Varicose Veins and

Chronic Venous
Insufficiency in
General Practice
Varicose Veins and associated symptoms
 How to proceed

1st edition 1981

Prof. Dr. H. Fischer, Tübingen Great saphenous vein
Dr. H. G. Füllemann, Basel
Prof. Dr. U.V. Brunner, Zürich
Prof. Dr. H. Partsch, Wien
Dr. R. Stemmer, Strasbourg
Prof. Dr. L.K. Widmer, Basel

2nd edition 1994

additional editors:
Dr. R. Fischer, Chirurgie, St.Gallen
Prof. Dr. K. Jäger, Basel
Dr. A. Oesch, Bern
Prof. J. Weber, Hamburg
Prof. Th. Wuppermann, Darmstadt
Femoral vein
3rd edition 2001
revised by: Sapheno-femoral junction
Prof. Dr. H. Partsch, Wien
Prof. Dr. K. Jäger, Basel
additional editors:
Dr. A. Frullini, Firenze
Dr. R. Weiss, Baltimore
Dr. M. Schadeck, Paris
Contents

is the diagnosis «varicose veins» enough? 2/3

do complications occur? 4/5

varicose veins occur frequently 6

varicosity – progression to be observed  7

classification? 8/9

medical history – specific questions? 10

differential diagnosis: furtheR INVESTIGATIONS 11

venous examinations: points to be considered 12/13

when are additional tests necessary? 14

etiology of varicose veins 15

instrumental diagnosis
cw Doppler 16
Duplex ultrasound 17
Venous Pump Function Test 18
Venography 19

TREATMENT?
Conservative 20
Sclerotherapy 21
Phlebectomy 22
Stripping 23

medical compression stockings 24/25

selected bibliography 26

guidelines for patients with venous disorders 27

1
Is the diagnosis «Varicose Veins» enough? 14, 15, 18, 23

Small Varicose Veins (CEAP-Classification C1)

telangiectasias reticular veins

Intradermal spider veins (web-like), <1 mm subdermal reticular veins, <3 mm

«Varicosity» is an inadequate diagnostic term.

A complete diagnosis of varicosities takes into consideration:
• the medical significance
• the complication rate
• the appropriate treatment


Large Varicose Veins (CEAP-Classification C2)

truncal varicosis side branch varicosis truncal varicosis

(Great Saphenous Vein) (Anterior Thigh Circumflex Vein) (Small Saphenous Vein)

Great saphenous vein with Circumflex vein: lateral branch Small saphenous vein –
pronounced chronic venous of the greater saphenous vein varicosis
insufficiency in medial ankle area


Do complications occur? 23

Chronic Venous Insufficiency (CVI)

?
Valvular insufficiency of deep-, superficial-,
Check presence of
and perforating veins results in:
CVI in ankle area?
venous hypertension with
signs of chronic venous
insufficiency

Stage I Stage II Stage III

ceap c 6
Ceap c 3 ceap c 4 C 5 = healed ulcer

Corona phlebectatica: Skin changes: Leg ulcer:

dilated cutaneous Pigmentation, Eczema, Florid ulcer
veins and oedema induration, atrophie blanche or scar

Type of varices and degree of CVI determines the division into:

mild pronounced or serious

mild or medium reticular veins,
spider veins, mild superficial trun-
cular varices
Combination of pronounced
reticular varicosis and spider
veins, pronounced truncular
varicosis and insufficient perfo-
rating veins
Skin changes resulting from
venous insufficiency (with or
without varices, often seen
with corona phlebectatica)

Mild varicosis Pronounced varicosis CVI

(C1 – C 2) (C 2 – C 3) (C 4 – C 6)


 Superficial Thrombophlebitis

Varicosity
combined
with:

Deep vein Thrombosis before Rupture of Varices after

Pulmonary embolism Pulmonary angiogram Pulmonary CT

Embolus


Varicose Veins occur frequently 23

complication rate is an indicator of medical relevance

mild pronounced serious

+ ++ +++

44 % 9% 3%

Varicosis + ++ ++

Complications Ø   + ++

impairment of health health risk disease

Significance low

Venous Changes Medically relevant varicosity

(Disorder) (Disease)

Treatment Must be treated!

depends on
symptoms or
complaints

More than 50% of the adult working population suffer from varicose veins
or from signs of chronic venous insufficiency. The frequency rises with
increasing age (23).


