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Venous Stasis

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... healed venous ulcer C6: active venous ulcer S: symptomatic, including ache, pain, tightness, skin irritation, heaviness, and muscle cramps, ... – PowerPoint PPT presentation

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Title: Venous Stasis


1
Venous Stasis
  • Joon Ho Jang MD

2
  • Incidence/Prevelance JOBST Coverage
  • It is estimated that more than 80 million
    Americans suffer from some form of venous
    disorder.
  • Up to 13 million people in the U.S. suffer
    from CVI
  • Peak incidence occurs in women aged 40-9 and
    men aged 70-79 years
  • Statistics show one in three Americans over
    the age of 45 is affected by vein disease, and of
    those, only 4 are
  • being treated.
  • Annual health care cost in the US to treat CVI
    is about 3billion about 2 million workdays are
    lost per year due to venous ulcers
  • Varicose Veins
  • More than 24 million Americans have varicose
    veins
  • Up to 50 of women have varicose veins while
    24 of men aged 30-40 and 43 of men over 70 have
    varicose veins
  • DVT / PTS
  • There are over 200,000 new cases of DVT each
    year in the U.S.
  • The incidence of pulmonary embolism in
    patients with DVT ranges from 5 20 and can be
    fatal
  • After an episode of DVT, 20 50 of patients
    develop Post Thrombotic Syndrome within the first
    2 years
  • Venous Stasis Ulcers
  • Affect 2.5 million people in the U.S.

3
Venous StasisHow?
  • Mechanics
  • Structure
  • Inflammation
  • Pressure
  • Obstruction- DVT

4
Function
  • Transport blood back to the heart
  • Prevent intravascular volume overload

5
Anatomy
  • Tunica intima endothelium with BM and elastic
    lamina
  • Produces endothelium derived relaxing factor and
    prostacyclin
  • Tunica media Circumferential SM
  • Maintains venous pressure gradient
  • Tunica externa Collagen
  • Stability

6
Valves
  • Venous valves
  • One way
  • Two cusps of CT skeleton covered by endothelium
  • Closure at gt 30cm/s
  • Exception IVC, common iliacs, portal, cranial
    sinus

7
Lower Extremity
8
Venous Hypertension
  • Hydrostatic pressure vs Mechanical/muscular
    pressure
  • A. K. Tassiopoulos et al.
  • 1153 cases of ulcerated legs and venous disease
  • Reflux in superficial, deep, and perforating
    veins
  • Incompetent valves

9
Valvular Dysfunction
  • Physical damage splitting, tearing, thinning,
    adhesion to wall
  • Reduction in number
  • Not age related
  • Monocyte and macrophage infiltration
  • Overexpression of Intracellular adhesion
    molecules
  • Wall hypertrophy, disruption of collagen
    synthesis, and destruction of extracellular
    matrix proteins

10
Shear Stress and Inflammation
  • Pulsatile venous blood flow
  • Valve closes Pvortical gt Pluminal
  • Minimal shear stress
  • Low shear stress starts cascade of inflammatory
    signals

11
Risk Factors
  • Genetic
  • More in females
  • Hormones
  • Progesterone, estrogen
  • Pregnancy
  • Age gt50
  • Greater height
  • Prolonged standing
  • Obesity

12
Signs and Symptoms
  • Telangiectasias
  • Reticular veins
  • Varicosity
  • Thrombophlebitis
  • Hyperpigmentation
  • Bleeding from clusters
  • Ulceration
  • Aching
  • Heaviness
  • Early fatigue
  • Edema
  • Itching
  • Restless legs
  • Cramps

13
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15
Physical Exam, Diagnostic Tests
  • Palpable veins
  • Perthes Test
  • For deep venous patency
  • Tourniquet and walk
  • Brodie-Trendelenburg Test
  • For superficial vein and valve patency
  • Venous filling time normal- within 35 secs
  • Duplex Ultrasound
  • Venography

16
Classification CEAP Eklof et al. J of Vasc
Surg 2004
  • Clinical classification
  • C0 no visible or palpable signs of venous
    disease
  • C1 telangiectasies or reticular veins
  • C2 varicose veins
  • C3 edema
  • C4a pigmentation or eczema
  • C4b lipodermatosclerosis or atrophie blanche
  • C5 healed venous ulcer
  • C6 active venous ulcer
  • S symptomatic, including ache, pain, tightness,
    skin
  • irritation, heaviness, and muscle cramps, and
    other
  • complaints attributable to venous dysfunction
  • A asymptomatic

