chronic venous insufficiency

1. BTKVResident of Cardiothoracic and Vascular Surgery,
Universitas Indonesia
Chronic Venous Insufficiency
Kevin Dilian Suganda
Mentor
Dr.Dicky Aligheri Wartono,Sp.BTKV (K)
Presented by

2. Definition
Ch ron ic Ven ou s In su ffic ien c y
Chronic venous insufficiency (CVI)
resulting from venous reflux or obstruction
leads to venous hypertension.
Cires-Drouet, R. S., Fangyang, L., Rosenberger, S., Startzel, M., Kidwell, M., Yokemick, J., … Lal, B. K. (2020). High
prevalence of chronic venous disease among health care workers in the United States. Journal of Vascular Surgery:
Venous and Lymphatic Disorders, 8(2), 224–230. doi:10.1016/j.jvsv.2019.10.017
2

3. FR
Beebe-Dimmer, J. L., Pfeifer, J. R., Engle, J. S., & Schottenfeld, D. (2005). The Epidemiology of Chronic Venous Insufficiency and Varicose Veins. Annals of Epidemiology, 15(3), 175–184. doi:10.1016/j.annepidem.2004.05.015 a footer
3
Risk Factors
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4. FRPrevalence of chronic venous disease among
health care workers in the United States
T h e b a s e l i n e c h a r a c t e r i s t i c s o f 6 3 6 p a r t i c i p a n t s ( 1 2 7 2 l e g s ) . T h e m a j o r i t y o f
p a r t i c i p a n t s w e r e w o m e n ( 9 3 % ) , a n d t h e m e d i a n a g e w a s 4 2 y e a r s
Cires-Drouet, R. S., Fangyang, L., Rosenberger, S., Startzel, M., Kidwell, M., Yokemick, J., … Lal, B. K. (2020).
High prevalence of chronic venous disease among health care workers in the United States. Journal of Vascular
Surgery: Venous and Lymphatic Disorders, 8(2), 224–230. doi:10.1016/j.jvsv.2019.10.017
4
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5. FR
Characteristic of Venous
Insufficiency
Pathogenesis
Ch ron ic Ven ou s In su ffic ien c y
Add a footer
5
CVI is caused by reflux
Increases
hydrostatic pressure
in the vein
The subcutaneous dermis and
skin
transmitted
This process occurs
with both primary and
secondary valvular
insufficiency
Blood flow
stasis
Vein distention and
endothelial activation
Leukocyte extravasation Transudative macromolecules
and iron
FE+2, Ferrous iron; PDGF, platelet-derived growth
factor; TGF-β, transforming growth factor-β.
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6. FR
Classification of CVI
th e CEA P ( Clin ic , Etiolog ic , A n atomic an d Path op hysiolog ical)
Lurie, F., Passman, M., Meisner, M., Dalsing, M., Masuda, E., Welch,
H., … Wakefield, T. (2020). CEAP classification system and reporting
standard, revision 2020. Journal of Vascular Surgery: Venous and
Lymphatic Disorders. doi:10.1016/j.jvsv.2019.12.075
6
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C
(Clinical)
E
(Etiology)
A
(Anatomy)
P
(Pathophysiology)
C0 : no visible or palpable sign
of venous disease
Ec : congenital As : superficial veins Pr : reflux
C1 : telangiectasis or reticular
veins
Ep : primary Ap : perforator veins Po : obstruction
C2 : varicose veins Es : secondary
(postthrombotic)
Ad : deep veins Pr.o : reflux and obstruction
C3 : edema En : no venous
cause identified
An : no venous
location identified
Pn : no venous pathophysiolo-
gy identifiable
C4a : pigmentation of eczema P1 : telangiectasias or reticular
veins
C4b : lipodermatosclerosis or
atrophic blanche
P2 : great saphenous vein
above the knee
C5 : healed venous ulcer P3 : great saphenous vein
below the knee
C6 : active venous ulcer P4 : small saphenous vein

