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Chronic Venous Insufficiency, Varicose Veins, Lymphedema, and Arteriovenous Fistulas

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Chronic Venous Insufficiency, Varicose Veins, Lymphedema, and Arteriovenous Fistulas 10 Chronic Venous Insufficiency, Varicose Veins, Lymphedema, and Arteriovenous Fistulas Andrew W. Bradbury and Peter J. Pappas Chronic Venous Insufficiency venous ulceration (CVU) are 30% to 50%, 5% to 10%, and 1% to 2%, respectively. The bulk of Chronic venous insufficiency (CVI) may be advanced disease affects the elderly, with up to defined as symptom or signs of ambulatory 5% of women over the age of 65 years having a venous hypertension. In developed countries, history of CVU. However, up to 50% of affected CVI affects up to half of the adult population. patients, especially men, develop their ulcer Furthermore, the treatment of CVI consumes before their 50th birthday. Women often relate up to 2% of total health spending and is a major the development of VVs to pregnancy and child- cause of lost economic productivity. These birth. The increase in female sex hormones and startling data, coupled with the ineffectiveness blood volume during the first trimester may be of current treatment modalities in many of the responsible. However, there is little evidence of most severely affected patients, underscore the an association with (multi)parity, and men and need for more research. women appear to be affected almost equally by CVI. The excess of women observed in clinical practice is mainly due to their longevity and the Classification reluctance of men to seek medical attention. There is no clear evidence that low socioeco- Chronic venous insufficiency has proved nomic class predisposes to CVI, although CVU difficult to classify for the purposes of scientific healing and recurrence rates may be worse. reporting. This has obfuscated attempts to Clinical experience suggests that occupations directly compare the findings of different epi- involving prolonged standing are associated demiological, pathophysiological, and clinical with an increased prevalence and severity of studies. The clinical, etiological, anatomical, and CVI, poor ulcer healing, and increased recur- pathophysiological (CEAP) classification, pro- rence rates. Data on the relationships between posed in 1994 by the American Venous Forum, physical activity and CVI are conflicting, but it is now the most widely accepted system seems reasonable to assume that an individual (Table 10.1). with a well-developed calf muscle pump is less likely to develop CVI. Although a consistent Epidemiology relationship between weight and height is lacking,VVs appear to be commoner in tall men In industrialized countries the lifetime risks of and CVU in obese women. Similarly, there is developing varicose veins (VVs), skin changes growing evidence of a hereditary predisposition (corona phlebectatica, lipodermatosclerosis, to CVI. For example, patients whose parents varicose eczema, atrophie blanche), and chronic both have VVs have a 90% chance of developing 105 106 VASCULAR SURGERY Table 10.1. Clinical, etiological, anatomic, and saphenous vein (LSV) and short saphenous pathophysiological (CEAP) classification vein (SSV) and their tributaries. As there are Clinical1 numerous communications between the long Class 0 No visible or palpable signs of venous and short saphenous systems, and between the disease superficial and deep systems through junctional Class 1 Telangiectasia2 or reticular veins3 and nonjunctional perforators, these three ele- 4 Class 2 Varicose veins ments are highly interdependent, both anatom- Class 3 Edema ically and functionally, in health and in disease. Class 4 Skin changes (lipodermatosclerosis, Most of the blood draining into the superficial atrophie blanche, eczema) Class 5 Healed ulceration veins from skin and subcutaneous tissues Class 6 Active ulceration immediately enters the deep venous system via perforators in the foot, calf, and thigh. In healthy Etiological subjects, less that 10% of the total venous return EC Congenital (may be present at birth or from the lower limb passes through the LSV and recognized later) E Primary (with undetermined cause) SSV to the saphenofemoral junction (SFJ) and P saphenopopliteal junction (SPJ), respectively. ES Secondary (with known cause): postthrombotic, posttraumatic, Blood is forced back up the leg during leg other muscle systole, and prevented from flowing back down the leg under the influence of gravity Anatomical 5 during diastole, through the actions of the AS Superficial veins (numbered 1 to 5) 6 muscle pumps and closure of venous valves, AD Deep veins (numbered 6 to 16) AP Perforating veins (numbered 17 and respectively. The act of walking sequentially 18) compresses venous sinuses in the sole of the foot, the calf (soleus, gastrocnemius), and to a Pathophysiological P Reflux lesser extent the thigh and buttock. During R relaxation these sinuses fill from the deep and PO Obstruction PR,O Both superficial venous systems and valves close in the superficial and axial veins to prevent reverse 1 Supplemented with (A) for asymptomatic or (S) for symptomatic, flow (reflux). In both the superficial and deep e.g., C6,A. systems, the density of valves is greatest in the 2 Intradermal venules up to 1mm in diameter. 