Chronic venous insufficiency of the lower limbs and its socio-economic significance.

The author, based on data furnished by the Brazilian Ministry of Social Welfare in the year 1983, draws attention to the socio-economic repercussion of chronic venous insufficiency (CVI) of the lower limbs on the contributors to social security in the country. The available statistical data have been restricted to small population groups. A comprehensive study is made for the first time, which includes twenty-five million workers. Despite the high incidence of the disease, the numbers do not reflect entirely Brazilian reality, since social security in Brazil, in the specific case of diseases, grants benefit only to the contributor, and not to his dependents. Nevertheless, CVI ranks in the 14th place among the 50 principal diseases that cause absence from work which consequently give the right to receive the benefit from Brazilian Social Security.     

Chronic venous insufficiency in primary varicose veins evaluated by plethysmographic technique

Venous hemodynamics were evaluated by plethysmography in normal subjects and patients with venous disorders of the lower extremity, to clarify the pathophysiology of chronic venous insufficiency (CVI) due to primary varicose veins. Expelled volume during five active dorsiflexions of the feet and venous recovery time were calculated to evaluate muscle pump efficiency and valvular competence. Limbs with CVI due to primary varicose veins showed a higher expelled volume and a more shortened refilling time than limbs with simple varicosities. With application of tourniquets, the refilling time normalized in limbs with CVI, as well as in limbs with simple varicosities. These results indicate that a high degree of venous congestion in the distal part of the calf and valvular incompetence of the superficial vein system might cause CVI due to primary varicose veins.     

Chronic venous insufficiency

Opinion statement Patients with chronic venous insufficiency arguably have been relegated to a standard of care that is lower than that for those with the more appealing entity of peripheral arterial disease. Fortunately, the collaboration of an expanding group of clinicians (including cardiologists and vascular medicine specialists) with vascular surgeons is stimulating a renewed interest in the management of patients afflicted with venous disease. With the increased level of awareness of venous disease, technologic advances undoubtedly will augment the armamentarium available for the treatment of patients with chronic venous insufficiency. The focus on the prevention of venous thromboembolic complications has been advanced greatly, as witnessed by the growth of new pharmacologic agents, such as heparinoids, antiplatelet agents, direct thrombin inhibitors, thrombolytics, and pentasaccharides. In addition, the more aggressive strategy of intervening in acute deep venous obstruction by using thrombolytic agents and adjunctive mechanical thrombectomy devices potentially may obviate the future sequelae of chronic venous insufficiency. The tremendous growth of endovascular techniques in recent years has revolutionized the management of problems due to acute and chronic arterial obstructive disease. The application of these techniques in the future may have a similar impact in improving the clinical outcomes of patients with chronic venous disease and potentially, if proven safe and efficacious in clinical trials, may lower the threshold for intervention to an earlier disease stage. Similarly, with the advent of endovascular and endoscopic techniques, surgical procedures will also continue to evolve, with these procedures complementing one another, as opposed to serving as surrogates, which traditionally has been the case.     

Chronic venous insufficiency

The author investigated in a group of 224 patients selected at random (380 extremities), indicated for different reasons for examination of the venous system of the lower extremities by coloured duplex and triplex sonography, the prevalence, site and clinical manifestations of deep venous insufficiency. Only 21.1% patients indicated for examination on account of clinical signs of deep venous thrombosis had objective signs of the disease, while almost half (47.7%) suffered from venous insufficiency. Venous insufficiency was detected also in a large percentage (59.9%) of patients without clinical symptoms. In the great majority of patients (99.8%) combined insufficiency was found affecting concurrently the femoral and popliteal vein and sometimes also the iliac vein.     

Chronic venous insufficiency

Chronic venous insufficiency of the lower extremities is a complicated disorder that affects the productivity and well-being of millions of people worldwide. Management requires careful differential diagnosis and a systematic long-term multidisciplinary care effort directed toward realistic goals within the context of the patient's lifestyle. Optimal therapy requires control of abnormal venous physiology combined with adjunctive treatments to correct secondary skin ulceration, infection, and lymphedema. Fundamental management tools are limb elevation, simple dressings, antibiotics, and elastic compression garments. Patients with large leg ulcers may benefit from split-thickness skin grafting. Other selected patients may benefit from ligation and stripping of superficial veins or subfascial interruption of perforating veins. New endoscopic methods have dramatically reduced morbidity from subfascial perforator surgery. Surgery directed at correcting valvular reflux and venous occlusion is possible in highly selected patients.     

Patterns of venous reflux in limbs with venous ulcers. Implications for treatment.

