4: Chronic venous insufficiency

Published on 22/06/2015 by admin

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Case 4 Chronic venous insufficiency

Description of chronic venous insufficiency

Definition

Chronic venous insufficiency (CVI) is a pathological condition of the venous system, characterised by impaired venous blood flow in the lower limbs. The disorder presents as pathological changes to the skin, subcutaneous tissue and vascular tissue, and is a precursor to varicose veins and venous leg ulceration.

CVI affects between 0.1 per cent and seventeen per cent of men, and from 0.2 per cent to twenty per cent of women.¹ While evidence that links CVI occurrence to gender is inconsistent, being female is associated with an increased risk of CVI manifestations, including varicose veins¹ and venous leg ulceration.² CVI prevalence is also associated with increasing age, a relationship that may be attributed to the decline in blood vessel wall integrity and calf muscle strength over time.¹

Aetiology and pathophysiology

A number of risk factors are connected with the development of CVI. Family history and increasing age, for instance, are both associated with an increased risk.¹ In terms of modifiable risk factors, several studies have observed a higher prevalence and severity of CVI and varicose veins among people in occupations that typically require prolonged periods of standing, such as nurses, flight attendants and factory workers.¹ The reduced calf-muscle pump activity associated with prolonged standing may contribute to the pathogenesis of CVI because of excessive lower limb venous congestion and pressure.

Another modifiable risk factor of CVI is macrovascular insult, the cause of which may be credited to lower limb trauma, surgery, deep vein thrombosis (DVT) and/or pregnancy. The injury to the venous system triggers a cascade of events that contribute to CVI, including valvular incompetence, venous reflux (or retrograde blood flow), ambulatory venous hypertension, venous wall dilatation and elevated capillary filtration. Over time, these pathological changes lead to the formation of interstitial oedema, localised hypoxia, malnutrition and tissue destruction. Two mechanisms are believed to be responsible for the progression from a state of elevated capillary filtration pressure to changes in tissue perfusion and local architecture, including the extravasation or leakage of fibrinogen into the subcutaneous tisues and the subsequent formation of pericapillary cuffs, the intraluminal trapping of leucocytes and subsequent release of toxic metabolites, proteolytic enzymes and tissue necrosis factor-alpha. The extravasation of fibrinogen and leucocyte products into pericapillary tissue may also mediate inflammation, which suggests that CVI may be a disease of chronic inflammation.³

Clinical manifestations

The early stages of CVI typically manifest as lower leg fatigue, heaviness, discomfort and pruritus. As the disease progresses, visible changes to the skin and subcutaneous tissue begin to emerge, such as lower leg oedema, ochre pigmentation, stasis dermatitis and lipodermatosclerosis. In the more advanced stages of CVI, a person may also present with superficial and deep varicose veins, as well as venous leg ulceration. The functional and cosmetic implications of these manifestations can significantly affect a person’s quality of life.⁴

Clinical case

44-year-old woman with mild chronic venous insufficiency

Rapport

Adopt the practitioner strategies and behaviours highlighted in Table 2.1 (chapter 2) to improve client trust, communication and rapport, as well as the accuracy and comprehensiveness of the clinical assessment.

Assessment

Once measures have been put into place to build client–practitioner rapport, the clinician can begin the clinical assessment.

Health history

History of presenting condition

A 44-year-old woman presents to the clinic with bilateral lower leg heaviness and discomfort. These symptoms began around 10 years ago and, until the last 6 months, have been short-lived, mild and tolerable. These symptoms are now persistent for most of the day, are frequently aggravated by prolonged standing and sitting, and relieved by leg elevation, lying in bed and with the use of support stockings. The lower limb heaviness and constant dull ache (pain score = 3/10) are accompanied by afternoon leg fatigue and intermittent pruritus to the bilateral, posterior lower legs. These symptoms are often problematic because as a flight attendant the client is required to stand for prolonged periods. Over the past month, the client has needed to rest her legs at least two to three times during long-haul flights, which is not only unusual but also disruptive to work. This disruption to work concerns the client, who has also expressed concern about developing a leg ulcer, as did her mother, if the condition goes untreated.

