LUCIE BEAUPRE, MD

Member of Advisory Board

Canadian Society of Phlebology
Fellow of Canadian Society of Phlebology
American Board of Phlebology Certified
Medical Director
Dr. Beaupre Vein Clinic





www.drbeaupreveinclinic.com
Copyright 2009 by American College of
Phlebology
2
It is ironic that medical
education does not cover three
of the most common medical
problems: back pain,
hemorrhoids, and
varicose veins.
P. Fujimura, MD
Surgical Intern
University of California School of Medicine
Copyright 2009 by American College of
Phlebology
3

The medical specialty devoted to
the diagnosis and treatment of
patients with venous disorders
PHLEBOLOGY
Copyright 2009 by American College of
Phlebology
4
THE SPECTRUM OF CHRONIC VENOUS
DISEASE
lipodermatosclerosis
telangiectasias
varicose veins
Superficial
phlebitis
venous
ulceration
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Phlebology
5
Copyright 2009 by American College of
Phlebology
6
Venous Disease
is a Hereditary Disorder
134 families were examined
The risk of developing varicose veins was:
89% if both parents had varicose veins
47% if one parent had varicose veins
20% if neither parent had varicose veins
Cornu-Thenard, A, J Dermatol Surg Oncol 1994 May; 20(5):318-26.
Copyright 2009 by American College of
Phlebology
7
Varicose Veins are 3 times more common in
women than men
"Varicose veins." The Mayo Clinic. January 2007. http://www.mayoclinic.com
Copyright 2009 by American College of
Phlebology
8
Each pregnancy worsens the
condition
405 women with varicose veins
13% had one pregnancy
30% had two pregnancies
57% had three pregnancies
Brand FN, et al The epidemiology of varicose veins: the
Framingham Study Am J Prev Med 1988; 4:96-101
Copyright 2009 by American College of
Phlebology
9
Copyright 2009 by American College of
Phlebology
10
Anatomy and physiology of the venous
system
in the lower extremity

Deep venous system: the channel through which 90% of
venous blood is pumped out of the legs
Superficial venous system: the collecting system of veins
Perforating veins: the conduits for blood to travel from the
superficial to the deep veins
Musculovenous pump: Contraction of foot and leg muscles
pumps the blood through one-way valves up and out of the
legs
Copyright 2009 by American College of
Phlebology
11
Illustration by Linda S. Nye
Copyright 2009 by American College of Phlebology 12
Superficial venous system
Great saphenous vein
-runs from dorsum of foot
medially up leg
-site of highest pressure
usually the saphenofemoral
junction, but may begin with
perforating or pelvic vein
Illustration by Linda S. Nye
Copyright 2009 by American College of Phlebology 13
Superficial venous system
Small saphenous vein
-runs from lateral foot up
posterior calf
-variations in termination
-segmental abnormalities
-site of highest pressure
frequently the saphenopopliteal
junction, but may begin with an
inter-saphenous connection or
perforating vein
Illustration by Linda S. Nye
Copyright 2009 by American College of Phlebology 14
Perforating veins
Mid-thigh Perforating Vein
Dodd
Proximal Calf Perforator
Cockett
Gastrocnemius
Lateral thigh (lateral
subdermic plexus)

Illustration by Linda S. Nye
Copyright 2009 by American College of Phlebology 15
Venous Valvular Function
Valve leaflets allow
unidirectional flow, upward
or inward
Dilation of vein wall
prevents opposition of
valve leaflets, resulting in
reflux
Valvular fibrosis,
destruction, or agenesis
results in reflux
Normal Blood Flow
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Phlebology
17
REFLUX: its
contribution to
varicose veins
Illustration by Linda S. Nye
Incompetent valves
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Phlebology
19
Pathophysiology: 2 components
REFLUX
Dilatation of vein wall leads
to valve insufficiency
Monocytes may destroy vein
valves
Retrograde flow results in
distal venous hypertension
OBSTRUCTION
Thrombosis and subsequent
fibrosis obstruct venous
outflow
Damage to vein valves may
also cause reflux
Both contribute to venous
hypertension
The presence of both is far worse than either one alone
Copyright 2009 by American College of
Phlebology
20
CEAP Classification
C = Clinical
C0 - no visible venous disease
C1 - telangiectasias or reticular veins
C2 - varicose veins
C3 - edema
C4 - skin changes without ulceration
C4a pigmentation or eczema
C4b LDS or atrophie blanche
C5 - skin changes with healed ulceration
C6 - skin changes with active ulceration
E = Etiology (primary vs. secondary)
A = Anatomy (defines location of disease within
superficial, deep and perforating venous systems)
P = Pathophysiology (reflux, obstruction, or both)
C.E.A.P. Clinic
Copyright 2009 by American College of
Phlebology
22
Presenting Symptoms of Chronic
Venous Disease
Aching
Fatigue, heaviness in legs
Pain: throbbing, burning, stabbing
Cramping
Swelling (peripheral edema)
Itching
Restless legs
Numbness

