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Management of venous insufficiency is often confounded by other medical issues. The most common of these conditions are covered in this chapter.


The combination of venous insufficiency and arterial insufficiency in the leg poses a highly challenging problem. Arterial insufficiency is more common in patients with severe venous insufficiency than in those without [1]. Here, blood flowing into the legs as well as out of the legs is compromised, and treatment for one condition may worsen the other. All interventions must be enlisted with this issue in mind.

Arterial blood flow into the legs is greater with the legs down. Many people with while advanced arterial insufficiency find relief to sleep by sitting with their legs down. Sleeping for hours in this position causes ankle swelling even in the absence of venous insufficiency.

When the femoral artery and its branches are severely obstructed, leg elevation to control the edema of venous insufficiency may seriously reduce blood flow into the legs. Elastic wrappings and stockings also restrict arterial blood flow by compressing the arteries and further reducing flow. In fact, this combination of vascular disease is a common cause of the failure of compression garments prescribed for the elderly.

When there is any question about the adequacy of arterial function, obtaining an Ankle–Brachial Index (ABI) in these patients is warranted before prescribing compression therapy [2]. In this way, systolic blood pressure in the leg is compared with that in the arm.


Ankle/brachial index.

Normally, the ABI index is above 1.00. Serious arterial insufficiency is diagnosed when the index is less than 0.70. If a compression stocking is prescribed where there is evidence of reduced arterial flow, the study can be repeated with the garment in place.

There is one note of caution in considering the ABI in decision-making. An exceptionally high ABI (above 1.3) suggests that the arteries resist compression. This situation may be caused by heavy calcinosis, common in arterio-sclerotic vessels when arterial blood flow can be severely reduced.

When arterial insufficiency coexisting with venous insufficiency is relatively mild, elastic garments applying fairly light compressions are usually useful and well tolerated. If arterial insufficiency in the legs is more advanced, a limited-stretch wrap or a non-stretch legging is preferred. One would expect that these garments produce less compression at rest and therefore compromise arterial flow to a lesser degree. The short periods of high compression generated by each step probably have little adverse effect on the arterial circulation.

There are some characteristics of arterial ulcers—such as pain, tenderness, location in the toe or distal foot—which help to distinguish them from venous ulcers. In addition, ulcers from arterial disease tend to have sharp edges. ...

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