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Chronic Superficial Venous InsufficiencyDr. Amena YasminHonorary Medical OfficerDept. of SurgerySOMCH

Chronic Superficial Venous Insufficiency (CSVI)

occurs when the venous wall and/or valves in the superficial leg veins are not working effectively, making it difficult for blood to return to the heart from the legs.

Clinical hallmarks:

Distal venous hypertension, which follows the development of valvular incompetence, reflux, and/or venous obstruction.

At the cellular level there is abnormal metabolism of the connective tissue matrix of the vein wall with a marked increase in fibrous tissue and abnormal deposition of collagen in both the vein wall and the skin.

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Venous System

Superficial venous system Saphenous veins Lateral venous complex

Deep venous system

Perforating veins

Deep femoral v.Femoral v.Popliteal v.Small saphenous v.Great saphenous v.Perforating v.

Perforating v.Image source: Fundamentals of Phlebology: Venous Disease for Clinicians. Illustration by Linda S. Nye. American College of Phlebology 2004.Deep femoral v.Perforating v.

4Venous blood flows from the capillaries to the heartFlow occurs against gravityMuscular compression of the veins Negative intra thoracic pressureCalf muscle pumpLow flow, low pressure system

Perforating Veins and RefluxMaintain one-way flow from superficial to deep veins

Perforator valve failure causes:Higher venous pressure and GSV/branch dilationIncreasing pressure results in GSV valve failureAdditional vein branches become varicoseFurther GSV incompetence and dilation

5Notes: Perforator veins serve as connections between the two networks of veins in the extremities, the superficial venous system and the deep venous system, somewhat like the rungs of a ladder connect the side rails, and normally drain blood from the superficial veins to the deep veins as part of the process of returning oxygen-depleted blood to the heart. Perforator veins have one-way valves designed to prevent backflow of blood down towards the superficial veins. When those valves no longer function properly and reflux occurs, the buildup of blood and pressure can cause not only the superficial veins but the perforators themselves to become incompetent. Incompetence can cause varicose veins by transmitting the deep systems higher pressure into the lower pressure superficial veins Perforator veins in the lower leg and ankle are particularly vulnerable to distention and incompetence, and the resultant circulatory problems create an increased likelihood of edema, skin discoloration, dermatitis and skin ulcers in the immediate area.

Pathophysiology of Venous Insufficiency

6Notes: Healthy leg veins contain valves that open and close to assist the return of blood back to the heart Venous insufficiency or venous reflux disease develops when the valves that keep blood flowing out of the legs and back to the heart become damaged or diseased Venous insufficiency is the result of over-dilation of the venous vessels in the legs. This dilation eventually prevents the valve cusps from closing properly, resulting in reflux. The pooling of blood results in ineffective flow back to the heart. In some cases the reflux is caused not only by the over-dilation of the vessel wall, but also by damaged or absent valves. In this case, the valves have been so badly damaged, or degenerated, that they are almost nonexistent and no longer function To assess if venous reflux is present, a duplex ultrasound scan is performed

RISK FACTORS

Advancing ageFamily history of venous diseaseProlonged standingIncreased body mass indexSmokingSedentary lifestyle

RISK FACTORS contd.

Lower extremity traumaPrior venous thrombosis Arterio-venous shuntHigh estrogen statesPregnancy Ligamentous laxity ( hernia, flat fleet)

CEAP classification

an international consensus conference initiated the Clinical-Etiology-Anatomy-Pathophysiology classification.C: ClinicalE: EtiologyA: AnatomyP: Pathophysiology

CEAP classification cont.C 0 no evidence of venous disease.C 1 telangiectasias/reticular veins.C 2 varicose veins.C 3 edema associated with vein disease.C 4a pigmentation or eczema.C 4b lipodermatosclerosis.C 5 healed venous ulcer.C 6 active venous ulcer.

CEAP classification cont.E c congenitalE p primary venous disease.E s secondary venous disorder.E n not specified.

CEAP classification cont.

A s superficial veins.A d deep veins.A p perforating veins.A n not specified.

P r venous reflux.P o venous obstruction.P n not specified.

20+ million 2 to 6 millionSkin Ulcers500,000 Manifestations of Venous InsufficiencySuperficial venous reflux is progressive and if left untreated, may worsen over time. Below are manifestations of the disease.5

Photos courtesy of Rajabrata Sarkar, MD, PhD.Swollen LegsSkin Changes Varicose Veins

Systemic Reflux in Venous UlcerationIncompetent perforators found in 63% of venous ulcer patientsComprehensive care treats all sources of refluxPhotos courtesy of Steven A. Kaufman, MD.Sources of Reflux in Venous Ulcer Patients8 SuperficialPerforatingDeep79%63%50%