Consultation
Symptoms
CVI
Cosmesis
SYMPTOMS

Aching Swelling
Tiredness Heaviness
Itching Burning
Night Cramp
INCREASED

Standing / sitting
Menses
Heat
IMPROVED

Exercise
Compression
Rest
NSAID
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Phlebology
24
History
Full patient history:

Medical
Surgical
Allergy
Medication


Special Attention:

Pregnancy, Still Birth
Prior DVT, SVT, PE
Thrombophilia
Onset of varicies
Evolution of varicies
Family history especially:

DVT. SVT. PE
Thrombophilia
Varicose Veins
Examination
STANDING
Inspection
Palpation

Look for trophic changes
I.V.C. I. Corona phlebetatica
II. Stasis dermatitis
III. Ulcer
Look for oedema (circumference of legs)
Look for signs of P.A.D.
Exam superficial venous insufficiency
Superficial System

Vein Classification
Type 1 : telangiectasias (0.1 - 1mm) red
Type 2 : (1 2mm) blue
Type 3 : reticular (2 4mm) blue
Type 4 : varicosities (3 8mm) saphenous
tributaries
perforator
Type 5 : saphenous truncal (> 5 mm)
Copyright 2009 by American College of Phlebology 30
Telangiectasias
Also known as spider veins
due to their appearance
Very common, especially in
women
Increase in frequency with age
85% of patients are
symptomatic
*

May indicate more extensive
venous disease
*
Weiss RA and Weiss MA J Dermatol Surg Oncol.
1990 Apr;16(4):333-6.

Copyright 2009 by American College of Phlebology 31
Lateral Subdermic Plexus
Very common, especially in
women
Superficial veins with direct
perforators to deep system
Remnant of embryonic deep
venous system
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Reticular Veins
Enlarged, greenish-blue
appearing veins
Frequently associated
with clusters of
telangiectasias
May be symptomatic,
especially in dependent
areas of leg
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Varicose Veins Great
Saphenous Distribution
Most common finding in
patients with varicose veins
Varicosities most commonly
along the medial thigh and calf
but cannot assume location
indicates origin
At least 20% of patients are at
risk of ulceration

Copyright 2009 by American College of Phlebology 34
Great Saphenous
Insufficiency

Skin changes are seen along
the medial aspect of the ankle
The presence of skin changes
is a predictor of future
ulceration
*

*
Kirsner R et al. The Clinical Spectrum of
Lipodermato-sclerosis, J Am Acad Derm, April
1993;28(4):623-7
Copyright 2009 by American College of Phlebology 35
Varicose Veins Small
Saphenous Distribution
Less frequent than Great
Saphenous involvement
Varicosities may be seen
on the posterior calf and
lateral ankle
Skin changes are seen
along the lateral ankle
Copyright 2009 by American College of Phlebology 36
Varicose Veins with
Pelvic Origins
Begin during pregnancy
Increased symptoms
during pre-menstrual
period and after
intercourse
May be associated with
pelvic congestion
syndrome
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Phlebology
37
Venous ulceration
Impending ulceration
Lipodermatosclerosis
(C4a)
Venous ulceration (C6)
Copyright 2009 by American College of Phlebology 38
Muscle fascia herniation
Frequently confused with
varicose veins
Usually found on the lateral
calf
Bulge disappears with
dorsiflexion of the foot
No flow is audible with
continuous-wave Doppler
examination

Ultrasound Evaluation
of Superficial Venous
System
Duplex Ultrasound - GSV
Standing position
Weight on other leg
Examine from SFJ to calf

