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360 Management of Chronic Venous Disorders
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47 Endovascular reconstruction of inferior vena cava obstructions 541
Young Erben and Haraldur Bjarnason
48 Open surgical reconstructions for non-malignant occlusion of large veins 553
Arjun Jayaraj, Peter Gloviczki, and Mark D. Fleming
49 The management of incompetent perforating veins with open and endoscopic surgery 563
Jeffrey M. Rhodes, Manju Kalra, and Peter Gloviczki
50 Radiofrequency and laser treatment ofincompetent perforating veins 577
Michael Harlander-Locke and Peter F. Lawrence
51 Local treatment of venous ulcers 585
William A. Marston and Thomas F. O’Donnell Jr.
52 Guidelines for the treatment of chronic venous disease in patients with venous ulcers 597
Thomas F. O’Donnell Jr. and Marc A. Passman
Clinical presentation and assessment of
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patients with venous disease
SARAH ONIDA, TRISTAN R. A. LANE, AND ALUN H. DAVIES
29
29.1 Introduction 361
29.2 The upper limb 361
29.3 The lower limb 364
29.1 INTRODUCTION
Patients with venous disease represent a signicant proportion of the patient population presenting to a vascular
specialist. e nature of the disease is such that symptoms can be non-specic and dicult to assess. e ability
to take an appropriate history and examination of the
patient prior to organizing investigations is of paramount
importance.
e assessment and clinical presentation of patients with
venous disease have been covered by previously published
guidelines.1 In this chapter, we will review and expand on
this topic.
29.2 THE UPPER LIMB
Vascular disorders of the upper extremity are less common than in the lower limb, aecting approximately 10%
of the population.2 e upper limb plays an important role
in individuals with chronic disease (e.g., in the formation of
arteriovenous stulae and the administration of long-term
intravenous therapy). Signicant venous disease aecting
the dominant arm can be life changing for an individual,
and can potentially cause disability.
29. 2.1 Tra uma
Acute trauma and repetitive micro-trauma can both result
in vascular disorders of the upper limb. is is particularly
prevalent in middle-aged males employed in manual-type
labor or young males involved in acute traumatic injury.
Individuals working with handheld vibrating tools may be
subject to chronic micro-trauma.
29.4 Conclusion 370
References 370
29.2.2 Intermittent subclavian/upper
extremity vein obstruction
Although uncommon, compression of the subclavian vein
can result in intermittent symptomatology including intermittent swelling, discomfort and tightness (relieved by
rest), and abnormally prominent supercial veins. ese
symptoms are aggravated in the erect position or when
the arm is raised (e.g., when typing, driving, or painting a
ceiling).
oracic outlet syndrome (TOS) may present in this
manner,3 usually secondary to the presence of a cervical
rib, a congenital brous band compressing neurovascular
structures, or compression at the costoclavicular junction.
TOS may be neurological or vascular in nature according
to whether the brachial plexus or subclavian artery or vein
is compressed. Patients with these symptoms should be
evaluated with their shoulders in the neutral position and
in specic stress tests to elicit signs and symptoms. ese
include braced in the military position (Figure 29.1) or with
arms hyperabducted and externally rotated at the shoulder
(Figure 29.2), as this will result in the subclavian vein being
compressed by the scissor-like closure of the costoclavicular
space. Arm discomfort, swelling, and venous distension in
this position suggest intermittent venous outow obstruction. However, as with arterial thoracic outlet obstruction,
these ndings can be reproduced in approximately 50%
of otherwise normal individuals at the extremes of movement.4 As subclavian vein thrombosis is a likely outcome of
intermittent obstruction, active investigations with a view
to surgical decompression are indicated. ese maneuvers
are useful in assessing patients, but have been reported to
have low sensitivity and specicity.
5
361
362 Clinical presentation and assessment of patients with venous disease
retraction of shoulder
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Backward and downward
Figure 29.1 Compression of the subclavian vein in the military position. When the shoulder is retracted backward and
downward, the subclavian vein is narrowed by the scissoring action of the clavicle and the first rib. (Adapted from
AdamsJT etal. Surgery 1968;63:147– 65.)
Figure 29.2 Compression of the subclavian vein with hyperabduction of the arm. With hyperabduction and external rotation
of the arm, the clavicle rotates backward and downward and causes compression of the subclavian vein secondary to narrowing of the costoclavicular space. (Adapted from Adams JT etal. Surgery 1968;63:147–65.)
