This document summarizes key information about venous disease, including varicose veins. It discusses risk factors like family history and prolonged standing. Symptoms include leg fatigue and aching. Evaluation involves patient history, physical exam looking for varicose veins and skin changes, and tests like Doppler ultrasound to check for reflux. Venous reflux and obstruction can cause hypertension and symptoms by impairing blood flow from the legs.

1. THE BASICS OF VENOUS DISEASE: What You Should Know. Copyright © 2009 by American College of Phlebology An Introductory Lecture

2. Disclosure of Conflict of Interest [REPLACE WITH SPEAKER NAME] I do not have relevant financial relationships with any commercial interests. [OR] LIST COMPANY(s) - RELATIONSHIP Copyright © 2009 by American College of Phlebology

3. Presentation Use Information This presentation is intended for Educational Purposes Only Reference to any product or procedure does not constitute its endorsement or recommendation by the ACP The ACP is not responsible for any changes or amendments to the original presentation Presentation material is based on the best science available when it was created Copyright © 2009 by American College of Phlebology

4. Copyright © 2009 by American College of Phlebology “ It is ironic that medical education does not cover three of the most common medical problems: back pain, hemorrhoids, and varicose veins.” P. Fujimura, MD Surgical Intern University of California School of Medicine

5. The medical specialty devoted to the diagnosis and treatment of patients with venous disorders Copyright © 2009 by American College of Phlebology PHLEBOLOGY

6. IMPORTANCE OF CHRONIC VENOUS DISEASE 1 in 22 or 4.5% or 12.2 million people in the USA are affected by varicose veins Incidence increases with age and is more common in women with over 40% of women in their 50’s suffering from some sort of venous disorder Across all ages and gender, 60% of Americans suffer from venous disease and its sequelae Copyright © 2009 by American College of Phlebology National Heart Lung and Blood Institute (NHLBI) http://www.nhlbi.nih.gov/

7. THE SPECTRUM OF CHRONIC VENOUS DISEASE Copyright © 2009 by American College of Phlebology lipodermatosclerosis telangiectasias varicose veins Superficial phlebitis venous ulceration

8. Presenting Symptoms of Chronic Venous Disease Aching Fatigue, heaviness in legs Pain: throbbing, burning, stabbing Cramping Swelling (peripheral edema) Itching Restless legs Numbness Copyright © 2009 by American College of Phlebology

9. Copyright © 2009 by American College of Phlebology Epidemiology: Who develops venous disease?

10. Venous Disease is a Hereditary Disorder 134 families were examined The risk of developing varicose veins was: 89% if both parents had varicose veins 47% if one parent had varicose veins 20% if neither parent had varicose veins Copyright © 2009 by American College of Phlebology Cornu-Thenard, A, J Dermatol Surg Oncol 1994 May; 20(5):318-26.

11. Heredity in Chronic Venous Insufficiency Risk Factors for chronic venous disease: The San Diego population study Although some risk factors for venous disease such as age, family history of venous disease are immutable others can be modified, such as weight, physical activity, and cigarette smoking. Copyright © 2009 by American College of Phlebology J Vasc Surg. 2007 August; 46(2): 331–337

12. The beginnings of venous disease may be found as early as childhood Copyright © 2009 by American College of Phlebology Phlebologie. 1990 Nov-Dec;43(4):573-7. Weindorf N, Schultz-Ehrenburg U. 740 pts 10-12 y/o 518 pts 14-16 y/o 459 pts 18-20 y/o Diagnosable Vein disease 2.5% 12.3% 19.8% Actual Varicose Veins 0 1.7% 3.3%

13. Inactivity aggravates venous disease 2854 patients with varicose veins, working in a factory 64.5% had jobs standing in one place 29.2% had jobs requiring prolonged periods of sitting 6.3% had jobs allowing frequent walking during their shift Copyright © 2009 by American College of Phlebology Santler, R Hautarzt 1956; 10:460

14. Varicose Veins are 3 times more common in women than men Copyright © 2009 by American College of Phlebology "Varicose veins." The Mayo Clinic. January 2007. http://www.mayoclinic.com

15. Each pregnancy worsens the condition 405 women with varicose veins 13% had one pregnancy 30% had two pregnancies 57% had three pregnancies Copyright © 2009 by American College of Phlebology Brand FN, et al The epidemiology of varicose veins: the Framingham Study Am J Prev Med 1988; 4:96-101

