
Superficial Venous Insufficiency: Varicose Veins and Venous Ulcers
Superficial venous disease broadly falls into two categories: venous insufficiency/reflux (eg, varicose veins [shown], chronic venous insufficiency) and veno-occlusive disease, including thrombosis (eg, superficial thrombophlebitis, deep venous thrombosis [DVT]). These conditions encompass a wide range of symptoms/signs and presentations. In more than 50% of the general population, superficial venous disease appears in the form of "spider" or reticular veins, but in approximately 20%-25% of the population, the disease can progress to visible varicosities at its extremes, such as ulceration or skin changes.[1,2]
This slideshow will focus primarily on venous insufficiency.
Superficial Venous Insufficiency: Varicose Veins and Venous Ulcers
Calf-Pump System
The venous supply to the leg is via a deep and superficial low-pressure system. The flow of blood is from the peripheries toward the heart, maintained by the calf-pump system. Within the veins, a system of valves helps overcome the pull of gravity and maintains a unidirectional flow of blood (shown). When these valves become incompetent, retrograde flow of blood predominates and leads to venous hypertension, resulting in the changes seen with superficial venous disease.
Superficial Venous Insufficiency: Varicose Veins and Venous Ulcers
Clinical Classification
The CEAP (clinical, etiologic, anatomic, pathophysiologic) criteria are used to aid classification of chronic venous disease, particularly in clinical studies and trials; thus, they help clinicians to stratify and communicate the severity of venous disease.[4] Typically, only the clinical portion (shown) of the CEAP classification system is fully utilized.[3]
Superficial Venous Insufficiency: Varicose Veins and Venous Ulcers
Superficial Venous Insufficiency
Much about the etiology of varicose veins remains unknown. These manifestations are seen more commonly in developed countries and in women, and they are strongly associated with family history, increasing age, pregnancy, and DVT. Weak associations include obesity and some rare genetic abnormalities.[4]
Although few studies document the natural history of varicose veins (shown), superficial venous insufficiency is considered to be progressive over time, typically beginning as reticular veins or corona phlebectatica ("corona"), developing into isolated calf varicosities and, eventually, resulting in a tortuous and distended great saphenous vein.[5]
Reticular veins are typically small (1-3 mm), highly visible, and often pose a cosmetic problem for patients. Varicose veins are superficial and dilated; they are typically found in the calf but may also occur in the thigh, corresponding to the course of the long saphenous vein. Incompetence of the perforator and short saphenous veins can result in posterior calf varicosities.
Superficial Venous Insufficiency: Varicose Veins and Venous Ulcers
Left untreated, superficial venous insufficiency can lead to the development of skin changes (shown) and, eventually, ulceration. The rate of progression and risk factors for developing chronic venous changes are still unknown.[6] Symptoms can include heaviness, swelling, aching, cramps, and itching.[7] Venous hypertension can subsequently develop due to excessive edema overwhelming the lymphatic system.
Venous eczema, hemosiderin staining, and lipodermatosclerosis are consequences of chronic venous stasis. Hemosiderin staining occurs from extravasation of red blood cells, causing a pigmented appearance to the limbs. Lipodermatosclerosis gives the affected limb a classic "inverted champagne bottle" appearance; this is thought to be caused by extravasation of fibrinogen or white blood cells into the dermal tissue due to capillary hypertension, thereby resulting in chronic inflammation and fibrosis of the subcutaneous tissue.[8]
Superficial Venous Insufficiency: Varicose Veins and Venous Ulcers
Venous insufficiency is the most common underlying etiology of chronic ulcers (shown) (range, 54%-75% in some observational studies).[9] Other conditions that should be considered in the differential diagnosis as a cause of such ulcers include arterial insufficiency, mixed venous and arterial disease, and vasculitic processes.
Venous ulcers take longer to heal, are often recurrent, and occur more frequently in older patients.[10] The Bonn Vein Study found a prevalence of 0.6% of healed and 0.1% of active venous ulcers in those younger than 79 years. These ulcers frequently affect the medial "gaiter" region but can also occur on the lateral aspect or the dorsum of the foot.[11] Venous ulcers rarely occur de novo but often manifest secondary to triggers such as cellulitis, injury, dermatitis, and rapid development of edema.[12]
Superficial Venous Insufficiency: Varicose Veins and Venous Ulcers
Imaging Studies
Duplex ultrasonography remains the gold standard for investigation of venous disease. The duplex ultrasound image shown demonstrates reflux (reverse flow) within the femoral vein.
These studies should provide a map of the deep and superficial lower limb venous systems, including perforating veins and saphenofemoral and saphenopopliteal junctions, demonstrating patency, competency (absence of reflux), and (where treatment is considered) tortuosity and caliber.
