Vascular: Chronic Venous Insufficiency & Varicose Veins

Chronic Venous Insufficiency (CVI)

Basics

  • Definition: Malfunctioning Veins Failing to Return Blood Back to the Heart
  • Results from Venous Hypertension
  • Causes:
    • Valve Incompetence
    • Obstruction (DVT, etc.)
  • Typically Referring to the Lower Extremities

Presentation

  • Discomfort/Heaviness
  • Pain
  • Swelling
  • Skin Discoloration
  • Pruritis
  • Numbness & Paresthesias
  • “Brawny Edema”
    • Brown-Blue-Grey Hyperpigmentation from Hemosiderin Deposition
  • Venous Ulcers
    • Most Common Site: Superior/Posterior to Medial Malleolus

Brawny Edema 1

Venous Stasis Ulcer 2

CEAP Classification

Clinical (C) Etiology (E) Anatomy (A) Pathophysiology (P)
0 – None
1 – Small Varicose Veins (Telangiectasia or Reticular Veins)
2 – Large Varicose Veins
3 – Edema
4 – Skin Changes
5 – Healed Ulceration
6 – Ulceration		 C – Congenital
P – Primary
S – Secondary		 S – Superficial
D – Deep
P – Perforators		 R – Reflux
O – Obstruction

Diagnosis

  • Often a Clinical Diagnosis
  • Duplex US – Preferred Test

Treatment Approach

  • Initial Treatment: Conservative Management
  • If Refractory: Surgical Treatment
    • First Step: Treat Superficial Venous Reflux
    • Second Step: Treat Perforator Venous Reflux
    • Last Step: Treat Deep Venous Reflux

Conservative Management

  • Lifestyle Modifications (Exercise, Ambulate, Weight Loss & Smoking Cessation)
  • Leg Elevation
  • Gradient Compression Stockings
    • Classes of Pressure:
      • Class 1: 10-15 mmHg
      • Class 2: 20-30 mmHg
      • Class 3: 30-40 mmHg
      • Class 3-High Compression: 40-50 mmHg
    • Use:
      • C1-2 Disease – Use Class 1-2 Stockings
      • C3 Disease – Use Class 2-3 Stockings
      • C4-6 Disease – Use Class 3 Stockings (Mainstay of Treatment)
  • Unna Boot
    • Multilayer Compression Device
      • Inner Layer: Gauze Soaked with Zinc Oxide, Calamine, Glycerin, Sorbitol & Magnesium Aluminum Oxide
      • Outer Layer: Elastic Wrap Providing Compression
    • Provides 50-60 mmHg Pressure
    • Dressing Changed Weekly
    • Used for Venous Ulcers (91% Healing Success)

Unna Boot

Surgical Treatment

  • Superficial/Perforator Treatment:
    • Radiofrequency Ablation (RFA)
      • Generally Preferred for Superficial Venous Reflux
      • Start Proximal & Then Move Distal
      • Contraindications: Proximal Tortuous GSV or Dilated > 15 mm
    • Endovenous Laser Ablation
    • Sclerotherapy
      • Generally Preferred for Perforator Venous Reflux
    • Vein Stripping/Ligation
  • Deep Treatment:
    • Valve Reconstruction
  • Contraindications: DVT or Severe Peripheral Arterial Disease

Endovenous Heat-Induced Thrombus (EHIT)

  • Thrombotic Complication of GSV/SSV Ablation Procedures
  • Prevent by Keeping Ablation ≥ 2.5 cm Away from the Deep Vein Junction
  • Generally Resolves Faster than Typical DVT’s
  • Classification:
    • Class I: Thrombus Stops at the Saphenofemoral or Saphenopopliteal Junction
    • Class II: < 50% Occlusion of the Deep Vein (Most Common)
    • Class III: > 50% Occlusion of the Deep Vein
    • Class IV: Occlusive DVT
  • Treatment:
    • Class I: None
    • Class II: Weekly Surveillance Until Resolution
    • Class III: Anticoagulation Until Resolved
    • Class IV: General DVT Management

Varicose Veins

Basics

  • Definitions:
    • Varicose Veins: Dilated (≥ 3 mm) Subcutaneous Veins of the Lower Extremities in the Upright Position
    • Reticular Veins: Dilated (1-3 mm) Thin-Walled Superficial Venules
    • Telangiectasias (Spider Veins): Dilated (0.1-1.0 mm) Superficial Venules, Capillaries & Arterioles
  • Serpentine Branches of:
    • Great Saphenous Vein
    • Small Saphenous Vein
    • Collateral Veins
  • Often Associated with Superficial Venous Insufficiency

Risk Factors

  • Smoking
  • Elderly
  • Obese
  • Pregnancy
  • Low Activity
  • DVT

Symptoms

  • Most Patients are Symptomatic
  • Aching/Pain
  • Burning
  • Swelling
  • Heaviness
  • Bleeding
  • Ulceration

Treatment

  • Evaluate for Venous Insufficiency Prior to Treatment
    • If Superficial Venous Insufficiency Found Consider Concurrent Treatment vs Delayed Treatment of Varicose Veins After Treatment of Insufficiency (Debated)
    • Never Treat Varicose Veins Before Superficial Insufficiency – Will Recur
  • Conservative Management: Compression & Elevation
    • Can Promote Symptomatic Relief
    • Will Not Resolve Underlying Pathology
  • Definitive Treatment Options:
    • Sclerotherapy – Often Preferred
    • Endovenous Laser Ablation (EVLA)
    • Stab Phlebectomy
    • High Ligation
    • Axial Stripping

Varicose Veins 3

Varicose Veins 4

References

  1. Chatterjee SS. Venous ulcers of the lower limb: Where do we stand? Indian J Plast Surg. 2012 May;45(2):266-74. (License: CC BY-NC-SA-3.0)
  2. Seyahi E, Yurdakul S. Behçet’s Syndrome and Thrombosis. Mediterr J Hematol Infect Dis. 2011;3(1):e2011026. (License: CC BY-2.0)
  3. National Heart Lung and Blood Institute. Wikimedia Commons. (License: Public Domain)
  4. Wikimedia Commons. (License: Public Domain)