superficial venous insufficiency 2015-6-4

8/19/2019 Superficial Venous Insufficiency 2015-6-4

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Superficial Venous Insufficiency: Varicose Veins and Venous

Ulcers

Jonathan Fong, MBBS, BMedSci, PGDipSurgnat! I"an Bayat, MBBS, M#$S,F#$S%Vasc&! Jason $huen, MBBS, PGDipSurgnat, F#$S%Vasc& | June 4, 2015

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Superficial venous disease broadly falls into two categories: superficial venous

insufficiencyreflu! "eg, varicose veins #s$own%, c$ronic venous insufficiency& and t$ro'bosis"eg, superficial t$ro'bop$lebitis, deep venous t$ro'bosis #()*%&+ *$ese conditions enco'pass

a wide range of sy'pto'ssigns and presentations+ n 'ore t$an 50- of t$e general population,superficial venous disease appears in t$e for' of .spider. or reticular veins, but in appro!i'ately20-/25- of t$e population, t$e disease can progress to visible varicosities at its e!tre'es, suc$

as ulceration or sin c$anges+#1,2%

*$is slides$ow will focus pri'arily on superficial venous insufficiency+

'age courtesy of Jonat$an ong, 33S, 3edSci, (ipSurgnat+


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$alf'Pu"p Syste"

*$e venous supply to t$e leg is via a deep and superficial low/pressure syste'+ *$e flow of

blood is fro' t$e perip$eries toward t$e $eart, 'aintained by t$e calf/pu'p syste'+ 7it$in t$eveins, t$ere is a syste' of valves t$at $elps overco'e t$e pull of gravity and 'aintains a

unidirectional flow of blood "s$own&+ 7$en t$ese valves beco'e inco'petent, retrograde flow

of blood predo'inates and leads to venous $ypertension, resulting in t$e c$anges seen wit$superficial venous disease+

'age courtesy of 8penSta! 9ollege+ 3lood flow, blood pressure, and resistance+ 8penSta!

9;+ June 141c4c/


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$linical $lassification

*$e 9A "clinical, etiologic, anato'ic, pat$op$ysiologic& criteria are used to aid classification

of c$ronic venous disease, particularly in clinical studies and trialsB t$us, t$ey $elp clinicians tostratify and co''unicate t$e severity of venous disease+ #4% *ypically, only t$e clinical portion

"s$own& of t$e 9A classification syste' is fully utiliCed+ #=%

*able courtesy of t$e aut$ors+


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Superficial Venous Insufficiency

uc$ about t$e etiology of varicose veins re'ains unnown+ *$ese 'anifestations are seen 'ore

co''only in developed countries and in wo'en, and t$ey are strongly associated wit$ fa'ily$istory, increasing age, pregnancy, and ()*+ 7ea associations include obesity and so'e rare

genetic abnor'alities+#4%

lt$oug$ few studies docu'ent t$e natural $istory of varicose veins "s$own&, superficial venous

insufficiency is considered to be progressive over ti'e, typically beginning as reticular veins orcorona p$lebectatica ".corona.&, developing into isolated calf varicosities and, eventually,

resulting in a tortuous and distended great sap$enous vein+#5%

Deticular veins are typically s'all "1/= ''&, $ig$ly visible, and often pose a cos'etic proble'

for patients+ )aricose veins are superficial and dilatedB t$ey are typically found in t$e calf but

'ay also occur in t$e t$ig$, corresponding to t$e course of t$e long sap$enous vein+nco'petence of t$e perforator and s$ort sap$enous veins can result in posterior calf varicosities+

'age courtesy of 7ii'edia 9o''onsEaeland1


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Eeft untreated, superficial venous insufficiency can lead to t$e develop'ent of sin c$anges

