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Hello! My name is Sherry Scovell and I am a vascular surgeon at the Department of Vascular and Endovascular Surgery at Beth Israel Deaconess Medical Center in Boston, Massachusetts, and today I would like to speak with you on venous insufficiency and its effects on the lower extremity.
Production of this PRESENT lecture was made possible by a generous grant from SIGVARIS Inc., a world leader in medical compression therapy for veno-lymphatic disorders. At the completion of this lecture, stay tuned for a short presentation by SIGVARIS.
It is always best to begin by reviewing lower extremity anatomy. The lower extremity venous anatomy is comprised of a deep venous system, as well as a superficial venous system and these systems run in parallel. They are connected by perforating veins.
With respect to the deep venous system, it parallels the arteries. There are femoral veins and popliteal veins, as well as posterior tibial veins in the lower extremity. With respect to the superficial venous system, this is comprised of a greater and lesser saphenous veins and they are situated right under the skin. The perforating veins, as mentioned before, serve to connect the deep and the superficial systems.
Once again in the deep venous system, there is the common femoral vein, the superficial femoral vein, the profunda femoris vein, as well as the popliteal vein, and paired posterior tibial and peroneal veins, all paralleling the arteries of the lower extremity.
With respect to the superficial venous system, the greater saphenous vein, which begins just anterior to the medial malleolus and runs up to medial aspect of the leg, there are five branches that are preserved and consistent in the groin. This vein connects to the deep venous system at the foramen ovale and drains into the deep venous system at the common femoral vein. With respect to the lesser saphenous vein, this vein runs up to the posterior aspect of the calf. It drains into the deep venous system at the popliteal fossa and enters the deep venous system at the popliteal vein.
The perforating veins serve to connect the deep and superficial venous systems. They do, however, have unidirectional flow with valves similar to other veins and the flow is directed from the superficial into the deep venous systems. These perforating veins are usually constant in their location.
Now that we have reviewed the anatomy of the lower extremity veins, we would like to move on to the pathology of venous disease.
There are two main etiologies of the venous disease, the first of which is valve incompetence where the small valves within the veins weaken and cease to function. The second etiology of venous disease is obstruction, which is represented by thrombus or blood clot, which develops within the vein.
In order to best treat our patients with venous disease, there is a clinical classification system. The patients are divided based upon symptoms. A Class 0 patient is asymptomatic. A class 1 patient has spider veins or small reticular veins, class 2 patient has varicose veins, class 3 has associated edema, class 4 has skin changes such as hyperpigmentation, class 5 has evidence of healed ulceration, and class 6 represent the patient with an active venous ulceration.
Let us begin with CEAP classification on spider and reticular veins.
These veins are the most superficial in the venous network and they lie within the dermal space. They are the subcutaneous varicosities. Quite similar to larger veins, they also have valves and they arise secondary to increased hydrodynamic pressure.
Although patients may present with some itching and some pain referable to these veins, the treatment is typically for cosmetic reasons and it involves injection sclerotherapy. The goals of sclerotherapy are to thrombose and therefore fibrose or both leading to the obliteration of these small varicosities.
There are many agents that are used for injection sclerotherapy and they range from the strong for larger veins to weak for the smaller spider veins. Hypertonic saline has been used as has sodium morrhuate, as well as sodium tetradecyl sulfate and numerous others.
As these substances are injected into the venous system, there are several side effects. Anaphylaxis is clearly one of the most severe but very uncommon. Epidermal necrosis may occur but is uncommon as well. Allergic reactions do occur more frequently, as does the postsclerotherapy hyperpigmentation. However, as a general rule, the lower
the concentration of the injectant, the less the side effects.
Moving on to CEAP classification two, we will now discuss varicose veins.
Varicose veins are large bulging veins and they may be seen in the distribution of the superficial venous system, the greater saphenous vein or the lesser saphenous vein or small accessory veins as seen here. These veins are associated with pain most typically, aching and tiredness of the leg, swelling, or recurrent episodes of thrombophlebitis.
When evaluating the patient with varicose veins, it is important to determine the site of the reflux. Often patients may have reflux in the deep venous system, some clearly have reflux in the superficial venous system, and reflux as well may be seen in the perforators as they do have valves that become incompetent. It is important also to rule out deep venous obstruction in your workup of patients with varicose veins. One of the most important things to remember is that the superficial venous system should never be removed if the deep venous system is occluded.