7. FR
Venous Clinical Severity Score (VCSS) of CVI
Raju, S., & Neglén, P. (2009). Chronic Venous Insufficiency and
Varicose Veins. New England Journal of Medicine, 360(22),
2319–2327. doi:10.1056/nejmcp0802444
7
Interpretation
Mild 1 – 10
Moderate 11 – 20
Severe 21 - 30
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8. FR
Eberhardt, R. T., & Raffetto, J. D. (2014). Chronic Venous
Insufficiency. Circulation, 130(4), 333–346.
doi:10.1161/circulationaha.113.006898
8
CVI Examinations
Non-invasive Testing
Invasive Testing
CVI
Venous Duplex Imaging
Air Plethysmography
Computed Tomographic
or Magnetic Resonance
Venography
Contrast Venography
Intravascular Ultrasound
Ambulatory Venous Pressure
The gold standard in assessing the hemodynamics of CVI.
The technique involves insertion of a needle into the dorsal
foot vein with connection to a pressure transducer.
It is rapidly gaining acceptance in the
management of venous disease and is
increasingly being used to help guide
interventions
Venography may be used to directly visualize
the venous system by either an ascending or
descending approach
Advances in imaging with computed tomography
and magnetic resonance have allowed for their
use in the evaluation of venous disease.
Air plethysmography (APG) has the ability to measure each
potential component of the pathophysiologic mechanisms of
CVI, including reflux, obstruction, and muscle pump dysfunction
Itis currently the most common technique
used to confirm the diagnosis of CVI and
assess its etiology and anatomy and is highly
recommended in the CPG (grade 1A)
CVI
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9. FR
Venous Duplex Imaging
Eberhardt, R. T., & Raffetto, J. D. (2014). Chronic Venous Insufficiency. Circulation, 130(4), 333–346. doi:10.1161/circulationaha.113.006898 9
Diagnose the presence of reflux
 0.5 seconds for superficial veins
 1.0 second for deep veins.
Flow in the
direction of the feet
is because of
incompetent valves
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10. Treatment of Chronic Venous Insufficiency

11. FRManagement of CVI
Eberhardt, R. T., & Raffetto, J. D. (2014). Chronic Venous
Insufficiency. Circulation, 130(4), 333–346.
doi:10.1161/circulationaha.113.006898
11
KD

12. FR
Conservative Management of CVI
12
Conservative
Management CVI
Compressive Leg Garments
Wound and Skin Care
Exercise Therapy
Venoactive Drugs
The objective is to provide graded external compression
to the leg and oppose the hydrostatic forces of venous
hypertension
• Graded elastic compressive stockings
• Paste gauze boots
• Layered bandaging
• Adjust-able layered compression garments
The use of graded elastic compressive stockings
(between 20 and 50 mmHg of tension)
It is important to maintain skin health
and prevent infection
• Reduce fissuring & skin breakdown
• Statis Dermatitis
• Control wound fluid drainage & maceration
• Control infection & restore tissue
Topical moisturizers, often with lanolin
Topical steroid
Hydrocolloids and foam dressings
Silver impregnated dressings
Graded exercise programs have been used in CVI to
rehabilitate the muscle pump action and improve symptoms
Reduce inflammation of the venous wall,
Reduce oedema formation
The development of skin changes
Protect endothelial cells from contraction
Relief of symptoms is the main objective of
pharmacological treatment
Strong evidence exists for an objective
effect on oedema and venous symptoms
KD
Eberhardt, R. T., & Raffetto, J. D. (2014). Chronic Venous Insufficiency.
Circulation, 130(4), 333–346. doi:10.1161/circulationaha.113.006898

13. FR
13
Venoactive Drug
In fact venoactive drug represents a reduction
oedema volume of approximately 25%
The majority of venoactive drugs require a 3−4-week runin
phase before achieving oedema-reducing efficacy.
Venoactive drugs cannot restore varicose veins or
resolve obstruction.
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EMJ Dermatol. 2017;5[Suppl 2]:2-13

