eMedicine Specialties > Dermatology > Diseases of the Vessels

Venous Insufficiency: Follow-up

Author: Robert Weiss, MD, Associate Professor, Department of Dermatology, Johns Hopkins University School of Medicine,
Coauthor(s): Craig F Feied, MD, FACEP, FAAEM, FACPh, Professor of Emergency Medicine, Georgetown University School of Medicine; General Manager, Microsoft Enterprise Health Solutions Group
Contributor Information and Disclosures

Updated: Apr 14, 2009

Follow-up

Further Inpatient Care

  • Patients who have had significant blood loss from a ruptured varicosity may be admitted to the hospital, particularly if the bleeding varicosity is large and if the overlying tissue is friable.

Further Outpatient Care

  • Patients with venous insufficiency syndromes should wear compression stockings unless they also have arterial insufficiency or unless they cannot tolerate the stockings for some other reason.
  • Increased pain or swelling is an indication for repeat duplex ultrasonography to rule out DVT.

Deterrence/Prevention

  • Patients should avoid prolonged standing or sitting.
  • Correction of the underlying problem prevents progression of the disease.
  • In patients with early venous insufficiency, progression to overt signs of disease such as stasis dermatitis, skin breakdown, and ulceration can virtually always be prevented with the use of gradient compression hose with a 30- to 40-mm Hg gradient between foot and knee.

Complications

  • Common sequelae of venous insufficiency include pain and paresthesias, stasis dermatitis, nonhealing venous ulcers, hemorrhage, recurrent cellulitis, deep and superficial thrombophlebitis, pulmonary embolism, and death. The local tissue sequelae of venous insufficiency are due to a combination of high venous pressures and reduced clearance of cellular metabolites from the lower extremity. Chronic pain, swelling, recurrent cellulitis, and chronic nonhealing leg ulcers (ulcer cruris) are the most common sequelae, but they are not the most severe.
  • Complications of untreated venous insufficiency
    • Recruitment of veins (High venous pressures may cause the recruitment of adjacent normal veins into refluxing circuits.)
    • Deep venous thrombosis
    • Pulmonary embolism
    • Venous ulceration
    • Secondary lymphedema
  • Potential complications of surgical ablation of refluxing veins
    • Infection
    • Nerve injury
    • Arterial injury
    • Undesirable cosmetic outcomes
  • Potential complications of RFA and EVLT
    • Skin burns
    • Thermal injury to adjacent tissues
    • Inadvertent injury to deep veins
  • Potential complications of sclerotherapy
    • Allergic reactions to sclerosants
    • Cutaneous necrosis due to extravasation
    • Inadvertent arterial injection (may cause loss of a limb)

Prognosis

  • Without correction of the underlying cause, venous insufficiency is inexorably progressive.
    • Subjective symptoms usually worsen over time.
    • In many patients, the skin eventually breaks down and nonhealing ulcers develop.
    • Patients have an increased lifetime risk of DVT and pulmonary embolism.
  • Reflux need not be entirely eliminated for the ulceration to resolve. Ulcers will heal if the net volume and pressure of reflux are reduced below a threshold level.
  • Tissue atrophy and staining are usually not reversible.
  • Venous insufficiency syndromes can also lead to death from thromboembolism or hemorrhage.

Patient Education

  • Patients should be instructed to wear compression hose as much as tolerated.
  • Patients should avoid prolonged standing or sitting. Walking or calf-muscle exercises should be performed at regular intervals.
  • For patient education resources, visit eMedicine's Circulatory Problems Center. Also, see eMedicine's patient education articles Blood Clot in the Legs, Varicose Veins, and Phlebitis.

Miscellaneous

Medicolegal Pitfalls

  • Missing the diagnosis of DVT
  • Missing the diagnosis of superficial venous thrombosis
  • The misdiagnosis of stasis dermatitis as contact dermatitis
  • The misdiagnosis of venous insufficiency as arterial insufficiency
  • Misdiagnosing venous disease often is lethal when venous thrombosis is involved, but other errors are rarely disastrous because nonthrombotic venous disease is slowly progressive: morbidity results in a decreased quality of life and an inability to work, but death is rare.

Special Concerns

  • Pregnancy is an important causative factor in the development of peripheral venous insufficiency.
 


More on Venous Insufficiency

Overview: Venous Insufficiency
Differential Diagnoses & Workup: Venous Insufficiency
Treatment & Medication: Venous Insufficiency
Follow-up: Venous Insufficiency
Multimedia: Venous Insufficiency
References
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References

  1. Coon WW, Willis PW 3rd, Keller JB. Venous thromboembolism and other venous disease in the Tecumseh community health study. Circulation. Oct 1973;48(4):839-46. [Medline].

  2. Racette S, Sauvageau A. Unusual sudden death: two case reports of hemorrhage by rupture of varicose veins. Am J Forensic Med Pathol. Sep 2005;26(3):294-6. [Medline].

  3. Chiesa R, Marone EM, Limoni C, Volonte M, Schaefer E, Petrini O. Chronic venous insufficiency in Italy: the 24-cities cohort study. Eur J Vasc Endovasc Surg. Oct 2005;30(4):422-9. [Medline].