Duplex Ultrasound - SSV
Standing position
Knee slightly flexed



Sapheno Femoral
Junction
Right Leg

Saphenous veins remains intra-
fascial

Tributary veins are outside
superficial fascia


SSV Duplex
Appearance
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Phlebology
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Copyright 2009 by American College of
Phlebology
46
Compression therapy
Reduces symptoms of aching, fatigue, pain,
and swelling
Increases fibrinolytic activity
Increases TCpO2
Mainstay of treatment for venous ulcers
NOTE: Graduated compression therapy and
wound care will heal venous stasis ulcers.
Elimination of the reflux will reduce the
recurrence.
Copyright 2009 by American College of Phlebology 47
Elastic compression stockings
Must be graduated
Calf high generally sufficient
Replace q 6 months to
assure proper pressure
Available in a variety of
strengths, styles, colors, and
fabrics
Copyright 2009 by American College of Phlebology 48
Graduated compression is not
the same as T.E.D. hose
T.E.D.s are meant for non-
ambulatory, supine patients
T.E.D.s are indicated to
decrease the incidence of
thrombosis
T.E.D.s do not provide
sufficient pressure for
ambulatory patients
Copyright 2009 by American College of
Phlebology
49
Compression
Strength
Indications
8-15mm Leg fatigue, mild swelling,
stylish
15-20mm Mild aching, swelling, stylish
20-30mm Aching, pain, swelling, mild
varicose veins
30-40mm * Aching, pain, swelling, varicose
veins, post-ulcer
40-50, 50-60mm * Recurrent ulceration,
lymphedema
* Requires a prescription
Copyright 2009 by American College of Phlebology 51
Exercise
Reduces symptoms such as aching and
pain
Reduces ulcer recurrence
Speeds resolution of superficial
phlebitis and DVT
30 minutes daily is best
Lower extremity exercise is helpful (stay
away from heavy weight-lifting or
other strenuous activity)
Contraction of leg
muscles results in deep
venous emptying and a
reduction in the venous
pressure
The hemodynamic effect of exercise
Copyright 2009 by American College of
Phlebology
53
Varicies Principle of Treatment
From deepest superficial to telangiectasia in epidermis
From top to bottom
IE treat point of highest reflux 1
st

From large to small
IE treat axial reflux 1
st

tributaries / perforators
reticulars
telangiectasia
Treatment
Axial or Truncal Insufficiency
GSV, SS, AAS, GIACOMINI (Intersaphenous), Perforators

STRIPPING
used to be Gold Standard
last line of treatment nowadays

ULTRASOUND-GUIDED TECHNIQUES

Endovenous Chemical Ablation (E.C.A.) or Ultrasound Guided Sclerotherapy (U.G.S.)
For varicies 1cm in diameter at SFJ, 1
st
line of treatment

Endovenous Thermal Ablation (E.T.A.)
Radio frequency
Endovenous Laser



Ultrasound Guided Sclerotherapy
Duplex Guided Injections
UGS ECA
Mapping of incompetent varicies
Point of highest reflux in truncal varix
Use - Angiocath (more secure)
- Closed needle more precise
End point of injection: vasospasm -3cc/session
FOAM more power than liquid per unit volume
Sotradecol
displaces blood
better contact with endothelium
echogenic: follow with U.S.


Doppler Reflux
Ultrasound Guided Injections
GSV Channel by UGS Foam
Copyright 2009 by American College of
Phlebology
61
Sclerotherapy Results
Before
After Ultrasound-guided sclerotherapy of
the Great Saphenous Vein and
sclerotherapy of branches
Photos courtesy of Steven Zimmet, MD, FACPh
Before & After Ultrasound Treatment

Bulgy Vein - Before & After
Before: After:
Endovenous Thermal Ablation
Radio frequency (RF Fiber)
VNUS PLUS, VNUS FAST

Endovenous Laser (Catheter)
Diode 810mm 940mm
Yag 1064
Copyright 2009 by American College of Phlebology 65
Radiofrequency Closure
Technique
Outpatient procedure
approximately 60 min.
long
Local tumescent
Temperature at vein wall
controlled
>90% closure at 2 yrs
FDA-approved for RX of
Great Saphenous Vein
NEED PIC
Copyright 2009 by American College of Phlebology 66
Endovenous Laser Ablation
Outpatient procedure
approximately 60 min long
Only local anesthesia
required
Continuous pullback
Closure of >93% Great
Saphenous Veins at 2 yrs
FDA-approved for RX of
Great Saphenous Vein

