boala varicoasa

1. The need for a holisticThe need for a holistic
aproach to patient care inaproach to patient care in
Chronic Venous DiseaseChronic Venous Disease
Alexandru ANDRITOIU, MD, MPhAlexandru ANDRITOIU, MD, MPh
Emergency Military HospitalEmergency Military Hospital
CraiovaCraiova

2. CVD definitionCVD definition
• Morphological and functional abnormalities of the
venous system of long duration manifested either
by symptoms and/or signs indicating the need for
investigation and/or care.
• It is caused by venous valvular incompetence
with or without associated venous outflow
obstruction, which may affect the superficial
venous system, the deep venous system, or both.
• Venous dysfunction may result from either a
congenital or an acquired disorder.
• CVD is the consequence of venous hypertension.
Eklof B, Perrin M, Delis KT, et al. Updated terminology of chronic venous disorders:the Vein Term Transatlantic interdisciplinary
Consensus Document. J Vasc Surg. 2009;49:498-501.

3. Venous anatomic segment classification

4. Superficial and perforating veinsSuperficial and perforating veins

5. Anatomical distribution of venous systemAnatomical distribution of venous system
1. Tegument
2. Fascia superficiala
3. Fascia musculara
4. Compartimentul profund
5. Compartimentul v. safene (interfascial)
6. Compartimentul subcutanat (vv colaterale sau tributare)

6. Venous haemodynamicsVenous haemodynamics
• About 75% of circulating blood in the
body is moving through the venous
system.
• Understanding the mechanisms by which
venous return to the heart is crucial to
understanding the physiology of the
vascular system.

7. Physiology of venous blood flowPhysiology of venous blood flow
Venous retourn from legs is governed by
• Arterial pressure
• Calf musculovenous pump
• Gravity
• Thoracic pump
• Valves in veins

8. Pathophysiology of CVIPathophysiology of CVI
• Muscle pump failure (primary)
• Venous obstruction
• Venous valvular incompetence
1. perforator incompetence
2. superf veins incompetence
3. deep vein incompetence

9. Phlebology 2008;23:85–98

10. John BERGAN, MD
The Vein Institute of La Jolla
Department of Surgery
UCSD School of Medicine La Jolla, CA, USA
MEDICOGRAPHIA, VOL 30, No. 2, 2008

12. Types of valvesTypes of valves
A). unicuspid B) bicuspid C) tricuspid D) quaricuspid

13. Classification of valvular lesions
• Functional valve lesions (type I)
• Traumatic organic valve lesions (type II)
• Inflammatory organic lesions (type III)
• Valvular vestiges (type IV)

14. Venous valvesVenous valves
Normal vein Varicose vein

15. VVenoenouuss RefluxReflux
Valvular incompetence
- Valsalva maneuver
- Calf compression

16. Competent VeinCompetent Vein
Start
Valsalva End Valsalva
Competent vein

17. Symptomatic varicose veinsSymptomatic varicose veins
• pain
• aching
• discomfort
• swelling
• heaviness
• itching
that are thought to be due to the effects of
superficial venous reflux and for which no
other more likely cause is apparent.

18. MEDICOGRAPHIA, Vol 33, No. 3, 2011

19. GuidelinesGuidelines

22. The ,,common language,,The ,,common language,,
1994). The American Venous Forum (AVF) has created the
CEAP (Clinical-Etiological-Anatomical-Pathophysiological)
classification.
1998). REVAS (REcurrence after VAricose vein Surgery)
2000). The Venous Clinical Severity Score (VCSS)
2004). Several consensus documents from the Union
Internationale de Phlébologie (UIP) led to the revision of
the CEAP classification system.
2009). The latest update of terminology for CVD-
VEINTERM consensus document.
All these efforts have led to the creation of a common
language in CVD, which is essential for the establishment
of clinical practice guidelines.
Medicographia. 2011;33:245-252

