yaeao4 Chronic venous disease UpToDate” @ Wolters Kluwer Official reprint from UpToDate® eatin] www.uptodate.com ©2014 UpToDate® Patient information: Chronic venous disease (Beyond the Basics) Authors. Section Editor Deputy Editor Patrick C Alguire, MD, FACP Robert H Fletcher, MD, MSc Kathryn A Collins, MD, PhD, FACS. Barbara M Mathes, MD, FACP, FAAD CHRONIC VENOUS DISEASE OVERVIEW Chronic venous disease is a common disorder that affects the veins of the legs. These veins carry blood from the legs to the heart, Normal veins have a series of valves that open and close to direct blood flow from the surface of the legs to the deep veins and back to the heart; the valves also control the pressure in smaller veins on the legs' surface, Ifthe valves within the veins fail to work properly, blood can flow backwards in the veins and pool in the legs. The pooled blood can increase pressure in the veins. This can cause problems that are mild (such as leg heaviness, aching, dilated or unsightly veins) or severe (such as swelling, skin color changes, skin rash on the leg, recurrent skin infections and chronic ulcers). People who develop these more severe symptoms are said to have chronic venous insufficiency. CHRONIC VENOUS DISEASE CAUSES ‘Any problem that increases pressure in the veins in the legs can stretch the veins. This can damage the valves, which leads to even higher pressures and worsened vein function, and can eventually lead to chronic venous disease. The pressure inside the veins can increase for a number of reasons, including: + Aolot inside a vein — A clot will block blood flow through the vein and cause pressure to build up. Often this causes permanent damage to the vein or valves, even after the clot has dissolved. + Leg injury or surgery — Injury or surgery that blocks the flow of blood through a vein can increase pressure. + Excess weight or weight gain - The added weight of pregnancy or obesity can increase pressure in the veins of the legs, and damage the veins and valves. + Standing or sitting for too long — Standing or sitting for prolonged periods without walking can decrease the movement of blood out of the legs and lead to increased pressure in the veins and pooling of blood. That's because the muscles in the legs play an important role in the circulation of blood, acting as a pump to move blood from the legs back to the heart. CHRONIC VENOUS DISEASE SYMPTOMS, Chronic venous disease can cause painless widened veins, skin irritation, skin rash, skin discoloration, itching, swelling, and skin ulcers, The legs may feel heavy, tired, or achy, usually at the end of the day or hitpiwwwuptadate.comiontents/chronic-venaus-sisease-beyond-the-basics?view= print 1arars014 Chronic venous disease after prolonged standing. (See "Clinical manifestations of lower extremity chronic venous disease".) Dilated veins — The most frequent feature of venous disease is widening (dilation) of the veins. Dilated veins may appear as thin blue flares, often called spider veins, (picture 1) or much wider, twisted veins, called varicose veins that bulge on the surface (picture 2) ‘Swelling — Long-standing chronic venous disease can cause swelling (edema) in the ankles and lower legs (picture 3), Sometimes this swelling is evident only at the end of the day; other times it is present all the time. Swelling often decreases with leg elevation, so it may be less prominent in the moming. The area around the ankle bones is often the first place that swelling is seen. However, swelling can be caused by conditions other than chronic venous disease, so this problem should be evaluated to determine the cause. (See "Patient information: Edema (swelling) (Beyond the Basics)".) ‘Skin changes — Pooling of blood and increased pressure in the veins can cause the skin to become red, and over months to years, the skin may become tan or a reddish-brown color. Often, the skin changes are initially noticeable around the ankle, but frequently occur over the shins and on the foot. Pooling of blood in the legs often causes the skin to become irritated and inflamed. This can cause redness, itching, dryness, oozing fluid, scaling, open sores from scratching, and crusting or scabbing. Some people develop an area of intensely painful skin that tums red or brown, and is hard, and scar-like. This usually develops after many years of venous disease but can occur suddenly. Venous ulcers — Open, nonhealing sores caused by chronic venous disease are called venous ulcers. These are usually located low on the inner ankle but can occur on the outer ankle and in the shin area. Venous ulcers rarely occur above the knee. Venous ulcers that occur higher on the leg are often the result of an injury, or trauma such as