3 Subdermal, nonpalpable venules up to 4mm. calf and gradually diminishes in the thigh. The 4 Palpable subdermal veins usually larger than 4mm. iliac veins and inferior vena cava are frequently 5 Telangiectasia/reticular veins (1); greater (long) saphenous vein devoid of valves. above (2) below (3) knee; lesser (short) saphenous vein (4); non- When standing completely motionless, with saphenous (5). all the leg muscles relaxed, the venous valve 6 Inferior vena cava (6); common (7), internal (8), external (9) iliac; pelvic (10); common (11), deep (12), superficial (13) femoral; leaflets come to lie in a neutral midposition. As popliteal (14); crural (15); muscular (16). a result, the venous pressure in the dorsal foot veins comes to represent the hydrostatic pres- sure exerted by the unbroken column of venous blood stretching up from the foot to the right atrium (approximately 90 to 100mmHg in a VVs,and CVU patients have a higher prevalence person of average height). Contraction of the leg of inherited thrombophilia (TP). The influence muscles immediately leads to the compression of race and ethnicity is unclear, as there are few of deep veins and sinuses and to the movement reliable data from nonwhite populations. of venous blood cranially. Retrograde blood flow is terminated by valve closure, and perfo- Normal Venous Function rators that allow unidirectional flow from the superficial to the deep venous system only. Venous blood from the lower limbs returns to Conventionally, this has also been ascribed to the right heart against gravity through the deep the closure of valves within the perforators. and superficial venous systems. The deep veins However, several studies have shown that many follow the named arteries and are often paired. perforators are devoid of valves. Instead, The superficial system comprises the long outward flow through perforators may be 107 CHRONIC VENOUS INSUFFICIENCY,VARICOSE VEINS, LYMPHEDEMA,AND ARTERIOVENOUS FISTULAS limited by external compression from contract- and reflux. As the vein dilates, the tension ing muscle and a pinch-cock mechanism involv- in the wall increases according to the law of ing the deep fascia. The importance of these Laplace, which leads to further dilatation. mechanisms is that the very high pressures The end result is an incompetent,elongated (up to 200mmHg) generated within the calf and tortuous varicose vein. Primary valvu- muscle pump are used exclusively to propel lar incompetence may also affect the deep blood back up the leg against gravity, and are venous system. not transmitted to the superficial or distal deep Postthrombotic syndrome (PTS): Approxi- systems. When the muscle pump relaxes, the mately 25% of CVU patients have a clear previously expelled venous blood tends to flow history of deep venous thrombosis (DVT), caudally under gravity but is prevented from and many more have probably suffered a doing so by valve closure. This has the effect of subclinical or undiagnosed thrombosis. dividing a single long (and heavy) column of Deep venous thrombosis leads to endothe- blood into a series of shorter columns lying lial hypoxia, valvular destruction, and between closed valves. The pressure within each mural inflammation. Even though most of these segments is low and the ambulatory DVTs recanalize, the end result is a thick- venous pressure (AVP) in the dorsal foot veins ened, valveless tube that permits gross falls typically to <25mmHg. During muscle reflux and poses an anatomical (narrow- pump diastole, blood in the superficial system ing, fibrous webs) and functional (lack flows in to the deep system along a pressure of compliance) obstruction to venous gradient. outflow. Obstruction leads to the formation of collateral pathways. For example, blood may be forced out of the calf via perfora- Pathophysiology tors into the superficial venous system and There are three basic mechanisms that lead to thence up the leg with the formation of raised AVP and the symptoms and signs of CVI: secondary VVs. Removal of such VVs (1) muscle pump dysfunction, (2) valvular increases AVP. Most patients with severe reflux, and (3) venous obstruction. and intractable CVU have PTS. Aging, general debility, and a wide range of musculoskeletal or neurological lower limb Clinical Assessment pathologies can impair calf muscle pump func- tion. The “fixed” ankle secondary to arthritis or History trauma is a common example. Muscle bulk and Inquiry should be made as to the duration of the tone are also important factors in the mainte- present ulcer as well as the duration of ulcer nance of perforator competence (see above). disease, the number of episodes, and any pre- Failure of perforator competence leads to calf cipitating factors (Table 10.2). Previous treat- pump inefficiency (akin to mitral regurgita- ment history and contact allergies are recorded. tion), as well as the transmission of high pres- Peripheral artery disease (20%), diabetes melli- sures directly to the skin of the gaiter area. tus (5%), and rheumatoid arthritis (8%) often Reflux is present in more than 90% of patients coexist.
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