1. Chronic Venous Insufficiency
Dr Mohanad Al-Bayati
ST1 VTS

2. Definition
Chronic venous insufficiency (CVI) refers to the complete spectrum of manifestations of venous hypertension in the lower limb ranging from varicosities to venous ulceration and, in long-standing disease, lymphoedema. The CEAP (clinical, aetiologic, anatomical, pathophysiological) classification was developed by Porter and Moneta in 1995 and endorsed by the American Venous Forum to provide a standard scheme for reporting the features and grading of CVI.

4. Skin changes Eczematous changes Skin pigmentation Oedema
Frank ulceration
Shallow, irregular with sloping edge, may develop malignant changes if untreated

5. Corona Phlebectatica
One of the earliest manifestations of CVI consisting of three components. These are dilated intradermal venules located at the medial or lateral aspects of the foot (i) extending to the plantar arch disappearing with elevation of the limb (ii) and with associated stasis spots or ‘blebs’ representative of purple areas that (iii) blanch with pressure. Corona has proven to be strongly indicative of venous stasis especially in the distal lower limb veins.

6. Lipodermatosclerosis
A form of indurated cellulitis and now known to result from underlying changes in the microcirculation. Capillary dilatation and endothelial damage due to increased venous pressure causes extravasation of fluid into pericapillary spaces. This results in inflammation and haemosiderin deposition from fragmented erythrocytes. It subsequently stimulates melanin production pigmenting the skin brown.
Such changes may develop insidiously or present acutely with severe pain and swelling that mimics cellulitis.

7. Management Conservative: Surgical intervention: Compression stockings
Avoiding prolonged standing
Elevation of the leg
Regular exercise
Modifying cardiovascular risk factors
Surgical intervention:
Sclerotherapy
Ablation
Vein stripping
Bypass
Valve repair
Angioplasty or stenting for severe CVI

8. Referral Criteria 1- Referral before treatment: uncertain diagnosis.
suspected arterial insufficiency.
suspected malignant lesion which can be rapidly deteriorating or atypical appearance that may require biopsy.
ulcers associated with systemic vasculitis.
ulcers in known diabetics or newly diagnosed diabetic patients.

9. Referral Criteria 2- Referral during treatment:
Development of complications (severe infection, uncontrolled pain)
Development of refractory ulcers that are not responding to 2-3 months of conservative treatment.
Recurring ulcers
Further problems (varicose veins)

10. Case 1
82 years old lady with PMH of IHD, NIDDM, HTN and overweight. Presented to the surgery with several months history of swollen legs, slightly itchy. She is otherwise feeling well. O/E she looked well, normal gait, stable observations, had fine bibasal creps with good air entry bilaterally.
How do you manage this lady?
When to refer?

11. Case 2
A 42 years old obese lady with poor mobility, had a DVT 6 months ago after which she developed gradually worsening left leg swelling and ulcer presented to the surgery with:
She is otherwise well and all obs stable.
Describe the lesion, and how would you manage it?