1. VENOUS INSUFFICIENCY P. Altes Mas, MD, FEBVS
Angiology and Vascular Surgery
Hospital Universitari Germans Trias i Pujol

2. DEFINITION
Chronic venous insufficiency encompasses diseases of the lower limb veins in which venous return is impaired, usually over a number of years, by reflux, obstruction or calf pump failure
This leads to venous hypertension

3. INTRODUCTION
Varicose veins and their complications affect up to half of the adult poplulation and lead to significance reduction in health-related quality of life (HRQL)
Treatment of such diease is given a low priority, clinically and in terms of research
VV surgery is a common cause of medico-legal claims and recurrence rates remain stubbornly high
Successfully meeting the expectations requires excellent comunication skills, as well as understanding of the anatomy, pathophysiolgy and available treatments

4. Physical activity mandatory Human genome not adapted :
The evolution…
Hunter/gatherer
Click n deliver
Human genome:
Few food
Physical activity mandatory
Human genome not adapted :
Plenty of food
Few physical activity 
Energy accumulation 4

5. VEIN ANATOMY 5

6. VEIN PHYSIOLOGY
IN THE VEIN PHYSIOLOGY WE SEE IT IS A SYSTEM THAT DEPENS ON MUSCLE CONTRACTION AND VALVES

7. PATHOPHYSIOLOGY Venous hipertension
VARICOSE VEINS
POST-TROMBOTIC SEQUELA

8. PATHOPHYSIOLOGY

9. PATHOPHYSIOLOGY
Primary valve failure: degenerative changes in the valve annulus
Secondary valve failure: weakness in the vein wall
The objective severity of VV is determined by the severity of that reflux and the ability of the patients´s calf muscle pump to overcome the haemodynamic consequences

10. ETIOLOGY
Multifactorial and complex, where the interaction between ambiental and genetical factors play an important role

11. DIAGNOSIS CLINICAL SIGNS AND SYMPTOMS PHISICAL EXPLORATION DUPLEX SCAN
Con la anamnesis y la exploración física podemos confirmar la presencia y el sector implicado, pero no localizamos el punto exacto de fuga o la válvula/s responsables

12. DUPLEX ULTRASONOGRAPHY
Routine preoperative duplex examination led to an improvement in results 2 years after surgery for patients with primary varicose veins*
*Blomgren L, Johannsen G, Bergqvist D. Randomised clinical trial of routine preoperative duplex imaging befor varicose vein surgery. Br J Surg 2005;92:688-94

13. CLINICAL FEATURES Swelling: due to oedema fluid
Skin changes: varicose eczema and pigmentation
Ulceracion: in the lower leg, more commonly medial
Varicose veins: the absence does not exclude reflux
Pain: general ache and heaviness in the leg, after standing in the end of the day

14. SIGNS
CEAP classification:
1. Telangiectasies or reticular veins

15. SIGNS
CEAP classification
2. Varicose veins

16. SIGNS
CEAP classification
3. Oedema

17. SIGNS
CEAP classification
4. Pigmentation or eczema

18. SIGNS
CEAP classification
5. Helaed venous ulcer

19. SIGNS
CEAP classification
6. Active venous ulcer

20. TREATMENTS

21. TREATMENT OPTION Water steam Sclerotherapy COMPRESSION THERAPY
Medication
Sclerotherapy
COMPRESSION THERAPY
Criosclerotherapy
Endoscopic ligature
Laser
Endolaser
Lo primero que se nos ocurre al ver tantas posibilidades de tratamiento es que ninguna es buena; sino alguna se impondría y si lo hace es por modas o de forma temporal. Las nuevas técnicas se van incorporando pero no acaban de desplazar a las previas.
Todas las técnicas quIrúrgicas si están bien realizadas mejoran la calidad de vida del paciente (síntomas); su utilización depende de la preferencia del cirujano, de intereses “mercantiles” . La idea en conseguir el menor dolor postoperatorio, el tratamiento ambulatorio y disminuir la posibilidad de recidivas.
Radiofrequency
CHIVA
Stripping
Criosurgery
Water steam
Flebectomy

22. PREVENTION
TRY TO MAXIMIZE ALL ACTIVITIES INVOLVED IN MUSCLE COMPRESSION

23. PHARMACOLOGICAL TREATMENT
Flebotonic
Nutritional complements
Symptoms relieve
Not organical improvement

24. GRADUATED COMPRESSION
Symptoms relieve
Prevent skin deterioration
Uncomfortable

25. SURGICAL TREATMENTS
Surgical treatments provides symptomatic relief and significant improvements in the quality of life in patients refered to secondary care with uncomplicated varicose veins*
* Michaels JA, Braizier JE, Campbell WB et al. Randomizes clinical trial comparing surgery with conservative treatment for uncomplicated varicose veins. Br J Surg 2006; 93:175-81

