A 52-year-old man presents to the emergency department because of pain and swelling in his left leg over the past few hours. He traveled from Sydney to Los Angeles 2 days ago. He has had type 2 diabetes mellitus for 10 years and takes metformin for it. He has smoked a pack of cigarettes daily for 25 years. His temperature is 36.9°C (98.4°F), the blood pressure is 140/90 mm Hg, and the pulse is 90/min. On examination, the left calf is 5 cm greater in circumference than the right. The left leg appears more erythematous than the right with dilated superficial veins. Venous duplex ultrasound shows non-compressibility. Which of the following best represents the mechanism of this patient’s illness?

Subcutaneous soft-tissue infection that may extend to the deep fascia

Infection of the dermis and subcutaneous tissues

A 50-year-old man presents to the emergency department with pain and swelling of his right leg for the past 2 days. Three days ago he collapsed on his leg after tripping on a rug. It was a hard fall and left him with bruising of his leg. Since then the pain and swelling of his leg have been gradually increasing. Past medical history is noncontributory. He lives a rather sedentary life and smokes two packs of cigarettes per day. The vital signs include heart rate 98/min, respiratory rate 15/min, temperature 37.8°C (100.1°F), and blood pressure 100/60 mm Hg. On physical examination, his right leg is visibly swollen up to the mid-calf with pitting edema and moderate erythema. Peripheral pulses in the right leg are weak and the leg is tender. Manipulation of the right leg is negative for Homan’s sign. What is the next best step in the management of this patient?

Send the patient to surgery for an emergency fasciotomy

Start intravenous heparin therapy immediately

Make a diagnosis of deep vein thrombosis based on history and physical

Perform intravenous venography within 24 hours

A 52-year-old woman comes to the physician because of swelling of her legs for 2 months. She has noticed that her legs gradually swell up throughout the day. Two years ago, she underwent a coronary angioplasty. She has hypertension and coronary artery disease. She works as a waitress at a local diner. Her father died of liver cancer at the age of 61 years. She has smoked one pack of cigarettes daily for 31 years. She drinks one to two glasses of wine daily and occasionally more on weekends. Current medications include aspirin, metoprolol, and rosuvastatin. Vital signs are within normal limits. Examination shows 2+ pitting edema in the lower extremities. There are several dilated, tortuous veins over both calves. Multiple excoriation marks are noted over both ankles. Peripheral pulses are palpated bilaterally. The lungs are clear to auscultation. Cardiac examination shows no murmurs, gallops, or rubs. The abdomen is soft and nontender; there is no organomegaly. Which of the following is the most appropriate next step in management?

Adjust antihypertensive medication

A 68-year-old woman comes to the physician because of a 3-month history of an oozing, red area above the left ankle. She does not recall any trauma to the lower extremity. She has type 2 diabetes mellitus, hypertension, atrial fibrillation, and ulcerative colitis. She had a myocardial infarction 2 years ago and a stroke 7 years ago. She has smoked 2 packs of cigarettes daily for 48 years and drinks 2 alcoholic beverages daily. Current medications include warfarin, metformin, aspirin, atorvastatin, carvedilol, and mesalamine. She is 165 cm (5 ft 4 in) tall and weighs 67 kg (148 lb); BMI is 24.6 kg/m2. Her temperature is 36.7°C (98°F), pulse is 90/min, respirations are 12/min, and blood pressure is 135/90 mm Hg. Examination shows yellow-brown spots and dilated tortuous veins over the lower extremities. The feet and the left calf are edematous. Femoral, popliteal, and pedal pulses are palpable bilaterally. There is a 3-cm (1.2-in) painless, shallow, exudative ulcer surrounded by granulation tissue above the medial left ankle. There is slight drooping of the right side of the face. Which of the following is the most likely cause of this patient's ulcer?

Drug-induced microvascular occlusion

A 54-year-old woman comes to the physician because of a 6-month history of dull, persistent pain and swelling of her right leg. The pain is worse at the end of the day and is relieved by walking or elevating her feet. Two years ago, she developed acute deep vein thrombosis in her right calf after a long flight, which was treated with anticoagulants for 6 months. Physical examination shows 2+ pitting edema of her right leg. The skin around the right ankle shows a reddish-brown discoloration and multiple telangiectasias. She has dilated varicose veins in the right leg. Which of the following is most likely to establish the diagnosis?

Computerized tomography scan with contrast

A 34-year-old woman, gravida 4, para 3, comes to the physician because of left ankle swelling for 2 months. She notes that the swelling is present throughout the day and decreases when she goes to sleep. One year ago, she has had an episode of deep venous thrombosis after the delivery of her third child. Her prepregnancy BMI was 34 kg/m2. Examination shows distended, tortuous veins in the legs bilaterally and pitting edema of the left ankle. There are erythematous scaling patches on the medial side of the left ankle. Duplex ultrasonography is performed. Which of the following directions of blood flow would most likely confirm the diagnosis?

Femoral vein to great saphenous vein

Femoral vein to external iliac vein

Anterior tibial vein to popliteal vein

Popliteal vein to small saphenous vein

Dorsal venous arch to great saphenous vein

A 35-year-old woman presents to her primary care physician for recurrent deep venous thrombosis (DVT) of her left lower extremity. She is a vegetarian and often struggles to maintain an adequate intake of non-animal based protein. She currently smokes 1 pack of cigarettes per day, drinks a glass of wine per day, and currently denies any illicit drug use, although she endorses a history of heroin use (injection). Her past medical history is significant for 4 prior admissions for lower extremity swelling and pain that resulted in diagnoses of deep venous thrombosis. Her vital signs include: temperature, 36.7°C (98.0°F); blood pressure, 126/74 mm Hg; heart rate, 87/min; and respiratory rate, 16/min. On physical examination, her pulses are bounding, the patient's complexion is pale, breath sounds are clear, and heart sounds are normal. The spleen is mildly enlarged. She is admitted for DVT treatment and a full hypercoagulability workup. Which of the following is the best initial management for this patient?

