Prevalence Definition 1 Chronic Venous Insufficiency/Varicose - PDF document

Chronic Venous Overview of Chronic Insufficiency Venous Insufficiency “an abnormally functioning venous system caused by venous valvular reflux with or Steven M. Dean, DO, FACP, RPVI without associated venous outflow Vascular Medicine Specialist obstruction which may affect the superficial, deep, and/or the perforating Assistant Professor of Internal Medicine venous system(s). The venous dysfunction Department of Cardiovascular Medicine may result from congenital or acquired The Ohio State University processes” SVS/ISCVC. J Vasc Surg 1988 Prevalence Definition 1

Chronic Venous Insufficiency/Varicose Veins: Prevalence • The prevalence of varicose veins in Western countries Epidemiology classically ranges between 25 to 30% in females and 10 to 20% in males 1 Duesseldorf/Essen civil servant study of 9261 employees, • 27% of subjects were identified with small cutaneous and/or reticular veins whereas only 9% had typical varicose veins 2 • Edinburgh Vein Study- over 80% of the studied population manifested telangiectatic and reticular veins. 3 1. Kurz et al. Int Angiol 1999;18:83-102. 2. Kroger et al.. Vasc Med 2003;8:249-255. 3. Evans et al. J Epidemiol Com Health 1999;53(3):149-53. Chronic Venous Established and potential risk factors for varicose veins (VV) and Insufficiency/Varicose Veins: chronic venous insufficiency (CVI). Prevalence • Clinical manifestations of CVI such as dermal hyperpigmentation, eczema, and edema vary from <1% to 17% in males and <1% to 20% in females • The prevalence of active or healed venous stasis ulcerations is lower, occurring in ~1% of the population � Collectively, CVI and varicose veins comprise the most common vascular condition Adapted from Beebe-Dimmer et al. Ann Epidemiol 2005;15:175-184 . 2

3 Types of Lower Socioeconomic Impact Extremity Veins • Stasis ulcerations are responsible for the loss of ~ 2 million working days and $ 3 billion/year in the US 1 • Chronic venous insufficiency responsible for 1 to 3% of the total health care budget in developed countries 2,3 • CVI is associated with a reduced QOL which is proportional to the severity of venous HTN 4 Perforating Vein 1. McGuckin. Am J Surg 2002;183:132-7 2. Kurz. Int Angiol 1999;18:83-102 3. Ruckley. Angiology 1997;48:7-9 4. Kaplan . J Vasc Surg 2003;37:1047-53. Nomenclature of the veins of the lower limbs: An international interdisciplinary consensus statement New terminology Old terminology [2002] [1998] Anatomy Great saphenous vein Greater or long saphenous vein Lesser or short Small saphenous vein saphenous vein Superficial femoral vein Femoral vein International Interdisciplinary Consensus Committee on Venous Anatomical Terminology J Vasc Surg 2002;36:416-22 3

Musculovenous Pump • Primary mechanism to return blood from the leg to heart Physiology • One way valves allow only upward and inward flow During muscle • contraction [systole], blood flows proximally through the popliteal vein • During muscle relaxation [diastole], deep valves close Illustration by Linda S. Nye Competent Venous Valve Macrovascular Pathophysiology 4

Venous Valvular Dysfunction Pathological • Dilation of vein wall Venous prevents opposition of valve leaflets, resulting Blood Flow in reflux • Valvular fibrosis, destruction, or agenesis results in reflux Doppler Exam: Reflux Microvascular Pathophysiology Illustration by Linda S. Nye 5

Microvascular pathophysiology Signs & symptoms of in CVI that ultimately provokes chronic venous disease skin changes [Varicose veins and CVI] • Swelling • Pain • Stinging • Pruritus • Burning • Ulcers • Aching • Nocturnal leg cramps • Fatigue • Restless legs syndrome • Heaviness • Peripheral neuropathy • Throbbing Venous claudication • Pascarella et al. Ann Vasc Surg 2005;19:921-927. History Physical 6

CEAP: Clinical Classification of Chronic Atrophie Venous Insufficiency Blanche [C 5 ] Hyperpigmentation[C 4 ] “Ankle Flair” Sign/ Corona Phlebectatica [C 1 ] 1994 Executive Committee of the American Venous Forum Swelling [C 3 ] Chronic Eczematous Chronic eczematous Stasis Dermatitis/ stasis dermatitis [C 4 ] Hyperpigmentation [C 4 ] 2° Lymphedema [C 3 ] 7

Acute Lipodermatosclerosis: [C 4 ] Stasis Ulcerations [C 6 ] Stasis associated sclerosing panniculitis[SASP] • Acute inflammation within the distal medial calf • DDX: cellulitis, superficial thrombophlebitis Chronic Lipodermatosclerosis [C 4 ] Stasis Associated Sclerosing I nverted Panniculitis “Champagne Bottle” or “Bowling Pin” Legs 8

