Chronic Venous Disease: A Complex Disorder. A N Nicolaides

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1 Chronic Venous Disease: A Complex Disorder A N Nicolaides Emeritus Professor of Vascular Surgery, Imperial College, London. Hon. Professor of Surgery, University of Nicosia Medical School, Cyprus

2 Disclosures Honoraria for lectures received from: Covidien / Medronic Alpha Wasserman / AlphaSigma Servier Pierre Fabre

3 Why is it a Complex Disorder? Complex Symptoms and Signs Complex Pathophysiology Complex Haemodynamics A better understanding of these complexities should better equip the clinician to manage patients with CVD Complex skills are required

4 Why is it a Complex Disorder? Complex of Symptoms and Signs Complex Pathophysiology Complex Haemodynamics A better understanding of these complexities should better equip the clinician to manage patients with CVD Complex skills are required

5 Chronic venous disease-related Symptoms 1 Heaviness, Pain, Sensation of swelling, Restless legs, Paresthesias, Night-time cramps, Tiredness, Throbbing, Itching. symptoms and signs Signs 2 C0s: None C1: Telangiectasia, reticular veins C2: Varicose veins C3: Edema C4: Skin changes: (a) pigmentation, eczema, (b) lipodermatosclerosis, atrophie blanche C5: Healed Venous ulcer C6: Active Venous ulcer 1. Garde C et al. Phlebolymphology 2005; 49: ; 2. Porter et al. J Vasc Surg 1995; 21:

6 Symptoms and signs Symptoms are not specific of CVD There is poor correlation between Symptoms and Signs: Advanced CEAP class can be present without symptoms and in C0s signs are absent in the presence of severe symptoms Scoring systems such as VCSS devote only 3 marks out of 30 for symptoms and 27 marks for signs

7 SymVein Publication The SymVein publication has changed our approach to the assessment and management of CVD Definition of venous symptoms Explanation of Pathophysiology of symptoms Attribution of symptoms to CVD Recommendations about scoring of symptoms Investigations needed

8 Why is it a Complex Disorder? Complex of Symptoms and Signs Complex Pathophysiology Complex Haemodynamics A better understanding of these complexities should better equip the clinician to manage patients with CVD Complex skills are required

9 Primary Varicose veins (VVs) Common disorder VVs present in 14-35% of the population 40% of venous leg ulcers are the result of longstanding VVs in the presence of normal deep veins Progressive Prevalence and severity increase with age

10 Leukocyte-endothelium interaction: a key role primary CVD Environmental and local factors plus genetic predisposition Leukocyte-endothelium interaction Chronic inflammatory processes Remodeling in venous wall, and venous valves REFLUX and HYPERTENSION Adapted from Eberhardt RT, Raffetto JD. Circulation. 2005; 111:

11 Progression of chronic venous disease MACROcirculation MICROcirculation Valve damage Vein wall remodeling Capillary leakage Capillary damage Reflux Varicose Veins (C2) Edema (C3) Skin Changes (C4) Venous Ulcer (C5,6) C0s Symptoms Symptoms Symptoms Symptoms HYPERTENSION Adapted from Eberhardt RT, Raffetto JD. Circulation. 2005; 111:

12 Why is it a Complex Disorder? Complex of Symptoms and Signs Complex Pathophysiology Complex Haemodynamics A better understanding of these complexities should better equip the clinician to manage patients with CVD Complex skills are required

13 Painful Leg Ulcer

14 Reflux: Volume Flow 739/60 = 12 ml/sec

15 Ambulatory venous pressure (AVP) a global hemodynamic test VFT, s % pressure drop

16 All reflux is not equal Marston WA et al. J Vasc Surg 2008;48:400-6

17 Post-thrombotic Syndrome 60% of venous ulcers are due to previous DVT Etiology 1. Obstruction (failure of recanalization) and recurrent DVT 2. Reflux (damage to valves) 3. Combination of reflux and obstrucion

18 Post-thrombotic Syndrome Predisposing factors to skin changes and ulceration 1. Persisting proximal obstruction 2. Axial reflux 3. Reflux > 5ml per sec 4. Combined obstruction and severe reflux 5. Recurrent DVT (obstruction of collaterals) 6. Increasing age 7. Obesity 8. Poor compliance to therapy

19 Ulcer Prevalence vs. AVP

20 Venous Hypertension and Protective Mechanisms Ability of lymphatic drainage to increase 5 times in some individuals but only 2 times in others (zero in patients with lymphedema) Variable fibrinolytic activity in blood and tissues. For patients having moderately raised AVP If fibrinolytic activity is low: 90% develop skin changes and 70% ulcer If fibrinolytic activity is normal-high: 16% develop ulcer Whawell SA et al, Br J Surg 1989;76 :

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25 Combination of Duplex and VFI Clinical severity class N VFI P 0 Asymptomatic ± Mild CVI (ache & swelling) ± 1.7 < Moderate CVI (skin changes) ± 5.6 < Severe CVI (Ulceration) ± 5.2 < The combination of VFI and duplex scanning (multisegment score) not only localized the reflux, but also separated severe clinical disease from mild with high sensitivity (83%) and high specificity (86%) Neglen and Raju 1993:17:590-5

26 Venous Obstruction Value of imaging techniques and outflow resistance (R)

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28

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30 Venous obstruction The degree at which a venous stenosis is critical is not known This is because outflow resistance for the limb depends on how well developed is the collateral circulation A reliable non-invasive test to grade stenosis is not available Best method for local grading of stenosis is IVUS Global effect of obstruction is provided by Outflow Resistance (R) Note: Because R is not measured, current practice of stenting relies on assessment of local stenosis. Only 50-60% of patients improve suggesting that many are stented unnecessarily

31 Labropoulos et al, Arch Surg 1997;132:46-51

32 Simultaneous Pressure and Volume Measurements

33 Simultaneous Pressure and Volume Recordings R = P/Q mmhg/ml/min

34 26 Limbs with CVD

35 Conclusions 1. Duplex provides information on presence or absence and anatomic extent of reflux or obstruction 2. If quantitative information is needed (how much reflux or how much obstruction there is) for clinical decisions, duplex should be complimented by plethysmography 3. R should be measured before and after stenting so that eventually we can correlate the baseline R with those that derive clinical benefit. This should provide a better selection of patients for stenting

36 C0s

37 Prevalence of C0s and significance The presence of symptoms in the absence of signs (C0s) are very common In the Bonn Vein Study 50% of 1800 participants reported such symptoms In the worldwide Vein Consult Program 20% of the symptomatic screened subjects presented with C0s

38 Prevalence of C0s and significance In a recent study of 41 C0s patients with normal duplex in the morning, 26 (63%) had reflux in the evening with increased GSV diameter (Tsoukanov Y. 2005) In the Basel longitudinal study, C0s individuals progressed to develop overt edema when seen 11 years later The majority of C0s patients improve with compression or VAD

39 CVD: Conclusion Complex of Symptoms and Signs Complex Pathophysiology Complex Haemodynamics A better understanding of these complexities should better equip the clinician to manage patients with CVD We may have to change our methods of investigation Complex skills are required

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