AIM: To investigate the anatomic distribution of vein reflux in limbs with healed or active ulcers (CEAP V and VI). METHODS: Sixty limbs (58 patients) belonging to CEAP classes V and VI were identified from 798 limbs (519 patients) with ultrasonically proven chronic venous insufficiency (CVI). Age, gender, duration of the venous ulcer, and history of deep venous thrombosis were correlated to the anatomic distribution of the venous reflux. RESULTS: The prevalence of active or healed ulcers in limbs with CVI was 7.5%. Among 60 limbs with ulcers, primary CVI was present in 34 (56.7%) and post-thrombotic CVI in 26 limbs (43.3%). No difference in age and gender was found between the 2 groups (p=0.2 and p=0.8, respectively). However, the duration of the ulcer was longer in limbs with post-thrombotic CVI (p<0.05). The prevalence of perforator reflux was 41.2% (14/34) in limbs with primary CVI and 38.5% (10/26) in limbs with post-thrombotic CVI (p=0.8). Superficial venous insufficiency, with or without perforating vein reflux, was the commonest pattern in limbs with primary CVI; it was rare in limbs with post-thrombotic CVI (22/34 or 64.7% vs 2/26 or 7.7%, p<0.01). Deep vein insufficiency was present in 35.3% (12/34) of the limbs with primary CVI and in 92.3% (24/26) of the limbs with post-thrombotic CVI (p<0.01). CONCLUSION: Superficial venous insufficiency, with or without perforating vein reflux, was the commonest pattern in limbs with primary CVI, whereas, deep venous insufficiency was present in most of the limbs with post-thrombotic CVI. The prevalence of perforating vein reflux was comparable in both settings. Thus, elimination of superficial reflux is expected to result in ulcer healing of most limbs with primary CVI, whereas, the value of such treatment in post-thrombotic limbs is not clear.     

Chronic venous insufficiency disease

Chronic venous insufficiency is a debilitating condition. It affects about 0.2% of the population and is very demanding on health resources. In the UK, there are about 100,000 patients with active leg ulcers and treating these patients costs the national health service between £100 and £400,000,000 per anum. This paper reviews the classification, epidemiology, pathophysiology, investigations and treatment of this condition. The etiology of venous ulceration is discussed and the various theories explaining the cause of ulceration examined. The latest research into the condition is reviewed and the relative roles of superficial venous incompetence and deep venous incompetence in the pathophysiology of ulceration is presented. Surgical and non-surgical treatment of the condition including surgical treatment of superficial and deep venous incompetence, compression therapy, and drug therapy is explored.Presented at the 37th Annual World Congress, International College of Angiology, Helsinki, Finland, July 1995.     

Pelvi-perineal venous insufficiency and varicose veins of the lower limbs: duplex Doppler diagnosis and endoluminal treatment in thirty females

Pelvic congestion is the most commonly recognized consequence of pelvi-perineal venous insufficiency (PPVI). The implication of PPVI in the generation of varicoceles and varicose veins of the lower limbs arising from perineal varices has not been studied specifically. We report our duplex-Doppler findings in a series of 150 women seen over a period of 36 months. All patients presented perineal varices and, more specifically, utero-ovarian venous reflux. Thirty women were retained for phlebography then treatment by embolization. All of the left utero-ovarian veins were incontinent, the right utero-ovarian vein could not be explored in one patient, and only three of the eight opacified veins were incontinent. Twenty-two patients presented an associated incontinence of the hypogastric branch (7 left, 15 bilateral). Embolization was performed on 29 left utero-ovarian veins and one right vein with, as complementary treatment, embolization of 15 hypogastric branches, six during a second session. There were no serious complications. At six months (range 2-20 months), no improvement was noted in 10% of the patients, symptoms had improved or the varices had diminished in 59%, and all symptoms had disappeared in 31%. A duplex-Doppler exploration should be performed to search for perineal involvement in all patients presenting varicose veins of the lower limbs. The good preliminary results obtained after embolization of the pelvic veins, and particularly the left utero-ovarian vein, suggests this therapeutic approach should be pursued. The long-term effect should be assessed because of the plexiform nature of recurrent venous disorders.     

