Chronic venous insufficiency

Why is it important to know?

  • Venous disease affects all age groups, gender and racial groups

  • 25% of the population has a degree of venous disease

  • If untreated it can progress all the way from visible varicosities to skin pigmentation and ultimately tissue loss/ ulceration

  • Prevalence of venous ulcers (VLUs) in NZ is in the order of 2.48 per 1000 adults.

Chronic venous insufficiency is incredibly common. Brand et al. Am J Prev Med 1988

Pathophysiology

  • Venous reflux develops when the valves stop working properly and allow blood to flow backward (i.e., reflux) and pool in the lower leg veins.

  • Risk factors include

    • age

    • family history

    • obesity

    • pregnancy

    • lack of exercise

    • leg injury or trauma

    • prolonged sitting or standing

Diseased valves cause blood to move in both directions, elevating venous pressure.

Focal dilation is typically asymptomatic, with little to no visual appearance. Varicosity and aneurysm are usually more symptomatic.

CEAP Classification

C = clinical; E = etiologic; A = anatomic; P = pathophysiologic

Who to refer?

Public

  • Thrombophlebitis

  • Skin change

  • Healed/ Open Venous Ulcer

Private (in addition)

  • moderately severe pain/ swelling not responsive to simple analgesics

  • episode of bleeding from a burst varicosity

Vein map

  • Femoral vein; saphenofemoral junction (SFJ), great saphenous vein (GSV)

  • Popliteal vein; small saphenous vein (SSV)

In this example, deep veins reflux to the level of the distal FV. POP vein and deep calf veins are competent. SPJ, GSV, and GSV tributaries in the calf reflux as shown. SPJ and SSV are competent. Two incompetent perforators were detected.

Treatment options

Conservative

  • Exercise

  • Elevation

  • Compression stockings

  • NSAIDS

Interventional

  • Surgical stripping

  • Thermal

    • Laser ablation

    • Radiofrequency ablation - for incompetent saphenous veins

      • Small access sheath placed into the saphenous vein

      • Through this the thin RFA probe is placed and manipulated to 2cm proximal to the SFJ/ SPJ

  • Non-thermal

    • Mechanochemical ablation

    • Foam Sclerotherapy - for small incompetent tributaries

      • Sodium Tetradecyl Sulphate is mixed with air to foam a foam an injected into the tributaries under ultrasound guidance

      • The foam displaces the blood in the vein and destroys the lining of the vein. The vein shuts down and is gradually broken down and absorbed

    • Cyanoacrylate ablation

Post-procedural care - RFA and sclerotherapy

  • Thigh high level II compression stocking for 10 days (helps with pain, swelling, prevent haematoma formation).

    Analgesics, NSAIDs

  • Walking: keeps calves pumping blood through deep veins and helps prevent DVT (1% risk).

  • Follow up appointment in 6 weeks. Ultrasound the legs with further sclerotherapy if needed for residual tributaries

Dr Rahul Bera