Beruflich Dokumente
Kultur Dokumente
Prakash Ramamoorthy
INTRODUCTION Author has personally seen a patient whose wife divorced him
due to his chronic ulcers. Also many young male patients have
India has made great strides in many aspects along with
their marriage delayed due to ulcers.
industrialization. We are witnessing the emergence of many new
Unfortunately, despite all of the above, physicians and the patients
diseases. One of the underestimated causes of morbidity, workplace
do not consider CVI seriously as it is neither life nor limb threatening.
absenteeism, increasing economic burden for the patient has been
the growing threat of chronic venous disease.
We do not have exact statistics for the Indian population figures
PRESENTATIONS OF VENOUS DISEASE
from the west make grim reading. India is likely to be only worse with (FIGURES 1A AND B)
regards to venous disease. The presentation may be one of the following:
Consider the following: 1. Varicose veins (dilated tortuous veins): Classification includes
Chronic venous disease affects 40% of the US population trunk veins (varicosities of greater and lesser saphenous veins),
Chronic venous insufficiency (CVI) with ulceration affects up reticular veins (subcutaneous veins that begin at the tributary of
to 2% of the population; an incidence comparable with the trunk veins) and telangiectasias (intradermal small varicose veins
incidence of diabetes which are asymptomatic)
In UK almost 1 billion dollars equivalent is spent on managing leg 2. Deep vein thrombosis (DVT): This may involve any deep vein
ulcers from tibial veins up to a totally occluded inferior vena cava (IVC)
Disease becomes more common with advancing age when other symptoms, in an appropriate settings, includes unilateral leg
issues in the family takes priority and these elderly patients may edema, pain, warmth, dilated veins
not find support from the family members 3. Superficial vein thrombosis or superficial thrombophlebitis
Many employers do not wish to employ these patients with active 4. Sequelae of old chronic venous insufficiency: Heaviness,
ulcers pigmentation, discoloration venous eczema, ulcerations. These
A B
Figures 1A and B: Venous ulcer
Surgery Section 25
to 40% of the patients may not test positive for hypercoagulability Sclerotherapy: Another procedure which has found wide spread
despite manifesting venous thromboembolism (VTE). acceptance has been the use of sclerosants. This is particularly
widespread in Europe and has given rise to group of specialists
CEAP CLASSIFICATION called sclerotherapists who do only sclerotherapy
(AMERICAN VENOUS FORUM 1994) Dermal laser and sclerotherapy have been used for treating
thread veins
In order to standardize reporting of venous diseases Clinical, Drugs which have been used to treat venous insufficiency include
Etiological, Anatomical, Pathophysiological (CEAP) classification flavonoid plant extracts (e.g. Daflon), anabolic steroids, aspirin, etc.
as defined by the American venous forum in 1994 has been adapted
worldwide. This underwent further modification in 2004. In order
TREATMENT OF DEEP VEIN THROMBOSIS
to encourage widespread acceptance a Basic CEAP has also been
defined. This involves initial treatment with heparin, either unfractionated or
low molecular weight, and then converting to oral anticoagulation.
Clinical Classification Proper advice must be given regarding duration, wearing proper
graduated compression stockings, dos and donts with regards to
C0: no visible or palpable signs of venous disease diet, intramuscular injections, other drug interaction, etc.