14. Interventional Management
Add a footer 14

15. FR
T h e l a r g e r v a r i c o s e v e i n s a r e r e m o v e d t h r o u g h s m a l l s k i n p u n c t u r e s a n d
h o o k s s p e c i f i c a l l y d e s i g n e d f o r t h i s p u r p o s e . I t i s o f t e n p e r f o r m e d i n t h e
o u t p a t i e n t s e t t i n g u s i n g l o c a l a n e s t h e t i c a n d t u m e s c e n t a n e s t h e s i a .
Phlebectomy
The principles
proper technique of
saphenous surgery
all sources of venous hypertension
must be controlled and eliminated
persisting reflux occurs after saphenofemoral
ligation without stripping when the greater
saphenous vein remains present in the thigh.
1
2
the refluxing saphenous
vein in the thigh
perforating veins in
the thigh and leg
Bergan, J. J. (2002). Advances in Venous Surgery: SEPS and
Phlebectomy for Chronic Venous Insufficiency. Dermatologic
Surgery, 28(1), 26–28. doi:10.1046/j.1524-
4725.2002.01185.x
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16. FR
Geersen, D. F., & Shortell, C. E. K. (2018). Phlebectomy Techniques for Varicose Veins. Surgical
Clinics of North America, 98(2), 401–414. doi:10.1016/j.suc.2017.11.008
16
Procedure Phlebectomy
the Trendelenburg
position Injecting tumescent
anesthesia
Make incisions perpendicular to
the vein keeping all horizontal.
Place on surgeon’s operative side
for easy pulling
Pinch the tissue over a bony
prominence to avoid
stabbing other structures
Catching the vein in the
phlebectomy hook
the vein
Anchor the vein
with a hemostat
Rock the vein back and
forth to extract
A 2-surgeon team can easily be used in
a larger phlebectomy case, reducing
operative time
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17. FR
Tr a n s i l l u m i n a t e d p o w e r e d p h l e b e c t o m y ( T I P P ) i s a m i n i m a l l y
i n v a s i v e t e c h n i q u e f o r v a r i c o s e v e i n r e m o v a l t h a t a d d r e s s e s
s o m e l i m i t a t i o n s o f t r a d i t i o n a l p r o c e d u r e s
Hartman, J., Wright, M., & Franz, R. (2012). Treatment of Varicose Veins by Transilluminated Powered Phlebectomy Surgery:
A 9-Year Experience. International Journal of Angiology, 21(04), 201–208. doi:10.1055/s-0032-1330229
17
Transilluminated Powered
Phlebectomy Surgery
Theoretical advantages of TIPP
• Decrease in the number of
incisions
• Removal of veins under direct
visualization
• Perceived faster technique for
removal of varicose veins,
especially large clusters.
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18. FR
Frank Vandy and Thomas W Wakefield (2012). Varicose veins:
evaluating modern treatments, with emphasis on powered phlebectomy
for branch varicosities. Section of vascular surgery USA
18
Procedure TIPP
TIPP (Trivex™, Inavein, MA, USA)
The Trivex system is made of a central tower
• Xenon light source,
• Irrigation pump
• Resection oscillation speeds.
Duplex ultrasound is used to confirm
ablation of the GSV as well as identify
subclinical hematomas or fluid collections.
One must be careful in examining the
patient’s bruising at this stage as fading
ecchymoses are often mistaken for cellulits.
Evaluating
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19. FR
O p e n s u r g i c a l p r o c e d u r e h a s b e e n t h e g o l d s t a n d a r d s u r g i c a l
p r o c e d u r e f o r l e g u l c e r a n d v e n o u s i n c o m p e t e n c e
High ligation, Division and Stripping (HL/S)
the great saphenous vein (GSV)
the short saphenous vein (SSV)
Add a footer 19
Large dilated and tortuous saphenous vein
located immediately under the skin
Aneurysmal enlargement at the
saphenofemoral junction
Case of thrombosed vein from past
thrombophlebitis attack where the probe
Channel for endovenous ablation
cannot be inserted
1
2
3
4
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20. FR
H i g h l i ga t i o n a n d d i v i s i o n o f G S V i s p e r fo r m e d a t t h e
l e v e l o f i t s c o n f l u e n c e w i t h c o m m o n fe m o ra l v e i n
Add a footer 20
High ligation and division
Ligation of GSV should be flushed with the
femoral vein to avoid a cul de sac
All the tributaries of GSV
ligated
divided
Ligation and division of SSV
• Done at the level of popliteal crease
• SSV is identified with an intra-operative
duplex scanning
• It can be ligated just below skin 3-4 cm
distal to the saphenopopleteal junction
Stripping
C o m p l e t e s t r i p p i n g i s u s u a l l y
a v o i d e d t o a v o i d p o s s i b l e
t r a u m a t o t h e n e r v e s
GSV
SSV
Done up to knee
Done up to mid-calf
• Perivenous tumescent anesthetic infiltration
reduces hemorrhages.
• Postoperative compression bandage also helps
to reduce bleeding
Stripping can be done either with:
• Intraluminal stripping method with silk thread or
• Cryostripping method, which is a new technique,
needs more study and is done with liquid nitrogen
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21. Add a footer 21