17
CEAP
  • Etiologic classification
  • Ec congenital
  • Ep primary
  • Es secondary (post-thrombotic)
  • En no venous cause identified
  • Anatomic classification
  • As superficial veins
  • Ap perforator veins
  • Ad deep veins
  • An no venous location identified
  • Pathophysiologic classification
  • Basic CEAP
  • Pr reflux
  • Po obstruction
  • Pr,o reflux and obstruction
  • Pn no venous pathophysiology identifiable

18
Treatment
  • Compression Therapy
  • Stockings, Unnas Boot
  • Drug Therapy
  • Surgery

19
Compression Stockings
  • Worn during the day
  • Elastic stockings with adjustments in pressure
  • Lower pressure stockings (20-30mm Hg) for edema
    and DVT prophylaxis
  • Higher pressure (30-40mm Hg) for ulcers and
    significant venous disease
  • Operator dependent
  • Difficult to put on
  • Physical impediments/Co-morbidities
  • 50 of patients were unable to them on alone
  • 30-65 noncompliance noted in clinical trials in
    venous centers

20
Efficacy of Compression Therapy
  • 22 trials comparing healing of venous ulcers
    using compression stockings
  • Compressive therapy more effective than
    non-compression
  • Higher pressure were more effective than lower
  • Multilayer compression was better than single
    layer bandaging
  • 466 patients with a healed ulcer
  • Continued use of compression stocking reduced
    reoccurrence within 3-5 year
  • ESCHAR study 500 limb trial that compares
    surgery and compression vs. compression alone for
    ulcer treatment
  • Combination therapy had lower rates of
    reoccurrence of ulcer at year 4 (24 vs. 52)

21
Drug Therapy
  • Pentoxifylline
  • PDE4 inhibitor that increases intracellular cAMP
    and stimulates protein kinase A activity
  • Reduces blood viscosity and decreases platelet
    aggregation and thrombus formation
  • Variable efficacy

22
More invasive
  • Sclerotherapy
  • 0.2 sodium tetradecyl injected directly into
    spider angiomas and smaller superficial
    varicosities
  • Complications (lt5) allergic reaction,
    hypo/hyper-pigmentation, local skin necrosis
  • Endovenous laser ablation of saphenous vein
    (EVLT)
  • Surgical excision of veins (Stripping)

23
Efficacy
  • Meta-analysis of 64 studies (12,320 legs)
  • Anaylzed ablation via Duplex US
  • Follow upto 5 years
  • Success rate of EVLT highest after 5 years
  • Complications DVT (lt3), local bruising and
    pain, paresthesias, foam emboli, stroke

24
Works Cited
  • Raju et al. Chronic venous insufficiency and
    varicose veins. NEJM 20093602319-27
  • Bergan et al. Chronic venous disease. NEJM
    2006355488-98.
  • Tassiopoulos et al. Current concepts in chronic
    venous ulceration. Euro J Vasc Endovasc Surg
    200020227-232.
  • Ono et al. Monocyte inflitration of venous
    valves. J Vasc Surg 199827158-66.
  • Sansilvestri-Morel et al. Imbalance in the
    synthesis of collagen type I and collagen type
    III in smooth muscle cells derived from human
    varicose veins. J Vasc Res 200128560-8.
  • Jacob et al. Extracellular matrix remodeling in
    the vascular wall. Pathol Biol 200149326-32
  • Eklof et al. Revision of the CEAP classification
    for chronic venous disorders Consensus
    statement. J Vasc Surg 2004401248-52.
  • Cullum et al. Copression bandages and stockings
    for venous leg ulcers. Cochrane Database Syst
    Rev 20002 CD000265
  • Mayberry et al. Fifteen-year results of
    ambulatory compression therapy for chronic venous
    ulcers. Surgery 1991109575-81.
  • Barwell et al. Comparison of surgery and
    compression with compression alone in chronic
    venous ulceration (ESCHAR study) randomised
    controlled trial. Lancet 20043631854-9.
  • Van den Bos et al. Endovenous therapy of lower
    extremity varicosities a meta-analysis/ J Vasc
    Surg 200949230-9.
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