Lower Extremity Venous Disease: Peripheral Venous

Insufficiency

Aman K Kakkar MD FACCHeart and Vascular Care, Inc

30 Million people suffer from venous reflux disease, the underlying cause for most varicose veins

Prevalence and Etiology of Venous Insufficiency

Annual U.S. Incidence

U.S. Prevalence

Millions

Venous reflux disease is 2x more prevalent than coronary heart disease (CHD) and 5x more prevalent than peripheral arterial disease (PAD)1

Prevalence of Venous Insufficiency

Age Female Male

20 - 29 8% 1%

40 - 49 41% 24%

60 - 69 72% 43%

Prevalence by Age and Gender3,4

Of the estimated 30 million people with symptomatic superficial venous reflux1 :

• Only 1.9 million seek treatment annually2

• Only 500K Patients receive treatment• Over 28 million go untreated

Venous System

Venous blood flows from the capillaries to the heart

Flow occurs against gravityMuscular compression of the

veins Negative intrathoracic pressureCalf muscle pump

Low flow, low pressure system

Deep femoral v.

Femoral v.

Popliteal v.

Small saphenous v.

Great saphenous v.

Perforating v.

Perforating v.

Image source: Fundamentals of Phlebology: Venous Disease for Clinicians. Illustration by Linda S. Nye. American College of Phlebology 2004.

Pathophysiology of Venous Insufficiency

Risk Factors and Symptoms of Venous Insufficiency

Risk factors of venous insufficiency:

• Gender

• Age

• Heredity

• Pregnancy

• Standing occupation

• Obesity

• Prior injury or surgery

• Sedentary lifestyle

Symptoms of venous insufficiency:

• Leg pain, aching, or cramping

• Burning or itching of the skin

• Leg or ankle swelling

• “Heavy” feeling in legs

• Skin discoloration or texture changes

• Open wounds or sores

• Restless legs

• Varicose Veins

20+ million 2 to 6 million

Skin Ulcers

500,000

Manifestations of Venous Insufficiency

Superficial venous reflux is progressive and if left untreated, may worsen over time. Below are manifestations of the disease.5

Photos courtesy of Rajabrata Sarkar, MD, PhD.

Swollen Legs Skin Changes Varicose Veins

PATHOPHYSIOLOGY

CEAP Classifications

Clinical Classifications of Venous Insufficiency (CEAP)

Class 0 - No visible or palpable signs of venous disease

Class 1 - Telangiectasias or reticular veins

Class 2 - Varicose veins

Class 3 - Edema

Class 4 - Skin changes (4a) Skin changes including pigmentation or venous eczema (4b) Skin changes with lipodermatosclerosis

Class 5 - Healed venous ulceration

Class 6 - Active venous ulceration

Great Saphenous Vein : The Culprit

American Venous Forum (AVF) Guidelines:

Diagnosis

Great Saphenous Vein (GSV) : Reflux

Small Saphenous Vein (SSV): Reflux

TREATMENT ALGORITHM

AVF Guidelines: Treatment

AVF Guidelines: Treatment

Vein Closure: Indications, Risks

Indication:

The Catheter ablation is intended for endovascular coagulation of blood vessels in patients with superficial venous reflux

Contraindications:

Patients with thrombus in the vein segment to be treated

Potential Risks & Complications:

Potential complications include, but are not limited to, the following: vessel perforation, thrombosis, pulmonary embolism, phlebitis, hematoma, infection, adjacent nerve injury, skin burns, deep vein thrombosis

Vein Closure: Options

Stripping

Foam Sclerotherapy

Radiofrequency Ablation

Laser Ablation

Overall Maximum Pain Score (0 none to 10 max)

RECOVERY Trial7: PainA Prospective, Multi-Center, Randomized Study

ClosureFAST Laser

p < 0.0001

2

4

RECOVERY Trial7: EcchymosisA Prospective, Multi-Center, Randomized Study

ClosureFAST Laser

p < 0.0001

Moderate to Severe Ecchymosis (Bruising) After TreatmentModerate to severe ecchymosis is defined as bruising over greater than 25% of the treated surface area

2.2%

51.3%

RadioFrequency Ablation The Radiofrequency Closure

System is a minimally invasive treatment alternative for patients with symptomatic superficial venous reflux and varicose veins

Using a catheter-based approach, catheter delivers radiofrequency (RF) energy to the vein wall

RF energy creates conductive heating that contracts the vein wall collagen, thereby occluding the vein

Procedure using the Radiofrequency Ablation Catheter

Procedure

SummaryEasily Diagnosed but vastly untreated

Although many aspects of treatment have remained the same for over a century

Recent advances have provided new and better treatment options for patients with chronic venous disease.