Chronic Venous Insufficiency and Varicose Veins Dr Sami Asfar by sammyc2007

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									Chronic Venous Insufficiency and Varicose Veins 2006-10-10
Done by: Ramla

Sami Asfar

Objectives: Learn    

Pathophysiology of CVI and V. Veins People at risk Clinical presentations and complications Principles of management

Outcome: Able to  Recognize patients suffering from CVI & V. Veins  To give advice about prevention and management Patient 1

Leg ache & heaviness, better by walking End of the day sensation of swelling Cramps Itching in lower third of the leg (without much physical signs)
Patient 2 Leg pain & Cramps No relief with walking Leg swelling Dry itchy lower third of the leg

Patient 3

 Varicose Veins  Or You notice:veins Dilated tortuous

Patient 4 Swollen lower third of the leg “Guitar area” Hyperpigmentation

* In this man, there is swelling in the lower third Of the leg. It is advanced case of chronic venous Insufficiency.

Patient 5 Ulcer on the lower third of the leg “Guitar area” Hyperpigmentation * An ulcer on the medial side. Very shallow and associated with hyperpigmantation. When the patient stand up it look like the inverted shampaine bottle.

Huntarian Dodd

● ● Boyd

● ● ●


*the venous blood returns to the heart throw the long saphenous vein. It starts from medial malleolus goes up medially behind the knee then in the groin, it joins the femoral vein. The short saphenous vein drains behind the knee into the popliteal vein. Each one of us has perforators; there on in the middle of the thigh called Huntarian, the one above the knee called dodd, there is one below the knee called boyd and above the ankle called cockett.

Ankle Vein Pressure (mmHg)




(Standing) (Walking)

* When you stand up there is a column of venous blood from your mouth to the toes and this blood needs to go back to the heart. When you laying down the pressure at the ankle is 10 once you stand up it goes up to 80 and if you walk it will drop to 40. This drop is because of venous pomp (the muscle). It compresses the vein and pushes the blood and the pressure drop. If it didn’t drop the transient drop of pressure increase. Therefore, the blood returns to the heart throw the venous muscle and the venous valve. Venous Return To The Heart

• • • • • •

Against gravitational forces by: Action of the venous valves Peripheral heart effect (calf muscles) Action of the diaphragm (respiratory movements) Arteriolo-venular reflex

Venous Valves

 Delicate membranous cusps  Act like pocket valves: Unidirectional flow  Open when blood moves upwards
 Close when blood flow

 Strong :  Support the hydrostatic pressure
*the pressure down in a big cylinder = to the length of the cylinder and the diameter of the cylinder. If u keep the pressure high in the bottom it will stay high, the function of valve is to break the big column into small ones. So that the pressure at each column will be lower than at the tip of the toes. The other function of the valve is to keep the blood going upwards. The valves are delicate membranes, when the blood flow it act like pockets and keep the flow unidirectional. When the blood going up it opens, once the blood goes back when the muscle relaxes the valve flips and close to prevent the blood from going down. In spite of its delicacy, the valves are very strong it even can support the hydrostatic pressure in the vein.

Venous Systems of the Lower Limbs

Standin g

De ep Sy ste m

Su pe rfi ci al Sy ste m


*in the lower limbs, there are two systems. The superficial system that consists of the long saphenous vein joining sapheno-femoral junction and the short saphenous vein, which joins the popliteal vein. The deep system is between the muscles, it goes up until it joins the common femoral vein in the groin. The valve at the sapheno-femoral junction should be competent so that it prevents the blood from going into the superficial system when standing up (prevent reflux). The perforators have valves; these valves will allow the blood from going from superficial system to the deep system only in one direction. If they are damage, (usually results from deep vein thrombosis) the blood will reflux back to the superficial system causing varicose veins.


Valves open

Muscle Pump “Calf”

* When you walk, the muscle contract sucks the blood from superficial system.

pushes the blood up and

Incompetent SFJ

High Hydrostatic P. in the Superficial system

*as mentioned the incompetence will lead to reflux to the superficial system and increase hydrostatic pressure. With that it will lead to torchiousity of the veins. The first veins, which are going to be tortuous, are the tubutaries of the long saphenous vein because they have very thin walls. Once the pressure goes up they become tortures and dilated because the wall can not withstand the pressure

*in left picture you cannot see all the varicose veins but what you can see is the long saphenous vein and it is tense under pressure. The right picture the long saphenous is not dilated and when you ably pressure at the groin the tubetaries are dilated so the incompetence is at the sapheno-femoral junction.

