Latest Treatment of Varicose Veins

Get Rid Varicose Veins Naturally

Here are some sneak previews on what you'll find in this report: Unlike popular belief, common dieting found in other diet books just don't work. You only need this special diet to help improve and lessen the veins discomfort. Forget about paying for expensive gyms for working out your fitness to prevent the horrible looking veins from coming back. Here are 7 simple exercises you can do instantly without costing you a dime. How to use special aromatherapy technique to literally help the blood leave the legs and return to the heart. This will reduce swelling while shrinking the blood vessels near the skin's surface. 3 top herbal therapies to relieve my pain from my veins. How to use 4 types of common homeopathic remedies to ease the pain and soreness that are worse from touch. Secret tips on using specific herbs which are used during naturopathic treatment. One of my favourite remedies to help me relieve aches and pain from varicose veins. This works effectively on spider veins as well. How to mix special juices to help strengthen the walls of the veins, which also help prevent blood clots, one of the serious complications of varicose veins. 5 massage secrets which you can do it yourself to alleviate discomfort associated with varicose veins. I'll even show you how to prepare massage oil treatment effectively. 1 common massage Mistake that could rupture your veins without you knowing. It simply worth knowing how to handle your massaging correctly. Not all yoga exercises can help you. Here are the top yoga exercises which can Worsen your varicose veins without you knowing. Some simple folk natural remedies you can easily prepare for yourself at home. Some of these remedies will either help shrink your varicosities and nourish the veins leaving your legs super smooth Continue reading...

Get Rid Varicose Veins Naturally Overview


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Fundamentals Of Laser Treatment Of Leg Veins

The advent of laser technology for treatment of leg veins began with the concept of selective photothermolysis developed in the late 1980s.5 The theory of selective photother-molysis states that selective damage to a tissue structure is achieved by means of a wavelength of light preferentially absorbed by a chromophore in light-absorbing molecules and laser exposure time less than or equal to the object's thermal relaxation time (i.e., the time required for the object to lose 50 of its thermal energy). The thermal relaxation times of leg veins vary depending upon vessel diameter (see Table 16.2).6 A physician employing laser therapy should routinely consider the utility of laser and intense pulsed light (IPL) technologies versus that of sclerotherapy for the treatment of lower extremity vessels.7 The fundamental requirements for a laser or IPL source in the treatment of leg veins are delineated in Box 16.2. TABLE 16.4 Optimal Laser Parameters for the Treatment of Leg Veins TABLE 16.4...

Conclusion For Varicose Veins

Variations of connections to the saphenous systems in limbs with primary varicose veins A study of 1481 limbs by duplex ultrasound scanning, J Phlebology. 2002. 2 11-17. 3. Myers KA, Ziegenbein RW, Zeng GH, Matthews PG. Duplex ultraso-nography scanning for chronic venous disease Patterns of venous reflux, J Vasc Surg. 1995. 21 605-612. 7. Labropoulos N, Touloupakis E, Giannoukas AD, Leon M, Katsamouris A, Nicolaides AN. Recurrent varicose veins Investigation of the pattern and extent of reflux with color flow duplex scanning, Surgery. 1996. 119 406-409. 15. Darke SG, Vetrivel S, Foy DM, Smith S, Baker S. A comparison of duplex scanning and continuous wave Doppler in the assessment of primary and uncomplicated varicose veins, Eur J Vasc Endovasc Surg. 1997. 14 457-461. 16. Lees TA, Beard JD, Ridler BM, Szymanska T. A survey of the current management of varicose veins by members of the Vascular Surgical Society, Ann R Coll Surg Engl. 1999. 81 407-417....

Etiology And Pathogenesis Of Varicose Veins

Hippocrates was the first to deal with the pathogenesis and epidemiology of varicose disease when he affirmed that varicose veins were more frequent in Scythians due to the prolonged time spent on the horseback with the legs hanging down. In 1514, Marianus Sanctus noted that varicose veins were more frequent after pregnancy and in longtime standing peoples (. . . standing too much before kings . . .). In 1545, Ambroise Par related varicose veins to pregnancy and long travelling and affirmed that they are more frequent in melancholic subjects. Ten years later, Jean Fernel (1554), Professor of Medicine at Paris, stated that varicose veins can develop after an effort or a trauma . . . the varix comes also from a blow ( ), from a contusion, from an effort . . . Virchow (1846) was the first to point out the hereditary tendency to varicose veins. Finally, the rare syndrome due to congenital absence of venous valves was first reported by Josephus Luke in 1941. The first to attribute the...

Cure And Reappearance Of Varicose Veins After Stripping Operation Fischer R

Beresford T, Smith JJ, Brown L, Greenhalgh RM, Davies AH. A comparison of health-related quality of life of patients with primary and recurrent varicose veins, Phlebology. 2003. 18 35-37. 3. Blomgren L, Johansson G, Dahlberg-Akerman A, Noren A, Brundin C, Nordstrom E, Bergqvist D. Recurrent varicose veins Incidence, risk factors and groin anatomy, Eur J Vasc Endovasc Surg. 2004. 27 269-274. 4. Creton D. Surgery of great saphenous vein recurrences The presence of diffuse varicose veins without a draining residual saphenous trunk is a factor of poor prognosis for long-term results, JP. 2002. 2 83-89. 6. De Maeseneer MG. The role of postoperative neovascularisation in recurrence of varicose veins From historical background to today's evidence, Acta Chirurgica Belgica. 2004. 104 281-287. 8. De Maeseneer MG, Giuliani DR, Van Schil PE, De Hert SG. Can interposition of a silicone implant after sapheno-femoral ligation prevent recurrent varicose veins, Eur J Vasc Endovasc Surg. 2002. 24...

Madelung Propose To Remove Varicose Veins

Varicose veins after high ligation of the saphena. In order to avoid innumerable skin incisions, Benedetto Schiassi, from Bologna (1909), performed multiple injections of a combined iodine and potassium iodide immediately after saphe-nous interruption (see Figure 1.9). Linser (1916) suggested to use compression to reduce complication and to enhance the effects of the therapy. Ungher (1927) used a urethral catheter to perfuse varicose veins with sclerosing agents. Mc Ausland recommended in 1939 to empty the vein to be injected by elevating the leg and to bandage the leg after treatment. In older civilizations, surgery of serpent-shaped dilatations of lower limb veins was advised to avoid dangerous hemorrhages and death (Papyrus of Ebers, 1550 bc). Only minimally invasive procedures were performed . . . the varix itself is to be punctured in many places, as circumstances may indicate . . . in order to avoid that . . . large ulcers be the consequence of the incisions . . . (Hippocrates)....

Ultrasound Monitoring During Sclerofoam Ablation Of Varicose Veins


Advent of foam sclerotherapy has added a new tool for the treatment of chronic venous insufficiency. Sclerosant agents provoke endothelial damage by several mechanisms.25 They change either the surface tension of the plasma membrane (detergents) or the intravascular pH and osmolarity. The final result is a chemical fibrosis of the treated Sclerosing foams (SF) are mixtures of gas with a liquid solution with surfactant properties. In 1993, Cabrera proposed the use of SF, made of sodium tetradecyl sulfate or polidocanol in the treatment of varicose veins.26 One of the intrinsic limits of liquid sclerosants in the treatment of varicose veins is dilution by the bloodstream with reduction of their efficacy.27 Also, they are rapidly cleared by the moving bloodstream. Sclerosing foams do not mix with blood and instead remain in the vessel, continuing to strip the endothelium.27 This persistence of the agent in the vessel causes an increased contact time with the intimal surface. Foam...

Implications for Pharmacological Treatment in Venous Disease

Although bandaging and stockings have been used effectively in the treatment of chronic venous insufficiency for many years, modern pharmacological science may provide assistance in healing venous ulcers and perhaps some insight into the mechanisms of the disease. Laurent et al. investigated micronized purified flavonoid fraction (MPFF)48 and showed that this drug reduced the symptoms of venous disease (aching, itching, feeling of swelling) and also reduced ankle edema. More recently MPFF has been studied for its effects on venous leg ulcer healing. A meta-analysis has been published in which five prospective, randomized, controlled studies involving 723 patients with venous ulcers were included.49 Patients were treated with compression bandaging and local wound care in all cases. In two studies MPFF was compared to placebo

Subfascial Endoscopic Perforator Vein Surgery SEPS for Chronic Venous Insufficiency

Surgical interruption of incompetent perforating veins was first suggested by Linton in 19381 to treat patients with venous ulcers. The rationale for ligating incompetent perforators was to decrease ambulatory venous hypertension in patients with advanced venous disease by decreasing abnormal transmission of pressure from the deep to the superficial veins. Linton's original operation, that required a long skin incision, resulted in a high rate of wound complications. Subsequently proposed operations using shorter skin incisions were either incomplete or, similar to Linton's operation, resulted in frequent wound complications. Subfascial endoscopic perforator vein surgery (SEPS) was developed to replace the open techniques and it became instantly popular because of the minimally invasive nature of the procedure combined with a lesser rate of wound complications. SEPS has been an effective, minimally invasive technique to interrupt incompetent medial perforating veins of the leg.2-25

Diagnostic Testing For Patients With

Photo Plethysmography Venous

The rational treatment of patients with chronic venous insufficiency (CVI) and its sequelae requires the use of Using this information, the clinician can determine the etiology, anatomy, and pathophysiology of CVI for the patient. For example, the patient that has superficial and perforator disease may be differentiated from the patient with superficial and deep reflux, allowing alternate treatment plans to be selected. Although duplex evaluation provides detailed information on the anatomy of venous disease, it cannot define the importance of anatomic abnormalities in the venous function of the limb. Clearly, one patient with gross reflux in the saphenous vein will have no resultant symptoms, whereas another patient may have class 6 CVI with an active ulcer from saphenous reflux alone. The clinical assessment of the severity of CVI is often subjective, so testing that allows objective measurement of the hemody-namic performance of the lower extremity venous system would greatly...

