Chronic venous insufficiency (CVI) is a poorly understood vascular disorder that affects 10% to 35% of people with venous disease.¹ The onset and progression of CVI are often insidious. Leg achiness or discomfort and swelling are early signs and symptoms that may be precursors to the most devastating consequences of CVI, leg ulcers.

Leg ulcers affect 1% to 22% of older people with CVI and are associated with an estimated per-episode cost exceeding $40,000.² The true incidence may be much higher because the prevalence of both varicose veins and venous ulceration increases consistently with age.^3,4 Older patients often present with leg symptoms of greater severity, and they have the highest ulcer recurrence rates of any age group (approaching 70%).^5,6

Physician assistants face many challenges in the management of older patients, all of whom have a higher risk of leg ulcers, functional impairment, depression and other comorbid conditions that decrease quality of life.⁷ Evidence-based guidelines for CVI are lacking. Therefore, this article offers a clinical guide to CVI care by exploring the current literature related to etiology, diagnosis and management.

Etiology

Although the exact pathologic mechanisms of CVI are unclear, venous hypertension is the hallmark of the disease. CVI affects the deep and superficial venous systems and initiates a cascade of physical inflammatory changes in the vessel wall. Factors associated with venous hypertension include dysfunction of the venous valves, perforating vein reflux in superficial or deep veins, calf muscle pump dysfunction, and venous obstruction from thrombus or iliac stenosis.^8-11

Chronic venous insufficiency is attributed to three types of venous hypertension: congenital, primary and secondary - the latter of which is ascribed to deep vein thrombosis (DVT).¹² Regardless of type, no direct links between venous hypertension and actual skin damage have been established - even though the clinical manifestations of telangiectasis, varicose veins, cutaneous hyperpigmentation, dermatitis, subcutaneous tissue fibrosis (lipodermatoscerlosis) and intractable ulceration are frequent sequelae of CVI.¹⁰ Skin damage is explained by contemporary theories, for example, that microcirculatory inflammation and systemic defective fibrinolysis may increase thrombotic potential, leading to gross venous dilatation, vessel elongation and eventually telangiectases, varicosities and skin changes.^9,13-15

Risk Factors for CVI

A review of studies that examined CVI risk factors suggests that DVT has the strongest association with CVI.¹⁶ Screen for additional risk factors in the history and during clinical examination of the lower legs to identify at-risk patients.^17-19

Clinical Manifestations

Signs and symptoms of CVI vary. Generally the affected patient complains of leg heaviness; tension; swelling; tingling, aching or itching; cramps; "hot legs;" and venous claudication relieved with elevation.^20-22

The severity of CVI may be assessed using several classification systems.^23,24 The most common and clinically useful is the CEAP system.^25,26 The acronym stands for Clinical signs, Etiology, Anatomical distribution of affected veins, Pathophysiological dysfunction.^25,26 Unlike other classification tools, this system takes into account the severity of each category. For this reason, the CEAP classification appears to be the best system available.²⁵ CEAP classification provides a system for documenting the severity of CVI and serves as a basis for diagnostic tests and clinical intervention.²⁷

Clinical Assessment

Quick clinical assessment techniques should be performed prior to referral to a vascular lab for diagnostic studies. In addition to inspection for the presence or absence of clinical signs, circulation screening is needed. For an estimation of arterial flow, calculate the ankle-brachial index (ABI) for each leg. The ABI is a screening test for arterial flow in which the systolic blood pressures in the arms and legs are compared. A hand-held Doppler and blood pressure cuff are needed to accurately determine ABI. For a thorough explanation of this test, see the article cited in the reference list.²⁸

A reading of less than 0.90 is indicative of arterial insufficiency. It is not uncommon for patients to have combined arterial and venous insufficiency (CAVI).¹⁸ Older patients with a decreased ABI require further arterial studies. All patients with complaints of leg pain or heaviness (arterial and venous claudication) should have a clinical vascular evaluation that incorporates the ABI.

A useful assessment of venous flow can be conducted in the clinical setting with a specialized Doppler and a probe attached to the lower leg. Appropriate devices on the market today are the venous Doppler (sold as the Rheo Dopplex II by Huntleigh Healthcare) and the infrared dermal thermometers marketed by Prizm Medical, Xilas Medical and Exergen Corp.

Reflux (venous filling index) and calf pump function (ejection and residual volume fraction) can be determined by having the patient tap the foot up and down (dorsiflexes) eight times while seated. This test can be used to screen patients with suspected lower limb DVT or CVI. Assessment of overall venous function, including the detection of venous reflux in specific vessels and differentiation between deep and superficial venous insufficiency, can provide immediate information about venous flow and whether a DVT is present.