  4. Bonnetblanc JM. Leg ulcerations: a clinical appraisal. Eur J Dermatol. May-Jun 2005;15(3):127-32. [Medline].

  5. Zimmet SE. Venous leg ulcers: modern evaluation and management. Dermatol Surg. Mar 1999;25(3):236-41. [Medline].

  6. Tretbar LL. Treatment of small bleeding varicose veins with injection sclerotherapy. Bleeding blue blebs. Dermatol Surg. Jan 1996;22(1):78-80. [Medline].

  7. Nael R, Rathbun S. Treatment of varicose veins. Curr Treat Options Cardiovasc Med. Apr 2009;11(2):91-103. [Medline].

  8. Nijsten T, van den Bos RR, Goldman MP, et al. Minimally invasive techniques in the treatment of saphenous varicose veins. J Am Acad Dermatol. Jan 2009;60(1):110-9. [Medline].

  9. Leopardi D, Hoggan BL, Fitridge RA, Woodruff PW, Maddern GJ. Systematic review of treatments for varicose veins. Ann Vasc Surg. Mar 2009;23(2):264-76. [Medline].

  10. Sadick NS. Advances in the treatment of varicose veins: ambulatory phlebectomy, foam sclerotherapy, endovascular laser, and radiofrequency closure. Dermatol Clin. Jul 2005;23(3):443-55, vi. [Medline].

  11. Diehm C, Allenberg JR. Color Atlas of Vascular Diseases. New York, NY: Springer Publishing; 1999:1-396.

  12. Feied CF. Deep vein thrombosis: the risks of sclerotherapy in hypercoagulable states. Semin Dermatol. Jun 1993;12(2):135-49. [Medline].

  13. Feied CF. Peripheral venous disease. In: Rosen and Barkin, eds. Emergency Medicine Principles and Practice. Vol 3. 4th ed. St. Louis, Mo: Mosby-Year Book; 1998:Chapter 107.

  14. Goldman MP. Sclerotherapy: Treatment of Varicose and Telangiectatic Leg Veins. 2nd ed. St. Louis, Mo: Mosby-Year Book; 1995:1-519.

  15. Weiss RA, Feied CF, Weiss MA. Vein Diagnosis & Treatment: A Comprehensive Approach. New York, NY: McGraw-Hill; 2001:1-304.

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Further Reading

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Keywords

venous insufficiency, venous stasis, postphlebitic syndrome, venous reflux, stasis dermatitis, stasis ulcer, venous ulcer, valvular incompetence, DVT, deep vein thrombosis, deep venous thrombosis, superficial venous incompetence, superficial venous insufficiency, varicose veins, junctional high-pressure disease, perforator high-pressure disease, venous hypertension

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Contributor Information and Disclosures

Author

Robert Weiss, MD, Associate Professor, Department of Dermatology, Johns Hopkins University School of Medicine,
Robert Weiss, MD is a member of the following medical societies: American Academy of Cosmetic Surgery, American Academy of Dermatology, American College of Phlebology, American Dermatological Association, American Society for Dermatologic Surgery, American Society for Laser Medicine and Surgery, and MedChi
Disclosure: Angiodynamics Honoraria Speaking and teaching; CoolTouch Corp Intellectual property rights Consulting; Cynosure Grant/research funds Independent contractor; Palomar Grant/research funds Independent contractor

Coauthor(s)

Craig F Feied, MD, FACEP, FAAEM, FACPh, Professor of Emergency Medicine, Georgetown University School of Medicine; General Manager, Microsoft Enterprise Health Solutions Group
Craig F Feied, MD, FACEP, FAAEM, FACPh is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, American College of Phlebology, American College of Physicians, American Medical Association, American Medical Informatics Association, American Venous Forum, Medical Society of the District of Columbia, Society for Academic Emergency Medicine, and Undersea and Hyperbaric Medical Society
Disclosure: Nothing to disclose.

Medical Editor

R Stan Taylor, MD, Professor of Dermatology, University of Texas Southwestern Medical School; Director of Skin Surgery and Oncology Clinic, Department of Dermatology, University of Texas Southwestern Medical Center
R Stan Taylor, MD is a member of the following medical societies: American Academy of Dermatology, American College of Mohs Micrographic Surgery and Cutaneous Oncology, American Medical Association, American Society for Dermatologic Surgery, Christian Medical & Dental Society, and Society for Investigative Dermatology
Disclosure: Nothing to disclose.

Pharmacy Editor

Michael J Wells, MD, Associate Professor, Department of Dermatology, Texas Tech University Health Sciences Center
Michael J Wells, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Dermatology, American Medical Association, and Texas Medical Association
Disclosure: Nothing to disclose.

Managing Editor

Mary Farley, MD, Dermatologic Surgeon/Mohs Surgeon, Anne Arundel Surgery Center
Disclosure: Nothing to disclose.

CME Editor

Glen H Crawford, MD, Assistant Clinical Professor, Department of Dermatology, University of Pennsylvania School of Medicine; Chief, Division of Dermatology, The Pennsylvania Hospital
Glen H Crawford, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Dermatology, American Medical Association, Phi Beta Kappa, and Society of USAF Flight Surgeons
Disclosure: Nothing to disclose.

Chief Editor

William D James, MD, Paul R Gross Professor of Dermatology, University of Pennsylvania School of Medicine; Vice-Chair, Program Director, Department of Dermatology, University of Pennsylvania Health System
William D James, MD is a member of the following medical societies: American Academy of Dermatology and Society for Investigative Dermatology
Disclosure: elsevier Royalty Other; american college of physicians Honoraria Other

 
 
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