29.2.3 Subclavian/upper vein thrombosis
29.2.3.1 PRIMARY UPPER EXTREMITY DEEP VENOUS
THROMBOSIS
Deep venous thrombosis (DVT) can arise as a result of
hypercoagulable disorders or acute or recurrent trauma to
a blood vessel.
Paget–Schroetter syndrome (eort vein thrombosis)
describes a syndrome of axillosubclavian vein thrombosis
associated with repetitive upper limb activities. e syndrome is due to repeated trauma to the endothelium of the
subclavian vein, which may be secondary to the presence of
the aforementioned congenital abnormalities, leading to the
development of venous TOS. is syndrome is more common in young, healthy men undertaking manual work, preferentially involving the dominant arm. Patients are usually
symptomatic, presenting with arm discomfort, swelling, and
dilated veins across the shoulder and upper arm (Urschel’s
6
e arm may be pale, cyanotic, or red. Patients usually
sign).
present acutely or subacutely, with sudden onset of symptoms. Oen, patients can identify a precipitating event, such
as a sports injury.
Pulmonary embolism (PE) following upper extremity
DVT (UEDVT) has been reported to occur in 2%–35% of
individuals.
7
Post-thrombotic syndrome, characterized by
chronic pain, heaviness, and swelling, develops in up to
29.2 The upper limb 363
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45% of individuals with UEDVT. Recurrent thrombosis is
another signicant complication. Considering the prevalence of UEDVT in young men and its preferential involvement of the dominant arm, it is important to bear in mind
the degree of disability which can result.
Duplex ultrasound is a useful initial test; however, contrast computed tomography (CT) venography is the gold
standard for diagnosis. Conservative management with
anticoagulant therapy is suboptimal, with residual disability. Interventional treatment consists of catheter-directed
thrombolysis with or without thoracic outlet decompression with or without venoplasty.
29.2.3.2 SECONDARY UEDVT
DVT can result from direct trauma to the vessel—this
can be iatrogenic or secondary to central venous cannulation, catheterization, or pacemaker insertion. Central
venous catheters present a signicant risk of thrombosis,
which is reported to occur in 14%–18% of cases.8 Recurrent
intervention to the central veins can lead to stenosis and
thrombosis. Unlike primary UEDVT, the onset of obstruction is gradual with recurrent intervention. Patients, therefore, have time to develop a collateral circulation and be
asymptomatic. When present, the symptoms may be vague
shoulder or neck discomfort or arm edema. Depending on
the clinical situation, the rst presentation may be a nonfunctioning line; venous duplex imaging or a “linogram”
(contrast injection) can reveal the thrombosis. Treatment
involves thrombolysis if the thrombus is extensive, or simply removal of the line and anticoagulation. Lines should
be placed, if possible, in the internal jugular, cephalic, or
external jugular vein, as chronic venous scarring with narrowing (stenosis) is particularly common following direct
subclavian vein cannulation. A history of central venous
cannulation is important in patients being considered for
hemodialysis access and or arterial reconstruction using
an arm vein due to the possibility of stenosis, especially
in the case of prior subclavian vein usage. If present, postoperative limb swelling may result in signicant patient
morbidity.
6
29.2.3.2.2 Phlegmasia cerulea dolens
is typically occurs in patients with advanced malignancy,
oen being treated with chemotherapy via an indwelling
central venous catheter. It is a variant of disseminated intravascular coagulation with thrombosis aecting not only
the major veins, but also extending into the venules and the
microcirculation. It is characterized by sudden, severe pain
associated with intense swelling and discoloration of the
aected limb. Development of a compartment syndrome is
a potential complication and may even progress to venous
gangrene requiring amputation. Further complications
include PE and death.
29.2.3.2.3 Post-thrombotic syndromes
Post-thrombotic symptoms are reported in 30%–70% of
patients following a primary subclavian vein thrombosis
and consist of chronic discomfort, heaviness, and swelling, particularly in positions that compress collaterals in
the costoclavicular space. However, the skin changes commonly found in the lower limb are extremely rare.
29.2.3.2.4 Arteriovenous malformations
ese can be frequently misdiagnosed and are associated
with localized limb hypertrophy. Examples include Klippel–
Trenaunay syndrome (KTS) and Parkes–Weber syndrome
(PWS); they usually aect the lower limb and are discussed
in further detail below.
