Venous Insufficiency

OUTLINE
Definition Etiology & risk factors Physiology Pathophysiology Clinical manifestations - Subjective symptoms - Dilated veins - Postthrombotic syndromes

 Diagnosis -Physical examination -Imaging -The C-E-A-P Classification

Non operative management -Compression stockings -Leg elevation -Unna boot -Venoablation Operative management

 The great and short saphenous veins, which join the deep system at the saphenofemoral and saphenopopliteal junctions SSV originates in the lateral foot and passes posteriorly lateral to the Achilles tendon in the lower calf,and reach upper calf where it enters popliteal space GSV originates in the medial foot and passes anterior to the medial malleolus, then crosses the medial tibia in a posterior direstion to ascend medially across the knee and finally join the common femoral vein at SFJ

 The posterior tibial veins originate behind the medial malleolus; the anterior tibial vein originates in the dorsum of the foot; and the peroneal vein is found between the tibia and fibula. The popliteal vein is another important intermuscular vein; originates in the popliteal space by the conjoining of the posterior and anterior tibial veins.It becomes the superficial femoral vein in the thigh, and is joined just below the saphenofemoral junction by the deep femoral vein to form the common femoral vein

Perforating Veins

VENOUS INSUFFICIENCY
Definition of venous insufficiency : A state where venous blood escapes from its normal antegrade path of flow and refluxes backward down the veins into an already congested leg. Peak incidence occurs in women aged 40-49 years and in men aged 70-79 years.

ETIOLOGY
Congenital Absence of or damage to venous valves in the superficial and communicating systems (eg : KilppelTrenaunay-Weber Syndrome; multiple arteriovenous fistulae; avalvulia)
Primary Valvular insufficiency

 Secondary i. Thrombosis ii. Hormonal changes (Progesteron-induced venous wall weakness) iii. Chronic environmental insult (eg : prolonged standing)

iv. Trauma

RISK FACTORS
Age Family history (FOXC2 gene) Lifestyle Obesity Smoking

Determinants of Venous Flow

Major mechanisms in body to prevent venous hypertension : I. Venous valves II. Venous pump (gastrocnemius and soleus muscles)
(a) healthy patients (b) patients with only varicose veins (c) patients with incompetent perforator veins (d) patients with deep and perforator incompetence.

PATHOPHYSIOLOGY
Valvular incompetence

Deep venous
DVT Chronic outflow obstruction Recanalize/ bypass

Superficial venous
Saphenofemoral junction (SFJ) and saphenopopliteal junction (SPJ) Hydrostatic pressure Perforating vein

Hydrodynamic pressure

(Ambulatory) venous hypertension

CHRONIC VENOUS INSUFFICIENCY

Increased venous pressuretranscends the venules to the capillariesimpede flowleukocyte trappingrelease proteolytic enzymes and oxygen free radicalsdamage 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.

CLINICAL MANIFESTATIONS
1. Subjective symptoms
2. Dilated veins varicose veins (venous insufficiency syndrome), reticular veins, telangiectasias.

3. Postthrombotic syndrome (also known as postphlebitic syndrome).

SUBJECTIVE SYMPTOMS
History : typically bothersome (early disease) become less severe (middle phases) worsen again (advancing age). Burning Swelling Throbbing Night cramps Aching Leg heaviness Restless legs Leg fatigue Exercise intolerance Pain /tenderness Paresthesias

DILATED VEINS

POST-THROMBOTIC SYNDROMES

Varicose vein : Tortuous,dilate, visible,palpable veins in the subcutaneous skin greater than 3 mm veins.

Pain : Hallmark, especially after ambulating.

Telangiectasis :Dilated intradermal Ulceration : stasis, non healing venules greater than 1 mm in diameter.

Reticular veins - Visible, dilated bluish subdermal, nonpalpable veins 1-3 mm.

Skin changes : venous dermatitis, lipodermatosclerosis, chronic cellulitis.

Edema

Atrophie blanche Corona phlebectatica

RV

T
VV

AB AB
CP

LD

DIFFERENCE BETWEEN VENOUS AND ARTERIAL

Venous Insufficiency
Aggravating factors : Warmth

Arterial insufficiency
Aggravating factors : Walking, elevation, cold, compression stockings

Alleviating factors :Cold, walking, by elevating the legs, compression stockings

VENOUS ULCER Ulcer is superficial at "gaiter" region of the legs Base : Moist granulating (pinkish) that oozes venous blood when manipulated. Slopping edge. Depth : superficial & shallow Has good chance in healing.

DIAGNOSIS
Physical examination I. Inspection : from distal to proximal and from front to back II. Palpation : lightly with the fingertips (location, size, shape, and the diameter of the largest vessel) : at SFJ & SPJ to elicit palpable thrill or sudden expansion (by asking patient to cough or do Valsalva) : Pain or tenderness, firm, thickened vein : Distinguish chronic or newly onset varices : Distal and proximal arterial pulses

III. Percussion : standing position a vein segment is percussed at one position while an examining hand feels for a "pulse wave" at another position IV. Trendelenburg test V. Perthes maneuver

TRENDELENBURG TEST

DUPLEX ULTRASONOGRAPHY
Duplex ultrasonography is the study of choice for the evaluation of venous insufficiency syndromes.
Red indicates flow in one direction (relative to the transducer) and blue indicates flow in the other direction. Latest-generation machines : the shade of the color may reflect the flow velocity (in the Doppler mode) or the flow volume (in the power Doppler mode).

DUPLEX ULTRASONOGRAPHY

VARICOGRAPHY
Allows detailed mapping of the varices to their termination. Extremely useful investigation in patients with recurrent varicose veins or those with complex anatomy

MAGNETIC RESONANCE VENOGRAPHY (MRV)

Most sensitive & specific test for the assessment of deep and superficial venous disease in the lower legs and pelvis, areas not accessible with other modalities. Useful in the detection of previously unsuspected nonvascular causes of leg pain and edema when the clinical presentation erroneously suggests venous insufficiency or venous obstruction.

PHYSIOLOGIC TESTS OF VENOUS RETURN

1. Venous refilling time (VRT) 2. Maximum venous outflow (MVO) 3. Calf muscle pump ejection fraction (MPEF).

THE C-E-A-P CLASSIFICATION

NON SURGICAL MANAGEMENT

Compression stockings To improve symptom management Classifications : light compression1620 mm Hg class I 20-30 mm Hg class II30-40 mm Hg class III40-50 mm Hg

Leg elevation For two brief periods during the day. Instructing the patient that the feet must be above the level of the heart, or toes above the nose.

Unna boot Triple-layer compression dressing application occurs once to twice a week.

Venoablation Sclerotherapy Endovenous laser therapy (EVT) Radiofrequency ablation (RFA)

SURGICAL MANAGEMENT
Indications : I. Cosmesis II. Symptoms refractory to conservative therapy III. Bleeding from a varix IV. Superficial thrombophlebitis V. Lipodermatosclerosis VI. Venous stasis ulcer

Stab avulsions

1. (Left) Vein stripping with ligation 2. (Right)Stab avulsions (with or without ligation)