16. Copyright © 2009 by American College of Phlebology Anatomy and Pathophysiology

17. Anatomy and physiology of the venous system in the lower extremity Deep venous system: the channel through which 90% of venous blood is pumped out of the legs Superficial venous system: the collecting system of veins Perforating veins: the conduits for blood to travel from the superficial to the deep veins Musculovenous pump: Contraction of foot and leg muscles pumps the blood through one-way valves up and out of the legs Copyright © 2009 by American College of Phlebology

18. Copyright © 2009 by American College of Phlebology Illustration by Linda S. Nye

19. Superficial venous system Great saphenous vein -runs from dorsum of foot medially up leg -site of highest pressure usually the saphenofemoral junction, but may begin with perforating or pelvic vein Copyright © 2009 by American College of Phlebology Illustration by Linda S. Nye

20. Superficial venous system Small saphenous vein - runs from lateral foot up posterior calf -variations in termination -segmental abnormalities -site of highest pressure frequently the saphenopopliteal junction, but may begin with an inter-saphenous connection or perforating vein Copyright © 2009 by American College of Phlebology Illustration by Linda S. Nye

21. Perforating veins Mid-thigh Perforating Vein Dodd Proximal Calf Perforator Cockett Gastrocnemius Lateral thigh (lateral subdermic plexus) Copyright © 2009 by American College of Phlebology Illustration by Linda S. Nye

22. Musculovenous pump Foot and calf muscles act to squeeze the blood out of the deep veins One way valves allow only upward and inward flow During muscle relaxation, blood is drawn inward through perforating veins Superficial veins act as collecting chamber Copyright © 2009 by American College of Phlebology Illustration by Linda S. Nye

23. Venous Valvular Function Valve leaflets allow unidirectional flow, upward or inward Dilation of vein wall prevents opposition of valve leaflets, resulting in reflux Valvular fibrosis, destruction, or agenesis results in reflux Copyright © 2009 by American College of Phlebology

24. Doppler exam: Normal flow Copyright © 2009 by American College of Phlebology Illustration by Linda S. Nye

25. Doppler: Reflux Copyright © 2009 by American College of Phlebology Illustration by Linda S. Nye

26. REFLUX : its contribution to varicose veins Copyright © 2009 by American College of Phlebology Illustration by Linda S. Nye

27. Pathophysiology: 2 components REFLUX Dilatation of vein wall leads to valve insufficiency Monocytes may destroy vein valves Retrograde flow results in distal venous hypertension OBSTRUCTION Thrombosis and subsequent fibrosis obstruct venous outflow Damage to vein valves may also cause reflux Both contribute to venous hypertension Copyright © 2009 by American College of Phlebology The presence of both is far worse than either one alone

28. CEAP Classification “ C” = Clinical C0 - no visible venous disease C1 - telangiectasias or reticular veins C2 - varicose veins C3 - edema C4 - skin changes without ulceration C4a – pigmentation or eczema C4b – LDS or atrophie blanche C5 - skin changes with healed ulceration C6 - skin changes with active ulceration “ E” = Etiology (primary vs. secondary) “ A” = Anatomy (defines location of disease within superficial, deep and perforating venous systems) “ P” = Pathophysiology (reflux, obstruction, or both) Copyright © 2009 by American College of Phlebology

29. AMBULATORY VENOUS HYPERTENSION The common denominator in the pathophysiology of venous disease Instead of dropping, the intravenous pressure rises during exercise and is transmitted to more superficial and distal veins May be due to reflux, obstruction, or both Copyright © 2009 by American College of Phlebology

30. Venous symptoms Reflux and obstruction lead to congestion and dilatation of the vein walls Symptoms, such as aching, pain, burning, throbbing, tiredness, itching, numbness and heaviness are worse with prolonged standing or sitting, heat,  progesterone states such as pregnancy/pre-menses Symptoms are improved with graduated compression, leg elevation, exercise Copyright © 2009 by American College of Phlebology

31. Copyright © 2009 by American College of Phlebology EVALUATION OF THE PATIENT WITH VENOUS DISEASE

32. History History of problem: onset, pregnancies, prior DVT, immobilization Associated symptoms and relationship to heat, menses, exercise and compression Current medications Family history Previous treatment and result Goals of patient Copyright © 2009 by American College of Phlebology

