Chronic venous insufficiency
is severe
manifestation of venous disorders that is skin pigmentation and
worse. Varicose
veins, deep venous reflux come under chronic venous disease.
Varicose veins affects about
32% of the population. Venous
ulceration may be seen in 1% of the
adult population and thus 1-2% of the health budget is spent on
treating
advanced venous disease.
Pathogenesis:
Venous
valvular incompetence, perforator valve incompetence and venous obstruction and muscle
pump dysfunction underpin venous insufficiency.
In the normal state, venous
pressure in the
foot drops with calf pumping, slowly returning to steady state.
With venous
valve incompetence, resting pressures are elevated and the drop
with exercise is
less pronounced. With venous obstruction, again resting
pressures are elevated
and there is no drop with exercise.
Deep venous valve
dysfunction is most
often due to DVT.
Deep venous obstruction may
lead to
abnormally elevated venous pressures with exercise and thus
secondary calf pump
dysfunction.
Superficial valve
dysfunction may be
primary or due to injury, phlebitis, excessive venous
distension. Junctional
vein valves can become incompetent and allow transmission of
high pressures
into the lower valves. Perforator incompetence can lead to calf
pump energy
being fed into the superficial system resulting in localized
superficial
reflux.
These macrocirc changes
leads to
microcirculatory dysfunction in which there is elongation and
dilatation of the
capillary beds with thickening of the basement membranes,
endothelial damage
leading to a leaky endothelium thus there is leakage of fluid
molecules, RBCs
into the interstitial space. This can lead to secondary damage
to the lymphatic
network, further embarising drainage mechanisms from the limb.
3 theories f venous
microangiopathy:
1)
Fibrin
cuff theory: leakage
leads to fibrin deposition around capillary hence imparing
diffusion of oxegyn
into tssue
2)
White
blood cell trapping
theory: WBC trapped in capillaries leading to activation of
leukocytes and
inflammation
3)
Growth
factor trapping theory:
growth factors trapped in capillary and thus unavailable to heal
tissues.
Genetic disorders with
varicose veins:
1)
Lymphoedema-distchiasis
syndrome:
varicose veins at early age FOXC2
2)
CADASIL:
varicose veins at
early age
3)
Ehler
Danlos Type 4: varicose
veins
4)
Haemochromatosis:
genetic
mutation associated with venous ulceration
5)
Klippel
Trenaunay: varicose
veins, limb hypertrophy and port wine stains: there may be
congenital venous
atresia/agenesis valve insuff, venous aneurysms, lymphatic
anomlaies
6)
Parke
Weber: Lymphatic
malformations, capillary malformation, AVF: assoc with muscle
pump dysfunction
Clinical:
History
iofedema, ulceration, DVT, phlebitis, previous venous surgery
suggest venous
aetiology to problems. Family
history of
venous ulceration and varicose veins, thrombotic disorders.
Examination:
1)
Inspect
for varocise veins,
colour change
2)
limb
girth
3)
palpate
for vein tenderness
4)
oedema
is initially pitting,
then becoming a brawny oedma: uncompressible
5)
corona
phlebectatica:
inframalleolar flair
The Trendelenburg
Test or Brodie-Trendelenburg
test (not to be confused with Trendelenburg's
sign) determines the competency of the valves
in the superficial and deep veins
of the leg. With the patient in the supine position the leg is
flexed at the
hip and raised above heart level until the veins become empty. A
tourniquet is
then applied around the upper thigh to compress the superficial
veins but not
too tight as to occlude the deeper veins. The leg is then
lowered by asking the
patient to stand. Normally the superficial saphenous vein will
fill from below
within 35 seconds as blood from the capillary beds reaches the
veins; if the
superficial veins fill more rapidly with the tourniquet in place
there is
valvular incompetence below the level of the tourniquet in the
"deep"
or "communicating" veins. After 20 seconds, if there has been no
rapid filling, the tourniquet is released. If there is sudden
filling at this
point it indicates that the communicating veins are competent
but the
superficial veins are incompetent.[1]
The
test is reported in two parts, the initial standing up of the
patient (positive
or negative based on rapid filling) and the second phase once
the tourniquet is
removed (positive or negative based upon rapid filling). For
example, a
possible outcome of the test would be negative-positive meaning
that the
initial phase of the test was negative indicating competence in
the
communicating veins and the second phase of the test was
positive meaning that
there is superficial vein incompetence.
The test
can be repeated with the
tourniquet at different levels to further pinpoint the level of
valvular
incompetence:
▪ above the knee - to assess the mid-thigh
perforators
▪ below the knee - to assess incompetence
between the short
saphenous vein and the popliteal vein.[2]
▪ Can add perthes test, where the patient
walks on standing up.
Incompetent perforators leads to enlargement of varicosities
below the
tourniquet
Doppler
test for reflux: Flow towards the feet lasting more than .5s is
indicative of
venous reflux.