The best way to determine the site of reflux is with a noninvasive duplex examination or ultrasound of the venous system. This serves to both rule out DVT. It may define reflux in the deep venous system and it also defines reflux in the superficial venous system.
In a venous duplex examination, the arteries and veins are interrogated with ultrasound. These arteries and veins are then compressed. When compressed, the artery remains
patent. When compressed, a normal vein without thrombus will compress easily and completely as seen here.
As mentioned previously, the duplex examination may also demonstrate reflux. Here is an example of a left greater saphenous vein demonstrating reflux with compression of the calf. This indicates incompetent valves.
Primarily, the treatment for varicose veins begins with compression stockings. Typically, 20- to 30-mmHg is an adequate amount of compression initially. If compression stockings fail, interventional or surgical management is appropriate at that time.
With respect to the interventional management of varicose veins, if the greater saphenous vein is found to be incompetent, it may be ablated with either radiofrequency ablation or the venous procedure or laser ablation. It may also be removed by stripping and ligation in a surgical setting. However, if the greater saphenous vein is not found to be incompetent, stab avulsion removal of these accessory varicosities may provide symptomatic relief. This is also done in the operating room through small incisions.
One of the complications of having varicose veins is that sometimes they may become inflamed.
This patient has superficial thrombophlebitis of the greater saphenous vein. This is an inflammatory process in the superficial veins. It is diagnosed easily with physical examination, as there is erythema over the distribution of a superficial vein and often a palpable cord may be felt. The treatment is simply NSAIDs and warm compresses. Antibiotics are not needed.
Occasionally, the patients may develop recurrent episodes of superficial thrombophlebitis. This is termed thrombophlebitis migrans and it has been associated with visceral malignancies such as pancreatic carcinoma.
A more critical aspect of the venous disease is chronic venous insufficiency.
Chronic venous insufficiency may be quite morbid. The etiology may be primary and approximately 30% of patients secondary to their congenital problems, vascular malformations, or Klippel-Trenaunay Syndrome. The etiology may also be secondary in approximately 70% of patients and this is likely due to post-thrombotic valvular reflux.
However, whatever the etiology may be for the venous disease, the valves do not function correctly and this leads to venous reflux and ambulatory venous hypertension.
What happens in the patients with venous hypertension? They develop this classic picture as seen here. There is hyperpigmentation, brawny edema, lipodermatosclerosis, and this is all occurring in the gaiter distribution around the ankle where the venous hypertension is the greatest.
If the venous hypertension remains untreated, ultimately venous ulceration may develop. Venous ulcerations are characteristic as they are always in the gaiter distribution and they have a beefy red granulating ulcer base with irregular borders. They tend to bleed readily upon debridement.
Venous ulcerations have a typical appearance and are quite different when compared to the arterial ulcerations. The patient on the left has a venous ulceration. As you can see, the foot is quite ruborous. The ulcer has an irregular borders and a beefy red granulation base. It bleeds briskly upon debridement. It is in the gaiter distribution around the ankle where the venous hypertension is the greatest. The patient on the right side has an arterial ulceration. These are classically further out on the foot and they have a pale base. They may have associated gangrene and they do not bleed readily upon debridement. The patientâs with venous disease typically have briskly palpable pulses; all those with arterial ulceration do not have palpable pulses.
It is important in the workup of the patients with chronic venous insufficiency to confirm your diagnosis of reflux and to quantify the degree of reflux. It is also important to detect any associated obstruction that may need to be treated such as DVT. The etiology should be identified as to whether this is primary or secondary and there should be some type of evaluation of the status of the lymphatic system.
This may be accomplished with the duplex ultrasound again. This is the initial diagnostic test of choice and it is noninvasive. It can again demonstrate the presence, location, and extent of the reflux and measure valve closure times.
Very rarely is an invasive procedure such as venography indicated. When is venography necessary? Only if conservative management fails and surgical correction of chronic venous insufficiency is contemplated. In this case, both ascending and descending venography is necessary. Ascending venography delineates any evidence of obstruction and descending venography delineates any evidence of reflux.
When evaluating the patient with chronic venous insufficiency, there are many disorders that may be confused with chronic venous insufficiency. Some of these are listed below and include restless leg syndrome, idiopathic calf cramps, lymphedema, and vasculitis, as well as numerous others.