33. Physical Examination Examine patient in the standing position, from the groin to the ankle Inspect and palpate for varicose and telangiectatic veins Check the medial and lateral malleolar areas for skin changes suggestive of chronic venous insufficiency (e.g., corona phlebectatica) Inspect the abdomen for enlarged superficial veins if ilio-femoral thrombosis is suspected Copyright © 2009 by American College of Phlebology

34. Telangiectasias Also known as “spider veins” due to their appearance Very common, especially in women Increase in frequency with age 85% of patients are symptomatic * May indicate more extensive venous disease Copyright © 2009 by American College of Phlebology * Weiss RA and Weiss MA J Dermatol Surg Oncol. 1990 Apr;16(4):333-6.

35. Lateral Subdermic Plexus Very common, especially in women Superficial veins with direct perforators to deep system Remnant of embryonic deep venous system Copyright © 2009 by American College of Phlebology

36. Reticular Veins Enlarged, greenish-blue appearing veins Frequently associated with clusters of telangiectasias May be symptomatic, especially in dependent areas of leg Copyright © 2009 by American College of Phlebology

37. Varicose Veins – Great Saphenous Distribution Most common finding in patients with varicose veins Varicosities most commonly along the medial thigh and calf but cannot assume location indicates origin At least 20% of patients are at risk of ulceration Copyright © 2009 by American College of Phlebology

38. Great Saphenous Insufficiency Skin changes are seen along the medial aspect of the ankle The presence of skin changes is a predictor of future ulceration * * Kirsner R et al. The Clinical Spectrum of Lipodermato-sclerosis, J Am Acad Derm, April 1993;28(4):623-7 Copyright © 2009 by American College of Phlebology

39. Varicose Veins – Small Saphenous Distribution Less frequent than Great Saphenous involvement Varicosities may be seen on the posterior calf and lateral ankle Skin changes are seen along the lateral ankle Copyright © 2009 by American College of Phlebology

40. Varicose Veins with Pelvic Origins Begin during pregnancy Increased symptoms during pre-menstrual period and after intercourse May be associated with pelvic congestion syndrome Copyright © 2009 by American College of Phlebology

41. Skin changes suggestive of chronic venous insufficiency Copyright © 2009 by American College of Phlebology Corona Phlebectatica (C1) Pigmentation (C4a) Atrophie blanche (C4b) Healed ulcer (C5)

42. Venous ulceration Over 50% of patients have only superficial venous disease; superficial venous disease may be primary factor in 50-85% of patients * <10% have only deep venous disease Results from ambulatory venous hypertension, which leads to WBC activation,  TCpO2, local release of proteolytic enzymes Copyright © 2009 by American College of Phlebology * Shami SK et al. J Vasc Surg 1993; 17:487-90

43. Venous ulceration Copyright © 2009 by American College of Phlebology Impending ulceration Lipodermatosclerosis (C4a) Venous ulceration (C6)

44. Venous vs. Arterial Ulcers Venous ulcers are significantly more common Venous ulcers are behind malleoli; arterial ulcers are in areas of chronic pressure or trauma Arterial ulcers usually have a more necrotic base and are more painful S/S of CVI (pigmentation, etc.) or ischemia (absent pulses, hair loss, etc.) are present Copyright © 2009 by American College of Phlebology Arterial ulcer Photo courtesy of John Bergan, MD

45. Muscle fascia herniation Frequently confused with varicose veins Usually found on the lateral calf Bulge disappears with dorsiflexion of the foot No flow is audible with continuous-wave Doppler examination Copyright © 2009 by American College of Phlebology

46. Copyright © 2009 by American College of Phlebology Conservative Treatment of Venous Disorders

47. Compression Therapy Provides a gradient of pressure, highest at the ankle, decreasing as it moves up the leg Reduces reflux of blood Improves venous outflow Increases velocity of blood flow to reduce the risk of blood clots Copyright © 2009 by American College of Phlebology Photo courtesy of Juzo

48. Compression therapy Reduces symptoms of aching, fatigue, pain, and swelling Increases fibrinolytic activity Increases TCpO2 Mainstay of treatment for venous ulcers NOTE: Graduated compression therapy and wound care will heal venous stasis ulcers. Elimination of the reflux will reduce the recurrence. Copyright © 2009 by American College of Phlebology

