Pathophysiology of 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 venous disease is a common medical problem that can result in significant morbidity and mortality. The clinical presentation of this disorder spans a spectrum from asymptomatic but cosmetically troublesome small blue ectatic veins and varicosities, to severe fibrosing panniculitis, dermatitis, edema, and ulceration. (See "Clinical manifestations of lower extremity chronic venous disease".)
The final common pathway that leads to chronic venous insufficiency is the development of venous hypertension. In most cases, venous hypertension results from obstruction to venous flow, dysfunction of venous valves, and/or failure of the "venous pump." In these situations, flow is directed abnormally from the deep to the superficial system, producing local tissue inflammation fibrosis, and occasionally ulceration.
This topic will review normal venous anatomy and physiology, and the pathophysiology of venous hypertension with its clinical consequences. Other aspects of chronic venous insufficiency are discussed separately.
NORMAL VENOUS ANATOMY AND PHYSIOLOGY
Three major vascular pathways are responsible for draining blood away from the superficial vessels of the skin and subcutaneous fat and include (see "Classification of lower extremity chronic venous disorders", section on 'Anatomy (The "A" component of CEAP)'):
●Superficial veins – The superficial veins are a network of subcutaneous veins that are superficial to the deep muscular fascia and include the great saphenous and small saphenous veins (figure 1 and figure 2).
- Tretbar LL. Deep veins. Dermatol Surg 1995; 21:47.
- Cetin C, Serbest MO, Ercan S, et al. An evaluation of the lower extremity muscle strength of patients with chronic venous insufficiency. Phlebology 2016; 31:203.
- Franzeck UK, Haselbach P, Speiser D, Bollinger A. Microangiopathy of cutaneous blood and lymphatic capillaries in chronic venous insufficiency (CVI). Yale J Biol Med 1993; 66:37.
- Takase S, Pascarella L, Lerond L, et al. Venous hypertension, inflammation and valve remodeling. Eur J Vasc Endovasc Surg 2004; 28:484.
- Takase S, Pascarella L, Bergan JJ, Schmid-Schönbein GW. Hypertension-induced venous valve remodeling. J Vasc Surg 2004; 39:1329.
- Pascarella L, Penn A, Schmid-Schönbein GW. Venous hypertension and the inflammatory cascade: major manifestations and trigger mechanisms. Angiology 2005; 56 Suppl 1:S3.
- Sales CM, Rosenthal D, Petrillo KA, et al. The valvular apparatus in venous insufficiency: a problem of quantity? Ann Vasc Surg 1998; 12:153.
- Browse NL. The etiology of venous ulceration. World J Surg 1986; 10:938.
- Stücker M, Schöbe MC, Hoffmann K, Schultz-Ehrenburg U. Cutaneous microcirculation in skin lesions associated with chronic venous insufficiency. Dermatol Surg 1995; 21:877.
- Jünger M, Klyscz T, Hahn M, Rassner G. Disturbed blood flow regulation in venous leg ulcers. Int J Microcirc Clin Exp 1996; 16:259.
- Christopoulos DC, Belcaro G, Nicolaides AN. The hemodynamic effect of venous hypertension in the microcirculation of the lower limb. J Cardiovasc Surg (Torino) 1995; 36:403.
- Sansilvestri-Morel P, Rupin A, Badier-Commander C, et al. Imbalance in the synthesis of collagen type I and collagen type III in smooth muscle cells derived from human varicose veins. J Vasc Res 2001; 38:560.
- Travers JP, Brookes CE, Evans J, et al. Assessment of wall structure and composition of varicose veins with reference to collagen, elastin and smooth muscle content. Eur J Vasc Endovasc Surg 1996; 11:230.
- Jacob MP, Badier-Commander C, Fontaine V, et al. Extracellular matrix remodeling in the vascular wall. Pathol Biol (Paris) 2001; 49:326.
- Bergan JJ, Schmid-Schönbein GW, Smith PD, et al. Chronic venous disease. N Engl J Med 2006; 355:488.
- Thomas PR, Nash GB, Dormandy JA. White cell accumulation in dependent legs of patients with venous hypertension: a possible mechanism for trophic changes in the skin. Br Med J (Clin Res Ed) 1988; 296:1693.
- Moyses C, Cederholm-Williams SA, Michel CC. Haemoconcentration and accumulation of white cells in the feet during venous stasis. Int J Microcirc Clin Exp 1987; 5:311.
- Wilkinson LS, Bunker C, Edwards JC, et al. Leukocytes: their role in the etiopathogenesis of skin damage in venous disease. J Vasc Surg 1993; 17:669.
- Pappas PJ, DeFouw DO, Venezio LM, et al. Morphometric assessment of the dermal microcirculation in patients with chronic venous insufficiency. J Vasc Surg 1997; 26:784.
- Herouy Y, May AE, Pornschlegel G, et al. Lipodermatosclerosis is characterized by elevated expression and activation of matrix metalloproteinases: implications for venous ulcer formation. J Invest Dermatol 1998; 111:822.
- Wenk J, Foitzik A, Achterberg V, et al. Selective pick-up of increased iron by deferoxamine-coupled cellulose abrogates the iron-driven induction of matrix-degrading metalloproteinase 1 and lipid peroxidation in human dermal fibroblasts in vitro: a new dressing concept. J Invest Dermatol 2001; 116:833.
- Bates DO, Curry FE. Vascular endothelial growth factor increases hydraulic conductivity of isolated perfused microvessels. Am J Physiol 1996; 271:H2520.
- Franzeck UK, Bollinger A, Huch R, Huch A. Transcutaneous oxygen tension and capillary morphologic characteristics and density in patients with chronic venous incompetence. Circulation 1984; 70:806.
- Raffetto JD, Mannello F. Pathophysiology of chronic venous disease. Int Angiol 2014; 33:212.