1. Update on Venous Insufficiency
Michael S. Blanc, FACC, FSCAI
Medical Director
Community Heart and Vascular Center
San Angelo Community Medical Center
San Angelo, TX

2. Chronic venous insufficiency
Requirements for venous return are:
Competent bicuspid venous valves
Effective calf muscle contraction: “ankle-calf pump”
Normal respiration

5. Superficial Venous System - GSV
Common Femoral Vein (CFV)
Fossa Ovalis
SFJ
GSV Trunk
Marginal Arch
Longest vein in body
Areas of aplasia/hypoplasia common in lower thigh, knee and calf
Often runs a superficial subcutaneous course from mid thigh-knee
May enter and exit the saphenous sheath at various locations
Closely associated with saphenous nerve below mid-calf
Often duplicated (25% in the calf; 8% in thigh)
Image courtesy of Dr. Labropoulos
Gloviczki P, ed. Handbook of Venous Disorders. 3rd ed. London, UK: Hodder Arnold; 2009

6. Normal venous flow in the Leg
Normal Flow
Superficial veins drain into the deep veins
From the foot up to the heart
Superficial vein disease always starts with abnormal valves and interruption to normal flow called venous reflux

7. Venous Pathophysiology
Normal Vein
Varicose Vein
Normal functioning calf pumps are capable of emptying 40% to 60% of their volume with one muscle contraction
7 to 12 steps = decreased venous pressure from 100 mmHg to 22 mmHg
Meissner MH, Gloviczki P, Bergan J, et al. J Vasc Surgery. 2007;46(suppl):4S-24S.

8. Important Statistics About CVI
Affects all age groups1
Is 5-10 times more prevalent then PAD1
Direct cost of CVI in the US is estimated to be between $150 million and $1 billion per year2
Mean incidence of hospital admission for CVI is 92/100,000 admissions3
At least 20,556 patients receive a new diagnosis of venous ulcers each year4
Notes: When left untreated, venous reflux can lead to significant clinical issues, like pain, swelling, varicose veins, skin changes, and ulcers
Gloviczki, P., MD., Comerota, A., MD., Dalsing, M., MD., Eklof, B., MD., Gillespie, D., MD., Gloviczki, M., MD.,… Wakefield, T., MD. The care of patients with varicose veins and associated chronic venous diseases: Clinical practice guidelines of the Society for Vascular Surgery and the American Venous Forum. J Vasc Surg May; 53(5 Suppl): 2S-48S
Lee, A. US markets for varicose vein treatment devices Millennium Research Group, Inc. (A Decision Resource, Inc. Company), May 2011.
1 Gordon P, Treat-Jacobson D, Sossoman L.B. Society for Vascular Nursing Position Statement on Inclusion of Vascular Disease into Nursing Education. Soc for Vascular Nursing. 2012;Sept:10.
2 Heller J. Treatment of chronic venous insufficiency. Supplement to Endovascular Today. 2011;Oct:12-15.
3 Weiss R, Venous Insufficiency. Medscape. November 21, 2012.
4 Gloviczki P, Comerota A.J, Dalsing M.C et al. The care of patients with varicose veins and associated chronic venous diseases: Clinical practice guidelines of the Society for Vascular Surgery and the American Venous Forum. J Vasc Surg. 2011;53(suppl):2S-48S.

9. Prevalence of Chronic Venous Insufficiency
More than 30 million Americans suffer from varicose veins or a more serious form of venous disease called Chronic Venous Insufficiency (CVI)1
Of the over 30 million Americans affected:
Only 1.9 million seek treatment annually.1,2
The vast majority remain undiagnosed and
untreated.
CVI Prevalence1,2* 30,000,000+
Seek Treatment *2 1,900,000
Notes: When left untreated, venous reflux can lead to significant clinical issues, like pain, swelling, varicose veins, skin changes, and ulcers
Gloviczki, P., MD., Comerota, A., MD., Dalsing, M., MD., Eklof, B., MD., Gillespie, D., MD., Gloviczki, M., MD.,… Wakefield, T., MD. The care of patients with varicose veins and associated chronic venous diseases: Clinical practice guidelines of the Society for Vascular Surgery and the American Venous Forum. J Vasc Surg May; 53(5 Suppl): 2S-48S
Lee, A. US markets for varicose vein treatment devices Millennium Research Group, Inc. (A Decision Resource, Inc. Company), May 2011.
Treated
447,0002
*Statistics based on individuals over the age of 40
1 Gloviczki P, et al. The care of patients with varicose veins and associated chronic diseases: clinical practice guidelines of the Society for Vascular Surgery and the American Venous Forum. JVS; May 2011.
2 Lee, A. US markets for varicose vein treatment devices Millennium Research Group, Inc. (A Decision Resource, Inc. Company), May 2011.