29.2.4 Examination findings
29.2.4.1 INSPECTION
Simply inspecting the arm and comparing it with the contralateral limb can yield useful clinical information. e examination process helps eliminate arterial, lymphatic, orthopedic,
or rheumatologic pathology from the dierential diagnoses.
Inspection should aim to identify the following: swelling, hypertrophy, discoloration, pallor, venous collaterals,
prominent veins, scars and/or puncture sites, evidence of
previous trauma, presence of indwelling lines, or cannulae.
29.2.3.2.1 Superficial venous thrombophlebitis
Supercial venous thrombophlebitis (SVT) is characterized
by localized pain, redness, and swelling over a segment of
a supercial vein. Iatrogenic injury, secondary to venous
cannulation, is the most common cause, and is usually
self-limiting. In some cases, the disease can be recurrent
and persistent. Spontaneous thrombophlebitis, especially
if recurrent, may be associated with malignant disease or
thrombophilia. Upon examination, palpation will reveal
tenderness over an underlying thrombus in the vein, with
surrounding induration. If the thrombus in the vein is
localized and not infected, there will not be signicant distal swelling. rombus propagating to the deep veins is rare.
A history of thrombophlebitis is important as it may have
important consequences for venous access and the utility of
an arm vein for arterial bypass.
29.2.4.2 PALPATION
1. To determine any dierence in temperature
2. Tenderness over an inamed supercial vein or in the
supraclavicular fossa
3. Evidence of obstructing pathology in the axilla and/or
supraclavicular fossa (e.g., enlarged lymph nodes or a
palpable cervical rib)
4. Hard and “cord-like” veins suggesting previous
thrombophlebitis
5. Presence of a full complement of pulses; presence of any
abnormal pulsations, either venous or arterial (arterio-
venous stula or malformation)
6. Presence of a palpable thrill
7. Presence of pitting edema
8. Allen’s test to conrm the arterial inow to the hand
and completeness of the palmar arch
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29.2.4.3 PERCUSSION
e presence of incompetence can be assessed by the “tap
test” of Chevrier. is is performed with the patient standing. One hand is placed on the proximal thigh, tapping
dilated veins, whilst the other feels for a transmitted impulse
in the veins of the lower leg. Venous return should ow from
the foot to the groin. A palpable thrill in the lower leg veins
is suggestive of continuity in the column of blood, implying the presence of non-functional valves and, therefore,
venousincompetence.
29.2 .4.4 AUSCULTATION
Listen for a continuous machinery murmur, which might
indicate an arteriovenous malformation.
29.2.4.5 ADDITIONAL STEPS
e blood pressure should be measured in each arm and
a full neurovascular examination should be performed.
If the arm is swollen, the examination should include
the axilla for lymphadenopathy and the breast to exclude
malignancy. If there is concern about the adequacy of the
deep venous outow, the arm can be observed for swelling aer application of a light supercial tourniquet.
Symptoms of PE should prompt a full cardiorespiratory
examination.
29.3 THE LOWER LIMB
Chronic venous disease is extremely common in the
Western world, with variable incidence reported worldwide.
Up to 80% of the general population will display evidence
of venous disease, with 20%–64% suering from varicose
veins (VVs) and 1%–2% aected by venous ulceration.9
Venous disease is known to negatively impact on quality
of life10 and has a signicant association with depression.11
Furthermore, European and U.S. data have estimated the
cost of venous disease to be approximately 1%–2% of the
total health care budget.
12
29.3.1 Superficial venous thrombophlebitis
Occasionally, SVT can arise in association with a known
or occult malignancy and, in this circumstance, is oen
migratory. It may also be associated with thrombophilia.
SVT can occur in diseased VVs in the form of sterile
thrombosis. is is particularly common in pregnancy and
presents as a hard, tender knot in the vein, with intense pain
and overlying erythema. e inammatory process can
extend beyond the vein wall, resulting in bleeding.
If any clot propagates through junctional and nonjunctional perforators, there is a signicant risk of PE.
Investigation of the deep veins (e.g., by duplex scan) is generally indicated, although symptoms of DVT may be absent.
On examination, signs of inammation are present,
including erythema, warmth, and tenderness (Figure 29.3).
Upon resolution, there is oen a residual mass or cord in the
aected supercial vein.
