The need for a holistic The need for a holistic aproach to patient care aproach to patient care

in in Chronic Venous DiseaseChronic Venous Disease

Alexandru ANDRITOIU, MD, Alexandru ANDRITOIU, MD, MPhMPh

Emergency Military Hospital Emergency Military Hospital Craiova Craiova

CVD definitionCVD definition• Morphological and functional abnormalities of the

venous system of long duration manifested either by symptoms and/or signs indicating the need for investigation and/or care.

• It is caused by venous valvular incompetence with or without associated venous outflow

obstruction, which may affect the superficial venous system, the deep venous system, or both.

• Venous dysfunction may result from either a congenital or an acquired disorder.

• CVD is the consequence of venous hypertension.

Eklof B, Perrin M, Delis KT, et al. Updated terminology of chronic venous disorders:the Vein Term Transatlantic interdisciplinary Consensus Document. J Vasc Surg. 2009;49:498-501.

Venous anatomic segment classification

Superficial and perforating Superficial and perforating veinsveins

Anatomical distribution of venous Anatomical distribution of venous systemsystem

1. Tegument2. Fascia superficiala3. Fascia musculara4. Compartimentul profund5. Compartimentul v. safene (interfascial)6. Compartimentul subcutanat (vv colaterale sau tributare)

Venous haemodynamicsVenous haemodynamics

• About 75% of circulating blood in the body is moving through the venous system.

• Understanding the mechanisms by which venous return to the heart is crucial to understanding the physiology of the vascular system.

Physiology of venous blood Physiology of venous blood flowflow

Venous retourn from legs is governed by

• Arterial pressure• Calf musculovenous pump• Gravity• Thoracic pump• Valves in veins

Pathophysiology of CVIPathophysiology of CVI

• Muscle pump failure (primary)• Venous obstruction• Venous valvular incompetence1. perforator incompetence2. superf veins incompetence3. deep vein incompetence

Phlebology 2008;23:85–98

John BERGAN, MDThe Vein Institute of La JollaDepartment of SurgeryUCSD School of Medicine La Jolla, CA, USA

MEDICOGRAPHIA, VOL 30, No. 2, 2008

Types of valvesTypes of valves

A). unicuspid B) bicuspid C) tricuspid D) quaricuspid

Classification of valvular lesions• Functional valve lesions (type I)• Traumatic organic valve lesions (type II)• Inflammatory organic lesions (type III)• Valvular vestiges (type IV)

Venous valvesVenous valves

Normal vein Varicose vein

VVenoenouuss Reflux Reflux

Valvular incompetence- Valsalva maneuver- Calf compression

Competent VeinCompetent Vein

Start Valsalva End Valsalva

Competent vein

Symptomatic varicose Symptomatic varicose veinsveins

• pain• aching• discomfort • swelling• heaviness• itching that are thought to be due to the effects of

superficial venous reflux and for which no other more likely cause is apparent.

MEDICOGRAPHIA, Vol 33, No. 3, 2011

Guidelines Guidelines

The ,,common language,,The ,,common language,,1994). The American Venous Forum (AVF) has created

the CEAP (Clinical-Etiological-Anatomical-Pathophysiological) classification.

1998). REVAS (REcurrence after VAricose vein Surgery) 2000). The Venous Clinical Severity Score (VCSS)2004). Several consensus documents from the Union

Internationale de Phlébologie (UIP) led to the revision of the CEAP classification system.

2009). The latest update of terminology for CVD-VEINTERM consensus document.

All these efforts have led to the creation of a common language in CVD, which is essential for the

establishment of clinical practice guidelines.

Medicographia. 2011;33:245-252

VEIN-TERMVEIN-TERMChronic venous disordersChronic venous diseaseChronic venous insufficiency (C3*-C6):Venous symptomsVenous aneurysm

Venous valvular incompetenceVenous reflux (primary, secondary)Axial reflux (superficial, deep, combined)Segmental reflux

Eklöf B, Perrin M, Delis KT, Rutherford RB, Gloviczki P. Updated terminology of chronic venous disorders: The VEIN-TERM transatlantic interdisciplinary consensus document. J Vasc Surg. 2009:49:498-501

VEIN TERM (contin…)VEIN TERM (contin…)• Perforator incompetence• Venous occlusion, obstruction• Venous compression• Recanalization

Eklöf B, Perrin M, Delis KT, Rutherford RB, Gloviczki P. Updated terminology of chronic venous disorders: The VEIN-TERM transatlantic interdisciplinary consensus document. J Vasc Surg. 2009:49:498-501

VEIN TERM (surgery)VEIN TERM (surgery)• High ligation and division• Stripping• Venous ablation• Perforating vein interruption-ligation-

ablation• Miniphlebectomy• Sclerotherapy• Endophlebectomy

Eklöf B, Perrin M, Delis KT, Rutherford RB, Gloviczki P. Updated terminology of chronic venous disorders: The VEIN-TERM transatlantic interdisciplinary consensus document. J Vasc Surg. 2009:49:498-501

CEAPCEAP

Telangiectasias (C1)Telangiectasias (C1)

• Confluence of dilated intradermal venules less than 1 mm in caliber.