Vein Wall Anatomy Histopathology and Functional Alterations

Whatever the initiating event, several unique anatomic and biochemical abnormalities have been observed in patients with varicose veins. Normal and varicose greater saphenous veins (GSVs) are characterized by three distinct muscle layers within their walls. The media contains an inner longitudinal and an outer circular layer, and the adventitia contains a loosely organized outer longitudinal layer.1214 In normal GSVs, these muscle layers are composed of smooth muscle cells (SMCs), which appear spindle-shaped (contractile phenotype) when examined with electron microscopy (see Figure 9.1).15 These cells lie in close proximity to each other, are in parallel arrays, and are surrounded by bundles of regularly arranged collagen fibers. In varicose veins, the orderly appearance of the muscle layers of the media is replaced by an intense and disorganized deposition of collagen.1517 Collagen deposits separate the normally closely opposed SMCs and are particularly striking in the media. SMCs...

Posterior Tibial Thrombectomy

Iliofemoral Artery

FIGURE 45.6 A red rubber catheter (largest diameter possible) is placed into the posterior tibial vein and vigorously injected with a heparin-saline solution using a bulb syringe to flush residual thrombus. After flushing, the femoral vein is clamped and the leg veins injected with 150-200 cc of a dilute UK or rt-PA solution.15 FIGURE 45.6 A red rubber catheter (largest diameter possible) is placed into the posterior tibial vein and vigorously injected with a heparin-saline solution using a bulb syringe to flush residual thrombus. After flushing, the femoral vein is clamped and the leg veins injected with 150-200 cc of a dilute UK or rt-PA solution.15

Deep Venous Thrombosis Examination by Plethysmography

When Continuous-wave Venous Doppler measurements, SVC, and MVO are performed as a diagnostic package, sensitivity and specificity of the combined testing reach 85 , respectively.11 It should be acknowledged Duplex Venous Doppler Ultrasonic Imaging, which requires more expensive equipment, clearly demonstrates a higher sensitivity and specificity. Further, ultrasound is able to more accurately localize obstruction and age thrombus. For this reason, plethysmographic methods have limited diagnostic use. There is one area in venous disease where SVC and MVO provide unique and important information. This is in the determination of venous collaterization following a DVT. Patients that normalize SVC and MVO rapidly have an improved prognosis when compared to subjects in which normalization is prolonged.

Sclerofoam Except For The Lower Limbs

Arms Varicose veins of upper limbs including fingers are rare we have treated some with Sclerofoam and observed good results, and it seems unlikely that any large study will be available on this matter. Regarding sclerotherapy of hand veins in elderly patients, we do not recommend any such suppression. Ambulatory phlebectomy has been proposed, and this kind of treatment of normal veins is likely to be questioned if a venous access is later necessary for other medical reasons (blood tests, chemotherapy, and emergency IV injections).

Surgical Thrombectomy

Surgical thrombectomy with distal arteriovenous fistula creation for acute DVT is mainly of historical interest because of its associated operative morbidity primarily related to blood loss and poor clinical outcomes. However, surgical thrombectomy may still be used in the clinical setting of venous gangrene with impending limb loss. The best reported results are from a 1999 study by Juhan et al.15 These authors demonstrated an improvement in long-term results following surgical venous thrombectomy for acute iliofemoral DVT in their personal series.15 In a review of 77 patients, principally young trauma victims, valvular competency was preserved at five years in 80 , and 90 of limbs had either mild symptoms of chronic venous insufficiency or no symptoms at all. Additionally, Meissner and colleagues reported their results of venous thrombectomy with arteriovenous fistula in 30 patients.16 In all but three patients, patency of the iliofemoral segment was maintained 12 months after clot...

Understanding Postthrombotic Venous Insufficiency

Iliofemoral Venous Segment

Many physicians fail to recognize the difference in the pathophysiology of primary versus postthrombotic venous insufficiency. As a result, the value of thrombus removal in preventing postthrombotic morbidity in patients with acute DVT is underestimated. The pathophysiology of chronic venous insufficiency is ambulatory venous hypertension, which is defined as an elevated venous pressure during exercise. In individuals with a normal deep venous system, ambulatory venous pressures in the lower leg and foot should drop to less than 50 of the standing venous pressure. In patients with postthrombotic syndrome, the ambulatory venous pressure drops very little, and in those with persistent proximal venous occlusion, the ambulatory pressures may actually rise above standing pressure. This degree of ambulatory venous hypertension often leads to the debilitating symptoms of venous claudication. FIGURE 49.1 Chronic venous disease in a patient who had iliofemoral DVT 10 years earlier. The patient...

Venous Reflux Examination And Venous Mapping

Iliocaval Junction Anatomy

The ultrasound examination is conducted with the patient standing.9 This position has been found to dilate leg veins maximally and challenges vein valves. Sensitivity and specificity in detecting reflux are increased in examinations performed with the patient standing rather than when the patient is supine.8,9 Supine examinations for reflux are unacceptable. FIGURE 23.3 The laser catheter is advanced proximally toward the saphenofemoral junction. Position of the laser fiber is confirmed by direct visualization of the red aiming beam through the skin. (Adapted from Navarro L, Min RJ, Bone' C. Endovenous laser A new minimally invasive method of treatment for varicose veins Preliminary observations using an 810 nm diode laser dermatologic surgery, Volume 27, 2 117. February 2001) FIGURE 23.3 The laser catheter is advanced proximally toward the saphenofemoral junction. Position of the laser fiber is confirmed by direct visualization of the red aiming beam through the skin. (Adapted from...

Background Knowledge Of Nonthrombotic Reflux Deep Vein Disease

Except for the publications of Gunnar Bauer in the 1940s,4 clinically important deep vein reflux disease had been attributed to post-thrombotic disease. Bauer was a brilliant investigator-surgeon who worked in a small hospital in Mariestad, Sweden, in the mid-1900s. He experimented with venogra-phy in patients suspected of having venous disease and devised a method of performing descending venography, described in 1948. These venograms were performed with a needle in the CFV and with the patient in the 45-degree erect position. Static films were obtained to document findings. Bauer was the first to report nonthrombotic cases with highgrade axial reflux in the deep veins, and to associate these cases with advanced stages of clinical venous insufficiency. He treated these cases with popliteal vein ligation and reported early clinical success, but later follow-up of some of these cases by his peers in Sweden discredited the long-term value of popliteal vein ligation.

Research On The Pathophysiology Of Saphenofemoral Recurrence And The Role Of Neovascularization

The ultimate answer to the question, does neovascularization at the ligated SFJ really exist still has to be given. Because animals do not suffer from varicose veins, an animal experiment is hardly possible to prove the existence of neovascularization. Therefore it can be proved only in an indirect way. Observations made in patients prospectively studied after varicose vein operations with duplex scan are very useful. Moreover in patients operated upon because of recurrent varicose veins preoperative duplex findings can be compared with visual inspection at the previous ligation site during reexploration and histological examination of the excised tissue blocks from the scar tissue in the groin. Although findings from such studies may be suggestive for neovascularization, none of them is conclusive. This means Lefebvre-Vilardebo17 has focused on the important role of the lymph nodes in the neighborhood of the ligated saphe-nous stump. At postoperative duplex examination of the groin...

Effectiveness Of Endovenous Laser Treatment

Long-term results about endovenous laser treatment of the Great Saphenous vein are still missing to date therefore, success can be reported only with respect to immediate post-procedural ablation of the vein and with respect to recana-lization events during midterm follow-up. Other interesting questions like five-year success rates or questions about randomized prospective comparison to traditional surgery cannot be answered today. Also the questions whether endo-venous laser treatment is not associated with future neoan-giogenesis or if the pattern of future disease progression of venous disease is generally influenced, remain open at present, even if there is an interesting publication suggesting one mechanism for recanalization of veins after endovenous ablation.12

The Great Saphenous Vein

Accessory Saphenous Vein

FIGURE 18.6 In 2005, a panel of experts proposed a new classification to be used in a prospective multicenter study testing the A.S.V.A.L. (selective ablation of varicose veins in local anesthesia) method. The classification reports five major types of saphenofemoral reflux. The recognition of each of them can guide different therapeutic approaches, such as the A.S.V.A.L. (Adapted from Pittaluga et al.2627) FIGURE 18.6 In 2005, a panel of experts proposed a new classification to be used in a prospective multicenter study testing the A.S.V.A.L. (selective ablation of varicose veins in local anesthesia) method. The classification reports five major types of saphenofemoral reflux. The recognition of each of them can guide different therapeutic approaches, such as the A.S.V.A.L. (Adapted from Pittaluga et al.2627)

Systemspecific Questionnaires

To allow the comparison of different treatments or results from different publications there is a need for standardization of the severity of the venous disease being studied. These scoring systems are an adjunct to the current armamentarium and are to be recommended for use in future venous outcome assessment studies. These studies are as yet to be applied to a large multicenter study of patients with varicose veins. Currently there are three system- or disease-specific instruments for measurement of health-related quality of life in patients with chronic venous disease of the lower limb that can be applied to patients with varicose veins (see Table 34.2). This initially was designed as a postal questionnaire. Published in 1993, it surveyed 373 patients with varicose veins selected from a hospital and general practice setting. A comparison group was made up of a random sample of 900 members of the general population selected from the electoral register of Aberdeen. They were sent a...

Arteriovenous Fistula Theory

The concept of increased venous flow in the dermal venous plexus was expanded upon by Pratt who reported that increased venous flow in patients with CVI could be clinically observed.32 He attributed the development of venous ulceration to the presence of arteriovenous connections and coined the term arterial varices. He reported that in a series of 272 patients with varicose veins who underwent vein ligation, 24 had arteriovenous connections. Of the 61 patients who developed recurrences, 50 occurred in patients with arteriovenous communications identified clinically by the presence of arterial pulsations in venous conduits. Pratt hypothesized that increased venous flow shunted nutrient and oxygen rich blood away from the dermal plexus leading to areas of ischemia and hypoxia and resulting in venous ulceration. Pratt's clinical observations however, have never been confirmed with objective scientific evidence. Experiments with radioactively labeled microspheres have never demonstrated...

