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Chronic Venous Insufficiency: Novel Management Strategies for an Under-Diagnosed Disease Process

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Chronic Venous Insufficiency: Novel Management Strategies for an Under-Diagnosed Disease Process THROMBOEMBOLIC DISEASE Chronic Venous Insufficiency: Novel Management Strategies for an Under-diagnosed Disease Process OMAR N. HYDER, MD; PETER A. SOUKAS, MD, FACC, FSVM, FSCAI, FACP ABSTRACT depends on patency of the venous system as well as proper Chronic venous insufficiency is an often-missed diagnosis functioning of a series of 1-way bicuspid valves. In addition, that results in a variety of clinical manifestations that lower extremity muscular function must be adequate in may severely compromise quality of life. Prompt recog- order to ensure central venous return. When the venous sys- nition is important to provide symptomatic relief and tem is functioning correctly, every movement of the lower prevent disease progression. Most patients can be treat- extremity moves blood inward and upward past competent ed with a comprehensive plan of conservative measures. valves that ensure that the hydrostatic pressure is near zero. However, it is important for providers to recognize those In patients with venous insufficiency, incompetent valves patients who require referral to a vascular specialist for remain in an open configuration, resulting in an unbro- more invasive therapies. Over the past 2 decades, a vari- ken column of blood from head to foot with a subsequent ety of endovenous strategies have demonstrated effective high hydrostatic pressure. and lasting results in treatment of severe symptomatic Failure of superficial venous valves occurs most commonly venous insufficiency. from weak vein walls that dilate under normal venous pres- KEYWORDS: Venous insufficiency, venous ulcer, sures, resulting in secondary valve failure. In addition, direct radiofrequency ablation, endovenous laser therapy, injury from superficial phlebitis, as well as congenital abnor- phlebectomy malities, can result in primary valve failure. Finally, normal valves can be excessively distensible under the influence of hormones as in pregnancy. The common pathway of these states leads to an inability to prevent backflow and venous pooling. BACKGROUND The CEAP classification (Figure 1) is commonly utilized Chronic venous disease is often underdiagnosed and conse- to reliably and reproducibly grade severity of venous insuffi- quently undertreated in a variety of healthcare settings. An ciency. Furthermore, therapy can be tailored to the severity estimated 25 million Americans are affected by some degree of venous insufficiency. of chronic venous insufficiency. Manifestations of chronic venous disease range from asymptomatic varicose veins in Figure 1. CEAP classification 30% of screened individuals, to more advanced disease in Clinical C – No clinical signs 10% of patients1. Varicose veins have an estimated preva- 0 C – Small varicose veins lence of 5-30% in adults with a female-to-male preponder- 1 C – Large varicose veins ance of 3:12. Non-healing and healed venous ulcers occur in 2 C – Edema approximately 1% of the US adult population3. Risk factors 3 C – Skin changes without ulceration associated with chronic venous disease including increasing 4 C – Skin changes with healed ulceration age, female gender, family history of venous insufficiency, 5 C – Skin changes with active ulceration obesity, pregnancy and prior leg injury or surgery. Further- 6 more, occupations that require prolonged standing predispose Etiology Ec – Congenital individuals to development of chronic venous insufficiency. EP – Primary Disability secondary to severe venous ulcers results in 2 ES – Secondary million workdays lost. Moreover, an estimated $1 billion are 5 spent annually in the treatment of chronic venous ulcers . Anatomy AS – Superficial The superficial venous system above the muscular fascial AD – Deep layer is composed of the great saphenous vein (GSV), the AP – Perforating small saphenous vein (SSV) as well as several accessory veins. Pathophysiology P – Reflux Along with the superficial venous system, the deep venous R P – Obstruction system and perforating veins serve as both a reservoir and O conduit to return blood to the heart. Normal venous return WWW.RIMED.ORG | ARCHIVES | MAY WEBPAGE MAY 2017 RHODE ISLAND MEDICAL JOURNAL 37 THROMBOEMBOLIC DISEASE PRESENTATION insufficiency. Graded external compression to the leg Early clinical manifestations of chronic venous insufficiency opposes the hydrostatic pressure that results in venous include the reporting of subjective symptoms. The character- hypertension. The presence of compression grades is essen- istic ache of venous insufficiency comes on after prolonged tial as non-graded ACE wraps and stockings cause a tour- standing and is described as pain, pressure, burning, itching