cardiovascular disorders
Chronic Venous Insufficiency and Post Thrombotic Syndrome
Treatment of Chronic Venous Insufficiency
Elevation Compression using bandages, stockings, and/or pneumatic devices Topical treatments Treatment of secondary infection, when present Some experts believe that weight loss, regular exercise, and reduction of dietary sodium may benefit patients with bilateral chronic venous insufficiency. However, all interventions may be difficult to implement. Elevating the legabove the level of the right atrium decreases venous hypertension and edema, is appropriate for all patients, and should be done a minimum of 3 times a day for≥30 minutes. However, most patients cannot reliably adhere to this schedule during the day. is recommended for treatment and prevention of the effects of chronic venous insufficiency (ie, edema, venous ulcers) and is indicated for all patients. Although the data are mixed as to whether compression stockings prevent post-thrombotic syndrome, they are useful to reduce symptoms of swelling, pain, and tightness that may occur after deep vein thrombosis ( Treatment references ). Elastic bandages are used initially until edema and ulcers resolve and leg size stabilizes; commercial compression stockings are then used. Stockings that provide 20 to 30 mm Hg of distal circumferential pressure are indicated for smaller varicose veins and mild chronic venous insufficiency; 30 to 40 mm Hg is indicated for larger varicose veins and moderate to severe disease. Infrequently, higher compression pressures (eg,>40 mm Hg) can be used but may not be tolerated for long-term use. Stockings should be put on when patients awaken, before leg edema worsens with activity, and should exert maximal pressure at the ankles and gradually less pressure proximally. Adherence to this treatment varies; many patients consider stockings irritating, restricting, or cosmetically undesirable; many patients have difficulty putting them on. Intermittent pneumatic compression (IPC) uses a pump to cyclically inflate and deflate hollow plastic leggings. IPC provides external compression, squeezing blood and fluid out of the lower legs. It effectively treats severe post-thrombotic syndrome and venous stasis ulcers but may be no more effective than compression stockings alone and is much less practical for patients to adhere to on an ongoing basis. is important in Direct wound care . When an Unna boot ( Medications have no role in routine treatment of chronic venous insufficiency, although many patients are givenaspirin, topical corticosteroids, diuretics for edema, or antibiotics. Surgery (eg, venous ligation, stripping, valve reconstruction) is also typically ineffective. Grafting autologous skin or skin created from epidermal keratinocytes or dermal fibroblasts may be an option for patients with stasis ulcers refractory to all other measures ( Treatment references ); however, there is a risk that the graft may reulcerate, especially if there is ongoing venous hypertension. 1.Kahn SR, Comerota AJ, Cushman M, et al. The postthrombotic syndrome: evidence-based prevention, diagnosis, and treatment strategies: a scientific statement from the American Heart Association [published correction appears in Circulation. 2015 Feb 24;131(8):e359].Circulation2014;130(18):1636-1661. doi:10.1161/CIR.0000000000000130 2.Jones JE, Nelson EA, Al-Hity A. Skin grafting for venous leg ulcers.Cochrane Database Syst Rev2013;2013(1):CD001737. Published 2013 Jan 31. doi:10.1002/14651858.CD001737.pub4 