Chronic Venous InsufficiencyThe Challenge of Edema

S. Lakhanpal MD, FACSPresident & CEO

Center for Vein Restoration

Case Presentation

• 67 year old male• Presents with Left Calf Ulceration

• Duration: 2 months• Associated Symptoms

• Pain and Heaviness left leg• Cramps• Itching

• PMH:• Arthritis, GERD, Gout, Hypertension• Right knee Surgery• Ex Smoker

• Meds:• Atenolol, Omeprazole, Nortriptyline, Allopurinol, Lasix,

Oxycodone

Physical Findings

• Left leg Ulcer – lateral and posterior calf

• Hyperpigmentation

• Pitting Edema lower leg

Images

Images

The Challenge of Edema

• Chronic Unilateral edema if trauma and malignant obstruction is ruled out is invariably due to venous insufficiency

• Acute onset edema U/L or B/L is not due to ‘chronic’ venous insufficiency

• For chronic B/L edema first document the presence of significant reflux, and the exclude systemic causes (cardiac, renal, hepatic, abdominal malignancies, thyroid disorders, sleep apnea and medications causing edema )

• Despite all the testing it remains a close call• Try treatment on one side and reassess?

Edema: Salient Features

• The most common cause of leg edema in adults over 50 is venous insufficiency

• The most common cause in women between menarche and menopause is idiopathic edema, formerly known as “cyclic” edema

• A common but under-recognized cause of edema is pulmonary hypertension, which is often associated with sleep apnea

Duplex Evaluation

• Ultrasound evaluation in office

• Left Leg:• Reflux present in greater saphenous vein

• No evidence of DVT

Duplex Ultrasound Evaluation

Lt gsv

Management

• Multidisciplinary approach

• Wound Care

• Management of Venous Insufficiency

• Lymphedema management

Minimally Invasive Procedures

• Radiofrequency – Heating element in contact with the vein wall: endothelium denudation, collagen contraction, vein shrinkage and fibrosis

• Laser – Hemoglobin is the chromosphere. Steam bubble injures the endothelium. Non thrombotic occlusion

• Sclerosants – Detergents with removal of endothelium and damage of the media

What is Lymphedema?

• Fluid accumulation in a limb• Due to an impairment in the

lymphatic system

• Functions of lymphatic system:– Immunological function-

lymphocytes break down bacteria

– Intestinal lymph vessels absorb fat

– To transport lymph fluid from the interstitium to the cardiovascular system• Lymph fluid = water,

protein, larger molecules

Lymphedema and Phlebopathies

Four ways his can occur:

1. Developmental defect lymphedema

accompanied by valveless veins

2. Every kind of lymphedema causes pathological changes in blood vessels

LE lymphedema impaired ambulatory venous function mild venous insufficiency

3. Late stage CVI combination form of lymphedema

4. Phlebectomies in a patient with lymphedema can cause it to worsen

Phlebolymphedema

The accumulation of fluid in the interstitial tissue that is caused by a

combination of venous and lymphatic disorders.

• Phase I (Intensive)

– Manual Lymph Drainage– Compression Bandaging– Exercise– Skin & Nail Care– Instruction in Self Care

In clinic At home

• Phase II (Self Care)

– Compression garment during the day

– Bandage at night– Self MLD– Skin & Nail Care– Exercise

Treatment for Lymphedema:Complete Decongestive Therapy

Thank You