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Copyright © 2009 by American College of Phlebology 1
THE BASICS OF
VENOUS INSUFFICIENCY:
What You Should Know.
An Introductory Lecture
Copyright © 2009 by American College of Phlebology 2
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
Copyright © 2009 by American College of Phlebology 3
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
Copyright © 2009 by American College of Phlebology 4
Venous Insufficiency
Epidemiology
Risk Factors
Anatomy and Physiology
Diagnosis
Classification
Treatment Options
Thrombosis thoughts
Ultrasound Demo
Copyright © 2009 by American College of Phlebology 5
“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
Copyright © 2009 by American College of Phlebology 6
The medical specialty devoted to
the diagnosis and treatment of
patients with venous disorders
PHLEBOLOGY
2
Venous Insufficiency
Hidden Disease?
Unseen physical dysfunction
Estimate 40% men, 50%
women
Inability to exercise
Impacts overall health
Impacts job performance
We are not talking about…..
Copyright © 2009 by American College of Phlebology 9
THE SPECTRUM OF CHRONIC
VENOUS DISEASE
lipodermatosclerosis
telangiectasias
varicose veins
Superficial
phlebitis
venous
ulceration
Copyright © 2009 by American College of Phlebology 12
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.
Copyright © 2009 by American College of Phlebology 15
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
Copyright © 2009 by American College of Phlebology 16
Varicose Veins are 3 times more
common in women than men
"Varicose veins." The Mayo Clinic. January 2007. http://www.mayoclinic.com
Copyright © 2009 by American College of Phlebology 17
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
Copyright © 2009 by American College of Phlebology 18
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Copyright © 2009 by American College of Phlebology 19
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
Copyright © 2009 by American College of Phlebology 20
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
Copyright © 2009 by American College of Phlebology 21
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
Illustration by Linda S. Nye
Copyright © 2009 by American College of Phlebology 22
Perforating veins
Mid-thigh Perforating Vein
Dodd
Proximal Calf Perforator
Cockett
Gastrocnemius
Lateral thigh (lateral
subdermic plexus)
Illustration by Linda S. Nye
Copyright © 2009 by American College of Phlebology 23
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
Illustration by Linda S. Nye
Copyright © 2009 by American College of Phlebology 24
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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Copyright © 2009 by American College of Phlebology 25
Doppler exam: Normal flow
Illustration by Linda S. Nye Copyright © 2009 by American College of Phlebology 26
Doppler: Reflux
Illustration by Linda S. Nye
Normal Valve Function
Normal Valve Function
Abnormal Valve Function
B mode ultrasound of the greater
saphenous vein
Normal bicuspid valve cusps
Copyright © 2009 by American College of Phlebology 30
REFLUX: its
contribution to
varicose veins
Illustration by Linda S. Nye
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Copyright © 2009 by American College of Phlebology 31
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
Copyright © 2009 by American College of Phlebology 32
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
Copyright © 2009 by American College of Phlebology 33 Copyright © 2009 by American College of Phlebology 34
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
Copyright © 2009 by American College of Phlebology 35
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.
Copyright © 2009 by American College of Phlebology 36
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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Copyright © 2009 by American College of Phlebology 37
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.
Copyright © 2009 by American College of Phlebology 38
Lateral Subdermic Plexus
Very common, especially
in women
Superficial veins with
direct perforators to deep
system
Remnant of embryonic
deep venous system
Copyright © 2009 by American College of Phlebology 39
Reticular Veins
Enlarged, greenish-
blue appearing veins
Frequently associated
with clusters of
telangiectasias
May be symptomatic,
especially in
dependent areas of leg
Copyright © 2009 by American College of Phlebology 40
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
Copyright © 2009 by American College of Phlebology 41
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
Copyright © 2009 by American College of Phlebology 42
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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Copyright © 2009 by American College of Phlebology 43
Skin changes suggestive of
chronic venous insufficiency
Corona Phlebectatica (C1)
Pigmentation (C4a)
Atrophie blanche (C4b)
Healed ulcer (C5)
Copyright © 2009 by American College of Phlebology 44
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
Copyright © 2009 by American College of Phlebology 45
Venous ulceration
Impending ulceration
Lipodermatosclerosis
(C4a)
Venous ulceration (C6)
Copyright © 2009 by American College of Phlebology 46
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
Copyright © 2009 by American College of Phlebology 47
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
Copyright © 2009 by American College of Phlebology 51
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.
Copyright © 2009 by American College of Phlebology 52
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
Copyright © 2009 by American College of Phlebology 54
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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Copyright © 2009 by American College of Phlebology 55
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
Copyright © 2009 by American College of Phlebology 56
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)
Copyright © 2009 by American College of Phlebology 57
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
Copyright © 2009 by American College of Phlebology 58
Copyright © 2009 by American College of Phlebology 59
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
Copyright © 2009 by American College of Phlebology 60
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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Copyright © 2009 by American College of Phlebology 61
Sclerotherapy of
Telangiectasias: Technique
Injection of sclerosant solution causes damage to endothelium which leads to fibrosis of vein
Copyright © 2009 by American College of Phlebology 62
Sclerotherapy Results
Before After Photos courtesy of Steven Zimmet, MD, FACPh
Copyright © 2009 by American College of Phlebology 63
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
Copyright © 2009 by American College of Phlebology 64
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
Copyright © 2009 by American College of Phlebology 65
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.
Copyright © 2009 by American College of Phlebology 66
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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Copyright © 2009 by American College of Phlebology 67
Ambulatory Phlebectomy
Very esthetic method
of removing varicose
veins
Usually requires only
local anesthetic
Especially useful for
tributaries of GSV,
SSV
Copyright © 2009 by American College of Phlebology 68
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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Copyright © 2009 by American College of Phlebology 73
Treatment Results
Before After Endovenous obliteration of the Great Saphenous Vein and
phlebectomy of tributaries Photos courtesy of Steven Zimmet, MD, FACPh
Copyright © 2009 by American College of Phlebology 74
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
Copyright © 2009 by American College of Phlebology 75
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
Copyright © 2009 by American College of Phlebology 77
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
Copyright © 2009 by American College of Phlebology 78
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
Copyright © 2009 by American College of Phlebology 81
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
Copyright © 2009 by American College of Phlebology 82
Summary:
Venous Insufficiency
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!
Copyright © 2009 by American College of Phlebology 83
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 PHLEBOLOGY
101 Callan Avenue, Suite 210 ● San Leandro, CA 94577-4558
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[email protected] ● www.phlebology.org
Copyright © 2009 by American College of Phlebology 84
THE FUNDAMENTALS OF
PHLEBOLOGY:
Venous Disease for
Clinicians
THANK YOU FOR YOUR ATTENTION!
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