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