29.3.2 Deep venous thrombosis
DVT leading to PE is the most common cause of potentially preventable death in adult patients, with an annual
incidence of 1:1000 adults.13 Risk factors include innate
(age and hypercoagulability) and environmental (surgery,
hospitalization, trauma, pregnancy, hormone therapy,
obesity, and cancer) factors.
e mortality rate of those diagnosed with PE is approximately 10%. Cadaveric studies have, however, identied PE
in up to 30% of individuals with a DVT, and this nding
highlights the fact that many PEs are subclinical. In fact, CT
pulmonary angiography is now identifying even more small
subclinical pulmonary emboli.14 Management depends
upon prophylaxis, a high index of suspicion in “at-risk”
patients regardless of symptoms, and early steps taken to
provide a denitive diagnosis.
It is helpful to consider the development of DVT in two
phases: embolic (early) and thrombotic (late). In the early
phase, the thrombus is non-occlusive and not yet organized.
As a result, there is no swelling, inammation, or distension of
supercial collateral veins, and the leg may appear quite normal
SVT is an unfortunate term because it tends to be dissociated from DVT when, in fact, the two commonly coexist as
part of the venous thromboembolism spectrum.
SVT can occur spontaneously or secondary to trauma or
intervention. Iatrogenic injury from intravenous cannulation and infusion of causative agents is the most common
cause in normal veins. is can present as a tender lump
or cord along the course of the vein. Treatment is via
removal of the intravenous catheter, and resolution of the
condition can take months. Iatrogenic thrombophlebitis
may be complicated by bacterial infection, particularly in
patients undergoing long-term intravenous cannulation.
Septic phlebitis and suppurative thrombophlebitis are serious complications requiring antibiotic treatment and even
surgical debridement in some cases. Systemic features and
abscess formation are uncommon.
Figure 29.3 Superficial thrombophlebitis of the left thigh.
29.3 The lower limb 365
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despite a signicant risk of embolism. In the late phase, the
thrombus becomes occlusive and incites a phlebitis, anchoring it to the vein wall; in addition, inammatory signs and
symptoms due to peri-phlebitis become apparent. e patient
develops all the “typical” clinical features of DVT. At this stage,
however, the risk of PE is low. e clinical diagnosis of DVT is
dicult to make due to the poor sensitivity and specicity of
“typical” signs. Even when symptoms are present, studies show
that fewer than half of such patients have a DVT. Homans’ sign
(pain in the calf elicited upon passive dorsiexion of the foot
with the patient in the supine position with the knee exed) is
unreliable, painful, and should not be performed.
e Wells15 scoring system is used to determine the
probability of a patient having DVT before diagnostic tests
are performed (Table 29.1). Patients with a score of 2 or
more are more likely to have DVT.
Anatomically, it is useful to consider three patterns of
disease (calf, femoral, and iliofemoral), although thrombosis
is a dynamic process and proximal propagation is common.
Calf vein thrombosis is usually localized to one or two of
the three major veins of the lower leg. Oen, the thrombi are
non-obstructive and, due to the pairing of tibial and peroneal
veins, venous drainage may remain adequate. Calf tenderness
may be present, but signicant swelling is usually absent. In
fact, most patients have no symptoms or signs whatsoever.
About 20%, if untreated, may propagate into an above-knee
Table 29.1 Clinical model for predicting the pre-test
probability of deep venous thrombosis
Clinical characteristic Score
Active cancer (patient receiving treatment for
cancer within the previous 6 months or
currently receiving palliative treatment)
Paralysis, paresis, or recent plaster
immobilization of the lower extremities
Recently bedridden for 3 days or more or major
surgery within the previous 12 weeks requiring
general or regional anesthesia
Localized tenderness along the distribution of
the deep venous system
Entire leg swollen 1
Calf swelling at least 3 cm larger than on the
asymptomatic side (measured 10 cm below
tibial tuberosity)
Pitting edema confined to the symptomatic leg 1
Collateral superficial veins (non-varicose) 1
Previously documented deep venous thrombosis 1
Alternative diagnosis at least as likely as deep
venous thrombosis.
Source: Adapted from Wells PS et al. Lancet 1997;350(9094):
1795–8.
Note: A score of 2 or higher indicates that the probability of deep
venous thrombosis is likely; a score of less than 2 indicates
that the probability of deep venous thrombosis is unlikely.
In patients with symptoms in both legs, the more symptomatic leg is used.
1
1
1
1
1
−2
deep vein. Calf vein thrombosis is the most common site
of lower limb DVT and may propagate to the femoral vein.
