Clinician-to-Clinician Update Clinician-to-Clinician Update

Management of Refractory Leg Edema (Chronic Venous Insufficiency)

August 2016

Contributed by Abdi Jama, MD, and Alan T. Hirsch, MD

An 86-year-old man presented with refractory bilateral leg edema and venous stasis pigmentation. His leg was painful, inhibited walking, and he suffered from an associated left shin skin ulcer. His history was significant for hypertension, obesity, and obstructive sleep apnea. An echocardiogram was normal, ruling out heart failure and pulmonary hypertension. His renal function and serum albumin were normal. A venous duplex ultrasound revealed incompetent superficial veins and significant reflux in the greater saphenous veins in both legs, but worse in the left. The patient was pleased to learn that his edema was associated with a treatable condition: chronic venous insufficiency due to his age, obesity, and obstructive sleep apnea.

Management

He began an exercise and wellness program. He was not told to “sit and keep your legs elevated” as this merely causes deconditioning and impedes the improved venous return achieved through use of the calf muscle pump. He was offered well-fitting compression stockings. He was taught that the use of donning and doffing aids could help his compliance in using the stockings. He learned that comfortable extrinsic compression was mandatory and key to lifelong success in managing the condition. He was referred to a wound care clinic. After 4 months, the patient’s edema and pain were much improved, yet the ulcer had not fully healed. He opted to undergo radiofrequency venous ablation of the left greater saphenous vein. With additional follow-up, the left leg ulcer completely healed. The patient is aware that to avoid edema and ulcer recurrence sustained use of leg compression is required. At follow-up visits, his use of venous compression stockings is re-assessed to ensure long-term success.

August-2016-Heart-Care-Case-Study-2-Article-Dr
— Drs. Abdi Jama and Alan Hirsch (left to right)

Discussion

Most leg edema is not caused by heart failure. Patients with venous ulceration may, however, have other co-morbid medical conditions (e.g., systolic or diastolic heart failure, pulmonary hypertension, sleep apnea, obesity, venous obstruction, or lymphedema) whose treatment is key to long-term success.1 Venous insufficiency, the most common primary etiology of leg edema, cannot be cured but can be successfully managed.1 Medical treatment --spanning use of compressive garments, 4-layer bandaging, or pneumatic compressive devices -- is core to all effective long-term care.2 For many, such care may be all that is required to control edema and pain and foster rapid ulcer healing. Yet, treatment of venous ulcers may require concomitant use of venous ablative techniques.3,4 When compared with surgical ligation and stripping, greater saphenous vein radiofrequency ablation may contribute, in select patients, to a higher rate of clinical success (complete ulcer healing at 95% vs. 31% for patients receiving ligation and stripping; p<0.001).5

References

  1. Trayes KP, et al. Edema: diagnosis and management. Am Fam Physician. 2013;88:102-110.
  2. Wittens C, et al. Editor's Choice - Management of chronic venous disease: clinical practice guidelines of the European Society for Vascular Surgery (ESVS). Eur J Vasc Endovasc Surg. 2015;49:678-737.
  3. Jull A, et al. The prepare pilot RCT of home-based progressive resistance exercises for venous leg ulcers. J Wound Care. 2009;18:497-503.
  4. White-Chu EF, Conner-Kerr TA. Overview of guidelines for the prevention and treatment of venous leg ulcers: a U.S. perspective. J Multidiscip Healthc. 2014;7:111-117.
  5. Shaidakov EV, et al. Radiofrequency ablation or stripping of large-diameter incompetent great saphenous varicose veins with C2 or C3 disease. J Vasc Surg Venous Lymphat Disord. 2016;4:45-50.
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