Complications And Postthrombotic Syndrome

The potential complications of acute DVT include venous gangrene, pulmonary embolism, recurrent thromboembolic events, and the development of chronic venous insufficiency or post-thrombotic syndrome. Anticoagulation therapy, the current standard of care for acute DVT, may inhibit further clot propagation and prevent pulmonary embolism. However, it does not in itself prevent chronic post-thrombotic complications. The consequences of chronic venous insufficiency and post-thrombotic syndrome are a major medical problem and often results in a significant lifestyle compromise for the patient. DVT can render the venous valves incompetent, resulting in a spectrum of clinical presentations ranging from telengectasias and varicose veins through chronic lower extremity pain and edema to venous skin changes with lipodermatosclerosis and ulceration. The incidence of post-thrombotic syndrome following proximal venous thrombosis has been measured at 16 to 82 .3,9 The incidence of ulceration has...

The White Cell Trapping Hypothesis

The search for alternative mechanisms of skin damage in venous disease has resulted in investigation of the blood itself. Thomas investigated a series of patients and control subjects who were subjected to experimental venous hypertension by sitting with the legs dependent for a period of 60 minutes.12 Blood samples were taken from the great saphenous vein at the ankle. After 60 minutes patients with venous disease were trapping 30 of the white cells and control subjects were trapping 7 . Based on the literature on myocardial ischemia, we proposed that white cells might cause occlusion of capillaries. If some of the capillaries were occluded this might result in heterogeneous perfusion and therefore tissue hypoxia and ischemia. This seemed a reasonable suggestion at the time, since it predated our attempts to measure the severity of the diffusion block, and we included this to explain the hypoxia observed by transcutaneous oximetry. I subsequently have concluded that this part of the...

Clinical Effects Of Compression Therapy

Improvement of venous pumping function in chronic venous insufficiency by compression depending on pressure and material, VASA. 1984. 13 58-64. 10. Kessler CM, Hirsch DR, Jacobs H et al. Intermittent pneumatic compression in chronic venous insufficiency favorably affects fibrinolytic potential and platlet activation, Blood Coagul Fibrinolysis. 1996. 7 437-446. 16. Lord RS, Hamilton D. Graduated compression stockings (20-30 mm Hg) do not compress leg veins in the standing position, ANZ J Surg. 2004. 74 581-583. 18. Partsch H, Menzinger G, Borst-Krafek B, Groiss E. Does thigh compression improve venous hemodynamics in chronic venous insufficiency J Vasc Surg. 2002. 36 948-952. 23. Abu-Own A, Shami SK, Chittenden SJ, Farrah J, Scurr JH, Smith PD. Microangiopathy of the skin and the effect of leg compression in patients with chronic venous insufficiency, J Vasc Surg. 1994. 19 1074-1083.

Clinical Aspects Of Iliocaval Obstruction

Ivc Obstruction Collaterals

Patients frequently report dyspnea on exertion, even in the absence of any history of pulmonary embolus or respiratory ailments. They may have been told they have asthma. One patient presented with hematuria due to bladder varicosities. In two young patients, presenting at age 17 and 21 years, caval occlusion probably occurred near birth, since each had a single left kidney with compensatory hypertrophy. The common use of central lines in premature and young infants has created a juvenile population with the sequela of central venous thrombosis. The incidence of catheter-related deep vein thrombosis is estimated to be 3.5 per 10,000 hospital admissions, whereas the IVC is affected in approximately 10 of pediatric DVT cases.43 In a longitudinal study, 40 children, diagnosed with IVC thrombosis between birth and 13 years of age, were followed for up to 20 years after recognition of an early thrombotic event.44 Among the patients, 21 were identified with...

Historical Perspective

Figure Stitch Varicose Vein

FIGURE 26.1 Prominent recurrent varicose veins with venous ulcer in a 32-year-old man who underwent comprehensive saphenofemoral junction ligation and stripping of the great saphenous vein above the knee 8 years earlier. FIGURE 26.1 Prominent recurrent varicose veins with venous ulcer in a 32-year-old man who underwent comprehensive saphenofemoral junction ligation and stripping of the great saphenous vein above the knee 8 years earlier. description of formation of new veins after ligation (which could possibly lead to recurrence of varicose veins later on). Starnes et al.6 described a radiological type of recurrence of varicose veins, which could occur even after skillful high ligation. He was convinced that ascribing all thigh recurrences to a missed venous branch at the time of high ligation of the saphenofemoral junction was too simple an explanation. In four out of six cases with clinical recurrence vari-cography demonstrated the presence of a new, tortuous segment of vein at the...

Pulsed Lasers And Light Sources

Laser Depth Penetration Graph

For small telangiectatic leg veins in fair-skinned patients, FIGURE 16.3 Systematic approach to the treatment of leg veins. The pump pulsed dye laser was the first laser to achieve notable results in the treatment of leg veins in the 1980s. This treatment system utilizes short wavelength technology, at a wavelength of 577 nm. This has become acceptable for treatment of leg vessels < 1.0 mm, but cannot be The most recent development in laser technology in the treatment of leg veins is the combination of bipolar radio-frequency and optical energy, using either the diode laser or an intense pulsed light source. The basis of this technology is rooted in the idea that the two forms of energy act syner-gistically to enhance clearance of the target vessel with utilization of this system a high energy penetration depth (> 2 mm) and a high energy density on the treated vein (> 100 J cm2) can be achieved. The laser component selectively heats the vessel, allowing the preferential...

Postsclerotherapy Hyperpigmentation

Haemosiderin After Scelerotherapy

FIGURE 15.1 Linear pigmentation along the course of a treated blood vessel. A. Before treatment. B. Eight weeks after treatment with POL 0.5 . C. Punctate pigmentation 8 weeks after treatment with Sclerodex. (From Goldman MP. Adverse sequelae of sclerotherapy treatment of varicose and telangiectatic leg veins. In Bergan JJ, Goldman MP, eds. Varicose veins Diagnosis and treatment. 1993, St Louis Quality Medical Publishing.) FIGURE 15.1 Linear pigmentation along the course of a treated blood vessel. A. Before treatment. B. Eight weeks after treatment with POL 0.5 . C. Punctate pigmentation 8 weeks after treatment with Sclerodex. (From Goldman MP. Adverse sequelae of sclerotherapy treatment of varicose and telangiectatic leg veins. In Bergan JJ, Goldman MP, eds. Varicose veins Diagnosis and treatment. 1993, St Louis Quality Medical Publishing.) Thrombi are best removed by gentle expression of the liquefied clot through a small incision made with a 21-gauge needle (see Figure 15.3). A...

The Role of Leukocytes

Although the evidence suggests that neutrophils rarely are found in the dermis of patients with severe CVI and that activation has not been detected, several studies have identified a role for neutrophils in CVI. Investigators evaluating patients with varicose veins with and without skin changes took blood samples from dependent legs in the foot in the supine position. Leukocyte surface marker CD11b and L-selectin expression were analyzed by flow cytometry, and plasma soluble L-selectin was measured by ELISA. In dependent legs with skin changes, both the median neutro-phil and monocyte CD11b and L-selectin levels decreased and remained low after venous hypertension was reversed

Efforts To Mitigate Neovascularizationrelated Recurrent Reflux

Containment involves constructing an anatomical barrier or inserting a prosthetic barrier between the ligated SFJ stump and the surrounding superficial veins in the groin. Various barrier techniques recently have been studied in primary as well as in recurrent varicose veins, with different rates of success.20,21 In particular, in repeat surgery at the SFJ, patch saphenoplasty at the level of the religated saphe-nous stump significantly improved the clinical and duplex scan results, after a follow-up period of five years.22 embraced the no stump, no stump-related neovascularization axiom. They found no notable between-group differences in 57 limbs at one year. Both groups had less than 10 recurrence of either reflux or varicosities. These results questioned the widely held but unproved axiom that SFJ ligation with ligation of all tributaries is an essential component of the treatment of GSV insufficiency. Maybe complete removal of the thigh portion of the GSV could be sufficient to...

Surgery For Ssv Reflux

Surgery generally is directed toward dividing the saphe-nopopliteal junction, presupposing that reflux through the junction is the cause of varicose veins in the SSV territory. Anatomical variations for patterns of reflux determine technique and results of surgery. Sites for recurrence have been defined by retrospective ultrasound studies for recurrent varicose veins after SSV surgery. Tong and Royle showed an intact SSV to be the most common finding, with varices from the popliteal vein to residual SSV in the remainder.22 Labropoulos and colleagues showed that the most common pattern after previous SSV ligation was reflux into the SSV (75 ), whereas the most common pattern after previous SSV stripping was reflux into SSV tributaries (64 ).7

Chemical Venous Closure

Some phlebologists have advocated liquid sclerotherapy of the saphenous vein, but the results of such treatment have been disappointing, and published long-term results are absent. Comparisons between liquid and foam sclerotherapy have been done and the results strongly favor foam.20,21 Ultrasound-guided sclerotherapy (USGS) with foam must be considered as a completely new treatment of varicose veins. Although it needs proper training and some skill, it is simple, affordable, and extremely efficient. 5. Mashiah A, Ross SS, Hod I. The scanning electron microscope in the pathology of varicose veins, Isr J Med Sci. 1991. 27 202-206. 6. Travers JP, Brookes CE, Evans J et al. Assessment of wall structure and composition of varicose veins with reference to collagen, elastin, and smooth muscle content, Eur J Vasc Endovasc Surg. 1996. 11 230-237. 11. Satokawa H, Hoshino S, Igari T. Angioscopic external valvuloplasty in the treatment of varicose veins, Phlebology. 1997. 12 136-141. 12....

