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Transcript of 20110113 Speakers Bureau Revised
Copyright © 2009 by American College of Phlebology 1
THE BASICS OF VENOUS DISEASE:
What You Should Know.An Introductory Lecture
Copyright © 2009 by American College of Phlebology 2
Disclosure of Conflict of Interest
[REPLACE WITH SPEAKER NAME]
I do not have relevant financial relationships with any commercial interests.
[OR]LIST COMPANY(s) - RELATIONSHIP
Copyright © 2009 by American College of Phlebology 3
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
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.”
P. Fujimura, MDSurgical Intern
University of California School of Medicine
Copyright © 2009 by American College of Phlebology 5
The medical specialty devoted to the diagnosis and treatment of patients with venous disorders
PHLEBOLOGY
Copyright © 2009 by American College of Phlebology 6
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/
Copyright © 2009 by American College of Phlebology 7
THE SPECTRUM OF CHRONIC VENOUS DISEASE
lipodermatosclerosis
telangiectasias
varicose veins
Superficial phlebitis
venous ulceration
Copyright © 2009 by American College of Phlebology 8
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 9
Copyright © 2009 by American College of Phlebology 10
Venous Diseaseis a Hereditary Disorder
134 families were examinedThe 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 11
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
Copyright © 2009 by American College of Phlebology 12
The beginnings of venous disease may be found as early as childhood
740 pts10-12 y/o
518 pts14-16 y/o
459 pts18-20 y/o
Diagnosable Vein
disease2.5% 12.3% 19.8%
Actual Varicose
Veins0 1.7% 3.3%
Phlebologie. 1990 Nov-Dec;43(4):573-7. Weindorf N, Schultz-Ehrenburg U.
Copyright © 2009 by American College of Phlebology 13
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
Copyright © 2009 by American College of Phlebology 14
Varicose Veins are 3 times more common in women than men
"Varicose veins." The Mayo Clinic. January 2007. http://www.mayoclinic.com
Copyright © 2009 by American College of Phlebology 15
Each pregnancy worsens the condition
405 women with varicose veins13% had one pregnancy30% had two pregnancies57% 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 16
Copyright © 2009 by American College of Phlebology 17
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
Copyright © 2009 by American College of Phlebology 18
Illustration by Linda S. Nye
Copyright © 2009 by American College of Phlebology 19
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 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 inter-saphenous 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
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
Copyright © 2009 by American College of Phlebology 23
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
Copyright © 2009 by American College of Phlebology 24
Doppler exam: Normal flow
Illustration by Linda S. Nye
Copyright © 2009 by American College of Phlebology 25
Doppler: Reflux
Illustration by Linda S. Nye
Copyright © 2009 by American College of Phlebology 26
REFLUX: its contribution to varicose veins
Illustration by Linda S. Nye
Copyright © 2009 by American College of Phlebology 27
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
Copyright © 2009 by American College of Phlebology 28
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)
Copyright © 2009 by American College of Phlebology 29
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
Copyright © 2009 by American College of Phlebology 30
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 Goals of patient
Copyright © 2009 by American College of Phlebology 33
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
Copyright © 2009 by American College of Phlebology 34
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.
Copyright © 2009 by American College of Phlebology 35
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 36
Reticular Veins Enlarged, greenish-
blue appearing veins Frequently associated
with clusters of telangiectasias
May be symptomatic, especially in dependent areas of leg
Copyright © 2009 by American College of Phlebology 37
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 38
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
Copyright © 2009 by American College of Phlebology 39
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 40
Varicose Veins with Pelvic Origins
Begin during pregnancy Increased symptoms
during pre-menstrual period and after intercourse
May be associated with pelvic congestion syndrome
Copyright © 2009 by American College of Phlebology 41
Skin changes suggestive of chronic venous insufficiency
Corona Phlebectatica (C1)
Pigmentation (C4a)
Atrophie blanche (C4b)
Healed ulcer (C5)
Copyright © 2009 by American College of Phlebology 42
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
Copyright © 2009 by American College of Phlebology 43
Venous ulceration
Impending ulceration Lipodermatosclerosis (C4a)
Venous ulceration (C6)
Copyright © 2009 by American College of Phlebology 44
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 presentArterial ulcer
Photo courtesy of John Bergan, MD
Copyright © 2009 by American College of Phlebology 45
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
Copyright © 2009 by American College of Phlebology 46
Copyright © 2009 by American College of Phlebology 47
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 48
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.
Copyright © 2009 by American College of Phlebology 49
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 50
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
Copyright © 2009 by American College of Phlebology 51
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
Copyright © 2009 by American College of Phlebology 52
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 (ie: ankle-brachial index < 0.9)
Copyright © 2009 by American College of Phlebology 53
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
Copyright © 2009 by American College of Phlebology 54
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.
Copyright © 2009 by American College of Phlebology 55
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)
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 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
Copyright © 2009 by American College of Phlebology 57
Copyright © 2009 by American College of Phlebology 58
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
Copyright © 2009 by American College of Phlebology 59
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.
Copyright © 2009 by American College of Phlebology 60
Sclerotherapy of Telangiectasias: Technique
Injection of sclerosant solution causes damage to endothelium which leads to fibrosis of vein
Copyright © 2009 by American College of Phlebology 61
Sclerotherapy Results
Before AfterPhotos courtesy of Steven Zimmet, MD, FACPh
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
Copyright © 2009 by American College of Phlebology 63
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
Copyright © 2009 by American College of Phlebology 64
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.
Copyright © 2009 by American College of Phlebology 65
Sclerotherapy Results
Before After Ultrasound-guided sclerotherapy of the Great Saphenous Vein and sclerotherapy of branches
Photos courtesy of Steven Zimmet, MD, FACPh
Copyright © 2009 by American College of Phlebology 66
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
Copyright © 2009 by American College of Phlebology 67
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
Copyright © 2009 by American College of Phlebology 68
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
PhotoPhoto courtesy of John Bergan, MD
Copyright © 2009 by American College of Phlebology 69
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
Copyright © 2009 by American College of Phlebology 70
Treatment Results
Before After Endovenous obliteration of the Great Saphenous Vein and phlebectomy of tributariesPhotos courtesy of Steven Zimmet, MD, FACPh
Copyright © 2009 by American College of Phlebology 71
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
Copyright © 2009 by American College of Phlebology 72
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
Copyright © 2009 by American College of Phlebology 73
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
Copyright © 2009 by American College of Phlebology 74
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
Copyright © 2009 by American College of Phlebology 75
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
Copyright © 2009 by American College of Phlebology 76
THE FUNDAMENTALS OF
PHLEBOLOGY:Venous Disease for
Clinicians
THANK YOU FOR YOUR ATTENTION!