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CHRONIC VENOUS INSUFFICIENCY (CVI). CVI Occurs when the vein valves become dysfunctional and impairs venous blood return. Occurs when the vein valves.

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Presentation on theme: "CHRONIC VENOUS INSUFFICIENCY (CVI). CVI Occurs when the vein valves become dysfunctional and impairs venous blood return. Occurs when the vein valves."— Presentation transcript:

1 CHRONIC VENOUS INSUFFICIENCY (CVI)

2 CVI Occurs when the vein valves become dysfunctional and impairs venous blood return. Occurs when the vein valves become dysfunctional and impairs venous blood return. Affects up to 20% of adults. Affects up to 20% of adults. By age 50 ~40% of women and 20% of men have significant vein problems. By age 50 ~40% of women and 20% of men have significant vein problems. More people lose work time from vein disorders then from artery disease. 1. More people lose work time from vein disorders then from artery disease. 1.

3 RISK FACTORS Advancing age Advancing age Family history of venous disease Family history of venous disease Ligamentous laxity (eg, hernia, flat fleet) Ligamentous laxity (eg, hernia, flat fleet) Prolonged standing Prolonged standing Increased body mass index Increased body mass index Smoking Smoking Sedentary lifestyle Sedentary lifestyle Lower extremity trauma Lower extremity trauma Prior venous thrombosis (superficial or deep) Prior venous thrombosis (superficial or deep) Arteriovenous shunt Arteriovenous shunt Hereditary conditions Hereditary conditions High estrogen states High estrogen states Pregnancy 2. Pregnancy 2.

4 PROGRESSION OF VEIN DISEASE ASYMPTOMATIC ASYMPTOMATIC SUPERFICIAL VENOUS DILATATION SUPERFICIAL VENOUS DILATATION Telangiectasias (intradermal) Telangiectasias (intradermal) Reticular veins (subdermal) Reticular veins (subdermal)

5 PROGRESSION OF VEIN DISEASE ASYMPTOMATIC VS SYMPTOMATIC ASYMPTOMATIC VS SYMPTOMATIC VARICOSE VEINS (subcutaneous) VARICOSE VEINS (subcutaneous)

6 PROGRESSION OF VEIN DISEASE CHRONIC VENOUS INSUFFICIENCY CHRONIC VENOUS INSUFFICIENCY Leg edema Leg edema

7 PROGRESSION OF VEIN DISEASE CHRONIC VENOUS INSUFFICIENCY CHRONIC VENOUS INSUFFICIENCY Skin changes Skin changes Hyperpigmentation Hyperpigmentation

8 PROGRESSION OF VEIN DISEASE CHRONIC VENOUS INSUFFICIENCY CHRONIC VENOUS INSUFFICIENCY Skin changes Skin changes Stasis dermatitis Stasis dermatitis

9 PROGRESSION OF VEIN DISEASE CHRONIC VENOUS INSUFFICIENCY CHRONIC VENOUS INSUFFICIENCY Skin changes Skin changes Corona phlebectatica Corona phlebectatica a. venous cups (veins) a. venous cups (veins) b. telangiectasias b. telangiectasias c. reticular veins c. reticular veins d. stasis spots (capillaries) d. stasis spots (capillaries)

10 PROGRESSION OF VEIN DISEASE CHRONIC VENOUS INSUFFICIENCY CHRONIC VENOUS INSUFFICIENCY Lipodermatosclerosis Lipodermatosclerosis a form of panniculitis just above the ankles. 9. a form of panniculitis just above the ankles. 9.

11 PROGRESSION OF VEIN DISEASE CHRONIC VENOUS INSUFFICIENCY CHRONIC VENOUS INSUFFICIENCY Venous stasis ulceration(s) Venous stasis ulceration(s)

12 EVALUATION CHARACTERISTICSVENOUSARTERIAL APPEARANCE Irregular, dark pigmentation, sometimes fibrotic, granulation, usually shallow. Irregular, smooth edge, minimum to no granulation, usually deep with a punched out appearance. LOCATION Distal lower leg, medial malleolus. Distal lower leg/feet/toes, lateral malleolus, anterior tibial area. PEDAL PULSES Usually present. May be diminished or absent. PAIN May be present. Usually improves with leg elevation. Usually painful especially with leg elevation. DRAINAGE Moderate to large. Minimal to none. TEMPERATURE May be increased. May be decreased. SKIN CHANGES Flaking, dry, hyperpigmented. Thin, shiny, hairless, yellow nails. 3.

