Venous insufficiency of the lower limbs

EBM Guidelines
2.7.2020

Essentials

  • Common disease with no cure available for the underlying condition
  • Superficial venous insufficiency is the most common form of the disease. Varicose veins are the most common visible sign of superficial venous insufficiency but not all patients have them.
  • Deep venous insufficiency is less frequent and often results from deep venous thrombosis.
  • Compression stockings are the first choice treatment for patients with mild symptoms.
  • Colour Doppler duplex ultrasound is the diagnostic method of first choice and indispensable when planning further treatment. Invasive procedures should not be performed without preceding ultrasonography.
  • Main trunk insufficiency in the superficial veins with troublesome symptoms is treated.

Epidemiology

  • Superficial venous insufficiency affects about 30–40% of adults in Western countries. As many as 80% of the population have telangiectasia and minor subcutaneous venectasia with no insufficiency of superficial venous trunks or their tributaries.
  • Risk factors include ageing, female sex, history of childbirth and family history.
  • Varicose veins often emerge or worsen during pregnancy.

Aetiology

  • The fundamental cause of venous insufficiency is unknown.
  • The most important feature of the disease is venous reflux. With time, it leads to venous hypertension and dilation of superficial veins, i.e. varices.
    • The most common manifestation of superficial venous insufficiency, primary varicosis, takes many forms. It often begins distally with varicosis of small subcutaneous veins, but sometimes varicose veins occur only in the thigh.
    • In a much rarer form of the disease, varicosity is minimal or nonexistent but reflux occurs in the great or small saphenous vein, and the disease may cause troublesome symptoms or even be complicated (C4–C6; see table «Assessment of the severity of venous disease »1).
  • Disease beginning as superficial insufficiency may subsequently lead to secondary insufficiency of perforating and deep veins.
  • Prolonged venous hypertension may cause skin changes in the leg and ankle area and a venous leg ulcer.
    • This may apparently damage the lymphatic system as well, leading to secondary insufficiency of the lymphatic system and mixed oedema.
  • -Deep vein insufficiency which is often a consequence of deep venous thrombosis (postthrombotic syndrome), causes on average more troublesome symptoms than insufficiency in the superficial veins.

Symptoms

  • The most common symptoms and findings are:
    • Swelling of the lower limbs (often becoming worse in the course of the day)
    • Aching
    • Feelings of heaviness and tightness
    • Itching
    • Visible varicose veins
    • Leg ulcer

Examination

Table 1. Assessment of the severity of venous disease
*Porter JM, Moneta GL. Reporting standards in venous disease: an update. International Consensus Committee on Chronic Venous Disease. J Vasc Surg 1995;21(4):635-45.
Clinical CEAP classification* «Porter JM, Moneta GL. Reporting standards in venous disease: an update. International Consensus Committee on Chronic Venous Disease. J Vasc Surg 1995;21(4):635-45. »1Normal finding, nothing suggestive of venous disease (C0)
Intradermal dilated veins (telangiectasia) (C1)
Varicose veins (C2)
Varicose veins and measurable swelling in the limb, no skin changes (C3)
Skin changes ascribed to venous disease, such as pigmentation, venous eczema or lipodermatosclerosis (C4)
Skin changes with healed leg ulcer (C5)
Skin changes with active leg ulcer (C6)
Disability classification for assessment of symptomsAsymptomatic (0)
Symptomatic, can work without compression stockings or supportive bandages (1)
Symptomatic, cannot work eight hours a day without compression stockings or supportive bandages (2)
Cannot work even with compression stockings or supportive bandages (3)

Differential diagnosis

  • Other conditions producing lower limb symptoms to be considered in differential diagnosis:
  • In differential diagnosis of swelling, conditions such as cardiac insufficiency must be considered; see article on leg oedema «Leg oedema»6.
  • If there are no clinical findings suggestive of venous insufficiency apart from swelling, the swelling is unlikely to be due to venous insufficiency.

Treatment

  • The aim is to alleviate symptoms and prevent the emergence of complications (bleeding of the varices, superficial or deep venous thrombosis, leg ulcer).
  • The most important basic treatment option consists of the regular wearing of compression stockings, irrespective of possible surgical treatment. The stockings prevent progression of the damage, and surgery can often be prevented by wearing them.
    • For classification of compression stockings, see article on leg oedema «Leg oedema»6.
    • The length and compression class of the stockings should be prescribed by a physician.
    • Compression stockings should be worn with caution if the patient is suspected of having impaired arterial circulation.
      • An ABI value of > 0.8 is considered safe for compression therapy.
      • If the ABI value is 0.5–0.8, the decision on treatment should be made by a specialist. The patient should be carefully monitored for symptoms of ischaemia.
      • If the ABI value is < 0.5, no compression should be used.
    • A compression class 2 knee stocking is usually sufficient. If such a stocking is too tight to put on even with aids, two compression class 1 stockings can be used on top of each other instead of compression class 2 stockings.
      • Measurements for compression stockings must be taken in the morning when the leg is not swollen.
      • Stockings should be replaced 2–3 times a year.
  • In many patients, compression stocking treatment is sufficient and no invasive treatment is needed.
  • Horse chestnut seed extract may reduce symptoms associated with chronic venous insufficiency (leg pain, swelling and itching).
  • Phlebotonics may reduce oedema associated with venous insufficiency. There is at least one product containing vine-leaf extract and flavonoids available without prescription.
  • Invasive treatment should be considered
    • in complicated cases (classes C4–6)
    • in patients with milder disease (C2–3) but numerous symptoms, who cannot reasonably cope in their work or daily activities despite compressive stockings (trial of 3–6 months) or cannot wear compressive stockings
    • in patients with repeated episodes of thrombophlebitis or a single extensive thrombophlebitis, or bleeding varicose veins.
  • Invasive treatment should be planned individually depending on the clinical status and based on colour Doppler examination.
    • Intravenous catheter treatment (laser or radiofrequency thermal catheter) is currently the first-line treatment in main trunk insufficiency.
    • The results of open surgery are comparable with those of catheter treatment, but the recovery period after surgery is longer than after catheter treatment.
    • Ultrasound guided intravenous foam sclerotherapy is best suited for the treatment of recurrent varicose veins, or when the main trunk to be treated is small.

