A patient presents with edema, stasis dermatitis, brown hyperpigmentation, varicosities, and ulcers above the medial malleolus. The workup includes an ankle-brachial index and duplex ultrasound. What is the most likely diagnosis?

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Chronic venous insufficiency from venous valvular incompetence best explains this picture. When the veins in the legs don’t drain properly, venous pressure stays high, causing fluid and red blood cells to leak into the skin. That leads to edema, stasis dermatitis, and brown hemosiderin pigmentation from trapped iron-containing breakdown products, which is why the skin looks brown and inflamed. Varicose veins reflect the underlying valvular dysfunction, and ulcers tend to form above the medial malleolus where venous pressure is highest in the leg’s dependent position.

The ankle-brachial index and duplex ultrasound are used to separate venous from arterial problems. A normal ABI argues against arterial occlusive disease, while duplex ultrasound would show valvular incompetence and venous reflux consistent with venous insufficiency. In contrast, arterial disease would typically cause diminished pulses, cooler skin, and ulcers at the toes, and lymphedema would present with nonpitting swelling and characteristic skin changes without the same hemosiderin staining pattern.