Chronic Venous DiseaseChronic Venous Disease

Patrik TosenovskyPatrik Tosenovsky

IssuesIssues

• Severity of CVDSeverity of CVD

• Appropriate referralAppropriate referral

• Benefit, side effects and cost of the Benefit, side effects and cost of the treatmenttreatment

CVD – Chronic Venous CVD – Chronic Venous DisordersDisorders

• Include s spectrum of clinical Include s spectrum of clinical presentations ranging from presentations ranging from teleangiectasias to venous ulceration.teleangiectasias to venous ulceration.

• Primary vs SecondaryPrimary vs Secondary

Chronic Venous Chronic Venous InsufficiencyInsufficiency

• Usually refers more specifically to Usually refers more specifically to the spectrum of skin changes the spectrum of skin changes associated with venous hypertensionassociated with venous hypertension

Primary CVD vs Secondary Primary CVD vs Secondary CVDCVD

• Primary - The cause is unknown Primary - The cause is unknown (varicose veins etc) --- varicose (varicose veins etc) --- varicose veins/swelling/skin changesveins/swelling/skin changes

• Secondary – usually following DVT --- Secondary – usually following DVT --- obstruction +/- reflux ---venous obstruction +/- reflux ---venous hypertension --- varicose hypertension --- varicose veins/swelling/skin changesveins/swelling/skin changes

ANATOMY/PHYSIOLOGYANATOMY/PHYSIOLOGY

ANATOMYANATOMY

DVT – obstruction (initially DVT – obstruction (initially always)always)

Thrombus formation – DVT - Thrombus formation – DVT - embolisation - PEembolisation - PE

Obstruction – Reflux – or bothObstruction – Reflux – or both

OBSTRUCTION

REFLUX or OBSTRUCTION or both

Competent valve and Competent valve and obstruction free lumen is the obstruction free lumen is the key for functionkey for function

Great Great SaphenousSaphenous Vein Valve Vein Valve ––magnified magnified

Classification of CVDClassification of CVD

• CEAP classification CEAP classification

• C – Clinical signs (1-6 i.e. retic.v.- C – Clinical signs (1-6 i.e. retic.v.- ulcer)ulcer)

• E – ethiology (cong., E – ethiology (cong., primaryprimary, , secondsecond.).)

• A – anatomy (deep, perf., superf)A – anatomy (deep, perf., superf)

• P – pathophysiology (reflux, P – pathophysiology (reflux, obstruction, both)obstruction, both)

Severity of CVDSeverity of CVD

• Venous Clinical Severity Score Venous Clinical Severity Score (VCSS) – more for research (VCSS) – more for research purposes and databasespurposes and databases

• Clinically more practical:Clinically more practical:1.1. Active ulcer, previous ulcer, Active ulcer, previous ulcer,

lipodermatosclerosislipodermatosclerosis2.2. Symptomatic - any stage of CVDSymptomatic - any stage of CVD3.3. Other (incl. vv’s, spider veins etc) Other (incl. vv’s, spider veins etc)

Severity of Acute venous Severity of Acute venous diseasedisease

• DVT – 2 weeks of durationDVT – 2 weeks of duration

• Severity:Severity:

1.1. Iliofemoral DVT + Iliofemoral DVT + swelling/discolorationswelling/discoloration

2.2. Other DVT (femoropopliteal, tibial, Other DVT (femoropopliteal, tibial, gastrocn., soleus veins)gastrocn., soleus veins)

Treatment optionsTreatment options

• Non-surgical – compression (venous Non-surgical – compression (venous hypertension)hypertension)

• Sclerotherapy – both for cosmetic vv’s and Sclerotherapy – both for cosmetic vv’s and synptomatic onessynptomatic ones

• Surgical – phlebectomy/strippingSurgical – phlebectomy/stripping• Percutaneous – RFA, Laser, angioplasty/stentPercutaneous – RFA, Laser, angioplasty/stent• Deep vein reconstructionDeep vein reconstruction• CombinedCombined

How effective is the How effective is the treatmenttreatment

• PercutaenousPercutaenous and and open surgicalopen surgical – up – up to 98% success rate (no difference)to 98% success rate (no difference)

• Sclerotherapy – good for small veins Sclerotherapy – good for small veins

• Angioplasty – up to 99% success rate Angioplasty – up to 99% success rate for iliac veinsfor iliac veins

• Deep vein reconstruction – 60 % Deep vein reconstruction – 60 % successsuccess

Right iliac vein occlusionRight iliac vein occlusion

Axillary vein transplantAxillary vein transplant

Transplantace Transplantace axillárníaxillární žílyžíly

ValvuloplastyValvuloplasty

Venous ulcer before Venous ulcer before treatmenttreatment

Venous ulcer 4 weeks after Venous ulcer 4 weeks after th.th.

Venous ulcers healed 12Venous ulcers healed 12thth week post deep vein week post deep vein reconstructionreconstruction