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Medical Management of Lower Extremity Chronic Venous Disease

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Medical Management of Lower Extremity Chronic Venous Disease Medical management of lower extremity chronic venous disease Authors: Patrick C Alguire, MD, FACP Barbara M Mathes, MD, FACP, FAAD Section Editors: John F Eidt, MD Joseph L Mills, Sr, MD Deputy Editor: Kathryn A Collins, MD, PhD, FACS Contributor Disclosures All topics are updated as new evidence becomes available and our peer review process is complete. Literature review current through: Jul 2020. | This topic last updated: Apr 22, 2020. INTRODUCTION Venous hypertension is associated with histologic and ultrastructural changes in the capillary and lymphatic microcirculation that produce important physiologic changes, which include capillary leak, fibrin deposition, erythrocyte and leukocyte sequestration, thrombocytosis, and inflammation. These processes impair oxygenation of the skin and subcutaneous tissues. The clinical manifestations of severe venous hypertension and tissue hypoxia are edema, hyperpigmentation, subcutaneous fibrosis, and ulcer formation. The medical management of chronic venous disease with and without ulceration is discussed here. The etiology, presentation, and pathophysiology of chronic venous disorders are discussed elsewhere: ●(See "Classification of lower extremity chronic venous disorders".) ●(See "Clinical manifestations of lower extremity chronic venous disease".) ●(See "Pathophysiology of chronic venous disease".) ●(See "Diagnostic evaluation of lower extremity chronic venous insufficiency".) OVERVIEW Treatment goals for patients with chronic venous disease include improvement of symptoms, reduction of edema, prevention and treatment of lipodermatosclerosis (picture 1), and healing of ulcers [1,2]. An algorithm for the medical management of venous insufficiency is based upon available data and published recommendations (algorithm 1) [3-5]. Lipodermatosclerosis Picture 1 Skin induration, redness, and hyperpigmentation involving the lower third of the leg in a patient with stasis dermatitis and lipodermatosclerosis. Reproduced with permission from: www.visualdx.com. Copyright VisualDx. All rights reserved. Treatment of chronic venous insufficiency Algorithm 1 Therapies enhancing venous flow (eg, limb elevation, exercise, and compression therapy) improve oxygen transport to the skin and subcutaneous tissues, decrease edema, reduce inflammation, and can be utilized for any patient with symptoms and signs of chronic venous disease. (See "Clinical manifestations of lower extremity chronic venous disease" and 'General measures' below and 'Compression therapy' below and "Compression therapy for the treatment of chronic venous insufficiency", section on 'Static compression therapy'.) Patients with symptoms that are refractory to compression therapy or who are unable to tolerate compression therapy may benefit from systemic therapy. (See 'Pharmacologic therapy' below.) Dry skin, itching, and eczematous changes are treated with various topical dermatologic agents. Contact dermatitis occurs not infrequently, so avoidance of topical products with common sensitizers is advised. (See 'Skin care' below and "Stasis dermatitis" and 'Contact dermatitis' below.) Venous ulceration is treated with a combination of ulcer wound management and compression therapy in the form of compression hosiery or compression bandaging systems. The treatment of chronic venous insufficiency with ulceration requires lifestyle changes to achieve treatment goals. An algorithm for medical management is based upon available data and published recommendations (algorithm 1). (See 'Compression therapy' below and 'Ulcer care' below and "Compression therapy for the treatment of chronic venous insufficiency", section on 'Static compression therapy'.) Superficial vein ablation has been evaluated both for the treatment of venous ulcers and for prevention of recurrence. Surgery is thought to produce beneficial effects via reduction of venous reflux from the deep to the superficial veins by ablating or removing incompetent perforating and superficial veins, thereby modifying the effect of venous hypertension upon the cutaneous tissues [6]. The role of venous ablation therapy in the treatment of lower extremity chronic venous disease with or without ulceration is discussed separately. (See "Clinical manifestations of lower extremity chronic venous disease".) GENERAL MEASURES Leg elevation — Simple elevation of the feet to at least heart level for 30 minutes three or four times per day improves cutaneous microcirculation and reduces edema in patients with chronic venous disease. In one study of 15 patients with lipodermatosclerosis, leg elevation resulted in a 41 percent increase in blood flow velocity as measured by Doppler fluximetry [7]. Limb elevation