Understanding Chronic Venous Insufficiency Khusrow Niazi, MD, FACC, FSCAI Director, Peripheral Vascular Intervention Emory University Atlanta, USA

Khusrow Niazi, MD, FACC, FSCAI  Disclosure: Research Grants: Medtronic Bard Peripheral Spectranetics   Speaker/Consultant: Examples of relationships are: Advisory Board/Board Member, Consultant, Honoraria, Research Support, Speaker’s Bureau, Stockholder Please list full company name

57 y.o M referred by Dr. Q for leg aching, swelling and cramps at night time. Pt states he has had these symptoms for some years and are getting worse. Also he has had pigmentation of his skin since age 30 that he has been told is due to smoking. He has CAD and has stents in 2009 and 2010 in Macon. Diet controlled diabetes, HTN and sleep apnea 57 y.o M referred by Dr. Q for leg aching, swelling and cramps at night time. Pt states he has had these symptoms for some years and are getting worse. Also he has had pigmentation of his skin since age 30 that he has been told is due to smoking. He has CAD and has stents in 2009 and 2010 in Macon. Diet controlled diabetes, HTN and sleep apnea

? What’s the prevalence How is this different from arterial disease?

Prevalence of Vein Problems More people in the U.S. miss productive work time due to vein problems than from artery problems. The most common leg ulcer in wound centers across the U.S. is the venous stasis ulcer, not the diabetic ulcer as is commonly thought. Nearly 5% of the U.S. population suffers from some type of leg vein abnormality.

Annual Incidence and Prevalence of Venous Insufficiency Venous reflux disease is 2x more prevalent than coronary heart disease (CHD) and 5x more prevalent than peripheral arterial disease (PAD)1

Prevalence of Varicosities by Age and Sex Age Female Male 20-29 8% 1% 40-49 41% 24% 60-69 72% 43%

Risk factors Heredity Age Female sex Obesity Pregnancy Prolonged standing Greater height

External Iliac v. Common Femoral v. Deep Femoral v. Femoral v. Popliteal v. Gastrocnemius vv. Soleal v. Post Tibial vv

Femoral v. Great saphenous v. Ant accessory great saphenous v. Post accessory great saphenous v. Post accessory great saphenous v. Great saphenous v.

Cranial extension of the small saphenous v. Intersaphenous v. Popliteal v. Small saphenous v. Dorsal venous arch

Venous HTN Reflux via incompetent valves Venous outflow obstruction Failure of calf- muscle pump

SPECTRUM OF VARICOSE VEINS Leg Pain or Aching or Heaviness Leg Cramps or Tingling Leg Swelling or feeling of swelling Itching Restless Legs Varicose veins Spider Veins Blood Clots Bleeding Ulcers

? How do you diagnose?

Ultrasound Diagnostic Study Required in order to determine the source of reflux Required in order to determine the source of reflux Evaluate for venous occlusion or thrombus Evaluate for venous occlusion or thrombus Map the course of the incompetent superficial veins

Transverse view of GSV

Diagnostic testing for Venous insufficiency CVI Venous Doppler *technique* S. V. reflux >3secs Stasis ulcer Stasis dermatitis S.V. reflux >3secs Vein diameter Symptoms Deep vein reflux No reflux Compression stockings Ablation

Treatment Options Conservative Therapies: Surgical Treatments: Exercise Leg elevation Compression Stockings Unna Boot These therapies treat the symptoms, not the underlying cause… Surgical Treatments: Vein Stripping & Ligation Exercise programs that target the calf muscle pump can improve the symptoms associated with venous insufficiency. Leg elevation is often prescribed to alleviate the pressure in the lower legs. Compression stockings or compression therapy narrows the veins, decreases venous volume, and reduces venous reflux by shifting blood volume. Compression therapy may be effective in relieving swelling and pain and can be used alone or in combination with other therapies, but compliance is usually poor. Unna Boot is used to treat venous disease which has progressed into venous ulcers. A moist gauze bandage made up of zinc oxide, calamine lotion and glycerine. It promotes healing, increases blood return to the heart and reduces infection. The boot is wrapped from the toes to just below the knee, covering the ulcer and the lower leg. The gauze then dries and hardens. An elastic bandage is wrapped snugly over the Unna boot. Conservative treatments often have poor patient compliance because they: - are difficult for patients to integrate into daily routine - are uncomfortable - require lengthy (lifelong) treatment - do not cure the underlying problem (pathology) Vein stripping and ligation is a surgical procedure that involves tying off the varicose veins associated with the main superficial vein in the leg and then using a specialized tool to physically remove the vessel. For nearly a century, this procedure was the standard surgical technique for treating severe venous reflux disease (Criqui MH et al. Epidemiology of chronic peripheral venous disease; JJ Bergan Editor, The Vein Book, Elsevier Academic Press (2007): 234 – 235) Usually performed in a hospital operating room under general anesthesia, a vein stripping procedure typically begins with an incision in the groin area to expose and ligate, or tie off, the diseased great saphenous vein and surrounding tributary veins. A stripping tool is inserted and threaded through the great saphenous vein, down along the length of the thigh and out through the skin just below the knee. The top of the vein is then tied to the stripping tool, which is pulled from below the knee to remove the vein from the leg (Rabe E, Pannier F. Epidemiology of chronic venous disorders; P. Glovicki, Editor, Handbook of venous disorders (3rd edition), Hodder Arnold (2009); 403 – 404) Recovery period following vein stripping surgery may run as long as four weeks before patients can return to normal activities

Treatment Options (cont’d) Non-Surgical Treatments: Endovenous ablation Radiofrequency LASER Chemical Ablation Medical Glue Venaseal® Non Surgical Treatments Both minimally-invasive treatments are outpatient procedures performed using imaging guidance. A thin catheter is inserted into the vein and is guided up the great saphenous vein in the thigh. Then laser or radiofrequency energy is applied to the inside of the vein. This heats the vein and causes the vein to close. Ultrasound study Duplex ultrasound is performed to assess the venous anatomy, vein valve function, and venous blood flow changes, which can assist in diagnosing venous insufficiency. The doctor will map the great saphenous vein and examine the deep and superficial venous systems to determine if the veins are open and to pinpoint any reflux. This will help determine if the patient is a candidate for a vein ablation procedure.

Take home message…..

Location of Ulcer J Vasc Surg 2007;45:S5-S67

History Leg pain/ulcer Physical exam Arterial insufficiency Venous insufficiency Other causes ABI Venous Doppler

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