Treatment of these patients again begins with conservative management, the goals of which are to promote healing of the ulcers, to prevent recurrence, and to allow the patient to have a functional and ambulatory life.
The patient must first be assessed for any presence of infection. If infection is present, it should be treated with antibiotics and local wound care. Topical agents should be avoided. The patient must also be assessed for the extent of the edema and if there is massive leg edema, a period of bed rest with leg elevation is required.
Conservative management begins with compression therapy, which is the Gold Standard. Gradient ambulatory compression elastic stockings are used. Typically for ulceration 30 to 40 mmHg is required. The patient should wear these stockings at all times while ambulatory. They should put them on when they get up in the morning and they may remove them before bedtime. The main problem, however, with compression stockings is the patient compliance. They are quite difficult to place, especially in the elderly patients.
There are, however, several tricks and hints that you may give to your patients to make them more compliant. Sometimes using a lesser degree of compression such as 20 to 30 mmHg to begin with or wearing the stockings for shorter periods of time initially may be helpful. They can gradually be increased as tolerance to these tight stockings increases. Using silk booties or yellow dishwashing gloves may also help the elderly apply the stockings.
There is, however, one major contraindication to elastic compression stockings and that is arterial insufficiency. If you see a patient with an ulceration and you believe there is a combination of both arterial and venous insufficiency, arterial revascularization in general should be pursued first.
Another method of conservative management is the Unna boot. These are paste gauze compression dressings. They provide both compression and topical therapy. These bandages contain calamine, zinc oxide, glycerin, sorbitol, gelatin, and magnesium aluminum silicate. They are applied by medical personnel and changed weekly. The major advantage to this dressing is minimal patient compliance is required since they are placed and changed weekly in the physicianâs office.
There are also several other adjunctive compression devices. These provide external compression and sometimes sequential gradient intermittent pneumatic compression. These are applied for 45-minute sessions 5 days a week and are quite helpful in patients with lymphedema. Between treatments, elastic compression wraps and wet-to-dry dressings may be used.
There is some data to suggest that pharmacologic therapy may be beneficial. Trental may be begun for its hemorheologic effects. It also reduces white blood cell adhesiveness and inhibits Cytokine-Mediated neutrophil activation. It reduces the release of superoxide free radicals as well. Some people believe that there may be a zinc deficiency in chronic venous insufficiency patients and that zinc might be helpful, and less commonly, prostaglandins are given intravenously.
A major cause of morbidity or mortality in patients with venous disease is deep venous thrombosis.
Deep venous thrombosis often arises when the components of Virchow Triad are present. These include venous statis, endothelial injury, and a hypercoagulable state.
The patientâs with deep venous thrombosis may be asymptomatic. They may have associated aching pain. This pain is typically exacerbated by activity and alleviated with elevation of the leg. There is often unilateral edema in these patients. It is important to remember that the patientâs bilateral lower extremity edema is unlikely to be secondary to DVT. It is more often secondary to systemic issues like congestive heart failure or less commonly IVC obstruction.
The patients with DVT often present with edema. Edema that is pitting suggests that the swelling is reversible and recent.
So who are those patients at high risk for DVT? There are host of risk factors listed here including increased blood coagulability, decreased fibrinolytic activity, immobility such as those patients following major operations such as orthopedic or neurosurgery procedures and abdominal operations, those patients with malignancy or heart failure are at increased risk, if there is a history of DVT in postpartum women or in women who are on oral contraceptives, definitely long airplane, bus, or auto trips where the patients are sitting for long periods of time are risk factors, as well as hypercoagulable states.
The diagnosis of DVT again is best made by the duplex examination, which is a noninvasive examination. It serves to precisely define the location of the clot. It is often able to define the characteristics of the clot regarding the age and chronicity and it can detect recanalization in a chronic DVT.
Once again, here we see a normal duplex examination with and without compression. We see that the right common femoral vein is patent without compression and then occluded with compression.
In a patient with DVT, the duplex examination will demonstrate an absence of flow within the vein and an inability to compress the vein completely.
As seen here in a patient with DVT, the vein will not collapse with compression.
As mentioned previously, venography is not typically necessary and it is an invasive examination. It is more difficult to perform and to evaluate when compared to the duplex examination and there is an associated complication of thrombophlebitis in approximately 10% of the patients.
