20110113 speakers bureau revised

Copyright © 2009 by American College of Phlebology 1

THE BASICS OF VENOUS DISEASE:

What You Should Know.An Introductory Lecture


Disclosure of Conflict of Interest

[REPLACE WITH SPEAKER NAME]

I do not have relevant financial relationships with any commercial interests.

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This presentation is intended for Educational Purposes Only

Reference to any product or procedure does not constitute its endorsement or recommendation by the ACP

The ACP is not responsible for any changes or amendments to the original presentation

Presentation material is based on the best science available when it was created


“It is ironic that medical education does not cover three

of the most common medical problems: back pain,

hemorrhoids, and varicose veins.”

P. Fujimura, MDSurgical Intern

University of California School of Medicine


The medical specialty devoted to the diagnosis and treatment of patients with venous disorders

PHLEBOLOGY


IMPORTANCE OF CHRONIC VENOUS DISEASE 1 in 22 or 4.5% or 12.2 million people in the USA are

affected by varicose veins Incidence increases with age and is more common in

women with over 40% of women in their 50’s suffering from some sort of venous disorder

Across all ages and gender, 60% of Americans suffer from venous disease and its sequelae

National Heart Lung and Blood Institute (NHLBI) http://www.nhlbi.nih.gov/


THE SPECTRUM OF CHRONIC VENOUS DISEASE

lipodermatosclerosis

telangiectasias

varicose veins

Superficial phlebitis

venous ulceration


Presenting Symptoms of Chronic Venous Disease

Aching Fatigue, heaviness in legs Pain: throbbing, burning, stabbing Cramping Swelling (peripheral edema) Itching Restless legs Numbness


Venous Diseaseis a Hereditary Disorder

134 families were examinedThe risk of developing varicose veins was:

89% if both parents had varicose veins 47% if one parent had varicose veins 20% if neither parent had varicose veins

Cornu-Thenard, A, J Dermatol Surg Oncol 1994 May; 20(5):318-26.


Heredity in Chronic Venous Insufficiency

Risk Factors for chronic venous disease:

The San Diego population study

Although some risk factors for venous disease such as age, family history of venous disease are immutable others can be modified, such as weight, physical activity, and cigarette smoking.

J Vasc Surg. 2007 August; 46(2): 331–337


The beginnings of venous disease may be found as early as childhood

740 pts10-12 y/o

518 pts14-16 y/o

459 pts18-20 y/o

Diagnosable Vein

disease2.5% 12.3% 19.8%

Actual Varicose

Veins0 1.7% 3.3%

Phlebologie. 1990 Nov-Dec;43(4):573-7. Weindorf N, Schultz-Ehrenburg U.


Inactivity aggravates venous disease

2854 patients with varicose veins, working in a factory

64.5% had jobs standing in one place 29.2% had jobs requiring prolonged periods of sitting 6.3% had jobs allowing frequent walking during their

shiftSantler, R Hautarzt 1956; 10:460


Varicose Veins are 3 times more common in women than men

"Varicose veins." The Mayo Clinic. January 2007. http://www.mayoclinic.com


Each pregnancy worsens the condition

405 women with varicose veins13% had one pregnancy30% had two pregnancies57% had three pregnancies

Brand FN, et al The epidemiology of varicose veins: the Framingham Study Am J Prev Med 1988; 4:96-101


Anatomy and physiology of the venous system

in the lower extremity

Deep venous system: the channel through which 90% of venous blood is pumped out of the legs

Superficial venous system: the collecting system of veins

Perforating veins: the conduits for blood to travel from the superficial to the deep veins

Musculovenous pump: Contraction of foot and leg muscles pumps the blood through one-way valves up and out of the legs


Illustration by Linda S. Nye


Superficial venous system

Great saphenous vein-runs from dorsum of foot medially up leg-site of highest pressure usually the saphenofemoral junction, but may begin with perforating or pelvic vein



Superficial venous system Small saphenous vein

-runs from lateral foot up posterior calf-variations in termination-segmental abnormalities-site of highest pressure frequently the saphenopopliteal junction, but may begin with an inter-saphenous connection or perforating vein



Perforating veins

Mid-thigh Perforating Vein Dodd Proximal Calf Perforator Cockett Gastrocnemius Lateral thigh (lateral

subdermic plexus)