23. VEIN-TERMVEIN-TERM
Chronic venous disorders
Chronic venous disease
Chronic venous insufficiency (C3*-C6):
Venous symptoms
Venous aneurysm
Venous valvular incompetence
Venous reflux (primary, secondary)
Axial reflux (superficial, deep, combined)
Segmental reflux
Eklöf B, Perrin M, Delis KT, Rutherford RB, Gloviczki P. Updated terminology of chronic venous disorders: The VEIN-TERM
transatlantic interdisciplinary consensus document. J Vasc Surg. 2009:49:498-501

24. VEIN TERM (contin…)VEIN TERM (contin…)
• Perforator incompetence
• Venous occlusion, obstruction
• Venous compression
• Recanalization
Eklöf B, Perrin M, Delis KT, Rutherford RB, Gloviczki P. Updated terminology of chronic venous disorders: The VEIN-TERM
transatlantic interdisciplinary consensus document. J Vasc Surg. 2009:49:498-501

25. VEIN TERM (surgery)VEIN TERM (surgery)
• High ligation and division
• Stripping
• Venous ablation
• Perforating vein interruption-ligation-ablation
• Miniphlebectomy
• Sclerotherapy
• Endophlebectomy
Eklöf B, Perrin M, Delis KT, Rutherford RB, Gloviczki P. Updated terminology of chronic venous disorders: The VEIN-TERM
transatlantic interdisciplinary consensus document. J Vasc Surg. 2009:49:498-501

26. CEAPCEAP

28. Telangiectasias (C1)Telangiectasias (C1)
• Confluence of dilated
intradermal venules less
than 1 mm in caliber.
• Synonym-spider veins.

29. Corona phlebectaticaCorona phlebectatica
Fan-shaped
pattern of
numerous small
intradermal veins
on medial or lateral
aspects of ankle
and foot.

30. Varicose veins (C2)Varicose veins (C2)
Subcutaneous dilated
vein 3 mm in diameter or
larger, measured in
upright position, may
involve saphenous veins,
saphenous tributaries,
or nonsaphenous
superficial leg veins.

31. Edema (C3)Edema (C3)
Perceptible increase in
volume of fluid in skin
and subcutaneous tissue,
which is
characteristically
indented with pressure.
Venous edema usually
occurs in the ankle
region, but may extend
to the leg and foot.

32. PigmentationPigmentation
Brownish darkening of
skin, resulting from
extravasated blood.
Usually occurs in the
ankle region, but may
extend to the leg and
foot

33. LipodermatosclerosisLipodermatosclerosis
LDS is a localized chronic
inflammation and fibrosis of
the skin and subcutaneous
tissues of the lower leg,
sometimes associated with
scarring or contracture of
the Achilles tendon.
LDS is a sign of severe CVD

34. White atrophy (C4b)White atrophy (C4b)
Localized, often circular
whitish and atrophic skin
areas surrounded by
dilated capillaries and
sometimes
hyperpigmentation.
Sign of severe CVD, and
not to be confused with
healed ulcer scars.

35. Venous eczema and ulcerationVenous eczema and ulceration

36. Healed ulcer (C5)Healed ulcer (C5)

37. Active venous ulcer (C6)Active venous ulcer (C6)
Full-thickness defect of
skin, most frequently in
the ankle region, that fails
to heal spontaneously and
is sustained by CVD

38. Degree of CVIDegree of CVI

39. Varicosity – Progression to be observedVaricosity – Progression to be observed

40. The Team involved in CVDThe Team involved in CVD
• GP
• Surgery/vascular surgery
• Radiologyt (CDUS, venography)
• Interventional radiology
• Cardiology
• Dermatologyy
• Angiology-Phlebology

