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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 leg veins, from which calf muscles pump blood back to the heart. The valves also control the pressure in smaller veins on the legs' surface.
If the valves within the veins fail to work properly, there is a blockage to normal flow, or the calf muscles cannot pump 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 range in severity from mild (such as a feeling of leg heaviness, aching, or dilated or unsightly veins) to severe (such as swelling of the leg, ankles or feet, 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 can sometimes affect the arms, for example, after a blood clot. This article focuses on chronic venous disease in the legs ("lower extremities").
CHRONIC VENOUS DISEASE CAUSES — Any problem that increases pressure in the veins in the legs can dilate 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:
●A clot 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 from the legs toward the heart and lead to increased pressure in the veins and pooling of blood. This is 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 enlarged 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 after prolonged standing.
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. Sometimes this swelling is evident only at the end of the day; other times it is present all the time. Swelling almost always decreases with leg elevation, so it may be less prominent in the morning.
The area just above 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 education: Edema (swelling) (Beyond the Basics)".)
Skin changes — Pooling of blood and increased pressure in the veins over months to years can cause the skin to become tan or a reddish-brown color. Often, the skin changes are initially noticeable around the ankle, starting first on the inside of 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 of fluid, scaling, open sores from scratching, and crusting or scabbing. Some people develop brown or red shiny areas that are hard and scar-like and can be painful. This usually happens after many years of venous disease but can occur suddenly.
Venous ulcers — Open, nonhealing sores caused by chronic venous disease are called venous ulcers or venous stasis ulcers. The most common location for stasis ulcers is low on the inner ankle, but they can also occur on the outer ankle and on the shin area. Venous ulcers never occur above the knee and do not usually occur on the foot itself or the toes. Venous ulcers that occur above the ankle 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 moderately uncomfortable, tender to touch, shallow, have a red appearance at the base, and may ooze or drain small to large amounts of fluid.
Venous ulcers can take months to heal. Healing is a gradual process, and the resulting scar is usually shiny pink or red, or white and shiny with red dots. Venous ulcers can come back even after they heal.
CHRONIC VENOUS DISEASE DIAGNOSIS — Doctors can diagnose chronic venous disease by examining a person for signs and asking about symptoms of the disorder, such as the presence of varicose veins, swelling in the legs, skin changes, or skin ulcers. The doctor may do additional testing, such as an ultrasound, to look at vein valve function and to identify if the problem is located in the superficial veins or the deep veins.
CHRONIC VENOUS DISEASE MANAGEMENT — Treatment of chronic venous disease is focused on reducing symptoms, such as swelling, treating skin problems, preventing and treating ulcers, and improving blood flow from the legs.
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. To be effective, it is important to elevate the legs above the level of the heart; simply putting your legs up on a footstool does little to improve drainage of blood from the legs.
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 and up (movement from the ankle) several times throughout the day can help move blood from the legs back to the heart, as can repeatedly lifting the heels off the floor to stand on the toes, repeating several sets of this exercise daily. This may be especially helpful for people who sit or stand for long periods of time. Walking is a good exercise to activate the calf muscle pump.
Compression therapy — Most experts consider compression therapy to be an essential treatment for chronic venous disease. 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 who stand for long periods of time, and those with venous ulcers usually require prescription stockings. A healthcare provider may take measurements for stockings, or may write a prescription for stockings that 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 fit or highly inflamed skin. The following figures show tips for using compression stockings (table 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.
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 several 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 may consist of one or more layers of an elastic wrap and may look similar to a soft cast. These are applied by a 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, or fluid from the wound leaks through the bandages, you should contact your doctor to have them changed.
Dressings — Ulcers may be 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.
●Antibiotics are only recommended when there is an infection. Topical antimicrobial agents are rarely needed and may cause allergic reactions that complicate rather than improve the condition.
●A supplement known as 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. Because dietary supplements are not regulated like prescription medicines, there can be variations in the actual dose of each pill. If you are interested in trying this, talk with your health care provider first.
●Micronized purified flavonoid fraction is also available as a dietary supplement; when added to compression therapy, it may improve healing of ulcers and many symptoms of chronic venous insufficiency, including lower extremity edema. It is usually taken as two 500 mg tablets daily. Talk to your health care provider if you want to try this.
●Hydroxyethylrutoside 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, often improves by using 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 education: Contact dermatitis (including latex dermatitis) (Beyond the Basics)".)
VEIN ABLATION TREATMENTS — Vein ablation treatments are treatments designed to close down the superficial veins that have abnormal valve function. The blood then flows through other veins into the deep veins of the leg. These treatments are usually reserved for people with symptoms who do not respond to the simpler treatments described above. (See 'Leg elevation' above and 'Exercises' above and 'Compression stockings' above and 'Dressings' above.)
Veins are closed in one of three ways:
Nonthermal ablation — With nonthermal ablation, the doctor injects a chemical or glue or uses a combination of a chemical and a small rotating wire (eg, mechanochemical ablation [MOCA]) into the diseased vein that causes it to close on itself. The vein stays in place, but it no longer carries blood. Nonthermal ablation can be done in a doctor's office with local anesthesia. (See "Injection sclerotherapy techniques for the treatment of telangiectasias, reticular veins, and small varicose veins".)
Thermal ablation — With thermal ablation procedures (eg, radiofrequency ablation or laser ablation), the doctor inserts a special catheter into the diseased vein. The tip of the catheter 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 but require a special kind of local anesthesia called "tumescent anesthesia." Thermal ablation can often be done in a doctor's office. (See "Clinical manifestations of lower extremity chronic venous disease".)
Vein ligation or stripping — These procedures involve surgery to remove the diseased vein or veins. People who have these procedures may be treated in a hospital, surgery center, or doctor's office depending on the size and number of veins. Veins are removed through small incisions. Surgery is rarely needed since most people can be treated with the above two procedures. (See "Open surgical techniques for lower extremity vein ablation".)
SUMMARY
●Lower extremity 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 legs and feet.
●People with chronic venous disease often report that their legs feel heavy, tired, or achy. These 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, especially without proper evaluation and treatment.
●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. Leg ulcers may be caused by problems other than chronic venous disease, so evaluation by a vascular or wound specialist is an important step before beginning treatment to ensure that the proper diagnosis has been made.
●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 (nonthermal or thermal) 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 information — 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 education: Deep vein thrombosis (blood clot in the legs) (The Basics)
Patient education: Swelling (The Basics)
Patient education: Varicose veins and other vein disease in the legs (The Basics)
Patient education: Pulmonary embolism (blood clot in the lungs) (The Basics)
Patient education: Duplex ultrasound (The Basics)
Patient education: Superficial vein phlebitis and thrombosis (The Basics)
Patient education: 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 education: Edema (swelling) (Beyond the Basics)
Patient education: 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
Clinical manifestations of lower extremity chronic venous disease
Diagnostic evaluation of lower extremity chronic venous insufficiency
Medical management of lower extremity chronic venous disease
Pathophysiology of chronic venous disease
Post-thrombotic (postphlebitic) syndrome
Injection sclerotherapy techniques for the treatment of telangiectasias, reticular veins, and small varicose veins
The following organizations also provide reliable health information.
●National Library of Medicine
(www.nlm.nih.gov/medlineplus/healthtopics.html)
●National Heart, Lung, and Blood Institute
●American Venous Forum
(http://www.veinforum.org/patients)
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