get leg up on Varicose Veins

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					    Get a Leg Up on Varicose

Richard Kettelkamp DO MHA- interventional and
           endovascular cardiology
                Cardiologist LC
          Tuesday October 19, 2010
 What is venous insufficiency (CVI)?

 Incidence/Epidemiology/Pathophysiology

 Risk factors for CVI

 Symptoms associated with CVI

 Problems associated with CVI

 Treatment options
PVD: What is it?
   Vein            Artery
 24 million Americans have varicose veins.
 6 million Americans have skin changes
  associated with CVI.
 Venous stasis ulcers affect approximately
  500,000 people.
 92 per 100,000 admissions are for CVI.
 Peak incidence occurs in women aged 40-49
  years and in men aged 70-79 years
What are Varicose Veins
    The word "varicose" comes from the Latin root
     "varix," which means "twisted."

    They are enlarged veins that are swollen and
     raised above the surface of the skin.

    Varicose veins are commonly found on the
     backs of the calves or on the inside of the leg.
Varicose veins
                  They develop when
                    valves in the veins that
                    allow blood to flow
                    toward the heart stop
                    working properly.

                  Blood pools in the veins
                    and causes them to get

                  Varicose veins affect 1
                    out of 2 people over
                    age 50.

                  More common in
                    women than men
Risk factors for developing CVI

•Age. Varicose veins occur most often in people ages 30 to 70, with your risk increasing
as you age. Aging causes wear and tear on the valves in your veins that help regulate
blood flow. Eventually, that wear causes the valves to allow blood to flow back into your
veins where it collects instead of flowing up to your heart.

•Gender. Women are more likely to develop the condition. Hormonal changes during
pregnancy, premenstruation or menopause may be a factor. Female hormones tend to
relax vein walls. Taking hormone replacement therapy or birth control pills may increase
your risk of varicose veins.

•Genetics: risk of developing CVI increases 5x’s if 2 1st degree relative have CVI

•Obesity. Being overweight puts added pressure on your veins.

•Standing for long periods of time. Your blood doesn't flow as well if you're in
the same position for long periods.

•Smoking: increased risk for DVT and incompetent valves
 Venous hypertension:
   Bicuspid valves prevent venous backflow:
    DVT’s damage these valves
   Ambulation keeps blood moving:
                                   Hemodynamic charting
                                   of (a) healthy patients,
                                   (b) patients with only
                                   varicose veins, (c)
                                   patients with
                                   incompetent perforator
                                   veins, and (d) patients
                                   with deep and
 Venous hypertension in diseased veins causes CVI
  by the following sequence of events:
      Increased venous pressure transcends the venules to
       the capillaries, impeding flow.
      Low-flow states within the capillaries cause leukocyte
      Trapped leukocytes release proteolytic enzymes and
       oxygen free radicals, which damage capillary
       basement membranes.
      Plasma proteins, such as fibrinogen, leak into the
       surrounding tissues, forming a fibrin cuff.
      Interstitial fibrin and resultant edema decrease oxygen
       delivery to the tissues, resulting in local hypoxia.
      Inflammation and tissue loss result.
Varicose veins
 Symptoms:
    Frequently asymptomatic
    Ache or heaviness in legs, burning,
     throbbing, muscle cramping and swelling
     in lower legs.
    Prolonged sitting or standing worsens
    Itching around one or more of veins.
    Skin ulcers near ankle
        represent a severe form of vascular
         disease and require immediate
    Blood clots
CEAP Classification
   Clinical severity
   Etiology or cause
   Anatomy
   Pathophysiology

   For the initial assessment of a patient, the clinical severity is the most important
    and can be made by simple observation and does not need special tests. There
    are seven grades of increasing clinical severity:

   GradeDescription
   C0 - No evidence of venous disease.
   C1 - Superficial spider veins (reticular veins) only
   C2 - Simple varicose veins only
   C3 - Ankle edema of venous origin (not foot edema)
   C4 - Skin pigmentation in the gaiter area (lipodermatosclerosis)
   C5 - A healed venous ulcer
   C6 - An open venous ulcer
Telangectasias & Reticular Veins (C1)
Varicose veins (C2)
Venous edema (C3)
Lipodermosclerosis (C4)
Healed venous ulcer (C5)
Venous ulcer (C6)
CVI: Non-Invasive Treatment
 Self-care —
    exercising,
    losing weight,
    not wearing tight clothes,
    elevating legs, avoiding long periods of standing or
     sitting — can ease pain and prevent varicose veins
     from getting worse
 Compression stockings
  Wearing compression stockings is often the first
  approach to try before moving on to other treatments.
  Compression stockings are worn all day. They
  steadily squeeze your legs, helping veins and leg
  muscles move blood more efficiently. The amount of
  compression varies by type and brand.
CVI: Invasive Management
    Sclerotherapy. A solution is injected into small- and medium-sized varicose veins
     that scars and closes those veins.

    Laser surgeries. Laser surgery works by sending strong bursts of light onto the
     vein, which makes the vein slowly fade and disappear.

    Catheter-assisted procedures. A catheter is inserted into an enlarged vein As the
     catheter is pulled out, the heat destroys the vein by causing it to collapse and seal
     shut. This procedure is usually done for larger varicose veins.

    Vein stripping. This procedure involves removing a long vein through small
     incisions. This is an outpatient procedure for most people

    Ambulatory phlebectomy. Removal of smaller varicose veins through a series of
     tiny skin punctures. Local anesthesia is used in this outpatient procedure. Scarring
     is generally minimal.

    Endoscopic vein surgery. Uesd only in an advanced case involving leg ulcers. A
     surgeon uses a thin video camera inserted in your leg to visualize and close
     varicose veins, and then removes the veins through small incisions
 Vein Stripping

 Requires general anesthesia
 Neo-revascularization rate at 2, 5 and 10 years: 20%,
  50% and 70%
EVLT   RF ablation