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Updated: Dec 8 2021

Deep Venous Insufficiency

  • 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
    • Associated conditions
      • varicose veins
  • 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
  • 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
  • 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
    • Making the diagnosis
      • based on clinical presentation and imaging
  • 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
  • Prognosis
    • Likely to recur even after treatment
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