Venous Disease: How it Relates to the Lower Extremity? 2017 Venous Disease.pdf · 2017-09-05 ·...

Venous Disease: How it Relates

to the Lower Extremity?

Parag J. Patel, MD MS FSIR

Associate Professor of Radiology & Surgery

Topics

• Scope of the problem

• Anatomy

• Pathophysiology

• Treatment

Prevalence of Venous Insufficiency / Venous Ulcers

• 3-8% total US population

• 10-15% adult males

• 20-25% adult females

• 1% adults > age 60 with ulceration

• Cost > $1 billion/year

Venous Insufficiency

• >30 Million Americans affected

• 1.9 million seek treatment annually

• Vast majority remain undiagnosed

Venous Hypertension

• Arteries no longer have significantly higher pressure than

veins

• Blood is not pumped effectively

• Blood proteins leak into extravascular space

• Fibrin builds up around vessels preventing oxygen and

nutrients from reaching cells

• WBC accumulate in small vessels releasing inflammatory

factors and free radicals

Clinical Impact

• Organ at risk is skin

– Pain

– Edema

– Pigmentation,

lipodermatosclerosis,

venous eczema

– Ulceration

Venous Anatomy of Lower Extremity

• Made up of 3 anatomic systems

– Deep

– Superficial

– Perforating

• Located in 2 separate

compartments

– Deep Compartment

– Superficial Compartment

Physiologic Function

• Deep System

– Transport system to

return blood to heart

– Drains superficial

system through

perforators

– >90% of venous blood

that leaves the limb goes

through DVS

Physiologic Function

• Superficial System

– Serves as reservoir to fill

DVS

– Helps regulate body temp. by

dilating/constricting

– Can dilate to accommodate

large volumes of blood with

little temp change

Venous Anatomy and Physiology

• Normal veins have valves that

allow uni-directional flow

• Leg muscle pump

• Valves normally close when

muscles relax

Venous Pressure changes

• Walk, Walk, Walk

• Venous Pumps

– Plantar, calf and foot pumps

• Standing has highest venous

pressure

• Walking pressure similar to

laying/sitting up

Ambulatory Venous Pressures

Venous Reflux

• Incompetent valves cause

pathologic retrograde flow

during calf muscle relaxation

• Increased venous

pressure/venous hypertension

• Venous hypertension causes

vvs and skin changes =

chronic venous insufficiency

Ambulatory Venous Pressures

Pathophysiology

• Incompetence of venous valves; Chronic obstruction

• Stasis of blood

• Chronic ambulatory venous hypertension

• Defective microcirculation

• RBCs diffuses into tissue planes

• Lysis of RBCs

• Release of hemosiderin

• Pigmentation

• Dermatitis

• Capillary endothelial damage

• Prevention of diffusion and exchange of nutrients

• Severe anoxia

• Chronic venous ulceration

Classification System

• CEAP: Clinical class, Etiology,

Anatomy, Pathology

0 = Normal

1 = Telangiectasias, spider veins

2 = Varicose veins

3 = Edema

4 = Skin changes

5 = Healed ulceration

6 = Active ulceration

Evaluation

• History

– Reflux vs obstruction, venous claudication

• Physical

– Supine and upright

– Pulse examination

• US

– Supine: anatomy, deep vein thrombosis

– Supine &/or Upright: reflux > 0.5

• CT, MR, venogram

– Assessment central veins (when pelvic source is suspected)

Pain

• Highly variable

• Range from fullness/heaviness, dragging or aching

• Exacerbated by standing, progressive throughout the day

• Typically felt in the calf or thigh

• Relieved with limb elevation

• Venous claudication (rare) during exercise

• Night cramps

Superficial Thrombophlebitis

• Common complication

• Most common associated with trauma or period of bed

rest

• Tender, hot, thickened area along course of varicose vein

• Extremely painful

• Potential for fever and malaise

Edema

• Progresses throughout the day

• Deep system insufficiency is more

severe and may be persistent

• Patients should be evaluated for

deep system incompetence

• Distinguish from lymphedema

(non-pitting) Brawny edema

Skin Changes - Pigmentation

• Prolonged venous hypertension

results in venous dilatation and

passage of RBC’s through the

endothelium into the interstitium

which subsequently breaks down

to hemosiderin.

• Typically located on the lower

medial third of the lower leg.