also promotes healing of venous ulcers [7-9]. Leg elevation alone may be sufficient to relieve symptoms in patients with mild venous disease but is usually not adequate in more severe cases. It may also not be practical for some people to elevate their legs several times per day because of the nature of their work. Elevation of the feet below the level of the heart, such as in a lounge chair, is ineffective for reducing venous hypertension. Exercise — The efficiency of the calf muscle pump in pushing venous blood up the legs is usually impaired in patients with chronic venous insufficiency, contributing to the development and delayed healing of venous ulcers [10-12]. Moreover, physical activity in patients with chronic venous insufficiency and ulceration tends to be very limited. In one study, 35 percent of the patients did not have a 10 minute walk even once a week [13]. Daily walking and simple ankle flexion exercises while seated are inexpensive and safe strategies in the management of chronic venous disease. Several small studies have shown improvement in hemodynamic parameters with simple calf muscle (plantar flexion) exercises [14-17]. In a meta-analysis of six trials, the addition of exercise to usual care (mostly compression) was associated with increased venous leg ulcer healing at 12 weeks [18-24]. The type of compression used was not specified for some studies. A combination of progressive resistance exercise (heel lifts) and prescribed physical activity (walking, treadmill, and/or cycling 30 minutes per day three times per week) appeared to be the most effective. COMPRESSION THERAPY Static compression therapy is an essential component in the treatment of chronic venous disease [25-27]. The options, characteristics, and choice of compression hosiery or compression bandages, and in particular for their use in the treatment of chronic venous insufficiency, is reviewed elsewhere. (See "Compression therapy for the treatment of chronic venous insufficiency".) Efficacy and choice of compression Superficial reflux and varicose veins — Many patients with varicose veins report rapid symptomatic improvement with use of compression hosiery [28-30]. However, due to methodological shortcomings, there are few high-quality data that demonstrate the effectiveness of compression hosiery for managing symptomatic varicose veins [31]. In clinical trials assessing the effectiveness of compression therapy, symptoms subjectively improved [31]. In the absence of clinical data, if the patient tolerates wearing compression hosiery, most patients can determine within a short period of time if their symptoms are sufficiently controlled enough to continue therapy, or whether to seek additional treatment. Treatment algorithms in studies comparing various endovenous therapies typically use a threshold of three months of conservative management prior to offering treatment [32]. (See "Compression therapy for the treatment of chronic venous insufficiency", section on 'Compression hosiery' and "Approach to treating symptomatic superficial venous insufficiency".) Chronic venous insufficiency — Randomized trials have repeatedly demonstrated the benefits of long-term compression therapy (hosiery or bandages) in patients with severe chronic venous disease associated with edema or venous stasis ulcers [27]. Issues related to the initial choice and application of compression therapy, in particular for the treatment of chronic venous insufficiency, are discussed separately. (See "Compression therapy for the treatment of chronic venous insufficiency", section on 'Choice of initial therapy'.) PHARMACOLOGIC THERAPY A variety of systemic agents have been used in the management of chronic venous disease. These are generally categorized as those that affect venous tone (ie, venoactive agents) such as the flavonoids (includes rutin, rutosides) and others, and those that affect the flow properties of blood (ie, rheologic agents) such as aspirin, pentoxifylline, prostacyclin analogs, stanazol, sulodexide, and defibrotide [33-37]. Most studies evaluating these agents provide only low-quality evidence of benefit. As an example, only 28 percent of the studies included in the Cochrane review discussed below [34] provided standard diagnostic criteria for chronic venous insufficiency, and misclassification of disease is possible. The studies used different methods to identify signs and symptoms. The outcomes were not categorized by severity of disease. Importantly, most of these agents have been studied over relatively short durations, typically three months; thus, long-term efficacy and safety cannot be assured. It is important to note that diuretics have no role in the treatment of edema due solely to chronic venous insufficiency; however, diuretics may be prescribed as a treatment for other medical conditions that exacerbate lower extremity
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