Clinical

Underlying peripheral arterial or venous disease in patients with lower extremity SSTIs


 

Mild to moderate CVI symptoms with superimposed cellulitis but no ulceration

Chronic venous insufficiency is a syndrome that has variable presentations based on the location and degree of valvular incompetence in the superficial or, less commonly, deep venous systems. For a patient with cellulitis and CVI, the clinical exam findings may be associated with venous hypertension syndrome – in which there is deep axial reflux and possible obstruction – and could also represent complex varicose disease which is usually caused by superficial reflux of the greater saphenous vein.3 The lack of advanced skin changes and ulceration raises the suspicion of mild to moderate CVI.

Guidelines from the American Venous Forum and the Society for Vascular Surgery recommend that all patients with suspected CVI, regardless of severity, undergo venous duplex ultrasound scanning as a first diagnostic test (grade 1A) to accurately classify the disease according to the Clinical Etiological Anatomical Pathophysiology (CEAP) system (Table 1).16

Table 1. CEAP classification of chronic venous disease
This test is different from the routine lower extremity ultrasound used to diagnose acute venous thrombosis, as it must be performed by an experienced technician who evaluates the patient both lying and standing and uses maneuvers to help localize regions of reflux in the deep and superficial veins, as well as perforators.17 This examination, occasionally called a “reflux study,” is often unavailable in the inpatient setting and may not be reimbursed if obtained during a hospitalization. Hence, this patient with suspected CVI should be referred for duplex ultrasound examination upon discharge with follow-up in a primary care clinic. Furthermore, the patient should be advised to lose weight, partake in an exercise program, and elevate the extremities as much as possible.

Compression therapy is commonly accepted as a noninvasive treatment option for all levels of CVI, yet most of the evidence comes from secondary prevention studies in patients with advanced CVI with venous ulcers.18 Strong evidence for the role of compression stockings in mild to moderate CVI is lacking. In fact, recent guidelines from the Society of Vascular Surgery, reviewed by the American Heart Association, do not recommend compression therapy as a primary treatment modality in patients with symptomatic varicose veins (without ulcers) if the patient is a candidate for saphenous vein ablation.19 This recommendation is based on clinical trial data that showed greater efficacy and cost-effectiveness of surgery versus conservative management in patients with CEAP2 (low severity) CVI as well as studies noting noncompliance with compression therapy as high as 75%.20-21

However, determining a patient’s candidacy for ablative or surgical therapy requires ultrasound data for accurate CEAP scoring, which is often not achieved as an inpatient. Given the potential benefit and lack of severe adverse effects, hospitalists can consider initiating compression therapy at the time of discharge in a patient with mild to moderate signs of CVI and a low risk profile for severe PAD. The prescription should specify knee-length elastic stockings with graduated compression between 20 to 30 mm Hg.22 The patient should also be encouraged to complete the outpatient duplex ultrasound testing prior to the PCP visit so that he or she can be referred to a vascular specialist appropriately.

Infected ulcer with CVI features

If the patient’s exam is suspicious for advanced venous disease with ulceration, the clinician should evaluate for the presence of scarring. This would indicate that there has been long-standing venous disease with recurrent ulceration. This patient should be asked about a previous diagnosis of CVI, prior compression therapy, and barriers to compliance with compression therapy such as poor fit or difficulty of use due to obesity or immobility. It is important to note that mixed ulcers are present in up to 20% of patients; a careful assessment of risk factors for PAD, pulse exam, and referral for outpatient ABI testing is warranted to rule out arterial insufficiency in this patient with likely venous ulcer.23

The AHA recommends prompt specialist evaluation for CEAP scores greater than or equal to 4; based on physical exam alone, this patient’s active venous ulcer yields the highest possible score of 6.2 If not previously done, this patient with advanced CVI and ulceration should be referred for an outpatient venous duplex ultrasound as well as urgent follow-up with a vascular specialist soon after discharge.

There is significant consensus in the literature that multilayer compression therapy between 30 and 40 mm Hg is the first-line treatment in patients with venous ulcers as it has been shown to promote ulcer healing and prevent recurrence.24-25 In addition, superficial venous surgery, including minimally invasive ablation, can reduce the recurrence of ulcers if used as adjunctive therapy in selected patients.26 However, compressive therapy should generally not be prescribed in patients with venous ulcers until PAD has been ruled out.

If ABI results are available, the clinician can consider compression at 30-40 mm Hg for ABI values greater than 0.8 and reduced compression at 20-30 mm Hg for values of 0.5-0.8; compression is contraindicated if the ABI is less than 0.5. Prompt follow-up with a vascular specialist can help direct compressive and/or surgical therapy. Wound care consultation as an inpatient can assist with dressing recommendations, though the evidence has not shown that dressings of any type worn under compressive garments improve ulcer healing.27

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