Ovarian or pelvic vein reflux can be assessed noninvasively by ultrasound, computed tomography (CT), or magnetic resonance (MR) venography. Catheter-directed venography is reserved for treatment of pelvic vein reflux via embolization or, in cases of proximal venous obstruction (iliofemoral DVT, May-Thurner syndrome), venous recanalization and stenting. This procedure can be assisted by intravascular ultrasound (IVUS).[13]
Superficial Venous Insufficiency: Varicose Veins and Venous Ulcers
Open Varicose Vein Surgery and Saphenous Vein Stripping
Since it was first described, in 1890, ligation of the great saphenous vein has been used to treat varicose veins to good effect. The procedure is typically done as a day surgery, under general or spinal anesthesia. The saphenofemoral junction, where the great saphenous vein enters the femoral vein through the cribriform fascia, is identified through a transverse incision (shown). The junction needs to be positively confirmed before ligation and disconnection.
Superficial Venous Insufficiency: Varicose Veins and Venous Ulcers
Typically, once the saphenofemoral junction and the surrounding tributaries have been ligated, the great saphenous vein is then stripped to reduce the risk of recurrence (shown).[14] Depending on the surgeon's preference, the vein can be stripped to the knee or the ankle; however, the risk of injury to the saphenous nerve is higher with more distal stripping.[15] If saphenopopliteal junction incompetence is present, the short saphenous vein can also be ligated. Large varicosities are removed by stab avulsions (ambulatory phlebotomy).
The saphenous nerve in the calf, the sural nerve behind the knee, and the peroneal nerve at the fibular head are all at risk of injury during stripping, ligation, and avulsion; sensory loss occurs if these nerves are injured. Although recurrence rates vary between 5% and 25% at 5 years and up to 80% at 20 years, patients have reported a high satisfaction rate (92%) on review at 5 years.[16,17]
Superficial Venous Insufficiency: Varicose Veins and Venous Ulcers
Postoperatively, the patient is encouraged to be mobile immediately. The leg is also compressed with bandages for 1-5 days to reduce bruising and hematoma (shown); once these compression bandages are removed, they are typically replaced by compression stockings for a brief period.[18]
Complications of open surgery include infection, bleeding, DVT, nerve injury, and recurrence. Bruising along the route of the vein strip is common, but bleeding that requires intervention is exceedingly rare. DVT is an uncommon (0.5%-5.3% in the literature) but concerning complication.
Superficial Venous Insufficiency: Varicose Veins and Venous Ulcers
Endovenous Thermal Ablation
An alternative to traditional surgery is the minimally invasive approach offered by endovenous thermal ablation—a term used to encompass techniques of endothelial injury delivered via a percutaneous intraluminal ablation catheter. Technologies in common use include endovenous laser ablation (EVLA) and radiofrequency ablation (RFA). Cryotherapy and steam ablation have also been described. Tumescent anesthetic is delivered outside the vein to prevent excess thermal injury, collapse the vein around the catheter, and reduce pain. Ideal veins are straight, broad (>3 mm), and deep (>1 cm from skin).
The ablation catheter is inserted under ultrasonographic guidance. Longitudinal duplex ultrasonogram of the saphenofemoral junction is shown during the positioning of the tip of a laser fiber for EVLA. The laser tip (arrow) is in the great saphenous vein (GSV) just beyond the superficial epigastric vein (SEV) termination. FV = femoral vein.
The advantages of this procedure lie in reducing the use of general anesthesia and the rates of bruising, bleeding, and nerve injury. Endovenous ablation can therefore promote an earlier return to work for patients.[19] Complications include skin burns and endovenous heat-induced thrombosis, with an incidence below 1%.
Superficial Venous Insufficiency: Varicose Veins and Venous Ulcers
Sclerotherapy and Pharmacomechanical Ablation
Instead of thermal ablation, chemical ablation can also be used to obliterate the varicose vein. Foam sclerotherapy, initially devised to treat small reticular veins, can now be used to sclerose incompetent great saphenous veins with only a slightly lower efficacy than traditional surgery, according to a meta-analysis.[20]
The procedure is performed on an outpatient basis under local anesthesia, or without anesthesia using a fine-bore needle. Multiple sessions are sometimes required to achieve a full result. A chemical agent such as polidocanol or sodium tetradecyl sulfate (STS) is selected and produced into a foam, which is then injected under ultrasonographic guidance into the varicose vein. The sclerosing agent induces thrombosis, leading to a lumpy coagulum as it takes effect; the site is usually compressed with bandaging or with a stocking.[21-23] Patients recover rapidly following the procedure; some may require aspiration of the coagulum but in most cases it dissipates over time.
