Examination of the patient should include a thorough lower extremity examination that includes evaluation of the function of the joints and muscles, inspection of the skin, and assessment of the vasculature. Documentation of lower extremity musculoskeletal findings should include mobility of the ankle mortise, ability of the patient to contract their calf muscle, and ability to ambulate. Documentation of the skin should include comments on skin temperature, hydration, any rubor or pallor, skin changes or lesions, scarring, nail changes, and hair distribution. Documentation of vasculature should include presence and strength of the pedal pulses on each side and whether there are any varicosities or telangiectasias.

Swelling and the degree of swelling should be described, including the extent or location of swelling. The presence or absence of any of these findings can be ascertained during a very brief lower extremity exam, including the assessment conducted for a routine diabetic foot exam.2,9

Testing


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Any patient who is thought to have CVI should undergo a venous duplex ultrasound to evaluate for incompetent valves and venous backflow. This is a more thorough version of the ultrasound performed to evaluate for deep vein thromboses. Venous duplex results will provide information regarding the presence and extent of CVD, and will show whether there are any conditions present that would be amenable to intervention by a vascular surgeon.5

Depending on the extent of edema or the presence of ulceration, compression may be an urgent priority. In this case, an ankle-brachial index test may be obtained before venous studies. The test measures the systolic blood pressure in the ankle and divides it by the systolic blood pressure in the arm, which allows determination of adequate arterial blood flow in the lower extremities. Adequate arterial flow is essential to prevent complications from therapeutic compression while waiting for the evaluation of venous disease to be completed.2

Management

Graduated compression is the cornerstone of CVI management.2,5 This involves the application of a garment, wrap, or device that provides more compression at the ankle than at the calf, thereby moving fluid out of the limb and toward the heart. Although garments with 30 to 40 mm Hg of pressure provide an optimal level of compression for management of CVD, lower levels of compression are always better than no compression at all.

If a patient has severe edema, initial management may best be undertaken in a wound care or lymphedema clinic, where a variety of compression types (including layered wraps) may be employed to reduce the swelling to a point where the patient may be measured for a more long-term option that maintains adequate compression. Some patients do well if they start in stockings that provide 15 to 20 mm Hg compression and then work their way up to higher levels of compression over time. Although some patients may worry at first about discomfort, once they get used to the compression, they find the support helps their symptoms of leg pain and heaviness.

When deciding on compression options, some things to consider include the patient’s ability to apply standard compression hose, whether he/she has someone at home who can help, and whether a donning device may be of assistance. Patients with home health services may be able to get Tubigrips (a light-weight compression sleeve that can be applied as a single layer, or as a double layer for increased compression) or Surepress wraps (which resemble white ace wraps, but have specific design components that allow consistent, measurable compression). In addition to stockings, other garments may have zip-up or Velcro features. For patients needing this type of compression, it may be best to refer them to a lymphedema management clinic so that specialty-trained occupational therapists can complete an evaluation, take specific measurements, and order the compression garments.2

Many clinicians are familiar with Unna boots, which may be an option for initial management, especially in patients with mild stasis dermatitis. However, Unna boots do not provide active compression: When the patient is at rest, the paste bandage does not provide any compression. Compression only occurs when the patient walks and the calf muscle pushes against the restriction provided by the semirigid paste bandage. As a consequence, this is not an appropriate compression option for nonambulatory patients. Note that antiembolism hose do not provide a level of compression that is therapeutic in the management of CVD. Similarly, ace wraps are not a good compression option, as they do not provide graduated compression and often bind or slide down.9

If there are concerns regarding arterial perfusion to a limb (based on claudication symptoms or decreased pedal pulses), patients should be advised to elevate their lower extremities as much as possible, and application of therapeutic compression should be delayed until the adequacy of perfusion can be determined by ankle-brachial index measurement or arterial ultrasound. Application of compression to a leg with compromised arterial flow may result in skin breakdown and other complications from decreasing the already-minimal bloodflow.2,9

Other nonsurgical interventions for venous disease typically target lifestyle modification, including weight loss, smoking cessation, and walking, and may help slow the progression and improve the outcome of CVI.2

Referral to a vascular surgeon for evaluation of venous changes amenable to surgical intervention, such as ablation of perforator veins, may provide a solution for some patients, and should be offered.5 Although there are pharmacologic interventions for CVI discussed in the literature, the strength of efficacy is limited to certain populations and situations, and typically these measures are implemented under the supervision of a vascular surgeon or wound care specialist.

Summary

A focused history and physical examination can readily reveal the hallmark findings of CVI long before patients develop life-altering sequelae, such as nonhealing ulcerations. Simple early interventions involving the application of compression wraps and lifestyle changes can significantly benefit patient quality of life and reduce the risk for future ulceration. For more complicated cases, vascular surgery, wound care, and lymphedema management (occupational therapy) may offer management options beyond that which is possible in a primary care setting.

Kristen Childress, DNP, ARNP, FNP-BC, CWCN-AP, is a lecturer, and Sarah Matthews, DNP, ARNP, FNP-BC, is an assistant professor at the School of Nursing at the University of Washington in Seattle.

References

1. Lal BK. Venous ulcers of the lower extremity: definition, epidemiology, and economic and social burdensSemin Vasc Surg. 2015;28(1):3-5.

2. Ratliff CR, Yates S, McNichol L, Gray M. Compression for primary prevention, treatment, and prevention of recurrence of venous leg ulcers: an evidence-and consensus-based algorithm for care across the continuumJ Wound Ostomy Continence Nurs. 2016;43(4):347-364.

3. Aloi TL, Camporese G, Izzo M, Kontothanassis D, Santoliquido A. Refining diagnosis and management of chronic venous disease: outcomes of a modified Delphi consensus processEur J Intern Med. 2019;65:78-85.

4. Eklöf B, Rutherford RB, Bergan JJ, et al. Revision of the CEAP classification for chronic venous disorders: consensus statementJ Vasc Surg. 2004;40(6):1248-1252.

5. McArdle M, Hernandez-Vila EA. Management of chronic venous diseaseTex Heart Inst J. 2017;44(5):347-349.

6. Sundaresan S, Migden MR, Silapunt S. Stasis dermatitis: pathophysiology, evaluation, and managementAm J Clin Dermatol. 2017;18(3):383-390.

7. Miteva M, Romanelli P, Kirsner RS. LipodermatosclerosisDermatol Ther. 2010;23(4):375-388.

8. Alavi A, Hafner J, Dutz JP, et al. Atrophie blanche: is it associated with venous disease or livedoid vasculopathy? Adv Skin Wound Care. 2014;27(11):518-526.

9. Bryant RA, Nix DP. Acute & chronic wounds: current management concepts. 5th ed. St. Louis, MO: Elsevier; 2016.