Begin warfarin, target INR 2.5–3.5

Consult IR for IVC filter placement

Begin warfarin, target INR 2.0–3.0

A 63-year-old man presents to the clinic complaining of burning bilateral leg pain which has been increasing gradually over the past several months. It worsens when he walks but improves with rest. His past medical and surgical history are significant for hypertension, hyperlipidemia, diabetes, and a 40-pack-year smoking history. His temperature is 99.0°F (37.2°C), blood pressure is 167/108 mm Hg, pulse is 88/min, respirations are 13/min, and oxygen saturation is 95% on room air. Physical exam of the lower extremities reveals palpable but weak posterior tibial and dorsalis pedis pulses bilaterally. Which of the following is the best initial treatment for this patient's symptoms?

Balloon angioplasty with stenting

Venous insufficiency and varicose vein treatment for USMLE Step 3: High-Yield Surgery Lessons

🌊 Pathophysiology - Backward Flow Blues

Core Defect: Venous valve incompetence allows retrograde blood flow (reflux), leading to sustained ambulatory venous hypertension.
Primary vs. Secondary:
- Primary: Idiopathic/degenerative valve failure (most common).
- Secondary: Post-thrombotic syndrome (DVT damages valves).
Calf Muscle Pump: Failure (e.g., immobility) is a key contributor, impairing venous return and worsening stasis.

⭐ The most common site of reflux is the saphenofemoral junction (SFJ), where the Great Saphenous Vein (GSV) joins the common femoral vein.

Venous valve incompetence and chronic venous insufficiency

🦵 Legs in Distress

Symptoms: Dull ache, heaviness, throbbing, cramping, itching.
- Worsens with prolonged standing/sitting; relieved by leg elevation.
Signs (Progressive):
- Telangiectasias (<1 mm) & reticular veins (1-3 mm).
- Varicose veins: Dilated, tortuous superficial veins >3 mm.
- Pitting edema, stasis dermatitis (eczema).
- Hyperpigmentation (hemosiderin staining).
- Lipodermatosclerosis: Fibrosis of skin/subcutaneous tissue ("inverted champagne bottle" leg).
- Venous ulcers: Shallow, irregular borders, typically over the medial malleolus.

⭐ Symptoms often do not correlate with the size or number of visible varicose veins.

Stages of Venous Insufficiency (C1-C6)

🩺 Diagnosis - Spotting the Backup

Primary Tool: Venous Duplex Ultrasound is the gold standard.
- Confirms diagnosis by showing venous reflux > 0.5 seconds.
- Maps anatomy of incompetent superficial, deep, and perforator veins.
Clinical Staging: CEAP classification grades severity (C0-C6).
Pre-Treatment Check:
- Ankle-Brachial Index (ABI) is crucial before compression therapy.

Normal vs. varicose vein with valvular insufficiency

⭐ An ABI < 0.9 indicates coexisting Peripheral Artery Disease (PAD). High-compression stockings are contraindicated as they can worsen arterial ischemia.

🩹 Management: Compression & Closure

Conservative ("Squeezing")
- First-line: Leg elevation, exercise (calf muscle pump), weight management.
- Compression Therapy: Graded stockings are mainstay.
  - 20-30 mmHg: For symptomatic varicose veins & mild edema.
  - 30-40 mmHg: For severe CVI, healed ulcers, lymphedema.
  - ⚠️ Check Ankle-Brachial Index (ABI) first; contraindicated in severe PAD (ABI < 0.5).
Procedural ("Sealing")
- Endovenous Thermal Ablation (EVTA): Laser or radiofrequency.
  - First-line for symptomatic great saphenous vein (GSV) incompetence.
  - Mechanism: Thermal energy → endothelial damage → vein fibrosis & occlusion.
- Sclerotherapy:
  - Injection of a sclerosant (e.g., polidocanol).
  - Best for smaller reticular veins or telangiectasias.
- Ligation & Stripping:
  - More invasive, largely replaced by ablation.

⭐ Post-procedure, duplex US is crucial to confirm successful vein occlusion and to screen for procedure-related deep vein thrombosis (DVT).

💥 Complications - When Veins Rebel

Venous stasis ulcer on medial malleolus

Stasis Dermatitis: Eczematous rash, pruritus, and hemosiderin deposition (brawny discoloration) from chronic venous hypertension and RBC extravasation.
Lipodermatosclerosis: Subcutaneous fibrosis and inflammation, leading to a hardened, "inverted champagne bottle" leg.
Venous Ulcers: Shallow, irregular, exudative ulcers.

⭐ Classically located over the medial malleolus. Contrast with painful arterial ulcers on toes or pressure points.
Superficial Thrombophlebitis: Painful, palpable, indurated cord.
Bleeding/Infection: Varicosities can rupture with minor trauma; cellulitis can complicate ulcers.

⚡ Biggest Takeaways

Chronic venous insufficiency (CVI) stems from incompetent venous valves, causing reflux and venous hypertension.

Presents with pitting edema, stasis dermatitis (hemosiderin deposition), and lipodermatosclerosis.

Venous stasis ulcers, especially over the medial malleolus, are a key complication.

Duplex ultrasound is the diagnostic test of choice to confirm reflux.

Initial treatment is conservative: leg elevation and compression therapy.

Refractory cases are treated with endovenous ablation or sclerotherapy.

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