When the popliteal or femoral vein is involved, there may be
swelling at the ankle and at the calf of greater than 1 cm in
most patients, but this rarely extends above the patella unless
outow via the deep femoral vein is compromised.
Iliofemoral DVT may originate in the pelvic veins and
not involve the distal femoral or calf veins in over 30% of
patients. Consequently, duplex scanning commonly fails
to detect it. Clinically, thigh swelling is present in addition
to calf swelling. If the inferior vena cava is involved, signs
and symptoms are usually bilateral. is type of thrombosis
frequently has a marked inammatory component, especially in pregnant women. Patients suspected of having this
condition are best investigated via contrast CT venography
or magnetic resonance venography.
29.3.3 Phlegmasia caerulea dolens
As described above with respect to the arm, extensive thrombosis may lead to phlegmasia, which in turn may precipitate
venous gangrene. Phlegmasia of the lower limb sequesters a
considerable proportion of the patient’s blood and body uids,
especially if bilateral. is can result in severe systemic eects,
which may include hypovolemic shock and renal failure.
29.3.4 Arteriovenous malformations
ese most commonly aect the lower limb; KTS and PWS
can present with abnormal varicosities.
KTS is a vascular malformation with capillary, venous, and
lymphatic abnormalities. Patients characteristically exhibit
the clinical triad of port wine stain, VVs, and limb hypertrophy. e lower limb is aected in approximately 70% of
individuals.16 Patients with KTS can present with SVT and
bleeding from enlarged supercial veins. Typically, the VVs
can present as anomalous veins or persistent embryonic veins;
these are present in 72% of patients with KTS. e most common abnormality is the persistence of a latera l embryonic vein,
identiable in the lateral thigh and not joining the deep system. Abnormal medial or suprapubic veins are less common.
16
Similarly to KTS, PWS usually aects the lower limb and
is characterized by the presence of fast-ow arteriovenous
stulae. Patients present with cutaneous capillary malformations, limb hypertrophy and arteriovenous malformations.
Supercial veins are prominent secondary to increased pressure. A bruit, or machinery murmur, is audible in the aected
limb, and a thrill is palpable throughout the cardiac cycle.
29.3.5 Varicose veins
29.3.5.1 EPIDEMIOLOGY
VVs are extremely common, with risk factors including family history, age, and obesity. eir prevalence is expected to
continue rising due to the aging population and obesity epidemic. VVs can be primary or secondary. Primary varicosities are due to incompetence in the supercial veins, oen
366 Clinical presentation and assessment of patients with venous disease
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located at the junctions between the supercial and deep
venous systems (saphenofemoral, saphenopopliteal, or perforator incompetence). Secondary varicosities arise as a result
of underlying pathology that has led to the development of
venous hypertension in the supercial venous system. is
includes DVT, deep venous incompetence, an intra-abdominal mass causing pressure on the pelvic veins, and obesity.
29.3.5.2 TRUNK VARICES
Trunk varices are VVs originating from the main stem
and/or major tributaries of the great saphenous vein (GSV)
and/or the small saphenous vein (SSV). ese are the result
of valvular incompetence and occur in the GSV distribution in 80% of individuals and the SSV distribution in
20%. ey are usually ≥3 mm in diameter, lie subcutaneously, are palpable, and do not discolor the overlying skin.
Although more women than men present for assessment
and treatment of their VVs, the actual prevalence is roughly
equal between the sexes.
29.3.5.3 RETICULAR VARICES
ese lie deep in the dermis, are 2–3 mm in diameter, are
not palpable, and may render the overlying skin darkish
blue in color. ey do not blanch on pressure. ey may or
may not be associated with trunk varices and are present in
about 80% of the adult population.
Table 29.2 CEAP classification
C: Clinical classification
C0: No visible or palpable signs of venous disease
C1: Telangiectasia or reticular veins
C2: Varicose veins
C3: Edema
C4a: Hyperpigmentation or eczema
C4b: Lipodermatosclerosis or atrophie blanche
C5: Healed venous ulcer
C6: Active venous ulcer
s: Symptomatic, including ache, pain, tightness, skin
irritation, heaviness, and muscle cramps
a: Asymptomatic
E: Etiological classification
Ec: Congenital
Ep: Primary (indeterminate cause)
Es: Secondary (e.g., post-thrombotic)
En: No venous cause identified
A: Anatomical classification
As: Superficial veins
Ap: Perforator veins
Ad: Deep veins
An: No venous location identified
29.3.5.4 TELANGIECTASIA
Also termed spider or hyphen web veins, they are intradermal, 1 mm or less in diameter, impalpable, blanching, and
render the overlying skin purple or bright red. Again, they
may be associated with trunk and reticular varices and are
present in 80% of adults.