"s$own& and, eventually, ulceration+ *$e rate of progression and ris factors for developingc$ronic venous c$anges are still unnown+#6% Sy'pto's can include $eaviness, swelling, ac$ing,

cra'ps, and itc$ing+#?% )enous $ypertension can subseFuently develop due to e!cessive ede'a

overw$el'ing t$e ly'p$atic syste'+

)enous ecCe'a, $e'osiderin staining, and lipoder'atosclerosis are conseFuences of c$ronicvenous stasis+ Ge'osiderin staining occurs fro' e!travasation of red blood cells, causing a

pig'ented appearance to t$e li'bs+ Eipoder'atosclerosis gives t$e affected li'b a classic

.inverted c$a'pagne bottle. appearanceB t$is is t$oug$t to be caused by e!travasation offibrinogen or w$ite blood cells into t$e der'al tissue due to capillary $ypertension, t$ereby

resulting in c$ronic infla''ation and fibrosis of t$e subcutaneous tissue+#>%

'age courtesy of edscape+


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)enous insufficiency is t$e 'ost co''on underlying etiology of c$ronic ulcers "s$own& "range,

54-/?5- in so'e observational studies&+#


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I"aging Studies

(uple! ultrasonograp$y "s$own& re'ains t$e gold standard for investigation of venous disease+

*$is i'aging 'odality allows assess'ent of t$e pattern of reflu! and w$et$er t$ere issap$enofe'oral Hunction inco'petence, inco'petent perforating veins, or anato'ic variants+

)enograp$y via co'puted to'ograp$y "9*& scanning or 'agnetic resonance i'aging "D& is

'ost useful for identifying ovarian or pelvic vein inco'petence+ 9at$eter/directed venograp$y is

typically reserved for direct evaluation of anato'ic variations suc$ as ay/*$urner syndro'e, inw$ic$ t$e left co''on iliac vein is co'pressed by t$e rig$t co''on iliac artery+

*$e longitudinal duple! ultrasonogra' of t$e sap$enofe'oral Hunction is s$own during t$e

positioning of t$e tip of a laser fiber during an endovenous laser ablation "A)E&+ *$e laser tip

"arrow& is in t$e great sap$enous vein "S)& Hust beyond t$e superficial epigastric vein "SA)&

origin+ ) I fe'oral vein+'age courtesy of edscapeSteven A i''et, (, 9G+


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(igation of Varicose Veins

Since it was first described in 1>


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)ndo*enous +lation

n alternative to traditional surgery is t$e 'ini'ally invasive approac$ offered by endovenous

ablation+ Andovenous ablation can be perfor'ed in t$e outpatient setting using t$e tec$niFue of.tu'escent anest$esia,. in w$ic$ local anest$etic is inHected around t$e vein to allow treat'ent+

n ideal veinsLw$ic$ are straig$t, broad "M= ''&, and deep "M1 c' fro' sin&Lan ablation

cat$eter is inserted under ultrasonograp$ic guidance "1&+ *$ereafter, eit$er a laser or aradiofreFuency cat$eter delivers t$er'al energy to t$e inti'a to ablate t$e vein "2,3&+

*$e advantages of t$is procedure lie in avoiding t$e use of general anest$esia and in reducing t$e

rates of bruising, bleeding, and nerve inHury+ Andovenous ablation can t$erefore pro'ote an

earlier return to wor for patients+#1>% Gowever, t$is tec$niFue can also cause sin burns and ()*,

nown as endovenous $eat/induced t$ro'bosis, wit$ an incidence below 1-+

'age courtesy of t$e aut$ors+


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nstead of t$er'al ablation, c$e'ical ablation can also be used to obliterate t$e varicose vein+

oa' sclerot$erapy, initially devised to treat s'all reticular veins, can now be used to scleroseinco'petent great sap$enous veins wit$ only a slig$tly lower efficacy t$an traditional surgery,

according to a 'eta/analysis+#1


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$o"pression Stocings

9o'pression stocings "s$own& $ave long been t$e 'ainstay of nonoperative 'anage'ent for

varicose veins+ Gowever, t$ere is a lac of good evidence to s$ow t$eir efficacy, and patientco'pliance is a significant $urdle, as 'any find t$e stocings to be itc$y, $ot, and difficult to put

on and tae off+

lt$oug$ a nu'ber of studies outline t$e potential of p$ar'acot$erapy in reducing sy'pto's,

particularly t$e use of $orse c$estnut e!tract, t$us far, t$e benefit of suc$ treat'ent $as beens$own to be li'ited+

