Updated: 6/1/2020

Deep Venous Insufficiency

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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 (5)
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(M2.CV.15.18) 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? Tested Concept

QID: 105655
1

Elevating the head of the bed to 45 degrees

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(0/30)

2

Nutritional supplementation

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(0/30)

3

Topical antibiotics

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(0/30)

4

Anti-coagulants

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(0/30)

5

Frequent repositioning

97%

(29/30)

M 7 E

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(M2.CV.15.5655) 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? Tested Concept

QID: 107054
FIGURES:
1

Twice daily massage of the heal with lotion

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Repositioning every 2 hours

84%

(16/19)

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Repositioning every 6 hours

11%

(2/19)

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Repositioning once per day

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(0/19)

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Discontinue warfarin therapy

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(0/19)

M 8 E

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Evidence (3)
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