc Surg 2001; 34:641.
- Palfreyman S. Assessing the impact of venous ulceration on quality of life. Nurs Times 2008; 104:34.
- Hareendran A, Bradbury A, Budd J, et al. Measuring the impact of venous leg ulcers on quality of life. J Wound Care 2005; 14:53.
- van Korlaar I, Vossen C, Rosendaal F, et al. Quality of life in venous disease. Thromb Haemost 2003; 90:27.
- Almeida JI, Kaufman J, Göckeritz O, et al. Radiofrequency endovenous ClosureFAST versus laser ablation for the treatment of great saphenous reflux: a multicenter, single-blinded, randomized study (RECOVERY study). J Vasc Interv Radiol 2009; 20:752.
- Kahn SR, Hirsch A, Shrier I. Effect of postthrombotic syndrome on health-related quality of life after deep venous thrombosis. Arch Intern Med 2002; 162:1144.
- Renner R, Gebhardt C, Simon JC, Seikowski K. Changes in quality of life for patients with chronic venous insufficiency, present or healed leg ulcers. J Dtsch Dermatol Ges 2009; 7:953.
- Wrona M, Jöckel KH, Pannier F, et al. Association of Venous Disorders with Leg Symptoms: Results from the Bonn Vein Study 1. Eur J Vasc Endovasc Surg 2015; 50:360.
- Van der Velden SK, Shadid NH, Nelemans PJ, Sommer A. How specific are venous symptoms for diagnosis of chronic venous disease? Phlebology 2014; 29:580.
- Newland MR, Patel AR, Prieto L, et al. Neuropathy and gait disturbances in patients with venous disease: a pilot study. Arch Dermatol 2009; 145:485.
- Padberg FT Jr, Maniker AH, Carmel G, et al. Sensory impairment: a feature of chronic venous insufficiency. J Vasc Surg 1999; 30:836.
- Shiman MI, Pieper B, Templin TN, et al. Venous ulcers: A reappraisal analyzing the effects of neuropathy, muscle involvement, and range of motion upon gait and calf muscle function. Wound Repair Regen 2009; 17:147.
- Abbade LP, Lastória S, Rollo Hde A. Venous ulcer: clinical characteristics and risk factors. Int J Dermatol 2011; 50:405.
- Moffatt CJ, Franks PJ, Doherty DC, et al. Prevalence of leg ulceration in a London population. QJM 2004; 97:431.
- Margolis DJ, Bilker W, Santanna J, Baumgarten M. Venous leg ulcer: incidence and prevalence in the elderly. J Am Acad Dermatol 2002; 46:381.
- O'Brien JF, Grace PA, Perry IJ, Burke PE. Prevalence and aetiology of leg ulcers in Ireland. Ir J Med Sci 2000; 169:110.
- Walsh SN, Santa Cruz DJ. Lipodermatosclerosis: a clinicopathological study of 25 cases. J Am Acad Dermatol 2010; 62:1005.
- Forssgren A, Nelzén O. Changes in the aetiological spectrum of leg ulcers after a broad-scale intervention in a defined geographical population in Sweden. Eur J Vasc Endovasc Surg 2012; 44:498.
- APPROACH TO THE PATIENT
- Risk factors for venous disease
- Medical history
- Quality of life
- PHYSICAL ASSESSMENT
- CLINICAL SIGNS BY CEAP CATEGORY
- No clinical signs
- Telangiectasia/reticular veins
- Varicose veins
- Skin pigmentation changes/dermatitis
- Venous ulceration
- INFORMATION FOR PATIENTS
- SUMMARY AND RECOMMENDATIONS