Chapter(8(*(The(importance(of(differen4a4ng(leg(edema(from(

venous(insufficiency(versus(that(of(conges4ve(heart(failure(

Ariel(D.(Soffer,(MD,(FACC(Faith(Jaslow,(ARNP(

(

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•  ''This(ac4vity(has(been(planned(and(implemented(in(accordance(with(the(accredita4on(requirements(and(policies(of(the(Accredita4on(Council(for(Con4nuing(Medical(Educa4on((ACCME)(through(the(joint(providership(of(The(University(of(Toledo(and(VeinExperts.org.(

•  The(University(of(Toledo(is(accredited(by(ACCME(to(provide(con4nuing(medical(educa4on(for(physicians.(

•  (The(University(of(Toledo(designates(this(enduring(ac4vity(for(a(maximum(of(1.00(AMA#PRA#Category#Credits™.((Physicians(should(claim(only(credit(commensurate(with(the(extent(of(their(par4cipa4on(in(the(ac4vity.(

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For(nurses,(we(are(also(able(to(issue(a(cer4ficate(of(aZendance(sta4ng(the(course(is(AMA(approved,(which(may(be(eligible(for(credit.((Nurses(are(responsible(for(submi[ng(the(cer4ficate(to(their(board.((Please(note(only(one(cer4ficate(can(be(issued(for(each(purchase.((Disclosures:((Peggy'Bush,'APN,(planning(member,(has(no(disclosures(or(financial(interests(and(is(contracted(by(Water’s(Edge(Dermatology(and(Soffer(Health.('Ronald'Bush,'MD,'FACS,(faculty(and(planning(member(discloses(he(is(on(the(Speaker’s(Bureau(for(Dornier/Refine(USA(and(is(contracted(with(Water’s(Edge(Dermatology(and(Soffer(Health.((Faith'Jaslow,'ARNP,(faculty,(has(not(financial(interest(or(other(rela4onships(with(any(manufacturer(of(commercial(product(or(service(to(disclose.((Richard'L.'Mueller,'MD,(faculty(and(planning(member,(discloses(he(receives(grant/research(support(from(Vascular(Insights,(LLC(Becky'Roberts,(planning(member,(has(no(financial(interest(or(other(rela4onships(with(any(manufacturer(of(commercial(product(or(service(to(disclose(Ariel'Soffer,'MD,(FACC,(faculty(and(planning(member,(discloses(he(is(on(the(Speaker’s(Bureau(for(Cutera(,(consults(for(Angiodynamics,(&(does(research(for(BTG.(

Mission:((Our(objec4ve(is(to(provide(current(evidence(based(informa4on,(as(well(as(new(technology(that(is(being(developed(for(the(treatment(of(venous(disease(presented(in(a(virtual(format.((((Target'Audience:((The(target(audience(for(this(ac4vity(includes(physicians(and(other(health(care(professionals(in(Cardiology,(Dermatology,(Interven4onal(Radiology,(Phlebology,(Surgery,(Vascular(Surgery,(Wound(Care(Specialists(who(care(for(pa4ents(with(venous(disease.((

Steps'to'successfully'complete'this'ac6vity:(CME'Credit'Instruc6ons(Steps'to'successfully'complete'this'ac6vity:(Register(for(CME(ac4vity(&(pay(your(CME(fees.(Read(the(Vein(Journal(Chapter(8,(en4tled(‘The'importance'of'differen6a6ng'leg'edema'from'venous'insufficiency'versus'that'of'conges6ve'heart'failure.’''Take(the(post(test((score(of(80%(or(greater(must(be(achieved.((A(pdf(copy(of(the(exam(can(be(emailed(to(you(if(requested).(Scan(and(email(post(test(and(evalua4on(to((pbush@veinexperts.org(or(you(can(fax(completed(paperwork(to(937*281*0200.((You(will(be(contacted(by(the(University(of(Toledo(CME(office(for(instruc4on(of(how(to(sign(on(and(print(your(cer4ficate.((

Technical(Support(

Email(your(ques4ons/concerns(to(pbush@veinexperts.org((or(you(can(call(us(at(407*900*8346(and(we(will(respond(in(24(hours.((('(

Objec4ves:(

•  Recognize(causes(for(leg(edema(•  Describe(accurate(ways(of(tes4ng(for(leg(edema(to(determine(the(primary(cause(

•  Iden4fy(the(common(causes(of(Venous(Insufficiency(

•  Iden4fy(the(common(causes(of(Conges4ve(Heart(Failure(

•  Recognize(appropriate(treatment(plans(for(conges4ve(heart((failure(vs.(venous(insufficiency(

Edema(–(CHF(vs.(VI(

•  In(the(United(States,(the(most(common(diagnosis(for(hospital(admission(is(Conges4ve(Heart(Failure(or(CHF(

