Case Study: Chapter 19

Chapter 19: Chronic Venous Insufficiency and Lymphedema

ANA I. CASANEGRA, MD; SUMAN RATHBUN, MD

CASE STUDY:

A 45-year-old female presents to your office with complaints of leg swelling and pain. She describes progressive dependent pain and swelling in the legs since her last pregnancy, 20 years ago. The swelling worsens throughout the day, improves with leg elevation, and is worse in the left leg, where she had a deep vein thrombosis after the delivery of her fourth child.

For the last several years, she has had disabling exertional pain in the left calf that is incompletely relieved with sitting and leg elevation.

She has 4 children, with no miscarriages. Her family history is negative for venous thromboembolism, but her mother has varicose veins and ulcers in her legs.

Case Study: Chapter 19

* 1.) What leg findings do you expect to see on the physical exam?
2.) On exam, she is obese and in no distress. The physical exam is remarkable for visible veins in the left lower abdomen and groin, as well as left greater than right lower extremity pitting edema (including left foot swelling).

Both great saphenous veins are dilated and palpable above and below the knee. Bilateral below-knee tributary varicosities are present. The skin on the right leg is soft and slightly pigmented above the internal malleolus. There is marked induration of the skin in the distal third of the left calf, with hyperpigmentation, eczematous changes, and erythema. Stemmer’s sign is negative on the right and positive on the left. The pulses at the dorsalis pedis are 2/2, posterior tibial 2/2 bilaterally. Which of the following is the optimal initial diagnostic test?

* 3.) The duplex ultrasound report states:

No evidence of deep vein thrombosis on the right leg. The left iliac vein is occluded and narrowed, with several collateral veins visualized. The left femoral vein and popliteal vein are patent, with residual thrombosis, and there is popliteal vein insufficiency.

Both saphenofemoral junctions are insufficient, as well as both great saphenous veins. There are dilated tributaries below the knee in both legs, with incompetent perforators.

What is the preferred method to decrease the edema before fitting her for compression stockings?

* 4.) Six months later, the patient returns for a fol- low-up appointment. The edema is markedly reduced, as she is faithfully wearing gradient compression stockings.

She still has some pain in both legs that is not completely improved with the stockings, particularly on the left. She inquires about endovenous ablation.
Based on results from an international endovascular working group registry, which of the following is the most common complication of endovenous ablation?