Medical history

Lifestyle history

Diet and fluid intake
Breakfast	Coffee, porridge with skim milk.
Morning tea	Coffee, apple.
Lunch	Vegetable hotpot, sandwich with white bread, lettuce, tomato and carrot, chicken salad with tomato, cucumber, mixed greens and mushrooms.
Afternoon tea	Cheese and water crackers, apple juice, coffee.
Dinner	Beef and onion stew, chicken curry with white rice, grilled haddock with steamed carrot, cauliflower and broccoli.
Fluid intake	2–3 cups of percolated coffee a day, 2–3 cups of water a day, 1 cup of juice a day.
Food frequency
Fruit	1–2 serves daily
Vegetables	3–4 serves daily
Dairy	2 serves daily
Cereals	3–4 serves daily
Red meat	3 serves a week
Chicken	4 serves a week
Fish	1 serve a week
Takeaway/fast food	<1 time a week

Quality and duration of sleep

Interrupted sleep. Has difficulty falling asleep due to changeable working hours (sleep latency of approximately 30 minutes); average duration is 6–7 hours.

Frequency and duration of exercise

The client has limited opportunities for physical exercise on working days, although does manage to exercise at least 1 hour, three times a week at the gym. Client also engages in incidental exercise (i.e. walking at work) approximately 4–6 hours, three times a week, and sedentary activities less than 2 hours a day.

Socioeconomic background

The client was born and raised in Northern Ireland, as were her parents. The client and her family – supportive husband and two children, aged 17 and 21 years – also reside in Northern Ireland, in their own home, in a quiet inner city suburb of Belfast. All are practising Catholics. Since completing her flight attendant training program more than 20 years ago, the client has been employed as a flight attendant for an international airline. While she enjoys the occupation, she finds the time spent away from her family distressing at times.

Physical examination

Inspection

The bilateral lower legs are pale with no visible pigmentary changes. Thin, superficial varicose veins are evident over the popliteal fossa and calf bilaterally, including four in the left lower leg and two in the right lower leg. Mild bilateral pedal oedema is present up to the ankle; the oedema is worse in the left foot. There is no dyspnoea on exertion, cyanosis, chest deformity or nail clubbing to suggest underlying cardiac disease. Lower limb skin integrity is intact with no lesions or ulcerations.

Olfaction

Not applicable.

Palpation

Popliteal, posterior tibial and dorsalis pedis pulses are strong, regular and of equal amplitude bilaterally. No thrills are present over the neck, upper extremity, abdominal and lower extremity pulses or over the auscultatory areas of the heart. The point of maximum impulse (PMI) is located in the fifth intercostal space at the midclavicular line. The lower limbs and digits are warm. Mild pitting pedal oedema is present up to the ankle bilaterally, but is worse in the left foot. There is no palpable tenderness, numbness or fibrotic or sclerotic changes to the skin of the lower legs. Varicose veins over the bilateral popliteal fossae and calf are palpable.

Percussion

Not applicable.

Auscultation

There are no audible murmurs over the auscultatory areas of the heart. There are no bruits over the pulse sites of the neck, upper extremities, abdomen or lower extremities.

Additional signs

Client is in the ideal weight range (BMI is 24.3 kg/m², waist circumference is 72 cm). Heart rate is 64 beats per minute and regular, and blood pressure is 135/82.

Clinical assessment tools

The mean score for all 10 items on the venous clinical severity score (VCSS) was 6/30. Two points were awarded to each of daily pain, multiple varicose veins and afternoon venous oedema. This score suggests the client has mild venous disease.

Diagnostics

CAM practitioners can request, perform and/or interpret findings from a range of diagnostic tests in order to add valuable data to the pool of clinical information. While several investigations are pertinent to this case (as described below), the decision to use these tests should be considered alongside factors such as cost, convenience, comfort, turnaround time, access, practitioner competence and scope of practice, and history of previous investigations.