From Nonsaphenous Origins

Bulging varicose veins on the surface of the skin can originate from different sources. Identification of these sources is important because this influences the treatment plan. Varicosities on the medial aspect of the thigh and calf are usually the result of GSV incompetence. In order to minimize the chance for recurrence, the GSV must be eliminated from the circulation. This concept has been substantiated in several prospective randomized clinical trials involving patients who were treated with or without saphe-nectomy by conventional vein stripping.1518 The recurrence rates for limbs without saphenctomy were much higher than those with saphenectomy. Of course, now thermal ablation In cases where no feeding source is found, phlebectomy of the varicosities may be all that is required. Labro-poulos21 has shown that varicose veins may result from a primary vein wall defect and that reflux may be confined to superficial tributaries throughout the lower limb. Without great and small...

Preulcerative Cutaneous Changes

When skin at the border of chronic venous insufficiency is compared to normal skin in the same individual, the strong expression of ICAM-1 is seen in addition to a dense infiltration by T lymphocytes and macrophages. In some instances, the tissue also is infiltrated by an increased number of mast cells.14 This is the typical picture of a chronic inflammatory reaction with an upregulation of endothelial adhesion molecules and dermal infiltration by T lymphocytes and macrophages in the skin of patients with CVI. Incompetent perforating veins are strongly associated with superficial venous reflux, and it is still controversial whether incompetent perforating veins are the primary cause of skin changes of chronic venous insufficiency or whether the incompetent perforating veins and skin changes are the result of superficial reflux. The cause of valvular dysfunction in perforating veins is not yet fully understood (see Figure 58.1).

Decrease of Venous Refluxes and Improvement of the Venous Pump

The reduction of venous refluxes in patients with chronic venous insufficiency by external compression explains the improvement of the venous pumping function. Plethysmo-graphic studies have shown an increasing improvement of the venous pump with increasing stocking pressures, starting with an ankle pressure of around 20 mm Hg.7,20 whereas inelastic, short-stretch bandages with a double as high resting pressure are able to achieve intermittently short venous occlusions during muscle systole while walking. In patients with severe stages of chronic venous insufficiency a higher compression pressure is needed to improve the disturbed venous pumping function, whereas lower pressure is sufficient in simple varicose veins.20 The key mechanism of compression therapy to reduce ambulatory venous hypertension in patients with severe chronic venous insufficiency is an intermittent occlusion of the veins during walking. To achieve complete venous occlusion the external pressure has to be higher...

Trigger Mechanisms For Cell Activation

D) Activation by mechanotransduction These mechanisms for cell activation involve fluid shear stress (force per unit area parallel to a surface) and normal stress (for per unit area normal to a surface, i.e., pressure). These two mechanical stresses likely play an important role in venous disease (see later). FIGURE 7.3 The plasma of (nonsmoking) patients with chronic venous disease contains an inflammatory mediator. Fraction of neutrophil activation as detected by nitroblue tetrazolium reduction to zymogen granules (left panel, red arrow) and by pseudopod projection (right panel, black arrow). Na ve leukocytes (NL) from healthy donors mixed with patient plasma has significantly higher activated neutrophil counts than either patient blood cells, healthy control cells, or patient neutrophils mixed with plasma of healthy controls. Adaped from (6). The cause of this activation is an important unresolved question in CVD. FIGURE 7.3 The plasma of (nonsmoking) patients with chronic venous...

Ap Versus Compression Sclerotherapy

The combination of compression therapy with intravenous injection of a sclerosing agent for the treatment of varicose veins was introduced in 1953.28 Early studies indicated compression sclerotherapy (Sclero) would be an efficient addition to varicose vein surgery practiced at that time. Although ambulatory phlebectomy was invented around the same period,2 this technique required considerable time to become well-established worldwide. There is one randomized controlled trial on recurrence rates and other complications after Sclero and AP. A total of 98 operations were randomized to either AP (n 49) or Sclero (n 49) in a total of 82 lateral accessory varicose veins (LAVs). In this study, polidocanol was used in a 3 solution (Aethoxysclerol Kreussler & Co., Wiesbaden, Germany), which is equivalent to 1.5 sodium tetradecyl sulfate. One year after Sclero, 12 LAVs had recurred (25 ), and only one postphlebectomy LAV (2.1 ). After two years, the difference in recurrence was even larger...

Conclusion Of Varicose Vein

Ambulatory phlebectomy is elegant by its mere simplicity. It is effective and safe with acceptable cosmetic results (see Figure 27.4). AP is a perfect complement to endovenous thermal ablation of the saphenous veins. With this combination, patients can expect all varicose veins to vanish following a one-hour procedure that employed only local anesthesia, in the comfort of a physician's office. 3. Goren G, Yellin AE. Surgery for varicose veins The ambulatory stab avulsion phlebectomy, Am J Surg. 1991. 162 166-174. 17. Dwerryhouse S, Davies B, Harradine K, Earnshaw JJ. Stripping the long saphenous vein reduces the rate of reoperation for recurrent varicose veins Five-year results of a randomized trial, J Vasc Surg. 1999. 29(4) 589-592. 18. Sarin S, Scurr JH, Coleridge Smith PD. Stripping of the long saphenous vein in the treatment of primary varicose veins, Br J Surg. 1994. 81(10) 1455-1458. 26. Cheshire N, Elias SM, Keagy B et al. Powered phlebectomy (TriVex) in treatment of varicose...

Endovascular Techniques

Forerunner of endovascular techniques for treatment of the varicose saphena was Gaetano Conti from Naples, who, in 1854, proposed a complex method based upon electro-puncture and cauterizations of varicose veins (see Figure 1.16). Modern endovascular techniques started in 1964 with Werner and McPheeters (electrofulguration) and Politowski (endovenous electrosurgical dessication). A similar technique was proposed by Watts (1972) to treat saphenous varicosities by endovenous diathermy. In 1981, a freezing technique was proposed by Milleret and Le-Pivert to treat saphenous trunk insufficiency. This technique was refined in 1997 by Constantin, who associated ligation and division of the saphenous junction with saphenous trunk

Comparison Of Results Of Coil And Surgical Treatment Of Ovarian Reflux

Vulval varicose veins in pregnancy, Br Med J. 1959. 1 831-832. 4. Dixon JA, Mitchell WA. Venographic and surgical observations in vulvar varicose veins, J Surg Gynaecol Obstet. 1970. 131 458-464. 13. Richardson GD, Beckwith TC, Sheldon M. Ultrasound assessment in the treatment of pelvic varicose veins. Presented to The American Venous Forum 1991. Fort Lauderdale.

Safety Measures In Microfoam Sclerotherapy

Elimination Varicose Veins

FIGURE 22.11 Voluminous and complex varicose veins before and after treatment. FIGURE 22.11 Voluminous and complex varicose veins before and after treatment. The efficacy of sclerotherapy with microfoam is now beyond doubt. It achieves the elimination of all varicose veins in all patients, with no limitations on the extent, size, site, or morphology of the vessels that can be treated by this method. Our final objective is to make these optimal outcomes stable over the long-term. The Achilles' heel of surgery is the high recurrence rate of varicose veins.18,19 This is a major limitation of the surgical approach along with the aggressive nature of surgery and its incomplete outcomes. TABLE 22.1 Compression Requirements of Large Superficial Varicose Veins Selective compression of dilated superficial varicose veins 1 Elimination of existing varicose veins We must warn you that varicose veins often can reappear in legs that were treated only a few months earlier, even when all varicose...

Preoperative Preparation

Over the years, much space has been given to clinical examination of the patient with varicose veins. Many clinical tests have been described. Most carry the names of now-dead surgeons who were interested in venous pathophysiology. This august history notwithstanding, the Trendelenburg test, the Schwartz test, the Perthes test, and the Mahorner and Ochsner modifications of the Trendelenburg test essentially are useless in preoperative evaluation of patients today.28 Three principal goals must be kept in mind in planning treatment of varicose veins 1) the varicosities must be permanently removed and the underlying cause of venous hypertension treated 2) the repair must be done in as Current practice of treating the source of venous hypertension, the saphenous vein alone either by EVLT or VNUS technology, is inadequate. The patient's complaint, the varicose veins, must be addressed. This is as important as the physician's knowledge that the sources of venous hypertension must be...

Previous Classifications Of

The most commonly used classification, particularly in Europe, was Widmer's classification from 19781 of chronic venous insufficiency The same year,5 Pierchalla and Tronnier suggested differentiation between primary and secondary (postthrombotic) disease, and between superficial, perforator, and deep venous disease using objective measures. In 1988,6 Porter et al. published reporting standards for venous disease developed by an ad hoc committee for the Society for Vascular Surgery (SVS) and the North American chapter of the International Society for Cardiovascular Surgery (ISCVS). This was similar to and based on the Widmer classification with the addition of etiology and anatomic distribution. This was the stimulus for the CEAP classification that followed later. In 1991,7 Cornu-Thenard et al. published a clinical classification of the severity of varicose veins by inspection and palpation and calculated the sum of maximum diameter at 7 sites of the leg. calf muscle pump Stage 3...

Simplified Diagnostic Criteria for Venous Insufficiency

These criteria may be applied to any plethysmograph. The only restriction is that the volume measurements be taken accurately. In order to simplify the diagnostic criteria for venous phlethysmographic studies we have focused on three parameters. The first is Venous Refilling Time (VRT). In patients with significant venous insufficiency, venous refilling develops secondary to venous reflux and clearly reduces the time necessary to complete the process. If VRT is > 20 seconds, the limb is not demonstrating significant reflux. If VRT is < 20 seconds, the diagnosis of venous reflux should be considered.17 This should be taken in light of the finding that subjects with VRT < 10 seconds very often present with venous ulceration.18 The second parameter is Ejection Fraction (EF). In patients with deep or superficial venous insufficiency or deep venous thrombosis, EF is reduced. If EF is > 60 the limb is presenting with normal venous hemodynamics. For superficial venous insufficiency...