13 EVALUATION CONSIDER A BIOPSY TO EVALUATE FOR POSSIBLE MALIGNANCY VS INFECTIOUS OR INFLAMMATORY PROCESS. CONSIDER A BIOPSY TO EVALUATE FOR POSSIBLE MALIGNANCY VS INFECTIOUS OR INFLAMMATORY PROCESS. DOPPLER ULTRASOUND - VENOUS. CONSIDER ARTERIAL DOPPLER IF THERE IS ANY CONCERN OF SIGNIFICANT ARTERIAL OCCLUSIVE DISEASE. DOPPLER ULTRASOUND - VENOUS. CONSIDER ARTERIAL DOPPLER IF THERE IS ANY CONCERN OF SIGNIFICANT ARTERIAL OCCLUSIVE DISEASE.

14 EVALUATION VENOUS DOPPLER ULTRASOUND VENOUS DOPPLER ULTRASOUND Evaluate for deep and superficial venous Evaluate for deep and superficial venous thrombosis. thrombosis. Evaluate for incompetent veins with Evaluate for incompetent veins with significant reflux disease. significant reflux disease. Evaluate for incompetent perforating Evaluate for incompetent perforating veins and tributaries. veins and tributaries.

15 ANATOMY OF THE LOWER EXTREMITY VENOUS SYSTEM

16 VIDEO SHOWING SIGNIFICANT REFLUX DISEASE OF THE GREAT SAPHENOUS VEIN

17 VENOUS INSUFFICIENCY WITH COLOR FLOW

18 CLASSIFICATION VEIN DISEASE CEAP – an international consensus conference initiated the Clinical-Etiology-Anatomy-Pathophysiology classification. CEAP – an international consensus conference initiated the Clinical-Etiology-Anatomy-Pathophysiology classification. C 0 – no evidence of venous disease. C 0 – no evidence of venous disease. C 1 – telangiectasias/reticular veins. C 1 – telangiectasias/reticular veins. C 2 – varicose veins. C 2 – varicose veins. C 3 – edema associated with vein disease. C 3 – edema associated with vein disease. C 4a – pigmentation or eczema. C 4a – pigmentation or eczema. C 4b – lipodermatosclerosis. C 4b – lipodermatosclerosis. C 5 – healed venous ulcer. C 5 – healed venous ulcer. C 6 – active venous ulcer. C 6 – active venous ulcer. E c – congenital E c – congenital E p – primary venous disease. E p – primary venous disease. E s – secondary venous disorder. E s – secondary venous disorder. E n – not specified. E n – not specified. A s – superficial veins. A s – superficial veins. A d – deep veins. A d – deep veins. A p – perforating veins. A p – perforating veins. A n – not specified. A n – not specified. P r – venous reflux. P r – venous reflux. P o – venous obstruction. P o – venous obstruction. P n – not specified. 7. P n – not specified. 7.

19 MANAGEMENT OF CVI LEG ELEVATION – heart level for 30 minutes 3-4 times daily improves micro-circulation reduces edema, and promotes healing of venous ulcers. 4. LEG ELEVATION – heart level for 30 minutes 3-4 times daily improves micro-circulation reduces edema, and promotes healing of venous ulcers. 4. EXERCISE – daily walking and simple ankle flexion exercises. EXERCISE – daily walking and simple ankle flexion exercises.

20 MANAGEMENT OF CVI Compression therapy Compression therapy - avoid contraindications such as cellulitis - avoid contraindications such as cellulitis or significant arterial occlusive disease. or significant arterial occlusive disease.

21 MANAGEMENT OF CVI – COMPRESSION THERAPY Compression bandages – elastic or non-elastic with single or multi-layers. Compression bandages – elastic or non-elastic with single or multi-layers.

22 MANAGEMENT OF CVI – COMPRESSION STOCKINGS

23 MANAGEMENT OF CVI – COMPRESSION STOCKINGS 4. CLASSPRESSURE LEVEL OF SUPPORT INDICATIO N CEAP OTC <15 mmHg MinimalAsymptomatic, comfort only. 0, 1 I mmHg Mild Minor varicosities, tired aching legs, minor swelling. 1, 2, 3 II mmHg Moderate Moderate to severe varicosities, moderate swelling,phlebitis, following ablation. 3, 4 III mmHg Firm Severe varicosities, swelling, management of ulcerations, following DVT, post surgery. 4, 5, 6 IV >40 mmHg Extra firm Lymphedema.NA

