Signs and Symptoms

• Chronically swollen limb (often permanent, brawny swelling)
• Skin changes – pigmentation with hardness of the subcutaneous tissues (lipodermatosclerosis)
• Bursting pain in limb on walking which settles with elevation or compression
• Ulceration

History and Examination

History:

• Previous DVT, pulmonary embolism or significant limb trauma
• Risk factors for DVT, including family history
• Previous ulcers

Examination:

• Chronically swollen limb
• Skin changes (eczema, lipodermatosclerosis)
• Normal arterial circulation (pulses palpable/biphasic Doppler signal /ABPI greater than 1)
• Ulceration

Differential Diagnoses

• Systemic causes of limb swelling (bilateral)
• Lymphoedema (swelling extends onto toes – pigmentation unusual)
• Acute DVT
• Venous compression (pelvic mass / anatomic abnormalities)

• Arterial assessment

• Compression therapy – usually well fitted class 2 below knee stocking
• Care of the skin (moisturise)

Joint formulary – Chapter 13, section Management of skin conditions

Referral Criteria

• Patients whose symptoms have become a persistent and significant disability
• Patients in whom there is doubt about the diagnosis
• Chronic unilateral limb swelling in the absence of a history of DVT (consistent with pelvic compression or anatomic abnormality) – in these cases an ultrasound or CT scan should be considered before or at the time of referral
• Ulceration (for detailed arterial and venous assessments)

Referral Instructions

Routine referral to vascular specialist

• e-Referral Service selection:
  • Specialty: Surgery - Vascular
  • Clinic Type: Not otherwise specified
  • Service: DRSS-Northern-Surgery Vascular- Devon ICB- 15N

Referral Form

DRSS Referral Form

Pathway Group

This guideline has been signed off on behalf of NHS Devon.

Publication date: May 2024