niquet effect that in turn exacerbates venous insufficiency. or heaviness in the affected limb. Importantly, episodic symp- Compliance with 30-50 mmHg compression therapy is suf- toms may occur temporally, related to hormonal changes ficient in the vast majority of patients to alleviate symptoms during pregnancy. Symptoms are alleviated by walking and of chronic venous insufficiency as well as improve mobility. leg elevation unlike in peripheral arterial disease. As the Even in more severe disease, compression therapy has been disease process advances, damage to the capillary basement associated with complete venous ulcer healing at 5 months. membrane results in leg edema. The characteristic appear- The most common compression stocking prescribed is for ance of lipodermatosclerosis results from the breakdown of knee-high garments. A general rule of tension prescription red blood cells and the subsequent deposition of hemosid- that correlates with disease severity would be 20–30 mmHg erin in the skin. In the most advanced cases, non-healing for C2-C3 disease, 30-40 mmHg for C4-C6 and 40–50 mmHg ulcers are noted around the medial malleolus where venous for recurrent ulcers. Stockings should be worn daily and pressure is maximal. Unlike typical arterial ulcers, the removed only at night for maximal benefit. Any compression wound of chronic venous insufficiency is shallow, superfi- garment should be replaced every 6 to 9 months. cial, irregular in shape and associated with painful edema. In addition to compression therapy, calf muscle exercises should be performed as part of any treatment plan. In very small studies, coumarins, flavonoids, saponosides and other DIAGNOSIS plant extracts have demonstrated mild improvement in ede- Venous duplex imaging is the simplest and most commonly ma-related symptoms6,7. However, currently, there are no used technique for establishing the diagnosis of venous pharmacological agents approved in the United States for insufficiency. Furthermore, duplex imaging is usually suf- treatment of chronic venous insufficiency. Although diuret- ficient enough to guide therapy and management. Presence ics are commonly used to treat edema for short periods of of venous reflux is confirmed by determining direction time, it is important to understand that chronic venous of blood flow. This is evaluated by placing the patient in insufficiency is not a state of volume overload. As a result, reverse Trendelenburg position, and assessing blood flow the benefit of temporary relief must be balanced with the direction during a Valsalva maneuver or after augment- metabolic and renal side effects of long-term diuretic usage. ing blood flow with more proximal limb compression. An Interventional therapy of chronic venous insufficiency alternative method requires venous duplex interrogation includes both venous ablation as well as sclerotherapy. Endo- following a rapid cuff inflation-deflation technique while venous ablation involves the application of thermal energy, the patient is standing. The presence of significant reflux is either radiofrequency (RF) or laser (EVLT), to the vein wall determined by the presence of reverse flow towards the feet which in turn leads to thrombosis followed by fibrosis of the for a significant amount of time:> 0.5 seconds for superficial treated segment. In the case of GSV ablation, both RF and veins and > 1.0 seconds for deep veins. A longer duration of EVLT procedures involve ultrasound-guided placement of a reflux corresponds with more severe disease but not neces- 7 Fr sheath in the GSV with subsequent passage of a catheter sarily with clinical manifestations. to the level of the saphenofemoral junction. Radiofrequency Venous duplex imaging is often more than sufficient in ablation of the greater saphenous vein has resulted in suc- diagnosing and managing patients with venous insuffi- cessful venous closure in 85% of patients with a 10% rate ciency. Air plethysmography is utilized occasionally to of recanalization at 2 years8. A very rare complication (< 1%) determine the relative contribution of venous reflux, as of RF is deep-vein thrombosis and subsequent pulmonary opposed to venous obstruction or muscle pump dysfunc- embolism8. Laser treatments have reported rates of closure tion, to the clinical syndrome. Computed tomography (CT) as high as 95% at 2 years with no major complications9. At and magnetic resonance (MR) are rarely utilized to evaluate present venous ablation, by either laser or RF, has a higher venous disease. The utility of advanced imaging modalities rate of success compared to sclerotherapy and lower rate of is mainly to diagnose both intrinsic and extrinsic compres- co-morbidity compared to traditional surgical ligation and sion of the venous system by surrounding structures. Inva- stripping10. Endovenous ablation is performed almost exclu- sive contrast venography is very
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