Pathology tests

Elevated levels of LDL-C, total cholesterol, triglycerides, homocysteine, apolipoprotein-B, asymmetric dimethylarginine (ADMA) and/or C-reactive protein (CRP) may be indicative of cardiovascular disease.⁵ While these tests have little diagnostic value in CVI, they can be helpful in determining whether a person with lower limb vascular disease also has signs of systemic vascular disease.

Radiology tests

Doppler or ultrasound uses sound waves to assess blood flow velocity and direction, as well as blood flow disturbances of major blood vessels, including the veins of the lower limbs. This procedure is particularly useful for identifying the presence of chronic venous insufficiency (evidenced by retrograde venous blood flow), varicose veins and venous occlusion (evidenced by absent venous blood flow).⁵

Functional tests

A comprehensive cardiovascular profile identifies a number of lipid-independent risk factors that are related to cardiovascular disease, such as homocysteine, CRP and fibrinogen. The diagnostic value of these tests in CVI is discussed above.

Invasive tests

Not applicable.

Miscellaneous tests

The presence of arcus senilis, a whitish ring at the perimeter of the cornea, is highly suspicious of hypercholesterolaemia.⁶ Even though this sign has little diagnostic value in CVI, it may be useful in determining whether a person with lower limb vascular disease also has signs of systemic vascular disease.

Diagnosis

Clusters of data extracted from the health history, clinical examination and pertinent diagnostic test results point towards the following differential CAM diagnoses.

• Lower limb heaviness (actual), secondary to CVI, related to family history (client’s mother has a history of severe leg ulceration, possibly due to CVI), decreased calf muscle pump activity and increased lower limb venous congestion (client’s occupation requires prolonged periods of standing, which may increase lower limb venous pressure and contribute to the pathogenesis of CVI).

• Lower limb discomfort (actual), secondary to CVI, related to family history; decreased calf muscle pump activity and increased lower limb venous congestion.

• Venous leg ulceration (potential), secondary to CVI, related to family history; decreased calf muscle pump activity and increased lower limb venous congestion.

Planning

The goals and expected outcomes that best serve the client’s needs and are most relevant to the case (as determined by the clinical assessment and CAM diagnoses) are as follows.

Goals

1. Client will be free from leg heaviness (client is concerned about the way this symptom is affecting her ability to work).

2. Client will be free from leg discomfort (client is concerned about the way this symptom is affecting her ability to work).

3. Client will not develop venous leg ulceration (client has expressed concern about developing a leg ulcer).

Expected outcomes

Based on the degree of improvement reported in clinical studies that have used CAM interventions for the management of CVI,⁷ the following are anticipated.

1. Client will report a thirty-five per cent reduction in baseline severity of leg heaviness in 7 weeks or by dd/mm/yyyy (measured by a visual analogue scale).

2. Client will report a forty per cent reduction in baseline intensity of leg discomfort in 8 weeks or by dd/mm/yyyy (measured by a 0–10 numerical scale).

3. Client will demonstrate a thirty per cent reduction in baseline severity of venous disease in 8 weeks or by dd/mm/yyyy (measured by VCSS).

4. Client will remain free from venous leg ulceration for 12 months or up to dd/mm/yyyy (according to client history).

Application

The range of interventions reported in the CAM literature that may be used in the treatment of CVI is appraised below.

Diet

While dietary modification – the modification of fibre, fat, fruit, vegetable and salt intake – plays a key role in the management of cardiovascular disorders, its effectiveness in CVI has not been adequately explored. This is not to say that dietary modification is ineffective, or that it should not be incorporated into a CVI management plan, only that dietary recommendations are not yet supported by high-level evidence.