• Synonym-spider veins.

Corona phlebectaticaCorona phlebectatica

Fan-shaped pattern of numerous small intradermal veins on medial or lateral aspects of ankle and foot.

Varicose veins (C2)Varicose veins (C2)

Subcutaneous dilated vein 3 mm in diameter or larger, measured in upright position, may involve saphenous veins, saphenous tributaries, or nonsaphenous superficial leg veins.

Edema (C3)Edema (C3) Perceptible increase in

volume of fluid in skin and subcutaneous tissue, which is characteristically indented with pressure.

Venous edema usually occurs in the ankle region, but may extend to the leg and foot.

PigmentationPigmentation

Brownish darkening of skin, resulting from extravasated blood.

Usually occurs in the ankle region, but may extend to the leg and foot

LipodermatosclerosisLipodermatosclerosis

LDS is a localized chronic inflammation and fibrosis of the skin and subcutaneous tissues of the lower leg, sometimes associated with scarring or contracture of the Achilles tendon.

LDS is a sign of severe CVD

White atrophy (C4b)White atrophy (C4b)

Localized, often circular whitish and atrophic skin areas surrounded by dilated capillaries and sometimes hyperpigmentation.

Sign of severe CVD, and not to be confused with healed ulcer scars.

Venous eczema and Venous eczema and ulcerationulceration

Healed ulcer (C5)Healed ulcer (C5)

Active venous ulcer (C6)Active venous ulcer (C6)

Full-thickness defect of skin, most frequently in the ankle region, that fails to heal spontaneously and is sustained by CVD

Degree of CVIDegree of CVI

Varicosity – Progression to be Varicosity – Progression to be observedobserved

The Team involved in The Team involved in CVDCVD

• GP• Surgery/vascular surgery• Radiologyt (CDUS, venography)• Interventional radiology• Cardiology• Dermatologyy• Angiology-Phlebology

Vascular serviceVascular service

NICE Guideline 2013

Diagnosis of CVDDiagnosis of CVD• Physical exam.Physical exam.• Noninvasive TestingNoninvasive TestingVenous DupplexPhotoplethysmographyAirplethysmographyCT-MRI Venography• Invasive TestingInvasive TestingContrast VenographyIntravascular US Ambulatory venous pressure (AVP)

Circulation 2005;111:2398-2409

VenographyVenography

Functional venous Functional venous diagnosis:diagnosis:

Ambulatory venous Ambulatory venous pressurespressures

Venous Insufficiency, Venous Insufficiency, RefluxReflux

J Vasc Surg 2005;41:645-51

Patterns of SSV refluxPatterns of SSV reflux

Engelhorn C et al. J Vasc Surg 2005;41:645-51

Treatment of CVDTreatment of CVD

•Conservative•Interventional•Surgical

Circulation. 2005;111:2398-2409

Conservative TreatmentConservative Treatment

• compression• wound and skin care• pharmacological (venoactive drugs)• exercise• loss weight

Elastic compression Elastic compression stockingstocking

• Reduces symptoms of aching, fatigue, pain,and swelling

• Increases fibrinolytic activity

• Mainstay of treatment for venous ulcers

Must be graduated

What degree of compression – What degree of compression – When?When?

Classification of theClassification of the main venoactive drugs main venoactive drugs

Nicolaides et al. Int Angiol. 2008;27:1-59.

InterventionalInterventional

• Sclerotherapy (chemical ablation)• Ablative therapy (cold, heat) -RF, laser, steam• Endovascular (stent)

Guided by CDUS

Sclerotherapy of Sclerotherapy of Telangiectasias:Telangiectasias:

TechniqueTechnique

damage to endothelium leads to fibrosis of vein

Ultrasound-guided Ultrasound-guided sclerotherapysclerotherapy

foamed solutions

Foam sclerotherapy

Compression after sclerotherapy improves results (less thrombus formation, fewer inflammatory reactions, less pigmentation)

Washout Foam Washout Foam sclerotherapysclerotherapy

Dr. Khalil Fattah-60,000 sclerotherapy sessions experience 

The foam sclerotherapy is associated with risk of DVT, pulmonary embolism, distant side effects such as vision disturbances and vascular headaches, etc. By removing the injected foam, as suggested by Dr. Khalil Fattahi, side effects can be minimized and treatment can be more selective in choosing the exact segment and extent of varicose veins to be treated by foam sclerotherapy (smart Foam Sclerotherapy).

