Disclosure of Conflict of Interest THE BASICS OF VENOUS INSUFFICIENCY: What You Should Know. An Introductory Lecture 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 1 Copyright 2009 by American College of Phlebology 2 Presentation Use Information Venous Insufficiency 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 Epidemiology Risk Factors Anatomy and Physiology Diagnosis Classification Treatment Options Thrombosis thoughts Ultrasound Demo Copyright 2009 by American College of Phlebology 3 Copyright 2009 by American College of Phlebology 4 It is ironic that medical education does not cover three of the most common medical problems: back pain, hemorrhoids, and varicose veins. PHLEBOLOGY The medical specialty devoted to the diagnosis and treatment of patients with venous disorders P. Fujimura, MD Surgical Intern University of California School of Medicine Copyright 2009 by American College of Phlebology 5 Copyright 2009 by American College of Phlebology 6 1
Venous Insufficiency We are not talking about.. Hidden Disease? Unseen physical dysfunction Estimate 40% men, 50% women Inability to exercise Impacts overall health Impacts job performance THE SPECTRUM OF CHRONIC VENOUS DISEASE telangiectasias Superficial phlebitis varicose veins lipodermatosclerosis venous ulceration Copyright 2009 by American College of Phlebology 9 Presenting Symptoms of Chronic Venous Disease Aching Fatigue, heaviness in legs Pain: throbbing, burning, stabbing Cramping Swelling (peripheral edema) Itching Restless legs Numbness Copyright 2009 by American College of Phlebology 12 2
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 13 Copyright 2009 by American College of Phlebology 14 Inactivity aggravates venous disease Varicose Veins are 3 times more common in women than men 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." The Mayo Clinic. January 2007. http://www.mayoclinic.com Copyright 2009 by American College of Phlebology 15 Copyright 2009 by American College of Phlebology 16 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 17 Copyright 2009 by American College of Phlebology 18 3
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 Copyright 2009 by American College of Phlebology 19 Copyright 2009 by American College of Phlebology 20 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 intersaphenous connection or perforating vein Illustration by Linda S. Nye Copyright 2009 by American College of Phlebology 21 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 22 Musculovenous pump Venous Valvular Function 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 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 Illustration by Linda S. Nye Copyright 2009 by American College of Phlebology 23 Copyright 2009 by American College of Phlebology 24 4
Doppler exam: Normal flow Doppler: Reflux Illustration by Linda S. Nye Copyright 2009 by American College of Phlebology 25 Illustration by Linda S. Nye Copyright 2009 by American College of Phlebology 26 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 Illustration by Linda S. Nye Copyright 2009 by American College of Phlebology 30 5
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 Copyright 2009 by American College of Phlebology 31 Copyright 2009 by American College of Phlebology 32 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 33 Copyright 2009 by American College of Phlebology 34 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) Copyright 2009 by American College of Phlebology 35 Copyright 2009 by American College of Phlebology 36 6
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 Copyright 2009 by American College of Phlebology 37 Copyright 2009 by American College of Phlebology 38 Reticular Veins Enlarged, greenishblue 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 Copyright 2009 by American College of Phlebology 39 Copyright 2009 by American College of Phlebology 40 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 Copyright 2009 by American College of Phlebology 41 Copyright 2009 by American College of Phlebology 42 7
Skin changes suggestive of chronic venous insufficiency Venous ulceration Corona Phlebectatica (C1) Atrophie blanche (C4b) 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 Pigmentation (C4a) Healed ulcer (C5) Copyright 2009 by American College of Phlebology 43 Copyright 2009 by American College of Phlebology 44 Venous ulceration Impending ulceration Lipodermatosclerosis (C4a) Venous ulceration (C6) Venous vs. Arterial Ulcers Photo courtesy of John Bergan, MD Arterial ulcer 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 Copyright 2009 by American College of Phlebology 45 Copyright 2009 by American College of Phlebology 46 Muscle fascia herniation Anita s Problem = Pain 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 Copyright 2009 by American College of Phlebology 47 8
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 49 Copyright 2009 by American College of Phlebology 50 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 Copyright 2009 by American College of Phlebology 51 Copyright 2009 by American College of Phlebology 52 Graduated compression is not the same as T.E.D. hose T.E.D.s are meant for nonambulatory, 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 Copyright 2009 by American College of Phlebology 54 9
Compression Strength 8-15mm 15-20mm 20-30mm 30-40mm * Indications Leg fatigue, mild swelling, stylish Mild aching, swelling Aching, pain, mild varicosities Large varicose veins, post-ulcer 40-50, 50-60mm * Recurrent ulceration, lymphedema 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 weightlifting or other strenuous activity) * Requires a prescription Copyright 2009 by American College of Phlebology 55 Copyright 2009 by American College of Phlebology 56 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 57 Copyright 2009 by American College of Phlebology 58 Treatment of telangiectasias 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 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. Copyright 2009 by American College of Phlebology 59 Copyright 2009 by American College of Phlebology 60 10
Sclerotherapy of Telangiectasias: Technique Sclerotherapy Results Injection of sclerosant solution causes damage to endothelium which leads to fibrosis of vein Before Photos courtesy of Steven Zimmet, MD, FACPh After Copyright 2009 by American College of Phlebology 61 Copyright 2009 by American College of Phlebology 62 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 NEED PIC 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 Copyright 2009 by American College of Phlebology 63 Copyright 2009 by American College of Phlebology 64 Ultrasound-guided Sclerotherapy Sclerotherapy Results Photo courtesy of CompuDiagnostics, Inc. 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 Photos courtesy of Steven Zimmet, MD, FACPh Before After Ultrasound-guided sclerotherapy of the Great Saphenous Vein and sclerotherapy of branches Copyright 2009 by American College of Phlebology 65 Copyright 2009 by American College of Phlebology 66 11
Ambulatory Phlebectomy Endovenous Laser Ablation Very esthetic method of removing varicose veins Usually requires only local anesthetic Especially useful for tributaries of GSV, SSV 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 Copyright 2009 by American College of Phlebology 67 Copyright 2009 by American College of Phlebology 68 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 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 12
Treatment Results Radiofrequency Closure Technique Before Photos courtesy of Steven Zimmet, MD, FACPh After Endovenous obliteration of the Great Saphenous Vein and phlebectomy of tributaries NEED PIC 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 Copyright 2009 by American College of Phlebology 73 Copyright 2009 by American College of Phlebology 74 Surgical Treatment of Varicose Veins: Vein Stripping Photo Photo courtesy of John Bergan, MD Vein stripping used to remove Great and Small saphenous veins Yields 60% long term improvement Neovascularization a problem Usually requires general anesthetic 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 Butler CM, et al Phlebology 2002. 17:59-63 Copyright 2009 by American College of Phlebology 75 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 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 Padberg FT et al J Vasc Surg 1996; 24:711-19 Copyright 2009 by American College of Phlebology 77 Copyright 2009 by American College of Phlebology 78 13
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 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 postthrombotic syndrome Patients with symptomatic legs should be maintained on a regimen of compression and daily walking for 1-2 years Prandoni et al, Ann Intern Med 2004;141:249-256 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 81 Copyright 2009 by American College of Phlebology 82 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 510.346.6800 510.346.6808 Fax info@acpmail.org www.phlebology.org THANK YOU FOR YOUR ATTENTION! THE FUNDAMENTALS OF PHLEBOLOGY: Venous Disease for Clinicians Copyright 2009 by American College of Phlebology 83 Copyright 2009 by American College of Phlebology 84 14