26. SURGICAL TREATMENTS
For patients with uncomplicated varicose veins and evidence of sapheno-femoral or sapheno-popliteal reflux, surgical treatment offers a modest health benefit for relatively little addtional National Health System cost relative to conservative treatment*
* Ratcliffe J, Brazier JE, Campbell WB et al. Cost-effectiveness analisys of surgery versus conservative treatment for uncomplicated varicose veins ina a randomized clinical trial. Br J Surg 2006; 93:182-6

27. SURGICAL TREATMENTS
Patient should be warned about the common consequences of surgery:
Bruisings
Areas of paesthesias
It´s impossible to remove all prominent veins with a stab avulsion technique

28. SURGICAL TREATMENTS GREAT SAFENOUS VEIN STRIPPING

29. SURGICAL TREATMENT STRIPPING
ONLY TREATS GREAT SAPHENOUS VEIN!!!!
CLOSURE OF PERFORANTS WITH COMPRESSION

30. SURGICAL TREATMENT One of the least invasive techniques: CHIVA
CHIVA: cure conservatrice et hémodynamique de l'insuffisance veineuse en ambulatoire
The ambulatory conservative hemodynamic correction of venous insufficiency method an approach based on venous hemodynamics with deliberate preservation of the superficial venous system
There are many surgical options: one of that is CHIVA based on the venous hemodynamics. It is more an strategy that a tecniche an can be aplied to all type of veins

31. CHIVA Venous hemodynamics: ultrasound
It´s an strategy based on surgical mapping
Day-case surgery under local anaesthesia

32. CHIVA: INTERRUPTION OF POINTS OF REFLUX
EXTIRPATION OF INCOMPETENT SEGMENTS
CONVERT TO A CORRECT DRAIN SYSTEM

33. SURGICAL TREATMENTS
Cochranes review evaluated the effectiveness and safety of the CHIVA method in CVI and included four randomized controlled trials with 796 participants*
CHIVA method reduced recurrence of varicose veins and produce less bruising and nerve damage than vein stripping
*Bellmunt-Montoya S, Escribano J, Dilme J, Martinez-Zapata M. CHIVA method for the treatment of chronic venous insufficiency. Cochrane Database of Systematic Reviews 2013, Issue 7. Art.

34. ENDOVENOUS LASER ABLATION (EVLA)
Involves using a percutaneous placed catheter to deliver laser light energy to create thermal damage to the vein

35. ENDOVENOUS LASER ABLATION
As effective as well-performed surgery but less morbidity and “down time”*
Expensive, it only treats the great saphenous vein
It´s LASER
*Darwood RJ, Theivacumar N, Dellagrammaticas D et al. Randomised clinical trial comparing laser ablation with surgery for the treatment of primary great saphenous varicose veins. Br J Surg 2008; 93:

36. RADIOFREQUENCY ABLATION (RFA)
Involves using a percutaneous catheter to deliver radiofrequency energy to the vein

37. RADIOFREQUENCY ABLATION (RFA)
The 2-year clinical results of RFA are at least equal stripping of GSV with improved quality of life*
Expensive and only treats the GSV
*Lurie F, Creton D, Eklof B et al. Prospective randomised study of endovenous radiofrequency obliteration (closure) versus ligation and vein stripping (EVOLVeS): two-year follow-up. Eur J Vasc Endovasc Surg 2005;29:67-73

38. SCLEROTHERAPY
The aim is to pace sclerosant in the vein lumen empty of blood and appose the walls with compression
Types sclerosants:
- detergent: polidocanol/ sodium tetradecyl sulphate
- osmotic: hypertonic saline
- chemical irritant: chromated glycerine

39. SCLEROTHERAPY
Tessari method: the conversion of detergent from liquid phase to foam:
Increases power
Pushes the blood out
Becomes echogenic

40. SCLEROTHERAPY
Ultrasound-guided foam sclerotherapy (UGFS) appears to be as effective as surgery, EVLA and RFA in the treatment of VV*
*Myers KA, Jolley D, Clough A et al. Outcome fo ultraosun-guided sclerotherapy for varicose veins: medium-term results assessed by ultrasound surveillance. Eur J Vasc Endovasc Surg 2007;33:116-21

41. SCLEROTHERAPY Many sessions Pigmentation
Treatment of any kind varicose veins
Good for recurrence
No special equipment
Quick
Not need to stop anticoagulation

42. VULVAL AND PERINEAL VARICES
Women after pregnancy or following pelvic vein thrombosis
Ovarian and internal iliac venous valve incompetence
Related to pelvic congestion sindrome
DX: US/MR/CT

43. VULVAL AND PERINEAL VARICES
Treatment: radiological ovarian vein scleroterapy and embolisation with coils*
*Creton D, Hennequin L, Kohler F et al. Embolisation of symptomatic pelvic veins in women presenting non-saphenous varicose veins of pelvic origin- three year follow-up. Eur J Vasc Endovasc Surg 2007; 34:112-17

44. Take home message!
Intervention for symptomatic VV improve quality of life
VV surgery is a common cause of medico-legal claims
Meeting the expectations requires excellent comunication skills
Ultrasound strongly recomended before any kind of surgery

45. Thanks for the attention!