Updated: 4/15/2018

Deep Venous Insufficiency

Topic
Review Topic
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Questions
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Evidence
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Snapshot
  • A 77-year-old woman presents to her primary care physician for varicose veins. She reports that she has had these for a few months now and hopes to improve their appearance. She also states that her legs often feel restless and heavy and that she often has nocturnal cramping of her calves. She has a past medical history of obesity, hypertension, and previous deep venous thromboses after periods of long travel. On physical exam, her bilateral lower legs are edematous with brown hyperpigmentation around the ankles. There are no ulcers. She is scheduled for a duplex ultrasound.
Introduction
  • Clinical definition
    • disorder of incompetent venous valves causing venous insufficiency
  • Epidemiology
    • demographics
      • elderly population
    • risk factors
      • deep venous thrombosis
      • venous hypertension
      • obesity
      • family history
  • Etiology
    • primary venous disease
      • intrinsic venous wall dysfunction
    • secondary venous disease
      • venous wall dysfunction (e.g., due to deep venous thrombosis)
      • congenital abnormality
  • Pathogenesis
    • incompetent venous valves cause reflux of blood
      • over time, this results in venous hypertension
    • prolong venous hypertension → inflammation, more valve loss, and more valve reflux
  • Associated conditions
    • varicose veins
  • Prognosis
    • likely to recur even after treatment
Presentation
  • Symptoms
    • lower leg swelling with
      • pain or ache
      • restlessness
      • feeling of heaviness
      • itch
      • burning or tingling
      • nocturnal leg cramping
    • lower leg symptoms relieved by elevation
  • Physical exam
    • stasis dermatitis
      • brown or dark purple hyperpigmentation
        • hemosiderin deposited in the skin
      • erythema
      • venous ulcers
    • varicose veins
      • secondary to venous insufficiency
      • serpentine cord-like lesion
    • lower extremity edema
Imaging
  • Duplex ultrasound
    • indication
      • for all patients
    • findings
      • venous reflux
      • may find thrombosis
Studies
  • Making the diagnosis
    • based on clinical presentation and imaging
Differential
  • Congestive heart failure
    • distinguishing factor 
      • other symptoms of heart failure, including dyspnea on exertion, orthopnea, and paroxysmal nocturnal dyspnea
  • Pressure ulcers  
    • distinguishing factor
      • typically on pressure points and associated with failure to reposition frequently
  • Lymphedema
    • distinguishing factors
      • edema with skin thickening
      • peau d’orange or fibrotic-appearing skin
      • no venous reflux on Doppler ultrasound
Treatment
  • Conservative
    • elevation of lower extremities
      • indication
        • for all patients
    • compression therapy
      • indications
        • for all patients
        • symptomatic relief
  • Non-operative
    • endovenous laser or radiofrequency ablation
      • indication
        • saphenous vein incompetence
  • Operative
    • surgical correction
      • indication
        • only if endovenous ablation is contraindicated
Complications
  • Dermatitis
 