49. Elastic compression stockings Must be graduated Calf high generally sufficient Replace q 6 months to assure proper pressure Available in a variety of strengths, styles, colors, and fabrics Copyright © 2009 by American College of Phlebology

50. Graduated compression is not the same as T.E.D. hose T.E.D.s are meant for non-ambulatory, supine patients T.E.D.s are indicated to decrease the incidence of thrombosis T.E.D.s do not provide sufficient pressure for ambulatory patients Copyright © 2009 by American College of Phlebology

51. Copyright © 2009 by American College of Phlebology * Requires a prescription Compression Strength Indications 8-15mm Leg fatigue, mild swelling, stylish 15-20mm Mild aching, swelling, stylish 20-30mm Aching, pain, swelling, mild varicose veins 30-40mm * Aching, pain, swelling, varicose veins, post-ulcer 40-50, 50-60mm * Recurrent ulceration, lymphedema

52. Prescribing graduated compression stockings Measure ankle, calf, thigh for proper fit Disproportionate legs require custom stockings Medical supply companies may have stocking fitters Avoid using at night in elderly, diabetics, and patients with arterial disease (ie: ankle-brachial index < 0.9) Copyright © 2009 by American College of Phlebology

53. Donning compression stockings: what to advise your patients Method #1: Turn stocking inside out to heel and pull onto foot. Then pull the stocking up the leg Method #2: Put stocking on like a trouser, not like a sock Rubber gloves and donning devices (Easy-Slide, Butler) improve ease of donning, and thus compliance Copyright © 2009 by American College of Phlebology

54. Inelastic compression Most physiologic in its effect Available as bandage, which requires significant skill CircAid is “user friendly,” series of nylon straps Good choice for elderly, diabetics, patients with arterial disease Copyright © 2009 by American College of Phlebology Photo courtesy CircAid Medical Products, Inc.

55. Exercise Reduces symptoms such as aching and pain Reduces ulcer recurrence Speeds resolution of superficial phlebitis and DVT 30 minutes daily is best Lower extremity exercise is helpful (stay away from heavy weight-lifting or other strenuous activity) Copyright © 2009 by American College of Phlebology

56. When to treat or refer a patient with venous disease Symptoms (aching, pain, swelling, etc.) that are unresponsive to conservative measures such as graduated compression and exercise Patient is unable to tolerate compression Cosmetic improvement requested Thickening or discoloration of the skin in the ankle region: skin changes suggestive of chronic venous insufficiency Impending or active ulceration or hemorrhage Copyright © 2009 by American College of Phlebology

57. Copyright © 2009 by American College of Phlebology Current Approaches to the Treatment of Varicose Veins and Related

58. Some Important Consideration… Most patients have a combination of varicose veins, reticular veins, and telangiectasias Different treatment methods may be best for each type of vein involved, or for different sized veins Therefore, more than one treatment method will be required for most patients In general, varicose veins and any associated reflux are treated prior to treatment of telangiectasias Copyright © 2009 by American College of Phlebology

59. Treatment of telangiectasias Sclerotherapy most effective Laser may be helpful Multiple treatments usually required Reduces symptoms in 85% of patients Improves quality of life Copyright © 2009 by American College of Phlebology Weiss RA and Weiss MA J Dermatol Surg Oncol. 1990 Apr;16(4):333-6.

60. Sclerotherapy of Telangiectasias: Technique Copyright © 2009 by American College of Phlebology Injection of sclerosant solution causes damage to endothelium which leads to fibrosis of vein

61. Sclerotherapy Results Copyright © 2009 by American College of Phlebology Before After Photos courtesy of Steven Zimmet, MD, FACPh

62. Treatment of Reticular Veins NEED PIC Copyright © 2009 by American College of Phlebology Frequently associated with telangiectasias, their Rx may enhance results of sclerotherapy of telangiectasias Visualization may be improved with transillumination

63. Non-surgical treatment of varicose veins Sclerotherapy effective; may be enhanced if ultrasound-guided Endovenous occlusion with radiofrequency or laser extremely effective Copyright © 2009 by American College of Phlebology Min R et al, J Vasc Interv Radiol 2001; 12:1167-1171 Rautio T et al, J Vasc Surg 2002; 35(5):958-65 NEED PIC

64. Ultrasound-guided Sclerotherapy Nearly any size vein can be treated Needle location inside vein, as well as movement of sclerosant and response of vein (spasm) visible Efficacy enhanced with foamed sclerosant Copyright © 2009 by American College of Phlebology Photo courtesy of CompuDiagnostics, Inc.

