AssessmentsChronic venous insufficiency
Chronic venous insufficiency
USMLE® Step 1 style questions USMLE
USMLE® Step 2 style questions USMLE
A 64-year-old woman comes to the office complaining of a left ankle lesion for the past five months. She has hypertension and diabetes, treated with chlorthalidone and metformin. She smokes a pack of cigarettes a day, for the past 10 years. Her BMI is 35 kg/m². Vital signs are normal. Her hemoglobin A1c is 6.6 percent. Examination shows a wet, red, painless ulcer, with elevated borders, along medial malleolus, with hyperpigmentation surrounding it. There is moderate peripheral edema, and her calves are painless. Peripheral pulses are not felt. Which of the following is the most likely etiology of this ulcer?
Content Reviewers:Rishi Desai, MD, MPH
Contributors:Tanner Marshall, MS
How do they form? Well - the arterial circulation, going away from the heart, is a high pressure system, meaning the movement of blood is dependent on high pressures that essentially push it through the arteries, on the order of 120 mmHg.
The venous circulation going back to the heart, on the other hand, is a low-pressure system with a central venous pressure around 5mm Hg.
This means that the movement of blood has to rely heavily on what’s called the skeletal muscle pump, which is just a way of saying that it relies on the contraction of surrounding skeletal muscles, which compresses the vein and propels blood through the vessels.
But let’s think about the veins in the legs when you’re standing, now to get to the heart the blood has to go up, right, which is working against gravity.
So if your calf muscles contract and squeeze the blood inside, some blood gets propelled downward, while some gets propelled upward, but then gravity pushes that upward-moving blood back down, and it doesn’t seem like much gets accomplished...and it wouldn’t, but that’s not the whole story—most veins also have one-way valves.
These valves only let blood move in one direction, toward the heart.
So now, as the skeletal muscles contract, it squeezes the veins, and this lower valve stays closed to prevent blood from going downward, while the upper valve lets blood through, but even though gravity wants to push it back down, that blood isn’t allowed to fall back down through the upper valve, right?
For some people, the downward gravitational pull on blood causes the walls of the leg veins to stretch apart over time, which tends to also pull apart those valves.
If these valves fail to close properly, they can allow blood to leak backward and pool in the veins, which can lead to more valves stretching out and failing.
The veins have now become varicose veins, and from this additional blood, they start becoming tortuous, or twisted.
This most commonly affects the superficial veins on the surface of legs, since they see high pressures when standing, rather than the deep veins buried inside the muscles.
Oftentimes, though, collateral veins are used instead, which is where other veins can take the blood as an alternate pathway so it doesn’t stagnate in the varicose vein, and these tend to actually be the deep veins in the legs.