14Notes: Both Superficial and Perforator reflux are usually involved in venous ulceration. Valvular incompetence associated with venous ulceration can occur in the superficial, deep, or perforating systems. A duplex imaging was used to evaluate 95 extremities (78 patients) with current venous ulceration to determine the location of incompetence in each extremity. 63% of the 95 extremities in the study experienced incompetence in the perforating systems: 8.4% in perforating system only 19% in perforating system + superficial system 4.2% in perforating system + deep system 31.6% in perforating system + deep system + superficial system(Source: Hanrahn L. et al. Distribution of valvular incompetence in patients with venous stasis ulceration. JVS 13,6, 805-812 June 1991)

Skin Changes at CSVIGravitational dermatitis

Hyperpigmentation

Lipodermatosclerosis

LipodermatosclerosisThere is a proliferation of the dermal capillaries and fibrosis on subcutaneous tissueIt is a combination of:indurationpigmentationinflammation

Venous UlcerClinical Findings:

Inner aspect of the distal third of the leg (commonly the pressure areas)

Shape - rounded, elongated or very large like a cuff (so-called gaiter ulcer) Base - flat, covered with fibrous sloughMargins - sharp or rolled

Venous ulcers are approximately 80% of all leg ulcerations and they are also known to have the highest recurring rates.Venous ulcers are not generally as painful, do not lead to amputation, do not require surgical intervention as often as ulcers caused by arterial insufficiency.

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CLINICAL CHARACTERISTIC

1. Venous ulcers are usually located over the medial malleolus where the long saphenous vein is more superficial and the pressure is greatest.2. Trauma or infection may localize ulcers more proximal or laterally. Ulcers above the mid calf or on the foot commonly suggest another cause.3. Venous ulcers are shallow, they generally have borders with irregular margins that are either flat or with a slight steep elevation. The ulcer bed is covered initially by yellow fibrinous slough. Healing is very slow, often from months to years.

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Diagnostic Evaluation Level 1 : history and clinical examination.

Level 2 : non-invasive vascular laboratory testing which now routinely include Duplex color scanning.

Level 3 : invasive investigations or more complex imaging studies including ascending and descending venography, Varicography, venous pressure measurements, magnetic resonance imaging.

CONSIDER A BIOPSY TO EVALUATE FOR POSSIBLE MALIGNANCY VS INFECTIOUS OR INFLAMMATORY PROCESS

VENOUS DOPPLER ULTRASOUND Evaluate for deep and superficial venous thrombosis. Evaluate for incompetent veins with significant reflux disease. Evaluate for incompetent perforating veins and tributaries.

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Venous reflux

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Greater saphoneous vein with reflux21

Management of Venous Stasis UlcersDressings -Occlusive dressings -Low adherent gauze dressings

Surgical debridement used to remove devitalized tissue.

Enzymatic agents used to break down necrotic tissue (Santyl).

Occlusive dressings . It stimulates collagen synthesis, angiogenesis and speeds re epithelialization. (impermeable to gases and liquids) or semi-impermeable (impermeable to liquids and partially permeable to gases and water vapor). It stimulates collagen synthesis, angiogenesis, and speeds reepithelialization.

Low adherent gauze dressings frequent changes but inexpensive.

-Hydrogels and alginate dressings are highly absorbent to handle heavily exudative ulcers, while hydrocolloids can help with wound debridement and skin protection.

-Silver can be incorporated if the ulcer is infected. 4.

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MANAGEMENT contd.Growth factors synthesized by many cell types such as platelets, neutrophils, and epithelial cells (e.g. Regranex).

Bioengineered tissue used for a variety of non-healing ulcers(e.g. Apligraf, Dermagraft).

Skin grafting an option for non-healing ulcers.

management of chronic superficial venous insufficiency

Conservative treatmentVein ablation treatmentsSurgical procedure

1. Conservative Treatment

Avoiding long periods of standingWhile sitting, legs should be above the thighAvoiding crossing legsIdeal body weightWalking programmeCompression therapyMicronised purified flavonoid fraction (diosmin+ hesperidin)

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Compression therapy- elastic compression bandages- compression stockings - Pneumatic compression therapy

The primary aims of graduated compression management ( from the toes to the knee) are:

-to reduce the pressure on the superficial venous system-to aid venous return of blood to the heart-to discourage oedema by reducing the pressure difference between the capillaries and the tissues

- avoid contraindications such as cellulitis or significant arterial occlusive disease.26

- Sclerotherapy

- Foam sclerotherapy (USG guided)2. Vein ablation treatments

DETERGENT AGENTS - Sodium tetradecyl sulfate - PolidocanolOSMOTIC AGENTS - Hypertonic saline - GlycerinThese substances cause endothelial damage by their actions as either osmotic or detergent agents. Osmotic agents achieve their effect by dehydrating endothelial cells through osmosis. Detergents are surface active agents which damage the endothelium by interfering with cell membrane lipids. 8.

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Alternative techniques

Radiofrequency ablation Endovenous laser ablation therapy.