Varicosity – Progression to be observed 23, 25

Varicose veins mild pronounced serious

Frequency in adults 44% 9 % 3%

+ ++ +++

Progression after 11 years

Complication rate (%)

Skin changes 21 34 56

Oedema   8 19 30

Ulceration   1   1 20

Phlebitis   8 17 37

Pronounced varicose veins – dependent on age and other factors – should

be treated! (recurring phlebitis in 37%, leg ulcer in 20% after 11 years.)


Classification? CEAP 18

C
Clinical Classification
C Clinical picture
C0 no clinical signs
C1 small varicose veins
C2 large varicose veins
Inspection, Palpation
C3 edema
(Doppler)
C4 skin changes
C5 healed ulcer
C6 active ulcer

E
Etiology
E Etiology
EC Congential
EP Primary Medical history
ES Secondary

A
Anatomy
A Anatomy
AS Superficial
Inspection
AD Deep
Additional examination
AP Perforating veins

P
Pathophysiology
P Pathophysiology
PR Reflux Additional examination
PO Obstruction (Basis = Duplex)

An anatomical score, a clinical score and a score for the evaluation of the
patient’s disability serve further differentiation:

Anatomical score Clinical score (0–2) Disability score

Segment 1–18 Pain 0)  Asymptomatic
e.g. Eedema 1)  Symptoms, but no
#2: Great Saphenous Vein Venous Claudication     compression
    above knee Pigmentation     necessary
#3: Great Saphenous Vein Lipodermatosclerosis 2)  8 hours work, with
    below knee Size of ulcer     compression possible
#4: Small Saphenous Vein etc. Form of ulcer     only
Recurrence of ulcer 3)  Unable to work even
details ref. (18) Number of ulcer     with compression


Clinical Classification (C) with examples

C1 telangiectasias C 2  VARICOSE veins

C 1 E PA S P R C 2 E PA S,p P R

C 3  edema+Corona C 4 lipodermato­
sclerosis and eczema

C 3 E s A d P o,R C 4 E PA S,P P R

C 5  Ulcer-SCAR C 6  ACTIVE ulcer

C 5 E s A S,d,P P o, r C 6 E s A d, p P R

Medical history – specific questions? 2, 9, 23

Patient complaints?

feeling of heavy legs, swollen legs, feeling of tension,

restless legs, aching legs, nocturnal cramps

Exacerbated:
• when sitting, standing, travelling
• in warm environment
• in the evening
• premenstrual syndrome (PMS)

Presently Previous history

Reason for visit First appearance of varices
symptoms spontaneous
cosmetic considerations post partum
preventative postoperative/injury
age related
Type of complaint
cf. above Complications
superficial phlebitis
Swelling
cellulitis
occasionally eczema
daily ulceration
evenings only deep vein thrombosis
starts in the morning pulmonary embolism
Degree of incapacitation Progression
Impairs ability to work:
rapid
yes no
slow
Risk factors
Treatment
routine activities compression
sitting occupation medication, ointment
standing occupation sclerotherapy
obesity surgery
oral contraceptives, HRT
(hormone replacement therapy)

10
Differential Diagnosis: Further Investigations

rheumatological

▼▼▼▼▼
LEG ACHE neurological
but not specifically orthopedic caUses
lymphatic
vein achE
arterial

Where What Pathological findings Possible diagnosis i.e.

Nail and Trophic changes Fungal infection

interdigital area Fissures Dermatitis
Inflammation Basal cell carcinaoma
Edema Melanoma
Tumors
Skin

Toes Malposition Hallux valgus

Hammertoe
Foot sole Calluses Splay-, club-, flat-footed

Foot arches

Leg axis Malposition Knock knee, bowleg

Joint Motility, friction Osteoarthritis/arthritis

Baker’s cyst

Joints

Palpation Pulses from foot to groin Peripheral-arterial

(Aneurysm) occlusive disease

Auscultation Bruit in popliteal area,

thigh, pelvis, abdomen
Leg arteries

Knee Swelling, joint effusion,

warmth to touch
Meniscus, ligaments Check function meniscal or tendon injury
Level of pain Lesion, peritendonitis,
Tendons, muscles,
muscle spasm
Soft tissues insertions

Motility Lasègue, reflexes, strength Discopathy

Postural Sensibility, sense of vibration Neuropathy

distortion (tuning fork)

Spine / nerves

11
Venous examination: points to be considered 15, 18, 23

Patient must be in standing position!

