Chapter 303 - Chronic Venous Disease and Lymphedema

Question 1

What is the prevalence estimated for varicose veins in the United States?

Answer 1

15% in men and 30% in women.

Question 2

How many patients with chronic venous insufficiency develop venous ulcers?

Answer 2

Approximately 20%.

Question 3

Chronic venous insuficieny is more frequent in men than in women.
True or False?

Answer 3

True.

“Chronic venous insuficiency with edema affects approximately 7,5% of men and 5% of women.”

Question 4

What is the estimated prevalence of chronic venous insufficiency with edema among those less than 50 years of age and those 70 years of age?

Answer 4

2% and 10%, respectively.

Question 5

Explain the venous anatomy regarding the superficial veins of the leg.

Answer 5

“The superficial veins are located between the skin and deep vascia. In the legs, these include the great and small saphenous veins and their tributaries. The great saphenous vein in the longest vein in the body. It originates on the medial side of the foot and ascends anterior to the medial malleolus and then along the medial side of the calf and thigh, and drains into the common femoral vein. The small saphenous vein originates on the dorsolateral aspect of the foot, ascends posterior to the lateral malleolus and along the posterolateral aspect of the calf, and drains into the popliteal vein.”

Question 6

What is the anatomic relation between the basilic, cephalic and median cubital veins?

Answer 6

“The basilic and cephalic veins course along the medial and lateral aspects of the arm, respectively, and these are connected via the median cubital vein in the antecubital fossa.”

Question 7

How to differentiate varicose veins from reticular veins and telangiectasias?

Answer 7

“Varicose veins are dilated, bulging, tortuous superficial veins, measuring at least 3 mm in diamter. The smaller and less tortuous reticular veins are dilated intradermal veins, which appear blue-green, measure 1 to 3 mm in diamter, and do not protrude from the skin surface. Telangiectasias, or spider veins, are small, dilated veins, less than 1 mm in diameter, located near the skin surfcace, and form blue, purple, or red linear, branching, or spider-web patterns.”

Question 8

What are the causes for varicose veins?

Answer 8

“Varicose veins can be categorized as primary or secondary. Primary varicose veins originate in the superficial system and result from defective structure and function of the valves of the saphenous veins, intrinsic weakness of the vein wall, and high intraluminal pressure. (…) Secondary varicose veins result from venous hypertension, associated with deep venous insufficiency or deep venous obstruction, and incompetent perforating veins that cause enlargement of superficial veins. Arteriovenous fistula also cause varicose veins in the affected limb.”

Question 9

What are the risk factors for primary varicose veins?

Answer 9

“Approximately one-half of these patients have a family history of varicose veins. Other factors associated with primary varicose veins include aging, pregnancy, hormonal therapy, obesity, and prolonged standing.”

Question 10

How do you differentiate pathophysiologically primary from secundary deep venous insufficiency?

Answer 10

“Primary deep venous insufficiency is a consequence of an intrinsic structural or functional abnormality in the vein wall or venous valves leading to valvular reflux. Secondary deep venous insufficiency is caused by obstruction and/or valvular incompetence from previous deep vein thrombosis.”

“Other causes of secondary deep venous insufficiency include May-Thurner syndrome, where the left iliac vein is occluded or stenosed by extrinsic compression from the overlapping right common iliac artery; arteriovenous fistulas resulting in increased venous pressure; congenital deep vein agenesis or hypoplasia; and venous malformations as may occur in Klippel-Trénaunay-Weber and Parkes-Weber syndromes.”

Question 11

What might be the dermatological findings associated with venous stasis?

Answer 11

“hyperpigmentation, erythema, eczema, lipodermatosclerosis, atrophie blanche, and a phlebectasia corona.”

Question 12

How do you differentiate between lipodermatosclerosis and atrophie blanche?

Answer 12

“Lipodermatosclerosis is the combination of induration, hemosiderin deposition, and inflammation, and typically occurs in the lower part of the leg just above the ancle. Atrophie blanche is a white patch of scar tissue, often with focal telangiectasias and a hyperpigmented border; it usually develops near the medial malleolus.”

Question 13

What is phlebectasia corona?

Answer 13

“A pbhelbectasia corona is a fan-shaped pattern of intradermal veins near the ankle or on the foot.”

Question 14

How do you characteriz venous ulcers?

Answer 14

“A venous ulcer is often shallow and characterized by an irregular border, a base of granulation tissue, and the presence of exsudade.”

Question 15

How do you perform and interpret Brodie-Trendelenburg and Perthes tests?