from repeated scratching, More than one ulcer can occur at a time. Venous ulcers often begin as small sores but can expand to become quite large. Venous ulcers are usually painful, tender to touch, shallow, have a red appearance at the bottom, and may ooze or drain small to large amounts of fluid Venous ulcers can take a long time (months or sometimes years) to heal. Healing is a gradual process and the resulting scar is usually shiny pink or red with distinct white marks. Venous ulcers can come back even after they heal CHRONIC VENOUS DISEASE DIAGNOSIS Doctors can diagnose chronic venous disease by examining a person and asking about symptoms of the disorder, such as the presence of varicose veins, swelling in the legs, skin changes, or skin ulcers. They often also do additional testing, such as an ultrasound, to look at vein valve function and to identify ifthe problem is located in the superficial veins or the deep veins, (See "Diagnostic evaluation of chronic venous insufficiency" ) CHRONIC VENOUS DISEASE MANAGEMENT Treatment of chronic venous disease is focused on reducing symptoms, such as swelling, treating skin problems, and preventing and treating ulcers. (See "Medical management of lower extremity chronic venous disease",) Leg elevation — Simply elevating the legs above heart level for 30 minutes three or four times per day can reduce swelling and improve blood flow in the veins. Improving blood flow can speed healing of venous ulcers. However, it may not be practical for some people to elevate their legs several times per day Leg elevation alone may be the only treatment needed for people with mild chronic venous disease, but additional treatments are usually needed in more severe cases. Exercises — Foot and ankle exercises are often recommended to reduce symptoms. Pointing the feet down hitpiwwwuptadate.comiontents/chronic-venaus-sisease-beyond-the-basics?view= print 24yaeao4 Chronic venous disease and up (movement from the ankle) several times throughout the day can help to move blood from the legs and back to the heart. This may be especially helpful for people who sit or stand for long periods of time. Walking is a good exercise for the calf muscle pump. People with chronic venous disease who walk less than 10 minutes a day have a greater risk for developing venous ulcers than those who are more physically active. Compression therapy — Most experts consider compression therapy to be an essential treatment for chronic venous disease [1,2]. Compression stockings are recommended for most people with chronic venous disease. People with more severe symptoms, such as venous ulcers, often need treatment with ‘compression bandages. Compression stockings — Compression stockings gently compress the legs, and may improve blood flow in the veins by preventing backward flow of blood. Effective compression stockings apply the greatest amount of pressure at the ankle and gradually decrease the pressure up the leg, These stockings are available with varying degrees of compression. * Stockings with small amounts of compression can be purchased at pharmacies and surgical supply stores without a prescription = People with moderate to severe disease, those on their feet a lot, and those with ulcers usually require prescription stockings. A healthcare provider may take measurements for stockings, or may write a prescription for stockings which can be filled at a surgical supply or specialty store where trained staff take the necessary measurements. ‘Stockings are available in several styles, including knee-high, thigh-high, and pantyhose with open or closed toes. Knee-high stockings are sufficient for most people. Some people experience skin irritation or pain, especially with initial use of compression stockings, which can be related to improper ft. The following figures show tips for using compression stockings (able 1 and figure 1A-C), Intermittent pneumatic compression pumps — Standard compression stockings may be less effective or difficult to use if you are very overweight or have a lot of swelling. An alternative approach is the use of intermittent pneumatic compression (IPC) pumps [3] These devices consist of flexible plastic sleeves that encircle the lower leg. Air chambers lining these plastic sleeves periodically inflate, compress the leg, and then deflate. These are generally used for four hours per day. ‘Similar to compression stockings, IPC pumps may be painful for some people, particularly with initial use, but this improves as swelling is reduced with treatment. Compression bandages — People with severe symptoms, like ulcers, may need to be treated with ‘compression bandages. Compression bandages look similar to a soft cast, and are applied on the leg