3 examination in groin area

Suprapubic collaterals
Coughing provokes retro- following pelvic deep-
grade flow-wave vein thrombosis (DVT)
3

1 degree of varicosity
Pronounced
2

2 insufficiency of perforating veins:

Blow-out with con- Check for edema
secutive malleolar CVI behind the ankle
Patient turns around
360°

12
…patient in supine position

4 comparative palpation
with muscles relaxed.

Increasing tone suggests

venous thrombosis and
postthrombotic syndrome

5 edema in thigh, pretibial 6 palpation:

or malleolar region, or in Superficial phlebitis
dorsum of the foot Indurations
Differential diagnosis includes Nodes
lymphatic edema Contact dermatitis

5
6

CIRCUMFERENCE:
indicate exact height and time
of day

13
When are additional tests necessary? 8, 14

additional examination Questions to be asked

Prior to each active therapy Is valve function at junction and

in perforating veins adequate?
• Pronounced CVI • Unobstructed flow in deep venous system
• Recurrence after therapy • Check perforating veins
• Post-DVT condition • Function of venous valves
• Atypical varicosities • Angiodysplasia7
• «doubled» saphena?

Recurrence: Duplex Deep venous insufficiency:

Convoluted varicosities in Great saphenous vein, Pseudoaneurysmatic distention
inguinal region following cross section of the thigh: of popliteal vein; deep venous
incomplete ligation «Egyptian Eye» system and insufficiency of
muscular calf veins

14
Etiology of Varicose Veins 23, 24

Pathogenesis
Primary varicosities Secondary varicosities
Venous wall weakness, Blockage or insuffici-
valvular insufficiency ency in deep veins
in superficial and deep
vein

in the superficial venous system The pathological in the deep venous system
process begins

Hypothetical Established
Heredity and environmental Thrombosis, valvular
factors, e.g. age, Etiology dysplasia, obstruction,
occupation, pregnancy, tumor, arterio-venous
overweight shunt

95% Frequency 5%

rare, less pronounced Chronic venous frequent, more pronounced

insufficiency

Treatment consists in Mostly symptom-

eradicating varices directed therapy
Treatment by
• By means of sclero- • Specialist
therapy or surgery

15
Instrumental Diagnosis CW Doppler 8, 14

1 check if blood flow in deep veins is adequate

(Examination in supine position)
Pathological: flow not breath-dependent
Normal: blood flow is breath-dependent (e.g. proximal phlebothrombosis)

Ein Ein

Aus Atmung Aus Atmung

proximal proximal

0 0
Doppler Doppler

distal distal

2 check if valves of deep or superficial veins function

properly
(Examination in standing or sitting position)
Pathological: Valsalva manoeuvre ➞ Doppler
Normal: Valsalva  ➞  no flow on Doppler reveals reflux

Ein Ein

Valsalva Valsalva

Aus Aus

proximal proximal

Doppler Doppler
0 0

distal distal

16
Duplex ultrasound 4, 8, 14

principle
B-Imaging: Imaging of vessels and surrounding tissues
Doppler: • Quantification and direction of blood flow
• Hemodynamic information displayed in color and superimposed on morphological
image
Sapheno-femoral junction

Orthograde flow (blue) Incompetent junction: reflux with Valsalva (red)

performance
Advantage: High information content, non-invasive
Disadvantage: User dependent picture, does not give overview picture

Distal thigh
Great saphenous vein (longitudinal section)

Normal: orthograde flow (blue) Reflux with Valsalva (red)

when is additional duplex ultrasound imaging Indicated?

Prior to active therapy, particulary in:
• unclear cw-Doppler results • recurrence after surgery
• varicosity with trophic skin changes (CVI 2 – 3) • after deep venous thrombosis (DVT)
• small saphenous vein incompetence • atypical varicosis (Angiodysplasia)
(localization of junction)

17
Venous Pump Function 14, 19, 21

Principle
Recording of volume or pressure changes at the distal lower extremity leg
during ankle-movement (tip-toes, knee bending, walking)
Methods
Photoplethysmography, strain gauge-plethysmography, foot volumetry,
air plethysmography (APG), measurement of pressure in a dorsal foot vein.

Pump
Normal: competent incompetent Pathological:
Movement ac- No reduction of
tivates the venous blood volume
blood pump. Re- (pressure) as a
duction of local result of valvular
blood volume insufficiency.
and venous pres- Blood flows back
sure in the foot and forth.
and distal lower
leg
Normal venous pump Venous (pump) insufficiency

Compression of superficial vein segments by finger or

tourniquet may block refluxes.