Musculovenous pump

Foot and calf muscles act to squeeze the blood out of the deep veins

One way valves allow only upward and inward flow

During muscle relaxation, blood is drawn inward through perforating veins

Superficial veins act as collecting chamber



Venous Valvular Function

Valve leaflets allow unidirectional flow, upward or inward

Dilation of vein wall prevents opposition of valve leaflets, resulting in reflux

Valvular fibrosis, destruction, or agenesis results in reflux


Doppler exam: Normal flow



Doppler: Reflux



REFLUX: its contribution to varicose veins



Pathophysiology: 2 components

REFLUX Dilatation of vein wall

leads to valve insufficiency

Monocytes may destroy vein valves

Retrograde flow results in distal venous hypertension

OBSTRUCTION Thrombosis and

subsequent fibrosis obstruct venous outflow

Damage to vein valves may also cause reflux

Both contribute to venous hypertension

The presence of both is far worse than either one alone


CEAP Classification “C” = Clinical C0 - no visible venous disease C1 - telangiectasias or reticular veins C2 - varicose veins C3 - edema C4 - skin changes without ulceration

C4a – pigmentation or eczemaC4b – LDS or atrophie blanche

C5 - skin changes with healed ulceration C6 - skin changes with active ulceration “E” = Etiology (primary vs. secondary) “A” = Anatomy (defines location of disease within

superficial, deep and perforating venous systems) “P” = Pathophysiology (reflux, obstruction, or both)


AMBULATORY VENOUS HYPERTENSION

The common denominator in the pathophysiology of venous disease

Instead of dropping, the intravenous pressure rises during exercise and is transmitted to more superficial and distal veins

May be due to reflux, obstruction, or both


Venous symptoms

Reflux and obstruction lead to congestion and dilatation of the vein walls

Symptoms, such as aching, pain, burning, throbbing, tiredness, itching, numbness and heaviness are worse with prolonged standing or sitting, heat, progesterone states such as pregnancy/pre-menses

Symptoms are improved with graduated compression, leg elevation, exercise


History History of problem: onset, pregnancies,

prior DVT, immobilization Associated symptoms and relationship to

heat, menses, exercise and compression Current medications Family history Previous treatment and result Goals of patient


Physical Examination Examine patient in the standing position, from

the groin to the ankle Inspect and palpate for varicose and

telangiectatic veins Check the medial and lateral malleolar areas for

skin changes suggestive of chronic venous insufficiency (e.g., corona phlebectatica)

Inspect the abdomen for enlarged superficial veins if ilio-femoral thrombosis is suspected


Telangiectasias

Also known as “spider veins” due to their appearance

Very common, especially in women

Increase in frequency with age

85% of patients are symptomatic*

May indicate more extensive venous disease

*Weiss RA and Weiss MA J Dermatol Surg Oncol. 1990 Apr;16(4):333-6.


Lateral Subdermic Plexus

Very common, especially in women

Superficial veins with direct perforators to deep system

Remnant of embryonic deep venous system


Reticular Veins Enlarged, greenish-

blue appearing veins Frequently associated

with clusters of telangiectasias

May be symptomatic, especially in dependent areas of leg


Varicose Veins – Great Saphenous Distribution

Most common finding in patients with varicose veins

Varicosities most commonly along the medial thigh and calf but cannot assume location indicates origin

At least 20% of patients are at risk of ulceration


Great Saphenous

Insufficiency

Skin changes are seen along the medial aspect of the ankle

The presence of skin changes is a predictor of future ulceration*

*Kirsner R et al. The Clinical Spectrum of Lipodermato-sclerosis, J Am Acad Derm, April 1993;28(4):623-7


Varicose Veins – Small Saphenous Distribution

Less frequent than Great Saphenous involvement

Varicosities may be seen on the posterior calf and lateral ankle

Skin changes are seen along the lateral ankle


Varicose Veins with Pelvic Origins

Begin during pregnancy Increased symptoms

during pre-menstrual period and after intercourse

May be associated with pelvic congestion syndrome


Skin changes suggestive of chronic venous insufficiency

Corona Phlebectatica (C1)

Pigmentation (C4a)

Atrophie blanche (C4b)

Healed ulcer (C5)


Venous ulceration Over 50% of patients have only superficial

venous disease; superficial venous disease may be primary factor in 50-85% of patients*

