Chronic Venous Insufficiency and Post-Thrombotic Syndrome
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Direct answer
Chronic venous insufficiency is long-standing venous hypertension in the legs, caused by incompetent valves or venous obstruction, most often from varicose veins or deep vein thrombosis. Its severity is graded by the CEAP classification, and it progresses through oedema, skin change and venous ulcers. Post-thrombotic syndrome is its deep-vein form after DVT, and graduated compression is the mainstay of treatment.
What you must remember
- Pathophysiology: venous hypertension from reflux through incompetent valves, obstruction, or both, with superficial and deep vein disease differing in cause.
- CEAP classification: clinical grades C0 to C6, where C0 has no visible signs, C2 is varicose veins, C3 is oedema, C4 is skin change, C5 is a healed ulcer and C6 is an active ulcer; E, A and P record aetiology, anatomy and pathophysiology.
- Investigation of choice: duplex ultrasound maps reflux and obstruction and is the initial test in both varicose veins and suspected post-thrombotic disease.
- Post-thrombotic syndrome: chronic leg pain, oedema and skin change after proximal DVT, with severity graded by the Villalta scale.
- Venous ulcer: typically over the medial malleolus in the gaiter area, usually less painful than an arterial ulcer, with ankle brachial pressure index usually preserved.
- Compression therapy: graduated stockings, typically 20 to 30 mmHg, for symptoms, and multilayer bandaging for ulcer healing once arterial supply is adequate.
- Definitive treatment: endovenous thermal ablation, foam sclerotherapy or surgery for incompetent superficial veins.
Staged management of a gaiter-area ulcer
A 58-year-old shopkeeper has long-standing varicose veins, brown pigmentation above the ankle and a shallow ulcer over the medial malleolus. His ankle brachial pressure index is 0.95, which is reassuring for compression.
- Assess arterial flow: Measure the ankle brachial pressure index before any compression, because significant arterial disease changes which bandage is safe.
- Confirm venous reflux: Duplex ultrasound maps the great and small saphenous veins, the perforators and the deep veins.
- Dress the ulcer: Clean and debride the wound, then apply multilayer compression to control venous hypertension.
- Control oedema: Elevate the leg, keep the patient mobile and continue compression after healing to reduce recurrence.
- Treat the reflux: Endovenous thermal ablation or foam sclerotherapy is preferred for incompetent great saphenous veins. Surgery is reserved for specific cases.
- Screen for red flags: Severe pain, necrosis or rapid spread suggest arterial disease or infection and need urgent review.
Where the exam tries to catch you
Venous and arterial disease look alike on the leg, and the options often test which one you have considered.
- Trap: applying high-pressure compression to a painful ulcer without checking flow. Correct: check the ankle brachial pressure index first, because severe arterial disease makes firm compression dangerous.
- Trap: attributing all leg oedema to venous disease. Correct: cardiac, renal, hepatic and lymphatic causes must be excluded, since venous oedema is only one of them.
- Trap: choosing stripping as the first step for every varicose vein. Correct: duplex mapping and endovenous ablation are the usual first-line options, with surgery reserved for specific cases.
Frequently asked questions
Which investigation is first-line for chronic venous insufficiency?
Duplex ultrasound is the first-line investigation for chronic venous insufficiency. It maps reflux in the saphenous and perforator veins and detects obstruction in the deep veins, which guides treatment.
What does the CEAP classification grade in chronic venous insufficiency?
The CEAP classification grades clinical signs from C0 to C6, with C6 denoting an active venous ulcer. It also records aetiology, anatomical site and pathophysiology, so chronic venous insufficiency is described in full.
How does post-thrombotic syndrome differ from primary varicose veins?
Post-thrombotic syndrome follows deep vein thrombosis and results from valve damage and obstruction in the deep veins. Primary varicose veins arise mainly from superficial vein reflux and are not usually preceded by a thrombotic event.
What compression pressure is used for symptomatic chronic venous insufficiency?
Graduated compression stockings of about 20 to 30 mmHg are typically used for symptomatic chronic venous insufficiency. Stronger multilayer bandaging is reserved for healing ulcers, and only after arterial supply has been confirmed as adequate.
Why is the ankle brachial pressure index measured before compression in venous ulcers?
The ankle brachial pressure index identifies coexisting arterial disease, which makes firm compression unsafe. A value below 0.8 is a warning sign that needs vascular assessment before compression is applied to a venous ulcer.