Venous Insufficiency of the Lower Extremity Physiology & Pathophysiology S. Lakhanpal MD, FACS President & CEO Center for Vein Restoration.

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Presentation transcript:

Venous Insufficiency of the Lower Extremity Physiology & Pathophysiology S. Lakhanpal MD, FACS President & CEO Center for Vein Restoration

Center for Vein Restoration has forty centers mostly in the Mid-Atlantic and the NE, providing state of the art vascular care in a compassionate and cost efficient manner in the outpatient setting.

Center for Vein Restoration Maryland/Virginia/DC Offices CVR CVM V IENNA T YSONS C ORNER DC 2- V ARNUM ST F REDRICK C ATONSVILLE F AIRFAX/ F AIROAKS F REDRICKSBURG H ERNDON O WINGS M ILLS M ANASSAS

Center for Vein Restoration NY, NJ, CT and PA Offices CVR CVM S TAMFORD W HITE P LAINS S CARSDALE H ACKENSACK N ORWALK N ORTH B ERGEN M ONTCLAIR B RISTOL PA NY CT NJ W OODLAND P ARK

Center for Vein Restoration Michigan Offices CVR CVM G RAND R APIDS

Physiology: Hemodynamics of the Infra-diaphragmatic Venous System

Hemodynamic Monitoring of Venous Stenosis J Vasc Surg 1986; 4:42-54 The diagnosis and treatment of venous disease did not progress for a long time because of lack of suitable investigative techniques. Goal of the investigations for lower extremity disease; – Establish the presence or absence of post ambulatory venous hypertension(AVH) – Identify the hemodynamic cause of this (P)AVH. Goal for infra-diaphragmatic pelvic disease – Identify the hemodynamic significance of a lesion. Phlebography(venography) is purely an anatomic not hemodynamic.

How does the calf muscle pump function?

Normal Venous Pressures in the Lower Extremity Hydrostatic pressure in the saphenous vein(at the ankle) at rest in a patient: mmHg. The pressure in the saphenous vein at the end of exercise is called Ambulatory venous pressure(AVP). – Normally Post exercise Hydrostatic pressure is reduced to <30 mmHg. – When active contractions cease Volume filling begins within 5-7 secs, about secs. are required to restore hydrostatic pressure in the normal limb.

Normal Pressure Relationships in the Lower Extremity Pressure is reduced from the resting hydrostatic pressure to a mean of 22mmHg within 7-12 steps. When resuming a static standing position hydrostatic pressure is restored to in a mean of 31 seconds. When resuming a static standing position the volume is restored to baseline a mean of 40 seconds. The pressures at the skin and superficial veins correlate best to the dermal pathophysiological changes During the contractions the intravenous pressures in the deep veins is higher than that of the superficial veins, however it is in the post contraction, relaxation phase that the pressure gradient favors superficial to deep flow. Fig 8 The pressure and volume changes with activation of the calf muscle pump are demonstrated. Beginning in the standing posture, the hydrostatic pressure baseline is demonstrated in a dependent, but non-weight bearing limb. The subject then performs 10 t... Mark H. Meissner, Gregory Moneta, Kevin Burnand, Peter Gloviczki, Joann M. Lohr, Fedor Lurie, Mark A. Matto... The hemodynamics and diagnosis of venous disease Journal of Vascular Surgery, Volume 46, Issue 6, Supplement, 2007, S4 - S24

Fig 7 Relative venous hydrostatic ( HP ) and dynamic ( DP ) pressures at various heights ( Ht ) and distances from the right atrium ( RA ) in the upright individual... Mark H. Meissner, Gregory Moneta, Kevin Burnand, Peter Gloviczki, Joann M. Lohr, Fedor Lurie, Mark A. Matto... The hemodynamics and diagnosis of venous disease Journal of Vascular Surgery, Volume 46, Issue 6, Supplement, 2007, S4 - S24 Relative Venous Hydrostatic and Dynamic Pressures at Various Heights

Post Exercise Pressures of > 30 mmHg = Ambulatory Venous Hypertension

Thank You