Skin temperature is emerging as a newer clinical marker, and research data support its use. Skin temperature measurement can establish baseline and normal variability, augment clinical findings, quantify the skin temperature "numerically," and track changes over time. It can also detect subclinical skin damage in patients at risk for ulcer development.^29,30 Contact and noncontact infrared thermometry are newer assessment techniques that may emerge as ways to measure inflamed areas of the skin at the bedside.

Another clinical assessment technique is estimation of edema. The validity and reliability of volume studies for edema estimation have not been firmly established, however. Currently, the best method to assess edema is to measure the circumference of the lower legs at two locations: 5 mm above the malleoli and at the largest part of the calf while the patient is seated, and with legs in the dependent position. Measurements should be made weekly or at every visit.

Diagnostic Studies

Diagnostic peripheral venous studies of the macrovascular circulation are useful in the diagnosis of valve insufficiency and the assessment of deep and superficial venous thrombosis. The conventional method for diagnosing venous disease is with duplex scanning, a technique that combines Doppler ultrasound and beta-mode, real-time imaging to maximize physiologic function and the anatomic location in the deep and superficial veins (occlusion, obstruction).²⁷ Methods to evaluate microvascular involvement include photoplethysmography (PPG) and impedance plethysmography (IPG). These determine venous occlusion, microvascular volume, pulsatility and capillary filtration. While these diagnostic methods require the use of a vascular lab, several bedside techniques such as the ankle-brachial index and venous volume studies can be used in clinical settings to evaluate the presence of arterial and venous disease.

The role of blood tests for inflammatory and other biomarkers for CVI and venous thrombosis remains controversial. Possible biomarkers for venous thrombosis risk include factors V, VII and VIII, anti-thrombin III, homocysteine, D-dimer, von Willebrand factors and prothrombin mutation.^31,32 Other research has found no correlation among symptoms of CVI and several inflammatory markers (e.g., von Willebrand factor, intercellular adhesion molecule 1, L-selectin, tumor necrosis factor-alpha).³³ More data are needed to determine the exact relationship between various biomarkers and venous disease.

Treatment

After determining the presence of CVI, the treatment approach should include compression therapy, exercise, elevation, meticulous skin care and pharmacologic management.³⁴

Nonpharmacologic Strategies

The hallmark of conservative treatment is class II or III knee-high graduated compression stockings or wraps.³⁵ Prescribe them for patients with ABIs greater than 0.90.³⁵ Class III stockings offer high compression of 40 mm Hg to 50 mm Hg; Class II versions provide moderate compression of 30 mm Hg to 40 mm Hg; and Class I stockings offer mild compression of 20 mm Hg to 30 mm Hg. High compression is recommended for patients with CEAP 4, 5 or 6; moderate compression is recommended for CEAP 2 and 3; and mild compression is indicated for CEAP 0 and 1. Stockings are appropriate for patients with ABIs less than 0.90.

Adherence with compression therapy is strongly linked with the belief that the stockings are worthwhile, so thorough patient education is essential. Conversely, nonadherence is associated with the belief that stockings are uncomfortable to wear.³⁶ Anecdotally, older patients often find the higher compression stockings difficult to put on and complain that they are hot and uncomfortably tight. Also anecdotally, patients appear to be more adherent with stockings falling in the compression range of 25 mm Hg to 35 mm Hg. Prescription and over-the-counter stockings are available, along with stocking aid devices, through durable medical equipment stores, pharmacies, drug stores and online sites such as ameswalker.com, jobst-usa.com, juzousa.com, and healthylegs.com.

Another nonpharmacologic intervention for CVI is exercise to strengthen the calf musculature and enhance ankle mobility. To achieve maximum benefit, this should be done at least twice each week for 1 hour. Consider referral to physical therapy for a formal individualized exercise program focused on lower limb and trunk stretching and strengthening with active gravity strengthening and resistive weights. The goal of exercise is to improve calf muscle pump strength and function.

In the clinic setting, instruct the patient to pump the calf by pushing the toes against a stationary object or to stand and push up with the toes. These movements "pump" the muscle. In addition, passive measures can be performed by dorsiflexing and plantarflexing the foot. Daily uphill walking (outdoors or on a treadmill) will further strengthen the calf. Some patients experience pain with walking, especially in the presence of severe edema or post-thrombotic syndrome. In patients with DVT, pain symptoms can worsen with exercise, especially walking.³⁷ When pain or discomfort occurs, patients should stop and rest, then resume activity. Regardless of pain, it is important to set up a walking schedule. Start with 10 minutes and increase to at least 30 minutes daily. Reassure the patient that symptoms will subside over time, and that he or she should continue walking daily.