Normaliza- No normali-
tion of pumping zation of pum-
by elimination of ping: incompe-
superficial reflux: tent deep veins
normal valvular
function of deep
veins

18
Venography
Varicose veins
Clarification of specific
questions (recurrence,
atypical course, evaluation)
acute thrombosis
If Duplex examination is
not conclusive
vascular malformation
Evidence of av-fistulas,
axial abnormalities,
phlebectasias, absence
of valves
contraindications
Pregnancy, allergy to contrast
medium, renal insufficiency
techniques
10, 11, 12, 14
Ascending pressure veno-
graphy
Venography with spot films, punc-
ture of dorsal vein of foot with but-
terfly needle, ankle compression
forces contrast medium into deep
veins, Valsalva manoeuvre disco-
vers back-flow of contrast medium
in the deep veins and valvular
insufficiency in the perforating
veins.
Varicography
Direct puncture of superficial vari-
ces with diluted contrast medium,
phleboscopy
Descending venography
Femoral vein puncture, imaging
of the great saphenous vein
and thigh branch varices during
Venography combined with ve-
­valsalva manoeuvre. Inguinal
nous pressure measurement on
­puncture indicated in pelvic or
the foot (phlebodynamometry)
cava pathology.
Venography with phlebo-
dynamometry
to test venous function
Varicosis of small saphenous vein
with high junction
Varicosity at ankle
Cockett
Ankle perforating vein
Stem varicosity greater
saphenous vein
(white arrows)
19
Treatment Conservative? 1, 17

Purpose
to alleviate discomfort, to prevent progression and complications

1 Prophylaxis
• Regular exercises («muscle pump»)
• Elevation of legs
• Advice for patients confined to bed, travelling

Sklero- Phleb-
sierung ektomie Operation
2 compression treatment
• Compression bandage: fresh swelling,
ulceration, lymphatic oedema, angiodyspla-
sia, venous swelling.
• Medical compression stocking for
leg complaints, pregnancy, pronounced
varicosis, CVI

Beratung
Kompressionsbehandlung 3 active treatment
Medikamente • Sclerotherapy
• Phlebectomy
• Surgery
4 medication (does not substitute points 1–3)

• for short-term relief of: pain, menstrual sym-

ptoms, travel discomfort, especially during
­summer months

Patient information
Implications, possible complications
Any active treatment:
• removes only existing varices
• disposition to varicosis remains

20
Sclerotherapy 7, 16, 20, 22, 24

principle
• Sclerosing agent destroys
endothelium.
• Plasma leaks into the vein
wall, fibrin formation. Che-
motactic signals activate the
connective tissue cells which
obliterate the vein lumen.
indications/
contraIndications
Indication
Spider veins, side branch varico-
sis, residual and recurring posto-
perative varicose veins.
Contraindication
Confinement to bed, allergy,
pronounced oedema, peripheral
­arterial occlusive disease (systolic
ankle-pressure below 80 mm Hg),
1. trimenon of pregnancy,
recent throm­bosis.
Technique
Different methods were descri-
bed, e.g. by Sigg, Tournay,
Fegan. New procedures include
ultrasound assisted injection
which is also suitable for sclero-
therapy of the sapheno-femoral
junction (20), and foam-sclero­
therapy (7).

Side effects
Inflammation, pigmentation,
­matting, ulceration (CAVEAT: in-
traarterial injection!)

after Sigg after Tournay after Fegan

in standing position in supine position perforating veins first

New techniques

Echo-Sclerotherapy Foam-Sclerotherapy
(Injection controlled by Duplex)

Compression after sclerotherapy improves results (less thrombus formation,

fewer inflammatory reactions, less pigmentation)