22. Ven ou s sc leroth erapy is a treatment mod ality for
ob literatin g telan g iec tases , varicose vein s, an d
ven ou s seg ments with reflu x.
Sclerotherapy
Nael, R., & Rathbun, S. (2009). Effectiveness of foam
sclerotherapy for the treatment of varicose veins. Vascular
Medicine, 15(1), 27–32. doi:10.1177/1358863x09106325
22
Sclerotherapy may be used as a primary treatment or in
conjunction with surgical procedures in the correction of CVI

23. FR
Indian Dermatol Online J. 2014 Jul-sel; 5(3): 390 - 395 23
Sclerotherapy
This is primarily used for
spider veins or telengiectasia
(size ≤3 mm)
The agent is injected with tuberculin
syringes and 30- or 32-gauge needle
Larger varicose
veins and proximal
parts affected are
treated first
Maximum 1.0 ml of the agent
per site and maximum 10-20
injections per session is
recommended
This is one of the most effective
and the least invasive among all
endovenous ablation techniques
with lower complication rates
Solution of polidocanol
mixed with carbon dioxide
(preferred) or air (max 20 ml)
It is injected, while the limb
is elevated at 30° and kept in
that position for 10-20 min
Intra-operative ultrasonography can monitor the
movement of the foam
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24. 24
Of the 217 legs that underwent EFS
• 142 (65%) achieved complete
obliteration,
• 73 (34%) achieved near-complete
obliteration,
• 2 (0.9%) had minimal obliteration
(after the initial injection)

25. FR
Th ermal en erg y in th e form of rad iofreq u en c y
or laser is u sed to ab late in comp etent vein s
Endovenous Ablative Therapy
Endovenous Laser
Ablation
(EVLA)
Radiofrequency
Ablation
(RFA)
810-nm or 940-nm diode
A potential complication of ablation remains deep venous thrombosis
and pulmonary embolism, although with a very low frequency.
It has provided excellent results,
with saphenous vein obliteration
in 93% at 2 years and no cases of
deep vein thrombosis
200 and 3000 kHz
90% of patients treated with
radiofrequency ablation are free
from saphenous vein reflux, and
95% of patients report satisfaction
and improvement of symptom
Eberhardt, R. T., & Raffetto, J. D. (2014). Chronic Venous Insufficiency.
Circulation, 130(4), 333–346. doi:10.1161/circulationaha.113.006898
KD

