Treatment of chronic venous insufficiency

Opinion statement Chronic venous insufficiency (CVI) results from venous hypertension secondary to superficial or deep venous valvular reflux. Treatment modalities are aimed at reducing venous valvular reflux, thereby inhibiting the ensuing pathologic inflammatory process. Compression therapy using pumps, bandaging, and/or graded compression stockings is the mainstay of treatment for CVI. Compression therapy has been shown to be effective in reducing venous hypertension retarding the development of inflammation and pathologic skin changes. Pharmacologic agents such as diuretics and topical steroid creams reduce swelling and pain short term but offer no long-term treatment advantage. Herbal supplements may reduce the inflammatory response to venous hypertension, but are not licensed by the US Food and Drug Administration, and vary in their efficacy, quality, and safety. However, several randomized controlled trials using the herbal horse chestnut seed extract containing aescin have shown short-term improvement in signs and symptoms of CVI. Endovascular and surgical techniques aimed at treatment of primary and secondary venous valvular reflux have been shown to improve venous hemodynamics promoting healing of venous ulcers and improving quality of life. The newer endovascular treatments of varicose veins using laser, radiofrequency ablation, and chemical foam sclerotherapy show some promise.     

Photoplethysmography in chronic venous insufficiency

Venous photoplethysmography (P.P.G.) is a non-invasive diagnostic technique using reflection of infrared light on the skin. The record gives a curve analogous to venous pressure. Normally the venous pressure of the leg decreases in response to calf muscle exercise. We have affixed the P.P.G. transducer to the skin above the medial malleolus and have analyzed the recovery half time (T 1/2) on 170 limbs: 49 normal, 82 with superficial venous insufficiency and 39 with deep venous insufficiency. Reference tests were ascending and retrograde phlebography and venous Doppler evaluation. A tourniquet was used to occlude the superficial venous network. T 1/2 without tourniquet is useful to screen limbs with venous insufficiency. T 1/2 with tourniquet differentiates deep and superficial venous insufficiency. P.P. G. can document the rise of deep venous insufficiency in patients with varicose veins and or repermeation of deep veins or post phlebitic syndrome among patients who have had thrombophlebitis.     

Microcirculation in chronic venous insufficiency.

In this review, the anatomy and physiology of the venous system and its pathophysiology are described. Theories regarding the possible causes of disturbances in venous microangiopathy are summarized. The theories concern the deoxygenation of red blood cells, arteriovenous shunts, fibrin cuffs, and the trapping of growth factors and/or white blood cells. Furthermore, microlymphatic, neurologic and hemorheologic disturbances in venous disease are outlined. Findings in venous microangiopathy obtained from histology, capillary microscopy, microlymphography, laser Doppler fluxmetry and transcutaneous oxygen partial pressure are detailed. Finally, the recently discovered pattern of perfusion in microcirculation within and around venous ulcers is discussed.     

The chronic cerebrospinal venous insufficiency syndrome

Chronic cerebrospinal venous insufficiency (CCSVI) is a syndrome characterized by stenosies of the internal jugular and/or azygous veins (IJVs-AZ) with opening of collaterals and insufficient drainage proved by reduced cerebral blood flow and increased mean transit time in cerebral MRI perfusional study. The present review is aimed to give a comprehensive overview of the actual status of the art of the diagnosis and treatment of this condition. As far as the origin of venous narrowing is concerned, phlebographic studies of the IJVs and AZ systems demonstrated that venous stenoses were likely to be truncular venous malformations; mostly, they are intraluminal defects such as malformed valve, septa webs. CCSVI condition has been found to be strongly associated with multiple sclerosis (MS), a disabling neurodegenerative and demyelinating disease considered autoimmune in nature. In several epidemiological observations performed at different latitudes on patients with different genetic backgrounds, the prevalence of CCSVI in MS ranges from 56% to 100%. To the contrary, by using venous MR and/or different Doppler protocols, CCSVI was not detected with the same prevalence. Two pilot studies demonstrated the safety and feasibility in Day Surgery of the endovascular treatment of CCSVI by means of balloon angioplasty (PTA). It determines a significant reduction of postoperative venous pressure. Restenosis rate was found out elevated in the IJVs, but negligible in the AZ. However, PTA seems to positively influence clinical and QoL parameters of the associated MS and warrants further randomized control trials.     