65. Sclerotherapy Results Copyright © 2009 by American College of Phlebology Before After Ultrasound-guided sclerotherapy of the Great Saphenous Vein and sclerotherapy of branches Photos courtesy of Steven Zimmet, MD, FACPh

66. Radiofrequency “Closure” Technique Outpatient procedure approximately 60 min. long Local tumescent Temperature at vein wall controlled >90% closure at 2 yrs FDA-approved for RX of Great Saphenous Vein Copyright © 2009 by American College of Phlebology NEED PIC

67. Endovenous Laser Ablation Outpatient procedure approximately 60 min long Only local anesthesia required Continuous pullback Closure of >93% Great Saphenous Veins at 2 yrs FDA-approved for RX of Great Saphenous Vein Copyright © 2009 by American College of Phlebology

68. Surgical Treatment of Varicose Veins: Vein Stripping Vein stripping used to remove Great and Small saphenous veins Yields 60% long term improvement Neovascularization a problem Usually requires general anesthetic Copyright © 2009 by American College of Phlebology Butler CM, et al Phlebology 2002. 17:59-63 Photo Photo courtesy of John Bergan, MD

69. Surgical Treatment of Varicose Veins: Phlebectomy Very esthetic method of removing varicose veins Usually requires only local anesthetic Especially useful for tributaries of GSV, SSV Copyright © 2009 by American College of Phlebology

70. Treatment Results Copyright © 2009 by American College of Phlebology Before After Endovenous obliteration of the Great Saphenous Vein and phlebectomy of tributaries Photos courtesy of Steven Zimmet, MD, FACPh

71. Venous ulceration Superficial venous disease present in >50% Initial Rx includes graduated compression and wound care All pts require Duplex evaluation Rx venous disease for long-term control Copyright © 2009 by American College of Phlebology Padberg FT et al J Vasc Surg 1996; 24:711-19

72. Superficial Thrombophlebitis: Management In the presence of varicose veins, DVT found in 10-20% Initial RX includes graduated compression and ambulation NSAID’s for pain Antibiotics rarely needed Copyright © 2009 by American College of Phlebology

73. Management of the lower extremity after Deep Venous Thrombosis: Considerations in addition to anti-coagulation Many patients with DVT continue to have leg pain, aching, and swelling Early ambulation and graduated compression (30-40mm) is helpful in lysing clot, restoring normal venous function, preventing post-thrombotic syndrome Patients with symptomatic legs should be maintained on a regimen of compression and daily walking for 1-2 years Copyright © 2009 by American College of Phlebology Prandoni et al, Ann Intern Med 2004;141:249-256

74. Pelvic Congestion Syndrome Affects thousands of women in the U.S. More common in multiparous women Due to reflux in the ovarian veins, iliac veins, etc. May result in severe pelvic discomfort during the pre-menstrual period, after intercourse, and with prolonged standing May be effectively treated by blocking the reflux with embolization and/or pelvic vein sclerotherapy Copyright © 2009 by American College of Phlebology Venbrux AC et al J Vasc Interv Radiol 2002; 13:171-178

75. A multi-disciplinary organization founded in 1986 Composed of over 2200 Physicians and Allied Health professionals interested in the diagnosis and treatment of venous disorders Offers grant support for basic science and clinical research in all aspects of venous disease Devoted to furthering the education of its members, the medical community, and the public Copyright © 2009 by American College of Phlebology AMERICAN COLLEGE OF PHLEBOLOGY 101 Callan Avenue, Suite 210 ● San Leandro, CA 94577-4558 510.346.6800 ● 510.346.6808 Fax [email_address] ● www.phlebology.org

76. THE FUNDAMENTALS OF PHLEBOLOGY: Venous Disease for Clinicians THANK YOU FOR YOUR ATTENTION! Copyright © 2009 by American College of Phlebology