Chronic Venous Disease

Scope

  • This relates to abnormalities of the deep venous system, as opposed to the superficial venous system (varicose veins)
  • The presentation is chronic as opposed to acute DVT: typically it is caused by DVT ("post-phlebitic syndrome")
  • Typical features are chronic swelling and discoloration, with lipodermatsclerosis, which can progress to ulceration

Assessment

Signs and Symptoms

  • Chronically swollen limb (often permanent, brawny swelling)
  • Skin changes – pigmentation with hardness of the subcutaneous tissues (lipodermatosclerosis)
  • Bursting pain in limb on walking which settles with elevation or compression
  • Ulceration

History and Examination

History
  • Previous DVT, pulmonary embolism or significant limb trauma
  • Risk factors for DVT, including family history
  • Previous ulcers
Examination
  • Chronically swollen limb
  • Skin changes (eczema, lipodermatosclerosis)
  • Normal arterial circulation (pulses palpable/biphasic Doppler signal /ABPI greater than 1)
  • Ulceration

Differential Diagnoses

  • Systemic causes of limb swelling (bilateral)
  • Lymphoedema (swelling extends onto toes – pigmentation unusual)
  • Acute DVT
  • Venous compression (pelvic mass / anatomic abnormalities)

Investigations

  • Arterial assessment

Management

  • Compression therapy – usually well fitted Class 2 below knee stocking
  • Care of the skin (moisturise)

Joint formulary - Chapter 13, section 13.1 Dry and scaling skin conditions

Referral

Referral Criteria

  • Patients whose symptoms have become a persistent and significant disability
  • Patients in whom there is doubt about the diagnosis
  • Chronic unilateral limb swelling in the absence of a history of DVT (consistent with pelvic compression or anatomic abnormality) – in these cases an ultrasound or CT scan should be considered before or at the time of referral
  • Ulceration (for detailed arterial and venous assessments)

Referral Instructions

Routine referral to vascular specialist
  • e-Referral Service Selection:
    • Specialty: Surgery - Vascular
    • Clinic Type: Not otherwise specified
    • Service: DRSS-Western-Vascular- Devon CCG-15N

Referral Forms

DRSS referral form

Supporting Information

Pathway Group

This guideline has been signed off by the Western Locality on behalf of NEW Devon CCG.

Publication date: June 2015

 

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