Air plethysmography in chronic venous insufficiency: clinical diagnosis and quantitative assessment.

To define the role of air plethysmography (APG) in the clinical diagnosis and quantitative assessment of chronic venous insufficiency (CVI), APG studies were performed on 582 limbs in 291 patients with signs and symptoms of CVI. One hundred and thirty-one limbs were classified into group I (no evidence of CVI), 291 into group II (mild CVI), and 160 into group III (advanced CVI). On APG, the mean venous filling index (VFI) was 1.45 mL/s, 3.90 mL/s, and 5.25 mL/s in groups I, II, and III respectively (p<0.05). The mean ejection fraction (EF) and mean residual volume fraction (RVF) also showed significant differences between the limbs with CVI and the contralateral normal limbs, but the values were similar for the different severities of CVI limbs. The amount of overlap in VFI, EF, and RVF values among the clinical groups was considerable. Discrimination analysis derived a VFI value of 2.67 mL/s as a cutoff point between normal limbs and limbs with CVI, with a positive predictive value of 96%. In conclusion, APG is a simple and noninvasive test for quantitative assessment of the different components of CVI, valvular reflux, and calf muscle pump function. However, only VFI correlated significantly with the severity of CVI. VFI, with its high positive predictive value, may be useful in diagnosis of CVI, and it may serve as an objective quantitative measurement for monitoring the effect of treatment.     

Effect of elastic stockings on edema related to chronic venous insufficiency. Videocapillaroscopic assessment

AIM: To evaluate the effect of class II (23-32 mm Hg) compression stockings on the edema of the ankle in patients with chronic venous insufficiency (CVI), and to assess the relationship between the microvascular phenomenon and the volume of the leg. MATERIAL AND METHOD: 11 patients (19 limbs, 5 women and 6 men, mean age 57 years) with CVI, CEAP 2-3 were studied through physical examination, Doppler color ultrasound test, measurement of leg volume and videocapillaroscopy. Patients were evaluated before (T0), after 7 days (T1) and 14 days (T2) of daily compression therapy with elastic stockings. Statistical comparisons used the Mac Nemar test for binomial variables and Wilcoxon test for paired quantitative data. RESULTS: All patients experienced significant improvement of symptoms, the volume of the limbs on the average decreased in the first week T0-T1=284.8 cm(3) +/- 307.5 cm(3) (6.27%, p<0.001). During the second week a small increase in volume was observed T2-T1=+ 12.23 cm(3), NS, 0.29%). The width of the capillary halo of edema decreased during the first week by an average of T0-T1=5.77 microm +/- 10.99 microm. During the second week the width of the edema halo continued diminishing, although in smaller proportion (T0-T2=7.89 microm +/- 11.77 microm). CONCLUSION: Daily use of grade II compression stockings induces a reduction in leg volume in patients with CEAP grades 2-3. This improvement of edema is paralleled by a decrease in the size of the pericapillary halo.     

Coagulation and fibrinolysis in chronic venous insufficiency

BACKGROUND: Varicose veins (VV) are common, but only some patients will develop chronic venous insufficiency (CVI) with skin changes or venous ulcer. The pathophysiology of venous ulcer development is complex, and may involve abnormalities in coagulation, fibrinolysis and proinflammatory cytokines. The purpose of this study was to correlate plasma markers within these systems and skin pathology. METHOD: A group of twenty consecutive patients with active or recent venous ulcer were matched for sex and age with further three groups of individuals i.e. controls and patients with VV with and without skin changes respectively. Blood samples were analysed for hemoglobin (HB), total platelet count (TPC), C-reactive protein (CRP), activated partial thromboplastin time (APTT), prothrombin complex (PT), fibrinogen, interleukin-1 beta (IL-1 beta), tumor necrosis factor alpha (TNF alpha), D-dimer, tissue plasminogen activator (t-PA), plasminogen activator inhibitor 1 (PAI-1), prothrombin fragments 1 and 2 (F1 + 2), and thrombin antithrombin III complex (TAT). RESULTS AND CONCLUSION: There was an increase of systemic levels of PAI-1 activity and tPA with progressive skin pathology in patients with CVI, and in the group with active ulcer there was an elevation of F1 + 2. Those findings could reflect a defect fibrinolysis, a thrombotic potential or a damaged endothelium.     