by an experienced nurse or doctor. Topical medicines may be applied to the skin, and if ulcers are present, they may be covered with special dressings before compression bandages are put on. ‘The bandages are usually changed once or twice a week and must stay dry. A cast bag or other plastic bag can be placed over the compression bandage to keep it dry while showering, If you have compression bandages and they get wet, you should contact your doctor to have them changed. Dressings — Ulcers are usually covered with special dressings before putting on compression stockings or ‘compression bandages. Dressings are important to help ulcers heal. They are used to absorb fluid oozing out of the wound, reduce pain, control odor, remove dead or infected cells, and help new skin cells to grow. There are several types of dressing material used for venous ulcers. The type and frequency of dressings is determined by the size of the ulcer, amount of drainage, and other factors. Medications — A variety of medications have been used for chronic venous disease and venous ulcers. = Aspirin (300 to 325 mg/day) may speed the healing of ulcers. itp tw uptodate.comicontetsichronic-venous-disease-beyondthe-basis?view=rint aneyaeao4 Chronic venous disease = Antibiotics are only recommended when there is an infection, + Horse chestnut seed extract reduces swelling and leg size in people with chronic venous disease. It may be recommended for people who cannot tolerate compression therapy, usually at a dose of 300 mg twice daily. Horse chestnut seed extract is available as a dietary supplement and does not require a prescription. However, its production is not regulated, and the dose may vary from one pill or bottle to another. 1» Hydroxyethyirutoside is a prescription medication available in Europe that can reduce leg volume, swelling, and other symptoms + The skin irritation caused by chronic venous disease, called stasis dermatitis, usually gets better with the use of moisturizers. Sometimes, a steroid cream or ointment is needed to help with itching and inflammation. Other creams and ointments, anti-itch products, and scented lotions should be avoided because there is a risk of developing an allergic rash (contact dermatitis) from these products. Treatment of contact dermatitis — Contact dermatitis is an allergic skin reaction that occurs when an irritating or allergy-producing substance touches the skin, The reaction can occur on the legs or other areas of the body. Contact dermatitis is common in people with chronic venous disease. Treatment of contact dermatitis is discussed separately. (See “Patient information: Contact dermatitis (including jatex dermatitis (Beyond the Basics)",) VEIN ABLATION TREATMENTS. Vein ablation treatments are treatments designed to destroy superficial veins that have abnormal valve function. These treatments are usually reserved for people with symptoms who do not respond to the treatments described above. (see ‘Lea elevation’ above and ‘Exercises’ above and ‘Compression stockings’ above and ‘Dressings’ above). Veins are destroyed in one of three ways: Sclerotherapy — For this procedure, the doctor injects a chemical into the diseased vein that causes it to collapse on itself. The vein stays in place, but it no longer carries blood, Sclerotherapy can be done in a doctor's office with local anesthesia (See "Liquid and foam sclerotherapy techniques for the treatment of lower extremity veins") Radiofrequency or laser ablation — For these procedures, the doctor inserts a special wire into the diseased vein. This wire heats up the vein and seals it from the inside (figure 2). The vein stays in place, but it no longer carries blood. These procedures involve no surgery and can be done with very little anesthesia. They can often be done in a doctor's office. (See "Clinical manifestations of lower extremity chronic venous dis ) Vein ligation or stripping — These procedures involve surgery to remove the diseased vein or veins. People who have these procedures must be treated in a hospital or surgery center. Veins are removed through many small incisions, ‘SUMMARY + Chronic venous disease is a problem that affects the veins of the legs. Normally, the leg veins carry blood back to the heart. In people with chronic venous disease, the veins do not work well. This can cause blood to collect in the lower logs and feet. «People with chronic venous disease often report that their legs fee! heavy, tired, or achy. These hitpiwwwuptadate.comiontents/chronic-venaus-sisease-beyond-the-basics?view= print anarars014 Chronic venous disease problems are more common at the end of the day or after standing for long periods. The feet and ankles may also become swollen, + People who