Chronic venous insufficiency: causes, symptoms, diagnosis, treatment

Chronic venous insufficiency is a modified venous outflow, sometimes causing discomfort in the lower limb, swelling and skin changes. Postphlebitic (post-thrombotic) syndrome - chronic venous insufficiency, accompanied by clinical symptoms. The causes are violations leading to venous hypertension, usually a venous valve damage or failure that occurs after deep venous thrombosis (GVT). The diagnosis is established during the collection of anamnesis, with the help of a physical examination and duplex ultrasonography. Treatment includes compression, prevention of injuries and (sometimes) surgical intervention. Prevention includes treatment of deep venous thrombosis and wearing of compression stockings.

Chronic venous insufficiency is recorded in 5% of people in the United States. Postphlebitic syndrome can occur in 1/2 - 2/3 of patients with deep venous thrombosis, usually within 1-2 years after acute deep venous thrombosis.

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Causes of chronic venous insufficiency

Venous outflow from the lower limbs is performed by contracting the muscles of the shank, necessary to push blood from the intramuscular (plantar) sinuses and gastrocnemius veins into the deep veins. Venous valves direct blood proximally to the heart. Chronic venous insufficiency occurs when venous obstruction develops (for example, with deep venous thrombosis), venous valve failure, or with a reduced contraction of the muscles surrounding the veins (for example, due to immobility), which reduces the venous flow and increases venous pressure (venous hypertension ). Prolonged venous hypertension causes swelling of the tissues, inflammation and hypoxia, leading to the development of symptoms. Pressure can be transmitted to the superficial veins, if the valves in the perforating veins that connect the deep and superficial veins are ineffective.

Deep venous thrombosis is the most frequent known risk factor for chronic venous insufficiency, but trauma, age and obesity are important. Idiopathic cases are often attributed to the transferred "mute" deep venous thrombosis.

Chronic venous insufficiency with clinical symptoms, which follows deep venous thrombosis, resembles post-phlebitis (or post-thrombotic) syndrome. Risk factors for post-phlebitis syndrome in patients with deep venous thrombosis include proximal thrombosis, repeated unilateral deep venous thrombosis, overweight (BMI 22-30 kg / m) and obesity (BMI> 30 kg / m). Age, female sex and estrogen therapy are also associated with the syndrome, but are likely to be nonspecific. The use of compression stockings after deep venous thrombosis reduces the risk.

[5], [6], [7], [8]

Symptoms of chronic venous insufficiency

Chronic venous insufficiency can not cause any symptoms, but always has characteristic manifestations. Postphlebitic syndrome always causes symptoms, but may not have noticeable manifestations. Both disorders are alarming because their symptoms can simulate signs of deep venous thrombosis, and both can lead to a significant limitation of physical activity and a decrease in the quality of life.

Symptoms include a feeling of overflow, severity, pain, seizures, fatigue and paresthesia in the legs. These symptoms are aggravated in standing or walking position and decrease in rest and lifting of the legs. Itching can accompany skin changes. Clinical symptoms gradually increase: from the absence of changes to the varicose veins (sometimes) and then to stagnant dermatitis of the legs and ankles, with the formation of ulcers or without it.

Clinical classification of chronic venous insufficiency

Class	Symptoms
0	No signs of veins
1	Extended or reticular veins *
2	Varicose veins *
3	Edema
4	Skin changes due to venous congestion (pigmentation, congestive dermatitis, lipodermatosclerosis)
5	Skin changes due to venous stasis and healed ulcers
6th	Skin changes due to venous stasis and active ulcers

* Can occur idiopathically, without chronic venous insufficiency.

Venous congestive dermatitis is a reddish-brown hyperpigmentation, induration, widening of veins, lipodermatosclerosis (fibrotic subcutaneous panniculitis) and venous varicose ulcers. All these signs indicate a prolonged permanent disease or a heavier venous hypertension.

Venous varicose ulcers can develop spontaneously or after the altered skin is scratched or damaged. They typically occur around the medial malleolus, are shallow and damp, may be fetid (especially with poor care) or painful. These ulcers do not penetrate the deep fascia, unlike ulcers arising from diseases of the peripheral arteries that eventually affect the tendon or bone.

Swelling of the leg is often one-sided or asymmetric. Bilateral symmetrical edema is more likely to indicate a systemic disease (eg, heart failure, hypoalbuminemia) or the use of certain medications (eg, calcium channel blockers).