Identifying The Problem

The vasculature of the lower extremity is comprised of a complex, intertwined network of superficial and deep venous plexuses. The superficial veins, as suggested by their name, lie directly underneath the skin surface. The deep veins, in contrast, traverse the muscle of the leg. The individual flow patterns of these two networks intertwine to such a great degree that superficial spider veins may be the direct result of increased hydrostatic pressure in the deep reticular veins. In contrast to the treatment of facial veins, the varying sizes, depths, flow patterns, and vessel thickness of leg veins make the treatment of leg veins more challenging. Presently, BOX 16.1 Indications for Laser Therapy Treatment of Leg Veins BOX 16.2 Fundamental Properties of a Laser for Leg Veins TABLE 16.1 Comparison of the 1064 nm Nd YAG, 810 nm Diode, and 755 nm Alexandrite Lasers for Leg Veins 0.33 mm in Diameter TABLE 16.1 Comparison of the 1064 nm Nd YAG, 810 nm Diode, and 755 nm Alexandrite Lasers...

Role of Physiologic Testing in Venous Disorders

Physiologic testing is used to define deep venous thrombosis and identify, grade, and follow venous insufficiency. Since more patients will be presenting for therapy because of improved outcomes with endovenous techniques over traditional surgery, physiologic testing will take on increasing importance. For purposes of this chapter, physiologic testing includes the various devices based on plethysmo-graphic concepts, and color flow duplex imaging. The goal of these studies is to provide accurate information describing the hemodynamic or anatomic characteristics of the patient with chronic venous insufficiency, precluding the need for invasive studies.2

The Venous Microcirculation

Numerous investigations have attempted to evaluate the microcirculation of patients with CVI.40,43-46 The majority of these investigations were qualitative descriptions of vascular abnormalities, which lacked uniformity of biopsy sites and patient stratification. Prior to 1997 it was widely accepted that endothelial cells from the dermal microcirculation appeared abnormal, contained Weibel-Palade bodies, were edematous, and demonstrated widened interendothelial gap junctions.45 Based on these descriptive observations it was assumed that the dermal microcirculation of CVI patients have functional derangements related to permeability and ulcer formation. It was not until 1997 that a quantitative morphometric analysis of the dermal microcirculation was reported.40 The objectives of this investigation were to quantify differences in endothelial cell structure and local cell type with emphasis on leukocyte cell type and their relationship to arterioles, capillaries, and post-capillary...

Management Of C4c6 Patients

For some authors,15,16 only patients who have chronic changes in the skin and subcutaneous tissues of the lower leg deserve to be referred to clinically as chronic venous insufficiency (CVI). This definition, also generally accepted, is used in this chapter, but in the updated CEAP1 C3 patients have been included in CVI. CVI is an expression of severity in chronic venous disease, therefore management guidelines for CVI patients need to be stated both in terms of investigations and treatment. In patients with CVI we recommend complementing the CEAP classification by using the venous severity scoring system17 we know that in patients with C4-C6, the three scoring systems, venous clinical severity score (VCSS), venous segmental disease score (VSDS), and the venous disability score (VDS) are particularly useful. To fulfill the VSDS, complementary investigations are needed occasionally, such as venography, venous helical CT scan, magnetic resonance imaging, and so on, according to the...

Diagnosis Of Venous Disorders

FIGURE 1.7 Post-thrombotic varicose veins (Cruveilhier, 1857). FIGURE 1.7 Post-thrombotic varicose veins (Cruveilhier, 1857). The history of phlebography started in 1923, when Berberich and Hirsch described the technique to demonstrate the venous system in living humans by infusion of strontium bromide. One year later, Sicard and Forestier performed the first phlebography in humans using Lipiodol. In 1929, McPheeters and Rice performed the first dynamic varicography and described the movement of blood in the varicose veins. Further developments were due to Ratschow (who in 1930 introduced water soluble contrast media for angiography), Dos Santos (who demonstrated in 1938 the utility of direct ascending contrast venography to detect deep venous thrombosis), and Farinas (who performed the first pelvic venography in 1947). Intraosseus phlebography was then proposed by Schobinger in 1960 and refined by Lea Thomas in 1970. Finally, Dow described in 1973 the technique to perform retrograde...

Modern Surgery Of Superficial Veins

Modern surgery of varicose veins started in 1806, when Tommaso Rima proposed a hemodynamic treatment with ligation of the upper GSV. This operation was reproposed in 1890 by Friedrich Trendelenburg . . . the saphenous reflux must be the first step in control distal varicosities . . . It consisted of a double ligation of the great saphenous just

Perforating Vein Surgery

The first to suggest selective interruption of perforators to treat varicose veins was probably Remy in 1901. In 1938, Linton proposed a medial subfascial approach to treat incompetent perforators. In 1953, Cockett and Jones proposed the epifascial ligature of medial ankle perforators. Two years later, Felder recommended that the fascial incision for perforating vein ligature should be placed in the posterior midline of the calf in order to avoid placing the lower end of the incision over the ulcer itself or in the compromised skin of the medial leg the so-called posterior stocking seam approach. Glauco Bassi and Robert Muller used a hook for transcutaneous stripping of perforators through small incisions. Special instruments have been proposed to facilitate subfascial perforator interruption, like those of Albanese (1965) and Edwards (1976). The use of endoscopy to interrupt perforator in the subfascial space goes back to 1985 by Hauer, but only extensive technical improvements...

Concordance Of Visible And Functional Disease

Figure 3.1 shows the concordance of visible and functional disease in the individual 4422 legs of the 2211 participants for this analysis. The majority of legs showed TSV, but the majority of legs were also functionally normal. If we consider TSV as a normal visible finding, visible disease would be defined as VV or TCS, and functional disease as SFD or DFD. The concordance between visible and functional disease was 92 , 17.4 concordant for disease presence and 74.6 concordant for disease absence. Discordance was thus 8 , 4.9 of the legs with visible but not functional disease, and 3.1 with functional but not visible disease. Surprisingly, 21 of all legs with VV were normal functionally (3.7 17.7 ), as were 26 of all legs with TCS (1.2 4.6 ). Thus, although the concordance was strong, visible disease did not invariably mark underlying functional disease, and functional disease was sometimes present in the absence of any visible venous disease.3

Risk Factors For Cpvd

We have completed an extensive analysis of risk factors for visible and functional CPVD.8 Table 3.3 summarizes this work and shows odds ratios for significant predictors of visible and functional venous disease in our population. Family history of venous disease based on subject recall was a risk factor for all levels of visible and functional disease. Although this finding could be biased, it is consistent with many other studies,9,10 although not all.11 Ankle motility was a risk factor for visible disease SFD in women and for TSV in men. It was protective for women with DFD and men with SFD. The association of increasing laxity in connective tissue with venous disease corroborated previous research (reviewed in Reference 8). The protective associations could reflect increased ankle motility leading to decreased venous pressure by increasing pumping action. CVD-related factors, such as angina, PTCA, hypertension, and diastolic pressure were associated with less TSV, SFD, and DFD for...

Symptoms By Visible And Functional Disease

To estimate the relative importance of each symptom to the clinical picture of venous disease we evaluated the odds ratios (OR) for each symptom in each of the 12 categories of venous status formed by crossing the three categories of functional disease with the four categories of visible disease using logistic regression adjusted for age, sex, BMI, education, and racial ethnic group (see Table 3.4). Aching (OR 2.20) and swelling (OR 2.99) were significantly associated with DFD even in subjects without visible disease. These two symptoms were significantly associated with DFD across all categories of visible disease, with the strongest association in subjects with TCS. Aching was significantly associated with VV regardless of venous functional status and was associated with TCS except in those with normal functional examinations. Itching followed a similar pattern being significantly associated with varicose veins regardless of functional status, and with TCS except in those with...

Histological Search for Angiogenic Factors

The vascular proliferation seen in the skin of patients with venous disease has been known for many years, but has not been explained. In recent years many angiogenic factors that stimulate the growth of blood vessels have been recognized. Immunohistochemistry was used to evaluate the presence of a number of such factors in the skin of patients with venous disease.40 Skin biopsies were taken at the time of surgery for varicose veins from the legs of patients with and without skin changes as well as of breast skin in patients without clinical evidence of venous disease, for use as a control. There was an increase in platelet derived growth factor, subtype BB (PDGF-BB) in patients with venous disease. This was found in the capillary wall in vessels of the dermal papillae. There was also considerable upregula-tion of the production of vascular endothelial growth factor (VEGF) in the epidermis of patients with venous disease, most marked in those with skin changes. It seems likely that...

Interpretation of Data from Existing Studies

Endothelial adhesion is a normal physiological activity of neutrophils and monocytes. During venous hypertension the fall in blood flow to the lower limb and increase in diameter of capillaries result in a fall in the shear rate in cutaneous capillaries. This favors leukocyte adhesion, which may be observed, even in control subjects, but is of greater magnitude in patients with venous disease, presumably due to the modifications that take place in the endothelium in chronic venous disease. It has been found that leukocyte-endothelial interaction occurs during short-term venous hypertension (within 30 minutes) and that during this period neutrophil degranulation may be detected, releasing primary and secondary granule enzymes into the region of the endothelium. At the same time an increase in von Willebrand factor and soluble endothelial adhesion molecules can be found in the leg blood. These arguments apply to control subjects as well as to patients, although the magnitude of change...

And Molecular Adhesion Mechanisms

The modern developments of the pathophysiological basis of the skin changes in CVD can perhaps be traced back to the simple observation that leukocytes have quite different biomechanical properties than the red cells. Even though they are clearly in the minority, they contribute to many microvascular events.46,47 One of them is local accumulation in the microcirculation and thus it is highly significant that blood returning from feet that have been passively dependent for 40 to 60 minutes is relatively depleted of leukocytes, especially in patients with CVD.48-50 Leukocytes are easily trapped in the microcirculation due to their stiff cyto-plasmic properties and their ability to express membrane adhesion molecules, further enhanced by the fact that these properties are changed dramatically after activation.51 This subtle mechanism suggests that leukocytes accumulate in the lower extremity under conditions of high venous pressure. It is possible that the accumulation in microvessels is...