•  One(of(the(most(common(signs(of(CHF(is(leg(swelling((edema)(

•  One(of(the(most(common(circulatory(disorders((albeit(woefully(undiagnosed(at(less(than(10%(of(affected(people(have(been(iden4fied)(is(venous(insufficiency(which(is(commonly(associated(with(edema(

Importance(of(Proper(Diagnosis(

•  Unfortunately(for(clinicians(and(pa4ents(the(treatment(of(these(two(forms(of(edema(are(completely(different,(and(therefore(mistaken(diagnoses(and(treatments(can(be(disastrous(to(our(en4re(health(system((see(Figure(1).(

•  (Thankfully,(the(advances(in(clinical(tools(such(as(Doppler(Ultrasonography(have(made(diagnosis(and(differen4a4on(of(these(disorders(readily(available.(

VENN'DIAGRAM''

• ##The#intersec7on#of#VI#(venous#insufficiency)#and#CHF#(conges7ve#heart#failure)#with#Edema#represents#an#important#and#challenging#area#of#differen7a7on.(• ##The#large#areas#of#Edema#with#VI#alone#(without#any#CHF)#represent#areas#of#medicine#that#have#poten7ally#easily#curable#Edema#and#should#not#be#mistaken#for#the#less#curable#CHF#that#is#treated#completely#differently.((((

Edema(

CHF(VI(

Figure(1(

Primary(Causes(of(Leg(Edema(•  Veins(in(the(legs(are(responsible(for(transpor4ng(blood(up(to(the(

veins(of(the(torso,(where(it(is(then(returned(to(the(heart.(•  The(veins(of(the(legs(have(valves(that(prevent(the(backward(flow(of(

blood(within(them.((•  Venous(insufficiency((VI)(is(incompetence(of(the(veins(that(occurs(

because(of(dila4on,(or(enlargement,(of(the(veins(and(dysfunc4on(of(their(valves.(

•  VI(leads(to(a(backup(of(blood(and(increased(pressure(in(the(veins,(thereby(resul4ng(in(edema(of(the(legs(and(feet(

•  Edema(of(the(legs(also(can(occur(with(an(episode(of(deep(vein(thrombosis((DVT),(which(is(a(blood(clot(within(a(vein(

•  A(clot(in(the(deep(vein(blocks(the(return(of(blood,(and(consequently(causes(increased(back*pressure(in(the(leg(veins(

•  It(is(also(postulated(that(VI(can(be(an(independent(risk(factor(for(DVT,(which(can(be(a(very(dangerous(condi4on(

Con4nua4on(of(Primary(Causes(of(Leg(Edema(

•  VI(is(a(problem(that(is(localized(to(the(legs,(ankles,(and(feet.(One(leg(may(be(more(affected(than(the(other((asymmetrical(edema).((

•  Open(both(legs(are(simultaneously(affected(as(the(underlying(anatomic(pathology(open(is(mimicked(bilaterally.(((

•  In(contrast,(systemic(diseases(that(are(associated(with(fluid(reten4on((most(common(one(being(conges4ve(heart(failure)(almost(always(cause(the(same(amount(of(edema(in(both(legs,(and(can(also(cause(edema(and(swelling(elsewhere(in(the(body.((

•  The(response(to(therapy(with(diure4c(drugs(in(pa4ents(with(venous(insufficiency(tends(to(be(unsa4sfactory.(This(is(because(the(con4nued(pooling(of(fluid(in(the(lower(extremi4es(makes(it(difficult(for(the(diure4cs(to(mobilize(the(edema(fluid.(

•  (Eleva4on(of(the(legs(periodically(during(the(day(and(the(use(of(compression(stockings(may(temporarily(help(the(condi4on,(but(ul4mately(venous(insufficiency(is(a(mechanical(problem(that(responds(to(mechanical(solu4ons(commonly(performed(today(such(as(thermal(or(chemical(energy(abla4on.(

Common'Causes'of'Venous'Insufficiency:((There(are(several(condi4ons(than(can(cause(the(valves(and(veins(to(

work(improperly:(•  Any(problem(that(increases(pressure(in(the(veins(in(the(legs(can(

stretch(the(veins.(This(can(damage(the(valves,(which(leads(to(even(higher(pressures(and(worsened(vein(func4on.(

•  A(clot(in(a(vein(will(block(blood(flow(back(through(the(vein,(which(can(increase(pressures,(open(permanently(damaging(the(vein(or(valves(even(aper(the(clot(has(dissolved.(

•  Leg(injury(or(surgery(can(damage(the(veins(or(valves.(•  Increased(body(weight((eg,(pregnancy,(obesity)(can(increase(

pressure(in(the(veins(of(the(legs,(and(this(can(usually(irreparably(damage(the(veins(and(valves.(