Answer 15

“The Brodie-Trendelenburg test is useful to determine whether varicose veins are secondary to deep venous insufficiency. As the patient is lying supine, the leg is elevated and the veis allowed to empty. Then, a tourniquet is placed on the proximal part of the thigh and the patient is asked to stand. Filling of the varicose veins within 30 s indicates that the varicose veinsa re caused by deep venous insufficiency and incompetent perforating veins. Primary varicose veins with superficial venous insufficiency are the likely diagnosis if venous refilling occurs promptly after tourniquet removal. The Perthes test assesses the possibility of deep venous obstruction. A tourniquet is placed on the midthigh after the patient has stood, and the varicose veins are filled. The patient is then instructed to walk for 5 min. A patent deep venous system and competent perforating veins enable the superficial veins below the tourniquet to collapse. Deep venous obstruction is likely to be present if the superficial veins distend further with walking.”

Question 16

Chronic venous insufficiency and lymphedema might occur simultaneously.
True or False?

Answer 16

True.

Question 17

Name the causes for bilateral leg edema.

Answer 17

“Bilateral leg swelling occurs in patients with congestive heart failure, hypoalbuminemia secondary to nephrotic syndrome or severe hepatic disease, myxedema caused by hypothyroidism or pretibial myxedema associated with Graves’ disease, and with drugs such as dihydropyridine calcium channel blockers and thiazolidinediones.”

Question 18

Name the differential diagnosis of venous ulcers.

Answer 18

“Leg ulcers may be caused by severe peripheral artery disease and critical limb ischemia; neuropathies, particularly those associated with diabetes; and less commonly, skin cancer, vasculitis, or rarely as a complication of hydrxiurea. The location ahd characteristics of venous ulcers help to differentiate these from other causes.”

Question 19

Using the CEAP classification for chronic venous disease, how would you classificate a patient with varicose veins without any cutanoues changes due to postthrombotic syndrome?

Answer 19

C2, Es, As, Pr,o

Question 20

Besides diagnosing venous disease, ultrassonography might have a use to quantify the severity of the disease.
True or False?

Answer 20

True.
“Some vascular laboratories use air or strange gauge plethysmography to assess the severity of venous reflux and complement findings from the venous ultrasoung examination. Venous volume and venous refilling time are measured when the legs are placed in a dependent position and after calf exercise to quantify the severity of venous reflux and the efficiency of the calf muscle pump to affect venous return.”

Question 21

Name examples of situations associated with risk for proximal vein thrombosis.

Answer 21

Previous proximal vein thrombosis, occlusion of inferior vena cava filters, extrinsic compression from tumors and May-Thurner syndrome.

Question 22

What is the graduation of elastic support for varicose veins?

Answer 22

“Graduated compression stockings with pressures of 20-30mmHg are suitable for most patients with simple varicose veins, although pressures of 30-40mmHg may be required for patients with manifestations of venous insufficiency such as edema and ulcers.”

Question 23

Besides using stockings or multilayered compression bandages as the standard care for chronic venous insufficiency, which other additional therapy might one consider?

Answer 23

“In addition to a compression bandage or stocking, patiensts with venous ulcers also may be trated with low adherent absorbent dressings that take up exudates while maintaining a moist environment. Other types of dressings include hydrocolloid (an adhesive dressing comprised of polymers such as carboxymethylcellulose that absorbs exudates by forming a gel), hydrogel (a nonabsrobent dressing comprising 80% water or glycerin that moisturizes wounds), foam (an abosrbent dressing made with polymers such as polyurethane), and alginate (an absorbent, biodegradable dressing that is derived from seaweed), but there is little evidence that these are more effective than low adherent absorbet dressing.”

Question 24

There is some evidence suggesting better outcomes in chronic venous disease for herbal supplements, more especifically aescin and micronized purified flavonoid fraction.
True or False?

Answer 24

True.
“Although meta-analyses have suggested that aescin reduces edema, pruritus, and pain and the micronized purified flavonoid fraction in conjunction with compresion therapy facilitates venous ulcer healing, there is insufficient evidence to recommend the general use of these substances in patiensts with chronic venous insufficiency.”

Question 25

Which endovenous thermal ablation procedure has higher occlusion rates?

Answer 25

Endovenous laser therapy has slightly higher rates comparing to radiofrequency ablation.

Question 26

Name the FDA approved sclerosing agents.

Answer 26

Sodium tetradeceyl sulfate, polidocanol, sodium morrhuate, and glycerin.

Question 27

Which nerves might be injuried using sclerotherapy or surgery below the knee for varicose veins?

Answer 27

Saphenous and sural nerves.

Question 28

How do you explain a 50% recurrence by 5 years of varicose veins following surgery therapy in comparison to occlusion rate >90% and slighly less for endovenous therapy and radiofrequency ablation?