Abnormalities with Matrix Metalloproteinase Metabolism

Varicose veins have characteristically tortuous and dilated venous walls. A possible explanation for these findings may In the recent decade there has been a significant interest in the role of MMPs in the pathophysiology of varicose vein formation. An early report evaluating the collagen and elastin content of nonthrombophlebitic varicose veins compared to normal saphenous veins found that there was increased collagen and a significant decrease in elastin in both varicose veins and in the vein segment not affected by valvular incompetence but with varicosities at other sites. In this study gelatin zymography and elastase activity failed to demonstrate any differences, indicating the presence of an imbalance in tissue matrix but not attributable to proteolytic activity.4 In support of this prior study, evaluation of the vein segment at the saphenofemoral junction in patients with varicose veins demonstrated that MMPs activity was unchanged with that of control, with most of the MMPs...

Alterations in Smooth Muscle Cells Dermal Fibroblasts and Collagen

Several studies have investigated cultured smooth muscle cells derived from varicose veins to determine if the extracellular matrix modifications seen in varicose vein tissue are related to smooth muscle cells. Smooth muscle cells cultured from varicose veins were found to have decreased number of cells staining for collagen type III and fibronectin, although the transcriptional products of these two proteins were not dissimilar. The synthesis and deposition of collagen type III but not type I was significantly lower in varicose veins. When MMPs and TIMPs were analyzed from the supernatant of confluent cells no differences were observed. These findings suggested that the regulation was altered during posttranscriptional events for both collagen type III and fibronectin in smooth muscle cells.10 Further work in this area demonstrated that varicose greater saphenous vein has a smaller spiraled collagen distribution specifically in the intima and media. In an interesting study,...

Alterations in Cellular Proliferation Motility and Regulation

The authors speculated that increased accumulation of senescent cells in venous ulcers may lead to the observed impaired healing.31 Of interest, taking ulcer fibroblasts and subjecting them to progressive passage had a significant effect on the expression of senescent associated-P galactosidase compared to normal fibroblast or fibroblasts cultured from patients with varicose veins only. Not only did the ulcer fibroblasts have an increased mean number of senescent associated-P galactosidase expressing cells (63.8 8.9 vs. 11.2 3.1 ), but after six passages nearly all the ulcer fibroblasts were senescent (> 95 ). These data indicated that venous ulcer fibroblasts were significantly advanced in cellular age and closer to replicative exhaustion, suggesting that the accumulation of senescent cells in venous ulcer wounds may lead to recalcitrant healing.32 In experiments evaluating the effect of bFGF on fibronectin and MMP-2 expression, fibroblasts from venous...

Alterations in Extracellular Remodeling and the Wound Fluid Environment

The extracellular matrix (ECM) is an important structural and functional scaffolding made up of proteins that are necessary for cell function, wound repair, epithelialization, blood vessel support, cell differentiation and signaling, and cellular migration. The ECM is particularly important in providing a substrate for keratinocytes to migrate and establish coverage in both acute and chronic wounds.39 Alterations in protease activity and the relation to abnormalities in ECM metabolism in wounds have been areas of active investigation in the past decade. In an early report evaluating wound fluid collected from patients with venous ulcers, the investigators determined that compared to acute wound fluid, the chronic wound fluid contained up to ten-fold increased levels of MMP-2 and MMP-9 as well as increased activity of the enzymes, suggesting high tissue turnover.45 Increased MMP-1 and gelatinase activity from the exudates of chronic venous leg ulcers also has been confirmed by other...

Genetics and the Role of Deep Venous Thrombosis DVT

Valves prevent retrograde flow or reflux. Venous reflux is observed when valvular destruction or dysfunction occurs in association with varicose vein formation. Valvular reflux causes an increase in ambulatory venous pressure and a cascade of pathologic events that manifest themselves clinically as lower extremity edema, pain, itching, skin discoloration, varicose veins, venous ulceration, and, in its severest form, limb loss. These clinical symptoms collectively refer to the disorder known as chronic venous insufficiency (CVI).5 Age, gender, pregnancy, weight, height, race, diet, bowel habits, occupation, posture, previous deep venous thrombosis, and genetics all have been proposed as predisposing factors associated with varicose vein formation. Except for previous deep vein thrombosis and genetics, there is poor evidence that indicates a causative relationship between these predisposing factors and the formation of varicose veins. Refer to Kevin Burnand's textbook, Diseases of the...

And Functional Status In

In 1988, Thomas et al. reported that 24 fewer white cells left the venous circulation after a period of recumbency in patients with CVI as compared to normal patients.37 They studied three groups of 10 patients each. Group 1 consisted of patients with no signs of venous disease. Group 2 were patients with uncomplicated primary varicose veins, and group 3 were patients with long-standing CVI as determined by Doppler ultrasonography, strain-gauge plethysmography, and foot volumetry. Patients had the greater saphenous vein cannulated just above the medial malleolus. Venous samples were obtained at various time points with patients in the sitting and supine position. Samples were then placed in an automated cell counter and the number of leukocytes and

Types And Distribution Of Leukocytes

FIGURE 9.3 Electron micrograph (Mag 4300x) of mast cells (MC), macrophages (MP) and fibroblast (F) surrounding a central capillary from dermal biopsy of a patient with CEAP class 4 chronic venous insufficiency. FIGURE 9.3 Electron micrograph (Mag 4300x) of mast cells (MC), macrophages (MP) and fibroblast (F) surrounding a central capillary from dermal biopsy of a patient with CEAP class 4 chronic venous insufficiency.

Venous Volume and Venous Blood Flow Velocity

Depending on the exerted pressure and the body position, external compression is able to narrow or to occlude superficial and deep leg veins.14 In the upright position elastic stockings will have only a minor effect on decreasing the diameter of the leg veins.16 However, a very small decrease of venous diameter will result in an overproportional decrease of the local blood

Terminology And New Definitions

The CEAP classification deals with all forms of chronic venous disorders. The term chronic venous disorder (CVD) includes the full spectrum of morphological and functional abnormalities of the venous system from telangiectasias to venous ulcers. Some of these, like telangiectasias, are highly prevalent in the normal adult population, and in many cases the use of the term disease is not appropriate. The term chronic venous insufficiency (CVI) implies a functional abnormality of the venous system and usually is reserved for patients with more advanced disease including those with edema (C3), skin changes (C4), or venous ulcers (C5-6). Telangiectasia A confluence of dilated intradermal venules of less than 1 mm in caliber. Synonyms include spider veins, hyphen webs, and thread veins. Reticular veins Dilated bluish subdermal veins usually from 1 mm in diameter to less than 3 mm in diameter. They usually are tortuous. This excludes normal visible veins in people with thin, transparent...

Refinement Of Cclasses In Ceap

C0 No visible or palpable signs of venous disease C2 Varicose veins distinguished from reticular veins by C4 Changes in the skin and subcutaneous tissue secondary to CVD (now divided into two subclasses to better define the differing severity of venous disease) C4a Pigmentation and or eczema C4b Lipodermatosclerosis and or atrophie blanche C5 Healed venous ulcer C6 Active venous ulcer To improve the assignment of designations under E, A, and P, a new descriptor n is now recommended for use where no venous abnormality is identified. This n could be added to E (En no venous etiology identified), A (An no venous location identified), and P (Pn no venous patho-physiology identified). Observer variability in assigning designations in the past may have been contributed to by the lack of a normal option. Further definition of the A and P has also been afforded by the new venous severity scoring system,12 which was developed by the ad hoc Committee on Outcomes of the AVF to complement CEAP....

Theoretical Risk Factors

One popular hypothesis for the development of varicose veins is Western dietary and defecation habits, which cause an increase in intraabdominal pressure. Population studies have demonstrated that a high-fiber diet is evacuated within an average of 35 hours.24 In contrast, a low-fiber diet has an average transit time of 77 hours. An intermediate diet has a stool transit time of 47 hours. Defecatory straining induced by Western-style toilet seats has also been cited as a cause of varicose veins, in contrast to the African custom of squatting during defecation.25,26 An association between prostatic hypertrophy, inguinal hernia, and varicose veins may be caused by straining at micturition with a resultant increase in intraabdominal pressure. Another mechanism for increasing distal venous pressure by proximal obstruction is the practice of wearing girdles or tight-fitting clothing. A statistically significant excess of varicose veins is noted in women who wear corsets compared with women...

Symptoms Of Primary Venous Insufficiency

It is well known that the presence and severity of symptoms do not correlate with the size or severity of the varicose veins present. Symptoms usually attributable to varicose veins include feelings of heaviness, tiredness, aching, TABLE 12.2 Symptoms of Varicose Veins and Telangiectasias Trendelenburg Test Cough Test Schwartz Test Perthes' Test burning, throbbing, itching, and cramping in the legs (see Table 12.2). These symptoms are generally worse with prolonged sitting or standing and are improved with leg elevation or walking. A premenstrual exacerbation of symptoms is also common. Generally, patients find relief with the use of compression in the form of either support hose or an elastic bandage. Weight loss or the commencement of a regular program of lower extremity exercise may also lead to a diminution in the severity of varicose vein symptoms. Clearly, these symptoms are not specific, as they may also be indicative of a variety of rheumatologic or orthopedic problems....

Effect Of Position On Varicose Geometry

1.7 at a distance of 1 cm and a concentration of about 0.6 at a distance of 5 cm (2 inches). This supine technique limits dilution enough to allow successful sclerosis of large vessels using detergent solutions, as long as sufficient concentrations and volumes of sclerosants are injected. The only problem is that if an injection of sclerosant at a high initial concentration is made directly into a perforating vessel, so that sclerosant flows directly into the deep system, dilution within the deep vessel will still permit Zone 1 and Zone 2 endothelial injury for a short distance within the deep vein. This can lead to deep vein valve damage and chronic venous insufficiency, to deep vein thrombosis, and to life-threatening pulmonary embolism.