Intravenous treatment evd

  • Radiofrequency and laser therapy are based on heating the vein wall to shrink the vein and obstruct the lumen.
    • They are most commonly used to shrink the great saphenous vein in the thigh or the small saphenous vein.
    • They can be used only for relatively straight segments of the main trunk or significant collaterals, not varices as such, which need to be treated by other methods.
    • Can be carried out at an outpatient clinic or in an operating theatre, usually under local anaesthesia.
    • There are fewer problems with recovery and fewer complications than with surgical treatment. Mild symptoms, such as tenderness and bruising, are common.
    • Individual cases of deep vein thrombosis, nerve damage or burn injury have been reported.
    • There is normally little need for sick leave.
    • Based on 2- to 5-year follow-up, the results of intravenous treatment of insufficiency of the great and small saphenous veins are at least as good as the results of surgery.
  • In sclerotherapy, a liquid or foam injected into the vein causes endothelial damage constricting the vein and leading to occlusive fibrosis.
    • Suitable for the treatment of small and medium-sized superficial veins.
    • Particularly suitable for recurrences after surgical treatment.
    • Carried out at an outpatient clinic, no need for local anaesthesia. The patient should walk immediately after the treatment and can be discharged after very short monitoring.
    • Contraindications include history of deep vein thrombosis or pulmonary embolism, diagnosed coagulation disorder, allergy to the sclerosant, patent foramen ovale (right-to-left shunt), and severe lower limb ischaemia.
    • The most common adverse effect is hyperpigmentation that may be persistent or even permanent. Transient thrombi and phlebitis in treated veins are common and may remain painful for weeks or even months. No treatment is needed unless the pain and swelling are severe.
    • The risk of serious complications (deep vein thrombosis, pulmonary embolism, skin necrosis) is small.

(Open) surgery evd

  • Surgical treatment is particularly suitable for large and extensive varices in superficial veins.
  • The operation is based on a map produced by ultrasonography.
  • The defective saphenous vein or its significant collateral is removed by stripping, and local varicosities are resected. Defective perforating veins, particularly those above the calf muscle pump, are often also closed.
    • Usually only defective venous segments are resected or closed.
    • Resection of varices is particularly important because the disease appears to begin from them.
  • The most common complications of superficial venous surgery are wound infection, haematomas, superficial sensory nerve damage and damage to the lymphatic system.
  • Sick leave is normally needed for about 2–4 weeks, depending on the extent of surgery and on the patient's job.
  • As only limited reliable long-term data is available on corrective surgery of deep veins (several techniques of treating the venous valve), this is not recommended as the treatment of choice for venous insufficiency.

Acute care

  • Acutely bleeding varicose vein
    • For first aid, elevate the leg and apply a dressing.
    • Bleeding easily recurs, and specialized care should be consulted about therapeutic options.
      • An acute case can be treated by e.g. sclerotherapy, and further measures can be considered thereafter.
  • Superficial phlebitis associated with varicose veins
    • Causes pain, erythema and swelling.
    • For examinations and treatment see article on treatment for superficial thrombophlebitis of the leg «Superficial venous thrombophlebitis»7.
    • A patient with extensive phlebitis or recurrent more limited phlebitis should be referred to specialized care for consideration of required procedures.
  • Acute lipodermatosclerosis
    • Symptoms increase within a few days: the leg becomes sore and swells, and the skin becomes erythematous.
    • There may have been some skin changes (hyperpigmentation and lipodermatosclerosis) on the leg even previously.
    • May be confused with erysipelas. However, laboratory values showing inflammation are not elevated and the patient has no general symptoms.
    • Acute lipodermatosclerosis should be treated first by elevating the leg, then by a compression stocking; referral for specialized care may be needed.

Leg ulcer

References

  1. Porter JM, Moneta GL. Reporting standards in venous disease: an update. International Consensus Committee on Chronic Venous Disease. J Vasc Surg 1995;21(4):635-45. «PMID: 7707568»PubMed