Venous Stasis
Joon Ho Jang MD
Incidence/Prevelance & JOBST Coverage
• It is estimated that more than 80 million Americans suffer from some form of venous disorder.
• Up to 13 million people in the U.S. suffer from CVI
• Peak incidence occurs in women aged 40-9 and men aged 70-79 years
• Statistics show one in three Americans over the age of 45 is affected by vein disease, and of those, only 4% are
being treated.
• Annual health care cost in the US to treat CVI is about $3billion; about 2 million workdays are lost per year due to venous
ulcers
Varicose Veins
• More than 24 million Americans have varicose veins
• Up to 50% of women have varicose veins while 24% of men aged 30-40 and 43% of men over 70 have varicose veins
DVT / PTS
• There are over 200,000 new cases of DVT each year in the U.S.
• The incidence of pulmonary embolism in patients with DVT ranges from 5 – 20% and can be fatal
• After an episode of DVT, 20 – 50% of patients develop Post Thrombotic Syndrome within the first 2 years
Venous Stasis Ulcers
• Affect 2.5 million people in the U.S.
• An estimated 500,000 persons are newly diagnosed each year
Venous Stasis…How?
• Mechanics
• Structure
• Inflammation
• Pressure
• Obstruction- DVT
Function
• Transport blood back to the
heart
• Prevent intravascular
volume overload
Anatomy
• Tunica intima: endothelium
with BM and elastic lamina
– Produces endothelium
derived relaxing factor and
prostacyclin
• Tunica media:
Circumferential SM
– Maintains venous pressure
gradient
• Tunica externa: Collagen
– Stability
Valves
• Venous valves:
– One way
– Two cusps of CT
skeleton covered by
endothelium
– Closure at > 30cm/s
– Exception: IVC, common
iliacs, portal, cranial
sinus
Lower Extremity
Venous Hypertension
– Hydrostatic pressure vs Mechanical/muscular pressure
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A. K. Tassiopoulos et al.
1153 cases of ulcerated legs and venous disease
Reflux in superficial, deep, and perforating veins
Incompetent valves
Valvular Dysfunction
• Physical damage: splitting, tearing, thinning,
adhesion to wall
• Reduction in number
– Not age related
• Monocyte and macrophage infiltration
– Overexpression of Intracellular adhesion molecules
– Wall hypertrophy, disruption of collagen synthesis,
and destruction of extracellular matrix proteins
Shear Stress and Inflammation
• Pulsatile venous
blood flow
• Valve closes:
Pvortical > Pluminal
– Minimal shear stress
• Low shear stress
starts cascade of
inflammatory
signals
Risk Factors
• Genetic
• More in females
• Hormones
– Progesterone, estrogen
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Pregnancy
Age: >50
Greater height
Prolonged standing
Obesity
Signs and Symptoms
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Telangiectasias
Reticular veins
Varicosity
Thrombophlebitis
Hyperpigmentation
Bleeding from
clusters
• Ulceration
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Aching
Heaviness
Early fatigue
Edema
Itching
Restless legs
Cramps
Physical Exam, Diagnostic Tests
• Palpable veins
• Perthes Test
– For deep venous patency
– Tourniquet and walk
• Brodie-Trendelenburg Test
– For superficial vein and valve patency
– Venous filling time: normal- within 35 secs
• Duplex Ultrasound
• Venography
Classification: CEAP
*Eklof et al. J of Vasc Surg 2004
Clinical classification
• C0: no visible or palpable signs of venous disease
• C1: telangiectasies or reticular veins
• C2: varicose veins
• C3: edema
• C4a: pigmentation or eczema
• C4b: lipodermatosclerosis or atrophie blanche
• C5: healed venous ulcer
• C6: active venous ulcer
• S: symptomatic, including ache, pain, tightness, skin
• irritation, heaviness, and muscle cramps, and other
• complaints attributable to venous dysfunction
• A: asymptomatic
CEAP
Etiologic classification
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Ec: congenital
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Ep: primary
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Es: secondary (post-thrombotic)
