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Copyright © 2009 by American College of Phlebology 1
THE FUNDAMENTALS OF PHLEBOLOGY:
Venous Disease for Clinicians
An Introductory Lecture
Copyright © 2009 by American College of Phlebology
2
Disclosure of Conflict of InterestDr John Rowen
I do not have relevant financial relationships with any commercial interests.
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
“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
Copyright © 2009 by American College of Phlebology
5
The medical specialty devoted to the diagnosis and treatment of patients with venous disorders
PHLEBOLOGY
Copyright © 2009 by American College of Phlebology
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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
National Heart Lung and Blood Institute (NHLBI) http://www.nhlbi.nih.gov/
Copyright © 2009 by American College of Phlebology
7
THE SPECTRUM OF CHRONIC VENOUS DISEASE
lipodermatosclerosis
telangiectasias
varicose veins
Superficial phlebitis
venous ulceration
Copyright © 2009 by American College of Phlebology
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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
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Copyright © 2009 by American College of Phlebology
10
Venous Diseaseis 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 veinsCornu-Thenard, A, J Dermatol Surg Oncol 1994 May; 20(5):318-26.
Copyright © 2009 by American College of Phlebology
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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.
J Vasc Surg. 2007 August; 46(2): 331–337
Copyright © 2009 by American College of Phlebology
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The beginnings of venous disease may be found as early as childhood
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%
Phlebologie. 1990 Nov-Dec;43(4):573-7. Weindorf N, Schultz-Ehrenburg U.
Copyright © 2009 by American College of Phlebology
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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
shiftSantler, R Hautarzt 1956; 10:460
Copyright © 2009 by American College of Phlebology
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Varicose Veins are 3 times more common in women than men
"Varicose veins." The Mayo Clinic. January 2007. http://www.mayoclinic.com
Copyright © 2009 by American College of Phlebology
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Each pregnancy worsens the condition
• 405 women with varicose veins• 13% had one pregnancy• 30% had two pregnancies• 57% had three pregnancies
Brand FN, et al The epidemiology of varicose veins: the Framingham Study Am J Prev Med 1988; 4:96-101
Copyright © 2009 by American College of Phlebology
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Copyright © 2009 by American College of Phlebology
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
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Illustration by Linda S. Nye
Copyright © 2009 by American College of Phlebology
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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
Illustration by Linda S. Nye
Copyright © 2009 by American College of Phlebology
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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
Illustration by Linda S. Nye
Copyright © 2009 by American College of Phlebology
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Perforating veins
• Mid-thigh Perforating Vein• Dodd• Proximal Calf Perforator• Cockett• Gastrocnemius• Lateral thigh (lateral
subdermic plexus)
Illustration by Linda S. Nye
Copyright © 2009 by American College of Phlebology
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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
Illustration by Linda S. Nye
Copyright © 2009 by American College of Phlebology
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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
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Doppler exam: Normal flow
Illustration by Linda S. Nye
Copyright © 2009 by American College of Phlebology
25
Doppler: Reflux
Illustration by Linda S. Nye
Copyright © 2009 by American College of Phlebology
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REFLUX: its contribution to varicose veins
Illustration by Linda S. Nye
Copyright © 2009 by American College of Phlebology
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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
The presence of both is far worse than either one alone
Copyright © 2009 by American College of Phlebology
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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 eczemaC4b – 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
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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
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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
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Copyright © 2009 by American College of Phlebology
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
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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
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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
*Weiss RA and Weiss MA J Dermatol Surg Oncol. 1990 Apr;16(4):333-6.
Copyright © 2009 by American College of Phlebology
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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
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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
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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
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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
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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
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Skin changes suggestive of chronic venous insufficiency
Corona Phlebectatica (C1)
Pigmentation (C4a)
Atrophie blanche (C4b)
Healed ulcer (C5)
Copyright © 2009 by American College of Phlebology
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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
*Shami SK et al. J Vasc Surg 1993; 17:487-90
Copyright © 2009 by American College of Phlebology
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Venous ulceration
Impending ulceration Lipodermatosclerosis (C4a)
Venous ulceration (C6)
Copyright © 2009 by American College of Phlebology
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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
Arterial ulcer
Photo courtesy of John Bergan, MD
Copyright © 2009 by American College of Phlebology
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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
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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
Photo courtesy of Juzo
Copyright © 2009 by American College of Phlebology
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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
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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
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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
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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* Requires a prescription
Copyright © 2009 by American College of Phlebology
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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
Copyright © 2009 by American College of Phlebology
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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
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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
Photo courtesy CircAid Medical Products, Inc.
Copyright © 2009 by American College of Phlebology
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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
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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
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Copyright © 2009 by American College of Phlebology
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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
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Treatment of telangiectasias
• Sclerotherapy most effective
• Laser may be helpful• Multiple treatments usually
required• Reduces symptoms in 85%
of patients• Improves quality of life
Weiss RA and Weiss MA J Dermatol Surg Oncol. 1990 Apr;16(4):333-6.
Copyright © 2009 by American College of Phlebology
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Sclerotherapy of Telangiectasias: Technique
Injection of sclerosant solution causes damage to endothelium which leads to fibrosis of vein
Copyright © 2009 by American College of Phlebology
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Sclerotherapy Results
Before AfterPhotos courtesy of Steven Zimmet, MD, FACPh
Copyright © 2009 by American College of Phlebology
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Treatment of Reticular Veins
NEED PIC
Frequently associated with telangiectasias, their Rx may enhance results of sclerotherapy of telangiectasias
Visualization may be improved with transillumination
Copyright © 2009 by American College of Phlebology
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Non-surgical treatment of varicose veins• Sclerotherapy effective;
may be enhanced if ultrasound-guided
• Endovenous occlusion with radiofrequency or laser extremely effective
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
Copyright © 2009 by American College of Phlebology
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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
Photo courtesy of CompuDiagnostics, Inc.
Copyright © 2009 by American College of Phlebology
65
Sclerotherapy Results
Before After Ultrasound-guided sclerotherapy of the Great Saphenous Vein and sclerotherapy of branches
Photos courtesy of Steven Zimmet, MD, FACPh
Copyright © 2009 by American College of Phlebology
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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
NEED PIC
Copyright © 2009 by American College of Phlebology
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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
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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
Butler CM, et al Phlebology 2002. 17:59-63 Photo
Photo courtesy of John Bergan, MD
Copyright © 2009 by American College of Phlebology
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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
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Treatment Results
Before After Endovenous obliteration of the Great Saphenous Vein and phlebectomy of tributariesPhotos courtesy of Steven Zimmet, MD, FACPh
Copyright © 2009 by American College of Phlebology
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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
Padberg FT et al J Vasc Surg 1996; 24:711-19
Copyright © 2009 by American College of Phlebology
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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
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Prandoni et al, Ann Intern Med 2004;141:249-256
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
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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
Venbrux AC et al J Vasc Interv Radiol 2002; 13:171-178
Copyright © 2009 by American College of Phlebology
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• 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
AMERICAN COLLEGE OF PHLEBOLOGY101 Callan Avenue, Suite 210 ● San Leandro, CA 94577-4558
510.346.6800 ● 510.346.6808 [email protected] ● www.phlebology.org