Chronic Venous Disease:
A Complex Disorder
A N Nicolaides
Emeritus Professor of Vascular Surgery, Imperial College,
London.
Hon. Professor of Surgery, University of Nicosia Medical School,
Cyprus
Disclosures
Honoraria for lectures received from:
Covidien / Medronic
Alpha Wasserman / AlphaSigma
Servier
Pierre Fabre
Why is it a Complex Disorder?
Complex Symptoms and Signs
Complex Pathophysiology
Complex Haemodynamics
A better understanding of these complexities should
better equip the clinician to manage patients with CVD
Complex skills are required
Why is it a Complex Disorder?
Complex of Symptoms and Signs
Complex Pathophysiology
Complex Haemodynamics
A better understanding of these complexities should
better equip the clinician to manage patients with CVD
Complex skills are required
Chronic venous disease-related
symptoms and signs
Symptoms1
Heaviness, Pain, Sensation of swelling,Restless legs,Paresthesias,Night-time cramps, Tiredness,Throbbing,Itching.
Signs2
C0s: NoneC1: Telangiectasia, reticular veins C2: Varicose veinsC3: EdemaC4: Skin changes: (a) pigmentation, eczema, (b) lipodermatosclerosis, atrophie blancheC5: Healed Venous ulcer C6: Active Venous ulcer
1. Garde C et al. Phlebolymphology 2005; 49: 384-396; 2. Porter et al. J Vasc Surg 1995; 21: 635-645.
Symptoms and signs
Symptoms are not specific of CVD
There is poor correlation between Symptoms and Signs:
Advanced CEAP class can be present without symptoms
and in C0s signs are absent in the presence of severe
symptoms
Scoring systems such as VCSS devote only 3 marks out
of 30 for symptoms and 27 marks for signs
SymVein Publication
The SymVein publication has changed our approach to the
assessment and management of CVD
Definition of venous symptoms
Explanation of Pathophysiology of symptoms
Attribution of symptoms to CVD
Recommendations about scoring of symptoms
Investigations needed
Why is it a Complex Disorder?
Complex of Symptoms and Signs
Complex Pathophysiology
Complex Haemodynamics
A better understanding of these complexities should
better equip the clinician to manage patients with CVD
Complex skills are required
Primary Varicose veins (VVs)
Common disorder
VVs present in 14-35% of the population
40% of venous leg ulcers are the result of longstanding
VVs in the presence of normal deep veins
Progressive
Prevalence and severity increase with age
Leukocyte-endothelium interaction:
a key role primary CVD
Environmental and local factors plus genetic predisposition
Chronic inflammatory
processes
Leukocyte-endothelium interaction
Remodeling in venous wall, and venous valves
REFLUX and HYPERTENSION
Adapted from Eberhardt RT, Raffetto JD. Circulation. 2005; 111:2398-2409
Progression of
chronic venous disease
Valve damage
Reflux Varicose Veins (C2)
Vein wall remodeling
Capillary damage
Capillary leakage
Edema (C3) Skin Changes (C4)
Venous Ulcer (C5,6)
Symptoms Symptoms Symptoms Symptoms
HYPERTENSION
MACROcirculation MICROcirculation
C0s
Adapted from Eberhardt RT, Raffetto JD. Circulation. 2005; 111:2398-2409
Why is it a Complex Disorder?
Complex of Symptoms and Signs
Complex Pathophysiology
Complex Haemodynamics
A better understanding of these complexities should
better equip the clinician to manage patients with CVD
Complex skills are required
Painful Leg Ulcer
Reflux: Volume Flow
739/60 =
12 ml/sec
Ambulatory venous pressure (AVP) –a global hemodynamic test
VFT, s
% pressure drop
All reflux is not equal
Marston WA et al. J Vasc Surg 2008;48:400-6
Post-thrombotic Syndrome
60% of venous ulcers are due to previous DVT
Etiology
1. Obstruction (failure of recanalization) and recurrent DVT
2. Reflux (damage to valves)
3. Combination of reflux and obstrucion
Post-thrombotic Syndrome
Predisposing factors to skin changes and ulceration
1. Persisting proximal obstruction
2. Axial reflux
3. Reflux > 5ml per sec
4. Combined obstruction and severe reflux
5. Recurrent DVT (obstruction of collaterals)
6. Increasing age
7. Obesity
8. Poor compliance to therapy
Ulcer Prevalence vs. AVP
Venous Hypertension and Protective Mechanisms
Ability of lymphatic drainage to increase 5 times in some
individuals but only 2 times in others (zero in patients with
lymphedema)
Variable fibrinolytic activity in blood and tissues.
For patients having moderately raised AVP 35-65
If fibrinolytic activity is low: 90% develop skin changes
and 70% ulcer
If fibrinolytic activity is normal-high: 16% develop ulcer
Whawell SA et al, Br J Surg 1989;76
:
Combination of Duplex and VFI
Clinical severity class N VFI P
0 Asymptomatic 34 1.6 ± 1.6 -------
1 Mild CVI (ache & swelling) 42 2.3 ± 1.7 < 0.05
2 Moderate CVI (skin changes) 11 8.0 ± 5.6 < 0.05
3 Severe CVI (Ulceration) 31 8.5 ± 5.2 < 0.001
“The combination of VFI and duplex scanning (multisegment score) not
only localized the reflux, but also separated severe clinical disease from
mild with high sensitivity (83%) and high specificity (86%)”
Neglen and Raju 1993:17:590-5
Venous Obstruction
Value of imaging techniques and outflow resistance (R)
Venous obstruction
The degree at which a venous stenosis is critical is not known
This is because outflow resistance for the limb depends on
how well developed is the collateral circulation
A reliable non-invasive test to grade stenosis is not available
Best method for local grading of stenosis is IVUS
Global effect of obstruction is provided by Outflow Resistance (R)
Note: Because R is not measured, current practice of stenting relies
on assessment of local stenosis. Only 50-60% of patients
improve suggesting that many are stented unnecessarily
Labropoulos et al, Arch Surg 1997;132:46-51
Simultaneous Pressure and Volume Measurements
Simultaneous Pressure and Volume Recordings
R = P/Q
mmHg/ml/min
26 Limbs with CVD
Conclusions1. Duplex provides information on presence or absence and anatomic
extent of reflux or obstruction
2. If quantitative information is needed (how much reflux or how much
obstruction there is) for clinical decisions, duplex should be complimented
by plethysmography
3. R should be measured before and after stenting so that eventually we can
correlate the baseline R with those that derive clinical benefit. This should
provide a better selection of patients for stenting
C0s
Prevalence of C0s and significance
The presence of symptoms in the absence of signs (C0s)
are very common
In the Bonn Vein Study 50% of 1800 participants reported such
symptoms
In the worldwide Vein Consult Program 20% of the symptomatic
screened subjects presented with C0s
Prevalence of C0s and significance
In a recent study of 41 C0s patients with normal duplex in the
morning, 26 (63%) had reflux in the evening with increased GSV
diameter (Tsoukanov Y. 2005)
In the Basel longitudinal study, C0s individuals progressed to
develop overt edema when seen 11 years later
The majority of C0s patients improve with compression or VAD
CVD: Conclusion
Complex of Symptoms and Signs
Complex Pathophysiology
Complex Haemodynamics
A better understanding of these complexities should
better equip the clinician to manage patients with CVD
We may have to change our methods of investigation
Complex skills are required
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