Chronic venous insufficiency: a focus on prevention of venous ulceration

Chronic venous insufficiency of the lower extremities is a common medical problem, with a high prevalence among older persons. Among the costly complications of this disease is venous ulceration, which adversely affects quality of life. As the population of older persons increases, the prevalence of this disease and resulting complications is expected to increase proportionately. Prevention of venous ulcers is key to containing health care costs and improving the overall quality of life for patients affected by chronic venous insufficiency. Armed with an understanding of the pathogenesis of the disease process and its clinical signs, ET nurses and other health care professionals must use their skills to identify and educate patients at risk. Prevention programs should be developed and implemented to prevent venous ulceration among patients with or at risk for chronic venous insufficiency.     

Noninvasive tests in venous insufficiency

To evaluate the usefulness of magnetic resonance imaging (MRI) enhanced with gadolinium-DTPA (Gd-DTPA) for the detection of the inflamed synovium and for the evaluation of the response to therapy in rheumatoid arthritis, we studied 49 patients with rheumatoid arthritis (RA) according to the 1987 revised criteria of American Rheumatism Association (ARA), 6 patients of systemic lupus erythematosus (SLE) complicated by arthritis, 3 patients of osteoarthritis (OA), 2 patients of Sj?gren syndrome, 2 patients of progressive systemic sclerosis and 10 healthy volunteers as an age matched control. The 49 patients with RA were divided into three groups: (1) early phase of RA, (2) non progressing RA and (3) slowly progressing RA, and the stage classification of plain X-ray film and enhancement pattern of MR images were classified into three groups. Synovial enhancement showed a linear, band-like or diffuse pattern. Almost all cases in early phase of RA group and non progressing RA group showed a linear pattern, a band-like pattern or even no enhancement, while slowly progressing group of stage II or higher showed the diffuse pattern of enhancement in all except 2 cases. Moreover, the linear pattern, the band-like pattern or even no contrast enhancement were seen in all except 1 stage I patient, whereas 26 out of 29 patients with stage II or higher change showed diffuse contrast enhancement. Furthermore, a comparison of MR images before and after administration of DMARDs in 10 patients showed that the improvement of clinical symptoms correlated fairly well with reduction of contrast enhancement.(ABSTRACT TRUNCATED AT 250 WORDS)     

Leucocyte activity in chronic venous insufficiency

We present the clinical and laboratory findings in an institutionalised adult patient originally referred for autism. A high risk of colorectal cancer was predicted when an interstitial deletion of the long arm of chromosome 5, del(5)(q15q22.3), was detected in her lymphocytes and deletion of the MCC and APC genes confirmed by molecular analysis. Adenomatous polyposis coli and carcinoma of the rectum were subsequently diagnosed in the patient. She was profoundly mentally retarded, autistic, and had minor dysmorphic features consistent with those of previous patients with similar deletions. The deletion arose as a result of recombination within the small insertion loop formed at meiosis by the direct insertion (dir ins(5)(q22.3q14.2q15)) found in the patient's mother. This family further confirms the cytogenetic mapping of both MCC and APC genes to 5q22 and comparison with other recent cases suggests that both genes and their closely linked markers lie within the 5q22.1 subband.     

Spontaneous platelet aggregation in arterial insufficiency: mechanisms and implications

To investigate the clinical implications and mechanisms of spontaneous platelet aggregation (SPA) in man, 150 normal subjects, 22 patient controls and 130 patients with vascular insufficiency were studied. SPA was negative in normal subjects and patient controls whereas it was positive in 36 of 66 (54%) patients with transient ischemic attacks, 6 of 32 (19%) patients with stable angina, 7 of 10 (70%) patients with acute myocardial infarction and 11 of 14 (80%) patients with acute peripheral arterial insufficiency. The SPA was inhibited with aspirin in vivo, and inhibited competitively in vitro by low concentrations of aspirin, 2-chloroadenosine, prostaglandin E1 or apyrase but only by high concentrations of heparin or hirudin. Addition of platelet-poor plasma from patients with positive SPA did not cause normal platelets to aggregate. Treatment of patients who had acute peripheral arterial insufficiency with aspirin and dipyridamole prevented SPA with notable clinical improvement of the ischemic changes.     

Chronic respiratory insufficiency: evaluation, evolution, prognosis

Chronic respiratory failure (CRF) is a major cause of morbidity and mortality. It is estimated that in France at least 60,000 patients exhibit severe CRF and that about 15,000 patients die each year from CRF. Chronic obstructive pulmonary disease (COPD) (chronic obstructive bronchitis, emphysema and their association) is by far the first cause of CRF (90% of the cases). The clinical picture of CRF depends on the causal disease, but exertional dyspnea is observed in almost all patients. Pulmonary function testing allows to assess whether the ventilatory defect is obstructive (COPD), restrictive or mixed. Severe CRF is usually defined by a Pa02 < 55 mmHg, in a stable state of the disease, with or without hypercapnia (PaC02 > 45 mmHg). The two major complications of CRF are acute exacerbations of the disease, with clinical and gasometric worsening, and pulmonary hypertension which may lead with time to right heart failure. Prognosis is poor in CRF since the 5 year survival rate is of 50% in COPD patients. Under long-term oxygen therapy (LTOT) the survival rate has been somewhat improved, being of 60-65% at 5 years. The best prognostic indices in CRF complicating COPD are the level of FEV1, Pa02, PaC02, the level of pulmonary artery mean pressure (PAP) and age. In COPD patients under LTOT the best prognostic indices are PAP and age.     