21
Phlebectomy 13, 16, 19, 22
principle
Removal of individual varices
and smaller perforating veins by
incisions under local anestesia.
(«Outpatient phlebectomy» by
Muller13).
22
indication/
contraindication
Indication
Varices of any size, except
­hyphen webs. For main stem
­varicosities, branch ligation
or stripping are required in
­addition.
Contraindication
cf. sclerotherapy and stripping.
Side effects
Occasional pigmentation,
­damage to minor skin nerves,
lymph fistulas.
technique
Anesthesia of skin directly above
varicose vein. Incisions 1–3 mm
long at intervals of 3–10 cm.
Varices are extracted from the
elevated leg using a special
hook. Careful compression ban-
daging, no ligature of vessels
and no suture of vein
required.
POSTOPERATIVE
Compression for 3 weeks.
Stripping 3, 5, 6
principle
Comprehensive correction
under one-time anesthe-
sia:
Ligation of side branches, vein
stem is ligated at junction (Fig.
1). Vein is stripped and removed
with flexible wire (Fig. 2).
Perforating veins are ligated,
e.g., with endoscopy (Fig. 3).
Phlebectomy using clamp (Fig. 4)
POSTOPERATIVE
Compression for 3 weeks
Indication /
contraindication
Indication
Superficial main stem varicosi-
ties, especially for larger
varices
Contraindications
• Thrombosis in recent months
• Lymphatic oedema
(debatable)
Side effects
Sensory disturbance of femoral
and calf nerves, occasionally
hematomas and symptoms due
to scarring. Scarring is rare.
Technique
Minor operations are possible
on outpatient, basis major sur-
gery better in hospital.
Spinal or general
anesthesia
New techniques:
Subfascial endoscopic perfora-
tor sugery (SEPS), Cryoprobe,
obliteration with heat source
(electromagnetic waves, laser).
TIPP (transilluminated powered
phlebectomy=removal of side
branches by suction). Paratibial
fasciotomy in CVI.
23
 Medical
Compression Stockings 17

For the purpose of:

• Basic treatment
• Decongestion
• Slowing down the progression of the disease
• Assuring successful treatment
• Prophylaxis of thrombosis
• Prevention of trophic disturbances

What degree of compression – When?

Depending on the indication, there are 4 compression classes

20-30 mmHg 30-40 mmHg

• Prophylaxis of venous disorders • More severe varicosis during
for patients at risk pregnancy
• Heaviness and fatigue in the leg • Varicosis with mild edema
• Mild varicosis during pregnancy • After superficial and deep
• Mild varicosis without significant thrombophlebitis
edema • Chronic venous insufficiency,
CEAP (C2–C4)
• After sclerotherapy or surgery to
maintain therapeutic success
• After healed venous ulcer in
chronic venous insufficiency (C5)

40-50 mmHg 50-60 mmHg

• Pronounced varicosis with • Serious postthrombotic syndrome
marked edema involving the pelvic area
• Advanced chronic venous • Irreversible lymphedema
insufficiency (Stage II and III),
CEAP (C3–C6)
• After healing of serious and
recurrent ulcers
• Posttraumatic edema
• Reversible lymphedema

Contraindications Cautions
Contraindications:
• Seriously
Arterial insufficiency, intermittent impaired
claudication, ischemiaarterial blood flow,
• oozing
Signs ofdermatoses,
infection infections, decompensated
• Uncontrolled congestive heart failure • Extensive venous ulceration
­c• ardiac failure, diabetic neuropathy and
Acute dermatitis, weeping dermatosis, cutaneous sepsis
microangiopathy. Unless
•
prescribed otherwise
Skin sensitivities or allergies
by physician compression
stockings
• class 30 mmHg or greater are not
No liability accepted for non-observance of contraindicationsworn during bedrest/confinement
• Neuropathy to bed. No liabiliy accepted for
non-observance of contraindications. • History of diabetes
• Confinement to bed or non-ambulatory use unless
otherwise prescribed by the physician
• No liability accepted for non-observance of cautions

24
Compression Stockings – how to prescribe?

the prescription for compression stockings should con-

tain the following information:

1. Number of Stockings

2. Model (e.g. SIGVARIS calf A – D)

3. Compression level

4. «Made-to-measure»-stockings, if necessary

5. Special fixation/grip-tops

6. Phlebologic or other diagnosis

7. Open/closed foot 

• Made-to-measure stockings are indicated in

particular anatomical conditions, especially
abnormal circumference or length of the leg.

• Prescription of «medical compression stockings

and pantyhoses» only. Do not use the term
«support stocking».

• Replace compression stockings after 6 months

following a medical check-up.

• Use SIGVARIS Phlebo-Press Pads to transfer or SIGVARIS Phlebo-Press Pads

intensify the concentric compression onto the
medial and lateral ankle area.