10. Incidence-Varicose Veins
annual incidence of varicose veins is about 2%
life-time prevalence of varicose veins approaches 40%
Varicosities are more common in women (about 2-3 times as prevalent in women than in men)
30% during 1st PX, 55% 2nd PX
10-20% actually are symptomatic enough to complain about their lower leg varicose veins and seek treatment.

12. CEAP Classification for Chronic Venous Disorders (CVD)
C4a: Pigmentation or Eczema
C4b: Lipodermatosclerosis or Atrophie Blanche
C5: Healed Venous Ulcer
C6: Active Venous Ulcer
Images courtesy of Gordon Gibbs, M.D. and Jennifer Heller, M.D

16. Treatment modalities

19. + Intravascular Ultrasound
IVUS-Guided DVS in CVI
Evaluation & Treatment Algorithm
+ Intravascular Ultrasound
Ricotta, Joseph, J., II and Peter Gloviczki. “Surgical Treatment of Chronic Venous Insufficiency.” Comprehensive Vascular and Endovascular Surgery. Philadelphia, PA: Mosby/Elsevier, pp
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21. Nonthrombotic Iliac Vein Lesions (NIVL)21
Nonthrombotic Iliac Vein Lesions (NIVL)
L Proximal NIVL
(May-Thurner)
R Proximal NIVL
R Distal NIVL
L Distal NIVL
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Negus D, Fletcher EW, Cockett FB, Thomas ML. Compression and band formation at the mouth of the left common iliac vein. Br J Surg 1968;55:

25. Clinical Value: Guiding Stent Sizing & Placement
Images courtesy of Volcano Corporation
Stenosis assessed by IVUS (diagnosis)
Identifying central and peripheral disease-free “landings zones” – vital for patency
Extent of stenting as per catheter cm markings
With recanalization – ensures correct tract along iliac artery
Diameter of stent assessed by IVUS
Post stenting IVUS assessment - degree of recoil and apposition to the venous wall
Iliac Vein
Iliac Vein
≥ 50% area reduction?
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27. Clinical Outcomes: Symptom Relief
Raju & Neglén Experience:
Outcome 2.5 years
Following Stenting
NIVL
with Reflux
without Reflux
No Pain
82%
77%
No Swelling
47%
53%
Ulcer Healed
67%
76%
Good/Excellent Outcome
75%
79%
Patient Characteristics
NIVL with Reflux (n=151)
32% Superficial reflux
20% Deep reflux only*
38% Combined superficial & deep reflux*
*Deep reflux axial in 1/3 of limbs
NIVL without Reflux (n=181)
Raju S and Neglén P. High prevalence of nonthrombotic iliac vein lesions in chronic venous disease: a permissive role in pathogenicity. J Vasc Surg 2006;44:136-43; discussion 144.
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29. SACMC-Venous Intervention
First procedures October 2015
Over 300 patients treated with excellent results

30. Vein Ablation Laser Ablation (EVLA ) Uses light to heat the vein
Radio Frequency (VNUS Procedure)
Uses radio frequency to heat the vein
Office based procedure
Done under local anesthesia
One needle puncture at the level of the knee
Takes about 1 hour
Patient resumes normal activity same day

31. Chronic Venous Insufficiency
Most common CV problem
Up to 50% of women will have venous disease
Extremely underdiagnosed
Impact of Iliac Vein obstruction underappreciated
Helpful and newly evolving treatments are signficantly underused

49. ORBITA in Context TCT/Lancet Small Study, 6 wk FU
Placebo effect of aggressive FU
35% pts had nml FFR/iFR
Single vessel disease
Most likely will not change practice

50. ORBITA in context
Ischemic driven revascularization still the standard of care for SIHD
Stress testing
FFR
Refractory angina despite maximal medical therapy
Does not apply to ACS