In patients with CVI, leg elevation for 3 to 4 hours per day is associated with a statistically significant reduction in edema.³⁸ However, patients who are obese or have respiratory problems may find it difficult to lie down and elevate the legs. To sufficiently reduce edema, the feet should be raised 45 cm (legs elevated at 30 degrees from the hip to the knee with legs extended). Many patients sit in recliners as a way to elevate their legs. This does not provide sufficient venous drainage, especially for people with large abdomens that "rest" on the upper iliac or femoral veins, occluding venous return.

Frequent, meticulous skin care is essential to prevent and ameliorate the dermal effects of CVI. Patients often present with xerosis and pruritis, as well as exfoliative, erythematous skin. Signs of dermatitis can be confused with cellultis, especially when the skin is red, edematous, flaky and painful. Patients should wash daily with tepid water (94º F) and a mild soap (Caress, Dove, Tone), rinse well and pat dry. They should apply emollients liberally every 3 hours when possible. Many patients report good results with emollients such petrolatum (Vaseline), petrolatum-based products and vegetable shortening.³⁹

Additional nonpharmacologic interventions may be helpful, such as foot pumps and pneumatic sequential compression devices. It is unclear whether efficacy is enhanced when these devices are used simultaneously with compression stockings. Some research has documented increased efficacy with Class II stockings worn during pumping for 2 hours per day over 3 months, but other data suggest that compression stockings should not be used simultaneously with pump devices.^40,41

Surgical options for CVI focus on the treatment of varicose veins and the correction of reflux or obstruction. Newer surgical techniques have made it possible to repair damaged valves in the large veins or to bypass them using a length of vein with healthy valves.⁴² Older methods such as venous valve transplantation, crossover bypass and banding are still performed, but there is little agreement in the literature about the long-term benefits of any of these procedures.⁴³

Pharmacologic Treatments

Complementary treatment is a standard of care in many European countries but not in the United States. However, there is strong evidence to support the use of micronised purified flavonoid fraction (MPFF) and horse chestnut seed extract (HCSE) in the treatment of CVI. An oral phlebotropic drug, MPFF consists of 90% (450 mg) micronised diosmin and 10% (50 mg) flavonoids expressed as hesperidin. Flavonoids are naturally occurring antioxidants in plants. In two randomized, double-blind, 2-month studies, MPFF 500 mg twice daily significantly decreased ankle or calf circumference and improved many symptoms of CVI and plethysmographic parameters.⁴⁴ MPFF is also marketed as Ardium, Alvenor, Arvenum 500, Capiven, Daflon 500, Detralex, Elatec, Flebotropin, Variton, and Venitol. The recommended dose is two tablets daily as a single dose in the morning or evening or one tablet twice daily.⁴⁴

HSCE, also known as Aesculus hippocastanum L, is another approach to reducing edema, leg volume, ankle and calf circumference.⁴⁵ Venastat, a brand of HSCE, is sold over the counter and has long been used as an herbal remedy for CVI. Caution should be used when recommending HCSE for internal use because chestnuts of the genus Aesculus are considered toxic.⁴⁶ Despite this, recent research determined that HCSE is an efficacious and safe short-term treatment for CVI.⁴⁷ The recommended dose is 300 mg (50 mg escin per dose) once or twice daily.

There is less evidence for the use of pycnogenol (French maritime pine bark extract) and butcher's broom preparations, or for total triterpenic fraction of Centella asiatica (TTFCA).^48-50 Additionally, there is limited evidence to support pentoxifylline, stanazolol, hydroxyrutosides, nicotine gum or patches, or nitroglycerin.^13,51 When considering herbal supplements, evaluate drug-drug interactions and side effects and provide education about potential problems with these agents.

Avoiding Complications

CVI is often underrecognized as a significant venous disease that can result in severely disabling complications such as leg ulcers. Unfortunately, the lack of evidenced-based guidelines and standards of care leaves providers without a clear preventive approach. There is, however, a vast literature that describes classification of signs, diagnostic testing and treatment considerations.

PAs can identify the anatomical location and pathologic processes related to CVI and facilitate early detection of disease by using the CEAP criteria, ascertaining information about pain and venous claudication, performing simple tests such as the ABI, and referring patients for more extensive noninvasive testing using Duplex scanning. Following an early and accurate diagnosis, NPs can initiate treatment. Preventive interventions can significantly reduce signs and symptoms and perhaps prevent disease progression.

Teresa Kelechi is a gerontological clinical nurse specialist with a PhD who is certified as a wound care nurse. She is an assistant professor in the college of nursing at the Medical University of South Carolina in Charleston, where she is also a research facilitator. She practices clinically at the university's diagnostic center, where she specializes in geriatrics and lower extremity wound care.

Barbara Edlund is an adult nurse practitioner with a PhD who specializes in gerontology. She is a professor in the college of nursing at the Medical University of South Carolina, where she is coordinator of the gerontological nurse practitioner and palliative care nurse practitioner programs. She practices clinically in the university's employee health services department.