Chronic Venous Insufficiency and Venous Leg Ulcers
Chronic venous insufficiency is a frequent problem among patients characterized by
leg swelling, varying symptoms of pain and may be attended by subtle changes in the
skin of the lower legs. Most patients’ diagnosis is evident by simply taking note of their
complaint of leg pain or swelling and noting the presence of varicose veins or
telangiectasia. However, some patients will have few or no visible leg veins making
ultrasound essential to the diagnosis.
A patient’s symptoms are often nonspecific. While aching is the most common
symptom in chronic venous insufficiency, it is also the least specific. Leg swelling,
cramping and restlessness have greater specificity. Other commonly described symptoms
include heaviness, fatigue, throbbing, burning or itching.
55 year old male with non healing ulcer present for past 12 months.
Important clinical signs to watch for include mild swelling, erythema or discoloration
about the lower leg and telangiectasia around the ankle, known as corona phlebectasia,
reflecting large insufficient saphenous veins refluxing from the thigh to the ankle with a
consequent “washing over” into spider veins.
It is this backward flow down the insufficient greater saphenous or other varicose
veins with gravity that leads to high pressures within the veins. The high pressures cause
an inflammatory response within the vein as white blood cells marginate, passing through
the vein wall into the skin. While a particular patient’s symptoms may vary greatly with
regard both to severity and type of symptom, it is this inflammatory response within the
vein wall that is the common denominator responsible for all of them.
When this inflammatory response begins to lead to leg swelling, erythema or
hyperpigmentation, vein disease is already far advanced. Treatment must begin to prevent
irreversible damage to the skin and lymphatics. The protein rich transudate of leg edema
over time will ultimately lead to lymphatic disease that is irreversible even when
underlying and treatable vein disease is addressed. The consequence is that when leg
edema has been present for many years — though it will improve with treatment of the
venous insufficiency — it will not remit entirely.
One month after laser ablation. By having treated the underlying saphenous insufficiency the 5 year ulcer recurrence rate is reduced from 50% to 15%.
In the case of skin erythema or discoloration, the site of erythema is in the distal most
leg because that is where the pressures are highest, at the bottom of the long veins
insufficient above analogous to when the pressure is felt greatest on our ears at the
bottom of the deep end of the pool. That is why this is the location where the skin
ultimately breaks down in response to the chronic inflammation.
A venous leg ulcer simply represents the end stage of the typically slow and gradual
progression of chronic venous insufficiency which might have been prevented. Once the
characteristic ulcers appear around the ankles, while local wound care and compression
therapy are important and Trental 400 mg twice daily helps healing, treatment of the
underlying venous insufficiency is essential for long-term management. Without
treatment of the underlying venous insufficiency, venous leg ulcers have a 50% five-year
recurrence rate. Treatment reduces the five-year recurrence rate to 15%.