Classification systemts:
The CEAP classification :
C: clinical classification
C3 oedema, C4a
pigmentation, C4b: LDP or atrophie blanche, C5 healed ulcer, C6
active ulcer
E: Etilogy: Congenitial
(Klippel
TReaunay), Primary, secondary
A: Anatomic: Superficial
Deep Perforator
P: Pa thophysioligic:
reflux, obstruction,
both
The Venous severity score
VSS: venous severity score,
made up of,
venous clinical severity score, venous segmental disease score,
venous
disabilty score,
Outcome of treatment
measures:
Many
different types, VEINEs, SF-36
The differential
diagnosis for leg swelling
is:
1)
Chronic
venous insuf
2)
DVT
3)
Systemic
causes of leg
swelling:
a.
CHF
b.
Nephrotic
syndrome
c.
Endocrine
diseases
d.
Side
effects of medications eg
Ca channel blockers. NSAIDs, hypoglycaemic agents
4)
Regional
disorders:
a.
Ruptured
popliteal cyst,
b.
Haemotoma,
muscle tumour
c.
Chronic
extertional compartment
syndrome
d.
Gastroc
tear
e.
Lymphoedema
The differential
diagnosis for pigmentation
of the lower limb is:
1)
CVI
2)
LDS
3)
Dermatitis
4)
Myxedema
5)
Necrobiosis
diabeticorum
6)
Ascities
7)
Morbid
obesity
The differential of
chronic ulceration:
1)
arterial
insuf
2)
AVF
3)
Peripheral
neuropathy
4)
Vasculitis
5)
Rheumatoid
arthritis
6)
Blood
dyscrasia eg sickle cell
7)
Infection
8)
Pyoderma
gangrenosum,
9)
malignancy
10)
trauma
11)
drug
side effects
Diagnostic evaluation:
Duplex
gives anatomic information. Air plethysmography and foot
pressures give an
estimate of disease severity.
Duplex: reflux longer than 1
s is
considered diagnostic in the deep system and .5s in the
superficial system
Photoplethysmography:
A light is placed on the
foot and light
sensor. The more blood in the skin, the weaker then signal
picked up by the
sensor. Thus Tests:
1)
The calf
is pumped to empty the
limb The time taken for the foot to refill to 90% of its
original signal is
calculated. If very quick refill ie less than 20s, indicates
venous reflux. If
venous refill time is >20s, indicates normal venous function.
2)
A
tourniquet is applied to
occlude the superficial veins only. The test is repeated and if
time is normal,
indicates superficial reflux only. Quick time indicates deep
reflux.
3)
Calf
pump function can be
assessed by comparing readings with emptying the leg with
gravity times against
calf pump times to empty leg,
Air plethysmography:
An
empty cuff is placed around calf which measures the volume of
the calf. Tests:
1)
Venous
outflow: leg elevated
and proximal tuoriquet appied: tourniquet let down and outflow
fraction at 1
second calculated: anything under 3*% is diagnostic if impaired
outflow
2)
Venous
reflux: limb placed in
dependant position: venous filling index calculated: measuring
the total venous
volume and then time taken to fill 90% of the venous volume in
upright
position. Values above 4ml/s indicate venous reflux
3)
Calf
pump function: total calf
volume measured and then reduction after toe raising measured.
Ejection
fraction is the amount ejected divided by total volume
Phlebograhy:
Can
be ascending and descending phlegram
Ambulatory venous pressure:
gold standard
for CVI: art line needle into pedal vein. Pressure measured at
rest, after
exercise and after placement of an ankle cuff to distinguish
deep from
superficial disease.
Management:
Conservative management:
Behaviour Measures:
Leg
elevation
Foot
of bed elevation
Weight
loss
Compression therapy: graded
external
compression reduces residual volume fraction (thus improved calf
pump function)
and decreases reflux in vein segments
Wound and skin care
Medications:
4
classes:
1)
coumarins
2)
flavonoids:
benzopyrones:
decrease leukocyte action and decrease endothelial permeability
3)
saponosides:
Horse chestnut
seed extract
4)
other
plant extracts
Exercise: Graded calf pump
exercise: does
not decrease reflux but can improve calf pump function as an
adjunct
Interventional management:
Sclerotherapy:
Sodium
tetradecyl sulfate: anionic detergent that damages intima thus
leading to
sclerosis of vein
Aethoxyscerol:
Polidocanol
Can
be used to treat telangiectasia, subcut varicose veins,
transfascial perf veins
and venous malformation. Can be used as a 1:5 foam. Main problem
is
hyperpigmentation around the sclerosed vessel from haemosiderin
in the vein
blood clot
RF
and Laser: potential complications parasthesia, STP, DVT and PE,
bruising, skin
burns and infection. .1% lidocaine tumescent analgesia. AS
effective as surgery
without the pain and swelling
Endovascular:
stenting of the illiacs improves outflow. Need close follow up
to ensure no
instent stenosis.