29.3.5.5 SYMPTOMS
e presentation of venous disease occurs across a spectrum,
including asymptomatic disease, VVs, skin changes, and
ulceration. is is best described and assessed via the CEAP
(Clinical, Etiological, Anatomical, Pathophysiological)
classication, an international system that enables the
assessment of venous disease and its severity (Table 29.2).
17
read and reticular veins can be unsightly but are not
symptomatic. Although rarely life threatening, trunk VVs
can have a signicant detrimental eect on a patient’s
quality of life that should not be ignored.10 e rate of
depression with trunk VVs is more than double that of
the general population.11 is may be due in part to the
cosmetic aspect and in part to the chronicity of the signs
and symptoms of venous disease, which can interfere with
patients’ daily activities.
Previous local guidance in the U.K. advised general
practitioners to refer a patient with VVs to secondary care
only in the presence of what was dened as advanced disease (C4–C6). Lower CEAP grades were to be managed in
the community with conservative measures, such as compression and lifestyle advice. Referral to secondary care
was warranted in the presence of ulceration, bleeding,
P: pathophysiological classification
Pr: Reflux
Po: Obstruction
Pr,o: Reflux and obstruction
Pn: No venous pathophysiology identifiable
Source: Adapted from Eklöf B et al. J Vasc Surg 2004;40(6):
1248–52.
progressive skin changes, recurrent SVT, and symptoms
having a severe impact on quality of life.
However, venous disease is a progressive disorder;
the rate of C class disease progression from C2 disease to
higher classes as reported by the Bonn Vein Study is 2% per
18
annum.
is change in evidence has led national bodies to
change referral pathways to all symptomatic disease with
the aim of preventing, as opposed to treating, higher CEAP
class stages. is is exemplied by the Society of Vascular
Surgery (SVS) and the National Institute of Health and Care
Excellence (NICE) guidelines (Table 29.3).
19
Patients with V Vs can be chal lenging to assess , as they may
present with a wide variety of lower limb symptoms, including aching, a dragging feeling, heaviness and tension, swelling, tiredness, restless legs, nocturnal cramps, and itching.
ese symptoms are not specic to VVs and are extremely
common in the general population. It is important to consider dierential diagnoses (e.g., back pain) and arrange for
the appropriate investigations to conrm the clinical suspicion. Management of patient expectations is paramount in
the presence of non-specic symptoms, particularly when
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Table 29.3 National Institute for Health and Care
Excellence (NICE) guidance 2013
Referral to a vascular service
• Patients with symptomatic primary or recurrent
varicose veins
• Patients with skin changes, such as pigmentation or
eczema, thought to be caused by chronic venous
insufficiency
• Superficial venous thrombosis and suspected venous
incompetence
• A venous leg ulcer
• A healed venous leg ulcer
• Immediate referral to a vascular service is warranted
if there is a bleeding varicose vein
Imaging
• Duplex ultrasound should be used to confirm the
diagnosis of varicose veins and the extent of truncal
reflux and to plan treatment for individuals with
suspected primary or recurrent varicose veins
Treatment
• Endothermal ablation (radiofrequency or laser) is
firstline
• If endothermal ablation is unsuitable, offer
ultrasound-guided foam sclerotherapy
• If ultrasound-guided foam sclerotherapy is
unsuitable, offer surgery
• If incompetent tributaries are present, consider
treating them at the same time
• Do not offer compression hosiery to treat varicose
veins unless interventional treatment is unsuitable
• Intervention should be avoided in pregnancy,
wherecompression stockings should be offered
discussing treatment options. In a patient with evidence of
reux on venous duplex, it is important to inform them that
intervention may not resolve their symptoms.
29.3.6 Chronic venous insufficiency
VVs are a manifestation of chronic venous disease. Chronic
venous insuciency (CVI) describes complications from
the presence of high venous pressures in the lower limb,
resulting in the cutaneous changes that are characteristic
of the disease. Ultimately, this leads to skin damage, which
may include ulceration of the lower leg.