Answer 28

“Recurrent varicose veins occur in up to 50% of patients by 5 years, due to technical failues, deep venous insufficiency, and incompetent perforating veins.”

Question 29

What does SEPS mean and what is it used for?

Answer 29

“Subfacail endoscopic perforator surgery (SEPS) uses endoscopy to identify and occlude incompetent perforating veins. It also may be performed along with other ablative procedures.”

Question 30

What is the general success rate for venous bypass procedures?

Answer 30

> 60%

>75% patency long-term for regarding iliac veins

Question 31

Define lymphedema.

Answer 31

“Lymphedema is a chronic condition caused by impaired transport of lymph (…) when there is an imbalance between lymph production and lymph absortion”

Question 32

How does one explain adipose and collagen deposition related to lymphedema?

Answer 32

“Persistent lymphedema leads to inflammatory and immune responses characterized by infiltration of mononuclear cells, fibroblasts, and adipocytes, leading to adipose and collagen deposition in the skin and subcutaneous tissues.”

Question 33

How is lymph drained centrally?

Answer 33

“Lymph is propelled centrally by the phasic contractile activity of lymphatic smooth muscle and facilitated by the contractions of contiguous skeletal muscle. The presence of lymphatic valves ensures unidirectional flow.”

Question 34

Name the subclinical types for primary lymphedema.

Answer 34

“congenital lymphedema, which appears shortly after birth; lymphedema praecox, which has its onset at the time of puberty; and lymphedema tarda, which usually begins after age 35.”

Question 35

Name one mutation associated with Milroy’s disease.

Answer 35

Milroy’s disease is a familial form of congenital lymphedema and mutation in VEGFR3 (Vascular Endothelial Growth Factor Receptor 3), a determinant of lymphangiogenesis, has been described in these patients.

Question 36

Name one mutation associated with cholestasis-lymphedema syndrome.

Answer 36

A mutation in chromosome 15q has been associated with this syndrome.

Question 37

FOXC2 gene, which encodes for a transcription factor that ineracts with a signaling pathway for the development of lymphatic vessels, is associated with which syndrome?

Answer 37

It has been reported in lymphedema-distichiasis syndrome.

Question 38

Name the syndromes that might be associated with lymphedema and the possible genetic mutations that explain it.

Answer 38

Cholestais-lymphedema syndrome - mutation 15q
Lymphedema-distichiasis syndrome - FOXC2
Hypotrichosis, lymphedema, telangiectasia syndrome - SOX18
Turner’s syndrome, Klinefelter’s syndomre and trisomy 18, 13 or 21.
Klippel-Trénaunay syndrome, Parkes-Weber syndrome and Hennekan’s syndrome.
Noonan’s syndrome, ellow nail syndrome, intestinal lymphangiectasia syndrome, lymphangiomyomatosis, and neurofibromatosis type 1.

Question 39

Excluding filarisis, name one infection frequently assocaited with secondary lymphedema.

Answer 39

Recurrent bacterial lymphagitis by Streptococcus.

Question 40

Lymphedema is more frequent after axillary node dissection compared to surgery plus radiotherapy.
True or False?

Answer 40

False.

13% and 22%, respectively.

Question 41

How frequent is lymphedema in the leg following inguinal lymph node dissection?

Answer 41

Approximately 15%.

Question 42

Name the secondary causes for lymphedema.

Answer 42

Infections, post-surgery, tumor infiltration, contact dermatitis, rheymatoid arthritis, pregnancy, and self-induced or factitious lymphedema after application of tourniquets.

Question 43

How does one explain initial pitting that disappears over time has lymphedema progresses?

Answer 43

“Lymphedema of the lower extremity initially involves the foot and gradually progresses up the leg so that the entire limb becomes edematous. In the early stages, the edema is soft and pits easily with pressure. Over time, subcutaneous adipose tissue accumulates, the limb enlarges further and loses its normal contour, and the toes appear squere. (…) In the chronic stages, the edema no longer pits and the limb acquires a woody texture as the tissues become indurated and fibrotic.”

Question 44

What is Stemmer’s sign?

Answer 44

“inbability to tent the skin at the base of the toes.”

Question 45

How do you differentiate lymphedema from lipedema?

Answer 45

“Lipedema usually occurs in women and is caused by accumulation of adipose tissue in the leg from the thigh to the ankle with sparing of the feet.”

Question 46

Honeycomb pattern is associated with one vascular condition and another pulmonar condition. Which are them?

Answer 46

Lymphedema of the epifascial compartment on MRI of the leg and Interstitial pulmonary fibrosis on CT scan of the thorax.

Question 47

Diuretics should be used on lymphedema.

True or False?

Answer 47

False.