Walking (Exercise)
Normal Venous Pump Function Pathologic Venous Pump Function

Competent valves

Incompetent valves

Venous Pressure

No Drop in Venous Pressure

*in a competent valve, when you walk the blood goes up, little will reflux. The venous pressure will drop (from 80 to 40). However, if the valve is incompetent there is always high pressure even when you walk.


Incompetence of valves (or Absence)

Slow down the large volume of fluid & blood which must move against gravity and hydrostatic forces

Venous pressure “CVI”
Leg Veins: distension & dilatation

Back to the patients (1&2): 1- Treatment by compression. She puts it in the morning before going to work. 2- There is difference between odema of the limbs due to CVI and odema due to other causes (renal failure, heart Failure).

Oedema of CVI

Ischaemic organic microangiopathy Results in trophic complications (ulcers)
*odema of CVI is painful. The odema develops becoz of ischemic organic microangiopathy. There will be high pressure in the veins, they will rapture and causes ischemia to the subcutaneous tissue and the skin that will lead to the release of cytokines, and fibrous tissue (causes pain).

Other Types of Oedema
(Cardiac, Renal or Nutritional)

No trophic changes Functional Angiopathy “Impairment of Capillary Permeability”
Chronic Venous Insufficiency

A group of clinical manifestations, functional conditions & cutaneous complications due to venous stasis


The 7th among the 28 most common chronic diseases

 AffectsThe vast majority remainpopulation (Europe) 30-50% of the general “ untreated”  Venous leg ulcer affects > 1 % of adults
Varicose veins:

25-35% Females

10-20% males

 Giudlines of the AmericanVenous Ulcers 25% per year Venous Forum: Recurrence rate of
CVI Risk Factors

(Jawien A et al, 2003; Janet G et al, 2002; Cornwall JV et al, 1986)

• • • •

Prolonged Standing Family history Females Parity ( > 2 pregnancies)( the baby growing in the pelvis for the job Calf exercises while in 9 months causing pressure on the veins) Compression support stockings Obesity MPFF (Micronized Purified Flavonoids) Lack of physical activity Sclerotherapy Age Congenital absence of valves: 8% Management of CVI

 •  • •

   

Calf exercises while in the job Compression support stockings MPFF (Micronized Purified Flavonoids) Sclerotherapy



*the difference between lyphoedema and CVI is that lymphoedema occur at the toes and the foot while the CVI does not occur at the toes.

Telangiectasia, Spider veins Reticular Veins Varicose Veins
*stages of CVI: 1- telangiectasia 2- spider veins 3- reticular veins 4- Varicose veins

Tourniquet Test
1 2 3 4

Valve above the tourniquet is:


Saphenfemoral Junction “SFJ”
*tourniquet test: ask the patient to stand up and look at the veins (decide whether it is the long or short saphenous). Then let the patient lay down and elevate the leg, milk the veins and put the tourniquet as high as possible. Then ask the patient to stand up. If the tourniquet is there, you will not see any veins. Once you release the tourniquet, the veins will show that means that there is sapheno-femoral incompetence. *if you put the tourniquet at the highest level and the veins are still visible then the patient has other incompetent valves. If you release it and they become more visible then the patient have both.

Lower Leg Incompetent Perforator
1 2 3 4

Mark the filling point

Torniquit above filling point Finger pressure on marked point

Incompetent Perforator

*ask the patient to stand up. Try to mark the filling point and put your finger or the tourniquet. Then make the patient stand up and see that the veins did not fill. When you release you finger or the tourniquet it fills.



Where is the incompetent valve ? Saphenofemoral junction “SFJ”

* The three-tourniquet test: you ask the patient to lay down; you put one tourniquet up, one above the knee and one below the knee. Make the patient stand up and start from below. If the veins are filling then the incompetence is in the perforators at that level. If the veins did not fill, you release the tourniquet and look at the veins if they fill then the incompetence is above the knee and so on. The doctor said that we do not use the test because it takes time. Varicose Veins Definition: Aetiology: 1. Primary (Familial) 2. Secondary (post-thrombotic) 3. Congenital Primary (Familial): • Early in life • More than one member of the family • Soon after 2nd or 3rd pregnancy • Occupational Secondary (post-thrombotic, post-DVT): • Perforator valves damage Congenital: • Venous malformation (Klippel-Trenaunay Syndrome) Varicose veins, Limb hypertrophy Klippel-Trenaunay Syndrome: patient will have skin discoloration and superficial varicous veins. The treatment is difficult and usually they live with it.

