Chronic Venous Insufficiency + Varicose Veins Flashcards
Define varicose veins (primary + secondary)
Dilated tortuous veins (≥3mm when standing)
- Primary = superficial/perforator veins (w/o DV incompetence)
- Secondary = deep veins (from inadequate DVT recanalisation / obstruction)
Define varicose veins (primary + secondary)
Dilated tortuous veins (≥3mm when standing)
- Primary = superficial/perforator veins (w/o DV incompetence)
- Secondary = deep veins (from inadequate DVT recanalisation / obstruction)
Appropriate venous return requires adequate fx of:
- muscle pump
* venous valves
Pathophysiology of VV
Valve incompetence (rarely muscle pump failure) –> reflux / venous blood stasis –> venous HTN –> venous distention (varicose veins)
Histology of VV
- marked increased collagen matrix
- disorganised SMCs
- decreased elastin
Define chronic venous insufficiency
Impaired venous fx secondary to chronically raised venous pressure
(usually oedema, skin chances, ulcers)
Normal venous pressure when walking in normal vs. CVI
Risk factors for VV / CVI
- age
- FHx (most sig. factor – esp. VV)
- smoking
- DVT
- obesity
- female, OCP, parity
- orthostatic occupation
What % of people w. DVT go onto suffer from VV / CVI?
up to 50%
What % of people w. DVT go onto suffer from VV / CVI?
up to 50%
Clinical Px of CVI / VV
VENOUS CHANGES • corona phlebectatica • telangectasias • reticular veins • varicose veins
SKIN CHANGES • dry scaly skin • hyperpigmentation (hemosiderin) • lipodermatosclerosis • eczema • atrophie blanche • venous ulcers
LEG SYX
• oedema
• leg “heaviness” (at the end of the day)
• leg ache / fatigue (at the end of the day / after long periods of standing – relieved by elevation)
• leg cramps
Pathophysiology of VV
Valve incompetence (rarely muscle pump failure) –> reflux / venous blood stasis –> venous HTN –> venous distention (varicose veins)
Histology of VV
- marked increased collagen matrix
- disorganised SMCs
- decreased elastin
Cx of CVI / VV
- Hemorrhage (erosion of veins)
- Ulcers
- Infx (uncommon if compliant w. Rx/stockings)
- Saphenectomy / endovenous-related DVT (1-3%)
Normal venous pressure when walking in normal vs. CVI
Aetiology of CVI
- REFLUX
- obstruction (e.g. poor DVT recanalisation)
- both
- other (e.g. AVM, venous malformation, connective tissue disorder…)
Risk factors for VV / CVI
- age
- FHx (most sig. factor – esp. VV)
- smoking
- DVT
- obesity
- female, OCP, parity
- orthostatic occupation
What % of people w. DVT go onto suffer from VV / CVI?
up to 50%
Classification of venous disease (clinical)
- C0 = no visible venous disease
- C1 = telangectasies
- C2 = varicose veins
- C3 = oedema
- C4a = pigmentation (hemosiderin +/- eczema due to irritation by blood products)
- C4b = lipodermatosclerosis (+/- calcification + atrophie blanche)
- C5 = healed venous ulcers
- C6 = active venous ulcers
Clinical Px of CVI / VV
VENOUS CHANGES • corona phlebectatica • telangectasias • reticular veins • varicose veins
SKIN CHANGES • dry scaly skin • hyperpigmentation (hemosiderin) • lipodermatosclerosis • eczema • atrophie blanche • venous ulcers
LEG SYX
• oedema
• leg “heaviness” (at the end of the day)
• leg ache / fatigue (at the end of the day / after long periods of standing – relieved by elevation)
• leg cramps
Ix of CVI / VV
Doppler U/S
• localise obstruction
• retrograde flow / reflux
• valve closure time >0.5 seconds
Consider:
• ambulatory venous pressure (gold standard)
• Photoplethysmography
Rx of CVI / VV
CONSERVATIVE
• graded pressure stockings
• elevation, avoid long periods of standing
• weight loss
• moisturizer
• ULCERS = wrap in zinc-oxide, split thickness grafts, ABX, debridement, phentoxyphillline
SURGICAL
• Valve incompetence –> valve repair
• Reflux –> excision of damaged vein, ligation, ablation, sclerotherapy (injection of NaCl/STD)
• Obstruction –> percutaneous iliac angioplasty + stent
Cx of CVI / VV
- Hemorrhage (erosion of veins)
- Ulcers
- Infx (uncommon if compliant w. Rx/stockings)
- Saphenectomy / endovenous-related DVT (1-3%)
Appearance of venous ulcers
LOCATION =
• ankle
• anterior to medial malleolus
• pretibial area
APPEARANCE
• shallow irregular borders
• ruddy granulation tissue (no dead tissue)
• leg shows evidence of venous insufficiency (leg warm, hair, pulses present)
PAIN = absent / mild (relieved w. elevation)
Rx of venous ulcers
Heal w. elevation + compression
May also add: • zinc oxide dressing • partial thickness graft • debridement • ABX • phentoxyphilline