24 MANAGEMENT OF CVI PNEUMATIC COMPRESSION THERAPY PNEUMATIC COMPRESSION THERAPY

25 CHRONIC VENOUS INSUFFICIENCY VERSUS LYMPHEDEMA

26 MANAGEMENT OF CVI - MEDICATIONS Diuretics – one of the most inappropriate treatments. Diuretics – one of the most inappropriate treatments. Aspirin – may accelerate the healing of chronic ulcers. Aspirin – may accelerate the healing of chronic ulcers. Pentoxifylline – more effective for complete or partial ulcer healing then placebo. Pentoxifylline – more effective for complete or partial ulcer healing then placebo. Stanozolol – an anabolic steroid that stimulates fibrinolysis and improves lipodermatosclerosis and possibly ulcer healing. Stanozolol – an anabolic steroid that stimulates fibrinolysis and improves lipodermatosclerosis and possibly ulcer healing. Escin (horseshoe chestnut) – 50mg twice daily reduces leg volume and edema. It stimulates the release of F series prostaglandins which induce venoconstriction, decreasing the permeability of vessel walls to low molecular proteins, water, and electrolytes. Escin (horseshoe chestnut) – 50mg twice daily reduces leg volume and edema. It stimulates the release of F series prostaglandins which induce venoconstriction, decreasing the permeability of vessel walls to low molecular proteins, water, and electrolytes. Hydroxyethylrutoside, Sulodexide, Prostacyclin Analogues – not available in the United States. 4. Hydroxyethylrutoside, Sulodexide, Prostacyclin Analogues – not available in the United States. 4.

27 MANAGEMENT OF CVI – SKIN CARE Skin cleansing – wash with a mild non-soap cleanser (e.g. Dove, Olay, Caress). Skin cleansing – wash with a mild non-soap cleanser (e.g. Dove, Olay, Caress). Emollients – provides a film of oil to lubricate the skin (e.g. Vaseline, Lubriderm, Aveeno). Emollients – provides a film of oil to lubricate the skin (e.g. Vaseline, Lubriderm, Aveeno). Barrier preparations – physically block chemical irritants and moisture.(e.g. Zinc oxide, Vaseline ). Barrier preparations – physically block chemical irritants and moisture.(e.g. Zinc oxide, Vaseline ). Topical corticosteroids – often used to treat stasis dermatitis. 4. Topical corticosteroids – often used to treat stasis dermatitis. 4.

28 MANAGEMENT OF CVI – VENOUS STASIS ULCERS Surgical debridement – used to remove devitalized tissue. Surgical debridement – used to remove devitalized tissue. Enzymatic agents – used to break down necrotic tissue (e.g. Santyl). Enzymatic agents – used to break down necrotic tissue (e.g. Santyl). Growth factors – synthesized by many cell types such as platelets, neutrophils, and epithelial cells (e.g. Regranex). Growth factors – synthesized by many cell types such as platelets, neutrophils, and epithelial cells (e.g. Regranex). Bioengineered tissue – used for a variety of non- healing ulcers (e.g. Apligraf, Dermagraft). Bioengineered tissue – used for a variety of non- healing ulcers (e.g. Apligraf, Dermagraft). Skin grafting – an option for non-healing ulcers. 4. Skin grafting – an option for non-healing ulcers. 4.

29 MANAGEMENT OF CVI – VENOUS STASIS ULCERS Dressings – depend upon the ulcer characteristics, frequency of dressing changes, and cost. Dressings – depend upon the ulcer characteristics, frequency of dressing changes, and cost. -Occlusive dressings may be fully occlusive (impermeable to gases and liquids) or semi-impermeable (impermeable to liquids and partially permeable to gases and water vapor). -Occlusive dressings may be fully occlusive (impermeable to gases and liquids) or semi-impermeable (impermeable to liquids and partially permeable to gases and water vapor). It stimulates collagen synthesis, angiogenesis, and speeds reepithelialization. It stimulates collagen synthesis, angiogenesis, and speeds reepithelialization. -Low adherent gauze dressings – frequent changes but inexpensive. -Low adherent gauze dressings – frequent changes but inexpensive. -Hydrogels and alginate dressings are highly absorbent to handle heavily exudative ulcers, while hydrocolloids can help with wound debridement and skin protection. -Hydrogels and alginate dressings are highly absorbent to handle heavily exudative ulcers, while hydrocolloids can help with wound debridement and skin protection. -Silver can be incorporated if the ulcer is infected. 4. -Silver can be incorporated if the ulcer is infected. 4.

30 MANAGEMENT OF CVI – ABLATION THERAPY Indications – patients with persistent signs/symptoms of venous disease after a minimum of 3 months of medical therapy (e.g. compression) and documented reflux (e.g. >0.5 seconds of reflux GSV). Indications – patients with persistent signs/symptoms of venous disease after a minimum of 3 months of medical therapy (e.g. compression) and documented reflux (e.g. >0.5 seconds of reflux GSV). Absolute contraindications – acute DVT or phlebitis and pregnancy. 5,6. Absolute contraindications – acute DVT or phlebitis and pregnancy. 5,6. Radiofrequency versus laser endovenous ablation therapy. Radiofrequency versus laser endovenous ablation therapy.