Skin Changes - Dermatitis

• Chronic inflammatory changes can

result in venous dermatitis or

varicose eczema.

• Dry, scaly or vesicular and weeping

• Venous ulceration may develop

Skin Changes - Lipodermatosclerosis

• AKA fat necrosis, folliculitis, or chronic cellulitis

• Progressive fibrosis of the skin and subcutaneous tissues

• Acute form is painful and disabling– Thickened raised red-brown area

– Hot

• Chronic form is stiff and shiny skin– Fixed, hard, indurated, contracting

– Inverted bottle shape

Skin Changes – Atrophie Blanche

• Skin necrosis with replacement by

scar tissue

• No ulceration or sloughing

• Small areas or patches that are

gray-white in color and only few

millimeters in size.

• Depression of the skin surface

• Halo of fine dilated venules

Skin Changes - Ulceration

• Previous mentioned conditions are

precursors

• Lead to impairment of tissue

nutrition and oxygenation

• 300k – 400k pts suffer from

venous ulcers in North America

Treatment Options

• Conservative management

– Compression hose therapy

• Excellent functional results

• Poor patient compliance

• Leg elevation

• Wound Care

– Debridement

– Infection Control

– Hyperbaric oxygen

• Surgical stripping

• IR: Endovascular Treatments

• Reflux

– Sclerotherapy

– Thermal ablation

• Obstruction

– Venous Stent Placement

Goal of Therapy

Eliminate or reduce reflux /

obstruction at its highest point

Saphenous Reflux

Min et al, JVIR 2003;14

Conservative Management

• Graduated compression

hose 1st line tx

– Compressing blood out of

superficial veins into deep

system

– Reduction of venous

pressure and subsequently

decreased swelling

• Graduated compression,

higher at the ankle

Classic Treatment

• High ligation

• Saphenous vein stripping

• Perforator interruption

• Deep system valve replacement

/ reconstruction

Downsides to stripping and ligation

• Done under general anesthesia in a hospital setting

• Post-operative pain requiring prescription drugs

• Severe bruising/ tenderness along the treated vein

• Typical recovery is between 2-4 weeks

Thermal Ablation

• Transmural injury

– Radiofrequency or laser

• Acute thrombosis

• Fibrosis

• Permanent obliteration of vein lumen

– Proximal tributaries may remain patent

Thermal Ablation GSV

• Outpatient procedure

• Local anesthetic

• US guided

– Fluoroscopy can be helpful in certain cases

• Immediate ambulation

• Quick return to normal activity

Laser Procedure

Laser Procedure

Laser Procedure

Pre Post

Endovenous Ablation

• Advantages to thermal ablation (RFA and Laser)

– Outpatient procedure

• iv sedation not necessary

– Quick return to normal activity (less patient discomfort)

• 93-95% closure at 2 years in published studies

When to treat obstructive component?

• Persistent Significant limb symptoms

– Pain, swelling, venous dermatitis, venous ulcer, recurrent

cellulitis

• Failed conservative management

– Compression therapy

• Severity of symptoms, NOT venographic findings

EW

• 44-year-old male with a history of extensive DVT

extending from the infrarenal IVC to the bilateral popliteal

veins. He was previously on Coumadin for

anticoagulation, and presented with left lower extremity

phlegmasia.

Outcomes of Venoplasty with Stent Placement for Chronic

Thrombosis of the Iliac and Femoral Veins: Single-Center

Experience

• 89 patients (91 limbs) included in study (189 patients

reviewed)

• 90/91 limbs patent at 30 days

• Primary patency/Primary assisted patency

– 1 year: 81%/94%

– 3 year: 71%/90%

• Study designed to primarily evaluate patency

Kurklinsky et al JVIR 2012;23:1009-15

Percutaneous Recan of Total Occlusion of

Iliac Vein• 139/167 (83%) successfully recanalized

• Stent patency at 4 years: 66%

• Symptom relief at 3 years

– Pain: 79%

– Swelling: 66%

• Venous ulcer healing

– 56% at 33 months

Raju and Neglen JVS 2009;50:360-8

Summary

• Venus ulcers are a significant burden to the healthcare

system

• Reflux and obstruction contribute to elevated ambulatory

venous pressures Venous Hypertension

• Endovascular treatments targeted at sites of venous

insufficiency and venous obstruction will relieve venous

hypertension

• Contributes to healing of venous ulcers

• IRs are a natural partner for podiatry