1. CHRONIC VENOUS INSUFFICIENCY
(CVI)

2. CVI
Occurs when the vein valves become dysfunctional and impairs venous blood return.
Affects up to 20% of adults.
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.

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

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

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

6. PROGRESSION OF VEIN DISEASE
CHRONIC VENOUS INSUFFICIENCY
Leg edema

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

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

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

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

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

12. EVALUATION CHARACTERISTICS VENOUS ARTERIAL APPEARANCE LOCATION
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.
DOPPLER ULTRASOUND - VENOUS. CONSIDER ARTERIAL DOPPLER IF THERE IS ANY CONCERN OF SIGNIFICANT ARTERIAL OCCLUSIVE DISEASE.

14. EVALUATION VENOUS DOPPLER ULTRASOUND
Evaluate for deep and superficial venous
thrombosis.
Evaluate for incompetent veins with
significant reflux disease.
Evaluate for incompetent perforating
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.
C 0 – no evidence of venous disease.
C 1 – telangiectasias/reticular veins.
C 2 – varicose veins.
C 3 – edema associated with vein disease.
C 4a – pigmentation or eczema.
C 4b – lipodermatosclerosis.
C 5 – healed venous ulcer.
C 6 – active venous ulcer.
E c – congenital
E p – primary venous disease.
E s – secondary venous disorder.
E n – not specified.
A s – superficial veins.
A d – deep veins.
A p – perforating veins.
A n – not specified.
P r – venous reflux.
P o – venous obstruction.
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.
EXERCISE – daily walking and simple ankle flexion exercises.

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

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

22. MANAGEMENT OF CVI – COMPRESSION STOCKINGS

23. MANAGEMENT OF CVI – COMPRESSION STOCKINGS4.
CLASS
PRESSURE
LEVEL OF SUPPORT
INDICATION
CEAP
OTC
<15 mmHg
Minimal
Asymptomatic,
comfort only.
0, 1 I
15-20 mmHg
Mild
Minor varicosities, tired aching legs, minor swelling.
1, 2, 3 II
20-30 mmHg
Moderate
Moderate to severe varicosities, moderate swelling,phlebitis, following ablation.
3, 4
III
30-40 mmHg
Firm
Severe varicosities, swelling, management of ulcerations, following DVT, post surgery.
4, 5, 6 IV
>40 mmHg
Extra firm
Lymphedema. NA

24. PNEUMATIC COMPRESSION THERAPY
MANAGEMENT OF CVI
PNEUMATIC COMPRESSION THERAPY

25. CHRONIC VENOUS INSUFFICIENCY VERSUS LYMPHEDEMA

26. MANAGEMENT OF CVI - MEDICATIONS
Diuretics – one of the most inappropriate treatments.
Aspirin – may accelerate the healing of chronic ulcers.
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.
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.

27. MANAGEMENT OF CVI – SKIN CARE
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).
Barrier preparations – physically block chemical irritants and moisture.(e.g. Zinc oxide, Vaseline).
Topical corticosteroids – often used to treat stasis dermatitis. 4.

28. MANAGEMENT OF CVI – VENOUS STASIS ULCERS
Surgical debridement – used to remove devitalized tissue.
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).
Bioengineered tissue – used for a variety of non-healing ulcers (e.g. Apligraf, Dermagraft).
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.
-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.
-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.
-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).
Absolute contraindications – acute DVT or phlebitis and pregnancy. 5,6.
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.
Superficial veins include – Great Saphenous Vein, Small Saphenous, and incompetent perforator veins.

32. MANAGEMENT OF CVI

33. MANAGEMENT OF CVI

34. MANAGEMENT OF CVI – RADIOFREQUENCY ENDOVENOUS ABLATION THERAPY

35. MANAGEMENT OF CVI – RADIOFREQUENCY ENDOVENOUS ABLATION THERAPY

36. MANAGEMENT OF CVI – RADIOFREQUENCY ENDOVENOUS ABLATION THERAPY

37. MANAGEMENT OF CVI – RADIOFREQUENCY ENDOVENOUS ABLATION THERAPY

38. MANAGEMENT OF CVI – RADIOFREQUENCY ENDOVENOUS ABLATION THERAPY

39. MANAGEMENT OF CVI – RADIOFREQUENCY ENDOVENOUS ABLATION THERAPY

40. MANAGEMENT OF CVI – RADIOFREQUENCY ENDOVENOUS ABLATION THERAPY

41. MANAGEMENT OF CVI – RADIOFREQUENCY ENDOVENOUS ABLATION THERAPY
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.
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.
- Vein ligation/stripping
- Stab phlebectomy
- Powered phlebectomy
- 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.
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
- Sodium tetradecyl sulfate
- Polidocanol
OSMOTIC AGENTS
- Hypertonic saline
- Glycerin

49. MANAGEMENT OF CVI - SCLEROTHERAPY

50. REFERENCES
2012 Vascular Disease Foundation Leesburg Pike, suite 301, Vienna Virginia
Alguire PC, Scovell S. Overview and medical management of lower extremity chronic venous disease UpToDate.
Venous stasis and arterial ulcer comparison. February 1,
Alguire PC, Mathes BM. Medical management of lower extremity chronic venous disease UpToDate.
Scovell S. Radiofrequency ablation for the treatment of lower extremity chronic venous disease UpToDate.
Ihnat DM. Endovenous laser ablation for the treatment of lower extremity chronic venous disease UpToDate.
Collins KA. Classification of lower extremity chronic venous disorders UpToDate.
Greenberg DL, Scovell S. Liquid and foam sclerotherapy techniques for the treatment of lower extremity veins UpToDate.
Alguire PC, Mathes BM. Pathophysiology of chronic venous disease UpToDate.

51. QUESTIONS