Dilated tortuous and prominent veins

Clinical presentation of varicous veins:  Asymptomatic  Symptoms: Dull aching pain, heaviness & night cramps Increase by:

End of the day After prolonged standing Less: Morning and on leg elevation

 Complication:

1. Bleeding ( becoz of high pressure), 2. Venous ulceration, 3. Thrombosis & Thrombophlebitis

Investigations: 1. Doppler ultrasound scans: Potency of veins Detects reflux Exclude arterial disease 2. Duplex ultrasound: Mickey Mouse appearance at SFJ Exclude Deep Vein Thrombosis 3. Venogram: Only if Duplex is not available Recurrent varicose veins * U put the tourniquet above the ankle (to prevent the blood from going to superficial system) and u injects the dorsum of the foot. We do venogram only if Doppler is not available or if the is recurrence. Usually we use the Doppler because is safe, no radiation, no contrast (injection). Management of Varicose Veins:  Incompetent SFJ:  High ligation & Stripping  With avulsion and/or sclerotherapy

 Incompetent perforators:  Sclerotherapy  Surgery:  SEPS: Subfacial Endoscopic Perforator Surgery( u


make small insione, u pass a scope, then deflate gas. U see perforators come u then u ligate them) Cockett-Linton procedure( a big insion at the back of the calf from down up)

High Ligation & Stripping of LSV

1. High ligation of SFJ

2. Stripping of LSV: 10-12 cm below the knee

*u make an insion at the inguinal ligament Medially. U ligate all the veins until u reach Sapheno-femoral jungtion and u high ligte it. The most reason of recurrence is incomplete clearance of this area. *stripping: u already made a wound at the groin. U make anther one below the knee by 10 cm (becoz if u do a full stripping there is one complication which is injury to the saphenous nerve) and u pass a stripper. U can strip it from up down or down up.


Compression Sclerotherapy of perforators

*u put the needle in the u elevate the leg and u inject with compression. U don’t inject it into a full vein? Becoz the material (STD) is irritant and will create thrombosis. The n it will recanalize later and u get recurrence. Normally u should inject in an empty vein so that the material hits the intema of the vein and causes chemical irritation and by compression u get good results. The compression should stay for at least 2 weeks with out removing it. In Kuwait, u cannot do that becoz the hot temperature and patient will get irritated. Complications of Varicose Veins:  Thrombosis & Thrombophlebitis



 Venous Ulcer Superficial Thrombophlebitis: Aetiology:  Prolonged i.v. infusion (>72 hrs)  Spontaneous:  Varicose veins  Polycythemia  Buerger’s disease


Visceral malignancy of the GIT : Stomach or pancreas (Trousseau’s sign)

Recurrent migrating thrombophlibitis (Thrombophlebitis migrans) due to :

• Anti-inflammatory agents • Bed rest and limb elevation • Compression bandage or stockings Lipodermatosclerosis “Posthrombotic or postphlebitic Leg: * This happens becoz of high pressure and the Continus release of leukocytes and RBC in to the Tissue cytokines release fibrous Tissue formation between the capillaries veins and the Lymphatic impairment of blood supply.

Summary 1  CVI is a common but under-diagnosed disorder  Early diagnosis and treatment

Improves life style Halts progression of the disease Safes funds in the health budget
 Support stocking for:

Professions requiring long periods of standing During pregnancy

Neuropathic Leg Ulcer: • Site: Sole of the foot Pressure points • Over toe joints • Under metatarsal heads • Heel • Over malleoli • Lack of pain • Hypertrophic callus and a deep ulcer. There is a callus around it.

Venous Leg Ulcer: • Site: • “Gaiter area” Above medial malleolus Venous Hypertension: • Hyperpigmentation • Skin indurated, firm & tethered to underlying


Arterial “Ischaemic” Leg Ulcer: • Site: Pressure points • Shin • Tip of toes • Over malleoli • Heel Absent foot Pulses

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