1. Venous Stasis
Joon Ho Jang MD

2. Incidence/Prevelance & JOBST Coverage
It is estimated that more than 80 million Americans suffer from some form of venous disorder.
Up to 13 million people in the U.S. suffer from CVI
Peak incidence occurs in women aged 40-9 and men aged years
Statistics show one in three Americans over the age of 45 is affected by vein disease, and of those, only 4% are
being treated.
Annual health care cost in the US to treat CVI is about $3billion; about 2 million workdays are lost per year due to venous ulcers
Varicose Veins
More than 24 million Americans have varicose veins
Up to 50% of women have varicose veins while 24% of men aged and 43% of men over 70 have varicose veins
DVT / PTS
There are over 200,000 new cases of DVT each year in the U.S.
The incidence of pulmonary embolism in patients with DVT ranges from 5 – 20% and can be fatal
After an episode of DVT, 20 – 50% of patients develop Post Thrombotic Syndrome within the first 2 years
Venous Stasis Ulcers
Affect 2.5 million people in the U.S.
An estimated 500,000 persons are newly diagnosed each year

3. Venous Stasis…How? Mechanics Structure Inflammation Pressure
Obstruction- DVT

4. Function Transport blood back to the heart
Prevent intravascular volume overload

5. Anatomy Tunica intima: endothelium with BM and elastic lamina
Produces endothelium derived relaxing factor and prostacyclin
Tunica media: Circumferential SM
Maintains venous pressure gradient
Tunica externa: Collagen
Stability

6. Valves Venous valves: One way
Two cusps of CT skeleton covered by endothelium
Closure at > 30cm/s
Exception: IVC, common iliacs, portal, cranial sinus

7. Lower Extremity

8. Venous Hypertension
Hydrostatic pressure vs Mechanical/muscular pressure
A. K. Tassiopoulos et al.
1153 cases of ulcerated legs and venous disease
Reflux in superficial, deep, and perforating veins
Incompetent valves

9. Valvular Dysfunction
Physical damage: splitting, tearing, thinning, adhesion to wall
Reduction in number
Not age related
Monocyte and macrophage infiltration
Overexpression of Intracellular adhesion molecules
Wall hypertrophy, disruption of collagen synthesis, and destruction of extracellular matrix proteins

10. Shear Stress and Inflammation
Pulsatile venous blood flow
Valve closes: Pvortical > Pluminal
Minimal shear stress
Low shear stress starts cascade of inflammatory signals

11. Risk Factors Genetic More in females Hormones Pregnancy Age: >50
Progesterone, estrogen
Pregnancy
Age: >50
Greater height
Prolonged standing
Obesity

12. Signs and Symptoms Telangiectasias Reticular veins Varicosity
Thrombophlebitis
Hyperpigmentation
Bleeding from clusters
Ulceration
Aching
Heaviness
Early fatigue
Edema
Itching
Restless legs
Cramps

15. Physical Exam, Diagnostic Tests
Palpable veins
Perthes Test
For deep venous patency
Tourniquet and walk
Brodie-Trendelenburg Test
For superficial vein and valve patency
Venous filling time: normal- within 35 secs
Duplex Ultrasound
Venography

16. Classification: CEAP *Eklof et al. J of Vasc Surg 2004
Clinical classification
C0: no visible or palpable signs of venous disease
C1: telangiectasies or reticular veins
C2: varicose veins
C3: edema
C4a: pigmentation or eczema
C4b: lipodermatosclerosis or atrophie blanche
C5: healed venous ulcer
C6: active venous ulcer
S: symptomatic, including ache, pain, tightness, skin
irritation, heaviness, and muscle cramps, and other
complaints attributable to venous dysfunction
A: asymptomatic

17. CEAP Etiologic classification Ec: congenital Ep: primary
Es: secondary (post-thrombotic)
En: no venous cause identified
Anatomic classification
As: superficial veins
Ap: perforator veins
Ad: deep veins
An: no venous location identified
Pathophysiologic classification
Basic CEAP
Pr: reflux
Po: obstruction
Pr,o: reflux and obstruction
Pn: no venous pathophysiology identifiable

18. Treatment Compression Therapy Drug Therapy Surgery
Stockings, Unna’s Boot
Drug Therapy
Surgery

19. Compression Stockings
Worn during the day
Elastic stockings with adjustments in pressure
Lower pressure stockings (20-30mm Hg) for edema and DVT prophylaxis
Higher pressure (30-40+mm Hg) for ulcers and significant venous disease
Operator dependent
Difficult to put on
Physical impediments/Co-morbidities
50% of patients were unable to them on alone
30-65% noncompliance noted in clinical trials in venous centers

20. Efficacy of Compression Therapy
22 trials comparing healing of venous ulcers using compression stockings
Compressive therapy more effective than non-compression
Higher pressure were more effective than lower
Multilayer compression was better than single layer bandaging
466 patients with a healed ulcer
Continued use of compression stocking reduced reoccurrence within 3-5 year
ESCHAR study: 500 limb trial that compares surgery and compression vs. compression alone for ulcer treatment
Combination therapy had lower rates of reoccurrence of ulcer at year 4 (24% vs. 52%)

21. Drug Therapy Pentoxifylline
PDE4 inhibitor that increases intracellular cAMP and stimulates protein kinase A activity
Reduces blood viscosity and decreases platelet aggregation and thrombus formation
Variable efficacy

22. More invasive Sclerotherapy
0.2% sodium tetradecyl injected directly into spider angiomas and smaller superficial varicosities
Complications (<5%): allergic reaction, hypo/hyper-pigmentation, local skin necrosis
Endovenous laser ablation of saphenous vein (EVLT)
Surgical excision of veins (“Stripping”)

23. Efficacy Meta-analysis of 64 studies (12,320 legs)
Anaylzed ablation via Duplex US
Follow upto 5 years
Success rate of EVLT highest after 5 years
Complications: DVT (<3%), local bruising and pain, paresthesias, foam emboli, stroke

24. Works Cited
Raju et al. Chronic venous insufficiency and varicose veins. NEJM 2009;360:
Bergan et al. Chronic venous disease. NEJM 2006;355:
Tassiopoulos et al. Current concepts in chronic venous ulceration. Euro J Vasc Endovasc Surg 2000;20:
Ono et al. Monocyte inflitration of venous valves. J Vasc Surg 1998;27:
Sansilvestri-Morel et al. Imbalance in the synthesis of collagen type I and collagen type III in smooth muscle cells derived from human varicose veins. J Vasc Res 2001;28:560-8.
Jacob et al. Extracellular matrix remodeling in the vascular wall. Pathol Biol 2001;49:326-32
Eklof et al. Revision of the CEAP classification for chronic venous disorders: Consensus statement. J Vasc Surg 2004;40:
Cullum et al. Copression bandages and stockings for venous leg ulcers. Cochrane Database Syst Rev 2000;2: CD000265
Mayberry et al. Fifteen-year results of ambulatory compression therapy for chronic venous ulcers. Surgery 1991;109:
Barwell et al. Comparison of surgery and compression with compression alone in chronic venous ulceration (ESCHAR study): randomised controlled trial. Lancet 2004;363:
Van den Bos et al. Endovenous therapy of lower extremity varicosities: a meta-analysis/ J Vasc Surg 2009;49:230-9.