CVI does not cause Venous Disease: marked pitting edema! Treatment Guidelines • Make the correct diagnosis � History and Physical � Appropriate testing • Document any arterial disease • Document level and degree of reflux Venous Disease: Treatment Guidelines Varicose Veins: Treatment • Try conservative methods first • Educate the Patient regarding Blair Vermilion, M.D. realistic outcomes and potential Associate Professor of Clinical Surgery complications Ohio State University • Compliance, Compliance, Compliance 9

Venous Disease: Venous Disease: Treatment Options Compression Therapy • Compression Therapy • Indications for Compression Therapy • Sclerotherapy • Surgery � Post Phlebitic Syndrome � “Stripping” � Lymphedema � SFJ Ligation � Post Trauma � Phlebectomy � Post Surgery � Ablation (Laser or Radio Frequency) � Pregnancy • Combination of any and all of the above Venous Disease: Venous Disease: Compression Therapy Compression Therapy • Indications for Compression Therapy • Contraindications for Compression Therapy � Chronic Venous Insufficiency � Diminished Arterial Flow (<70 mm Hg ) � Venous Ulcers, Dermatitis � Acute DVT without sufficient collaterals � Post Sclerotherapy or Surgery � Severe CHF � Superficial Phlebitis � Undefined, non-venous Ulcers � DVT (with anticoagulation) 10

Venous Disease: Venous Disease: Compression Therapy Compression Therapy � Dorsiflex ankle joint when applying • Bandages bandage � Unna’s Boot � Foam padding to protect malleolar or thin-skinned area � High working pressure � Graduated pressure is achieved by � Low resting pressure applying even pressure. Smaller � Can be worn at night diameter areas have increased pressure with equal tension � Use for Dermatitis, Ulcers � Increase pressure by applying multiple � Can be changed once/week layers Venous Disease: Venous Disease: Compression Therapy Compression Therapy • Gradient support stockings • Bandaging Principles � Low working pressure—minimal effect � Start at the base of the toes on deep venous return � Apply no more than 50% stretch � High resting pressure—excellent reflux prevention � Overlap ~50% to avoid skin pinching � Uniform application with right size � Oblique turns (not circular) to minimize constriction � Can be hard to get on 11

Venous Disease: Venous Disease: Compression Therapy Compression Therapy � Uncomfortable at night due to high • 30 to 40 mm Hg resting pressure � Post phlebitic syndrome, severe edema, � Great for maintenance and long term lipodermaosclerosis, ulcerations treatment • 40 to 50 mm Hg � Reduces further dilatation of Varicose � Lymphedema, failure of lower Veins compressions � Examples Sivaris, Jobst, Medi Venous Disease: Sclerotherapy Compression Therapy • Guidelines • 15 to 20 mm Hg � Works best if no reflux from truncal � Leg fatigue,mild varicies veins � Treat larger veins first • 20 to 30 mm Hg � Treat proximal to distal � Aching, heaviness, mild edema, moderate varicies, post sclerotherpy � Treat entire vessel 12

Venous Disease: Sclerotherapy Sclerotherapy � Maintain post injection compression � Venous thrombosis � Ambulate patient � Arterial Injection/injury � Re-evaluate @ 7 to 10 days � Select solution and concentration based � Nerve Injection/injury on vein size � Skin Discoloration � Telangiectatic matting Venous Disease: Venous Disease: Sclerotherapy Sclerotherapy • Contraindications to Sclerotherapy Of Varicose Veins • Complications of Sclerotherpy � Bedridden Patient � Vasovagal Attack � Severe Arterial Disease � Allergic reaction � Hypercoagulable state � Pregnancy � Skin necrosis � Morbid Obesity � Poor tolerance of compression hose � Allergies to the agents used 13

EndoVenous Laser EndoVenous Laser Treatment Treatment • Ambulatory procedure • Results in ablation of treated vein • Can be done in most cases under local, tumescent anesthesia with • The laser introduces thermal energy sedation to the venous tissues, causing irreversible localized venous tissue • Patients typically resume activity damage immediately and see results quickly, with minimal chance of scarring, sutures, long hospital stay, lengthy recovery, or surgical complications EndoVenous Laser EndoVenous Laser Treatment Treatment • Laser energy (most commonly from • Disadvantages: an 810-nm diode laser) is delivered inside the vein through a bare laser � 3% failure rate fiber that has been passed through a � Ecchymosis sheath to the desired location � Paresthesias • The laser is continuously fired (or in pulses) as the laser fiber is gradually � DVT (1%) withdrawn along the course of the � Not as effective on larger (>1.5cm.) veins vein until the entire vessel is treated 14