Venous Disease

Venous disease is also known as venous insufficiency, chronic venous disease (CVD), venous stasis, and venous disorders.

Introduction

Venous disease refers to a group of conditions that affect the veins and impair the return of blood to the heart. It occurs when the veins in the lower extremities become damaged, weakened, or blocked, leading to blood pooling and increased venous pressure. The condition encompasses a wide range of disorders, including varicose veins, deep vein thrombosis (DVT), and chronic venous insufficiency (CVI).

History/Origin of Disease

The study and understanding of venous diseases date back to ancient times. The first documented observations were made by Hippocrates, who described the appearance of varicose veins and associated complications. In the 17th century, William Harvey’s discovery of the circulatory system further advanced knowledge about the function of veins and the role of venous valves. The development of modern diagnostic techniques and treatment options in the 20th and 21st centuries has significantly improved the management of venous disorders.

Types/Classification

Venous disease can be classified as follows:

1. Superficial venous disease:
   • Varicose veins
   • Spider veins (telangiectasias)
2. Deep venous disease:
   • Deep vein thrombosis (DVT)
3. Chronic venous insufficiency (CVI):
   • Venous ulcers
   • Lipodermatosclerosis
   • Skin discoloration

Varicose vein

Anterior abdominal varicose vein

Talangiectasia

Venous ulcer

Pathophysiology

Venous disease is primarily caused by venous valve dysfunction, venous wall abnormalities, or both. Normally, venous valves prevent the backflow of blood and maintain unidirectional flow toward the heart. When these valves become incompetent, blood pools in the lower extremities, increasing venous pressure and causing venous distension. This leads to venous stasis, inflammation, and tissue damage.

Clinical Features

Cardinal Signs and Symptoms

• Varicose veins: Enlarged, twisted veins visible beneath the skin
• Edema: Swelling of the lower limbs, especially after prolonged standing
• Skin changes: Hyperpigmentation, dermatitis, and lipodermatosclerosis
• Pain: Aching, heaviness, or discomfort in the legs
• Ulceration: Non-healing wounds, usually near the ankles
• Itching or burning sensation: Due to skin irritation
• Night cramps: Muscle spasms in the calves

Diagnosis

1. Clinical examination: Visual inspection and palpation of the lower extremities
2. Duplex ultrasound: To assess venous reflux and detect thrombi
3. Venography: Used in complex cases to visualize vein structure
4. Photoplethysmography: To evaluate venous function
5. Magnetic Resonance Venography (MRV): For detailed imaging

Differential Diagnosis

• Arterial disease (e.g., peripheral artery disease)
• Lymphedema
• Cellulitis
• Lipedema
• Neuropathy

Difference Between Arterial and Venous Disease

Feature Arterial Disease Venous Disease Cause Atherosclerosis Valve incompetence Blood flow direction Away from the heart Toward the heart Skin appearance Pale, cool, hairless Discolored, warm, swollen Pain Worsens with activity Worsens with prolonged standing Ulcer location Toes, foot, or lateral malleolus Medial malleolus Pulse Weak or absent Normal Edema Rare Common

Treatment/Management

Conservative Management

• Lifestyle modifications: Regular exercise, weight management, and leg elevation
• Compression therapy: Elastic stockings to improve venous return
• Pharmacological treatment:
  • Venoactive drugs (e.g., diosmin, hesperidin)
  • Anticoagulants (for DVT)

Interventional Treatments

• Sclerotherapy: Injection of sclerosant to close affected veins
• Endovenous thermal ablation: Radiofrequency or laser treatment
• Venous stripping: Surgical removal of varicose veins
• Venoplasty and stenting: For venous obstruction
• Ulcer care: Wound dressings and debridement

Complications

• Venous ulcers
• Deep vein thrombosis (DVT)
• Pulmonary embolism (PE)
• Infection (cellulitis)
• Chronic leg pain and disability

Recent Update

Recent advancements in the management of venous disease include:

• Minimally invasive procedures: Endovenous thermal ablation and glue closure techniques
• Advanced imaging technologies: Improved diagnostics using MRV and duplex ultrasound
• Biological agents: Research into new pharmacological treatments targeting venous inflammation
• Patient-specific compression therapy: Custom-fit compression garments for optimal management

Summary

Venous disease encompasses a spectrum of disorders affecting venous return. It ranges from cosmetic concerns like varicose veins to serious conditions like DVT and chronic venous insufficiency. Early diagnosis and appropriate management are crucial for preventing complications and improving the quality of life. Recent advancements in diagnostic tools and minimally invasive treatments have revolutionized patient care.

References

1. Eberhardt RT, Raffetto JD. Chronic venous insufficiency. Circulation. 2014;130(4):333-346.
2. Gloviczki P, Comerota AJ, Dalsing MC, et al. The care of patients with varicose veins and associated chronic venous diseases: Clinical practice guidelines. J Vasc Surg. 2011;53(5 Suppl):2S-48S.
3. Mansilha A, Sousa J. Pathophysiological mechanisms of chronic venous disease and implications for venoactive drug therapy. Int J Mol Sci. 2018;19(6):1669.
4. Labropoulos N, Leon LR Jr. Venous disease: Epidemiology, pathophysiology, and classification. J Vasc Surg. 2009;49(5):826-830.