•  The(muscles(in(the(legs(play(an(important(role(in(the(circula4on(of(blood,(ac4ng(as(a(pump.(Standing(or(si[ng(for(prolonged(periods(without(walking(can(decrease(the(movement(of(blood(out(of(the(legs(and(lead(to(increased(pressures(in(the(veins(and(pooling(of(blood(

Common'Causes'of'Conges6ve'Heart'Failure:((

•  Coronary(Artery(Disease(•  High(Blood(Pressure((Hypertension)(•  Diseases(of(the(heart(muscle((Cardiomyopathy)(

•  Disorders(of(the(heart(valves(

Conclusion:((

•  Edema(of(the(legs(is(a(very(common(and(uncomfortable(sign(of(underlying(disease.((

•  With(the(advent(of(Doppler(Ultrasonography,(accurate(diagnosis(and(appropriate(treatment(can(be(readily(administered.((

•  As(the(common(causes(and(treatment(paradigms(are(very(different(for(the(two(most(frequent(causes(of(edema((CHF(and(VI)(it(is(very(important(that(proper(diagnoses(are(made.((

•  More(research(on(this(topic(appears(to(be(warranted(for(poten4al(pa4ent(benefit(and(health(system(op4miza4on.(((

1.(Meir,(P.,(Tabencki,(S.,(Rose,(H.,(&(Spigleman,(A.,(Nonvascular(Pathology(iden4fied(by(duplex(scanning(during(tes4ng(for(venous(thrombosis(in(the(edematous(and/or(painful(lower(extremity.(Journal#of#Vascular#Technology,##1999#23(4),197*200.(2.(Zygmunt,(J.(What(is(new(in(duplex(scanning(of(the(venous(system.(Perspec7ves#in#Vascular#Surgery#and#Endovenous#Therapy,#21(2),#94*104(3.(St.(Anna,(L.(What(is(the(differen4al(diagnosis(of(chronic(leg(edema(in(primary.(Journal#of#Family#Prac7ce.(((

Exam(

Complete'the'exam'&'evalua6on'below'and'email'your'results'to'pbush@veinexperts.org'along'with'your'contact'informa6on.'('(A'score'of'80%'or'greater,'must'be'achieved'on'the'post`test'and'be'completed'in'less'than'3'aaempts.''

Venous(Insufficiency(is(associated(with(leg(edema(is(commonly(undiagnosed.(Approximately(was(percentage(of(people(have(been(iden4fied?(

A.  5%(B.  10%(C.  25%(D.  35%(((

Venous(Insufficiency(and(Conges4ve(Heart(Failure(are(completely(different(and(therefore(appropriate(

diagnosis(is(extreme(important.(What(test(would(you(order(to(rule(of(VI(vs.(CHF?(

A.  CT(Scan(B.  Echocardiogram(C.  Venous(Doppler(Ultrasonography(D.  Stress(Test(

(

What(is(the(defini4on(of(venous(insufficiency?(

A.  A(condi4on(of(incompetence(of(the(veins(that(occur(because(of(dila4ons(and(dysfunc4on(of(the(valves.(

B.  A(condi4on(of(large,(dark(veins(that(tend(to(bulge(but(are(not(severe(enough(to(require(surgical(treatment.(

C.  A(condi4on(of(abnormally(large(fluid(volume(in(the(circulatory(system(or(in(4ssues(between(the(body’s(cell.(

D.  A(condi4on(marked(by(weakness,(edema(and(shortness(of(breath(that(is(caused(by((the(inability(of(the(heart(to(maintain(adequate(blood(circula4on(in(the(peripheral(4ssues(and(the(lungs(

What(are(common(causes(of(venous(insufficiency?(

A.  Coronary(Artery(Disease(B.  Hypertension(C.  Disorder(of(heart(valves(D.  Leg(Injury(

What(is(the(ul4mate(way(to(treat(venous(insufficiency?(

A.  Thermal/Chemical(abla4on(B.  Compression(stockings(C.  Diure4cs(D.  Ibuprofen(therapy(

(

Evalua4on(((How(well(did(this(ac4vity(present(the(objec4ves?(((Excellent((Good( ( (Sa4sfactory( ( (Poor((((((How(do(you(rate(the(overall(usefulness(of(the(online(material(to(mee4ng(your(needs?((((Excellent((Good( (( (Sa4sfactory( ( (Poor((((((How(do(you(rate(the(overall(presenta4on(material?((((Excellent((Good( ( (Sa4sfactory( ( (Poor(((((

Was(any(commercial(bias(presented(in(the(material?(((No( (Yes((Please#explain)#((____________________________________________________((((I(will(be(able(to(change(my(clinical(prac4ce(as(a(result(of(par4cipa4ng(in(this(ac4vity.(((Yes( (No((((((What(topics(about(venous(disease(would(you(like(to(hear(about(in(the(future?((((____________________________________________________((((((((

((Addi4onal(Comments/Recommenda4ons((

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Contact'Informa6on((

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