The treatment of DVT begins with anticoagulation, initially using heparin or heparin derivative such as Lovenox. The patient is then converted to an oral anticoagulant such as Coumadin for 3 to 6 months. This anticoagulation is primarily to prevent the complication of pulmonary embolus, as well as to prevent propagation of the clot. However, some patients have a contraindication to anticoagulation, and in this case, it is important to place an IVC filter.
With respect to IVC filters, there are permanent or temporary filters that are both available. These tiny filters are placed in the inferior vena cava below the level of the renal veins. They serve as a mechanism to catch the clot coming from the lower extremity veins and they serve to prevent the dreaded complication of pulmonary embolus.
The dreaded complication of venous gangrene occurs when venous disease is out of control. Phlegmasia Alba Dolens occurs first. This presents as a white painful leg. There is diffuse swelling of the entire leg and pallor. There is moderate pain with this condition and it is indicative of complete iliofemoral venous thrombosis.
The treatment of Phlegmasia Alba Dolens is heparinization and elevation of the leg.
Occasionally in this situation, the leg may become worse. This is Phlegmasia Cerulea Dolens, which is represented by a painful blue leg. There is a deep cyanosis and the leg is severely swollen. It is extremely painful for the patient. This occurs when the majority of both the deep and the superficial veins are filled with thrombus, and because of the extensive swelling, there may actually be the comprise of the arterial circulation at this point and what we term as venous gangrene.
This condition is quite ominous and may require venous thrombectomy. Certainly, systemic heparinization should be immediately initiated. Even with surgical thrombectomy, the patency rates are extremely low and there is an extremely high rate of amputation.
In conclusion, venous disease affects a wide range of patients and the clinical features of each of these patients are specific and distinct. The clinical scenarios range from cosmetic to limb threatening issues and the
treatment will vary widely based upon the CEAP classification, which should be used in all of your patients.
Production of this PRESENT lecture was made possible by a generous grant from SIGVARIS Inc., a world leader in medical compression therapy for veno-lymphatic disorders. Stay tuned for a short presentation by SIGVARIS.
SIGVARIS medical compression socks and stockings are designed to work with the bodyâs venous flow and to help push the blood up the legs. They exert the greatest pressure at the ankle, with compression gradually decreasing in the direction of the knee and thigh. SIGVARIS medical compression socks and stockings supports distended veins, prevents blood from pooling in the leg veins, speeds up sluggish blood flow, forces fluid out of the swollen legs and ankles and back into circulation, and are versatile, comfortable, and attractive. The medical effectiveness of the SIGVARIS medical compression socks and stockings has been proven in over 120 medical studies, more than any other brand.
Physicians recommend SIGVARIS products for the purposes of basic treatment, decongestion, slowing down the prognosis of venous disease, assuring successful treatment after vein surgery, phlebectomy and sclerotherapy, prophylaxis of thrombosis, and prevention of trophic disturbances.
SIGVARIS medical compression socks and stockings come in five different compression levels and depending on the diagnosis, physicians can recommend 15 to 20 mmHg, which is for prevention and for patients who suffer from tired, aching legs or swollen ankles at the end of the day. A 20 to 30 mmHg which is for mild varicosities with minimal edema, postsclerotherapy of small veins, and mild varicosities during pregnancy. A 30 to 40 mmHg, which is for moderate to severe varicosities, severe edema, use after sclerotherapy or vein surgery of the large veins, primary venous leg ulcer treatment, post DVT, and for orthostatic/postural hypotension. A 40 to 50 mmHg which is for severe varicosities, severe edema, CEAP classification 4 through 6, and for recurrent venous ulceration, and finally, a 50 to 60 mmHg which is for primary lymphedema after decongestant therapy and severe postthrombotic syndrome.
For successful treatment with the use of medical compression socks and stockings, the patientâs compliance is a must. Without patient compliance, there will not be a successful patient outcome. SIGVARIS has designed its socks and stockings such that patients can chose from many different fabrics and colors. Products are designed with high bi-directional stretch so that patients find SIGVARIS products easier to put on than other brands. SIGVARIS also has cotton products for patients who have sensitive skin or who live in the hot, humid regions. To learn more about SIGVARIS products, go to www.sigvaris.com or call 1-800-322-7744.