Common complications include skin pigmentation and thrombophlebitis, but chemical ablation rarely causes DVT or pulmonary embolism (PE) (0.19%-0.7%).[21-23]
Chemical ablation can be combined with mechanical irritation to induce venous spasm and increase efficacy. More recently, cyanoacrylate glue has been used to create an adhesive obliteration of the venous lumen.[24]
Superficial Venous Insufficiency: Varicose Veins and Venous Ulcers
Phlebectomy
Phlebectomy, also referred to as stab avulsions, is the removal of large varicosities by direct incision. It is often performed in conjunction with open surgery, but may also be done as part of a course of minimally invasive saphenous vein treatments such as endovenous thermal ablation or injection sclerotherapy. The procedure can be performed under local anesthesia and in some cases can be assisted by transillumination or powered phlebectomy devices.
Superficial Venous Insufficiency: Varicose Veins and Venous Ulcers
Compression Stockings
Compression stockings (shown) have long been the mainstay of nonoperative management for varicose veins. However, there is a lack of good evidence to show their efficacy, and patient compliance is a significant hurdle, as many find the stockings to be itchy, hot, and difficult to put on and take off.
Although a number of studies outline the potential of pharmacotherapy in reducing symptoms, particularly the use of horse chestnut extract, thus far, the benefit of such treatment has been shown to be limited.
Superficial Venous Insufficiency: Varicose Veins and Venous Ulcers
Considerations in Treatment Selection
When selecting the appropriate treatment for patients with superficial venous disease, many factors must be taken into account. These include the severity and extent of the venous disease, the anatomy of the varicosities, the presence of ulceration (shown) and/or comorbid conditions, any previous treatments, and the goal of treatment (cosmetic, ulcer healing, or symptom management).
The availability of therapeutic options and the expertise of the treating surgeon also have roles in the decision-making process. For example, EVLA and radiofrequency ablation (RFA) treatments are more financially costly than traditional surgery because they often require a heavier investment in instruments.
Patients should be made aware that surgery for varicose veins can result in bruising and short-term pain and, most importantly, recurrence is common. Moreover, although the bulk of the varicosities is removed, residual small veins often remain and may require further intervention.
Superficial Venous Insufficiency: Varicose Veins and Venous Ulcers
A number of systematic reviews and meta-analyses have compared the three main procedures for the treatment of varicose veins (ie, open surgery, endovenous ablation, foam sclerotherapy). Note, however, that the results of these analyses must be considered against the heterogeneity in the methodology of the randomized controlled trials used in the analyses.
Although several recent guidelines have suggested that endovenous ablation should be considered first-line therapy for suitable patients,[25-27] open varicose vein surgery is still considered the gold standard to which other treatments are compared. A Cochrane review found little difference between treatments in terms of the risk of early clinical recurrence (shown) or recanalization of the great saphenous vein on the basis of early duplex sonograms.[20] EVLA and RFA typically cost more, but they have the benefit of reduced rates of wound infections and hematoma, as well as an earlier return to work.[28] Although the Cochrane review showed equal effectiveness with sclerotherapy,[20] other studies have reported that, at 5-year follow-up, those who underwent surgery were more likely to remain recurrence free.[29]
Superficial Venous Insufficiency: Varicose Veins and Venous Ulcers
Ulcers
Venous leg ulceration is a common yet difficult condition to treat, particularly in the elderly. Management of these ulcers is costly, and without definitive early and ongoing long-term management, recurrence rates are high.
Multi-modality treatment of ulceration must include debridement of necrotic tissue and control of infection and microbial colonization. Arterial supply should be assessed and a suitable wound-healing environment supported. Pressure care, analgesia, nutrition, and smoking cessation should be addressed, along with medical comorbidities such as diabetes and cardiac failure. The presence of venous reflux or outflow insufficiency should be determined.
If present, venous disease should be treated with surgery or intervention—ideally after healing of the ulcer, which may be assisted with compression therapy and, if necessary, bed rest and elevation. Skin grafts or local flaps may be necessary to cover the defects (shown).
Superficial Venous Insufficiency: Varicose Veins and Venous Ulcers
Compression therapy has also been the mainstay of preventing recurrence of venous ulcers. However, there is evidence that in patients with incompetence of the great or small saphenous vein, surgical intervention is associated with improved rates of healing as well as lower recurrence rates than with compression therapy alone.[30] Outcomes with surgical intervention do not appear to differ on the basis of the type of surgery performed (ie, open, endovenous, and sclerotherapy).
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