'age courtesy of 7ii'edia 9o''onsran 9+ Nller+


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$onsiderations in -reat"ent Selection

7$en selecting t$e appropriate treat'ent for patients wit$ superficial venous disease, 'any

factors 'ust be taen into account+ *$e severity and e!tent of t$e venous disease, t$e anato'y of t$e varicosities, t$e presence of ulceration "s$own& andor co'orbid conditions, t$e type"s& of

previously ad'inistered treat'ents, as well as t$e ai' of treat'entLcos'etic or sy'pto'

'anage'entL'ust be elicited via a t$oroug$ $istory and p$ysical e!a'ination+

*$e availability of t$erapeutic options and t$e e!pertise of t$e treating surgeon also $ave roles int$e decision/'aing process+ or e!a'ple, A)E and radiofreFuency ablation "D& treat'ents

are 'ore financially costly t$an traditional surgery because t$ey often reFuire a $eavier

invest'ent in instru'ents+ not$er factor t$at patients s$ould be 'ade aware of is t$at surgery

for varicose veins can result in bruising and s$ort/ter' pain but, 'ost i'portantly, recurrence isco''on+ oreover, alt$oug$ t$e bul of t$e varicosities is re'oved, residual s'all veins are

often left be$ind and 'ay reFuire furt$er intervention+

'age courtesy of Jonat$an ong, 33S, 3edSci, (ipSurgnat+


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nu'ber of syste'atic reviews and 'eta/analyses $ave co'pared t$e t$ree 'ain procedures for

t$e treat'ent of varicose veins "ie, open surgery, endovenous ablation, foa' sclerot$erapy&+ ote, $owever, t$at t$e results of t$ese analyses 'ust be considered against t$e $eterogeneity in

t$e 'et$odology of t$e rando'iCed controlled trials used in t$e analyses+

8pen varicose vein surgery is still considered t$e gold standard to w$ic$ ot$er treat'ents are

co'pared+ 9oc$rane review found little difference between treat'ents in ter's of t$e ris ofearly clinical recurrence "s$own& or recanaliCation of t$e great sap$enous vein on t$e basis of

early duple! sonogra's+#1


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Venous Ulcers

)enous leg ulceration is a co''on yet difficult condition to treat, particularly in t$e elderly+

anage'ent of t$ese ulcers is costly+ *$e treat'ent obHectives are twofold: to create anenviron'ent for $ealing of t$e ulcer and to prevent recurrences+

irst/line 'anage'ent is always to address t$e presence of sepsis t$roug$ debride'ent,

antibiotics, and bed rest+ 8ften, consideration 'ust be 'ade to i'prove t$e patientKs overall

'edical condition, including ad'inistration of adeFuate and appropriate nutrition and patientcessation of s'oing, and 'anage'ent of cardiac failure, diabetes, andor perip$eral ede'a+ f

t$e ulcer $as a good c$ance of $ealing, sin grafts or local flaps can be used to cover t$e defects

"s$own&+

'age courtesy of t$e aut$ors+


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9o'pression t$erapy $as also been t$e 'ainstay of preventing recurrence of venous ulcers+

Gowever, t$ere is evidence t$at, in t$e presence of great sap$enous vein or s'all sap$enous veininco'petence, surgical intervention is associated wit$ i'proved rates of $ealing as well as lower

recurrence as co'pared to co'pression t$erapy alone+#25% n ter's of outco'es, t$ere does not

appear to be any difference on t$e basis of t$e type of surgery perfor'ed "ie, open, endovenous,and sclerot$erapy&+

'age of c$ronic 'edial leg ulceration associated wit$ long/standing venous insufficiency

courtesy of edscape+

http://reference.medscape.com/features/slideshow/supercial-venous-

insuciency#page=16

superficial venous insufficiency 2015-6-4

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