Chronic venous disease of the lower limbs, the condition responsible for so-called “varicose veins”, is one of the most frequent disorders in our population, affecting up to 56% of men and 60% of women (Epidemiology of chronic venous disease. Phlebology. 2008;23(3):103-11).
Up to 2% of the population reaches the most severe stages of the disease, thus suffering from chronic skin ulceration associated with venous hypertension (Ma H. The real cost of treating venous ulcers in a contemporary vascular practice. J Vasc Surg Venous Lymphat Disord. 2014 Oct;2(4):355-61).
The diagnosis of chronic venous disease requires a detailed analysis of the patient’s clinical history and an accurate description of signs and symptoms.
The most common symptoms are: aching, cramps, heaviness, fatigue, swelling, itching, tingling, heat and restless leg.
The leg may present mainly six progressive stages of impaired venous drainage:
1. “Spider veins”
Small-calibre veins such as so-called telangiectasias (<1 mm) and reticular veins (<3 mm), affected by modest alterations of venous flow and therefore visible and aesthetically unattractive. In 26% of cases this clinical class is associated with alterations of the deeper venous system (Telangiectasia in the Edinburgh Vein Study: epidemiology and association with trunk varices and symptoms. Eur J Vasc Endovasc Surg 2008;36:719–724).
2. Varicose veins
Dilatation of the larger-calibre veins of the lower limbs (varicosis). These vessels are generally tortuous and clearly visible, but they may also be invisible if located deep within the leg. Contrary to what is commonly believed, these vessels are NOT the saphenous vein (one of the main veins of the leg, see the dedicated article on this website), but rather “daughter” veins of the saphenous vein itself (CHIVA: instructions for users. Phlebology Journal 2014). In the presence of varicose veins, these daughter veins of the saphenous vein, instead of carrying blood into the saphenous vein and from there towards the heart and lungs, “steal” that same blood from the saphenous vein, directing it towards the surface of the leg.
3. Varicose veins with oedema
The same venous dilatation as in the second stage described above, but in this case more advanced and associated with oedema. Oedema means an increase in body fluids located between the cells, caused by impaired drainage of venous blood from the lower limb towards the heart.
4. Lipodermatosclerosis
“Rust”-coloured pigmentation of the skin, generally located in the ankle–foot region and in the lower third of the leg. This discoloration arises from the increased pressure within veins affected by chronic insufficiency and therefore from a reflux that causes the iron contained in the haemoglobin of the blood to leak out. This iron is deposited in the tissues and to all intents and purposes becomes like a tattoo.
5. Healed ulcer
This stage describes cases in which there has previously been a venous ulceration (an open wound on the leg due to a venous problem) that has now healed. Once a patient has developed an ulceration, even a healed one, they will belong for life to the fifth stage and therefore to the maximum severity of the disease. This is because anyone who has had an ulcer, even after healing, will retain a significantly higher risk of developing another ulcer compared with someone who has never had this problem. Specifically, up to 69% of patients with an ulcer will see the lesion recur (What’s new: management of venous leg ulcers: approach to leg ulcers. J Am Acad Dermatol 2016;74:627-40).
6. Open ulcer
The most severe stage, characterised by the opening of a lesion on the skin. This ulceration is due to the release of inflammatory products associated with the failure of adequate venous return from the more peripheral parts of the leg towards the heart and lungs.
The lesion may be small or large and can come to affect the patient’s quality of life as much as chemotherapy treatment does (Ma H. The real cost of treating venous ulcers in a contemporary vascular practice. J Vasc Surg Venous Lymphat Disord. 2014 Oct;2(4):355-61).
Once the specialist physician has completed the DETAILED collection of the clinical history, symptoms and manifestations of the venous disease, an equally detailed duplex ultrasound examination must be performed.
This consists of an ultrasound scan – therefore NON-invasive diagnostics – to be performed on BOTH legs, regardless of whether the clinical manifestations are present on only one limb (Superficial vein thrombosis: a consensus statement. Int Angiol 2012;31:203-16).
This recommendation stems from the higher risk of developing venous problems in the leg contralateral to the one with evident disease (Leg symptoms of somatic, psychic, and unexplained origin in the population based Bonn Vein Study. Eur J Vasc Endovasc Surg 2013;46:255-62).
The ultrasound examination must cover ALL venous compartments (superficial, saphenous and deep). Indeed, if reflux is found in veins deeper than those visible at the surface with the naked eye, the risk of developing varicose disease increases by 4.4 to 7.3 times over the following 13 years (Incidence and Risk Factors for Venous Reflux in the General Population: Edinburgh Vein Study 2014;48(2):208-214).
It is advisable that the detailed ultrasound examination be performed by the same specialist physician who will carry out any subsequent treatment (CHIVA: hemodynamic concept, strategy and results. International Angiology 2016;35(1):8-30).
Unlike an X-ray or a CT scan, for example, ultrasound examination is OPERATOR-DEPENDENT. This means that the result will depend on what the specialist physician has set out to visualise and on how it has been visualised.
The correlation between the clinical picture reported by the patient, the visual assessment of the signs of disease and the ultrasound findings will together define the indication for the specific, best therapeutic pathway for the venous disease: a pathway that today is built on various possible strategies, to be chosen precisely on the basis of each individual case. The description of these strategies and their appropriateness is set out on the dedicated web page, which can be consulted at the following link.