26. FRProcedure EVLA and RFA
EVLA
Target Vein
Using ultrasound (US) guidance, a
sheath is placed into the target vein
The fiber tip is placed at least 2
cm downstream from the deep
vein junction.
After the careful administration
of tumescent anesthesia,
ablation can proceed.
A randomized comparison of EVLA versus surgery (SFJ
ligation and GSV stripping) found higher rates of
clinically visible recurrence with EVLA at 5 years.
RFA
An electrode element is
inserted into the target vein
Thermal injury occurs
within the vein
lumen leading to
thrombosis and
eventual occlusion
The ClosureFast radiofrequency
ablation catheter.Dietzek, A. M. (2007). Endovenous
Radiofrequency Ablation for the Treatment
of Varicose Veins. Vascular, 15(5), 255–
261. doi:10.2310/6670.2007.00062
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27. 27
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28. E n d ove n o u s d e e p sy ste m t h e ra p y to re sto re ve n o u s
o u t f l ow a n d to p rov i d e re l i e f f ro m o b st r u c t i o n
Endovenous Deep System Therapy
Several series of patients with CVI and
outflow obstruction have shown that iliac
vein stenting resulted in significant
clinical improvement
complete pain relief in ≈50%
complete resolution of edema in ≈30%
complete healing of ulcers in ≈50%
Prognosis
The patency of iliac vein stents appears good, with primary
patency of 75% to 80% at 3 to 6 years for non thrombotic
disease but ≈60% for thrombotic disease.
Eberhardt, R. T., & Raffetto, J. D. (2014). Chronic Venous Insufficiency. Circulation, 130(4), 333–346.
doi:10.1161/circulationaha.113.006898

29. New amb u lator y su rg ical tec h n iq u e th at ob literates fac ial
d efec ts th rou g h wh ic h in comp etent calf p erforators cou rse
in patients with recalcitrant venous ulceration.
Perforator Ligation by
Purse-string Suture (PS)
(Vasc Surg 1997;25:437-41). 29
Identification perforator by
clinical examination and
venous Duplex scanning
The perforation area were
treated with Unna's compres-
sive bandages,
The perforating veins were
marked with indelible ink
after localization was
performed with a duplex
scanner.
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30. (J Vasc Surg 1997;25:437-41.) 30
Procedure Purse-string Suture (PS)
All ulcers healed within 6
weeks of the procedure
(mean, 23 days)
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31. FR
• Only used local anaesthesia puncture
• Without tumescent due to No thermal injury risk
• MOCA can be performed in the GSV and SSV which
doesn’t impact sural nerve injury like drop foot
M e c h a n o c h e m i c a l e n d o v e n o u s a b l a t i o n ( M O C A ) i s a n e w
t e c h n i q u e f o r t h e t r e a t m e n t o f v a r i c o s e v e i n s t h a t
c o m b i n e s m e c h a n i c a l d a m a g e t o t h e v e n o u s e n d o t h e l i u m
w i t h t h e i n f u s i o n o f a l i q u i d s c l e r o s a n t .
Mechanochemical Endovenous Ablation
(MOCA)
The major reasons to prefer MOCA
Van Eekeren, R. R. J. P., Boersma, D., Holewijn, S., Werson, D. A. B., de Vries, J. P. P. M., & Reijnen, M. M. J. P. (2014).
Mechanochemical endovenous ablation for the treatment of great saphenous vein insufficiency. Journal of Vascular
Surgery: Venous and Lymphatic Disorders, 2(3), 282–288. doi:10.1016/j.jvsv.2014.01.001
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32. FR
Van Eekeren, R. R. J. P., Boersma, D., Holewijn, S., Werson, D. A. B., de Vries, J. P. P. M., & Reijnen, M. M. J. P. (2014). Mechanochemical endovenous ablation for the treatment of great saphenous vein insufficiency. Journal of
Vascular Surgery: Venous and Lymphatic Disorders, 2(3), 282–288. doi:10.1016/j.jvsv.2014.01.001 32
Prodecure MOCA
MOCA was performed with the Clari Vein catheter (Vascular Insights, Madison, Conn)
2 mL of local anesthesia
(lidocaine) wasapplied at
the puncture site
By a Seldinger technique, a
4F introducer sheath was
introduced into the GSV
the catheter was positioned with the
tip of the dispersion wire 1.5 cm
distal of the saphenofemoral
junction under ultrasound guidance
After proper positioning of the
tip, the wire was activated for a
few seconds to induce spasm of
the proximal vein
the activated catheter
with rotating tip was
steadily withdrawn at
1 cm every 7 secondsIts dispersing liquid polidocanol
(Aethoxys-klerol; Kreussler Pharma,
Wiesbaden, Germany) to the
damaged vein wall simultaneously
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33. FR
Add a footer 33
No major complications
were observed.
Importantly, deep venous
thrombosis, saphenous
nerve neuralgia, and skin
necrosis did not occur.
KD