<10% have only deep venous disease Results from ambulatory venous hypertension,

which leads to WBC activation, TCpO2, local release of proteolytic enzymes

*Shami SK et al. J Vasc Surg 1993; 17:487-90


Venous ulceration

Impending ulceration Lipodermatosclerosis (C4a)

Venous ulceration (C6)


Venous vs. Arterial Ulcers Venous ulcers are

significantly more common Venous ulcers are behind

malleoli; arterial ulcers are in areas of chronic pressure or trauma

Arterial ulcers usually have a more necrotic base and are more painful

S/S of CVI (pigmentation, etc.) or ischemia (absent pulses, hair loss, etc.) are presentArterial ulcer

Photo courtesy of John Bergan, MD


Muscle fascia herniation• Frequently confused

with varicose veins• Usually found on the

lateral calf• Bulge disappears with

dorsiflexion of the foot• No flow is audible with

continuous-wave Doppler examination


Compression Therapy Provides a gradient of

pressure, highest at the ankle, decreasing as it moves up the leg

Reduces reflux of blood Improves venous

outflow Increases velocity of

blood flow to reduce the risk of blood clots

Photo courtesy of Juzo


Compression therapy Reduces symptoms of aching, fatigue, pain,

and swelling Increases fibrinolytic activity Increases TCpO2 Mainstay of treatment for venous ulcers

NOTE: Graduated compression therapy and wound care will heal venous stasis ulcers. Elimination of the reflux will reduce the recurrence.


Elastic compression stockings Must be graduated Calf high generally

sufficient Replace q 6 months to

assure proper pressure Available in a variety of

strengths, styles, colors, and fabrics


Graduated compression is not the same as T.E.D. hose

T.E.D.s are meant for non-ambulatory, supine patients

T.E.D.s are indicated to decrease the incidence of thrombosis

T.E.D.s do not provide sufficient pressure for ambulatory patients


Compression Strength

Indications

8-15mm Leg fatigue, mild swelling, stylish

15-20mm Mild aching, swelling, stylish

20-30mm Aching, pain, swelling, mild varicose veins

30-40mm * Aching, pain, swelling, varicose veins, post-ulcer

40-50, 50-60mm * Recurrent ulceration, lymphedema

* Requires a prescription


Prescribing graduated compression stockings

Measure ankle, calf, thigh for proper fit Disproportionate legs require custom

stockings Medical supply companies may have

stocking fitters Avoid using at night in elderly, diabetics,

and patients with arterial disease (ie: ankle-brachial index < 0.9)


Donning compression stockings: what to advise your patients

Method #1: Turn stocking inside out to heel and pull onto foot. Then pull the stocking up the leg

Method #2: Put stocking on like a trouser, not like a sock

Rubber gloves and donning devices (Easy-Slide, Butler) improve ease of donning, and thus compliance


Inelastic compression

Most physiologic in its effect

Available as bandage, which requires significant skill

CircAid is “user friendly,” series of nylon straps

Good choice for elderly, diabetics, patients with arterial disease

Photo courtesy CircAid Medical Products, Inc.


Exercise

Reduces symptoms such as aching and pain

Reduces ulcer recurrence Speeds resolution of superficial

phlebitis and DVT 30 minutes daily is best Lower extremity exercise is helpful

(stay away from heavy weight-lifting or other strenuous activity)


When to treat or refer a patient with venous disease Symptoms (aching, pain, swelling, etc.) that are

unresponsive to conservative measures such as graduated compression and exercise

Patient is unable to tolerate compression Cosmetic improvement requested Thickening or discoloration of the skin in the

ankle region: skin changes suggestive of chronic venous insufficiency

Impending or active ulceration or hemorrhage


Some Important Consideration… Most patients have a combination of varicose veins,

reticular veins, and telangiectasias Different treatment methods may be best for each

type of vein involved, or for different sized veins Therefore, more than one treatment method will be

required for most patients In general, varicose veins and any associated reflux

are treated prior to treatment of telangiectasias


Treatment of telangiectasias

Sclerotherapy most effective

Laser may be helpful Multiple treatments usually

required Reduces symptoms in 85%

of patients Improves quality of life

Weiss RA and Weiss MA J Dermatol Surg Oncol. 1990 Apr;16(4):333-6.