29.3.6.1 SYMPTOMS
All of the symptoms described above for VVs may be associated with CVI, and there is a stronger relationship between
symptoms and disease severity in this group. is group of
patients is signicantly older and, as such, comorbidities are
more common, including peripheral vascular disease and
diabetes. When assessing these patients, arterial disease
and musculoskeletal problems should not be overlooked.
Unlike patients with simple VVs, in whom actual swelling is
unusual, the majority of patients with CVI have a degree of
edema. is is usually of mixed etiology: venous hypertension, cardiac failure, and a degree of lymphedema. Severe
pain is unusual and suggests that the patient may have
coexisting arterial disease and/or infection.
29.3.6.2 HISTORY
is should explore the current episode of skin change/
venous ulceration and any previous episodes. A history of
vascular risk factors should be taken, including previous
thrombotic episodes, vascular and non-vascular interventions to the lower limb, pelvis, and abdomen, malignancy,
arterial risk factors, diabetes, autoimmune disease, and
smoking. A general history, including family history, medications, and allergies, should also be taken. Furthermore,
patients should be asked if symptoms of chronic venous disease are present, such as itching, restlessness, aching, heaviness, swelling, and fatigue.
29.3.6.3 EXAMINATION FINDINGS
29.3.6.3.1 Position
e patient should be examined standing under a good light
and in a warm room. Patients may feel faint and a support
should be available. e examiner should be sat on the oor
or, ideally, on a small stool with the patient on a platform
with a handrail for balance.
29.3.6.3.2 Inspection
VVs are dilated and tortuous, due to the pathological reux
commonly but not exclusively associated with a cephalad
incompetent valve. e main trunks themselves may be
dilated, but they are rarely tortuous, as they are supported
by the deep fascia. e distribution of varices can give an
indication as to whether they are GSV or SSV tributaries
(orboth) (Figure 29.4). However, in obese patients or those
with previous surgical interventions, the anatomical connections may be less dened. In thin, athletic patients,
highly visible and enlarged veins may be erroneously
considered to be pathological. ese are uniformly dilated
and do not exhibit tortuosity. It is also important to note the
presence of telangiectasia during inspection.
Veins lying in an abnormal distribution (such as
laterally along the leg, vulval, or in the abdominal wall) are
suggestive of a congenital cause, an underlying pathological
process (e.g., intra-abdominal mass), or pelvic congestion
syndrome.
e signs of CVI include corona phlebectatica, venous
eczema, lipodermatosclerosis, hemosiderin deposition,
and open (or healed) ulceration. ese are most commonly
found around the gaiter area, above the medial malleolus.
Corona phlebectatica comprises a fan-shaped are of small
intradermal varices on the medial aspect of the ankle and
foot. e apex of the are is in the region of the one or more
incompetent perforators and fans out towards the sole of
the foot. Lipodermatosclerosis may be acute or chronic. In
the acute phase, it is an inammatory reaction that may be
mistaken for cellulitis or phlebitis. It will overlie an area of
368 Clinical presentation and assessment of patients with venous disease
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perforator incompetence but, unlike cellulitis, the overlying skin will not be warm. In the chronic phase, the skin
of the mid to lower calf is pigmented, shiny, hard to the
touch, and xed to the underlying chronically inamed
and contracted subcutaneous tissue. Surrounding dermatitis is common and may be a sensitivity reaction to topical
medication applied to the area. White scar tissue (atrophie
blanche) is oen present. e site of lipodermatosclerosis
relates to maximum ambulatory pressure, usually communicated by incompetent perforators. is also applies to the
sites of ulceration, although as ulcers increase in size, this
association becomes less dened. An ulcer characterized by
a location or shape typical of pressure damage is an important pointer to coexisting arterial disease (see Table 29.4).
29.3.6.3.3 Palpation
Features such as temperature change, the presence of pulses
or thrills, tenderness, induration, and edema provide useful
information regarding the underlying disease process. e
varicosities should also be palpated and an assessment of
their course determined. In individuals with bilateral VVs,
an abdominal and groin examination is essential to identify
signs of intra-abdominal pathology.
