This document discusses chronic venous disease, including its pathophysiology, risk factors, stages, and management options. It describes how chronic venous disease is a progressive inflammatory condition caused by damaged valves in the veins. The pathophysiology involves leukocyte activation and damage to the venous walls and valves from increased hydrostatic pressure. Management options discussed include lifestyle modifications, compression therapy, sclerotherapy, endovascular ablation procedures, surgery, and drug therapies. The document focuses on understanding the disease process and providing an overview of diagnostic and treatment approaches.

1. Dr Shahzad Alam Shah
Laparoscopic and Endoscopic Surgeon
Fatima Jinnah Medical University/ SGRHL Lahore
Pakistan
Chronic Venous Disease
From Pathophysiology To Clinical Practice
A Progressive
Inflammatory Disease

2. • Understanding the Pathogenesis
• Diagnostic Implications
• Why there are diversified treatment options?
• And what are these options?
Chronic Venous Disease;
Objectives

3. Risk or Predisposing Factors
• Hereditary
• Prolonged Standing
• Obesity
• History of DVT, DM,
• Number of Pregnancies
https://medlineplus.gov/ency/article/000203.htm

4. Current challenges for the management of
Chronic Venous Disease.
Disease awareness low
Continue to ignore at initial stages.
Culture to wear the full dress
Late Presentations
Delay in diagnosis and treatment

5. Pathophysiological process of chronic venous disease

6. PERFORATORS

7. PATHOPHYSIOLOGY
• MACROVASCULAR
• MICROVASLAR

8. Pathophysiological process of chronic venous disease:
Leukocyte Activation
Adapted from Danziger N. J Mal Vasc.
2007;32:1-7 and Bergan JJ et al. N Engl J Med.
2006;355:488-498.

9. • Junctions:
Saphenofemoral and
Sephenopopliteal
• Valves along the veins
• Perforators

10. Normal Valve Vs Damaged Valve
Veins have problems sending blood
from the legs back to the heart
https://medlineplus.gov/ency/a
rticle/000203.htm

11. Tissue Viability
Wound Healing
Glucose
Amino
Acids
Minerals
Vitamin
s
Fatty Acids
Hypoxia
Oedema Fibrinogen
Fibrin Cuff
Leukocyte Trapping
Proteolytic Enzyme
Oxygen Free Radicles
Damage Basement Membrane
Reduced Circulation of Blood
Red Cell
Oxygen
Hydrostatic Pressure
Flow RateCirculation
Dilated Vessels
Increased Back Pressure
because of venous hypertention
Enzymetic Actiivty
Removal of Waste
Co2+ Hco2
Carbonic Acid
Lactic Acid
Ph in Tissues
Removal of Waste
Co2+ Hco2
Carbonic Acid
Lactic Acid

12. Hydrostatic Pressure
Flow RateCirculation
Removal of Waste
Increased Back Pressure
because of venous hypertention
Hemosideros
is
Ankle Flare
Varicosity
Oedema
Tight Swelling Lipodermosclero
sis
Cramps
Aching
Throbing
Eczema
Dermatitis
Itching
Restless Leg
Pain
Dilated Vessels
Leukocyte Trapping
Chronic Venous Insufficiency
Syndrome

13. C0s C1 C3 C4 C5-C6
Stages of CEAP Classification
Ankle Flare Varicosity
Oedema Tight Swelling
Lipodermosclerosis
Venous Ulcers
C2

14. VENOUS ULCER
Complication of CVD: C4-C6
UlcerationSkin Atropy and Proximal Edema

15. Management options for the
Chronic Venous Disorder

16. Treatment options
• Life Style Modification
• Venoactive Drugs
• Compression Therapy
• Foam Injection Sclerotherapy: sodium tetradecyl sulfate, polidocanol
• Endovascular Procedures
– Endovenous Laser Ablation
– Radiofrequency Ablation
• Surgery

17. Treatment options
• SURGERY
– Ligation of Incompetent Saphenopopliteal and
Saphenofemoral Junctions
– LSV Stripping
– Phelebectomies
– Perforator Ligation
• ENDOSCOPIC
– Subfascial Endoscopic Perforator Surgery

18. MPFF acts at the heart of venous inflammation
in the venous valves and walls
Adapted from Shoab SS et al. Endothelial activation response to oral Micronized Flavonoid therapy in patients with chronic venous disease – a
prospective study. Eur J Vasc Endovasc Surg. 1999;17:313-318.
Leucocyte
Venous wall
endothelium
CD11b/CD18
VLA-4
VCAM-1 E-selectin ICAM-1
L-selectin
MPFF

19. Venotonic and Anti-Inflammatory Action of Drugs
• MPFF improves venous tone by modulating noradrenergic
signaling and reducing norepinephrine metabolism
• MPFF also protects against inflammation-related valve damage
by inhibiting the leukocyte-endothelium interaction,
decreasing capillary permeability, improving capillary
resistance, and increasing lymphatic ...

20. MPFF inhibits the expression of adhesion molecules on
the surface of leukocytes
MPFF exerts anti-inflammatory effects by
inhibiting the expression of adhesion
molecules on the surface of leukocytes,
thereby limiting leukocyte rolling,
adhesion, and subsequently, infiltration
into the venous valves and walls.
Shoab SS, Porter JB, Scurr JH, Coleridge-Smith PD. Effect of oral micronized
purified flavonoid fraction treatment on leukocyte adhesion
molecule expression in patients with chronic venous disease: a pilot study. J Vasc
Surg. 2000;31(3):456-461.
MPFF significantly reduces edema
Blume J, Langenbahn H, De Champvallins M.
Quantification of oedema using the volometer technique:
therapeutic application of Daflon 500 mg in chronic venous
insufficiency. Phlebology. 1992;7:37-40.
MPFF increased venous tone
Barbe R, Amiel M. Pharmacodynamic properties and
therapeutic efficacy of Daflon 500 mg.
Phlebology.1992;7(suppl 2):41-44.
MPFF significantly reduces pain,
heaviness, and cramps.
Tsukanov YT, Tsukanov AY, Nikolaychuk A. Great
saphenous vein transitory reflux in patients with symptoms
related to chronic venous disorders, but without visible signs
(C0s), and its correction with MPFF treatment.
Phlebolymphology. 2015;22(1):18-24.

21. Injection Foam Sclerotherapy
Sodium tetradecyl sulfate, polidocanol

22. Compression Therapy
Adaptive Compression Bandages
Compression
Stocking

23. Compression Therapy
• Multicomponent systems Intermittant Pneumetic Compreession

24. Endovascular Ablations
Endovenous Radio Frequency Ablation Endovenous Laser Ablation

25. Sub Fascial Endoscopic Perforator Surgery
SEPS

27. THANK YOU
Dr Shahzad Alam Shah