Cardiovascular · Topic 45 of 48

Chronic Venous Insufficiency & Venous Ulcers

Cardiovascular · peripheral venous disease

Chronic Venous Insufficiency & Venous Ulcers

Venous hypertension causes edema, stasis skin changes and shallow medial-ankle ulcers. Check the ABI, exclude DVT, then compress and elevate.

Key numbers

Compression is the cornerstone of treatment30–40 mmHg

Check the ABI before compressingABI < 0.5: no compression

01 · Look forVenous ulcer: shallow, at medial malleolus

Venous stasis ulcers typically form around the medial malleolus; they are shallow, moist, sometimes malodorous or painful, and do not penetrate the deep fascia, unlike arterial ulcers.

02 · DoCompression is the cornerstone of treatment

Compression treats edema and heals ulcers: bandages until edema and ulcers resolve, then graduated stockings — 20–30 mmHg for mild disease, 30–40 mmHg for moderate to severe disease, put on at waking.

03 · AvoidCheck the ABI before compressing

Measure the ankle-brachial index before compression: 0.8–1.3 allows standard compression, 0.5–0.8 only modified low-pressure compression, and below 0.5 (severe PAD) contraindicates it — refer to vascular surgery.

What it is

Core idea

Cause: venous hypertension from valve failure or obstructionValvular incompetence, venous obstruction (often after DVT) or a weak calf-muscle pump raise venous pressure, causing edema, inflammation and tissue hypoxia; post-thrombotic syndrome is symptomatic insufficiency after DVT.

Presentation

What you'll see

Leg heaviness worse standing, better with elevationSymptoms are fullness, heaviness, aching, cramps and pruritus that worsen with standing or walking and ease with rest and elevation; edema is usually unilateral or asymmetric.

Stasis dermatitis: hyperpigmentation and lipodermatosclerosisVenous stasis skin changes include hyperpigmentation, erythema, eczema, induration and lipodermatosclerosis (fibrosing panniculitis); healed ulcers leave atrophie blanche, small white stellate scars.

Diagnosis & monitoring

Work-up

CEAP classes: C3 edema to C6 active ulcerCEAP clinical classes: C1 telangiectasias, C2 varicose veins, C3 edema, C4 skin changes, C5 healed ulcer, C6 active venous ulcer.

Management

Orders

Duplex ultrasound to exclude DVT must knowDiagnosis is clinical, but order lower-extremity duplex ultrasound to exclude DVT, because chronic venous insufficiency and post-thrombotic syndrome mimic acute DVT.

Elevate legs above heart, 30 minutes thrice dailyElevating the legs above the level of the right atrium for at least 30 minutes three times a day lowers venous pressure and edema, though adherence is difficult.

Ulcer care: Unna boot and moisture-matched dressingsVenous ulcers are dressed under compression — an Unna boot changed weekly, occlusive (hydrocolloid) dressings for light-to-moderate exudate, absorptive dressings for heavy exudate; pentoxifylline is an oral adjunct.

Early ablation of superficial reflux speeds healingAdding early endovenous ablation of superficial venous reflux to compression heals venous ulcers faster (median 56 vs 82 days) and lengthens ulcer-free time compared with deferred ablation.

No diuretics for local venous edemaMedications add little: diuretics are reserved for systemic volume overload, and antibiotics for a secondary infection — not for the edema or the ulcer itself.

Venous or arterial ulcer?

Commonly confused

Location	Around the medial malleolus
Depth and base	Shallow, moist; never below deep fascia
Surrounding skin	Edema, hyperpigmentation, lipodermatosclerosis
Effect of elevation	Symptoms ease
Mainstay of treatment	Compression after ABI check

More detail

Reference

Show 8 reference facts

Risk factors for chronic venous insufficiency: prior DVT, older age, obesity, trauma, pregnancy and jobs with prolonged standing or heavy lifting; post-thrombotic syndrome is more likely after proximal or recurrent ipsilateral DVT.

Post-thrombotic syndrome develops in up to 50% of patients after DVT, moderate to severe in about 5–23%.

Prevention rests on DVT prophylaxis and adequate anticoagulation after DVT; compression stockings after DVT relieve symptoms, but trials have not shown that they prevent post-thrombotic syndrome.

The Villalta score grades post-thrombotic syndrome from 5 symptoms and 6 signs (0–3 each): 5–14 on two visits 6 months apart is mild to moderate, ≥ 15 severe.

Intermittent pneumatic compression helps severe post-thrombotic syndrome and stasis ulcers; skin grafting, valve reconstruction, venous bypass or venous stenting are options for refractory disease.

Weight loss, regular supervised exercise and dietary sodium reduction help bilateral venous insufficiency and post-thrombotic syndrome.

Refer to a wound specialist when a venous ulcer has not shrunk by 30% after 4 weeks of adequate compression; recheck the ABI every 6 months while compression above 20 mmHg continues.

Bilateral symmetric leg edema suggests a systemic cause (heart failure, hypoalbuminemia) or a drug such as a calcium channel blocker rather than venous insufficiency.

Pearl

Venous ulcers are wet, shallow and medial, and feel better with the leg up; arterial ulcers are dry, deep and distal, and hurt more with the leg up.

Sources · Merck Manual Professional — Chronic Venous Insufficiency and Post-Thrombotic Syndrome · WoundReference — How to select compression therapy (ABI-based algorithm) · Gohel MS et al. A randomized trial of early endovenous ablation in venous ulceration (EVRA). N Engl J Med 2018;378:2105–2114 · Merck Manual Professional — Peripheral Artery Disease · Starter sheet built from the verified AGACNP fact map (facts reviewed 2026-10-15).