CHRONIC VENOUS INSUFFICIENCY

DEFINITION
When your leg veins cannot pump enough blood back to your heart, you have chronic
venous insufficiency (CVI).
CVI is also sometimes called chronic venous disease, or CVD.

ETIOLOGY
 Long term blood pressure that is higher than normal inside leg veins
 Deep vein thrombosis (DVT)
 Phlebitis
 Obstructing the free flow of blood through the veins.
 Neoplastic obstruction of the pelvic veins or congenital or acquired arteriovenous
fistula.
 Occur in association with superficial venous reflux and varicose veins

EPIDEMIOLOGY
 Extremely common
 Risk factors for chronic venous disease include
 Heredity (family history of  Prolonged standing or sitting
varicose veins)  Greater height
 Age (Women older than 50)  History of leg trauma
 Female sex  Not exercising enough
 Obesity  Smoking.
 Pregnancy

Symptoms
Leg fullness
Aching discomfort
Heaviness
Nocturnal leg cramps
Bursting pain on standing
Signs
Very early
Tenderness to palpation
Early
Edema
Hyperpigmentation
Stasis dermatitis
Varicose veins
Late
Venous ulcers
Atrophie blanche
Lipodermatosclerosis
Acroangiodermatitis of Mali
Post-phlebitic syndrome

CLINIAL FEATURE

1. SIGN SYMPTOM
 Most patients complain of leg swelling  dikasih diuretic  gak ngefek!!! Tidak
seperti edema in salt-retaining states, like heart failure, cirrhosis, and nephritic
syndrome.
 Ulceration may occur, biasanya di above the ankle, on the medial or anterior
aspect of the leg
 Venous ulcers may or may not be painful.
  The soft tissue injury sebelum ulceration begins in the subcutis 
Appearance of petechial lesions  As the hemoglobin in the petechial lesions
breaks down, the iron remains in the skin as hemosiderin and may lead to
impressive discoloration.
 Stasis dermatitis, characterized by erythema, scaling, pruritus, erosions,
oozing, crusting, and occasional vesicles.
 Varicose veins, especially noticeable when the patient is standing  Although
they are usually asymptomatic, patients may complain of symptoms of aching,
cramping, itching, fatigue, and swelling that are worse with prolonged standing.
 The skin at the ankle is usually thin, shiny, atrophic, and a brownish
pigmentation often develops.

2. DIFFERENTIAL DIAGNOSIS
 Patients with congestive heart failure, chronic renal disease, or
decompensated liver disease may have bilateral edema of the lower extremities.
Tapi edema karena penyakit itu, causes pits easily and brawny discoloration is rare.
 Lymphedema is associated with edema, usually unilateral, in the
subcutaneous tissue that does not respond readily to elevation; varicosities are
absent, and there is often a history of recurrent cellulitis.
 Other conditions associated with chronic ulcers of the leg include autoimmune
diseases (eg. Felty's syndrome), arterial insufficiency (often very painful
with absent pulses), sickle cell anemia, erythema induratum (bilateral and
usually on the posterior aspect of the lower part of the leg), and fungal
infections (cultures specific: no chronic swelling or varicosities).

3. HISTOPATHOLOGY of VARICOSE VEIN

 Macroscopic : Veins with varicosities are dilated, tortuous, elongated, and
scarred, with thinning at the points of maximal dilation. Intraluminal
thrombosis and valvular deformities (thickening, rolling, and shortening of the
cusps) are frequently discovered when these vessels are opened.
 Microscopically: the changes consist of variations in the thickness of the
vein wall caused by dilation in some areas and by compensatory
hypertrophy of the smooth muscle and subintimal fibrosis in others.
Frequently there is elastic tissue degeneration and spotty calcifications within
the media (phlebosclerosis).

4. IMAGING
 Duplex ultrasound  measure the speed of blood flow and to see the
structure of your leg veins.
 Venogram  to see the anatomy of your veins. During this test, your
physician injects a dye, properly called contrast, which makes the blood in your veins
appear on an x-ray.

MANAGEMENT
1. MEDICAL
 Aspirin
 Pentoxifylline
 Topical steroids (for stasis dermatitis)
 Horse chestnut seed extract
 If cellulitis is suspected  empiric therapy (topical antibiotic) with coverage for
S. aureus and Streptococci.
2. SURGICAL
 Sclerotherapy
 Injects a chemical into your affected veins  The chemical scars veins from the
inside  abnormal veins can then no longer fill with blood. Blood that would
normally return to the heart through abnormal vein returns to the heart through
other veins.
  Long saphenous vein stripping
 Makes a small incision in the groin area and calf below the knee  Disconnects
and ties off all veins associated with the saphenous vein (main superficial vein) 
Removes this vein from your leg.
 By Pass
 Connect an artificial vein, called a graft, or a transplanted vein to a vein not
affected by CVI to help blood flow from your affected leg around the blocked vein.

3. REHABILITATION
 Compression stocking
 Compression stockings are elastic stockings that squeeze your veins and
stop excess blood from flowing backward. Wear it daily for the rest of your life.
 DON’T WEAR compression stockings on edematous limbs, especially
those that are tender.
 Raising legs and avoiding standing for long periods of time to decrease the
pressure in the veins.
 When you do need to stand for a long period, you can flex your leg muscles
occasionally to keep the blood flowing.
 Maintaining your ideal body weight or losing weight if you are overweight.

COMPLICATION
 Recurrent ulceration is frequent. Any open wound provides a portal of entry for
bacteria.
 Many patient are predisposed to thrombi, and recurrent episodes of venous
thrombosis are common.
 All patients with advanced venous disease have some degree of lymphatic
impairment  Loss of lymphatic drainage from the lower leg may lead to
verrucous changes and cutaneous hypertrophy, elephantiasis nostras (Acquired
Lymphedema).

PREVENTION
 Valvular failure may develop during pregnancy  Use of supportive stockings
throughout maternitycan be recommended.
 If one's occupation or lifestyle involves long periods of immobility  Stockings are
advisable.
 Prevention of venous thrombosis prevents venous insufficiency.

PROGNOSIS
 The prognosis for healing areas of ulceration and inflammation is excellent in
the absence of comorbid illness that interferes with healing.
 The vast majority of uncomplicated patients respond well to outpatient
therapy.
 Loss of valvular function is irreversible.
 Withdrawal of continual lifelong cutaneous support (compression stockings) 
Skin and soft tissue injury continues.

Reference
Fitzpatrick, Dermatology in General Medicine
Harisson, Principles of Internal Medicine
Current Medical Diagnosis and Treatment 2008
Robin Cotran Pathologic Basis Of Disease
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