25
Selected Bibliography

  1 ABENHAIM L., CLEMENT D., NORGREN L. et al.: The management of chronic venous disorders of
the leg: an evidence-based report on an international task force. Phlebology 14, Suppl. 1, 1999
  2 BLÄTTLER W.: Über einen eventuellen Zusammenhang zwischen Venenbeschwerden und
psychischem Befinden. VASA 1991 Suppl. 32:599
  3 BRUNNER U.: Die Chirurgie des oberflächlichen Venensystems. In: Breitner: Chirurgische
Operationslehre, 2.Aufl./1993, Band Xll Teil 1: Gefäßchirurgie
  4 EICHLISBERGER R., FRAUCHIGER B., JÄGER K.: Abklärungen der Beinvenen mit Duplexultraschall.
Therap. Umschau 48, 697, 1991
  5 FISCHER R.: Die chirurgische Behandlung der Varizen. Aktuelle Probleme in der Angiologie:
29. H. Huber, Bern, Stuttgart, Wien, 1976
  6 FISCHER R.: Eine neue Generation der Varizenchirurgie? Vasa 20, 311 (1991)
  7 HENRIET P.: Foam-Sclerotherapy. In press.
  8 JÄGER K., BOLLINGER A.: Duplex-Sonographie der Becken- und Extremitätenvenen. Praxis der
Doppler-Sonographie (Hrsg.: Kriessmann A., Bollinger A., Keller H. M.), Thieme, Stuttgart, 118,
1990
  9 LEU A. und LEU H. J.: Pein im Bein – Differentialdiagnose von Ödem/Schmerzen der unteren
Extremitäten. VASA 18, 246, 1989
10 LEU H. J.: Pathomorphology of Vascular malformations. Intern. Angiology 9,147, 1990
11 MAY R., KRIESSMANN A.: Periphere Venendruckmessung. Thieme, Stuttgart 1978
12 MAY R., WEBER J. (eds.): Pelvic and Abdominal Veins. Progress in Diagnostics and Therapy.
Excerpta Medica, Amsterdam, Oxford, Princeton, 1981
13 MULLER R.: La phlébectomie ambulatoire. Phlébologie 31, 273 (1978)
14 NICOLAIDES AN., Investigation of Chronic Venous Insufficiency – A Consensus Statement.
Circulation 102,e126 (2000)
15 OESCH A.: Formen und moderne Therapie der Varikosis. Schweiz. med. Wschr. 1242 (1988)
16 OESCH A.: Indikationen und Ergebnisse der ambulanten Varizentherapie. Therap. Umschau 48,
692 (1991)
17 PARTSCH H., RABE R., STEMMER R.: Kompressionstherapie der Extremitäten. Editions Phlebologi-
ques Françaises , Paris, 1998
18 PORTER JM., MONETA GL., International Consensus Committee on Chronic Venous Disease:
Reporting Standards in Venous Disease: An Update. J Vasc Surg 21, 635, 1995
19 RAMELET AA., MONTI M., Phlebology. The Guide. Elsevier Amsterdam 1999
20 Schadeck M., Duplex Phlebology. Gnocchi, Napoli 1994
21 Weber J., May R.: Funktionelle Phlebologie, Phlebographie, Funktionstests, interventionelle
Radiologie. G. Thieme, Sturttgart-New York, 1990
22 Weiss RA., Feied CF., Weiss M.: Vein diagnosis and treatment. McGraw-Hill, New York 2001
23 Widmer LK., Stähelin HB., Nissen C., da Silva A.: Venen-, Arterien-Krankheiten, koronare
Herzkrankheit bei Berufstätigen. Hans Huber, Bern, Stuttgart, Wien 1981
24 WUPPERMANN Th.: Varizen, Ulcus cruris und Thrombose, Springer-Verlag, Heidelberg 1986
25 Zbinden O.: Progredienz der Varikosis. Veränderung des Varizenbefundes in 11 Jahren. Thesis,
Universität Basel 1994

26
 This leaflet can be
ordered separately!

Guideline for Patients with Venous Disorders

The arteries supply our cells, muscles and organs Stasis causes:
with nutrients. The veins transport waste products • Development of varicose veins
to the body’s stations for detoxification, and back • Swollen legs, edema
to the heart. The sufficient function of this cycle is
• Leg ulcers
essential for living and to stay healthy.
• Risk of thrombosis
During sitting, standing and walking the venous
blood must flow «uphill». In healthy veins this pro-
blem is easily overcome by the calf muscle pump.
Venous disorder however can lead to stasis in the
legs.