Sclerotherapy of Telangiectasias: Technique

Injection of sclerosant solution causes damage to endothelium which leads to fibrosis of vein


Sclerotherapy Results

Before AfterPhotos courtesy of Steven Zimmet, MD, FACPh


Treatment of Reticular Veins

NEED PIC

Frequently associated with telangiectasias, their Rx may enhance results of sclerotherapy of telangiectasias

Visualization may be improved with transillumination


Non-surgical treatment of varicose veins

Sclerotherapy effective; may be enhanced if ultrasound-guided

Endovenous occlusion with radiofrequency or laser extremely effective

Min R et al, J Vasc Interv Radiol 2001; 12:1167-1171 Rautio T et al, J Vasc Surg 2002; 35(5):958-65

NEED PIC


Ultrasound-guided Sclerotherapy

Nearly any size vein can be treated

Needle location inside vein, as well as movement of sclerosant and response of vein (spasm) visible

Efficacy enhanced with foamed sclerosant

Photo courtesy of CompuDiagnostics, Inc.


Sclerotherapy Results

Before After Ultrasound-guided sclerotherapy of the Great Saphenous Vein and sclerotherapy of branches

Photos courtesy of Steven Zimmet, MD, FACPh


Radiofrequency “Closure” Technique

Outpatient procedure approximately 60 min. long

Local tumescent Temperature at vein wall

controlled >90% closure at 2 yrs FDA-approved for RX of

Great Saphenous Vein

NEED PIC


Endovenous Laser Ablation

Outpatient procedure approximately 60 min long

Only local anesthesia required

Continuous pullback Closure of >93% Great

Saphenous Veins at 2 yrs FDA-approved for RX of

Great Saphenous Vein


Surgical Treatment of Varicose Veins: Vein Stripping

Vein stripping used to remove Great and Small saphenous veins

Yields 60% long term improvement Neovascularization a

problem Usually requires general

anesthetic

Butler CM, et al Phlebology 2002. 17:59-63

PhotoPhoto courtesy of John Bergan, MD


Surgical Treatment of Varicose Veins: Phlebectomy

Very esthetic method of removing varicose veins

Usually requires only local anesthetic

Especially useful for tributaries of GSV, SSV


Treatment Results

Before After Endovenous obliteration of the Great Saphenous Vein and phlebectomy of tributariesPhotos courtesy of Steven Zimmet, MD, FACPh


Venous ulceration Superficial venous

disease present in >50%

Initial Rx includes graduated compression and wound care

All pts require Duplex evaluation

Rx venous disease for long-term control

Padberg FT et al J Vasc Surg 1996; 24:711-19


Superficial Thrombophlebitis: Management

In the presence of varicose veins, DVT found in 10-20%

Initial RX includes graduated compression and ambulation

NSAID’s for pain Antibiotics rarely

needed


Prandoni et al, Ann Intern Med 2004;141:249-256

Management of the lower extremity after Deep Venous Thrombosis: Considerations in addition

to anti-coagulation

Many patients with DVT continue to have leg pain, aching, and swelling

Early ambulation and graduated compression (30-40mm) is helpful in lysing clot, restoring normal venous function, preventing post-thrombotic syndrome

Patients with symptomatic legs should be maintained on a regimen of compression and daily walking for 1-2 years


Pelvic Congestion Syndrome

Affects thousands of women in the U.S. More common in multiparous women Due to reflux in the ovarian veins, iliac veins, etc. May result in severe pelvic discomfort during the pre-

menstrual period, after intercourse, and with prolonged standing

May be effectively treated by blocking the reflux with embolization and/or pelvic vein sclerotherapy

Venbrux AC et al J Vasc Interv Radiol 2002; 13:171-178


A multi-disciplinary organization founded in 1986 Composed of over 2200 Physicians and Allied Health

professionals interested in the diagnosis and treatment of venous disorders

Offers grant support for basic science and clinical research in all aspects of venous disease

Devoted to furthering the education of its members, the medical community, and the public

AMERICAN COLLEGE OF PHLEBOLOGY101 Callan Avenue, Suite 210 ● San Leandro, CA 94577-4558

510.346.6800 ● 510.346.6808 [email protected] ● www.phlebology.org

mailto:[email protected]


THE FUNDAMENTALS OF

PHLEBOLOGY:Venous Disease for

Clinicians

THANK YOU FOR YOUR ATTENTION!

20110113 speakers bureau revised

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