31 MANAGEMENT OF CVI – RADIOFREQUENCY ENDOVENOUS ABLATION THERAPY Radiofrequency devices – generate a high frequency alternating current for which the energy heats the adjacent vein walls to the probe which alters the protein structure of the vein effecting its closure. 5. Radiofrequency devices – generate a high frequency alternating current for which the energy heats the adjacent vein walls to the probe which alters the protein structure of the vein effecting its closure. 5. Superficial veins include – Great Saphenous Vein, Small Saphenous, and incompetent perforator veins. Superficial veins include – Great Saphenous Vein, Small Saphenous, and incompetent perforator veins.

32 MANAGEMENT OF CVI

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34 MANAGEMENT OF CVI – RADIOFREQUENCY ENDOVENOUS ABLATION THERAPY

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41 BEFORE AFTER BEFORE AFTER

42 MANAGEMENT OF CVI – ENDOVENOUS LASER ABLATION THERAPY Lasers emit a single, coherent wavelength of light. Laser therapy of venous structures is based upon the concept of selective photothermolysis (ie, selective thermal confinement of light induced damage). Vein wall injury is mediated directly by absorption of photon energy by the vein wall and indirectly by thermal convection from steam bubbles, and from heated blood. Lasers emit a single, coherent wavelength of light. Laser therapy of venous structures is based upon the concept of selective photothermolysis (ie, selective thermal confinement of light induced damage). Vein wall injury is mediated directly by absorption of photon energy by the vein wall and indirectly by thermal convection from steam bubbles, and from heated blood. Superficial veins include – Great Saphenous Vein, Small Saphenous Vein, incompetent perforator veins, telangiectasias and reticular veins. 6. Superficial veins include – Great Saphenous Vein, Small Saphenous Vein, incompetent perforator veins, telangiectasias and reticular veins. 6.

43 MANAGEMENT OF CVI – ENDOVENOUS LASER ABLATION THERAPY

44 MANAGEMENT OF CVI – MECHANICAL ABLATION Physical destruction of a vein with its partial or complete removal. Physical destruction of a vein with its partial or complete removal. - Vein ligation/stripping - Vein ligation/stripping - Stab phlebectomy - Stab phlebectomy - Powered phlebectomy - Powered phlebectomy - Open or endoscopic perforator ligation. - Open or endoscopic perforator ligation.

45 MANAGEMENT OF CVI – STAB PHLEBECTOMY

46 MANAGEMENT OF CVI – VEIN STRIPPING/LIGATION

47 MANAGEMENT OF CVI - SCLEROTHERAPY Chemical irritants injected to close unwanted veins. Preparations include liquid and foam. It is used primarily in the treatment of telangiectasias, reticular veins, and small varicose veins. Chemical irritants injected to close unwanted veins. Preparations include liquid and foam. It is used primarily in the treatment of telangiectasias, reticular veins, and small varicose veins. These substances cause endothelial damage by their actions as either osmotic or detergent agents. Osmotic agents achieve their effect by dehydrating endothelial cells through osmosis. Detergents are surface active agents which damage the endothelium by interfering with cell membrane lipids. 8. These substances cause endothelial damage by their actions as either osmotic or detergent agents. Osmotic agents achieve their effect by dehydrating endothelial cells through osmosis. Detergents are surface active agents which damage the endothelium by interfering with cell membrane lipids. 8.

48 MANAGEMENT OF CVI - SCLEROTHERAPY DETERGENT AGENTS DETERGENT AGENTS - Sodium tetradecyl sulfate - Sodium tetradecyl sulfate - Polidocanol - Polidocanol OSMOTIC AGENTS OSMOTIC AGENTS - Hypertonic saline - Hypertonic saline - Glycerin - Glycerin

49 MANAGEMENT OF CVI - SCLEROTHERAPY

50 REFERENCES Vascular Disease Foundation Leesburg Pike, suite 301, Vienna Virginia Alguire PC, Scovell S. Overview and medical management of lower extremity chronic venous disease UpToDate. 3. Venous stasis and arterial ulcer comparison. February 1, Alguire PC, Mathes BM. Medical management of lower extremity chronic venous disease UpToDate. 5. Scovell S. Radiofrequency ablation for the treatment of lower extremity chronic venous disease UpToDate. 6. Ihnat DM. Endovenous laser ablation for the treatment of lower extremity chronic venous disease UpToDate. 7. Collins KA. Classification of lower extremity chronic venous disorders UpToDate. 8. Greenberg DL, Scovell S. Liquid and foam sclerotherapy techniques for the treatment of lower extremity veins UpToDate. 9. Alguire PC, Mathes BM. Pathophysiology of chronic venous disease UpToDate.

51 QUESTIONS


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