Chronic Venous Disease:

A Complex Disorder

A N Nicolaides

Emeritus Professor of Vascular Surgery, Imperial College,

London.

Hon. Professor of Surgery, University of Nicosia Medical School,

Cyprus

Disclosures

Honoraria for lectures received from:

Covidien / Medronic

Alpha Wasserman / AlphaSigma

Servier

Pierre Fabre

Why is it a Complex Disorder?

Complex Symptoms and Signs

Complex Pathophysiology

Complex Haemodynamics

A better understanding of these complexities should

better equip the clinician to manage patients with CVD

Complex skills are required

Why is it a Complex Disorder?

Complex of Symptoms and Signs

Complex Pathophysiology

Complex Haemodynamics

A better understanding of these complexities should

better equip the clinician to manage patients with CVD

Complex skills are required

Chronic venous disease-related

symptoms and signs

Symptoms1

Heaviness, Pain, Sensation of swelling,Restless legs,Paresthesias,Night-time cramps, Tiredness,Throbbing,Itching.

Signs2

C0s: NoneC1: Telangiectasia, reticular veins C2: Varicose veinsC3: EdemaC4: Skin changes: (a) pigmentation, eczema, (b) lipodermatosclerosis, atrophie blancheC5: Healed Venous ulcer C6: Active Venous ulcer

1. Garde C et al. Phlebolymphology 2005; 49: 384-396; 2. Porter et al. J Vasc Surg 1995; 21: 635-645.

Symptoms and signs

Symptoms are not specific of CVD

There is poor correlation between Symptoms and Signs:

Advanced CEAP class can be present without symptoms

and in C0s signs are absent in the presence of severe

symptoms

Scoring systems such as VCSS devote only 3 marks out

of 30 for symptoms and 27 marks for signs

SymVein Publication

The SymVein publication has changed our approach to the

assessment and management of CVD

Definition of venous symptoms

Explanation of Pathophysiology of symptoms

Attribution of symptoms to CVD

Recommendations about scoring of symptoms

Investigations needed

Why is it a Complex Disorder?

Complex of Symptoms and Signs

Complex Pathophysiology

Complex Haemodynamics

A better understanding of these complexities should

better equip the clinician to manage patients with CVD

Complex skills are required

Primary Varicose veins (VVs)

Common disorder

VVs present in 14-35% of the population

40% of venous leg ulcers are the result of longstanding

VVs in the presence of normal deep veins

Progressive

Prevalence and severity increase with age

Leukocyte-endothelium interaction:

a key role primary CVD

Environmental and local factors plus genetic predisposition

Chronic inflammatory

processes

Leukocyte-endothelium interaction

Remodeling in venous wall, and venous valves

REFLUX and HYPERTENSION

Adapted from Eberhardt RT, Raffetto JD. Circulation. 2005; 111:2398-2409

Progression of

chronic venous disease

Valve damage

Reflux Varicose Veins (C2)

Vein wall remodeling

Capillary damage

Capillary leakage

Edema (C3) Skin Changes (C4)

Venous Ulcer (C5,6)

Symptoms Symptoms Symptoms Symptoms

HYPERTENSION

MACROcirculation MICROcirculation

C0s

Adapted from Eberhardt RT, Raffetto JD. Circulation. 2005; 111:2398-2409

Why is it a Complex Disorder?

Complex of Symptoms and Signs

Complex Pathophysiology

Complex Haemodynamics

A better understanding of these complexities should

better equip the clinician to manage patients with CVD

Complex skills are required

Painful Leg Ulcer

Reflux: Volume Flow

739/60 =

12 ml/sec

Ambulatory venous pressure (AVP) –a global hemodynamic test

VFT, s

% pressure drop

All reflux is not equal

Marston WA et al. J Vasc Surg 2008;48:400-6

Post-thrombotic Syndrome

60% of venous ulcers are due to previous DVT

Etiology

1. Obstruction (failure of recanalization) and recurrent DVT

2. Reflux (damage to valves)

3. Combination of reflux and obstrucion

Post-thrombotic Syndrome

Predisposing factors to skin changes and ulceration

1. Persisting proximal obstruction

2. Axial reflux

3. Reflux > 5ml per sec

4. Combined obstruction and severe reflux

5. Recurrent DVT (obstruction of collaterals)

6. Increasing age

7. Obesity

8. Poor compliance to therapy

Ulcer Prevalence vs. AVP

Venous Hypertension and Protective Mechanisms

Ability of lymphatic drainage to increase 5 times in some

individuals but only 2 times in others (zero in patients with

lymphedema)

Variable fibrinolytic activity in blood and tissues.

For patients having moderately raised AVP 35-65

If fibrinolytic activity is low: 90% develop skin changes

and 70% ulcer

If fibrinolytic activity is normal-high: 16% develop ulcer

Whawell SA et al, Br J Surg 1989;76

:

Combination of Duplex and VFI

Clinical severity class N VFI P

0 Asymptomatic 34 1.6 ± 1.6 -------

1 Mild CVI (ache & swelling) 42 2.3 ± 1.7 < 0.05

2 Moderate CVI (skin changes) 11 8.0 ± 5.6 < 0.05

3 Severe CVI (Ulceration) 31 8.5 ± 5.2 < 0.001

“The combination of VFI and duplex scanning (multisegment score) not

only localized the reflux, but also separated severe clinical disease from

mild with high sensitivity (83%) and high specificity (86%)”

Neglen and Raju 1993:17:590-5

Venous Obstruction

Value of imaging techniques and outflow resistance (R)

Venous obstruction

The degree at which a venous stenosis is critical is not known

This is because outflow resistance for the limb depends on

how well developed is the collateral circulation

A reliable non-invasive test to grade stenosis is not available

Best method for local grading of stenosis is IVUS

Global effect of obstruction is provided by Outflow Resistance (R)

Note: Because R is not measured, current practice of stenting relies

on assessment of local stenosis. Only 50-60% of patients

improve suggesting that many are stented unnecessarily

Labropoulos et al, Arch Surg 1997;132:46-51

Simultaneous Pressure and Volume Measurements

Simultaneous Pressure and Volume Recordings

R = P/Q

mmHg/ml/min

26 Limbs with CVD

Conclusions1. Duplex provides information on presence or absence and anatomic

extent of reflux or obstruction

2. If quantitative information is needed (how much reflux or how much

obstruction there is) for clinical decisions, duplex should be complimented

by plethysmography

3. R should be measured before and after stenting so that eventually we can

correlate the baseline R with those that derive clinical benefit. This should

provide a better selection of patients for stenting

C0s

Prevalence of C0s and significance

The presence of symptoms in the absence of signs (C0s)

are very common

In the Bonn Vein Study 50% of 1800 participants reported such

symptoms

In the worldwide Vein Consult Program 20% of the symptomatic

screened subjects presented with C0s

Prevalence of C0s and significance

In a recent study of 41 C0s patients with normal duplex in the

morning, 26 (63%) had reflux in the evening with increased GSV

diameter (Tsoukanov Y. 2005)

In the Basel longitudinal study, C0s individuals progressed to

develop overt edema when seen 11 years later

The majority of C0s patients improve with compression or VAD

CVD: Conclusion

Complex of Symptoms and Signs

Complex Pathophysiology

Complex Haemodynamics

A better understanding of these complexities should

better equip the clinician to manage patients with CVD

We may have to change our methods of investigation

Complex skills are required