venous insufficiency

venous insufficiency


 Chronic venous insufficiency
DEFINITION AND ETIOPATOGENIA top

It is manifested by the development of symptoms of venous congestion caused by blood reflux or stenosis or obstruction of the veins. Chronic venous insufficiency (CVI) includes: varicose disease (varicose vein is a permanent dilation of a superficial vein of ≥3 mm in the sitting position), post-thrombotic syndrome, primary venous valvular insufficiency, and compressive syndromes (p. eg syndrome of entrapment of the popliteal vein by the medial head of the gastrocnemius muscle). Risk factors: age, female sex, weakness of the venous wall and the valvular structure genetically conditioned (produce primary varicose veins), pregnancy, sedentary or standing work, obesity.

Regardless of the cause, the main pathophysiological alteration is venous hypertension due to absence, hypodevelopment, insufficiency or destruction of the venous valves, impermeability or constriction due to thrombosis (incomplete or failed post-thrombotic recanalization) or compression exerted on the veins.

The venous ulcer may be accompanied by eczema of the leg caused by trauma and microtraumas, bacterial infections and contact allergy.

CLINICAL PICTURE above

1. Symptoms: in the initial phases, feeling of heaviness of the lower limbs and an exaggerated relief that normally worsens at night, decreases after rest with the extremities elevated, accompanied by visible dilated superficial veins of bluish color, painful cramps in the twin region of nocturnal predominance and "restless legs" syndrome. In more advanced stages is frequent dull pain that gets worse during the day, rarely pain during walking (venous claudication), which suggests deep venous insufficiency at the level of the calves.

2. Signs: telangiectasias (dilated cutaneous venules <1 mm in diameter and small arachnoid veins and reticular varices). With the passage of time, varicose veins appear at the level of the greater and lesser saphenous veins that are widened and tortuous, forming lagoons; edema (first soft reversible, that yields with the nocturnal rest, with the hard and elastic time); ocher supramalleolar hyperpigmentation, foci of cutaneous white atrophy, venous ulcers (typical in distal 1/3 above the internal malleolus and in advanced stages involving the entire supramalleolar perimeter); dry or exudative eczema of different magnitude, persistent dermatitis and cellulitis (common in advanced CVI); lipodermatosclerosis; secondary lymphatic edema. Symptoms that accompany the eczema: intense redness and inflammation foci in one or both extremities, sometimes with hematogenous generalization (in that case, erythematous or micropapular rash that sometimes affects the skin of the head, trunk and upper limbs), pruritus persistent, frequent bacterial superinfection of skin lesions.

DIAGNOSTICS above

Based on the symptoms and signs and the result of Doppler-color echocardiography of the lower limb veins. To diagnose the post-thrombotic syndrome and assess its severity, the Villalta scale is used → Table 31-1.

Table 31-1. Villalta scale of the post-thrombotic syndrome (SPT)

symptomAbsent

Mild

Medium

Serious

Pain

0

1

2

3

Muscle cramps

0

1

2

3

Heaviness

0

1

2

3

Paresthesias

0

1

2

3

Pruritus

0

1

2

3

Signs



Absent

Mild

Medium

Serious

Pretibial edema

0

1

2

3

Induration of the skin

0

1

2

3

Hyperpigmentation

0

1

2

3

Redness

0

1

2

3

Dilation of the veins

0

1

2

3

Painful compression of the calf

0

1

2

3

Venous ulcer

Present / absent

Each symptom is assessed by the patient himself and each sign by the doctor.

Interpretation of the result: 0-4 pts. - SPT absent, 5-9 pts. - SPT slight, 10-14 pts. - SPT moderate,> 14 pts. or presence of ulcer - severe SPT

Differential diagnosis

Edema of both limbs and unilateral edema → cap. 1.17.

TREATMENT top

Conservative treatment

1. General recommendations: avoid excess local heat and sunbathing in addition to prolonged standing and sedentary lifestyle with knees bent and hips at right angles. The work place must be ergonomic with inclined chair backrest, elevation of the feet; walks of a few minutes duration or active exercises of the members in people with prolonged sedentary lifestyle; regular physical activity (hiking, walking or running, cycling, swimming); Frequent rest with elevation of the lower limbs above the level of the heart resting on the entire length of the calf (and not on a point).

