28. Chronic venous insufficiency of the extremities; postphlebitic syndrome and secondary varicosity: indications for surgical treatment

Chronic venous insufficiency, postphlebitic syndrome and secondary varicosity

Venous return from the lower limb depends on deep veins, superficial veins, perforators, one-way valves and the calf-muscle pump.
Chronic venous insufficiency results from venous hypertension due to reflux, obstruction or both. Causes include primary valve failure and post-thrombotic damage after DVT.
Persistent venous hypertension causes capillary leakage, oedema, inflammation, haemosiderin deposition, lipodermatosclerosis and venous ulceration, typically around the medial gaiter region.

Symptoms include aching/heaviness, swelling, itching, cramps and symptoms worse after prolonged standing and improved by elevation.
Signs include ankle oedema, varicosities, telangiectasia, corona phlebectatica, pigmentation, eczema, lipodermatosclerosis and shallow irregular venous ulcers.
Post-thrombotic syndrome follows DVT and may cause chronic pain, swelling, heaviness, skin changes and ulceration. Use CEAP classification to describe clinical severity, aetiology, anatomy and pathophysiology.

Duplex ultrasound is the main investigation to assess deep and superficial venous patency, reflux, obstruction and mapping before intervention.
Assess arterial supply before strong compression, especially in diabetes or suspected PAD; ABPI or toe pressure may be required.
Consider alternative causes of oedema such as heart failure, renal disease, lymphoedema, medication effects and proximal venous obstruction.

First-line measures include leg elevation, walking/calf exercises, weight management, skin care, emollients and compression therapy when arterial supply permits.
Venous ulcers require compression, appropriate dressings, infection assessment and specialist wound care. Antibiotics are used only for clinical infection, not colonisation.
Treat superficial reflux with endovenous thermal ablation, foam sclerotherapy or surgery when symptomatic reflux is confirmed and anatomy is suitable.
Post-thrombotic obstruction may require specialist assessment for selected venous stenting; anticoagulation is used for active/recurrent thrombosis according to guidelines, not simply for chronic reflux.
Surgical/endovenous treatment is considered for persistent symptoms, recurrent bleeding, skin changes or ulceration despite conservative measures. Complications include ulcer recurrence, cellulitis, bleeding and recurrent thrombosis.