If the lower extremities are not subjected to careful care, patients with any manifestation of chronic venous insufficiency or post-phlebitis syndrome are at risk of transition to a more severe form of the disease.

Diagnosis of chronic venous insufficiency

The diagnosis is usually based on anamnesis and physical examination. A clinical scoring system that takes into account five symptoms (pain, convulsions, heaviness, pruritus, paresthesia) and six signs (swelling, hyperpigmentation, induration, veins, redness, pain from the lower leg) ranges from 0 (absence or minimal expression ) to 3 (severe). It is increasingly recognized as a standard diagnostic method. The number of points 5-14 for two examinations performed at intervals of more than 6 months, indicates an easy or moderate severity, and the number> 15 - for a serious illness.

Duplex ultrasonography of the lower extremity helps to exclude deep venous thrombosis. Absence of edema and a decreased shoulder-ankle index distinguishes peripheral arterial disease from chronic venous insufficiency and post-phlebitis syndrome. Absence of pulsations in the ankle joint area involves the pathology of the peripheral artery.

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Prophylaxis and treatment of chronic venous insufficiency

Primary prophylaxis involves anticoagulant therapy after deep venous thrombosis and the use of compression stockings for 2 years after deep venous thrombosis or damage to the venous vessels of the lower limb. Changes in lifestyle (eg, weight loss, regular exercise, reduced intake of salt) also play an important role.

Treatment includes elevated leg position, compression using bandages, stockings and pneumatic devices, caring for skin lesions and surgical treatment depending on the severity of the pathology. Drugs do not play any role in the routine treatment of chronic venous insufficiency, although many patients are prescribed acetylsalicylic acid, glucocorticoids for external use, diuretics for the elimination of edema or antibiotics. Some experts believe that reducing body weight, regular exercise and reducing the intake of table salt can benefit patients with bilateral chronic venous insufficiency. However, all these activities are difficult for many patients.

Raising the leg above the level of the right atrium reduces venous hypertension and edema, which is suitable for all patients (this must be done at least 3 times a day for 30 minutes or more). However, most patients can not comply with this regime during the day.

Compression is effective for the treatment and prevention of manifestations of chronic venous insufficiency and post-phlebitis syndrome, it is indicated to all patients. Elastic bandaging is used first, until the swelling and ulcers disappear, and the size of the foot does not stabilize; then ready-made compression stockings are used. Stockings providing distal pressure 20-30 mm Hg. St., appointed with small varicose veins and moderate chronic venous insufficiency; 30-40 mm Hg. Art. - with large varicose veins and moderate severity of the disease; 40-60 mm Hg. Art. And more - with a serious illness. Stockings should be worn immediately after awakening, until the swelling of the leg is increased due to physical activity. Stockings should provide maximum pressure in the area of ankle joints and gradually reduce pressure proximally. Adherence to this method of treatment varies: many young or active patients consider stockings irritating, limiting or having a bad cosmetic effect; older patients may have difficulty putting them on.

Intermittent pneumatic compression (PKI) uses a pump for cyclical filling and pumping air from hollow plastic gaits. IPC provides external compression and the flow of venous blood and fluid up the vascular bed. This measure is effective in severe post-phlebitic syndrome and venous varicose ulcers, but the effect can be comparable with the wearing of compression stockings.

Care for skin lesions is very important for ulcers with venous stasis. After applying the bandage "Unna boot" (impregnated zinc oxide bandage), covered with a compression bandage and weekly changed, almost all ulcers heal. Compression products and devices [eg hydrocolloids such as aluminum chloride (DuoDERM)] provide a moist environment for wound healing and stimulate the growth of new tissue. They can be used to treat ulcers to reduce exudation, but, most likely, they are not much more effective than the usual bandage "Unna" and the road. Normal bandages have an absorbent effect, which has a good effect with more pronounced sweat.

Drugs play no role in the routine treatment of chronic venous insufficiency, although many patients are prescribed acetylsalicylic acid, glucocorticoids for external use, diuretics for the elimination of edema or antibiotics. Surgical treatment (for example, ligation of the vein, its removal, reconstruction of the valve) is also generally ineffective. Transplantation of autologous skin or skin created from epidermal keratocytes or skin skin fibroblasts may be an option for patients with persistent varicose ulcers, when all other measures are ineffective, but the transplant can be repeatedly ulcerated if primary venous hypertension is not eliminated.