Chronic Deep Vein Insufficiency

(Postphlebitic Syndrome)

A syndrome occurring after thrombosis and caused by destruction of the valves in the deep and communicating veins of the leg and by obliteration of the thrombosed veins.

Chronic deep vein insufficiency almost always results from previous symptomatic or asymptomatic deep vein thrombosis, although most patients cannot recall having had symptoms of that disorder. Rarely, an arteriovenous fistula in the leg causes chronic venous stasis, leading to chronic venous hypertension and eventual valvular incompetence.

Symptoms and Signs

Symptoms include chronic edema, which is generally worse at the end of the day. Hyperpigmentation, stasis dermatitis (scaling and pruritus), and hyperemic ulcers occur around and just above the medial malleolus. Varicose veins may be present. Pain is rare.

If edema is severe and persistent, fibrosis occurs, leading to secondary lymphedema and trapping fluid. The calf becomes permanently enlarged and hard. Ulcers then occur more often and are more difficult to heal.

Prophylaxis and Treatment

Elastic support, usually with elastic stockings, helps prevent edema and ulceration from increasing. A stocking that exerts 30 mm Hg pressure from the toes to just below the knee is usually sufficient. Patients should elevate their legs intermittently during the day and avoid standing still for extended periods. Ambulation should be encouraged. If significant swelling persists overnight, patients should sleep with their legs elevated 3 to 4 inches (8 to 10 cm) above heart level. For severe edema, constrictive stockings powered by pumps can reduce swelling.

For ulcers, elastic support and leg elevation can help; for infected ulcers, topical antimicrobial therapy (eg, povidone-iodine) and warm soaks are indicated. A plaster boot often helps large, clear ulcers heal. Using a boot, although it has to be changed every 1 to 2 weeks, is preferable to limiting ambulation. A boot should not be used if the ulcer shows signs of infection.