Lifestyle

Physical exercise (Level III–1, Strength C, Direction o)

Physical exercise is likely to improve calf muscle pump function and lower limb venous haemodynamics and thus may be of benefit to people with venous insufficiency. While findings from a small RCT (n = 31 patients with CVI) demonstrated that a supervised calf muscle strength exercise program, together with wearing compression hosiery, was significantly more effective than control at improving mean venous ejection fraction at 6 months, the intervention was no more effective than control at improving venous reflux, venous severity scores and quality of life.⁸ Given that prolonged standing contributes to the pathogenesis of CVI, it is likely that a structured exercise program may still be useful in preventing the onset and/or progression of the disorder.

Nutritional supplementation

Ascorbic acid, beta-carotene, copper, glycine, hesperidin, leucine, lysine, quercetin, rutin, selenium and silicon

These nutrients play an important role in collagen synthesis. Many of them also exhibit actions pertinent to the management of CVI, including antienzymatic, antioxidant and anti-inflammatory effects.⁹^–¹¹ Still, it is unclear whether monopreparations of these nutrients offer any clinical benefit to people with CVI, because of the paucity of clinical evidence in this area.

Herbal medicine

Aesculus hippocastanum (Level I, Strength A, Direction + (for mild to moderate CVI only))

Horsechestnut seed was traditionally used in Western herbal medicine to treat musculoskeletal, gastrointestinal and venous disorders, including haemorrhoids, varicose veins and leg ulceration. The majority of research to date, which has focused on the vascular effects of the plant, reveals that horsechestnut seed extract (HCSE) and the saponins and sapogenins of the plant inhibit hyaluronidase activity in vitro,¹² scavenge superoxide-anions, increase fibroblast survival,¹³ inhibit histamine-induced vascular permeability in vivo and inhibit carageenin-induced paw oedema.¹⁴ These effects are fundamental to the management of venous insufficiency and may explain why a Cochrane review of 17 RCTs found orally administered HCSE (standardised to 50–150 mg aescin daily, for 20 days to 16 weeks) to be more effective than placebo and as effective as other phlebotonic agents at reducing leg pain, pruritus, oedema, leg volume, and ankle and calf girth in individuals with mild to moderate CVI.⁷ In severe or advanced CVI, HCSE appears to be less effective.¹⁵

Centella asiatica (Level II, Strength B, Direction +)

Gotu kola is used across several traditional systems of medicine as a treatment for skin complaints.¹⁶ Research to date suggests that the plant may also be suitable for the treatment of vascular disorders. Experimental data demonstrate that Centella asiatica flavonoids exhibit free radical scavenging activity in vivo.¹⁷ Clinically, titrated extracts of C. asiatica (60–180 mg daily) have been shown in three RCTs to be more effective than placebo at reducing ankle circumference and oedema at 4 weeks,¹⁸ lower leg volume at 6 weeks¹⁹ and leg heaviness and oedema at 8 weeks.²⁰ While these effects are promising, further investigation is needed regarding the long-term safety and effectiveness of gotu kola in CVI.

Folia vitis viniferae (Level II, Strength B, Direction +)

Red vine leaf extract (RVLE) has been shown under experimental conditions to prevent venous endothelial damage from blood platelet and polymorphonuclear granulocyte release products, and to facilitate venular endothelial repair in vitro.²¹ These effects can be attributed to the flavonoids quercetin and isoquercitrin. The best available evidence from two RCTs supports these actions; it shows RVLE (360–720 mg daily) to be statistically significantly more effective than placebo at reducing calf circumference and CVI symptoms at 6²² and 12 weeks.²³ Changes in ankle girth were not consistent across the two studies, however.

Pinus maritima (Level II, Strength B, Direction +)

French maritime pine bark extract, or pycnogenol, is not only a powerful scavenger of free radicals,²⁴ but also an inhibitor of nuclear factor-kappaB and the proinflammatory cytokine interleukin-1.²⁵ These effects are fundamental in maintaining and improving venous wall integrity; they also appear to be of benefit in people with CVI. In fact, two RCTs involving a total of 80 patients with CVI found P. maritima extract (300 mg daily) to be significantly more effective than placebo at reducing leg heaviness and subcutaneous oedema at 8 weeks.^26,²⁷ Changes in venous haemodynamics were not consistent between studies.