Dr. Samuel P. Martin

Venous disease is estimated to affect 25 million people in the United States. Venous ulcers, the most significant complication, affect approximately 500 thousand people. More than 2 million working days are lost each year and approximately 3 billion dollars is spent treating venous disease. In addition, venous disease is estimated to account for 1 to 3 percent of the total healthcare budget. Although venous disease cannot be avoided, greater awareness among patients and physicians can diminish the impact.

Risk factors include heredity, age, gender (females > males), hormonal (estrogen and progesterone), pregnancy, obesity, jobs with prolonged standing, trauma, and previous superficial or deep vein thrombosis. Graduated compression stockings are the first line of therapy for patients that show any signs of varicose veins, significant spider teleangiectasias, ankle edema, pregnant women, or those who have jobs that entail standing for prolonged periods of time. Patients will complain they are hot or hard to get on, but we must be firm and tell them about the problems that can follow. Insurance companies often insist on 3 to 6 months of conservative therapy including compression prior to approving any treatment.

The majority of patients with advanced skin changes have superficial venous valvular insufficiency. Many will also have perforator or deep vein involvement. Patients with peripheral arterial disease and or significant type I diabetes must be treated cautiously. If pulses can’t be detected, or the patient has an ankle/arm index of less than 0.5, compression is contraindicated. In patients with chronic swelling or pain in an extremity, obvious varicosities, or florid patterns of teleangiectasia (spider veins), the vascular lab is the first step in the treatment algorithm. But, a word of warning, when a venous evaluation is ordered, most hospitals and diagnostic labs perform a test for venous thrombosis. One must specifically ask for an evaluation for venous insufficiency and even then, most exams are inadequate. A study should be performed with the patient standing using valsalva and compression maneuvers to check for valvular reflux. The deep, superficial, and perforator systems should be studied and reflux times should be noted. The exam reveals whether a patient has evidence of old deep vein thrombosis. Therapy for superficial veins should not be undertaken if there is a significant obstructive component in the deep system. I see a large number of patients who have had a venous evaluation at an outside lab and 99% of these exams are inadequate for evaluation of venous insufficiency. Patients with severe type I diabetes or known arterial disease should have an arterial evaluation to rule out significant disease, which would contraindicate compression or venous therapy.

Early skin changes consist of pink to red discoloration which may be blotchy and dry (stasis dermatitis). The underlying tissue may be firm. These areas should be lubricated and massaged at least two times a day. With time a darker brown discoloration develops and the tissue becomes firmer. This is referred to as lipodermatosclerosis. The cause is inflammation, secondary to metalloproteinases, lymphocytes, macrophages, and red cells that traverse the capillary membrane because of hydrostatic and hydrodynamic pressure in the veins. The brown discoloration is the end result of red cell destruction with deposition of feratin. This tissue is very vulnerable to ulceration. Some patients will go on to develop lymphedema with swelling of the foot because the lymphatics in the lower leg are fibrosed by the inflammation. Flare ups of this tissue frequently occur with long periods of standing and the tissue can become erythematous and even exude fluid. Sometimes this fluid has a scaly appearance or can even appear as a white exudate. It is important to recognize this as an exacerbation of stasis dermatitis, an inflammation, not cellulitis, an infection. In these times of concern about noscomial and opportunistic infections, we must avoid using antibiotics for this condition. The erythema will often persist for weeks and if left on antibiotics for that period of time, patients are vulnerable to fungal infections, MRSA, and clostridia difficil colitis. The best treatment is to focus on the underlying veins, but this takes time. Use of hydrocortisone cream, elastic compression, and elevation are bridge maneuvers. Biopsy of the skin should never be an option. The only place for a biopsy is at a site of long standing ulceration, or an ulcer, which is refractory to optimal therapy.

We must be aware of patient’s complaints of aching, heaviness in the leg, and swelling as the day progresses. Varicose veins can lead to significant problems and should not be treated as merely a cosmetic concern. Early attention can avoid later problems. Modalities of venous therapy will be discussed in a later article.


Dr. Samuel P. Martin is one of the leaders in venous diagnosis and treatment. Since their inception, the Vascular Vein Centers have served the Central Florida community as a recognized, educated resource with more than 25 years experience treating venous disease.



July 2008

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