the fundamentals of phlebology: venous disease ......the risk of developing varicose veins was: 89%...

THE FUNDAMENTALS OF PHLEBOLOGY:

Venous Disease for Clinicians

Domenic A. Zambuto, M.D.

Domenic A. Zambuto, M.D. Vein Clinics of America, Canton, CT

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What my med school and residency taught me about varicose veins…

They’re primarily cosmetic

Treatment options are poor

The veins almost always come back

You might need them some day for CABG


2

Lecture Objectives

Phlebology

Normal anatomy and physiology

Pathophysiology

Evaluation

Treatment options


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4

The medical specialty devoted to the diagnosis and treatment of patients

with venous disorders

PHLEBOLOGY

Vein Anatomy Telangiectasia

Superficial Vein

Perforator Vein

Deep Vein

Reticular Vein


5

Greater Saphenous Vein

• Largest superficial vein -Normally 3-4 mm diam

• Contained within thin superficial fascia

• Medial foot/calf/thigh

• Sapheno-femoral Junction (SFJ) – Confluence of GSV and

common femoral vein

*

RA Weiss 2001

6 Domenic A. Zambuto, M.D.

Vein Clinics of America, Canton, CT

Small Saphenous Vein

• Lateral foot & posterior to malleolus

• Courses between heads of Gastrocnemius

• Termination variable – Popliteal Vein

– Vein of Giacomini

– Smaller deeper Veins

RA Weiss 2001




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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

Illustration by Linda S. Nye


9

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

Venous Insufficiency

A. In the normal situation,

valves in the vein wall keep

blood flowing toward the

heart (green arrows).

B. When the valves are

damaged, blood can flow

backwards (red arrows)

dilating the vein and pooling

in the leg.

C. When the vein is ablated,

normal blood flow direction

is restored.

http://www.ohsu.edu/dotter/venous_ablation.htm

A B C

10 Domenic A. Zambuto, M.D. Vein Clinics of

America, Canton, CT


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REFLUX: its contribution to varicose veins

Illustration by Linda S. Nye


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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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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

Symptoms and Prevalence

Jawien A, Grzela T, and Ochwat A. Prevalence of chronic venous insufficiency in men and women in Poland:

multicentre

cross-sectional study in 40,095 patients. Phlebology 2003; 18(3): 110-122.

Other Common Symptoms – itching, burning, fatigue and ankle swelling

VCA_07-09-04

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Physical Exam Findings • Unremarkable

• Small, medium, large veins

• Edema

• Corona Phlebectatica Paraplantaris

• Hyperpigmentation

• Dermatitis

• Lipodermatosclerosis

• White atrophy

• Ulcers


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17

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

Impending ulceration Lipodermatosclerosis (C4a)

Venous ulceration (C6)


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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, local release of proteolytic enzymes

*Shami SK et al. J Vasc Surg 1993; 17:487-90


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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


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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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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)

Prevalence

Sadick NS (2000). Manual of Sclerotherapy. Philadelphia, PA: Lippincott Williams & Wilkins

•20% of Adults Worldwide

Range 7-60%

•25% of Women and 15% of Men

•80+ Million Americans

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Prevalence of Venous Disease

Varicose Veins 20+ million

Swollen Leg 6 million

Skin Changes 1 million

Skin Ulcer 500,000



Prevalence & Incidence of Vascular Disease

0 5 10 15 20 25

Millions of Americans

Heart valve disease

Cardiac arrhythmias

Venous reflux disease

Peripheral arterial disease

Stroke

Congestive heart failure

Coronary heart disease

Annual incidence

Prevalence

Sources: American Heart Association, SCVIR, Brand et al. “The Epidemiology of Varicose Veins: The Framingham Study”


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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.


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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

shift Santler, 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

Complications of Untreated Varicose Veins

•Chronic Pain Syndrome

•Venous Stasis Dermatitis/Ulceration

•Bleeding

•Superficial Thrombophlebitis (STP)

• 4.4% develop DVT+/- Pulmonary Embolus w/in 3 months of initial STP diagnosis


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Duplex US

• Maps out normal and abnormal pathways

• Identifies the sources of incompetence and the levels of obstruction

• Guides treatment

• Allow endovascular techniques to be used as an acceptable alternative to traditional surgery

• Provides reliable and objective follow up


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Technique for evaluating SVI

Standing position with the patient’s weight supported on the contralateral limb


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Duplex Exam



Duplex Exam

Transducer

GSV

Normal Venous

Reflux

Squeeze

Squeeze

Reflux

TIME

V

E

L

O

C

I

T

Y Modified from K P Moresco, MD


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America, Canton, CT


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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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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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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

Surgical Stripping and Ligation

• Gold Standard procedure

• Performed in the OR under GA

• Surgical removal of the incompetent GSV by means of two incisions and a mechanical “stripper”

• Prolonged recovery and morbidity

• High recurrence rates – – 10 to 25%



Endovenous Laser Ablation



Stripping

Surgical

40-100%16

<2% 16

1:10,000 17

Severe Bruising >50% 9

Moderate Pain 28% 9

Groin Infection 5.6% 9

Nerve Injury 7% 16

Compression stockings prescribed

Walking +/-

Limited activity for 2-4 wks

Combine stripping & phlebectomy

*

66% 18

Sclerotherapy

• The introduction of a substance into the vein to be treated designed to destroy the endothelium so that the vessel subsequently is resorbed by the body.

• Historically many substances have been tried.

• Currently in the United States there are two main agents: Sotradechol and Hypertonic saline.


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Sclerotherapy

• Goal of sclerotherapy is complete treatment of abnormal vessels without damage to adjacent or connected vessels


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Examples

• 32 year-old male

• Bilateral leg pain, heaviness, fatigue, itching, restlessness, throbbing, and swelling

• Symptoms are worse with prolonged standing and sitting

• Mother with a history of varicose veins and maybe a blood clot


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America, Canton, CT

Example

• 66 year-old female

• School bus driver

• Bilateral leg pain, itching, and swelling.

• Symptoms are worse with sitting and standing, but the pain is preventing her from sleeping well.

• Has tried compression stockings for years with progressive symptoms

• G2 P2


America, Canton, CT


America, Canton, CT

Example

• 40 year-old female

• Dental hygienist

• Left leg aching, heaviness, fatigue, and cramping. Worst at the groin.

• Symptoms are worse with sitting, standing, and sleeping.

• Has tried exercise, leg elevation, and pain medications with limited improvement in symptoms

• G2 P2


America, Canton, CT


America, Canton, CT

Thank You

Domenic A. Zambuto, M.D. Vein Clinics of America, Canton, CT 71

Domenic A. Zambuto, M.D. Vein Clinics of America, Canton, CT 72


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the fundamentals of phlebology: venous disease ......the risk of developing varicose veins was: 89%...

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