Clinical tests such as the “tap” test of Chevrier or the
Trendeleburg test have been used to help assess the patient
with venous disease. e “tap” test of Chevrier consists of
Figure 29.4 Varicose veins in the right great saphenous
vein distribution.
percussing over a varix while palpating caudally to help trace
out the vein. A palpable transmitted impulse suggests an
Table 29.4 Differential diagnosis of leg ulceration
Clinical features Arterial ulcer Venous ulcer
Gender Men > women Women > men
Age >60 years 40–60 years, but patients may not present until much
older; multiple recurrences
Risk factors Smoking, diabetes, hyperlipidemia,
hypertension
Past medical
history
Symptomatology Severe pain is present unless there is
Site Pressure areas (malleoli, heels, metatarsal
Edge Regular, “punched-out,” indolent Irregular, with neo-epithelium
Base Deep, green (sloughy), or black (necrotic)
Surrounding skin Features of chronic ischemia (hairless,
Veins Empty, guttering on elevation Full, usually varicose
Swelling Absent Present
Most have a clear history of peripheral,
coronary, and cerebrovascular disease
severe neuropathy. Pain may be
relieved by dependency
heads, fifth metatarsal base)
with no granulation tissue, exposing
major tendons, bones, and joint
dry, pale)
Previous deep venous thrombosis, thrombophilia,
varicose veins
>20% clear history of deep venous thrombosis. History
suggestive of occult deep venous thrombosis is very
common (e.g., leg swelling after childbirth, hip/knee
replacement, or long bone fracture)
Approximately 30% have pain, but it is not usually severe
and may be relieved upon elevation
Medial (70%) and lateral (20%) or both malleoli and gaiter
area
Pink and granulating, may be covered in a yellow–green
slough
Lipodermatosclerosis (pigmentation, induration, varicose
eczema, atrophie blanche)
Figure 29.5 Ulceration in the gaiter area of the left lower
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limb.
29.3 The lower limb 369
incompetent vein between the two sites. e Trendelenburg
test consists of applying a tourniquet to the upper thigh to
compress the GSV. e patient is then asked to stand, with
the examiner assessing for supercial vein lling. e test can
be repeated at dierent levels to identify the level of incompetence. Handheld Doppler ca n be used as an adjunct to insonate
over the site of incompetence. Again, this was said to be useful in the obese patient, but has been found to have a sensitivity of as low as 56% at the saphenofemoral junction and 23%
at the saphenopopliteal junction.20 Overall, these tests have
been found to be poorly predictive of venous anatomy, and
should not be relied upon to plan surgery. Duplex scanning
is the gold standard investigative tool allowing hemodynamic
assessment of the supercial and deep venous systems.
29.3.6.3.4 Ulcer assessment
Ulcer assessment (Figure 29.5) should include:
1. Description of the ulcer, concentrating on the features
outlined in Table 29.4
2. Pulse status and Ankle Brachial Index (ABI)
Guidelines 4.1.0 of the American Venous Forum on the clinical presentation and assessment of patients with venous
disease
Level of evidence
(A: high quality; B:
moderate quality;
C: low or very low
quality)
No. Guideline
4.1.1 For clinical examination of the upper limb, we recommend inspection
with comparison with the contralateral limb, palpation, auscultation,
and examination of the axilla for adenopathy. In patients with
adenopathy or swollen arms, we recommend examination of the
breast to exclude malignancy.
4.1.2 For clinical examination of the lower limbs in patients with
suspectedacute deep venous thrombosis, we recommend
inspection (edema, cyanosis, and varicosity), palpation (tenderness
and pitting edema), auscultation (arterial bruit and heart and lung
examination), and examination of the deep and superficial veins
andcalf muscles.
4.1.3 We suggest the use of the clinical scoring system of Wells to predict
the pre-test probability of deep venous thrombosis.
4.1.4 For clinical examination of the lower limbs for varicosity and chronic
venous insufficiency, we recommend inspection (varicosity, edema,
skin discoloration, corona phlebectatica, ulcer, and
lipodermatosclerosis), palpation (cord, varicosity, tenderness,
induration, reflux, pulses, and thrill), auscultation (bruit), and
examination of the groin and abdomen (masses, collateral veins, or
lymphadenopathy) and ankle mobility.
4.1.5 Clinical presentation of patients with varicose veins may include
symptoms like aching, heaviness and tension, sensation of swelling,
tiredness, restless legs, nocturnal cramps, and itching. We suggest
that there is little or no relationship between these symptoms and
the presence and severity of varicose veins or the pattern and
severity of reflux.
Grade of
recommendation
(1: strong;
2:weak)
1 B
1 B
2 B
1 B
2 B
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