Idea Transcript
THE FUNDAMENTALS OF PHLEBOLOGY: Venous Disease for Clinicians Domenic A. Zambuto, M.D.
Domenic A. Zambuto, M.D. Vein Clinics of America, Canton, CT
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What my med school and residency taught me about varicose veins… They’re primarily cosmetic Treatment options are poor The veins almost always come back You might need them some day for CABG Domenic A. Zambuto, M.D. Vein Clinics of America, Canton, CT
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Lecture Objectives Phlebology
Normal anatomy and physiology Pathophysiology Evaluation
Treatment options Domenic A. Zambuto, M.D. Vein Clinics of America, Canton, CT
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PHLEBOLOGY The medical specialty devoted to the diagnosis and treatment of patients with venous disorders
Domenic A. Zambuto, M.D. Vein Clinics of America, Canton, CT
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Vein Anatomy Telangiectasia
Reticular Vein Superficial Vein
Perforator Vein
Deep Vein Domenic A. Zambuto, M.D. Vein Clinics of America, Canton, CT
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Greater Saphenous Vein • Largest superficial vein -Normally 3-4 mm diam • Contained within thin superficial fascia • Medial foot/calf/thigh • Sapheno-femoral Junction (SFJ)
*
– Confluence of GSV and common femoral vein RA Weiss 2001 Domenic A. Zambuto, M.D. Vein Clinics of America, Canton, CT
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Small Saphenous Vein • Lateral foot & posterior to malleolus • Courses between heads of Gastrocnemius • Termination variable – Popliteal Vein – Vein of Giacomini – Smaller deeper Veins
RA Weiss 2001
Domenic A. Zambuto, M.D. Vein Clinics of America, Canton, CT
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Musculovenous pump • Foot and calf muscles act to squeeze the blood out of the deep veins • One way valves allow only upward and inward flow • During muscle relaxation, blood is drawn inward through perforating veins • Superficial veins act as collecting chamber
Illustration by Linda S. Nye Domenic A. Zambuto, M.D. Vein Clinics of America, Canton, CT
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Venous Valvular Function • Valve leaflets allow unidirectional flow, upward or inward • Dilation of vein wall prevents opposition of valve leaflets, resulting in reflux • Valvular fibrosis, destruction, or agenesis results in reflux
Domenic A. Zambuto, M.D. Vein Clinics of America, Canton, CT
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Venous Insufficiency A. In the normal situation, valves in the vein wall keep blood flowing toward the heart (green arrows). B. When the valves are damaged, blood can flow backwards (red arrows) dilating the vein and pooling in the leg. C.
A
B
C
When the vein is ablated, normal blood flow direction is restored.
http://www.ohsu.edu/dotter/venous_ablation.htm
Domenic A. Zambuto, M.D. Vein Clinics of America, Canton, CT
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REFLUX: its contribution to varicose veins
Illustration by Linda S. Nye
Domenic A. Zambuto, M.D. Vein Clinics of America, Canton, CT
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Pathophysiology: 2 components REFLUX • Dilatation of vein wall leads to valve insufficiency • Monocytes may destroy vein valves • Retrograde flow results in distal venous hypertension
OBSTRUCTION • Thrombosis and subsequent fibrosis obstruct venous outflow • Damage to vein valves may also cause reflux • Both contribute to venous hypertension
The presence of both is far worse than either one alone Domenic A. Zambuto, M.D. Vein Clinics of America, Canton, CT
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AMBULATORY VENOUS HYPERTENSION • The common denominator in the pathophysiology of venous disease • Instead of dropping, the intravenous pressure rises during exercise and is transmitted to more superficial and distal veins • May be due to reflux, obstruction, or both
Domenic A. Zambuto, M.D. Vein Clinics of America, Canton, CT
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Venous symptoms • Reflux and obstruction lead to congestion and dilatation of the vein walls • Symptoms, such as aching, pain, burning, throbbing, tiredness, itching, numbness and heaviness are worse with prolonged standing or sitting, heat, progesterone states such as pregnancy/pre-menses • Symptoms are improved with graduated compression, leg elevation, exercise
Domenic A. Zambuto, M.D. Vein Clinics of America, Canton, CT
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Symptoms and Prevalence
Other Common Symptoms – itching, burning, fatigue and ankle swelling
VCA_07-09-04
Jawien A, Grzela T, and Ochwat A. Prevalence of chronic venous insufficiency in men and women in Poland: multicentre cross-sectional study in 40,095 patients. Phlebology 2003; 18(3): 110-122.
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Physical Exam Findings • • • • • • • • •
Unremarkable Small, medium, large veins Edema Corona Phlebectatica Paraplantaris Hyperpigmentation Dermatitis Lipodermatosclerosis White atrophy Ulcers Domenic A. Zambuto, M.D. Vein Clinics of America, Canton, CT
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Telangiectasias • Also known as “spider veins” due to their appearance • Very common, especially in women • Increase in frequency with age • 85% of patients are symptomatic* • May indicate more extensive venous disease
*Weiss
RA and Weiss MA J Dermatol Surg Oncol. 1990 Apr;16(4):333-6.
Domenic A. Zambuto, M.D. Vein Clinics of America, Canton, CT
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Lateral Subdermic Plexus • Very common, especially in women • Superficial veins with direct perforators to deep system • Remnant of embryonic deep venous system
Domenic A. Zambuto, M.D. Vein Clinics of America, Canton, CT
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Reticular Veins • Enlarged, greenish-blue appearing veins • Frequently associated with clusters of telangiectasias • May be symptomatic, especially in dependent areas of leg
Domenic A. Zambuto, M.D. Vein Clinics of America, Canton, CT
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Varicose Veins – Great Saphenous Distribution • Most common finding in patients with varicose veins • Varicosities most commonly along the medial thigh and calf but cannot assume location indicates origin • At least 20% of patients are at risk of ulceration
Domenic A. Zambuto, M.D. Vein Clinics of America, Canton, CT
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Great Saphenous Insufficiency • Skin changes are seen along the medial aspect of the ankle • The presence of skin changes is a predictor of future ulceration* *Kirsner
R et al. The Clinical Spectrum of Lipodermato-sclerosis, J Am Acad Derm, April 1993;28(4):623-7
Domenic A. Zambuto, M.D. Vein Clinics of America, Canton, CT
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Varicose Veins – Small Saphenous Distribution • Less frequent than Great Saphenous involvement • Varicosities may be seen on the posterior calf and lateral ankle • Skin changes are seen along the lateral ankle
Domenic A. Zambuto, M.D. Vein Clinics of America, Canton, CT
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Varicose Veins with Pelvic Origins • Begin during pregnancy • Increased symptoms during pre-menstrual period and after intercourse • May be associated with pelvic congestion syndrome
Domenic A. Zambuto, M.D. Vein Clinics of America, Canton, CT
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Skin changes suggestive of chronic venous insufficiency
Atrophie blanche (C4b)
Corona Phlebectatica (C1)
Pigmentation (C4a) Healed ulcer (C5) Domenic A. Zambuto, M.D. Vein Clinics of America, Canton, CT
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Venous ulceration
Impending ulceration Lipodermatosclerosis (C4a)
Venous ulceration (C6)
Domenic A. Zambuto, M.D. Vein Clinics of America, Canton, CT
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Venous ulceration • Over 50% of patients have only superficial venous disease; superficial venous disease may be primary factor in 50-85% of patients* •