41. Vascular serviceVascular service
NICE Guideline 2013

42. Diagnosis of CVDDiagnosis of CVD
• Physical exam.Physical exam.
• Noninvasive TestingNoninvasive Testing
Venous Dupplex
Photoplethysmography
Airplethysmography
CT-MRI Venography
• Invasive TestingInvasive Testing
Contrast Venography
Intravascular US
Ambulatory venous pressure (AVP)
Circulation 2005;111:2398-2409

43. VenographyVenography

44. Functional venous diagnosis:Functional venous diagnosis:
Ambulatory venous pressuresAmbulatory venous pressures

45. Venous Insufficiency, RefluxVenous Insufficiency, Reflux

46. J Vasc Surg 2005;41:645-51

47. Patterns of SSV refluxPatterns of SSV reflux
Engelhorn C et al. J Vasc Surg 2005;41:645-51

48. Treatment of CVDTreatment of CVD
• Conservative
• Interventional
• Surgical

49. Circulation. 2005;111:2398-2409

50. Conservative TreatmentConservative Treatment
• compression
• wound and skin care
• pharmacological (venoactive drugs)
• exercise
• loss weight

51. Elastic compression stockingElastic compression stocking
• Reduces symptoms
of aching, fatigue,
pain,and swelling
• Increases fibrinolytic
activity
• Mainstay of treatment
for venous ulcers
Must be graduated

52. What degree of compression – When?What degree of compression – When?

53. Classification of theClassification of the
main venoactive drugsmain venoactive drugs
Nicolaides et al. Int Angiol. 2008;27:1-59.

55. InterventionalInterventional
• Sclerotherapy (chemical ablation)
• Ablative therapy (cold, heat)
-RF, laser, steam
• Endovascular (stent)
Guided by CDUS

56. Sclerotherapy of Telangiectasias:Sclerotherapy of Telangiectasias:
TechniqueTechnique
damage to endothelium
leads to fibrosis of vein

57. Ultrasound-guided sclerotherapyUltrasound-guided sclerotherapy
foamed solutions

58. Foam sclerotherapy
Compression after sclerotherapy improves results (less thrombus formation, fewer inflammatory reactions, less pigmentation)

59. Washout Foam sclerotherapyWashout Foam sclerotherapy
Dr. Khalil Fattah-60,000 sclerotherapy sessions experience
The foam sclerotherapy is associated with risk of DVT, pulmonary embolism, distant side effects
such as vision disturbances and vascular headaches, etc. By removing the injected foam, as suggested
by Dr. Khalil Fattahi, side effects can be minimized and treatment can be more selective in choosing
the exact segment and extent of varicose veins to be treated by foam sclerotherapy (smart Foam
Sclerotherapy).

60. Vein Specialty Medical ClinicVein Specialty Medical Clinic
Campbell, CACampbell, CA
Dr. Khalil Fattah colection

61. RF-ablationRF-ablation
The Venefit procedureThe Venefit procedure

62. Radiofrequency ablationRadiofrequency ablation
Closure FAST™ Catheter.
The circular heating element of the catheter measures 7 cm in length which makes
it possible to treat an equivalent length of vein in a few seconds.

63. GSV Ablation by LaserGSV Ablation by Laser

64. Pre-Treatment Post-TreatmentPre-Treatment Post-Treatment

65. René MILLERET
Vein Center
Clinique Pasteur
3 Rue Pasteur
34120 Pézenas
France
Phlebolymphology. 2011;19(4):174-181
Obliteration of Varicose Veins with Superheated Steam

66. VenaSeal Sapheon Closure SystemVenaSeal Sapheon Closure System
Cyanoacrylate

67. SurgicalSurgical
• Ligation
• Stripping
• Miniphlebectomy
• Subfascial Endoscopic Perforator Surgery
• Valve Reconstruction

