9- Chronic venous insufficiency. Clinical presentation, physical and imaging examination, treatment.

what is chronic venous insufficiency

• blood pools in the veins, straining vessel walls

• functional venous valves are impaired→ sswelling, ulcer formation

what is the etiology of CVI

• changes in microcirculation

  • valve insufficiency

  • occlusion- thrombosis

  • lymphatic flow obstruction

  • impaired muscle pump function

• other

  • increasing age, female, prolonged standing, obesity, smoking, pregnancy, prior thrombosis, preior extremity trauma

what is the pathomechanism of varicose veins

1. elevated venous pressure

2. incompetence of venous valves

3. reflux of blood into superficial veins back into extremity

4. further increase of venous pressure

5. formation of varicose veins

what is the pathomechanism of CVI

1. varicose vein formation

2. extravasation of protein and leukocytes

3. release of free radicals → damage of capillary BM

4. leakage of plasma proteins → oedema

5. decrease O2 supply

6. tissue hypoperfusion and hypozia

7. inflammation and atrophy

8. possible ulcer formation

what are the main complaints in CVI

• swelling of legs and ankles

• pain, lower extremity discomfort

• cramping

• itching, tingling, numbness

what are the skin findings of CVI

• yellow- brown or re brown skin pigmentation

  • RBC breakdown → haemosiderin release + accumulation

• oedema formation

• telangiectasis

  • spider veins

• lipodermatosclerosis

• venous ulceration

how do you classify CVI

• CEAP classification

• C-clinical

• E-etiological

• A-anatomical

• P-pathophysiological

what can be seen on physical examination in CVI

• Trendelenburg test

  • examines function of superficial and perforating venous valves

    • supined position with legs elevated → tourniquet is applied to compress superficial veins → leg is lowered

how can you interpret the trendelenburg test

• normal

  • no filling of superficial veins- flows from superficial to perforating veins

• Tren. 1 positive

  • if stasis- rapid filling from deep to superficial venous system

  • insufficient perforating veins

• Tren. 2 positive

  • after stasis removal, rapid filling within superficial venous system

    • insufficient superficial valves

what are ways to diagnose CVI

• Duplex US
  • detect reflux, obstruction, mapping prior intervention
  • chek blood flow and direction
• MRV- venography
  • visualise → in complicated cases
• venous plethysmography
  • non invasive measurement of the venous refill time via infrared light

what is the most common venous disease that needs intervention

• venous thromboembolism
  • 3rd most common CV disease

what is the imagine modality of choice for venous disease

• US first imaging
• CTA, MRA can be used to plan subsequent intervention

what is the treatment of venous thrombosis

• selective catheter thrombolysis of acute DVT

what is post thrombotic syndrome

• chronic, long term complication of DVT
• affects 30-60% of patients within 2 years of the event, with 10% developing venous ulcerations

what are the types of thrombolysis

• systemic
• selective- catheter into thrombus

what is the systemic thrombolysis

• inefficient
• insufficient recanalization

what are the disadvantages of selective thrombolysis

• time consuming intervention
• major bleeding complication

what is mechanical thrombectomy

• faster clot reduction
  • greater surface area than thrombolysis
• mechanical aspiration
• hydrodynamic (reolytic) devices
  • high pressure recirculation system for thrombus dissolution and aspiration

what is chronic venous occlusion

• insufficient collateralisation of ilio caval occlusion → post thrombotic complaints, leg ulcers

what is the treatment of chronic venous occlusion

• not responding cases of conservative therapy→ revascularisation procedures
• surgical interventions are invasive- only considered in cases of failed endovascular intervention
• after successful recanalisation appropriate anticoagulation → further angiology follow ups are needed

what are the catheter based interventions

• puncture sites- jugular, femoral, GSV
• pre dilation with balloon→ using long self expanding stents
• post dilation balloon

what are the open surgical treatment of venous diseases

• varicose veins- endovenous surgery, varicectomy
• rarely in thrombophlebitis- GSV, LSV ligation
• proximal (ilio femoral) deep vein thrombosis
• superior vena cava- PTA, stent
• inferior vena cava
  • acute thrombosis- lysis, thrombus aspiratio, cava filter
  • chronic stenosis/ occlusion- PTA, stent
  • tumour thrombus- cava thrombectomy

What are the types of contemporary varicose vein surgeries

• thermal procedures
• non thermal procedures

what are the thermal procedures for varicose veins

• radiofrequency
  • mono/bipolar
• laser
  • different wavelength
  • linear/ radial fiber
• steam
• cryostripping

what are the non thermal procedures for varicose veins

• foam sclerotherapy
• mechanochemical ablation
• glue- cyanoacrylate

what is radiofrequency catheter ablation

• RF energy affect collagen in vein wall
  • fast ablation
• lumen decreases, vein closure and scarring

describe a traditional varicectomy

• crossectomy
• stripping
• perforant vein ligation
• side branch remova