2. Compressive treatment: it is the only method that can stop the development of IVC, also used as prevention. Compression bands (in patients with venous ulcers), compression stockings or short stockings (adjusted individually by a professional to a limb without edema → Table 31-2), pneumatic intermittent compression are used.

Table 31-2. Types of compression stockings and indications for use

Class
Pressure
Indications
I
20-30
Prevention of venous thrombosis, prevention of thrombosis and varicose veins in pregnant women, small varicose veins during pregnancy, heaviness and fatigue of the extremities, small varicose veins without visible edema, postoperative varicose veins
II
30-40
Varicose veins of large size during pregnancy, varicose veins with small edema, postphlebitic states in superficial veins, after varicose vein sclerotherapy, after healing of small ulcers
III
40-50
Varicose veins of very large size with significant edema, after healing of large ulcers, post-traumatic edema, reversible lymphatic edema
IV
50-60
Severe post-thrombotic syndrome, irreversible lymphatic edema
a Exercised at the level of the ankle (mm Hg).

Contraindications: dermatitis and acute cellulitis, exudative skin lesions, grade III / IV arterial ischemia according to the Fontaine classification (Rutherford classification> 3) equivalent to an ankle-brachial index (ABI) <0.6 (always before using any compression method, explore the pulses in the lower limbs and in case of doubts measure the ITB), advanced heart failure, poorly controlled hypertension, deformations of the limb that prevent a precise compression, arteritis of the lower limbs.

3. Pharmacological treatment: adjuvant (does not replace the compressive treatment). Flavones derived from benzopyrene obtained from plants or synthetics (rutin and its derivatives, hesperidin, diosmin), saponins (escin), calcium dobesilate, extracts of grape seeds or citrus can, in some patients, improve the quality of life and relieve symptoms, but they do not protect against the progression of the disease.

Treatment of venous ulcers

1. Elevation of the limb in a sitting or recumbent position.

2. Compressive treatment: multilayer compression therapy with special bandages or special compression systems already prepared for use in the presence of ulcers (indicated pressure at the level of the ankle: 40 mm Hg, below the knee: 17-20 mm Hg, in the case of mixed arteriovenous ulcers and with ABI 0.6-0.9, the use of compression with a maximum pressure of 17-25 mm Hg is allowed).

3. Resection of necrotic tissues, wound cleansing, skin and skin-muscle grafts.

4. Treatment of the infection: topical disinfectants containing octenidine, cures with gauze soaked in 7-10% iodopovidone solution or ethacridine solution and systemic antibiotics (non-topical).

5. Treatment of pain, especially important during the cleaning of the wound and changes of the cures.6. Treatment of eczema of the leg: VO antihistamines, topical glucocorticoids and compresses with 1% tannin and 0.1% silver nitrate.

7. Correction of the possible protein deficit that makes healing difficult (assessment of the state of nutrition is necessary before starting the treatment of the ulcer).

8. If the ulcer does not heal despite adequate treatment for> 3 months → refer to a specialist and rule out an underlying neoplastic process.

Invasive therapy

1. Indications: advanced symptoms of CVI, varicose veins with complications (varicoflebitis, rupture, varicorrhagia, skin trophic disorders, venous ulceration), aesthetic issues. Do not propose surgical treatment in the case of secondary varices, that is, in case of veins with dilated collateral circulation or in the case of deep, non-permeable veins.

2. Methods: extraction of varicose veins by stripping, surgery of incompetent perforators by open method (Linton),non-invasive methods (microflebectomy, cryosurgery, laser operations), varicose vein ablation by laser,radiofrequency thermoablation, water vapor ablation, sclerotherapy (obliteration of the veins by injectionof fibrosing substances). Recurrences occur in up to 50% of cases after surgical treatment.The good outcome of surgery to a large extent depends on the continuous use of the compressor treatment.