34. Thank You.

35. Q&AQuestions and Answers

36. 1. Pada teknik High Ligation, manakah cabang dari
GSV yang tidak boleh diligasi? Apa saja
komplikasinya?
KD

37. 1. Pada teknik High Ligation, manakah cabang dari
GSV yang tidak boleh diligasi? Apa saja
komplikasinya?
KD

39. 2. Mengapa pada Tindakan EVLA, jarak
kateter harus minimal 2 cm dari SVJ?
KD
Jawaban :
Untuk menghindari Vena
femoralis agar tidak terjadi
Deep Vein Thrombosis

40. 3. Apa saja Kontraindikasi penggunaan
stocking?
KD

41. 4. Kapan pasien perlu
menggunakan
stocking terus
menerus dan
sementara? Apakah
perbedaan stocking
hingga lutut dan
paha?
KD

42. 4. Kapan pasien perlu
menggunakan
stocking terus
menerus dan
sementara? Apakah
perbedaan stocking
hingga lutut dan
paha?
KD

43. 4. Kapan pasien perlu
menggunakan
stocking terus
menerus dan
sementara? Apakah
perbedaan stocking
hingga lutut dan
paha?
KD

44. 4. Kapan pasien perlu
menggunakan
stocking terus
menerus dan
sementara? Apakah
perbedaan stocking
hingga lutut dan
paha?
KD

45. 4. Kapan pasien perlu
menggunakan
stocking terus
menerus dan
sementara? Apakah
perbedaan stocking
hingga lutut dan
paha?
KD

46. 4. Kapan pasien perlu menggunakan
stocking terus menerus dan
sementara? Apakah perbedaan
stocking hingga lutut dan paha?
KD
Jawaban :
Stocking hingga paha sedikit lebih
efektif dalam mencegah emboli
namun lebih tidak nyaman dan
mudah berkerut. Oleh karena itu
untuk pasien dengan derajat
kepatuhan rendah dan
mengeluhkan kesulitan dalam
memakai stocking
direkomendasikan menggunakan
stocking hingga lutut saja.

47. 4. Kapan pasien perlu menggunakan
stocking terus menerus dan
sementara? Apakah perbedaan
stocking hingga lutut dan paha?
KD

48. 5. Apakah perbedaan ulkus vena, ulkus arteri, dan ulkus DM? KD

49. 5. Apakah perbedaan ulkus vena, ulkus arteri, dan ulkus DM? KD

50. 6. Bagaimana mekanisme terjadinya
hiperpigmentasi pasca scherotherapy?
KD
Jawaban :
Hiperpigmentasi pasca schlerotherapy terjadi
karena deposisi hemosiderin pada superfisial
dermis. Hal ini terjadi sebagai akibat dari
ekstravasasi eritrosit menuju ke dermis dan
jaringan subcutan pada proses skleroterapi
(injeksi hingga complete schlerosis tercapai).
Eritrosit tersebut kemudia di fagositosis oleh
Makrofag Dermal dan hemoglobin secara
cepat terurai menjadi pertikel partikel
ferritin. Partikel ferritin teragregasi pada
sitoplasma makrofag dan membentuk
hemosiderin. Kumpulan hemosiderin inilah
yang membentuk hiperpigmentasi pada kulit

51. KD