Indications

Persistent signs/symptoms of venous disease after a minimum of 3 months of medical therapy Documented reflux (e.g. >0.5 seconds of reflux GSV).

Absolute contraindications acute DVT or phlebitis and pregnancy.

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Radiofrequency ablation

Radiofrequency devices generate a high frequency alternating current for which the energy heats the adjacent vein walls to the probe which alters the protein structure of the vein effecting its closure.

Superficial veins include Great Saphenous Vein, Small Saphenous, and incompetent perforator veins.

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Endovenous laser ablation therapyLasers emit a single, coherent wavelength of light. Laser therapy of venous structures is based upon the concept of photothermolysis. Vein wall injury is mediated directly by absorption of photon energy by the vein wall and indirectly by thermal convection from heated blood.

Superficial veins include Great Saphenous Vein, Small Saphenous Vein, incompetent perforator veins, telangiectasias and reticular veins. 6.

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ENDOVENOUS LASER ABLATION THERAPY

Endovenous RF ablation

3. Surgical optionsSapheno-femoral/ sapheno-popliteal flush ligationVenous strippingMultiple phelebectomiesLigation of the perforators

Sapheno-femoralflush ligationVenous stripping

SFJ is identified after giving a groin incision lateral to pubic tubercle.LSV tributaries are ligated and dividedA flush SFJ ligation is then performed LSV retrogradely stripped to the kneeTributaries of varicocities then avulsed through small incisions

The sapheno-femoral junction, where all thetributaries have been ligated.

Sutured small groin incision

Stripper passed from groin to upper leg.

Graduated compression stockings or bandages are worn day & night for 7-10days; thereafter they are worn only during day for one monthPatient should sit with his feet elevated Patient should return to work and driving within 10days of surgerySwimming and cycling are allowed after dressing have been removedPost-operative care

37Notes: Following the VNUS Closure procedure, patients can resume normal activities within one to two days compared to the postoperative convalescence of two or more weeks commonly experienced following traditional vein stripping By addressing the underlying condition of venous reflux disease, the appearance of the legs may improve following the VNUS Closure procedure After the VNUS Closure procedure, patient symptoms can improve quickly and cosmetic issues become easier to address The Closure procedure is also widely covered by Medicare and most private insurance plans

Venous Ulcer Patient OutcomesTreating the underlying cause of venous ulceration results in improved clinical outcomes

Treating both the superficial and perforator hypertension results in:Faster ulcer healing timeLower ulcer recurrence ratethan with compression therapy alone9,10

38Notes: Sources:Jamie R Barwell, Colin E Davies, Comparison of surgery and compression with compression alone in chronic venous ulceration (ESCHAR study): randomized controlled trial,THE LANCET, Vol 363, June 04Nelzen O. Fransson I. True long-term healing and recurrence of venous leg ulcers following SEPS combined with superficial venous surgery: a prospective study. Eur J Vasc Endovasc Surg 34, 605-612 (2007)

ComplicationEczema UlcersBleedingThrombophlebitisDVT

PreventionWeight controlAdequate physical exerciseAvoidance of smokingAvoidance of sedentary activitiesControl of hypertensionModification of profession

Certain factors such as genetic predisposition , genetc and increasing age are unavoidable.

May all be significant in preventing the development of varicose veins.40

ReferencesAmerican Heart Association, SIR, Brand et al. The Epidemiology of Varicose Veins: The Framingham StudyUS Markets for Varicose Vein Treatment Devices 2006, Millennium Research Group 2005. Coon WW, Willis PW, Keller JB: Venous thromboembolism and other venous disease in the Tecumseh Community Health Study Circulation 1973; 48:839-846. Barron HC, Ross BA. Varicose Veins: A guide to prevention and treatment. NY, NY: Facts on File, Inc. [An Infobase Holdings Company]; 1995;vii. White JV, Ryjewski C. Chronic venous insufficiency. Perspect Vasc Surg Endovasc Ther 2005;17:319-27Dietzek A, Two-Year Follow-Up Data From A Prospective, Multicenter Study Of The Efficacy Of The ClosureFAST Catheter, 35th Annual Veith Symposium. November 19, 2008. New York.Alameida JI. Lessons Learned After 2000 Endovenous Ablations. 34th Veith Symposium. Nov 14-18, 2007. New YorkHanrahn L. et al. Distribution of valvular incompetence in patients with venous stasis ulceration. JVS 13,6, 805-812 June 1991Jamie R Barwell, Colin E Davies, Comparison of surgery and compression with compression alone in chronic venous ulceration (ESCHAR study): randomized controlled trial,THE LANCET, Vol 363, June 04Nelzen O. Fransson I. True long-term healing and recurrence of venous leg ulcers following SEPS combined with superficial venous surgery: a prospective study. Eur J Vasc Endovasc Surg 34, 605-612 (2007)

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