Vein Specialty Medical Vein Specialty Medical ClinicClinic

Campbell, CACampbell, CA

Dr. Khalil Fattah colection 

RF-ablationRF-ablationThe Venefit procedureThe Venefit procedure

Radiofrequency ablationRadiofrequency ablation

Closure FAST™ Catheter. The circular heating element of the catheter measures 7 cm in length which

makes it possible to treat an equivalent length of vein in a few seconds.

GSV Ablation by LaserGSV Ablation by Laser

Pre-Treatment Post-Pre-Treatment Post-TreatmentTreatment

René MILLERETVein Center

Clinique Pasteur3 Rue Pasteur

34120 PézenasFrance

Phlebolymphology. 2011;19(4):174-181

Obliteration of Varicose Veins with Superheated Steam

VenaSeal Sapheon Closure SystemVenaSeal Sapheon Closure System

Cyanoacrylate

SurgicalSurgical• Ligation• Stripping• Miniphlebectomy• Subfascial Endoscopic Perforator

Surgery• Valve Reconstruction

Ligation & stripping Ligation & stripping techniquetechnique

Surgical Treatment of VaricoseSurgical Treatment of VaricoseVeins: PhlebectomyVeins: Phlebectomy

The CHIVA procedureThe CHIVA procedure hemodynamic preservation in venous

insufficiency in ambulatory practice• Is designed to create new hemodynamic

conditions by dividing the pressure column in the varicose veins by disconnecting some venous anastomoses and by redirecting the reflux from the diseased superficial veins into the deep venous system

• The incompetent saphenous trunk is left in place

1988-Franceschi (France)

C ConservatriceH HemodinamiqueI InssufisanceV VeinoseA Ambulatoire

CIVA methodCIVA method

The ASVAL TechniqueThe ASVAL Technique

The ASVAL method recommends preserving the great saphenous vein, unless there is a serious terminal valve insufficiency, and suggests the surgical removal of the superficial varicose reservoir as a primary treatment.

Pittaluga P, Marionneau N, Creton D et al. Traitement chirurgical des varices des membres inferierus: approche moderne. Phlebologie 2004; 57:301–307.

Pittaluga P, Rea B, Barbe R. Methode ASVAL (Ablation Selective des Varices sous Anesthesie Locale): principes et resultats preliminaries. Phlebologie 2005; 2:175–181.

Ablation Selective des Varices sous Anesthesie Locale

A AblationS SelectiveV VaricesA AnestesieL Locale

The endovenous ASVAL method is feasible and has very good technical success rates and clinical results for treating varicose vein disease in patients with segmental GSV reflux and a competent terminal valve.

Subfascial endoscopic perforator Subfascial endoscopic perforator surgerysurgery

The perforating vein The perforating vein after sectioning between the 2 clips

Valvular reconstructionValvular reconstruction• The principle consists in restoring

valvular competence by using different procedures to eliminate reflux through these valves: valvular repair (L. Corcos, Italy 1997), and exo-stent repair of the junction to reduce the diameter of the vein (S. Camilli, Italy 2002, J.R. Lane, Australia 2002).

Venous valvuloplastyVenous valvuloplasty

• Internal valvuloplasy• External valvuloplasty

Internal valvuloplastyInternal valvuloplasty

External valvuloplastyExternal valvuloplasty

 the placement of sutures decreases the diameter of the venous wall but keeps the valve cusps from harm’s way. The sutures lie outside the vein lumen in this

approach.

External valvular External valvular stentingstenting

PRP-External PRP-External valvuloplastyvalvuloplasty

PRP in venous ulcerPRP in venous ulcer

(a) a patient of venous ulcer of duration 3 months, (b) after one sitting of platelet rich plasma, (c) ulcer at 4th week and (d) ulcer being healed at 6th week

J Cutan Aesthet Surg. 2013;6(2): 97–99

Echipa Sp. Clinic Militar CraiovaDr Silosi CristianDr Alexandru AndritoiuAblatia prin RF a vv safene

Reporter: Ați afirmat că Angio-Center (Tg. Mures) este un centru unic la nivel național pentru soluțiile aduse bolilor vasculare periferice. Despre ce este vorba?Conf. Dr. Puskás Attila: Este vorba despre o viziune holistică pe domeniul vascular, pentru că această categorie de bolnavi sunt lăsați undeva la periferia actului medical, şi  nu numai în țara noastră.

28 oct 2014Medic primar Medicina interna

Masterat Angiologie-Milano

Societatea Română de Angiologie și Chirurgie Vasculară (SRACV), după 25 de ani de la înființarea sa oficială și 10 manifestări știinţifice organizate, continuă să reprezinte o societate științifică de interes general, cu caracter științific și educațional.

The need for Vein Care The need for Vein Care CentersCenters

• Phlebology/Angiology: a distinct medical speciality

• The need for Interventional Phlebology • The role of the Team (holistic aproach)• The need for combination therapies at

the same patient