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.     

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.     

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.     

Chronic venous insufficiency today (a status determination)

Primary as well as secondary cvi (due to deficiency of the deep venous reflux) is a disease that necessitates a thorough therapy planning and a life-long medical care. Neither operation nor sclerotherapy alone can cure these patients. Active measures must always be combined with conservative procedures such as individually manufactured pressure gradient stockings, occasional intermittent medical treatment of complications and careful guiding of the patients over many years. The first measure is of course a careful establishment of the diagnosis by clinical examination and modern technical methods such as Doppler ultrasound, plethysmography and, in selected cases, phlebography. The therapy concept must consider the advantages and disadvantages of the various methods. A combined treatment in team work with the vascular surgeon may be the starting point, but must always be followed by an intensive life-long guidance of the patients with additional treatments according to necessity.     

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: an open trial of FLEBS Crema

AIM: This study was realized to evaluate the FLEBS CREMA tolerability and its therapeutic efficacy, in patients with functional disease linked to not complicated venous or lymphatic insufficiency. This compound acts as vasoconstrictor thanks to the vegetable extract of Ruscus aculeatus, but it is also able to reduce the edema, thanks to the vegetable extract of Melilotus officinalis. METHODS: All the patients were treated for three weeks with FLEBS CREMA, that was applied 2 or 3 times a day, on both legs. The traditional clinical parameters of chronic venous insufficiency (IVC) (edema, pain, heaviness, itch, cramps and other symptoms) were evaluated during the treatment. RESULTS: The results show an improvement for all the monitored symptoms, also if the positive clinical response was different for each evaluated parameter. The best results were obtained for edema, pain, heaviness and itch: the statistical analysis shows indeed a significant difference between the beginning and the end of the treatment. In this study the dermo-cosmetic qualities and the tolerability of FLEBS CREMA were also evaluated: both these parameters obtained a positive clinical evaluation. CONCLUSIONS: Basing on these data, the final evaluation for this compound was good/very good for the 80-90% both doctor and patients.     

Chronic venous insufficiency and the therapeutic effects of Daflon 500 mg

Chronic venous insufficiency is linked to venous hypertension and forces of shear stress on the endothelium. Venous hypertension depends upon two forces: the weight of a column of blood from the right atrium transmitted through the valveless vena cava and iliac veins to the femoral vein, and pressure generated by contracting skeletal muscles of the leg transmitted through failed perforating veins. When valve failure occurs in superficial axial veins and perforating veins, the venous pressure in the veins and venules of the skin and subcutaneous tissue is raised. The skin changes in chronic venous insufficiency are directly related to the severity of the venous hypertension. Also, pathologic changes in the valves are linked to venous hypertension and leukocyte infiltration and activation. It is hypothesized that acute venous pressure elevations cause a shift in the venous hemodynamics with changes in wall shear stress. This initiates the inflammatory cascade. Daflon 500 mg ameliorates the effects of chronic inflammation. In randomized trials, 60 days of therapy with Daflon at a dosage of 500 mg 2 tablets daily was effective, in addition to elastic compression, in accelerating venous ulcer healing. Because venous insufficiency is linked to venous hypertension and an inflammatory reaction, it appears that Daflon 500 mg 2 tablets daily shows a great potential for accomplishing blockade of the inflammatory cascade.     

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.     

Varicose veins. Chronic venous insufficiency. Lower limbs venous ulcers. Point of view

PURPOSE: Lower limbs chronic venous disorders are still considered as a minor disease from a university hospital point of view, yet it is a very common problem, affecting the quality of life, generating disability, and expensive for healthcare resources. Its teaching is neither satisfactory nor easy to do. KEY POINTS: Apart from the fact that it rarely causes death, the complexity of venous anatomy and physiopathology, the lack of animal model, common practices lumping together visible varicose veins and chronic venous insufficiency, and moreover a certain carelessness in the vocabulary probably largely explain these difficulties. Our purpose is to discuss chronic venous disorders (varicose veins, chronic venous insufficiency, venous ulcers) on the basis of semantic, of anatomical, haemodynamic and clinical forms and finally of nosology.     

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.     

Hemorheology of venous insufficiency

The aim of this paper is to study the rheological properties of blood in patients with venous insufficiency. MATERIAL AND METHODS: Measurements have been performed for 20 healthy control subjects and 20 patients presenting a venous insufficiency with varicose veins of lower limbs. Blood has been withdrawn from the veins of the lower limbs at rest and after 10 minutes of venous stasis (standing position and 100 mmHg tourniquet). The following measurements have been performed: hematocrit by microcentrifugation; fibrinogen by nephelometry; plasma viscosity by means of capillary viscosimeter (Myrenne KSPV4); deformability by Hanss hemorheometer using nucleopore membranes and red blood cell aggregation and disaggregation by means of a SEFAM erythro-aggregometer. RESULTS: 1. Hematocrit was not significantly different between both groups of subjects at rest. However, it increased significantly after venous stasis in patients with varicose veins but it was not found to be increased in healthy subjects. 2. Before and after stasis, the fibrinogen level was higher in patients than in controls. After stasis, a significant increased was found only in the patient group. 3. Plasma viscosity was found to be modified as the same manner as the fibrinogen level. Besides, the fibrinogen level and plasma viscosity were found to be correlated to each other. 4. Before and after stasis, red cells of patients were significantly less deformable than those of controls. After stasis, they were found to be more altered, in patients. But there were no difference in controls before and after stasis. 5. Aggregation and disaggregation parameters have been found to be disturbed in patient group. Disturbances were more pronounced after stasis. CONCLUSION: Venous insufficiency can be characterized by alteration of rheological parameters and the blood stasis in varicose veins may enhance these alterations. These results indicate the importance of hemorheological disturbances in the pathogenesis of this disease.     

Neuromyopathy in venous insufficiency

Since July, 1985, the authors have studied 23 patients with history and physical findings of venous insufficiency syndrome (VIS) confirmed by venous pressure, muscle biopsy, ascending and descending venography, electromyography, and nerve conduction velocity studies. Clinically, swelling appears to be the most important symptom, along with high venous pressure, particularly ambulatory venous pressure, correlated with venography findings. Muscle atrophy was present in 18 cases. Electromyography and nerve conduction velocity studies yielded abnormal findings in 20 of 23 cases. The authors suggest that nerve conduction velocity and EMG studies could perhaps be used as noninvasive tests for diagnosis and follow-up of cases with VIS.