68. Ligation & stripping techniqueLigation & stripping technique

69. Surgical Treatment of VaricoseSurgical Treatment of Varicose
Veins: PhlebectomyVeins: Phlebectomy

70. The CHIVA procedureThe CHIVA procedure
hemodynamic preservation in venous
insufficiency in ambulatory practice
• Is designed to create new hemodynamic
conditions by dividing the pressure column in the
varicose veins by disconnecting some venous
anastomoses and by redirecting the reflux from
the diseased superficial veins into the deep
venous system
• The incompetent saphenous trunk is left in place
1988-Franceschi (France)
C Conservatrice
H Hemodinamique
I Inssufisance
V Veinose
A Ambulatoire

71. CIVA methodCIVA method

72. The ASVAL TechniqueThe ASVAL Technique
The ASVAL method recommends
preserving the great saphenous vein,
unless there is a serious terminal
valve insufficiency, and suggests the
surgical removal of the superficial
varicose reservoir as a primary
treatment.
Pittaluga P, Marionneau N, Creton D et al. Traitement chirurgical des varices des membres inferierus: approche moderne.
Phlebologie 2004; 57:301–307.
Pittaluga P, Rea B, Barbe R. Methode ASVAL (Ablation Selective des Varices sous Anesthesie Locale): principes et resultats
preliminaries. Phlebologie 2005; 2:175–181.
Ablation Selective des Varices sous Anesthesie Locale
A Ablation
S Selective
V Varices
A Anestesie
L Locale

73. The endovenous ASVAL method is feasible and
has very good technical success rates and
clinical results for treating varicose vein disease
in patients with segmental GSV reflux and a
competent terminal valve.

74. Subfascial endoscopic perforator surgerySubfascial endoscopic perforator surgery
The perforating vein The perforating vein
after sectioning between the 2 clips

75. Valvular reconstructionValvular reconstruction
• The principle consists in restoring
valvular competence by using different
procedures to eliminate reflux through
these valves: valvular repair (L. Corcos,
Italy 1997), and exo-stent repair of the
junction to reduce the diameter of the
vein (S. Camilli, Italy 2002, J.R. Lane,
Australia 2002).

76. Venous valvuloplastyVenous valvuloplasty
• Internal valvuloplasy
• External valvuloplasty

77. Internal valvuloplastyInternal valvuloplasty

78. External valvuloplastyExternal valvuloplasty
the placement of sutures decreases the diameter of the venous wall but keeps the
valve cusps from harm’s way. The sutures lie outside the vein lumen in this approach.

79. External valvularExternal valvular
stentingstenting

80. PRP-External valvuloplastyPRP-External valvuloplasty

83. PRP in venous ulcerPRP in venous ulcer
(a) a patient of venous ulcer of duration 3 months, (b) after one sitting of platelet rich plasma, (c) ulcer at 4th week and (d) ulcer being healed at 6th week
J Cutan Aesthet Surg. 2013;6(2): 97–99

84. Echipa Sp. Clinic Militar Craiova
Dr Silosi Cristian
Dr Alexandru Andritoiu
Ablatia prin RF a vv safene

85. Reporter: A i afirmat căț Angio-Center (Tg. Mures)
este un centru unic la nivel na ional pentru solu iileț ț
aduse bolilor vasculare periferice. Despre ce este
vorba?
Conf. Dr. Puskás Attila: Este vorba despre o viziune
holistică pe domeniul vascular, pentru că această
categorie de bolnavi sunt lăsa i undeva la periferiaț
actului medical, şi nu numai în ara noastrăț .
28 oct 2014
Medic primar Medicina interna
Masterat Angiologie-Milano

86. Societatea Română de Angiologie i Chirurgieș
Vasculară (SRACV), după 25 de ani de la înfiin area saț
oficială i 10 manifestări tiinţifice organizate,ș ș
continuă să reprezinte o societate tiin ifică deș ț
interes general, cu caracter tiin ific i educa ional.ș ț ș ț

88. The need for Vein Care CentersThe need for Vein Care Centers
• Phlebology/Angiology: a distinct medical
speciality
• The need for Interventional Phlebology
• The role of the Team (holistic aproach)
• The need for combination therapies at
the same patient