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En: no venous cause identified
Anatomic classification
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As: superficial veins
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Ap: perforator veins
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Ad: deep veins
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An: no venous location identified
Pathophysiologic classification
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Basic CEAP
Pr: reflux
Po: obstruction
Pr,o: reflux and obstruction
Pn: no venous pathophysiology identifiable
Treatment
• Compression Therapy
– Stockings, Unna’s Boot
• Drug Therapy
• Surgery
Compression Stockings
• Worn during the day
• Elastic stockings with
adjustments in pressure
• Lower pressure stockings
(20-30mm Hg) for edema
and DVT prophylaxis
• Higher pressure (3040+mm Hg) for ulcers
and significant venous
disease
• Operator dependent
– Difficult to put on
– Physical impediments/Comorbidities
• 50% of patients were
unable to them on alone
• 30-65% noncompliance
noted in clinical trials in
venous centers
Efficacy of Compression Therapy
1. 22 trials comparing healing of venous ulcers using
compression stockings
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Compressive therapy more effective than non-compression
Higher pressure were more effective than lower
Multilayer compression was better than single layer
bandaging
2. 466 patients with a healed ulcer
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Continued use of compression stocking reduced
reoccurrence within 3-5 year
3. ESCHAR study: 500 limb trial that compares
surgery and compression vs. compression alone for
ulcer treatment
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Combination therapy had lower rates of reoccurrence of
ulcer at year 4 (24% vs. 52%)
Drug Therapy
• Pentoxifylline
– PDE4 inhibitor that increases intracellular
cAMP and stimulates protein kinase A activity
– Reduces blood viscosity and decreases
platelet aggregation and thrombus formation
– Variable efficacy
More invasive
• Sclerotherapy
– 0.2% sodium tetradecyl injected directly into
spider angiomas and smaller superficial
varicosities
• Complications (<5%): allergic reaction,
hypo/hyper-pigmentation, local skin necrosis
• Endovenous laser ablation of saphenous
vein (EVLT)
• Surgical excision of veins (“Stripping”)
Efficacy
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Meta-analysis of 64 studies (12,320 legs)
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Anaylzed ablation via Duplex US
Follow upto 5 years
Success rate of EVLT highest after 5 years
Complications: DVT (<3%), local bruising and pain, paresthesias, foam emboli,
stroke
Works Cited
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Raju et al. Chronic venous insufficiency and varicose veins. NEJM 2009;360:231927
Bergan et al. Chronic venous disease. NEJM 2006;355:488-98.
Tassiopoulos et al. Current concepts in chronic venous ulceration. Euro J Vasc
Endovasc Surg 2000;20:227-232.
Ono et al. Monocyte inflitration of venous valves. J Vasc Surg 1998;27:158-66.
Sansilvestri-Morel et al. Imbalance in the synthesis of collagen type I and collagen
type III in smooth muscle cells derived from human varicose veins. J Vasc Res
2001;28:560-8.
Jacob et al. Extracellular matrix remodeling in the vascular wall. Pathol Biol
2001;49:326-32
Eklof et al. Revision of the CEAP classification for chronic venous disorders:
Consensus statement. J Vasc Surg 2004;40:1248-52.
Cullum et al. Copression bandages and stockings for venous leg ulcers. Cochrane
Database Syst Rev 2000;2: CD000265
Mayberry et al. Fifteen-year results of ambulatory compression therapy for chronic
venous ulcers. Surgery 1991;109:575-81.
Barwell et al. Comparison of surgery and compression with compression alone in
chronic venous ulceration (ESCHAR study): randomised controlled trial. Lancet
2004;363:1854-9.
Van den Bos et al. Endovenous therapy of lower extremity varicosities: a metaanalysis/ J Vasc Surg 2009;49:230-9.