Chronic venous insufficiency and microcirculation. Physiopathologic and therapeutic reflections

In patients with chronic venous insufficiency, tissular damage occurs as a consequence of microcirculatory disturbances. Venular distension, venulo-arteriolar reflex and probably valves in collecting venules are the only microcirculatory protective mechanisms against venous pressure overload. Edema is primarily a consequence of increased capillary hydrostatic pressure. However, the increase of endothelial macromolecular transport and a true lymphatic microangiopathy are important contributive factors. Venous ulceration is hypoxic although the amount of total blood flow is normal in the surrounding tissue. Several hypothesis were proposed for explaining this nutritional steal: arterio-venous shunt vessels have never been shown consistently, peri-capillary fibrin deposition might block oxygen diffusion, and last but not least, the abnormal geometrical arrangement of the capillary bed is facilitating functional shunting. On a therapeutic point of view, behind the classical hemodynamic therapy, the microvascular approach to chronic venous insufficiency supports the use of lymphatic manual drainage for controlling edema and rheologic therapy for improving skin capillary perfusion.     

Chronic venous insufficiency: the genetic influence

Many contributing factors are involved in the genesis of varicose disease of the lower limbs such as age, sex, heredity, sedentary life style among others. For physicians the decisive role played by heredity leaves no doubt. Few studies have, however, attempted to prove the importance of the hereditary factor on a clinical level, and no study has been conducted in molecular genetics. The impact of the hereditary factor is variably estimated and its nature is open to discussion. Despite the numerous limits of the research focusing on the hereditary aspect of varicose disease, the authors can nevertheless claim that the genetic factor definitively exists and has a great impact. There are few studies conducted among twins. The data collected in these studies point to the reality of various types of heredity. With the predominant impact of the hereditary factor, and despite the role played by environmental factors, it can be supposed that a single genetic anomaly may be the determining factor of the disease in a given family. Thus we have conducted an original study in order to identify one or several mutations predisposing to varicose disease, based on the approach called "reverse genetic" and linkage study. The study of a first family whose varicose disease segregates in an autosomal dominant manner allowed us to identify 3 potential loci, if we accept the hypothesis of 2 or 3 phenocopies. No candidate gene has been singled out in these regions in the first analysis. The study of a second family whose phenotype of the varicose disease is particularly homogeneous and segregates in an autosomal dominant manner did not confirm any of the previously identified loci, probably related to a genetic heterogeneity of the varicose disease. As a consequence, the second part of this study was devoted to determining the complete genotype of each individual within this family, in order to identify new loci of interest. A potential locus has just been identified. The third part of this research, currently being pursued, is devoted to the sequencing of potential genes. In parallel, the analysis of new large families is underway. The presentation will include an update on the hereditary and genetic aspects of varicose disease, and secondly identify the limits and difficulties of the genetic study of the families.     

Chronic venous insufficiency: dysregulation of collagen synthesis

Varicose vein disease is a common condition. Its pathology is not well characterized. A disorganization of smooth muscle cells and extracellular matrix components in the venous wall have been described. The objective of this paper is to offer an explanation for the abnormal distensibility of varicose veins. The content of hydroxyproline was quantified in control and varicose human saphenous veins. The synthesis of collagen types I, III, and V was quantified in cultured venous smooth muscle cells and dermal fibroblasts of control subjects and patients with varicose veins. The proportion of collagen type III in the heterofibrils composed by collagen types I, III, and V was calculated. The level of hydroxyproline was increased in varicose veins, suggesting an increased content of collagen. This augmentation of collagen in diseased tissues appears to be correlated with an increase of collagen type I since the collagen I mRNA was overexpressed in varicose veins, whereas collagen type III mRNA was not altered. The quantification of collagen synthesis in cultured cells shows that proportion of collagen type III was significantly decreased in cultured smooth muscle cells and dermal fibroblasts derived from patients with varicose veins. The results indicate a deficiency in collagen type III in patients with varicose veins. Since collagen type III is involved in tissue elasticity, these results offer an explanation for the abnormal distensibility of varicose veins. Moreover, this defect seems to be generalized in different tissues and argues in favor of a genetic alteration of remodeling in these patients.     

Phlebodynamometry studies in patients with chronic venous insufficiency and phlebography verified insufficiency of muscle veins

23 patients with complaints in the sense of a chronic venous insufficiency were examined by means of phlebodynamometry, who phlebographically did not show any postthrombotic changes of the deep conducting veins, but had clear signs of an insufficiency of the muscle veins stage I-III. Cases with isolated insufficiency of the muscle veins (n = 5) and combination forms with additional insufficiency of the conducting veins and/or superficial varicosis (long and short saphenous veins) were found. Measured at the decrease of pressure (delta-p) after exercise in the combined forms the epifascial varicosis has the greatest haemodynamic effects. The isolated findings of an insufficiency of the muscle veins with or without additional insufficiency of the conducting veins has apparently only smaller haemodynamic effects. For the isolated insufficiency of the muscle veins normal limit values for delta-p could still be measured, which also could only insignificantly be bettered by application of a tourniquet. This knowledge is important for therapy planning.