have chronic venous disease can develop problems such as skin infections, skin color changes, rashes, or sores that do not heal. These sores, called ulcers, can be difficult to treat, and sometimes take months or years to heal + The goal of treatment is to improve symptoms, reduce swelling, and prevent skin infections and ulcers. + Treatments for swelling include propping up the legs when possible, wearing stockings that gently compress the ankles and lower legs, performing foot and ankle exercises, and walking + Treatments for skin ulcers include special coverings for the area and antibiotics if there is an infection. ‘Some people need compression bandages to help ulcers heal = Antibiotic ointments or salves that are rubbed on the skin, anti-itch creams, and scented lotions are not recommended because these products can cause an allergic skin reaction + Vein ablation treatments (sclerotherapy, laser or radiofrequency ablation, or surgical stripping) are an ‘option for people who have symptoms that do not respond to other treatments. WHERE TO GET MORE INFORMATION Your healthcare provider is the best source of information for questions and concerns related to your medical problem. This article will be updated as needed on our web site (\www.uptodate,com/patients). Related topics for patients, as well as selected articles written for healthcare professionals, are also available. Some of the most relevant are listed below. Patient level inform: n — UpToDate offers two types of patient education materials. The Basics — The Basics patient education pieces answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials. Patient information: Deep vein thrombosis (blood clots in the legs) (The Basics} Patient information: Swelling (The Basics Patient information: Varicose veins and other vein disease in the legs (The Basics) Patient information: Pulmonary embolism (blood clot in the lungs) (The Basics! Patient information: Doppler ultrasound (The Basics, Patient information: Superficial phlebitis (The Basics! Patient information: Vein ablation (The Basics Beyond the Basics — Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed, These articles are best for patients who want in-depth information and are comfortable with some medical jargon. Patient information: Edema (swelling) (Beyond the Basics Patient information: Contact dermatitis (including latex dermatitis) (Beyond the Basics} Professional level information — Professional level articles are designed to keep doctors and other health professionals up-to-date on the latest medical findings. These articles are thorough, long, and complex, and they contain multiple references to the research on which they are based. Professional level articles are best for people who are comfortable with a lot of medical terminology and who want to read the same materials their doctors are reading. Classification of lower extremity chronic venous disorders hitpiwww uptadate.comicontents/chronic-venaus-sisease-beyond-the-basics?view= print 54yaeao4 Chronic venous disease i if f remity chroni Diagnostic evaluation of chronic venous insufficiency Medical management of lower extremity chronic venous disease Pathophysiology of chronic venous disease. Post-thrombotic (postphlebitic) syndrome Liquid and foam sclerotherapy techniques for the treatment of lower extremity veins The following organizations also provide reliable health information. = National Library of Medicine (www.nim.nih.gov/medlineplus/healthtopics. html = National Heart, Lung, and Blood Institute (wwww.nhibi_nih gov!) + American Venous Forum (httovwww.veinforum.ora/patients) 1-4 Literature review current through: Nov 2014. | This topic last updated: Jul 8, 2013. The content on the UpToDate website is no intended nor recommended as a substitute for medical advice, diagnosis, of treatment. Always sok the advice of your onn physician ar other qualfied heath care protessional regarding any medical questions or conditions, The use of hs website is gaverned by the UpToDate Terms af Use ©2014 UpToDate, Inc. References 1, Douglas WS, Simpson NB. Guidelines for the management of chronic venous leg ulceration. Report of a multidisciplinary workshop. British Association of Dermatologists and the Research Unit of the Royal College of Physicians. Br J Dermatol 1995; 132:446. 2, Nelson EA, Bell-Syer SE, Cullum NA. Compression for preventing recurrence of venous ulcers. Cochrane Database Syst Rev 2000; :CD002303. 3, Mani R, Vowden K, Nelson EA. Intermittent pneumatic compression for treating venous leg ulcers. Cochrane Database Syst Rev 2001; :CD001899. 