From the Guidelines
Chronic venous stasis can indeed cause pitting edema, and management should prioritize compression therapy, leg elevation, and lifestyle modifications to reduce morbidity, mortality, and improve quality of life. Pitting edema occurs when pressure applied to a swollen area leaves an indentation that remains for some time after the pressure is released. In chronic venous insufficiency, damaged valves in the veins allow blood to pool in the lower extremities, increasing pressure in the veins and forcing fluid into surrounding tissues. This fluid accumulation typically causes pitting edema in the ankles and lower legs that worsens throughout the day with prolonged standing or sitting and improves with elevation.
Causes and Risk Factors
The clinical presentation of varicose veins varies, and some patients may be asymptomatic, while others may experience localized symptoms such as pain, burning, itching, and tingling at the site of the varicose veins 1. Established risk factors for varicose veins include family history of venous disease, female sex, older age, chronically increased intra-abdominal pressure due to obesity, pregnancy, chronic constipation, or a tumor, prolonged standing, deep venous thrombosis causing damage to valves and secondary revascularization, and arteriovenous shunting 1.
Management
Management includes:
- Compression therapy with a minimum pressure of 20 to 30 mm Hg, and pressures of 30 to 40 mm Hg for more severe disease 1
- Leg elevation above heart level for 30 minutes several times daily
- Regular exercise to improve calf muscle pump function
- Weight loss if applicable
- Diuretics may be prescribed in some cases but address only the symptom rather than the underlying venous dysfunction
Importance of Compression Therapy
Compression therapy has been widely described as a helpful initial treatment for varicose veins and venous leg ulcers, reducing venous stasis and improving symptoms 1. The use of compression therapy can help contain edema, improve lymphatic drainage, and increase venous blood flow velocity, reducing blood pooling and improving venous pumping function 1.
Recent Guidelines
Recent guidelines from the American College of Radiology recommend compression therapy as the initial treatment for lower extremity chronic venous disease, with a minimum pressure of 20 to 30 mm Hg and pressures of 30 to 40 mm Hg for more severe disease 1. These guidelines also emphasize the importance of proper fitting, education, and detailed instructions to encourage adherence to compression therapy 1.
From the Research
Chronic Venous Stasis
- Chronic venous stasis, also known as chronic venous insufficiency (CVI), is a condition where the veins have problems returning blood to the heart due to valve incompetence and failure of the calf muscle pump 2.
- This condition can lead to increased venous hypertension, tissue oedema, hypoxia, and subsequent fibrosis, resulting in various clinical manifestations such as varicose veins, pigmentation, ulceration, and scarring 2.
- Localized, chronic inflammation is also a key player in the development of CVI, contributing to stasis dermatitis and hypercoagulable state 2.
Treatment and Management
- Therapeutic compression stockings are an effective treatment for CVI, providing a statistically significant improvement in patient severity scores for lower extremity swelling, pain, skin discoloration, activity tolerance, depression, and sleeping problems 3.
- Medical compression stockings are a standard, non-invasive treatment option for all venous and lymphatic diseases, with evidence-based recommendations for their use in chronic and acute venous disorders 4.
- However, patient adherence to wearing compression stockings can be a problem, with reasons for non-adherence including financial constraints, pain, ignorance of the need to wear them, heat, and other factors 5.
Clinical Presentations and Complications
- CVI can progress to chronic leg ulcer, causing serious morbidity and affecting the quality of life of the affected patient, as well as contributing to loss of work productivity 2.
- Long-standing cases of CVI may develop ankle joint stiffness, fixed flexion deformity, periostitis, and even Marjolin ulcer 2.
- CVI is also associated with serious systemic morbidities such as arterial and cardiac disease, highlighting the need for early recognition and intervention to prevent ongoing and debilitating complications 2, 6.