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Copyright © 2009 by American College of Phlebology 1

THE BASICS OF

VENOUS INSUFFICIENCY:

What You Should Know.

An Introductory Lecture


Disclosure of Conflict of Interest

Donald Ives, MD, RVT, RPVI

Board Certified Family Physician

Diplomate of the American Board of Phlebology

Laser Vein Centers

Of Fairbanks, Anchorage, and MatSu


Presentation Use Information

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


Venous Insufficiency

Epidemiology

Risk Factors

Anatomy and Physiology

Diagnosis

Classification

Treatment Options

Thrombosis thoughts

Ultrasound Demo


“It is ironic that medical

education does not cover three

of the most common medical

problems: back pain,

hemorrhoids, and

varicose veins.”

P. Fujimura, MD

Surgical Intern

University of California School of Medicine


The medical specialty devoted to

the diagnosis and treatment of

patients with venous disorders

PHLEBOLOGY

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Hidden Disease?

Unseen physical dysfunction

Estimate 40% men, 50%

women

Inability to exercise

Impacts overall health

Impacts job performance

We are not talking about…..


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

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Copyright © 2009 by American College of Phlebology 13 Copyright © 2009 by American College of Phlebology 14

Venous Disease

is a Hereditary Disorder

134 families were examined

The 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.


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

shift

Santler, 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 veins

13% had one pregnancy

30% had two pregnancies

57% had three pregnancies

Brand FN, et al The epidemiology of varicose veins: the

Framingham Study Am J Prev Med 1988; 4:96-101


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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


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

Illustration by Linda S. Nye


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

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Doppler exam: Normal flow

Illustration by Linda S. Nye Copyright © 2009 by American College of Phlebology 26

Doppler: Reflux


Normal Valve Function

Normal Valve Function

Abnormal Valve Function

B mode ultrasound of the greater

saphenous vein

Normal bicuspid valve cusps


REFLUX: its

contribution to

varicose veins


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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


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

Patient selection is critical


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)

Check the peripheral pulses, ?ABI

Vertical ultrasound is crucial.


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 eczema

C4b – 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)

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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

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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 present

Arterial 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

Anita’s Problem = Pain

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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

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Compression

Strength

Indications

8-15mm Leg fatigue, mild swelling,

stylish

15-20mm Mild aching, swelling

20-30mm Aching, pain, mild varicosities

30-40mm * Large varicose veins, post-ulcer

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

lymphedema * Requires a prescription


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

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

Superficial laser marginal

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.

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Sclerotherapy of

Telangiectasias: Technique

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


Sclerotherapy Results

Before After Photos 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

Ultrasound guided

sclerotherapy effective

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

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Ambulatory Phlebectomy

Very esthetic method

of removing varicose

veins

Usually requires only

local anesthetic

Especially useful for

tributaries of GSV,

SSV


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

Endovenous Laser

Catheter placed into the

abnormal GSV by a small nick in

the skin

Performed when saphenous

incompetent

Tumescent anesthesia injected

around the vein

Laser energy delivered to close

off the vein

Tumescent Anesthesia

0.1% lidocaine (not 1%) with epi

Large volumes useable

Injected in the perivascular

space

Serves as a heat sink

Laser energy (heat) delivered to

close off the vein

Tumescent Anesthesia

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Treatment Results

Before After Endovenous obliteration of the Great Saphenous Vein and

phlebectomy of tributaries 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


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

Photo

Photo courtesy of John Bergan, MD

Laser Treatment vs. Vein

Stripping?

More effective than vein stripping

Less long-term recurrence

Significantly less recovery time

Minimal or no scarring

No hospitalization or anesthesia

Proven effective in > 1,000,000 patients


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

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SVT Management

“Anticoagulation is suggested for

patients with more extensive

superficial thrombophlebitis,

particularly at anatomic sites at

risk for extension into the deep

venous system (eg,

saphenofemoral junction)” --

UptoDate and ACCP Feb 2012.

SVT anticoagulation?

If within 5 cm of saphenofemoral junction

If within 10 cm of the saphenopopliteal junction

If progressive into the thigh, or > 8 cm length

There is a 30% risk of progression to a DVT

There is a 6% risk of progression to a PE


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


Summary:


Common

Frequently painful

Significant morbidity

Easily treatable in an outpatient setting

Ultrasound evaluation is critical

Superficial thrombosis not benign

Venous ulcers can be prevented.

Cure now better than the disease!


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

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101 Callan Avenue, Suite 210 ● San Leandro, CA 94577-4558

510.346.6800 ● 510.346.6808 Fax

[email protected] ● www.phlebology.org


THE FUNDAMENTALS OF

PHLEBOLOGY:

Venous Disease for

Clinicians

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