Venous Disease: How it Relates to the Lower Extremity? 2017 Venous Disease.pdf · 2017-09-05 ·...
Transcript of Venous Disease: How it Relates to the Lower Extremity? 2017 Venous Disease.pdf · 2017-09-05 ·...
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Venous Disease: How it Relates
to the Lower Extremity?
Parag J. Patel, MD MS FSIR
Associate Professor of Radiology & Surgery
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Topics
• Scope of the problem
• Anatomy
• Pathophysiology
• Treatment
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Prevalence of Venous Insufficiency / Venous Ulcers
• 3-8% total US population
• 10-15% adult males
• 20-25% adult females
• 1% adults > age 60 with ulceration
• Cost > $1 billion/year
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Venous Insufficiency
• >30 Million Americans affected
• 1.9 million seek treatment annually
• Vast majority remain undiagnosed
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Venous Hypertension
• Arteries no longer have significantly higher pressure than
veins
• Blood is not pumped effectively
• Blood proteins leak into extravascular space
• Fibrin builds up around vessels preventing oxygen and
nutrients from reaching cells
• WBC accumulate in small vessels releasing inflammatory
factors and free radicals
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Clinical Impact
• Organ at risk is skin
– Pain
– Edema
– Pigmentation,
lipodermatosclerosis,
venous eczema
– Ulceration
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Venous Anatomy of Lower Extremity
• Made up of 3 anatomic systems
– Deep
– Superficial
– Perforating
• Located in 2 separate
compartments
– Deep Compartment
– Superficial Compartment
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Physiologic Function
• Deep System
– Transport system to
return blood to heart
– Drains superficial
system through
perforators
– >90% of venous blood
that leaves the limb goes
through DVS
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Physiologic Function
• Superficial System
– Serves as reservoir to fill
DVS
– Helps regulate body temp. by
dilating/constricting
– Can dilate to accommodate
large volumes of blood with
little temp change
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Venous Anatomy and Physiology
• Normal veins have valves that
allow uni-directional flow
• Leg muscle pump
• Valves normally close when
muscles relax
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Venous Pressure changes
• Walk, Walk, Walk
• Venous Pumps
– Plantar, calf and foot pumps
• Standing has highest venous
pressure
• Walking pressure similar to
laying/sitting up
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Ambulatory Venous Pressures
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Venous Reflux
• Incompetent valves cause
pathologic retrograde flow
during calf muscle relaxation
• Increased venous
pressure/venous hypertension
• Venous hypertension causes
vvs and skin changes =
chronic venous insufficiency
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Ambulatory Venous Pressures
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Pathophysiology
• Incompetence of venous valves; Chronic obstruction
• Stasis of blood
• Chronic ambulatory venous hypertension
• Defective microcirculation
• RBCs diffuses into tissue planes
• Lysis of RBCs
• Release of hemosiderin
• Pigmentation
• Dermatitis
• Capillary endothelial damage
• Prevention of diffusion and exchange of nutrients
• Severe anoxia
• Chronic venous ulceration
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Classification System
• CEAP: Clinical class, Etiology,
Anatomy, Pathology
0 = Normal
1 = Telangiectasias, spider veins
2 = Varicose veins
3 = Edema
4 = Skin changes
5 = Healed ulceration
6 = Active ulceration
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Evaluation
• History
– Reflux vs obstruction, venous claudication
• Physical
– Supine and upright
– Pulse examination
• US
– Supine: anatomy, deep vein thrombosis
– Supine &/or Upright: reflux > 0.5
• CT, MR, venogram
– Assessment central veins (when pelvic source is suspected)
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Pain
• Highly variable
• Range from fullness/heaviness, dragging or aching
• Exacerbated by standing, progressive throughout the day
• Typically felt in the calf or thigh
• Relieved with limb elevation
• Venous claudication (rare) during exercise
• Night cramps
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Superficial Thrombophlebitis
• Common complication
• Most common associated with trauma or period of bed
rest
• Tender, hot, thickened area along course of varicose vein
• Extremely painful
• Potential for fever and malaise
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Edema
• Progresses throughout the day
• Deep system insufficiency is more
severe and may be persistent
• Patients should be evaluated for
deep system incompetence
• Distinguish from lymphedema
(non-pitting) Brawny edema
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Skin Changes - Pigmentation
• Prolonged venous hypertension
results in venous dilatation and
passage of RBC’s through the
endothelium into the interstitium
which subsequently breaks down
to hemosiderin.
• Typically located on the lower
medial third of the lower leg.
