1. Chronic Venous Disease Patrik Tosenovsky

2. Issues Severity of CVD Severity of CVD Appropriate referral Appropriate referral Benefit, side effects and cost of the treatment Benefit, side effects and cost of the treatment

3. CVD – Chronic Venous Disorders Include s spectrum of clinical presentations ranging from teleangiectasias to venous ulceration. Include s spectrum of clinical presentations ranging from teleangiectasias to venous ulceration. Primary vs Secondary Primary vs Secondary

4. Chronic Venous Insufficiency Usually refers more specifically to the spectrum of skin changes associated with venous hypertension Usually refers more specifically to the spectrum of skin changes associated with venous hypertension

5. Primary CVD vs Secondary CVD Primary - The cause is unknown (varicose veins etc) --- varicose veins/swelling/skin changes Primary - The cause is unknown (varicose veins etc) --- varicose veins/swelling/skin changes Secondary – usually following DVT --- obstruction +/- reflux ---venous hypertension --- varicose veins/swelling/skin changes Secondary – usually following DVT --- obstruction +/- reflux ---venous hypertension --- varicose veins/swelling/skin changes

6. ANATOMY/PHYSIOLOGY

7. ANATOMY

8. DVT – obstruction (initially always)

9. Thrombus formation – DVT - embolisation - PE

12. Obstruction – Reflux – or both OBSTRUCTION REFLUX or OBSTRUCTION or both

13. Competent valve and obstruction free lumen is the key for function

14. Classification of CVD CEAP classification CEAP classification C – Clinical signs (1-6 i.e. retic.v.- ulcer) C – Clinical signs (1-6 i.e. retic.v.- ulcer) E – ethiology (cong., primary, second.) E – ethiology (cong., primary, second.) A – anatomy (deep, perf., superf) A – anatomy (deep, perf., superf) P – pathophysiology (reflux, obstruction, both) P – pathophysiology (reflux, obstruction, both)

15. Severity of CVD Venous Clinical Severity Score (VCSS) – more for research purposes and databases Venous Clinical Severity Score (VCSS) – more for research purposes and databases Clinically more practical: Clinically more practical: 1. Active ulcer, previous ulcer, lipodermatosclerosis 2. Symptomatic - any stage of CVD 3. Other (incl. vv’s, spider veins etc)

16. Severity of Acute venous disease DVT – 2 weeks of duration DVT – 2 weeks of duration Severity: Severity: 1. Iliofemoral DVT + swelling/discoloration 2. Other DVT (femoropopliteal, tibial, gastrocn., soleus veins)

17. Treatment options Non-surgical – compression (venous hypertension) Non-surgical – compression (venous hypertension) Sclerotherapy – both for cosmetic vv’s and synptomatic ones Sclerotherapy – both for cosmetic vv’s and synptomatic ones Surgical – phlebectomy/stripping Surgical – phlebectomy/stripping Percutaneous – RFA, Laser, angioplasty/stent Percutaneous – RFA, Laser, angioplasty/stent Deep vein reconstruction Deep vein reconstruction Combined Combined

18. How effective is the treatment Percutaenous and open surgical – up to 98% success rate (no difference) Percutaenous and open surgical – up to 98% success rate (no difference) Sclerotherapy – good for small veins Sclerotherapy – good for small veins Angioplasty – up to 99% success rate for iliac veins Angioplasty – up to 99% success rate for iliac veins Deep vein reconstruction – 60 % success Deep vein reconstruction – 60 % success

19. Right iliac vein occlusion

20. Axillary vein transplant

21. Valvuloplasty

22. Venous ulcer before treatment

23. Venous ulcer 4 weeks after th.

24. Venous ulcers healed 12 th week post deep vein reconstruction