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Copyright © 2009 by American College of Phlebology 1

THE FUNDAMENTALS OF PHLEBOLOGY:

Venous Disease for Clinicians

An Introductory Lecture

Copyright © 2009 by American College of Phlebology

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Disclosure of Conflict of InterestDr John Rowen

I do not have relevant financial relationships with any commercial interests.


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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


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“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


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The medical specialty devoted to the diagnosis and treatment of patients with venous disorders

PHLEBOLOGY


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IMPORTANCE OF CHRONIC VENOUS DISEASE

• 1 in 22 or 4.5% or 12.2 million people in the USA are affected by varicose veins

• Incidence increases with age and is more common in women with over 40% of women in their 50’s suffering from some sort of venous disorder

• Across all ages and gender, 60% of Americans suffer from venous disease and its sequelae

National Heart Lung and Blood Institute (NHLBI) http://www.nhlbi.nih.gov/


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THE SPECTRUM OF CHRONIC VENOUS DISEASE

lipodermatosclerosis

telangiectasias

varicose veins

Superficial phlebitis

venous ulceration


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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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Venous Diseaseis 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 veinsCornu-Thenard, A, J Dermatol Surg Oncol 1994 May; 20(5):318-26.


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Heredity in Chronic Venous Insufficiency

Risk Factors for chronic venous disease:

The San Diego population study

Although some risk factors for venous disease such as age, family history of venous disease are immutable others can be modified, such as weight, physical activity, and cigarette smoking.

J Vasc Surg. 2007 August; 46(2): 331–337


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The beginnings of venous disease may be found as early as childhood

740 pts

10-12 y/o

518 pts

14-16 y/o

459 pts

18-20 y/o

Diagnosable

Vein disease

2.5% 12.3% 19.8%

Actual

Varicose Veins

0 1.7% 3.3%

Phlebologie. 1990 Nov-Dec;43(4):573-7. Weindorf N, Schultz-Ehrenburg U.


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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

shiftSantler, R Hautarzt 1956; 10:460


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Varicose Veins are 3 times more common in women than men

"Varicose veins." The Mayo Clinic. January 2007. http://www.mayoclinic.com


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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


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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


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Illustration by Linda S. Nye


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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



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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



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Perforating veins

• Mid-thigh Perforating Vein• Dodd• Proximal Calf Perforator• Cockett• Gastrocnemius• Lateral thigh (lateral

subdermic plexus)



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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



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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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Doppler exam: Normal flow



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Doppler: Reflux



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REFLUX: its contribution to varicose veins



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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


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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 eczemaC4b – 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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AMBULATORY VENOUS HYPERTENSION

• The common denominator in the pathophysiology of venous disease

• Instead of dropping, the intravenous pressure rises during exercise and is transmitted to more superficial and distal veins

• May be due to reflux, obstruction, or both


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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


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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• Goals of patient


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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)

• Inspect the abdomen for enlarged superficial veins if ilio-femoral thrombosis is suspected


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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.


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Lateral Subdermic Plexus

• Very common, especially in women

• Superficial veins with direct perforators to deep system

• Remnant of embryonic deep venous system


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Reticular Veins

• Enlarged, greenish-blue appearing veins

• Frequently associated with clusters of telangiectasias

• May be symptomatic, especially in dependent areas of leg


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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


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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


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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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Varicose Veins with Pelvic Origins

• Begin during pregnancy• Increased symptoms

during pre-menstrual period and after intercourse

• May be associated with pelvic congestion syndrome


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Skin changes suggestive of chronic venous insufficiency

Corona Phlebectatica (C1)

Pigmentation (C4a)

Atrophie blanche (C4b)

Healed ulcer (C5)


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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


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Venous ulceration

Impending ulceration Lipodermatosclerosis (C4a)

Venous ulceration (C6)


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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


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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


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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


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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.


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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


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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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Compression Strength

Indications

8-15mm Leg fatigue, mild swelling, stylish

15-20mm Mild aching, swelling, stylish

20-30mm Aching, pain, swelling, mild varicose veins

30-40mm * Aching, pain, swelling, varicose veins, post-ulcer

40-50, 50-60mm * Recurrent ulceration, lymphedema* Requires a prescription


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Prescribing graduated compression stockings

• Measure ankle, calf, thigh for proper fit• Disproportionate legs require custom

stockings• Medical supply companies may have

stocking fitters• Avoid using at night in elderly, diabetics,

and patients with arterial disease


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Donning compression stockings: what to advise your patients• Method #1: Turn stocking inside out to

heel and pull onto foot. Then pull the stocking up the leg

• Method #2: Put stocking on like a trouser, not like a sock

• Rubber gloves and donning devices (Easy-Slide, Butler) improve ease of donning, and thus compliance


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Inelastic compression

• Most physiologic in its effect

• Available as bandage, which requires significant skill

• CircAid is “user friendly,” series of nylon straps

• Good choice for elderly, diabetics, patients with arterial disease

Photo courtesy CircAid Medical Products, Inc.


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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)


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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• Cosmetic improvement requested• Thickening or discoloration of the skin in the

ankle region: skin changes suggestive of chronic venous insufficiency

• Impending or active ulceration or hemorrhage


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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


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Treatment of telangiectasias

• Sclerotherapy most effective

• Laser may be helpful• 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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Sclerotherapy of Telangiectasias: Technique

Injection of sclerosant solution causes damage to endothelium which leads to fibrosis of vein


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Sclerotherapy Results

Before AfterPhotos courtesy of Steven Zimmet, MD, FACPh


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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


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Non-surgical treatment of varicose veins• Sclerotherapy effective;

may be enhanced if ultrasound-guided

• 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


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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.


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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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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


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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


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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


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Surgical Treatment of Varicose Veins: Phlebectomy

• Very esthetic method of removing varicose veins

• Usually requires only local anesthetic

• Especially useful for tributaries of GSV, SSV


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Treatment Results

Before After Endovenous obliteration of the Great Saphenous Vein and phlebectomy of tributariesPhotos courtesy of Steven Zimmet, MD, FACPh


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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


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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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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


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Pelvic Congestion Syndrome• Affects thousands of women in the U.S.• More common in multiparous women• Due to reflux in the ovarian veins, iliac veins, etc.• May result in severe pelvic discomfort during the pre-

menstrual period, after intercourse, and with prolonged standing

• May be effectively treated by blocking the reflux with embolization and/or pelvic vein sclerotherapy

Venbrux AC et al J Vasc Interv Radiol 2002; 13:171-178


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• 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 PHLEBOLOGY101 Callan Avenue, Suite 210 ● San Leandro, CA 94577-4558

510.346.6800 ● 510.346.6808 [email protected] ● www.phlebology.org

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