Venous Insufficiency

OUTLINE Definition Etiology & risk factorsPhysiologyPathophysiologyClinical manifestations

- Subjective symptoms - Dilated veins- Postthrombotic syndromes

Diagnosis-Physical examination-Imaging-The C-E-A-P Classification

Non operative management-Compression stockings-Leg elevation-Unna boot-Venoablation

Operative management

• The great and short saphenous veins, which join the deep system at the saphenofemoral and saphenopopliteal junctions

• SSV originates in the lateral foot and passes posteriorly lateral to the Achilles tendon in the lower calf,and reach upper calf where it enters popliteal space

• GSV originates in the medial foot and passes anterior to the medial malleolus, then crosses the medial tibia in a posterior direstion to ascend medially across the knee and finally join the common femoral vein at SFJ

• The posterior tibial veins originate behind the medial malleolus; the anterior tibial vein originates in the dorsum of the foot; and the peroneal vein is found between the tibia and fibula.

• The popliteal vein is another important intermuscular vein; originates in the popliteal space by the conjoining of the posterior and anterior tibial veins.It becomes the superficial femoral vein in the thigh, and is joined just below the saphenofemoral junction by the deep femoral vein to form the common femoral vein

Perforating Veins

VENOUS INSUFFICIENCY

• Definition of venous insufficiency :“A state where venous blood escapes from its

normal antegrade path of flow and refluxes backward down the veins into an already

congested leg.”

• Peak incidence occurs in women aged 40-49 years and in men aged 70-79 years.

ETIOLOGY

• CongenitalAbsence of or damage to venous valves in the superficial and communicating systems (eg : Kilppel-Trenaunay-Weber Syndrome; multiple arteriovenousfistulae; avalvulia)

• Primary Valvular insufficiency

• Secondary i. Thrombosis

ii. Hormonal changes (Progesteron-induced venous wall weakness)

iii. Chronic environmental insult (eg : prolonged standing)

iv. Trauma

RISK FACTORS

• Age• Family history (FOXC2 gene)• Lifestyle • Obesity• Smoking

Determinants of Venous Flow• Major mechanisms in body to prevent venous

hypertension : I. Venous valvesII.“Venous pump” (gastrocnemius and soleus

muscles)(a) healthy patients (b) patients with only

varicose veins(c) patients with

incompetent perforator veins

(d) patients with deep and perforator incompetence.

PATHOPHYSIOLOGYValvular incompetence

(Ambulatory) venous hypertension

Hydrostatic pressure Hydrodynamic pressure

Deep venous Superficial venous

Saphenofemoral junction (SFJ) and saphenopopliteal

junction (SPJ)

DVT Perforating vein

Chronic outflow obstruction

Recanalize/ bypass

CHRONIC VENOUS INSUFFICIENCY

• Increased venous pressuretranscends the venules to the capillariesimpede flowleukocyte trappingrelease proteolytic enzymes and oxygen free radicalsdamage capillary basement membranes.

• Plasma proteins, such as fibrinogen, leak into the surrounding tissues, forming a fibrin cuff. Interstitial fibrin and resultant edema decrease oxygen delivery to the tissues, resulting in local hypoxia. Inflammation and tissue loss result.

CLINICAL MANIFESTATIONS

1. Subjective symptoms

2. Dilated veins varicose veins (venous insufficiency syndrome), reticular veins, telangiectasias.

3. Postthrombotic syndrome (also known as postphlebitic syndrome).

SUBJECTIVE SYMPTOMS

• History : typically bothersome (early disease) become less severe (middle phases) worsen again (advancing age).

Burning SwellingThrobbing Night crampsAching Leg heavinessRestless legs Leg fatigueExercise intolerance Pain

/tendernessParesthesias

DILATED VEINS POST-THROMBOTIC SYNDROMES

Varicose vein : Tortuous,dilate, visible,palpable veins in the subcutaneous skin greater than 3 mm veins.

Pain : Hallmark, especially after ambulating.

Telangiectasis :Dilated intradermal venules greater than 1 mm in diameter.

Ulceration : stasis, non healing

Reticular veins - Visible, dilated bluish subdermal, nonpalpable veins 1-3 mm.

Skin changes : venous dermatitis, lipodermatosclerosis, chronic cellulitis.

Edema

Atrophie blanche

Corona phlebectatica

V V

A B

T

R V

CP

A B

LD

DIFFERENCE BETWEEN VENOUS AND ARTERIAL

Venous Insufficiency Arterial insufficiencyAggravating factors : Warmth Aggravating factors : Walking,

elevation, cold, compression stockings

Alleviating factors :Cold, walking, by elevating the legs, compression stockings

• Ulcer is superficial at "gaiter" region of the legs• Base : Moist granulating (pinkish) that oozes venous blood

when manipulated.• Slopping edge.• Depth : superficial & shallow• Has good chance in healing.

VENOUS ULCER

DIAGNOSISPhysical examinationI. Inspection : from distal to proximal and from front to backII. Palpation

: lightly with the fingertips (location, size, shape, and the diameter of the largest vessel)

: at SFJ & SPJ to elicit palpable thrill or sudden expansion (by asking patient to cough or do Valsalva): Pain or tenderness, firm, thickened vein: Distinguish chronic or newly onset varices: Distal and proximal arterial pulses

III. Percussion : standing position a vein segment is percussed at one position while an examining hand feels for a "pulse wave" at another position

IV. Trendelenburg test

V. Perthes maneuver

TRENDELENBURG TEST

DUPLEX ULTRASONOGRAPHY

• Duplex ultrasonography is the study of choice for the evaluation of venous insufficiency syndromes.

• Red indicates flow in one direction (relative to the transducer) and blue indicates flow in the other direction.

• Latest-generation machines : the shade of the color may reflect the flow velocity (in the Doppler mode) or the flow volume (in the power Doppler mode).

DUPLEX ULTRASONOGRAPHY

VARICOGRAPHY• Allows detailed

mapping of the varices to their termination.

• Extremely useful investigation in patients with recurrent varicose veins or those with complex anatomy

MAGNETIC RESONANCE VENOGRAPHY (MRV)

• Most sensitive & specific test for the assessment of deep and superficial venous disease in the lower legs and pelvis, areas not accessible with other modalities.

• Useful in the detection of previously unsuspected nonvascular causes of leg pain and edema when the clinical presentation erroneously suggests venous insufficiency or venous obstruction.

PHYSIOLOGIC TESTS OF VENOUS RETURN

1. Venous refilling time (VRT)2. Maximum venous outflow (MVO)3. Calf muscle pump ejection fraction (MPEF).

THE C-E-A-P CLASSIFICATION

NON SURGICAL MANAGEMENTCompression stockings • To improve symptom

management

• Classifications : light compression16-

20 mm Hg class I 20-30 mm Hg class II30-40 mm Hg class III40-50 mm Hg

Leg elevation

• For two brief periods during the day.

• Instructing the patient that the feet must be above the level of the heart, or “toes above the nose.”

Unna boot• Triple-layer compression dressing• application occurs once to twice a week.

1

2 3

Venoablation

SclerotherapyEndovenous laser

therapy (EVT)Radiofrequency

ablation (RFA)

SURGICAL MANAGEMENT

• Indications :I. Cosmesis II. Symptoms refractory to conservative therapy

III. Bleeding from a varix IV.Superficial thrombophlebitis V. Lipodermatosclerosis VI.Venous stasis ulcer

Stab avulsions

1. (Left) Vein stripping with ligation2. (Right)Stab avulsions (with or without

ligation)