1. Chronic Venous Insufficiency
The Challenge of Edema
S. Lakhanpal MD, FACS
President & CEO
Center for Vein Restoration

2. Case Presentation 67 year old male Presents with Left Calf Ulceration
Duration: 2 months
Associated Symptoms
Pain and Heaviness left leg
Cramps
Itching
PMH:
Arthritis, GERD, Gout, Hypertension
Right knee Surgery
Ex Smoker
Meds:
Atenolol, Omeprazole, Nortriptyline, Allopurinol, Lasix, Oxycodone

3. Physical Findings Left leg Ulcer – lateral and posterior calf
Hyperpigmentation
Pitting Edema lower leg

4. Images

5. Images

6. The Challenge of Edema
Chronic Unilateral edema if trauma and malignant obstruction is ruled out is invariably due to venous insufficiency
Acute onset edema U/L or B/L is not due to ‘chronic’ venous insufficiency
For chronic B/L edema first document the presence of significant reflux, and the exclude systemic causes (cardiac, renal, hepatic, abdominal malignancies, thyroid disorders, sleep apnea and medications causing edema )
Despite all the testing it remains a close call
Try treatment on one side and reassess?

7. Edema: Salient Features
The most common cause of leg edema in adults over 50 is venous insufficiency
The most common cause in women between menarche and menopause is idiopathic edema, formerly known as “cyclic” edema
A common but under-recognized cause of edema is pulmonary hypertension, which is often associated with sleep apnea

8. Duplex Evaluation Ultrasound evaluation in office Left Leg:
Reflux present in greater saphenous vein
No evidence of DVT

9. Duplex Ultrasound Evaluation
Lt gsv

10. Management Multidisciplinary approach Wound Care
Management of Venous Insufficiency
Lymphedema management

11. Minimally Invasive Procedures
Radiofrequency – Heating element in contact with the vein wall: endothelium denudation, collagen contraction, vein shrinkage and fibrosis
Laser – Hemoglobin is the chromosphere. Steam bubble injures the endothelium. Non thrombotic occlusion
Sclerosants – Detergents with removal of endothelium and damage of the media

12. What is Lymphedema? Fluid accumulation in a limb
Due to an impairment in the lymphatic system
Functions of lymphatic system:
Immunological function-lymphocytes break down bacteria
Intestinal lymph vessels absorb fat
To transport lymph fluid from the interstitium to the cardiovascular system
Lymph fluid = water, protein, larger molecules

13. Lymphedema and Phlebopathies
Four ways his can occur:
Developmental defect lymphedema
accompanied by valveless veins
Every kind of lymphedema causes pathological changes in blood vessels
LE lymphedema impaired ambulatory venous function mild venous insufficiency
Late stage CVI combination form of lymphedema
Phlebectomies in a patient with lymphedema can cause it to worsen

14. Phlebolymphedema
The accumulation of fluid in the interstitial tissue that is caused by a combination of venous and lymphatic disorders.

15. Treatment for Lymphedema: Complete Decongestive Therapy
Phase I (Intensive)
Manual Lymph Drainage
Compression Bandaging
Exercise
Skin & Nail Care
Instruction in Self Care
Phase II (Self Care)
Compression garment during the day
Bandage at night
Self MLD
Skin & Nail Care
Exercise
In clinic
At home

16. Thank You