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VENOUS INSUFFICIENCY

Jessie Stewart
Morning Report
July 09
Vasodilatory Edema
• Biggest culprit drugs are arteriolar smooth
muscle relaxers.
• Minoxidil (7%): opens K channels, preventing
smooth muscle contraction.
• Hydralazine (?%): prevents Ca accumulation,
may protect nitric oxide.
CCB also guilty
• Amlodipine (2-15%, dose related). Blocks
calcium transport.

NEJM Volume 341:1447-1457. November 4, 1999. Calcium-Antagonist Drugs. Darrell R.


Abernethy, M.D., Ph.D., and Janice B. Schwartz, M.D.
Vasodilatory edema caused by:
• 1. Increased intracapillary pressure.
• 2. Activation of the Renin-Angiotensin System
– Can diminish edema by concomitant use of ACE
inhibitor.

Image at: http://www.nature.com/ajh/journal/v21/n1/images/ajh200737i1.jpg


Venous Insufficiency

• 7 million Americans with VI.


• 1 in 1000 with a venous ulcer
• Internists, vascular surgeons, plastic surgeons,
dermatologists.
• $1 billion/ year in USA.
• $40,000 per person
• Veins:
– Hold 75% of the blood
volume
– Are organized into
superficial and deep veins
connected by perforating
veins
– Have valves for
unidirectional flow
– Are low pressure systems
(10-15mmHg)
– Have thin walls (superficial
veins have thicker walls
than deep veins.)
http://www.wsiat.on.ca/english/wsiatDocs/mlo/venous_screen.htm
Venous Insufficiency is…
• Valvular incompetence and venous obstruction.
• Symptoms worsen as more sites are involved.
• Iliac veins as especially susceptible.
– Injured by crossing arteries
• Venous hypertension leads to ?
– Dilation of capillary beds, fibrinogen leak, formation
of a fibrin cuff that then stops delivery oxygen,
nutrients, growth factors.
– WBC entrapment in the capillary wall, setting up an
inflammatory reaction, injuring the vein and valves.
Risk factors?
• Age
• Obesity
• Family history
• Pregnancy
• Female Gender
• Heart failure, hypertension, renal disease
• H/o Leg injury (fx, burn, crush, penetrating
injury), phlebitis, DVT
• Previous varicose vein surgery
• Long hours standing, or sitting.
Symptoms and Signs
• Nocturnal pain, restless legs
• Orthostatic pain
• Edema, Varicosity, Hyperpigmentation, ulceration

http://www.icvein.com/images/signs-of-venous-insufficiency-iowa.jpg
Venous Stasis Dermatitis

http://www.dukehealth.mobi/Services/VeinClinic/About/WhatIsVenousDisease
Stasis Eczema

http://www.scielo.br/scielo.php?script=sci_arttext&pid=S0365-05962006000600002&tlng=en&lng=en&nrm=iso
Corona Phlebectasica

http://www.scielo.br/scielo.php?script=sci_arttext&pid=S0365-05962006000600002&tlng=en&lng=en&nrm=iso
Lipodermatosclerosis (LDS)

Induration, Fibrosis, the shape of an inverted bottle

http://www.scielo.br/scielo.php?script=sci_arttext&pid=S0365-05962006000600002&tlng=en&lng=en&nrm=iso
Venous Ulcer

•Medial Malleolus
•Shallow
•Irregular borders
•Base with granulation tissue
•Surrounding white scar (atrophie blanche)
•Surrounding hemosiderin deposition
•Surrounding Edema
•80% of LE ulcers
•$40,000

Venous Ulcer. A. Khachemoune & C. L. Kauffman : Diagnosis Of Leg Ulcers . The


Internet Journal of Dermatology. 2002 Volume 1 Number 2
Clinical Aspects of the Most Common Types of Ulcers of the Lower Limbs

de Araujo, T. et. al. Ann Intern Med 2003;138:326-334


Arterial Ulcer

http://www.worldwidewounds.com/1997/september/Thomas-
Bandaging/bandage-paper.html
Evaluation
• VI (valvular incompetence, dilated veins)
evaluated by duplex ultrasonograhy.
• AI evaluated by ABI
• Check rest and stress
• 0.9 adequate
• <0.5 severe
• Compressive tx not helpful

http://www.vascularweb.org/graphics/northpoint_graphics_jpg/AortoOccl_03_250_darker.jpg
Duplex ultrasonography
http://www.urgomedical.com/uploaded-files/img/images/schema-ceap-02.jpg
CEAP
• A patient has painful swelling of the leg, and varicose veins,
lipodermatosclerosis, and active ulceration. Duplex
scanning on May 17, 2004, showed axial reflux of the great
saphenous vein above and below the knee, incompetent
calf perforator veins, and axial reflux in the femoral and
popliteal veins. There are no signs of postthrombotic
obstruction.

• Classification according to basic CEAP: C6,S, Ep,As,p,d, Pr.

• Classification according to advanced CEAP: C2,3,4b,6,S,


Ep,As,p,d, Pr2,3,18,13,14 (2004-05-17, L II).

Revision of the CEAP classification for chronic venous disorders: Consensus statement.
Journal of Vascular Surgery Volume 40, Issue 6, December 2004, Pages 1248-1252.
Treatment
• Compression is the cornerstone of treatment.
• At least 40mmHg at the ankle is the goal.
• Range of 10-60mmHg (TED hose 18mmHg)
• Knee-High as good as Thigh-High.
• Open or closed toe per pt preference.
• Either graduated stockings and wraps
• Caution with CHF, invasive infection, arterial
insufficiency.
• Compliance very difficult.
• Replace every 6 months.
• Size S, M, L, XL based on ankle, calf circum.
Compression Therapy is Key!

Unna

Jobst $6
$60
Compression Plus…
• Leg Elevation. Above heart-level for 30
minutes 3 times per day.
• Diuretics. May help but can’t do much alone.
• Pentoxifylline. May improve oxygen delivery,
inhibit WBC activation. Shown to accelerate
ulcer healing. 400-800mg tid.
• Aspirin may help some.
Surgical Treatment
• UNC Vascular Surgery
– Wound Healing Clinic
– Vein Center

William Marston, MD
Grand Rounds
2/19/09
Other References
• Managing the Patient with Venous Ulcers. Tami de Araujo, MD; Isabel Valencia, MD; Daniel G.
Federman, MD; and Robert S. Kirsner, MD. 18 February 2003 | Volume 138 Issue 4 | Pages
326-334
• State-of-the-Art Treatment of Chronic Venous Disease. Michael S. Weingarten. Clinical
Infectious Diseases, Vol. 32, No. 6 (Mar. 15, 2001), pp. 949-954
• Jull AB, Waters J, Arroll B. Pentoxifylline for treating venous leg ulcers. Cochrane Database
Syst Rev. 2002.
• Wiersema-Bryant LA. Management of edema. In: Sussman C, Bates-Jensen BM, eds. Wound
Care: A Collaborative Practice Manual for Physical Therapists and Nurses. Gaithersburg, MD:
Aspen; 1998:179-200.