The document discusses chronic venous insufficiency (CVI) and its management, highlighting the anatomy and physiology of the venous system, as well as the pathophysiology, risk factors, and clinical manifestations of CVI. It emphasizes that reflux is a key factor in CVI, leading to symptoms such as edema and ulceration, while identifying diagnostic evaluations and treatment options including wound care, compression therapy, and surgical interventions. Successful management of CVI relies on addressing the root causes of reflux and employing effective compression therapy.

1. Chronic Venous Insufficiency
&
varices
Dr. Pezhman Kharazm
Assistant Professor of Vascular Surgery
Golestan University of Medical sciences

2. Today’s objectives
• To know anatomy of venous system
• To describe the physiology of venous system
• To know pathophysiology of CVI
• To diagnose Clinical Manifestations of CVI
• To name para clinic investigations in CVI
• To manage patients with CVI

3. Lower extremity venous anatomy
Cross sectional

4. Lower extremity venous anatomy
Longitudinal
Small Saphenous Vein (S.S.V)
Great Saphenous Vein (G.S.V)
Perforating Veins (P.V)

5. Determinants of Venous Flow Direction
Transmitted arterial pressure

6. Muscle Pump

8. Venous Insufficiency
• Insufficiency contributes to:
Reflux

9. Reflux is the keyword of the CVI
and occurs secondary to:
Valvular incompetency

10. Valvular incompetency
Types:
• Primary
• Secondary
Causes:
• Primary
• Hereditary
• Senile
• Trauma
• Thrombosis
• AVF/AVM

11. C.V.I Risk Factors
• Advanced age..................
• Height.........................
• Pregnancy....................

12. C.V.I Risk Factors (cont.)
• Obesity……………..
• Smoking……………
• Family history..........

13. C.V.I Risk Factors (cont.)
• Prolonged standing..........
• Female sex........

14. Pathophysiology:
Everything starts with venous
hypertension!
But How?

15. • Standing position + reflux = venous drainage problem
• Same inflow + less outflow = volume overload in
venous system = venous hypertension

16. Pathophysiology
• Venous hypertension at first results in venous dilation for
pooling more blood
• Clinical manifestation:
• Heaviness and warmness of the involved limb which
resolves with limb elevation and upward massage.

17. • Next step:
• Small veins start to elongation and
twisting in addition to dilation.
Pathophysiology
• Clinical manifestation:
• Telangiectasia and reticular veins (grade 1)
• Varicosity (grade 2)
Varicose veins are not present in all
cases of chronic venous insufficiency

18. • Next step:
• No more pooling is possible: endothelial
gapping and fluid extravasation occurs.
• Clinical manifestation:
• Edema

19. • Next step:
• Intercellular gap enlargement allows larger
molecules such as proteins and blood cells
leave the vessel lumen.
• Clinical manifestation:
• Hyperpigmentation
• lipodermatosclerosis

20. And at last:
Ulceration is the final result of this pathologic process.

21. Diagnostic Evaluation:
History& physical examination:
• Consider risk factors
• Past medical history (DVT)
• D&H (IV. Drug abuse)
• Ph/E
• Detailed examination of the target limb

22. Physical Examination
• Adjuncts:
Trendelenburg test
Perthes test
• Inspection:
Color
Scar (GSV harvest)
Edema
Hyperpigmentation
Ulcer
Telangectasia, reticular
& varicose veins
Lipodermatosclerosis
• Auscultation:
bruit
• Palpation:
Warmness
Pitting
Thrill
Distal pulses

23. Radiologic Studies:
Purposes of the study:
• Detection of the existing thrombosis (S&D systems)
• Localization of the reflux point

24. After ruling out the thrombosis, localization of
the “POINT OF REFLUX” is the key factor in
CVI management.

25. Radiologic modalities:
• Detection of thrombosis:
• CT scan
• MRI
• Venography & IVUS
• Duplex Ultrasonography
• Localization of the reflux point:
• Venography & IVUS
• Duplex Ultrasonography

26. Duplex ultrasonography (DUS) is the most
useful modality in diagnosis and
management of the “CVI”

27. Principles of treatment
• Wound care
• Compression therapy
• Medical treatment
• Endovascular interventions
• Surgical treatments

28. Wound care
• Dressing
• Growth factors
• Skin grafts
*** wound recurrence is inevitable, unless
the venous hemodynamic is corrected

29. Compression
*** Compression therapy is the mainstay of CVI management
• Elastic compression stockings (30-40 mm Hg for ulcers)
• Multilayer elastic wraps or dressings
• Pneumatic compression devices

30. Medical treatments
• Increasing venous wall strength (flavonoids, chest nut oil)
• Increasing RBC flexibility (pentoxifylline)
• Decreasing blood coagulability (anti platelets and anticoagulants)
***Medications have a low grade of recommendation
and only prescribed in conjunction with effective
compression therapy

31. Interventions
• Purposes:
• Obstruction management
• Reflux elimination
*** Failure of treatment and recurrence are
the rule, unless these issues are taken into
account

32. Obstruction management
• Endovascular management
• Surgical treatment

33. Reflux elimination
• Treatment is tailored based on point of reflux
• Superficial system reflux:
Ablative
• Deep system reflux:
Reconstructive
• Perforating vein reflux:
Ablative

34. Superficial system reflux
1. Sapheno Femoral Junction (SFJ):
• Surgical ligation
• Stripping
• Chemical ablation
• Thermal ablation ( laser or radiofrequency)

35. Superficial system reflux
2. Sapheno Popliteal Junction (SPJ)
• Ligation
• Stripping
• ablation

36. Superficial system reflux
• Communicating veins & varicosities: (size dependent)
• Phlebectomy
• Sclerotherapy
• Cutaneous laser

37. Deep system reflux
• Valve reconstruction
• Valve transplantation

38. Perforating vein reflux
• Ligation
• Cut
• SEPS

39. Summary
• Lower extremity venous system includes deep, superficial and
perforating veins
• Cardiac pump, muscle contractions and venous valves are
determinants of upward flow in venous system
• Reflux is the key factor in chronic venous insufficiency
• Edema, varicosity, hyperpigmentation and ulcer are clinical
manifestations of CVI
• Compression therapy is the mainstay of management of CVI
patients
• Elimination of the highest point of reflux is the key factor in
successful treatment of CVI.

40. Thank You