chronic venous disease: in brief
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chronic venous disease for general surgical residents
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chronic venous disease: in brief
- 1. FB Fanpage: Happy Friday Knight
- 2. Outlines • General Consideration: Definition and Risk Factors • Anatomy of venous system • Pathophysiology • Clinical presentation • Scoring system • Investigation • Management of CVD
- 3. Definition: VEIN-TERM • Chronic venous disease (CVD) • Any morphological and functional abnormality of venous system • Long duration • Manifest signs and/or symptoms • Need for intervention and/or care • Chronic venous disorders • Full spectrum of morphological and functional abnormalities • Either manifest signs/symptoms or not • Chronic venous insufficiency (CVI) • Advanced CVD: C3 to C6
- 5. C: Clinical Abnormal dilated vein around ankle panniculitis (inflammation of the layer of fat under the skin) White atrophie
- 8. Risk Factors • female • age • obesity • prolonged standing • positive family history • parity
- 9. Anatomy of Lower Limb Venous System • Venous system: • Superficial veins • Consist of GSV, SSV and tributaries • Lie uppermost fascial layer of the thigh and leg • Perforating veins • Connect superficial and deep system • Deep veins • Follow the course of major arteries
- 11. Pathophysiology of CVD • Superficial veins • Valve incompetence • Changes in vasomotor tone • Reflux • Inflammatory phenomena • Deep veins • Obstruction • Reflux • Secondary to DVT
- 12. Clinical Presentation • Symptoms • Signs • Acute complications
- 13. Clinical Presentation: Symptoms • Extremely variable • Heaviness • Tired legs • Feeling of swelling • Skin itching • Nocturnal cramps • Throbbing • Burning pain • Aching of the legs • Exacerbated by prolonged standing or sitting • Venous claudication: pain on exercise
- 14. Clinical Presentation: Signs • C1 to C6
- 15. Clinical Presentation: Acute Complications • Uncommon • Most common: superficial vein thrombosis (SVT) • hemorrhage
- 16. Scoring Systems • For quality improvement and research • Dynamic assessment of the patient status over time
- 19. Clinical Examination • History taking: • Venous symptoms • Thromboembolic history • Allergies • medication • Physical examination: • Examine in standing position if possible • Look for signs C1 to C6 • Scar of previous VV surgery • Look for abdominal wall collaterals • Look for arterial, ortho, rheumato, neuro diseases • Measure both legs circumference • photograph
- 20. Investigation • Handheld Doppler US • Duplex US • Cross sectional imaging • MRV • CTV • Endovenous imaging • Venography • IVUS • Plethymography
- 21. Investigation: Doppler • No information of venous morphology • Adjunct if concomitant atherosclerotic disease
- 22. Investigation: Duplex US • Primary diagnostic test of choice for CVD • Information: • venous anatomy • patency • vein wall pathology • Flow • Upright position with knee slightly bent • Reflux test: Valsalva maneuver, pneumatic pressure cuff, manual compression
- 23. Investigation: DUS • Varicose veins • CFV, FV, POPV exam for patency, reflux, post-thrombotic obstruction • GSV, AASV, SSV, SFJ, SPJ: exam for reflux • Venous leg ulcers: • Look for perforator incompetence
- 24. Diagnostic Strategy • DUS: dx, rx, intra-op guidance, post-op assessment, surveillance • Full leg DUS should be performed routinely • Others as indicated
- 27. Conservative Treatment • Physical methods • Compression • Pharmacological treatment
- 28. Conservative Treatment: Physical Methods • Adjuncts to interventional treatment • Exercise targeting lower limb muscle strength and ankle mobility • Promote weight loss • Strengthen calf muscle pump • Increase ROM of ankle • Leg elevation • Holistic approach
- 29. Conservative Treatment: Compression • Check pulse before use • Modalities: • Elastic compression stockings • Adjustable compression garments • Inelastic bandages • Intermittent pneumatic compression devices
- 31. • Symptomatic CVD: elastic compression stocking pressure at ankle at least 15 mmHg • C3, C4b, post-thrombotic syndrome: pressure 20 – 40 mmHg Conservative Treatment: Compression
- 34. Management of CVD: Interventional Treatment • For superficial venous incompetence • For deep venous pathology • Venous ulceration • Pelvic venous disorders causing VVs • Special consideration • Gaps
- 35. Intervention for Superficial Venous Incompetence • General principles and strategy • Sites: GSV, SSV, AASV, tributaries • Techniques
- 36. • Principles and strategy • reflux lasting > 0.5 seconds on DUS • Symptomatic C2 to C6 • Anesthesia: tumescence: 500 ml • Crystalloid 445 mL • 1% lidocaine + 1: 100 000 adrenaline 50 mL • 8.4% NaHCO3 5 mL • Compression after treatment • 40 mmHg • 3 – 10 days Intervention for Superficial Venous Incompetence
- 37. • Techniques • Thermal ablation: endovenous, radiofrequency • Non-thermal ablation: glue, foam, MOCA • High ligation and stripping • Phlebectomies • hybrid Intervention for Superficial Venous Incompetence
- 48. Step of Procedure: Conventional HLS • Anesthesia: spinal block ± tumescence • Incision: • 1 -2 cm along inguinal skin crease • 3 – 4cm long medial from femoral pulse • Steps: • Approach SFJ and ligate 5 tributaries • High ligation of GSV: 1 cm from SFJ • Vein stripping at the level of knee by cannulate stripper wire from GSV opening, incision at tip of wire as a landmark, encircle wired GSV, ligate, then strip • Concomitant stab avulsion