The veno-arteriolar reflex in chronic venous insufficiency

The aim of this study was to evaluate the veno-arteriolar reflex in the gaiter area and in the big toe of patients with chronic venous insufficiency (CVI). Twenty patients with lipodermatosclerosis and CVI comprised the disease group, and twenty subjects without venous disease comprised the control group. The activity of the veno-arteriolar reflex in the gaiter area and in the big toe in the affected and unaffected limbs of patients with CVI, and in normal controls was assessed by calculating the percentage fall in skin blood flux on dependency as measured by Laser Doppler fluxmetry. The results showed that the veno-arteriolar reflex was normal in the gaiter area in both the affected limb and the unaffected limb in patients with CVI compared to normal controls, [median percentage fall in flux and interquartile range for affected limb in patients with CVI = 49 (35-69), for the unaffected limb of patients with CVI = 41 (24-58), for normal controls = 49 (31-57), p value (Mann-Whitney) for patient groups compared to normals = 0.52, 0.60 respectively]. However in the big toe the veno-arteriolar reflex was impaired in the affected limb of patients with CVI compared to both the unaffected limb and to normal controls, [median percentage fall in flux and interquartile range for affected limb in patients with CVI = 52 (29-64), for the unaffected limb of patients with CVI = 69 (45-78), for normal controls = 75 (51-80), p value (Mann-Whitney) for patient groups compared to normals = 0.017, 0.92 respectively].(ABSTRACT TRUNCATED AT 250 WORDS)     

Chronic renal insufficiency: 1) adaptation of nephron function in chronic renal insufficiency and 2) progression of chronic renal insufficiency

In chronic renal insufficiency resulting from destruction of the vast majority of nephrons, the surviving nephrons adapt their functions to the conditions of vigorous haemodynamic and osmolar overloads. They acquire an appropriate behaviour to preserve the principal renal functions and to achieve the balance of inner space. In the long period of time, similarly as in healthy people. Glomerulotubular balance as well as tubuloglomerular balance distinguish the remaining nephron function, while autoregulation of perfusion pressure along the glomerulus rapidly vanishes. All three regulation mechanisms are characteristic of the nephron function under physiologic conditions. Intense work of the remaining nephrons in chronic renal failure is under the high level controls of the group of hormones, among them are rennin-angiotensin system, arginine-vasopressin and atrial natriuretic peptide playing very important and particular roles. Comparison of different published studies emerge the idea that chronically increased arginine-vasopressin levels in chronic renal failure could block the autoregulation of blood flow and hydraulic pressure in glomeruli, which together with other mediator actions give high and fluctuating tense within remaining glomeruli, during every single cardiac cycle. It is probably the main event in the further course of kidney disease progression resulting in definite damage of the overloaded nephrons. Angiotensin II is one of reliably recognised mediators of unfavourable outcome in the process of nephron adaptation in chronic renal failure. Knowing the pathophysiologic processes in the remaining functionally adapted nephrons in chronic renal insufficiency determines a more adequate therapeutic approach in these patients.     

The 4 rights of compression therapy for patients with chronic venous insufficiency and venous ulceration

Compression therapy has become an ever increasing component in the care of patients with Chronic Venous Insufficiency (CVI) and venous ulcerations. Although compression therapy is of great benefit to many of these patients, this treatment option does not come without risks. The increased use of compression therapy has coincided with an increase in its improper application. This article simplifies the principles of compression and highlights the common pitfalls of its use, with an emphasis on the home healthcare setting.     

Chronic venous insufficiency--from pathophysiology to therapy. 3: Physical therapy of venous diseases

In patients with chronic venous insufficiency (CVI), stage-oriented physiotherapy can be employed in addition to surgery, drug treatment and sclerotherapy, with both prophylactic and curative intent. Apart from improving the hemodynamic situation, physiotherapy aims in particular to preserve or reactivate the active and passive pump mechanisms of the lower limbs, for example, the calf muscle pump and the ankle pump. Consequently the wide spectrum of physiotherapeutic measures includes such measures as compression therapy, anticongestion positioning, massage and exercise, all of which can be supplemented or replaced, as didacted by the condition prevailing, by hydrotherapy, electrotherapy, balneotherapy or climatic therapy.     

