The Official Journal of Center for Vein Restoration Part 1 Lower Extremity Venous Insufficiency ...................................................................... Page 1-3, 8-9 Wellness Today ............................................................................................................... Page 4 Vol. 8, Issue 2 Q&A’s ............................................................................................................................. Page 5 June 2015 Stronger Together ........................................................................................................... Page 6 Community Outreach........................................................................................................ Page 7 inside this issue Your Career Journey ........................................................................................................ Page 10 Our Physicians & Locations .............................................................................................. Page 11 Lower extremity venous insufficiency MUST be evaluated and treated as a part of ‘Infra-diaphragmatic venous disease’. ‘A FIVE PART SERIES’ By Sanjiv Lakhanpal, MD, FACS Summary: Our venous system from toes to the right atrium is one continuous system of fancy pipes with anatomic and physiological enhancements to facilitate venous return to the heart. Compartmentalizing the evaluation of this one single system of veins only makes sense for lower grades (CEAP 0-1) of venous insufficiency in the legs. For higher grades (CEAP 2-6) of venous insufficiency it is essential to evaluate the entire infra-diaphragmatic venous system. In this five part review I will lay out the compelling case for such clinical evaluation and for appropriate treatment tailored to the needs of the individual patient if the need is substantiated by a more detailed diagnostic workup. This review will be broken down into the following parts: Editor-in-Chief, President & CEO, Center for Vein Restoration Sanjiv Lakhanpal, MD, FACS Part I: The anatomic logic Part III: Pathologic Part V: Treatment of for evaluation of the entire conditions leading to Infra-diaphragmatic infra-diaphragmatic venous post-ambulatory venous venous insufficiency, system in patients with hypertension in the lower venous diseases of the advanced lower extremity extremities. lower extremity and Pelvic venous disease. Congestion syndrome. Part IV: Diagnosis of Part II: The physiologic logic Infra-diaphragmatic Associate Editor, for evaluation of the entire venous insufficiency, Director of Research Director of Vascular Labs infra-diaphragmatic venous venous diseases of the Shekeeb Sufian, MD, FACS system in patients with lower extremity and Pelvic advanced lower extremity Congestion syndrome. Managing Editor • Kathleen A. Hart ISSN 2159-4767 (Print), ISSN 2159-4775 (Online) venous disease. Continued on Page 2 Copyright © 2015 Center for Vein Restoration. All rights reserved. Lower extremity venous insufficiency MUST be evaluated and treated as a part of ‘Infra-diaphragmatic venous disease’. Part I: THE ANatOMIC LOGIC. Small Saphenous Vein Superficial venous system of the lower extremity: The (SSV) begins as the lateral continuation of the The skin and the dorsal venous arch. It may drain completely into the popliteal vein, have subcutaneous tissues are drained by the great and the small saphenous a small extension that continues cranially as the cranial extension, or the veins. Both the GSV and the SSV start from the medial and lateral entire SSV may continue cranially to drain into the femoral vein or the GSV. extensions of the dorsal venous arch respectively. The intersaphenous vein starts below the facia and then penetrates the fascia to come superficial to it, the intersaphenous vein is seen in 2/3rds of the limbs with venous disease. SSV valves; More numerous (median 7-10) Range 4-13. Highest valve is close to the termination of the SSV. Valves in a SSV GSV connections directs flow from from SSV to GSV. Image 001 The Great Saphenous Vein (GSV) begins just anterior to the medial ankle, ascends medial to the knee ascending along the medial side of the thigh and enters the fossa ovalis 3 cms. inferior and three cms. lateral to the pubic tubercle. It is duplicated in the calf in 25% and in the thigh in 8%. Image 003 Tributaries of the GSV include: Posterior accessory GSV of the leg (>75%)– joins the GSV distal to the knee, begins posterior to the medial malleolus, Like the rest of our body, the lower extremity is drained by a system of anterior accessory GSV of the leg, Posterior accessory GSV of the thigh superficial and deep veins. ‘Classic’ superficial veins lie superficial to and anterior accessory GSV of the thigh. GSV usually has at least 6 valves the deep (muscular) fascia. The perforator veins, as the name implies, (14-25), with a constant valve between 2-3 cms from the SFJ(85%). The perforate the deep fascia to connect the superficial veins to the deep frequency of valves is greater below the knee. veins. Varicosities invariably lie superficial to the superficial (saphenous fascia - GSV, membranous layer - SSV) fascia, free of any fascial restraints. Reticular veins lie in the sub-dermal connective tissue and the so-called pin veins or spider veins are caused by the dilatation of the dermal plexus of veins. Saphenous fascia is an additional layer of fascia which encapsulates the great saphenous vein. The great and the small saphenous veins are interfascial veins. Image 004 Image 002 (800) FIX-LEGS www.centerforvein.com 2 Lower extremity venous insufficiency MUST be evaluated and treated as a part of ‘Infra-diaphragmatic venous disease’. Continued from Page 2 The deep veins in general follow the corresponding arteries. The deep plantar venous arch from around the heads of the metatarsals continues as the medial and lateral plantar veins, which both become the posterior tibial veins behind the medial ankle. In over 80% of the samples they are paired and in about 10% they are triplicate. They perforate the soleus muscle close to its bony arcade and continue as the popliteal vein. The peroneal veins originate in the distal third of the calf. The peroneal receives the large soleal veins. The peroneal and the posterior tibial have constant connections in the distal leg. The peroneal and the posterior tibial form the TP trunk which then joins the popliteal. On the dorsum of the foot the major deep veins continue as the dorsalis pedis veins. The anterior tibial veins ascend in the anterior compartment. The popliteal vein is formed by Image 005 the confluence of the calf veins. The popliteal and the femoral veins run around the arteries of the same name. The femoral vein is the continuation of the popliteal vein. The deep femoral vein usually communicates with the popliteal vein either directly or through tributaries. The deep veins of the lower extremity: Tibial veins (deep venous system) The sapheno femoral junction and communications with the superficial form by the confluence of the medial and lateral planter veins while on the veins of the lower extremity and the pelvic/abdominal veins: dorsum of the foot the major deep veins continue as the dorsalis pedis vein. The tributaries of the GSV, namely the superficial circumflex iliac vein, the superficial external pudendal vein and the superficial epigastric vein, communicate freely with the deep veins with similar names that drain into the External iliac vein. Image 006 Image 009 Image 010 Image 008 (800) FIX-LEGS www.centerforvein.com 3 WELLNESS Today What is Pelvic Congestion Syndrome? By: Vinay Satwah DO, FACOI, RPVI Many women with Pelvic Congestion Syndrome spend years trying to get an answer as to why they have this chronic pelvic pain. Pelvic Congestion Syndrome is an under-diagnosed condition which is associated with venous disease in the pelvic area, lower abdomen and thighs. Often accompanied by chronic pelvic pain and/or pressure, it is estimated that this condition affects more than one third of all women. Sometimes suffering with this VENOGRAM: THE MOST ACCURATE TEST condition for years, many of these women are told the problem is not due to a specific medical cause and may be “all in their FOR DIAGNOSIS head.” However, recent advancements have allowed physicians Many women with Pelvic Congestion Syndrome spend years at Center for Vein Restoration to show that the pelvic pain may trying to get an answer to why they have this chronic pelvic be due to varicose vein reflux causing pelvic venous insufficiency. pain. Living with chronic pelvic pain is difficult and affects not only the woman directly, but also her interactions with her family, PAINFUL SYMPTOMS CAN friends, and her general outlook on life. Our patients will undergo INTERRUPT DAILY ACTIVITIES a thorough history and physical. Those with a high suspicion may undergo pelvic ultrasound and venography. Thought to be the The symptoms related to Pelvic Congestion Syndrome include most accurate method for diagnosis, a venogram is performed pelvic pain associated with standing and sitting, which worsens by injecting contrast dye in the veins of the pelvic organs to make throughout the day. This chronic pain is typically dull and aching them visible during an X-ray. in nature. Patients often experience relief from pain when lying flat and when legs are elevated. The symptoms may worsen following Once a diagnosis is made by a Center for Vein Restoration intercourse, during menstrual periods, and during pregnancy. physician, if the patient is symptomatic, a pelvic