Chronic Venous Insufficiency and Venous Ulceration

Abstract

OBJECTIVE:To review and summarize the literature on the normal venous circulation of the leg, and the epidemiology, pathophysiology, and treatment of chronic venous insufficiency (CVI).DATA SOURCES: English-language articles identified through a MEDLINE search using the terms venous insufficiency or varicose ulcer and epidemiology, pathophysiology, diagnosis, and clinical trial (pt), and selected cross-references. STUDY SELECTION:Articles on epidemiology, pathophysiology, and treatment of CVI. Randomized, controlled studies were specifically sought for treatment efficacy. DATA EXTRACTION:Data were manually extracted from selected studies and reviews; emphasis was placed on information relevant to the general internist. pproximately 5 million people in the United States exhibit some evidence of chronic venous insufficiency (CVI) and between 400,000 and 500,000 of these individuals have or will develop a venous leg ulcer. 1-3 The signs of CVI include engorgement of the cutaneous veins and dependent edema in mildly affected patients to pigmentation, dermatitis, and ulceration in the more severe cases. Although most patients are asymptomatic, others have leg heaviness and aching or recurrent and recalcitrant leg ulcers punctuated by bouts of cellulitis. These more severe cases are associated with recurrent hospitalization, high health-care costs, and disability. 4,5 Venous insufficiency with trophic skin changes or ulceration is a frustrating problem, which many physicians approach with a sense of ennui. This may be due to the chronic and remitting nature of the problem, the need for lifestyle modification, inconvenient therapies, and contradictory information regarding medical and surgical management. Nevertheless, CVI, including ulceration, is a manageable problem. The purpose of this review is to present the normal anatomy and physiology of the venous circulation and to summarize the epidemiology, pathophysiology, and treatment of CVI. DATA SYNTHESIS: METHODSA MEDLINE search for relevant English-language articles published between 1966 and 1996 was completed using the following MeSH terms: venous insufficiency or varicose ulcer and epidemiology, pathophysiology, diagnosis, and clinical trial (pt). When selecting articles on treatment, randomized, controlled trials were reviewed whenever possible. Emphasis was placed on reviewing articles with clinical relevance for internal medicine physicians. ANATOMY AND NORMAL PHYSIOLOGYVenous blood from the skin and subcutaneous fat is collected in a system of superficial venules and veins that drain toward the deep venous system underneath the fascia via three major pathways: (1) through the long or short saphenous veins, which join the deep system at the saphenofemoral and saphenopopliteal junctions; (2) through the perforating veins originating from the long or short saphenous veins or their branches; or (3) directly into the deep venous system or bypass the deep system entirely and enter the pelvis. 6 Deep veins are categorized as either intramuscular or intermuscular; o...

Leg Ulceration in Chronic Venous Insufficiency Caused by an Absent Inferior Vena Cava

“…Venous ulcération constitutes the majority of all leg ulcers, and is caused by increased pressure in the venous system. This sustained ambulatory pressure has been temied "venous hypertension", and is also referred to as "chronic venous insufficiency" (7,8). Venous insufficiency occurs due to various conditions, such as: (/) dysfunction of valves in the superficial and/or communicating veins because of congenital or acquired incompetence; (//) dysfunction of valves in the deep system because of congenital absence, inherent weakness, or thrombotic damage; (///) deep venous outflow obstruction rather than valvular incompetence; and (A) muscle dysfunction and calf muscle pump failure Irom innammatoiy conditions of the joints or muscles, fibrosis.…”

The Post-thrombotic Syndrome: The Forgotten Morbidity of Deep Venous Thrombosis

“…A recent small study suggested that hydroxyethyl rutosides may also be effective in improving symptoms and signs of PTS [85] however their long-term effectiveness and safety require evaluation in large controlled trials. Postthrombotic venous ulcers are managed with compression therapy, leg elevation, topical dressings, and sometimes surgery [2,90,91]. However, these are often refractory to treatment, tend to recur [91], cause pain and suffering to patients [92,93] and incur high costs to society [60,94].…”

“…Postthrombotic venous ulcers are managed with compression therapy, leg elevation, topical dressings, and sometimes surgery [2,90,91]. However, these are often refractory to treatment, tend to recur [91], cause pain and suffering to patients [92,93] and incur high costs to society [60,94]. To date, there is no evidence that longterm use of diuretics is effective for the treatment of PTS-related edema.…”

Design and verification of a shape memory polymer peripheral occlusion device

“…These venous conditions include chronic venous insufficiency, pelvic congestion syndrome, varicoceles, and varicosities associated with portal vein hypertension. In each of these conditions, venous valves are weakened, become incompetent, and allow regurgitation of blood in peripheral vessels, causing a sudden rise in venous pressure and the subsequent formation of varicose veins (Alguire and Mathes, 1997; Beebe-Dimmer et al, 2005; Laborda et al, 2013; Masson and Brannigan, 2014). To treat many of these disorders, physicians rely on peripheral occlusion devices to block or divert blood flow from the susceptible region of incompetent veins, thus forcing blood flow through healthy vessels.…”