lower extremity venous disease: peripheral venous insufficiency aman k kakkar md facc heart and...
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Lower Extremity Venous Disease: Peripheral Venous
Insufficiency
Aman K Kakkar MD FACCHeart and Vascular Care, Inc
30 Million people suffer from venous reflux disease, the underlying cause for most varicose veins
Prevalence and Etiology of Venous Insufficiency
Annual U.S. Incidence
U.S. Prevalence
Millions
Venous reflux disease is 2x more prevalent than coronary heart disease (CHD) and 5x more prevalent than peripheral arterial disease (PAD)1
Prevalence of Venous Insufficiency
Age Female Male
20 - 29 8% 1%
40 - 49 41% 24%
60 - 69 72% 43%
Prevalence by Age and Gender3,4
Of the estimated 30 million people with symptomatic superficial venous reflux1 :
• Only 1.9 million seek treatment annually2
• Only 500K Patients receive treatment• Over 28 million go untreated
Venous System
Venous blood flows from the capillaries to the heart
Flow occurs against gravityMuscular compression of the
veins Negative intrathoracic pressureCalf muscle pump
Low flow, low pressure system
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.
Pathophysiology of Venous Insufficiency
Risk Factors and Symptoms of Venous Insufficiency
Risk factors of venous insufficiency:
• Gender
• Age
• Heredity
• Pregnancy
• Standing occupation
• Obesity
• Prior injury or surgery
• Sedentary lifestyle
Symptoms of venous insufficiency:
• Leg pain, aching, or cramping
• Burning or itching of the skin
• Leg or ankle swelling
• “Heavy” feeling in legs
• Skin discoloration or texture changes
• Open wounds or sores
• Restless legs
• Varicose Veins
20+ million 2 to 6 million
Skin Ulcers
500,000
Manifestations of Venous Insufficiency
Superficial 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 Legs Skin Changes Varicose Veins
PATHOPHYSIOLOGY
CEAP Classifications
Clinical Classifications of Venous Insufficiency (CEAP)
Class 0 - No visible or palpable signs of venous disease
Class 1 - Telangiectasias or reticular veins
Class 2 - Varicose veins
Class 3 - Edema
Class 4 - Skin changes (4a) Skin changes including pigmentation or venous eczema (4b) Skin changes with lipodermatosclerosis
Class 5 - Healed venous ulceration
Class 6 - Active venous ulceration
Great Saphenous Vein : The Culprit
American Venous Forum (AVF) Guidelines:
Diagnosis
Great Saphenous Vein (GSV) : Reflux
Small Saphenous Vein (SSV): Reflux
TREATMENT ALGORITHM
AVF Guidelines: Treatment
AVF Guidelines: Treatment
Vein Closure: Indications, Risks
Indication:
The Catheter ablation is intended for endovascular coagulation of blood vessels in patients with superficial venous reflux
Contraindications:
Patients with thrombus in the vein segment to be treated
Potential Risks & Complications:
Potential complications include, but are not limited to, the following: vessel perforation, thrombosis, pulmonary embolism, phlebitis, hematoma, infection, adjacent nerve injury, skin burns, deep vein thrombosis
Vein Closure: Options
Stripping
Foam Sclerotherapy
Radiofrequency Ablation
Laser Ablation
Overall Maximum Pain Score (0 none to 10 max)
RECOVERY Trial7: PainA Prospective, Multi-Center, Randomized Study
ClosureFAST Laser
p < 0.0001
2
4
RECOVERY Trial7: EcchymosisA Prospective, Multi-Center, Randomized Study
ClosureFAST Laser
p < 0.0001
Moderate to Severe Ecchymosis (Bruising) After TreatmentModerate to severe ecchymosis is defined as bruising over greater than 25% of the treated surface area
2.2%
51.3%
RadioFrequency Ablation The Radiofrequency Closure
System is a minimally invasive treatment alternative for patients with symptomatic superficial venous reflux and varicose veins
Using a catheter-based approach, catheter delivers radiofrequency (RF) energy to the vein wall
RF energy creates conductive heating that contracts the vein wall collagen, thereby occluding the vein
Procedure using the Radiofrequency Ablation Catheter
Procedure
SummaryEasily Diagnosed but vastly untreated
Although many aspects of treatment have remained the same for over a century
Recent advances have provided new and better treatment options for patients with chronic venous disease.