Harvey's Garden

Chronic venous disease

2 min read

Epidemiology

  • Advanced age.
  • Female sex.
  • Obesity, sedentary lifestyle.
  • Prolonged standing/sitting.
  • Pregnancy.
  • Hx of DVT (Post-thrombotic syndrome). c
    • Previous acute DVT causes inflammation and scarring of the delicate venous valves, leading to valvular incompetence, venous reflux, and sustained venous hypertension.
  • Fam hx of venous disease.
  • Pathophysiology: Incompetent venous valves → venous HTN → capillary leak of fluid/proteins/RBCs → tissue inflammation & fibrosis.

Etiology

Pathophysiology

Clinical features

  • Leg heaviness, aching, swelling (worse at end of day / prolonged standing; improves w/ elevation).
  • Varicose veins & telangiectasias.
  • Pitting edema.
  • Stasis dermatitis: Erythema, scaling, pruritus of lower extremities.
  • Hemosiderin deposition: Red-brown discoloration (from extravasated RBC breakdown).
  • Lipodermatosclerosis: Subcutaneous fibrosis resulting in an “inverted champagne bottle” appearance of the lower leg.
  • Venous stasis ulcers: Typically shallow, exudative, located at the medial malleolus.

Diagnostics

  • Initial: Clinical diagnosis based on typical H&P.
  • Confirmatory/Best Test: Venous duplex ultrasound (evaluates for retrograde flow/venous reflux and rules out deep/superficial vein thrombosis).
  • Note: Must evaluate arterial supply (ABI) prior to applying compression therapy.

Treatment

  1. First-line (Conservative):
    • Leg elevation (above heart level).
    • Graduated compression stockings (Contraindicated if concurrent severe PAD [ABI < 0.5]).
    • Weight loss, exercise (calf muscle pump).
  2. Wound Care (for ulcers):
    • Debridement of necrotic tissue.
    • Specialized dressings (e.g., Unna boot - zinc oxide-impregnated bandage).
    • Pentoxifylline or aspirin (may accelerate ulcer healing when added to compression).
  3. Dermatitis Treatment: Mild-to-med potency topical corticosteroids for stasis dermatitis.
  4. Interventional/Refractory:
    • Endovenous thermal ablation (laser or radiofrequency).
    • Sclerotherapy (for telangiectasias/small varicosities).
    • Vein stripping/ligation (rarely used now).

Complications

Stasis dermatitis

  • Definition: eczematous dermatitis of the lower extremities caused by chronic venous hypertension and inflammation
  • Clinical features
    • Poorly defined erythematous, eczematous, and sometimes scaly patches commonly involving the medial malleolus
    • Can involve pruritus; scratching may cause lichenification.
    • Acute stasis dermatitis can manifest with weeping, vesicles, and worsening erythema and edema.
  • Diagnostics
    • Perform diagnostic studies for CVI, including duplex US.
    • Consider skin biopsy if there is diagnostic uncertainty.
      • Extravasated erythrocytes, siderophages, and perivascular lymphocytes
  • Treatment
    • Initiate treatment of CVI, including compression therapy and referral for interventional treatment.
    • Identify and treat superimposed infections.

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