Venous insufficiency and ulcers: Clinical sciences

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Introduction0:00–0:55

Venous insufficiency occurs when the veins in the legs are not able to effectively return blood to the heart due to defective valves, obstruction, or insufficient muscle pump function.
These can cause blood to reflux and pool in the veins, leading to venous congestion, hypertension, and dilation. Venous insufficiency can occur in superficial veins, which include greater and lesser saphenous, and in deep veins, like femoral and popliteal.
Over time, fluid and other substances leak out into the surrounding tissues, causing increased hydrostatic pressure within the capillary bed.
This reduces oxygen transport and promotes accumulation of metabolic waste, causing skin changes, and eventually can lead to the development of an ulcer.
Your first step in evaluating a patient presenting with signs and symptoms suggestive of venous insufficiency with or without an ulcer is to obtain a focused history and physical examination.

Red flags for superimposed infection0:55–2:02

An important thing to keep in mind about venous insufficiency is that abnormal blood flow can increase risk of infection especially if there is a break in the skin that can introduce bacteria into the area.
Because of this, you should be on the lookout for any red flag signs of superimposed infection such as fever, rapidly progressive erythema with a possible crepitus, and septic shock.
If you see any of these red flags, obtain a wound culture, start IV broad-spectrum antibiotics, and obtain an emergent surgical evaluation for debridement of the infected ulcer.
Timely diagnosis and treatment is very important because these infections can quickly progress into necrotizing soft tissue infection, which can be life-threatening.Now that we’ve treated the superimposed infection, let’s turn to chronic venous insufficiency and venous insufficiency ulcers without infection.

Focused H&P2:02–3:38

History often reveals lower extremity heaviness , pain, and swelling. Sometimes, patients report pruritus, tingling, and numbness of their lower extremities as well.
Some of the risk factors you should look for include a history of deep vein thrombosis, or DVT, an occupation that requires standing for long periods of time, or obesity.
These factors tend to impede proper venous return within the lower extremities increasing the risk of developing incompetent venous valves.
When it comes to the physical exam, you can expect to find symptoms of stasis dermatitis due to chronic inflammation. This includes yellow-brown pigmentation of the skin, which occurs as a result of hemosiderin deposits in the skin from stagnant blood within the lower extremity.
Patients may also have lipodermatosclerosis, which includes skin changes such as brawny edema and hardening of the skin, so it looks like the bark of a tree due to fibrotic changes under the skin.
You might also see telangiectasias, reticular veins, varicose veins, and spider veins. Lastly, you might see associated ulcers located on the same affected extremity.
If you see these findings, you can suspect chronic venous insufficiency.Alright, once you suspect chronic venous insufficiency, your next step is to order a venous duplex ultrasound.

Alternative diagnosis3:38–4:26

With this ultrasound, you would be able to visualize any pathologic venous reflux, as well as the presence of any coexisting DVT.
During the ultrasound, you can use a blood pressure cuff around the affected extremity or have the patient perform a Valsalva maneuver to better assess the presence of pathologic reflux within the vein.
If the lower extremity veins appear normal with no abnormal retrograde reflux, you should consider an alternative diagnosis.

Chronic venous insufficiency4:26–5:33

Now, if on the other hand you see abnormal reflux within the veins, your next step is to assess for the presence of ulcers on the affected limb.
If there are no ulcers, you can make your diagnosis of chronic venous insufficiency. The treatment for this is mostly non-surgical, which includes lower extremity elevation when seated or lying down, as well as the use of compression stockings.
These are continued for at least four to six weeks. If after this period, the patient reports persistent symptoms and edema even with these methods, you can obtain a surgical consultation for a venous ablation.
Here’s a clinical pearl! If the patient needs CABG in the future, it will be important to let the cardiac surgeon know they had a vein ablation.
This is what surgeons typically use as the bypass graft in multivessel coronary disease.Alright, let’s go back and talk about patients with an associated ulcer.

Chronic venous insufficiency with ulcer5:33–6:11

On physical examination of the ulcer, you’ll typically see it located above the ankle along the medial malleolus. These ulcers tend to have irregular borders and are often covered with fibrinous exudate.
On palpation, they are usually mildly tender. If you see an ulcer with these characteristics, you can confirm your diagnosis of chronic venous insufficiency with an ulcer.
Because many of these ulcers have other associated vasculopathies, your next step is to order an ankle-brachial index, or an ABI, to evaluate for arterial insufficiency.

Venous ulcer6:11–6:41

A normal ABI of 0.9 or greater rules out the presence of arterial disease, which helps confirm your diagnosis of a venous ulcer.
Your management should include lower extremity elevation, compression stockings, and wound care. If the ABI is abnormal, or less than 0.9, the ulcer is due to both arterial and venous insufficiency, so you can diagnose a mixed arterial and venous ulcer.

Mixed venous and arterial ulcer6:41–7:14

Your next step is to obtain an urgent surgical consultation for a possible revascularization procedure in addition to wound care.
Revascularization in these patients is important to re-establish blood flow to the ulcer and promote proper wound healing.
Remember, lack of blood flow will result in poor healing. Alright, as a quick recap… Venous insufficiency is the reflux of blood through veins in the opposite direction as normal due to incompetent valves within the veins.

Review7:14–8:00

A duplex venous ultrasound showing retrograde reflux is diagnostic of venous insufficiency, and treatment may include elevation, compression stockings, and ablation for persistent disease.
For venous insufficiency with associated ulcers, ABI can be used to identify venous or mixed arterial and venous causes.
Venous ulcers are treated with lower extremity elevation, compression stockings, and wound care, while mixed ulcers need surgical evaluation for revascularization.