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Questions (4)
Lab Values
Blood, Plasma, Serum Reference Range
ALT 8-20 U/L
Amylase, serum 25-125 U/L
AST 8-20 U/L
Bilirubin, serum (adult) Total // Direct 0.1-1.0 mg/dL // 0.0-0.3 mg/dL
Calcium, serum (Ca2+) 8.4-10.2 mg/dL
Cholesterol, serum Rec: < 200 mg/dL
Cortisol, serum 0800 h: 5-23 μg/dL //1600 h:
3-15 μg/dL
2000 h: ≤ 50% of 0800 h
Creatine kinase, serum Male: 25-90 U/L
Female: 10-70 U/L
Creatinine, serum 0.6-1.2 mg/dL
Electrolytes, serum  
Sodium (Na+) 136-145 mEq/L
Chloride (Cl-) 95-105 mEq/L
Potassium (K+) 3.5-5.0 mEq/L
Bicarbonate (HCO3-) 22-28 mEq/L
Magnesium (Mg2+) 1.5-2.0 mEq/L
Estriol, total, serum (in pregnancy)  
24-28 wks // 32-36 wks 30-170 ng/mL // 60-280 ng/mL
28-32 wk // 36-40 wks 40-220 ng/mL // 80-350 ng/mL
Ferritin, serum Male: 15-200 ng/mL
Female: 12-150 ng/mL
Follicle-stimulating hormone, serum/plasma Male: 4-25 mIU/mL
Female: premenopause: 4-30 mIU/mL
midcycle peak: 10-90 mIU/mL
postmenopause: 40-250
pH 7.35-7.45
PCO2 33-45 mmHg
PO2 75-105 mmHg
Glucose, serum Fasting: 70-110 mg/dL
2-h postprandial:<120 mg/dL
Growth hormone - arginine stimulation Fasting: <5 ng/mL
Provocative stimuli: > 7ng/mL
Immunoglobulins, serum  
IgA 76-390 mg/dL
IgE 0-380 IU/mL
IgG 650-1500 mg/dL
IgM 40-345 mg/dL
Iron 50-170 μg/dL
Lactate dehydrogenase, serum 45-90 U/L
Luteinizing hormone, serum/plasma Male: 6-23 mIU/mL
Female: follicular phase: 5-30 mIU/mL
midcycle: 75-150 mIU/mL
postmenopause 30-200 mIU/mL
Osmolality, serum 275-295 mOsmol/kd H2O
Parathyroid hormone, serume, N-terminal 230-630 pg/mL
Phosphatase (alkaline), serum (p-NPP at 30° C) 20-70 U/L
Phosphorus (inorganic), serum 3.0-4.5 mg/dL
Prolactin, serum (hPRL) < 20 ng/mL
Proteins, serum  
Total (recumbent) 6.0-7.8 g/dL
Albumin 3.5-5.5 g/dL
Globulin 2.3-3.5 g/dL
Thyroid-stimulating hormone, serum or plasma .5-5.0 μU/mL
Thyroidal iodine (123I) uptake 8%-30% of administered dose/24h
Thyroxine (T4), serum 5-12 μg/dL
Triglycerides, serum 35-160 mg/dL
Triiodothyronine (T3), serum (RIA) 115-190 ng/dL
Triiodothyronine (T3) resin uptake 25%-35%
Urea nitrogen, serum 7-18 mg/dL
Uric acid, serum 3.0-8.2 mg/dL
Hematologic Reference Range
Bleeding time 2-7 minutes
Erythrocyte count Male: 4.3-5.9 million/mm3
Female: 3.5-5.5 million mm3
Erythrocyte sedimentation rate (Westergren) Male: 0-15 mm/h
Female: 0-20 mm/h
Hematocrit Male: 41%-53%
Female: 36%-46%
Hemoglobin A1c ≤ 6 %
Hemoglobin, blood Male: 13.5-17.5 g/dL
Female: 12.0-16.0 g/dL
Hemoglobin, plasma 1-4 mg/dL
Leukocyte count and differential  
Leukocyte count 4,500-11,000/mm3
Segmented neutrophils 54%-62%
Bands 3%-5%
Eosinophils 1%-3%
Basophils 0%-0.75%
Lymphocytes 25%-33%
Monocytes 3%-7%
Mean corpuscular hemoglobin 25.4-34.6 pg/cell
Mean corpuscular hemoglobin concentration 31%-36% Hb/cell
Mean corpuscular volume 80-100 μm3
Partial thromboplastin time (activated) 25-40 seconds
Platelet count 150,000-400,000/mm3
Prothrombin time 11-15 seconds
Reticulocyte count 0.5%-1.5% of red cells
Thrombin time < 2 seconds deviation from control
Volume  
Plasma Male: 25-43 mL/kg
Female: 28-45 mL/kg
Red cell Male: 20-36 mL/kg
Female: 19-31 mL/kg
Cerebrospinal Fluid Reference Range
Cell count 0-5/mm3
Chloride 118-132 mEq/L
Gamma globulin 3%-12% total proteins
Glucose 40-70 mg/dL
Pressure 70-180 mm H2O
Proteins, total < 40 mg/dL
Sweat Reference Range
Chloride 0-35 mmol/L
Urine  
Calcium 100-300 mg/24 h
Chloride Varies with intake
Creatinine clearance Male: 97-137 mL/min
Female: 88-128 mL/min
Estriol, total (in pregnancy)  
30 wks 6-18 mg/24 h
35 wks 9-28 mg/24 h
40 wks 13-42 mg/24 h
17-Hydroxycorticosteroids Male: 3.0-10.0 mg/24 h
Female: 2.0-8.0 mg/24 h
17-Ketosteroids, total Male: 8-20 mg/24 h
Female: 6-15 mg/24 h
Osmolality 50-1400 mOsmol/kg H2O
Oxalate 8-40 μg/mL
Potassium Varies with diet
Proteins, total < 150 mg/24 h
Sodium Varies with diet
Uric acid Varies with diet
Body Mass Index (BMI) Adult: 19-25 kg/m2
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(M2.CV.18) An 83-year-old bedbound man presents with a shallow open ulcer over his sacrum, with a red wound bed. Upon further examination, he also has areas of non-blanching redness on his lateral malleoli. Which of the following interventions would most likely have prevented his condition? Review Topic

QID: 105655
1

Elevating the head of the bed to 45 degrees

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2

Nutritional supplementation

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3

Topical antibiotics

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4

Anti-coagulants

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5

Frequent repositioning

97%

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(M2.CV.5655) An 89-year-old female with a history of type II diabetes mellitus, hypertension, and a recent stroke is seen in her long-term care facility by a geriatrician. Her medications include lisinopril, hydrochlorothiazide, and warfarin. Although the patient's speech is slurred, she reports feeling well overall, except for burning pain on her left foot. Her left foot is shown in Figure A. Which of the following would have been the most effective way to prevent this patient's symptoms? Review Topic

QID: 107054
FIGURES:
1

Twice daily massage of the heal with lotion

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2

Repositioning every 2 hours

84%

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Repositioning every 6 hours

11%

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Repositioning once per day

0%

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5

Discontinue warfarin therapy

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