Chronic bronchitis: primary care management

Chronic bronchitis is a clinical diagnosis characterized by a cough productive of sputum for over three months' duration during two consecutive years and the presence of airflow obstruction. Pulmonary function testing aids in the diagnosis of chronic bronchitis by documenting the extent of reversibility of airflow obstruction. A better understanding of the role of inflammatory mediators in chronic bronchitis has led to greater emphasis on management of airway inflammation and relief of bronchospasm. Inhaled ipratropium bromide and sympathomimetic agents are the current mainstays of management. While theophylline has long been an important therapy, its use is limited by a narrow therapeutic range and interaction with other agents. Oral steroid therapy should be reserved for use in patients with demonstrated improvement in airflow not achievable with inhaled agents. Antibiotics play a role in acute exacerbations but have been shown to lead to only modest airflow improvement. Strengthening of the respiratory muscles, smoking cessation, supplemental oxygen, hydration and nutritional support also play key roles in long-term management of chronic bronchitis.     

Patterns of venous reflux in limbs with skin changes associated with chronic venous insufficiency

The distribution of venous reflux in patients with skin changes associated with chronic venous insufficiency presenting to a specialist clinic was assessed. A total of 300 limbs in 153 patients were examined by Doppler ultrasonography with colour-flow imaging for the presence of venous reflux in superficial veins, deep veins and medial perforating veins, both above and below the knee. Ninety-eight limbs had skin changes, which included hyperpigmentation, lipodermatosclerosis, atrophie blanche and ulceration. Of this group, 2 per cent had no evidence of venous reflux on duplex scanning, 39 per cent had deep vein incompetence, 57 per cent had superficial vein incompetence and 2 per cent had isolated medial perforating vein reflux. Of 25 limbs with ulceration, 13 had superficial and 12 deep vein reflux. A total of 202 legs, which included 20 normal control limbs, had no skin changes; 22.3 per cent of these had no venous reflux, 8.4 per cent had deep vein incompetence, 65.3 per cent had superficial incompetence and 4.0 per cent had isolated medial calf perforating vein incompetence.     

Capillary underperfusion in chronic venous insufficiency: a cause for leg ulceration?

Dermal capillaries in the goiter area of the lower leg were examined by video-microscopy before and after the administration of intravenous fluorescein in 13 patients with chronic venous insufficiency (CVI) who were at risk of developing leg ulceration, and in 13 normal controls. The influence of posture on capillary perfusion was determined by viewing the same area of skin with the leg in both the supine and dependent positions. Capillary density was lower in patients than in controls, irrespective of the position of the leg (P < 0.01). Fluorescence angiography studies in normal controls showed a reduction in capillary density with dependency (P < 0.01), but patients with CVI showed no significant change. Fluorescence angiography revealed a greater number of capillaries than seen during native capillaroscopy (P < 0.05). The decreased capillary density, and the loss of the postural vasoconstrictor reflex in patients with chronic venous incompetence may play a role in the pathogenesis of ulceration.     

Fasciotomy, chronic venous insufficiency, and the calf muscle pump

OBJECTIVE: To test the hypothesis that fasciotomy may impair the function of the calf muscle pump, which in turn could result in the development of chronic venous insufficiency. DESIGN: A cohort study of patients with a history of lower extremity fasciotomy. SETTING: An urban trauma center. PATIENTS: Seventeen of the 83 patients identified through trauma, vascular, and/or orthopedic registries consented to participation in this study. INTERVENTIONS: Participating patients completed a study questionnaire, and then underwent a complete vascular examination, including air plethysmographic (APG) assessment. Patients with a history of venous injuries were also studied with color flow duplex venous imaging. MAIN OUTCOME MEASURES: Function of the calf muscle pump as measured by APG, and evidence of chronic venous insufficiency as measured by APG, findings on clinical examination, and by venous ultrasonography. RESULTS: Seventeen patients completed the study, including 8 with a history of vascular injuries, 6 with old fractures, and 3 who had undergone fasciotomy for soft tissue infections. The time from injury to examination ranged from 5 months to 20 years. Eight patients had signs or symptoms of venous insufficiency, the severity of which appeared to be time dependent. The APG data showed significant mean differences between fasciotomy and control extremities in ejection fraction (P<.001) and residual volume fraction (P<.001), both measures of calf muscle pump function. There were no significant changes in venous filling index, a measure of venous reflux, or in outflow fraction, which correlates with venous obstruction. There were no differences in APG variables between patients with vascular injuries vs those with orthopedic or soft tissue injuries. CONCLUSIONS: Lower extremity fasciotomy impairs long-term calf muscle pump function, as measured by APG, in patients with and without vascular injuries. These patients are at risk for the long-term development of chronic venous insufficiency following lower extremity trauma.     

Pathophysiology and management of venous ulcers

Venous ulcers account for the majority of chronic lower extremity wounds. The cause of venous ulceration is not completely understood; however, risk factors, such as a history of deep venous thrombosis (DVT) and a family history of venous ulceration, have been identified. Venous ulceration is postulated to occur when fibrin cuffs form, leading to increased diffusion distance and impaired local perfusion. This article will review the cause, pathophysiology, clinical manifestations, and management of venous ulcers.