Venous Stasis

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Venous Stasis

• Joon Ho Jang MD

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• Incidence/Prevelance JOBST Coverage

• It is estimated that more than 80 million
  Americans suffer from some form of venous
  disorder.
• Up to 13 million people in the U.S. suffer
  from CVI
• Peak incidence occurs in women aged 40-9 and
  men aged 70-79 years
• Statistics show one in three Americans over
  the age of 45 is affected by vein disease, and of
  those, only 4 are
• being treated.
• Annual health care cost in the US to treat CVI
  is about 3billion about 2 million workdays are
  lost per year due to venous ulcers
• Varicose Veins
• More than 24 million Americans have varicose
  veins
• Up to 50 of women have varicose veins while
  24 of men aged 30-40 and 43 of men over 70 have
  varicose veins
• DVT / PTS
• There are over 200,000 new cases of DVT each
  year in the U.S.
• The incidence of pulmonary embolism in
  patients with DVT ranges from 5 20 and can be
  fatal
• After an episode of DVT, 20 50 of patients
  develop Post Thrombotic Syndrome within the first
  2 years
• Venous Stasis Ulcers
• Affect 2.5 million people in the U.S.

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Venous StasisHow?

• Mechanics
• Structure
• Inflammation
• Pressure
• Obstruction- DVT

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Function

• Transport blood back to the heart
• Prevent intravascular volume overload

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Anatomy

• Tunica intima endothelium with BM and elastic
  lamina
• Produces endothelium derived relaxing factor and
  prostacyclin
• Tunica media Circumferential SM
• Maintains venous pressure gradient
• Tunica externa Collagen
• Stability

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Valves

• Venous valves
• One way
• Two cusps of CT skeleton covered by endothelium
• Closure at gt 30cm/s
• Exception IVC, common iliacs, portal, cranial
  sinus

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Lower Extremity
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Venous Hypertension

• Hydrostatic pressure vs Mechanical/muscular
  pressure
• A. K. Tassiopoulos et al.
• 1153 cases of ulcerated legs and venous disease
• Reflux in superficial, deep, and perforating
  veins
• Incompetent valves

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Valvular Dysfunction

• Physical damage splitting, tearing, thinning,
  adhesion to wall
• Reduction in number
• Not age related
• Monocyte and macrophage infiltration
• Overexpression of Intracellular adhesion
  molecules
• Wall hypertrophy, disruption of collagen
  synthesis, and destruction of extracellular
  matrix proteins

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Shear Stress and Inflammation

• Pulsatile venous blood flow
• Valve closes Pvortical gt Pluminal
• Minimal shear stress
• Low shear stress starts cascade of inflammatory
  signals

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Risk Factors

• Genetic
• More in females
• Hormones
• Progesterone, estrogen
• Pregnancy
• Age gt50
• Greater height
• Prolonged standing
• Obesity

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Signs and Symptoms

• Telangiectasias
• Reticular veins
• Varicosity
• Thrombophlebitis
• Hyperpigmentation
• Bleeding from clusters
• Ulceration

• Aching
• Heaviness
• Early fatigue
• Edema
• Itching
• Restless legs
• Cramps

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Physical Exam, Diagnostic Tests

• Palpable veins
• Perthes Test
• For deep venous patency
• Tourniquet and walk
• Brodie-Trendelenburg Test
• For superficial vein and valve patency
• Venous filling time normal- within 35 secs
• Duplex Ultrasound
• Venography

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Classification CEAP Eklof et al. J of Vasc
Surg 2004

• Clinical classification
• C0 no visible or palpable signs of venous
  disease
• C1 telangiectasies or reticular veins
• C2 varicose veins
• C3 edema
• C4a pigmentation or eczema
• C4b lipodermatosclerosis or atrophie blanche
• C5 healed venous ulcer
• C6 active venous ulcer
• S symptomatic, including ache, pain, tightness,
  skin
• irritation, heaviness, and muscle cramps, and
  other
• complaints attributable to venous dysfunction
• A asymptomatic