The Benefits Of Laser Therapy

Another comparative study examined the effectiveness of the 1064 nm Nd YAG versus the 810 nm diode and the 755 nm alexandrite lasers in the treatment of 0.3-3 mm in diameter. The results summarized in Table 16.1 demonstrated that the Nd YAG laser was the most effective treatment modality at three months follow up. Purpura and matting were problematic with the alexandrite laser the results produced by the long-pulsed diode were unpredictable in the subjects enrolled.13 Presently, no long-term controlled studies have been done regarding the persistence of vessel clearing after laser treatment of leg veins.

Addressing The Common Pitfalls In Laser Therapy

The laser treatment of leg veins is not free of common pitfalls (see Box 16.3). Retreatment or double pulsing of the target vessels vessel should be avoided to prevent excessive thermal damage that potentially can result in scarring and ulceration. The physician or the medical personnel admin- Complications of the laser therapy of leg veins include epidermal damage, thrombosis, hyperpigmentation, matting, and incomplete clearance (see Box 16.4). During the actual procedure patients typically complain of discomfort, but rarely do they feel uncomfortable postoperatively. For those patients who develop telangiectatic matting of incomplete vessel clearance, retreatment should be offered with either laser or microsclerotherapy as deemed appropriate. Localized areas of thrombosis may resolve independently from treatment or easily can be expressed with an 18-gauge needle. Post-procedure hyperpigmentation is usually transient and has become less of an issue with the advent of the longer...

The Future Of Laser Therapy

The laser treatment of leg veins continues to gain momentum with advances in laser, pulsed light, and combined radiofrequency pulse light technologies. Other advances include enhancement of longer wavelength treatment systems, improved cooling technologies, varied spot size, pulse durations, and fluence-related monomodal approaches and combined lasers radiofrequency systems. The continued development of laser technologies not only enhances the phlebologist's armamentarium in the treatment and management of telangiectasias and reticular veins, but also provides the patient with an array of safe, noninvasive treatment options with minimal side effects or complications. 1. Kauvar A. The role of lasers in the treatment of leg veins, Sem Surg Cutan Med. 2000. 19 245-252. 6. Dover J, Sadick N, Goldman M. The role of lasers and light sources in the treatment of leg veins, Dermatol Surg. 1999. 25 328336. 7. Sadick N. Updated approaches to the management of cosmetic leg veins, Phlebol. 2003....

Primary Venous Insufficiency

The manifestations of simple primary venous insufficiency appear to be different from one another. However, reticular varicosities, telangiectasias, and major varicose veins are all elongated, dilated, and are tortuous. Investigations into valve damage and venous wall abnormalities eventually may lead to an understanding of the problem, and therefore, a solution by surgery or pharmacotherapy.1-4 Scanning electron microscopy has shown varying degrees of thinning of the varicose venous wall. These areas of thinning coincide with areas of varicose dilation and replacement of smooth muscle by collagen, which is also a characteristic of varicose veins.5,6 Our approach to this has been to assume that both the venous valve and the venous wall are affected by the elements that cause varicose veins. We and others have observed that in limbs with varicose veins, an absence of the subterminal valve at the sapheno-femoral junction is common.7 Further, perforation, splitting, and atrophy of...

Intravascular Effect Of Circumferential Compression

Direct observation using ultrasound has shown that compression stockings of 35 mm Hg have no noticeable effect on the morphology or function of large varicose veins. Since the vein preserves its dimensions, there is nothing to prevent the formation of a thrombus. Even when rolls of gauze or other nonelastic cylinders are placed on the varicose vein and strongly compressed by a bandage of little elasticity (Peha-Haft Hartmann), no reduction in the diameter of trunk varicose veins is produced on standing. Thus, the joint application of these compressive measures (i.e., stocking + bandage + nonelastic cylinders) does not occlude the lumen of the vessel.

Pretreatment Ultrasound Mapping

Duplex venous scanning is the essential pretreatment investigation prior to either sclerotherapy or UGS of major varicose veins and truncal incompetence. Through duplex scanning, patterns of venous incompetence will be found to be extremely variable and often unexpected. Duplex scanning involves B-mode imaging of the deep and superficial veins combined with directional pulsed Doppler assessment of blood flow. Color-duplex imaging superimposes blood flow information onto the B-mode ultrasound image, permitting visual assessment of blood flow while creating an anatomical map of the venous anatomy. The details of venous duplex examination have been described in a previous chapter and will not be dealt with here.

Pretreatment Assessment

The patient should be examined in a standing position to demonstrate patterns of teleangiectasias, reticular veins, and varicose veins.5 Cold light transillumination of the skin (vein light) may be used to identify reticular veins, and a handheld Doppler device can verify the presence of reflux

Marianne De Maeseneer

At the beginning of the twenty-first century, surgical treatment of varicose veins continues to be marred by the development of recurrent varicosities. This has always been a very disappointing phenomenon for patients and surgeons alike. Most commonly, recurrent reflux develops in the area of the saphenofemoral junction (SFJ), causing recurrent varicose veins from the thigh downward to the entire leg (see Figure 26.1).1 Even in clinical centers with a special focus on minimizing recurrence surgeons do not seem to be able to avoid such disfiguring and often disabling recurrent varicose veins. Many surgeons only start to recognize the phenomenon after having to reoperate on patients with recurrent varicose veins some years after a previous varicose vein operation correctly performed by themselves. The observations during reexploration of the groin at the level of the saphenofemoral junction then frequently show neovascu-larization as the explanation for the recurrence. Despite the fact...

Principles of Ambulatory Phlebectomy

Ambulatory phlebectomy (AP) is a surgical procedure designed to allow outpatient removal of bulging varicose veins. This treatment originally was described and performed by Aulus Cornelius Celsus (56 bc-30 ad) in ancient Rome.1 However, the art of AP was revived, redefined, and practiced by the sagacious Swiss dermatologist Robert Muller in 1956. Prior to Muller's reintroduction of AP, veins were removed with relatively large incisions and ligation of venous ends. Muller developed the stab avulsion method that is now in widespread use. Characteristics of Muller's AP technique are absence of venous ligatures, exclusive use of local infiltration anesthesia, immediate ambulation after surgery, 2-mm incisions, absence of skin sutures, and a postoperative compression bandage kept in place for two days, then replaced with daytime compression stockings for three weeks.

Epidemiology And Socioeconomic Consequences

They are not easy to determine as most studies are retrospective, analyzing patients that were not evaluated preoperatively by duplex scanning (DS), and usually the detailed operative report is not available. In a 34-year follow-up,12 varicose veins were present in 77 of the lower limb examined and were mostly symptomatic. Fifty-eight percent were painful, 83 had a tired feeling and edema had reappeared in 93 . In the Kostas series from Crete,16 true recurrent varices were present in eight limbs (8 28, 29 ), primarily caused by neovascularization, new varicose veins as a consequence of disease progression were seen in seven limbs (7 28, 25 ), residual veins were found in three limbs (3 28, 11 ) mainly due to tactical errors (e.g., failure to strip the GSV), and complex patterns were identified in 10 limbs (10 28, 36 ). In the limbs with recurrence, 42 sources of venous reflux were identified 19 new sites of venous reflux were due to disease progression, 15 of the operated limbs 13...

Risk Factors For Venous Thromboembolism

In order to improve survival, avoid recurrence, prevent complications, and reduce health care costs, the occurrence of venous thromboembolism must be reduced. To reduce venous thromboembolism incidence, persons at risk for venous thromboembolism first must be identified. Independent risk factors for venous thromboembolism include patient age, surgery, trauma, hospital or nursing home confinement, active malignant neoplasm with or without concurrent chemotherapy, central vein catheterization or transvenous pacemaker, prior superficial vein thrombosis, varicose veins among the young, and neurological disease with extremity paresis patients with chronic liver disease have a reduced risk (see Table 36.4).42,43 The incidence of VTE increases significantly with age for both idiopathic and secondary VTE, suggesting that the risk associated with advancing age may be due to the biology of aging rather than simply an increased exposure to VTE risk factors with advancing age.44 Compared to...

Presentation Of Patients With

A commonly held perception is that less severe CVI (CEAP clinical classes 2-3) is typically a sequela of superficial venous reflux, whereas more severe CVI (CEAP classes 4-6) is associated with deep venous reflux. For this reason, the majority of patients treated with venous leg ulcers are never referred to a venous specialist for consideration of a corrective procedure. It is mistakenly believed that all are due to deep venous disease and that none are candidates for correction of reflux or obstruction. Several authors have defined the anatomy of reflux in patients with advanced CVI, and isolated saphenous or saphenous and perforator reflux is not uncommon, occurring in 20 to 35 of patients in various series. Also, as outlined by Drs. Neglen, Raju, and Kistner in other chapters, many patients with deep venous insufficiency causing severe CVI may be improved with surgical or endovenous procedures, reducing symptoms and the incidence of recurrent ulcers.

Clinical Considerations

Indications for USGS are not different from indications to surgical interruption of perforating veins. Cases of symptomatic chronic venous disease from C2 to C6 clinical class (CEAP) that have demonstrable incompetent perforating veins at duplex ultrasound constitute the majority of indications. In primary disease, USGS can be performed at the time of initial treatment of saphenous reflux, or as a separate stage. In secondary (post-thrombotic) disease, careful consideration should be given to the pathophysiologic role of incompetent perforator in each individual extremity. Incompetent perforators can constitute a major outflow track around an obstructed segment in some cases and be a contributor to skin ulceration in others.

Diagnosis Of Venous Obstruction

Often when algorithms are constructed for workup of patients with chronic venous insufficiency, investigations for estimating the degree of reflux are emphasized, and testing for outflow obstruction is omitted completely. This is mainly owing to a lack of accurate objective noninvasive or invasive tests for evaluation of hemodynamically significant chronic venous obstruction. There are many tests for delineating focal and global reflux, but this is not so for outflow obstruction.