C1: telangiectasias or reticular veins
C2: varicose veins
PROBLEMS PECULIAR TO INDIAN SCENARIO
C3: edema
C4a: pigmentation or eczema Many patients regard varicose veins as nerves and are scared of
C4b: lipodermatosclerosis or atrophie blanche treatmentthey fear that they may not be able to walk again. In
C5: healed venous ulcer fact, many patients go to a neurologist for treatment
C6: active venous ulcer There is a misconception that even after surgery, varicose veins
will recursurgeons have to mention a recurrence rate of 5%
Etiologic Classification when getting consent
Patients present only advanced state in fact, it is one of the
Ec: congenital complications of varicose veins which brings the patient to
Ep: primary the surgeon-ulcer, bleeding from varicose, superficial vein
Es: secondary (post-thrombotic) thrombosis which can lead to DVT in about 1015%
En: no venous cause identied Unlike west, request for surgery from a cosmetic point of view
does not happen in India due to full length dresses worn by
Anatomic Classification patients with even advanced cases
As: supercial veins Even specialist doctors like dermatologist do not refer the patient
Ap: perforator veins at the appropriate time for some reason best known to them
Ad: deep veins Some of the worst sufferers come from the group involved in long
An: no venous location identied standing occupations like grocery shop, bakery, hotel, police who
do not have the awareness nor the means to change occupation
Pathophysiologic Classification Deep vein thrombosis has always been under recognized, under
diagnosed and under treated in India. These patients present very
Pr: reux late due to severe stasis changes. Physicians should remember
Po: obstruction that the post-thrombotic syndrome of today is the neglected DVT
Pr,o: reux and obstruction of yesterday
Pn: no venous pathophysiology identiable There is a very high incidence of pro-thrombotic state in the
Indian population; one condition which is easy to diagnose and
TREATMENT OF VARICOSE VEINS treat is secondary polycythemia due to smoking
Classical operation of Trendelenburg: It involves dissection in the Fear of surgery, fear of recurrence, neighbors and relatives are the
groin, disconnecting all the named tributaries of long saphenous main reasons why the Indian patient typically comes very late
vein, stripping up to ankle. This may be combined with perforator Employers attitude: A famous textile chain in south forbids
ligation its employees from sitting throughout the dayno chairs are
Thermal ablation: Current minimally invasive alternatives available and they are forced to stand throughout their duty
include radiofrequency ablation (RFA), laser ablation, steam which may be between 8 and 10 hours. This is unheard of and
ablation. These are currently very expensive unacceptable in a western society.
755
Surgery Section 25
CONCLUSION 3. Eklof B, Rutherford RB, Bergan JJ, et al. Revision of the CEAP classifi-
cation for chronic venous disorders: consensus statement. J Vasc Surg.
Patient and doctors are to be educated regarding morbidity 2004;40(6):1248-52.
caused by chronic venous problems and persuaded to seek 4. Evans CJ, Fowkes FG, Ruckley CV, et al. Prevalence of varicose veins
surgical treatment at the earliest. Skin changes, once they set in, andchronic venous insufficiency in men and women in the general
almost become permanent population: Edinburgh Vein Study. J Epidemiol Community Health.
1999;53(3):149-53.
Have a low threshold for getting a venous Doppler for any patient
5. Fowkes FG, Lee AJ, Evans CJ, et al. Lifestyle risk factors for lower limb
with a unilateral swelling in an appropriate clinical setting to rule venous reflux in the general population: Edinburgh Vein Study. Int J
out DVT-post-thrombotic syndrome of today is neglected DVT of Epidemiol. 2001;30(4):846-52.
yesterday 6. Glinski W, Chodynicka B, Roszkiewicz J, et al. The beneficial augmen-
In all patients with idiopathic DVT suspect and rule out underlying tative effects of micronised purified flavonoid fraction (MPFF) on the
malignancy and thrombophilias by ordering appropriate tests healing of leg ulcers: an open multicenter, controlled, randomized
Proper compression stockings are essential to prevent post- study. Phlebology. 1999;14:151-7.
thrombotic syndrome 7. Kurz X, Kahn SR, Abenhaim L, et al. Chronic venous disorders of the
leg: epidemiology, outcomes, diagnosis and management: summary
Varicose veins and venous eczema must be aggressively treated,
of an evidence-based report of the VEINES task force. Int Angiol.
especially in the diabetics as they run a high risk of developing 1999;18(2):83-102.
limb threatening cellulitis. 8. Labropoulos N. Hemodynamic changes according to the CEAP classifi-
cation.Phlebolymphology. 2003;40:130-6.
9. Moffatt CJ, Franks PJ, Doherty DC, et al. Prevalence of leg ulceration in
BIBLIOGRAPHY a London population. QJM. 2004;97(7):431-7.
1. Brand FN, Dannenberg AL, Abbott RD, et al. The epidemiology of 10. Porter JM, Moneta GL. Reporting standards in venous disease: an
varicoseveins: the Framingham Study. Am J Prev Med. 1988;4(2): update. International Consensus Committee on Chronic Venous
96-101. Disease. J Vasc Surg. 1995;21(4):635-45.
2. Carpentier PH, Hildegard RM, Biro C, et al. Prevalence, risk factors 11. Roztocil K, Stvrtinova V, Strejcek J. Efficacy of a 6-month treatment
and clinical patterns of chronic venous disease of the lower limbs: a with Daflon 500 mg in patients with venous leg ulcers associated with
population-based study in France. J Vasc Surg. 2004;40(4):650-9. chronicvenous insufficiency. Int Angiol. 2003;22(1):24-31.
756