Surgical
Management:
Ligation
and stripping: reduces recurrence of ulceration in RCT even if
they have deep
reflux. ESCHAR study: surgery does not heal ulcers quicker but
leads to less
recurrence and improved ulcer free time.
Perforator
ligation: endoscopic vs open
Valve
reconstruction: Primary valve incompetence: valvuloplasty,
external stent
Secondary valve incompetence: neovalve
Open Surgery
Aetiology: still unclear
however the
constant associations are previous DVT and genetics. DVT leads
to venous
hypertension which thus causes diltation of the superficial
veins and hence
valve incompetence thence varicosities.
Telangiectasia: less than
1mm, Reticular
veins 1-3mm, Varicose veins >3mm.
Auscultate for an AVF.
Natural History: once
present, the veins
never regress. Complications of varicose veins include STP,
acute bleeding,
eczema, ulceration.
Perforators can be direct or
indirect.
Indirect join the superficial veins to the deep via a muscular
vein. Direct
perforators are fairly constant in location.
The incision for high
ligation is 1cm above
and parallel to the groin crease beginning at the femoral pulse
and going
medial. The junction should be dissected out and 2cm above and
below to ensure
no other junctions.
Treatment of GSV reflux
leads to decreased recurrence
rates of ulcers and improve quality of life compared to
conservative mx alone.
In the surgery vs endovenous
debate, there
is an obvious advantage to EVA in the immediate post procedure
window. There
does not appear to be any difference in long term results
between the two.
REcurence after SSV surgery
is high about
50%. The U/S is thus critical to locating the junction and any important local
venous branches.
Who to still do Surgery on
as opposed to
EVLT or RF:
A:
GSV or GSV branch that is less than 1cm deep to the skin ie a
subcutaneous
saphenous tributary
B:
GSV aneurysm or dilatation: usually a proximal segment 2.5-3cm
in diameter will
not spasm effectively with EV techniques and may even form
thrombus that may
embolise etc.
C:
chronic thrombophlebitis: where a thickwalled vein or webbing
through vein
prevent advancement of RF catheter through vein. The vein may
not spasm down
effectively with EV. These need high ligation and sequatial
avulsions.
D:
Excessive tortuosity preventing EV catheter advancement
E:
Acute superficial thrombosis: if the thrombus has extended to
the junction they
need anticoagulation +/- junction ligation. EV is
contraindicated when fresh
thrombus is present
F:
Economic
G:
Surgeon choice
Endovenous surgery:
Duplication of the GSV
occurs in 25% of
calves and 8% of thighs. True
duplications
where both veins are in the saphenous compartment is rare. There
is about 6 valves in the thigh GSV.
The saphenous eye refers to
the superior saphenous
fascia, vein and muscular fascia beneath.
Veins at the junction
include SEPV,
Superficial epigastric and superficial circumflex illac,
anterior and posterior
thigh circumflex veins.
The SSV lies within its own
compartment,
starts posterior to the lateral malleolus and the junction is
often with 5cm of
the pop skin crease. There may be no junction and several deep
conenctions up
the thigh or a giacomini to connect to the GSV.
Perforator Anatomy:
There
are 6 divides to perforator location: foot, ankle, leg, knee,
thigh, gluteal
region. The medial perforators in the calf are the posterior
tibial
perforators, lower, middle and upper: connects the posterior
arch vein to the
posterior tibial vein. Paratibial perforator (anteromedial
postio of calf). Inferior
femoral canal perforators connect GSV to the pop vein. Superior
femoral canal
perforators connect GSV to the femoral vein mid thigh.
Perforators can be taken
out with subfascial endoscopic perforator surgery but in the era
of sclera, it
seems crap.
Reticular veins lie in the
superficial
compartment and for a lateral subdermic venous system that
largely exists in
the lateral leg.
The RF catheter should be
positioned 2cm
distal to junction. This proximal bit may require two 20s
treatments. Post op
patients should be given a grade III above knee stocking and
repeat ultrasound
in 72 hours.
Absolute
contraindications to sclerotherapy are a known allergy to the
sclerosant, acute
cellulitis, acute respiratory or skin disease, severe systemic
disease, phlebitis
migrans, acute superficial thrombophlebitis, pregnancy,
hyperthyroidism, and
bedridden status. Foam is best for reticular veins and larger
varicose veins
where as liquid is better for small reticular veins and
telangiectasia. Long
term foam results are not as good and EV. Pain during
sclerotherapy injection
may be due to intra-arterial puncture, and thus the injection
has to be stopped
immediately. Should such pain occur, injection of procaine
around the injected
artery, local cooling, systemic heparinization, and infusion
with
low-molecular-weight dextran are recommended.
Cutaneous lasers allow
targeting of smaller
reticular and telangiectasia.
Deep venous surgery: The
peroneal and
tibial veins have anout 12 valves. The popliteal has 3 valves,
most distal. The
SFV has 5 valves, the most constant one is 1-2 cms distal to the
CFV.