How to prevent stasis in the legs?

1. By activating the calf muscles (walking, jiggling the foot)

the venous blood is pumped towards the heart.
This function is called «muscle pump».

2. By elevating the legs.

3. By wearing medical compression stockings or compression

bandages. They produce external pressure on varicose veins and
swelling, and increase blood flow towards the heart.

27
Advices
Unlike in other diseases, the patient can take preventive measures against the development of venous diseases and can
support the physician with treatment of the disease.

Six practical advices:

No. 1

Avoid sitting and standing Lying down or walking is better

This means: more movement, walking, walking the stairs, gymnastics, cycling, swimming and all other sports which
activate the muscles of the leg.

NO. 2
When sitting or standing cannot be avoided:
activate muscle pump!

This means: when sitting or standing, feet should be frequently moved up and down
(«pumping»).
At work, or during long tavel hours in car, train or plane: get up/out more often and move a
few steps.

NO. 3
wrong During the day:
foots higher on a chair
on the windowsill
than on the desk

the heart

At night:
15 cm right elevate foot of the bed,
ideally the frame is adjustable,
or put a pillow under the
matress
This means: relieving the veins by repeated 15 cm
leg elevation.

NO. 4
Avoid excessive heat

No hot baths – no sunbathing – always avoid sunburns on the legs

Daily, cold showers are ideal:

They always begin at the foot – alternating the outside and inside of the foot –
1 to 2 times a day, 15 seconds on each leg

28
 NO. 5
Avoid overweight

It stresses heart, arteries and veins

This means concisely:

ER = Eat Right
EH = Eat Half

NO. 6
Consequent, daily wearing of medical compres-
sion stockings. In general, «support stockings»
prove not to be sufficient

Special medical prescription, e.g.

after thrombosis
during pregnancy
for swollen legs
for pronounced, bulging varicose veins

Special cases
• Confinement to bed
Lying in bed for a longer period of time in the hospital or at home, can lead to thrombosis (formation of blood clots in the
veins). This can affect in particular patients suffering from venous disease, but also healthy people.

How to prevent thrombosis?

– By elevating the foot of the bed
– By frequent moving of the legs (e.g. circulating foot movements, jiggling of the foot, «playing the piano» with the toes,
pulling and streching the leg etc.)
– By repeated «flushing of the lungs» – ca. 10 times deep inhaling and strong exhaling.
– Patients with bulging varicose veins, after thrombosis or pulmonary embolism, should wear compression stockings or
bandages day and night, as long as they are bedridden. In addition, the administration of anticoagulants may become
necessary (consult your physician).
– Physician must be informed in case of sudden calf muscle pain or extraordinary swelling.

• Sitting for long hours (traveling by plane, bus, car)

– Graduated support stockings (SIGVARIS-Samson & Delilah) prevent swelling of the legs.
– Medical compression stockings (SIGVARIS) in chronic venous insufficiency.
– Moving the foot (jiggle), taking breaks and walking around during long hour traveling by car.

• Risks in cases of ulceration

– Avoid skin lesions.
– Compress critical areas with foam rubber in addition to compression stocking.
– Even the smallest lesion requires a medical visit.

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This brochure, or extracts from it, may not be reproduced, processed, duplicated or disseminated in any form
(photocopy, microfilm, electronic procedures), without the written permission of the authors.
GANZONI & CIE AG SIGVARIS INC.
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Tel. +41 (0)71 279 33 66 Tel. +1 (0)770 631 1778
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SIGVARIS BRITAIN LTD
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GANZONI GmbH Kingsworthy – Winchester SO 23 7QD/GB
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D-87700 Memmingen Fax +44 (0)1962 886 212
Tel. +49 (0)8331 757 0
Fax +49 (0)8331 757 111

SIGVARIS GmbH SIGVARIS DO BRASIL

Wehlistrasse 29/Stiege 1/1.OG INDUSTRIA E COMERCIO LTDA.
A-1200 Wien Estrada dos Pinheiros 155 – Condominio Sta. Maria
Tel. +43 (0)1 877 69 12 CEP 06850 000 Itapecerica Da Serra – São Paulo
Fax +43 (0)1 877 69 15 Tel. +55 (0)11 4666 4001
e-mail: sigvaris.wien@ganzoni.com Fax +55 (0)11 4666 2705

i m p r o v i n g q u a l i t y o f l i f e
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