Chronic venous insufficiency is an advanced stage of venous disease caused either by superficial (severe varicose veins) or deep (after deep vein thrombosis)venous pathology and characterized by an increased venous pressure during walking. The main symptoms are pain, swelling of the leg, pigmentation in the ankle area , induration of skin and even skin breakdown with overt ulceration. The non invasive assessment is a must in these extreme cases. Those found to have only superficial disease (varicose veins) will be most probably cured with the previously described ambulatory phlebectomy. Those who have deep vein disease will be treated with compressive treatment for the rest of their lives. This will lower the increased venous pressure and improve, even heal, the consequences of this elevated pressure. Topical application of antibiotic ointments or creams is a mistake.

There are two forms of compression: elastic and non-elastic: High pressure gradient surgical stockings such as Medi- Strumpf, Sigvaris, Jobst,etc. are used for elastic compression. Usually calf length is sufficient. For elderly people, especially with back problems and arthritis in the fingers it may be to difficult to apply them on the leg. Personally, I prefer to start with a non-elastic compressive device. Many physicians are sold on the old fashioned Unna boot. This is an non-elastic gauze dressing soaked in zinc paste and glycerine to avoid skin problems. It is expensive and very messy and difficult to put on and keep it on the leg. Dr. Unna introduced it close to 100 years ago! Unfortunately not too many physician have heard of the new Circ-Aid Legging. This is made out of several non-elastic strips held in place by velcro. It is extremely easy to apply, is not messy and if well cared for it may last 2 years. This is my preferred dressing and if patients comply with my orders to walk as much possible, in 2-3 months all venous ulcers will have healed with this treatment. Should your physician be unaware of this orthotic device, please call the company direct in Coronado, California tel : 800-CIRCAID or 619-576-3550 and Sandra Shaw will be glad to help and find the closest dealer to you or visit their website at www.circaid.com. A new and less expensive version of the Circaid is the THERABOOT distributed by COLOPLAST. The customer service number is (800) 633-0464 and the website is www.us.coloplast.com Only after the ulcer has healed, would I consider switching to elastic compression.

Another form of conservative treatment are the sequential compressive devices. It has been reported that such treatment speeds up the healing of venous ulcers up to ten times. One of the best machines available is the Lymphapress. These devices are indicated in patients who cannot sustain an active form of life needed during treatment with the Circ-Aid legging.

Should compressive treatment fail, one could consider perforator vein ligation. Today this is done endoscopically like gall bladder surgery, through a small skin opening in the mid or upper calf. Perforator veins are veins that connect the superficial skin veins to the main deep ones. In cases following deep vein thrombosis (clot) there may be residual obstruction or incompetence in the deep system. The existing increased venous pressure is transmitted to the skin vein. With passage of time the increased ambulatory venous pressure will cause all the symptoms including the induration and ulceration of the skin in the gaiter area. A few selected patients could be candidates for direct surgical repair of the deep vein valves.

For people with chronic venous insufficiency the following suggestions, some of them I learned from of Dr. Rivlin of London, could be of further benefit:

Reduce excessive weight.

Elevate your leg at least 3-4 times a day for 15-20 minutes. For a good gravitational drainage of the leg the foot has to elevated above the level of your heart.

Elevate the foot of your bed 7-9 inches so that the leg should be gravitationally drained during the night as well. Obese people or those suffering from hiatal hernia and heart disease should refrain from this step.

Never shower in the morning. Heat dilates the vein. Shower only in the evening before bedtime. Similarly, never sit in front of a stove or source of heat like a fireplace.

Wear laced up shoes, never sandals as this will permit fluid accumulation in your foot.

Walk a lot, exercise to activate the muscle pump, but have compression on your legs at all times. During prolonged travel, wear compression stockings and every hour or so, get up and walk around.

Venous ulcer treated with Circ-Aid compressive dressing:

For additional information check http://www.ucl.ac.uk/~rehk999/pdcs.htm