Iliac vein stenting for chronic venous insufficiency

Chronic venous insufficiency has devastating sequelae in terms of patients' lifestyles and negative economic impact on society. Traditional surgical procedures have yielded variable patency results, and follow-up has not always been reported. This review summarizes the current applications, patency rates, stent selection, and complications of balloon angioplasty and stenting in the treatment of chronic venous outflow obstruction in the lower extremity. We conclude that endovenous stenting is the current method of choice in the treatment of chronic venous obstruction.     

Classification of chronic venous insufficiency: a review

Chronic venous insufficiency (CVI) is a very variable and complex entity that has stimulated different attempts at classification. Several proposals have been made in recent years, based on objective and anatomical criteria, most of them incomplete and unsatisfactory. Finally the CEAP classification was presented in 1994. This certainly is the most nearly complete classification, since it takes into consideration not only the main aspects of CVI: Clinical, Etiological, Anatomical, and Pathophysiological, but also the degrees of severity, reported in the form of scores. It is now accepted internationally although it still has some flaws (such as the absence of the corona phlebectactica sign) and inaccuracies (above all in the clinical part and the scoring). Recently, some members of the Promoting Committee proposed a substantial modification of the part on scores, coming closest to the clinical reality, instrumental diagnosis, and current therapies. The characteristics of CEAP enable us to affirm that this represents the most original and useful classification, not only for clinical studies, but also in the assessment of therapeutic results and in patient follow-up. Like all classifications, CEAP also needs to be validated by means of clinical studies in order to demonstrate its applicability. For this purpose, a European Working Group was set up in 1997. The first interesting results of 872 dossiers collected by means of a computerized program (European Phlebological File) were presented at several international congresses and concentrated on the consistency and reproducibility of the clinical part of the CEAP classification in different clinical settings.     

Prevalence and risk factors of chronic venous insufficiency

Venous disease in the legs occurs very commonly in the general population in Western countries. Around one third of women have trunk varices. A lower prevalence has been observed in men but some recent surveys have suggested that the occurrence in men may be comparable to that in women. The prevalence increases with age but the incidence of new cases appears to be constant throughout adult life. Open venous ulcers occur in about 0.3% of the adult population and a history of open or healed ulceration occurs in around 1%. The etiology of chronic venous disease in the legs is unknown. A genetic predisposition may be present but evidence for this and for a mode of inheritance is lacking. There is some suggestion that prolonged standing may be a risk factor but studies are open to considerable bias. In women, obesity and previous pregnancy has been associated with the presence of varicose veins but the evidence is inconsistent. There have been few well-conducted studies examining diet and bowel habit as a risk factor. The risk of ulceration is related to the severity of varicosities and venous insufficiency, and is increased following deep vein thrombosis. Much further research is required to investigate the cause of this common condition in the general population.     

Elasticity of the skin in chronic venous insufficiency

The results of our measurements of skin elasticity at the level of the calf, show that the existence of a cutaneous pump is unlikely. In addition, they are not consistent with the suggestion that the skin acts as an elastic stocking. In case of chronic venous insufficiency (CVI), the loss of elasticity which is demonstrated, is probably secondary to a persisting dermal edema. In patients with essential varicosities, a significant loss of elasticity is only noted in case of reticular varicosities. Essential truncular varicosities are not accompanied with a significant loss of elasticity. It is therefore highly likely that truncular varicosities and reticular varicosities do not have the same etiology.     

Dosage of O-beta hydroxyethylrutoside in chronic venous insufficiency

45 patients suffering from varicose veins with or without a chronic insufficiency up to stage II, took 1, 2 or 3 g of Oc-beta hydroxyerhylrutoside P.O. Photo reflexometry and plethysmography with mercury gauge demonstrated the results. The various parameters showed the medication to be effective after 10 and 21 days of treatment. A dosage adjusted to the gravity of the venous involvement improves the venous pump of the leg and therefore the venous return.