Practical Implications

There are no reliable tests to measure a hemodynamically significant stenosis. This lack of gold standard is the major obstacle to assess the importance of chronic outflow obstruction, select limbs for treatment, and evaluate the outcome. Although a positive noninvasive or invasive test may support further studies, a negative test should not exclude it. The diagnosis and treatment must presently be based on invasive morphological investigations of the iliac venous outflow (transfemoral multiplane venography or IVUS), or perhaps in the future MRV or spiral CT. Limiting workup of patients with significant chronic venous disease to only duplex ultrasound will not suffice. The key for the physician is to be aware of the importance and possibility of venous blockage combined with increased suspicion in patients with history and clinical signs and symptoms suggestive of outflow obstruction. Patients with previous DVT patients with limb symptoms, especially pain, out of proportion to...

Open Surgical Reconstruction

Patent it often is combined with temporary or permanent arteriovenous fistula and life-long anticoagulation with inherent risk of complications. Strict criteria for surgery, including severe disabling symptoms and markedly increased venous pressure levels, are used and only a minority of patients with chronic venous disease (CVD) are selected.

Stenting Of Chronic Nonmalignant Obstruction

A few studies describe stenting of nonmalignant chronic obstruction with no adjuvant therapy in patients with chronic venous disease. Bl ttler and Bl ttler reported in 1999 treatment of chronic venous and neurogenic claudication due to pelvic venous blockage and achieved 100 patency in 11 successfully stented limbs with a mean follow-up of 15 months (range 1-43 months).4 A group of 18 patients were reported by Hurst et al.16 Twelve limbs were treated for chronic obstruction. The primary patency rates at 12 and 18 months were 79 and 79 , respectively. Hartung et al. has reported the result after stenting of 44 patients with

Clinical Outcome After Stenting

The reports referred to earlier describing patency rates indicate clinical improvement in most patients (> 80 ).3,4,37 Hurst et al. showed resolution or substantial improvement in 72 of limbs.16 However, five remaining patients continued to have pain despite resolved swelling and widely patent stents on venogram. In addition to assessment of ulcer healing, Raju and Neglen have evaluated pain, swelling, and quality-of-life. Median follow-up 789 993 limbs in the updated material was 11 months (range 1-88 months). The degree of swelling was assessed by physical examination (Grade 0 none Grade 1 pitting, not obvious Grade 2 ankle edema Grade 3 obvious swelling involving the limb), the level of pain was measured by the visual analogue scale method,46 and quality-of-life by a questionnaire, validated for assessment of chronic venous insufficiency.26 The incidence of ulcer healing after iliac vein balloon dilation and stent placement in 41 limbs with active ulcer was 68 and the cumulative...

Treatment Of Deep Vein Reflux Prior To 1968

There was great interest in the aggressive management of the chronic venous disease (CVD) leg prior to 1960, which is well summarized in the papers of Robert Linton of Boston from 1938 to 1953.2,7 Linton refers to the epic work of Homans8 who drew attention to the importance of the perforator veins and concentrated on the excision of the diseased skin and scar tissue in the lower leg. Homans' understanding of the pathophysiology of CVD is amazing in view of the fact that he had no imaging studies to visualize the leg veins and depended entirely upon clinical acumen to divine the relationship between the skin changes of CVD and the venous system. He came to understand that these changes were related to deep vein disease, which was attributed to post-thrombotic changes in the veins through clinical examination alone. Linton embraced and amplified this thinking and devised a multipronged surgical effort to control venous hypertension by removing the saphenous vein, radically eliminating...

Distribution Of Primary Incompetent Valves

Four-year increments during primary and secondary school and demonstrated progressive reflux in the saphenous and perforator veins, with minimal involvement of the deep veins. This is consistent with the observation that large numbers of early primary cases with varicose veins have no reflux in the deep veins, but progressive involvement beyond the saphenous and into the perforator veins and later into the deep veins is found in patients with more severe degrees of clinical disease as skin changes and ulceration becomes manifest. This contrasts sharply with the natural history of post-thrombotic disease, which nearly always begins in the deep veins and spares the superficial veins.

Surgical Considerations Arising From Deep Vein Reflux Patterns

The axial reflux patterns of primary deep venous disease must be thoroughly diagnosed prior to planning deep vein valve repair. Primary cases often present with a single axial reflux tract that courses from the CFV through the femoral vein of the thigh to the popliteal and into the calf veins. In this case, a single valve repair in the femoral vein has been shown to be all that is needed to restore clinical compensation to the venous return. These cases usually have little or no communication between the distal profunda veins and the popliteal vein and seldom have other collaterals. The lack of collaterals is due to the lack of an obstructive element in the development of primary disease, in contrast to post-thrombotic deep vein disease.

Clinical Contributions To The Experience Of Deep Vein Valve Repair

Important contributions in the 1990 decade include a new variant in the technique of internal primary valve repair by Sottiurai followed by the initial reports of his series of deep vein reconstructions that has become one of the largest in the world,34 and description of an angioscopic technique for valve repair by Gloviczki of the Mayo Clinic in 199135 supported by confirmatory series from Boston36 and Japan.37 DePalma described a type of cross-over study,38 in which cases with unsuccessful nonsurgical management for advanced venous disease were converted to a surgical approach in 1996 and were followed for comparative control of the venous insufficiency state. In 2001, a well-designed study from Russia reported by Makarova39 provided a glimpse into the natural history of primary disease and the potential effect deep surgical repair may have upon this progression. Recently, the trap door technique of valve repair was reported by Tripathi in 2001,40 followed by another large series...

Preoperative Evaluation

It is incumbent upon the surgeon who undertakes deep vein reconstruction to have expert scanning available to guide his choices at all stages of diagnosis and follow-up. The minimal requirements of the ultrasonographer should include experience in identification of reflux and obstruction in all the venous segments, ability to identify hemodynami-cally important tributaries of major veins and collateral flow routes, and most important, the capacity to individualize the scanning protocol to identify the anatomically and physiologically unique variations that occur in advanced venous disease. Since the knowledge of flow routes in CVD is still evolving, the ultrasonographer should have sufficient background to contribute to this progress as an essential member of the venous team.

Physiologic Noninvasive Testing

The use of pressures and plethysmography in evaluation of the patient for surgery can be helpful in confirming that there is significant venous disease, but is seldom helpful in determining critical details of the preoperative workup. These tests are global in nature, especially the venous pressure test, and for this reason it can be used on a highly selective basis. Plethysmography provides more detail and is more practical than venous pressure, especially the VFI (venous filling index), which provides a measure of the reflux in the veins when the extremity is inverted. It has been related to the severity of venous insufficiency and certain centers use this test as an important part of their estimation of severity of reflux in CVD and in reconstruction.51

Compression Therapy

Compression therapy is the oldest and until recently the only therapeutic option available to treat PTS. It has been reported anecdotally to be ineffective in PTS but no systematic study has been undertaken. Compression therapy remains the initial approach in chronic venous disease including PTS. Some patients do fail compression therapy despite faithful compliance. Noncompliance, however, is the major cause of compression failure and recurrent symptoms.27-29 Noncompliance is high even in cold climates as documented in several community surveys. Long-term supervision or monitoring by health care workers has been advocated to improve compliance. However, noncompliance is high even under supervision.29,30 The reasons for


The beginning of sclerotherapy commonly is dated back to the invention of the the syringe by Pravaz (1831), and of the hypodermic needle by Rynd (1845). However, antique phlebologists could not wait for Rynd's and Pravaz's discoveries. In fact, the first endovenous treatment goes back to 1665 when Sigismond Johann Elsholz treated venous ulcers by irrigating them with intravenous injection of distilled water and essences from plants using a chicken bone as a needle and a bladder of pigeon as a syringe. Some authors credit Zolliker as the first to perform sclerotheraphy in 1682, by injecting acid into varicose veins. The rationale of sclerotherapy was furnished by Joseph Hodgson (1815) who noted first that thrombosis extinguished varicose veins. In the second half of the eighteenth century, various substances were used (see Table 1.3), but adverse sequelae (local tissue necrosis, extravasation, pulmonary embolism, and scarring caused by poor technique and causticity of solutions) were...

Symptoms And Cpvd

The SDPS reported data for ever having any of seven symptoms of venous disease aching, cramping, tired legs, swelling, heaviness, restless legs, and itching.13 Aching legs was the most commonly reported venous symptom, with an overall prevalence of 17.7 . Cramping was present in 14.3 of legs, tired legs in 12.8 , and swelling in 12.2 . Heaviness and restless legs had similar prevalence at 7.5 and 7.4 . Itching was the least commonly reported symptom, affecting 5.4 of legs. With the exception of restless legs, all these symptoms increased in prevalence with increasing severity of venous functional disease (see Figure 3.2). The rate was lowest in normal legs, increased in legs with SFD, and highest in legs with DFD. These differences were statistically significant (p < 0.01) for all symptoms except for restless legs (p 0.56). Although each symptom was more common in women than men, trends were similar in both sexes.

Qol And Cpvd

Despite the high prevalence of venous disease, the impact upon daily functioning and quality of life is still poorly documented. Venous disease has been considered as a cosmetic problem that might affect emotional well-being. Several studies have shown that venous disease affects selected aspects of daily functioning (reviewed in Reference 19). An ad hoc committee of the SVS ISCVS recommended the expansion of outcome measures in studies of venous disease to include patient reported functioning and quality of life measures.20 In their review, the ad hoc committee noted that comprehensive evaluation of venous disease must Chapter 3 Epidemiology of Chronic Peripheral Venous Disease


Venous disease increased with age, and NHW had more disease than Hispanics, African-Americans, or Asians. were discordant, the presence of one condition did not necessarily imply the other. In addition, fully one-fourth of limbs with TCS did not have functional venous disease. 1. The most consistent risk factor across all definitions of venous disease was family history, suggesting the importance of a genetic link. 6. Cardiovascular diseases tended to be inversely associated with venous disease. 8. Key risk factors for venous thrombosis, older age, obesity, and hormonal factors were also risk factors for visible and functional venous disease. 1. Symptoms are significantly more common in legs with visible venous disease compared to legs without, and are greater the more severe the visible disease. 2. Symptoms are significantly more common in legs with functional venous disease compared to legs

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