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CEAP

• Etiologic classification
• Ec congenital
• Ep primary
• Es secondary (post-thrombotic)
• En no venous cause identified
• Anatomic classification
• As superficial veins
• Ap perforator veins
• Ad deep veins
• An no venous location identified
• Pathophysiologic classification
• Basic CEAP
• Pr reflux
• Po obstruction
• Pr,o reflux and obstruction
• Pn no venous pathophysiology identifiable

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Treatment

• Compression Therapy
• Stockings, Unnas Boot
• Drug Therapy
• Surgery

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Compression Stockings

• Worn during the day
• Elastic stockings with adjustments in pressure
• Lower pressure stockings (20-30mm Hg) for edema
  and DVT prophylaxis
• Higher pressure (30-40mm Hg) for ulcers and
  significant venous disease

• Operator dependent
• Difficult to put on
• Physical impediments/Co-morbidities
• 50 of patients were unable to them on alone
• 30-65 noncompliance noted in clinical trials in
  venous centers

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Efficacy of Compression Therapy

• 22 trials comparing healing of venous ulcers
  using compression stockings
• Compressive therapy more effective than
  non-compression
• Higher pressure were more effective than lower
• Multilayer compression was better than single
  layer bandaging
• 466 patients with a healed ulcer
• Continued use of compression stocking reduced
  reoccurrence within 3-5 year
• ESCHAR study 500 limb trial that compares
  surgery and compression vs. compression alone for
  ulcer treatment
• Combination therapy had lower rates of
  reoccurrence of ulcer at year 4 (24 vs. 52)

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Drug Therapy

• Pentoxifylline
• PDE4 inhibitor that increases intracellular cAMP
  and stimulates protein kinase A activity
• Reduces blood viscosity and decreases platelet
  aggregation and thrombus formation
• Variable efficacy

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More invasive

• Sclerotherapy
• 0.2 sodium tetradecyl injected directly into
  spider angiomas and smaller superficial
  varicosities
• Complications (lt5) allergic reaction,
  hypo/hyper-pigmentation, local skin necrosis
• Endovenous laser ablation of saphenous vein
  (EVLT)
• Surgical excision of veins (Stripping)

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Efficacy

• Meta-analysis of 64 studies (12,320 legs)
• Anaylzed ablation via Duplex US
• Follow upto 5 years
• Success rate of EVLT highest after 5 years
• Complications DVT (lt3), local bruising and
  pain, paresthesias, foam emboli, stroke

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Works Cited

• Raju et al. Chronic venous insufficiency and
  varicose veins. NEJM 20093602319-27
• Bergan et al. Chronic venous disease. NEJM
  2006355488-98.
• Tassiopoulos et al. Current concepts in chronic
  venous ulceration. Euro J Vasc Endovasc Surg
  200020227-232.
• Ono et al. Monocyte inflitration of venous
  valves. J Vasc Surg 199827158-66.
• Sansilvestri-Morel et al. Imbalance in the
  synthesis of collagen type I and collagen type
  III in smooth muscle cells derived from human
  varicose veins. J Vasc Res 200128560-8.
• Jacob et al. Extracellular matrix remodeling in
  the vascular wall. Pathol Biol 200149326-32
• Eklof et al. Revision of the CEAP classification
  for chronic venous disorders Consensus
  statement. J Vasc Surg 2004401248-52.
• Cullum et al. Copression bandages and stockings
  for venous leg ulcers. Cochrane Database Syst
  Rev 20002 CD000265
• Mayberry et al. Fifteen-year results of
  ambulatory compression therapy for chronic venous
  ulcers. Surgery 1991109575-81.
• Barwell et al. Comparison of surgery and
  compression with compression alone in chronic
  venous ulceration (ESCHAR study) randomised
  controlled trial. Lancet 20043631854-9.
• Van den Bos et al. Endovenous therapy of lower
  extremity varicosities a meta-analysis/ J Vasc
  Surg 200949230-9.