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Skin Changes - Dermatitis
• Chronic inflammatory changes can
result in venous dermatitis or
varicose eczema.
• Dry, scaly or vesicular and weeping
• Venous ulceration may develop
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Skin Changes - Lipodermatosclerosis
• AKA fat necrosis, folliculitis, or chronic cellulitis
• Progressive fibrosis of the skin and subcutaneous tissues
• Acute form is painful and disabling– Thickened raised red-brown area
– Hot
• Chronic form is stiff and shiny skin– Fixed, hard, indurated, contracting
– Inverted bottle shape
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Skin Changes – Atrophie Blanche
• Skin necrosis with replacement by
scar tissue
• No ulceration or sloughing
• Small areas or patches that are
gray-white in color and only few
millimeters in size.
• Depression of the skin surface
• Halo of fine dilated venules
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Skin Changes - Ulceration
• Previous mentioned conditions are
precursors
• Lead to impairment of tissue
nutrition and oxygenation
• 300k – 400k pts suffer from
venous ulcers in North America
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Treatment Options
• Conservative management
– Compression hose therapy
• Excellent functional results
• Poor patient compliance
• Leg elevation
• Wound Care
– Debridement
– Infection Control
– Hyperbaric oxygen
• Surgical stripping
• IR: Endovascular Treatments
• Reflux
– Sclerotherapy
– Thermal ablation
• Obstruction
– Venous Stent Placement
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Goal of Therapy
Eliminate or reduce reflux /
obstruction at its highest point
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Saphenous Reflux
Min et al, JVIR 2003;14
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Conservative Management
• Graduated compression
hose 1st line tx
– Compressing blood out of
superficial veins into deep
system
– Reduction of venous
pressure and subsequently
decreased swelling
• Graduated compression,
higher at the ankle
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Classic Treatment
• High ligation
• Saphenous vein stripping
• Perforator interruption
• Deep system valve replacement
/ reconstruction
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Downsides to stripping and ligation
• Done under general anesthesia in a hospital setting
• Post-operative pain requiring prescription drugs
• Severe bruising/ tenderness along the treated vein
• Typical recovery is between 2-4 weeks
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Thermal Ablation
• Transmural injury
– Radiofrequency or laser
• Acute thrombosis
• Fibrosis
• Permanent obliteration of vein lumen
– Proximal tributaries may remain patent
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Thermal Ablation GSV
• Outpatient procedure
• Local anesthetic
• US guided
– Fluoroscopy can be helpful in certain cases
• Immediate ambulation
• Quick return to normal activity
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Laser Procedure
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Laser Procedure
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Laser Procedure
Pre Post
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Endovenous Ablation
• Advantages to thermal ablation (RFA and Laser)
– Outpatient procedure
• iv sedation not necessary
– Quick return to normal activity (less patient discomfort)
• 93-95% closure at 2 years in published studies
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When to treat obstructive component?
• Persistent Significant limb symptoms
– Pain, swelling, venous dermatitis, venous ulcer, recurrent
cellulitis
• Failed conservative management
– Compression therapy
• Severity of symptoms, NOT venographic findings
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EW
• 44-year-old male with a history of extensive DVT
extending from the infrarenal IVC to the bilateral popliteal
veins. He was previously on Coumadin for
anticoagulation, and presented with left lower extremity
phlegmasia.
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Outcomes of Venoplasty with Stent Placement for Chronic
Thrombosis of the Iliac and Femoral Veins: Single-Center
Experience
• 89 patients (91 limbs) included in study (189 patients
reviewed)
• 90/91 limbs patent at 30 days
• Primary patency/Primary assisted patency
– 1 year: 81%/94%
– 3 year: 71%/90%
• Study designed to primarily evaluate patency
Kurklinsky et al JVIR 2012;23:1009-15
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Percutaneous Recan of Total Occlusion of
Iliac Vein• 139/167 (83%) successfully recanalized
• Stent patency at 4 years: 66%
• Symptom relief at 3 years
– Pain: 79%
– Swelling: 66%
• Venous ulcer healing
– 56% at 33 months
Raju and Neglen JVS 2009;50:360-8
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Summary
• Venus ulcers are a significant burden to the healthcare
system
• Reflux and obstruction contribute to elevated ambulatory
venous pressures Venous Hypertension
• Endovascular treatments targeted at sites of venous
insufficiency and venous obstruction will relieve venous
hypertension
• Contributes to healing of venous ulcers
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• IRs are a natural partner for podiatry