CHRONIC VENOUS INSUFFICIENCY

Prepared by Gihan Hany

Nakhleh
Med III-Balamand University
SGHUMC

OUTLINE
Definition
Prevalence
Anatomy Review
Pathophysiology
Risk Factors
Clinical Features
Diagnosis
Treatment

DEFINITION
A condition that

affects the venous

system of the lower
extremities with
venous hypertension
causing various
pathologies including
pain, swelling,
edema, skin changes,
and ulcerations.

PREVALENCE
Female : male 3:1
Affects up to 5-30% of adults
By age 50, 40% of women and 20% of

men have significant vein problems

VENOUS ANATOMY
Superficial
Great Saphenous
Small Saphenous

Deep
Anterior & Posterior

Tibial
Peroneal
Popliteal
Femoral
Perforating

VENOUS ANATOMY

MUSCLE PUMPS

VENOUS PATHOPHYSIOLOGY AND

DYSFUNCTION
Valvular incompetence reflux
Venous obstruction
Exacerbated by muscle pump

dysfunction

VALVULAR INCOMPETENCE
Congenital: Klippel Trenaunay and Parkes

Weber syndromes
Primary: preexisting weakness in vessel wall
or valve leaflet (uncertain cause)
Secondary:
Direct injury
Phlebitis
Excessive venous distention due to hormonal

effects
Post-thrombotic syndrome

VALVULAR INCOMPETENCE

VENOUS OBSTRUCTION
Intrinsic
Previous DVT with inadequate recanalization
Venous stenosis

Extrinsic
May-Thurner syndrome (compression of left common

iliac vein as it traverses between the right common

iliac artery and lumbosacral region)
Pelvic tumors

ILIAC COMPRESSION SYNDROME

MUSCLE PUMP DYSFUNCTION

Age
Neuromuscular conditions or muscle

wasting syndromes
Immobility

RISK FACTORS
Advancing age

Sedentary lifestyle

Family history of venous

Lower extremity trauma

disease
Ligamentous laxity (eg,

hernia, flat feet)

Prolonged standing or

sitting
Increased BMI
Smoking

Prior venous thrombosis

(superficial or deep)
High estrogen states
Pregnancy

CLINICAL FEATURES
Pain most commonly
Ankle and calf edema (relieved by foot elevation)
Pruritus and brownish pigmentation (due to

hemosiderin deposits)
Stasis dermatitis
Lipodermatosclerosis
Ulceration: above the medial malleolus, wet,
painless

CEAP
C- Clinical
7 categories +/- symptoms

E- Etiology
Congenital, primary, or secondary

A- Anatomy
Superficial, deep, or perforating

P- Pathophysiology
Reflux, venous obstruction, calf muscle

dysfunction

C- CLINICAL CLASSIFICATION

DIAGNOSIS
History
Physical Exam
Noninvasive testing
Duplex, APG, PPG

Invasive testing
Phlebography, AVP

PHYSICAL EXAM FINDINGS

Telangiectasia

PHYSICAL EXAM

Varicose veins

PHYSICAL EXAM

Hyperpigmentation

PHYSICAL EXAM

Stasis dermatitis

PHYSICAL EXAM

podermatosclerosis and atrophie blanche

PHYSICAL EXAM

PHYSICAL EXAM

VENOUS DUPLEX IMAGING REFLUX

VENOUS DUPLEX IMAGING - DVT

AIR PLETHYSMOGRAPHY

PHLEBOGRAPHY

TREATMENT
Conservative
Elastic compression stockings, ambulation, periodic rest

elevation, avoid prolonged standing

Ulcers: multilayer compression bandage, antibiotics PRN,

hydrocolloids, aggressive wound care.

Stasis dermatitis: topical steroids, moisturize
Exercise: improve calf muscle function

CONSERVATIVE

Ulcer management

PHARMACOLOGICAL TREATMENT
Flavonoids e.g. Daflon Venoactive

drug Decreases chronic vein

inflammation, promotes ulcer healing,
effective in elastic compression

Coumarin Competitive inhibitor of

vit K Anticoagulant

INTERVENTIONAL TREATMENT
Sclerotherapy
Endovascular therapy (stenting)
Ablative therapy with endovenous

radiofrequency and laser

FOAM SCLEROTHERAPY

SURGICAL TREATMENT
Ligation and stripping and venous

phlebectomy
Subfacial endoscopic perforator surgery
Valve reconstruction

SURGICAL TREATMENT

THE END