Endovenous Thermal Ablation
J wire/sheath advanced in GSV
Endovenous Thermal Ablation
Ultrasound-guided
Tumescent Anesthesia
Circumferential Tumescence
RESULTS

ECA
87% median rate vein closure
80% healing ulcers
(JIA et AL British Journal of
Surgery, August 2007)


ETA
RF 83% - 90% success at 2-5 years
Laser 90% - 100% success at 1-2
years
(The Vein Book, Bergan 2007)
COMPLICATIONS

ECA
DVT .3 to .5%
SVT 2 3%
TIA transient
Migraine, P.F.O.
Visual disturbance

ETA
DVT 1%
Paresthesia 0 16%
SVT O 6%

Principles of Treatment Tributaries
3mm to 8 mm (non truncal)

Sclerotherapy
Ambulatory Phlebectomy
Copyright 2009 by American College of Phlebology 72
Surgical Treatment of Varicose
Veins: Phlebectomy
Very esthetic method of
removing varicose veins
Usually requires only
local anesthetic
Especially useful for
tributaries of GSV, SSV
Principles of Ambulatory Phlebectomy
1) Microincisions
2) No ligation
3) Local anesthesia
4) Immediate ambulation
5) Compression

Most commonly used for veins of legs, but also
effective for hands and face.
Technique of Ambulatory Phlebectomy
Visual Sclerotherapy of Tributaries
Strong Sclerosants
Sotradecol

Detergent
Liquid or Foam
Diffuse

Protein theft denaturation of endothelium of veins walls

Iodine

Chemical
Liquid
Local

Direct destruction of endothelium
Sclero Tributaries
Alam, Nguyen. Treatment
of Leg Veins, 2006.

(Note : anterolateral
branch now called
anterior circumflex)
Before and After
Before: After:
Visual Sclerotherapy
of Reticulars Telangiectasia
Dermis Epidermis

Weak Sclerosant

Sclerodex Complications
25% Dextrose - telangiectatic matting
10% Nacl. - pigmentation
- cutaneous necrosis
Hyperosmolar dehydration of endothelium cells
Copyright 2009 by American College of Phlebology 80
Treatment of Reticular Veins
NEED PIC
Frequently associated
with telangiectasias,
their Rx may enhance
results of
sclerotherapy of
telangiectasias
Visualization may be
improved with
transillumination
Before/After

Copyright 2009 by American College of Phlebology 82
Treatment of telangiectasias
Sclerotherapy most effective
Laser may be helpful
Multiple treatments usually
required
Reduces symptoms in 85% of
patients
Improves quality of life

Weiss RA and Weiss MA J Dermatol Surg Oncol. 1990 Apr;16(4):333-6.
Copyright 2009 by American College of
Phlebology
83
Sclerotherapy of Telangiectasias:
Technique
Injection of sclerosant solution causes damage to
endothelium which leads to fibrosis of vein
Copyright 2009 by American College of
Phlebology
84
Sclerotherapy Results
Before After Photos courtesy of Steven Zimmet, MD, FACPh
Sclerotherapy
Injection of sclerosing agent to collapse veins
Inflammation of intima + vasa vasorum of
media of veins walls
Very small thrombus/thickening of vascular
wall
Replacement of vein by fibrosis
Formation of scar tissue (nothing at the
surface of the skin)
Sclerosis Phlebitis
Technique
All aseptic disposable material
3cc-10cc seringes
~ 25 injections per session (1 to 40)
~ 8 sessions (1-25) 15 minutes per session
100% ambulatory procedure
Annual check-up recommended
A very small needle is used

CONCLUSIONS

Varicose veins affect a large proportion of the population.

Ultrasound allows accurate diagnosis of superficial veins.

Ultrasound guidance allows efficient non invasive
treatment of saphenous reflux especially ECA UGS.

Modern sclerotherapy treats varicose veins of all sizes,
telangiectasia to saphenous.

Compression for post treatment care and prevention.