4, Callam MJ. Epidemiology of varicose veins. Br J Surg 1994; 81:167. hitpiwwwuptadate.comiontents/chronic-venaus-sisease-beyond-the-basics?view= print enayaeao4 Chronic venous disease GRAPHICS Telangiectasias (spider veins) on the lower leg This is a picture of telangiectasias (spider veins), which are small veins that are swollen, These are also called "hyphen webs" or "thread veins. Courtesy of Patrick C Alguire, MD. Graphic 54276 Version 3.0 hitpiwwwuptadate.comiontents/chronic-venaus-sisease-beyond-the-basics?view= print m4yaeao4 Chronic venous disease Severe varicose veins This is a picture of varicose veins, which are swollen and twisted veins in the legs. Courtesy of Patrick C Alguire, MD. Graphic 71564 Version 2.0 hitpiwwwuptadate.comiontents/chronic-venaus-sisease-beyond-the-basics?view= print anayaeao4 Chronic venous disease This picture shows how a doctor or nurse can check for swelling in a person's foot, To check for swelling, a doctor or nurse presses down on the skin near the ankle (as shown in Picture A) and then lifts his or her finger up. If the skin stays indented (as shown in Picture B), the person has swelling Reproduced with permission from: Bickley LS, Szilagyi PG. Bates’ Guide to Physical Examination and History Taking, 9th ed, Lippincott Williams & Wilkins, Philadelphia 2005. Copyright © 2005 Lippincott Williams & Wilkins. Graphic 61706 Version 9.0 hitpiwwwuptadate.comiontents/chronic-venaus-sisease-beyond-the-basics?view= print ongyaeao4 Chronic venous disease Tips for using compression stockings Here are tips for using compression stockings: = Wash new compression stockings before wearing them to reduce thelr stiffness and to make them easier to put on. * Put on stockings as early as possible in the morning after you bandage any sores you have because swelling is less in the morning. If you do not put the stockings on early, raise your legs for 20 to 30 minutes before putting the stockings on. * When putting on stockings, sit on a chair with firm back support (not on the bed). + Knee-high stockings can be put on using the "heel-pocket-out method.” The heel-pocket- ‘out method to put on compression stockings is as follows: 1. Turn the leg part of the stocking inside-out down to the heel. 2. Put your foot into the stocking, hold onto the folded edge, and pull the stocking onto your foot and over the heel 3. Gently work the stocking up your leg by turning it right-side out. Some people find it helpful to wear rubber gloves to put their stockings on. This can make it easier to slide the stockings up the legs, + Heavy compression stockings may go on more easily if light silk pantyhose are worn under the compression stockings, or if you first put powder on your legs. * Skin moisturizers and treatments that are used to treat open sores can make the stockings dirty and wear them out. Wash the stockings each day after wearing them if possible, Stockings can be washed in cold water by hand. You can also wash them with cold water and a small amount of mild detergent in a washing machine. Hang the stockings up to dry, and do not dry them in a machine, Buying at least two pairs of stockings at 2 time will let you wear one pair while the other pair is drying. If you have an allergy to rubber (latex), you can buy compression stockings without elastic. If you are not able to pull on your stockings, talk with your doctor or nurse. There are different stockings you can use or devices that can help you put on stockings. Graphic 57705 Version 5.0 hitpiwwwuptadate.comiontents/chronic-venaus-sisease-beyond-the-basics?view= print sonyaeao4 Chronic venous disease Putting on compression stockings Graphic 81922 Version 3.0 hitpiwwwuptadate.comiontents/chronic-venaus-sisease-beyond-the-basics?view= print a4yaeao4 Chronic venous disease Heel-pocket-out method to put on compression stockings The heel-pocket-out method to put on compression stockings is as follows: 1, Turn the leg part of the stocking inside-out down to the heel (as shown in A) 2. Put your foot into the stocking, hold onto the folded edge, and pull the stocking onto your foot and over the heel (as shown in B). 3. Gently work the stocking up your leg by turning it right (as shown in C). Graphic 53659 Version 7.0 hitpiwwwuptadate.comiontents/chronic-venaus-sisease-beyond-the-basics?view= print raneyaeao4 Chronic venous disease Using a stocking donner to put on compression stockings Graphic 80635 Version 2.0 hitpiwwwuptadate.comiontents/chronic-venaus-sisease-beyond-the-basics?view= print sanChronic venous disease yaeao4 Radiofrequency vein ablation )n, the doctor inserts a special wire into the diseased vein. The wire heats up the vein from the inside and seals it closed. Laser vein ablation works in a very similar way. Graphic 87609 Version 1.0 hitpiwwwuptadate.comiontents/chronic-venaus-sisease-beyond-the-basics?view= print sana