Outline of Venous Disease Management - PDF Document

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  1. Outline of Venous Disease Management Manifestations of Venous Disease of Lower Extremity: The underlying pathology is Venous Insufficiency which starts in the superficial veins and eventually involves the deep veins. 1.Varicose veins 2.Spider veins (also known as venous telangiectasias, venous hemangiomas) 3.Edema 4.Chronic Lymphovenous Edema 5.Hemorrhage (recurrent bruising of the skin or frank bleeding) 6.Venous ulceration 7.Superficial thrombophlebitis 8.Deep Venous Thrombosis 9.Postphlebitic syndrome 10.Pulmonary embolism 11.Restless legs and chronic venous insufficiency Investigation: 1.Complete examination 2.Venous Duplex scan a)Assessment of deep venous system to detect DVT and Venous Insufficiency b)Complete examination of superficial venous system including: 1)Great Saphenous and Small Saphenous veins 2)Accessory Saphenous veins 3)Perforating veins (Thigh, Paratibial, and Posterior Tibial Perforators) 3.Venogram, CT Venogram (CTV), Magnetic Resonance Venogram (MRV)-for abdominal and pelvic veins 4.Lymphography Treatment of Superficial Venous Disease: Conservative (only for symptomatic relief while waiting for definitive treatment) 1)Compression stockings 2)Leg elevation 3)Leg exercises 4)Daily walks 5)Avoidance of high heals 6)Drugs and Dietary Supplements Definitive 1)Treatment of Reflux: Venous closure of incompetent superficial veins (Saphenous Veins, Accessory Saphenous Veins, Perforators)--Endovenous Laser or Radiofrequency Venous Closure 2)Varicose Veins: Ambulatory stab-phlebectomy for varicose veins in multiple sessions (or Foam Sclerotherapy)

  2. 2 3)Spider Veins: Laser treatment (or Foam Sclerotherapy) for symptomatic spider veins in multiple sessions (even asymptomatic spider veins should be considered for treatment-AVF Guideline) 4)Perforators: Laser or Radiofrequency Closure (or Foam Sclerotherapy) 5)Lymphovenous Edema: Compression therapy, (graduated compression stockings, Intermittent Pneumatic Compression pump therapy) 6)Venous ulcer management- surgical debridement, skin grafting, antibiotics, specialized compression therapy e.g., Una Boot applications, CircAid stockings, hyperbaric oxygen therapy. Treatment of Deep Venous Thrombosis: Conservative: 1.Anticoagulation therapy 2.Compression therapy-graduated compression stockings, Intermittent Pneumatic Compression Pump Therapy (for post-phlebitic syndrome) Definitive: 1.Thrombectomy 2.Intravenous thrombolysis 3.Catheter thrombolysis 4.Catheter thrombectomy with mechanical devices Patients with venous disease may present with following signs and symptoms: Symptoms 1.Pain (heaviness, aching, throbbing, cramping, itching, numbness, and, burning of legs) 2.Swelling 3.Hemorrhage (frequent bruising of skin of legs with minor trauma or frank bleeding episodes) 4.Skin discoloration (Dyschronia, Pigmentation) 5.Ulcer (active or healed) 6.Restless legs Signs 1.Varicose veins 2.Spider veins 3.Edema 4.Tenderness of lower legs (assessed at the medial surface of the tibia) 5.Pigmentation 6.Induration of the skin of lower legs 7.Lipo-dermatosclerosis

  3. 3 8.Eczema at the lower legs 9.Atrophy blanche 10.Corona phlebectatica 11.Ulcer (active or healed) Varicose and Spider Veins Varicose Veins develop due to the dilatation of the previously existing veins are located in the subcutaneous tissue, under the influence of venous insufficiency, which is caused by the diseased incompetent venous valves. The varicose veins are greater than 2 mm in diameter. Clusters of varicose veins always have an associated feeding vein or veins connected to the deeper veins causing significant reflux of blood under pressure in the wrong direction causing distention of these veins. If left untreated, these veins lead to dilatation of the deep veins due the reflux over-flow of blood causing the deep venous insufficiency. Spider Veins develop due the proliferation of new capillaries caused by venous hypertension due to incompetent venous valves and are located in the dermis of the skin. The spider veins are less than 1 mm in diameter. This new growth of capillaries is called vascular neogenesis, and is due to proliferation of endothelial stem cells present in the dermal layers of the skin. These stem cells are embryonic remnants left over during the early stages of venous development. Spider veins always drain into to the deeper veins through feeding veins and can be responsible for significant reflux, which produces pressure in these tiny thin-walled vessels and can cause pain with varying intensity and can result in bleeding. If left untreated, these veins lead to dilatation of the deep veins due the reflux over-flow of blood causing the deep veins to enlarge; thus, the venous valves become incompetent and cause venous insufficiency. Reticular Veins are one to two millimeter in diameter, are located mainly in the dermal skin layer. These veins are connected to the deeper veins and frequently function as feeding veins for clusters of spider veins also located in the dermal layer of skin. Spider Veins Connection to deep Veins--The following articles support the view that spider veins are connected to the deeper veins and the possible embryological origin: J. Cardiovasc. Surg. 1962. 3, 415-419 Moraes I.N., Puech-Leao L.E., Simone J.C., Martins de Toledo. O., Correa Netto A., Microangiographic Study of Telengiectasia. This study demonstrated, direct connection of the telengiectasias with named veins such as greater saphenous and other superficial veins; and, also demonstrated communicating veins directly connecting the telengiectasias to the sapheno-femoral junction.

  4. 4 Dermatologica 1963, 127; 321-329 . Faria J.L., Moraes I.N., Histopathology of the Telengiectasias associated with Varicose Veins Telengiectasias are associated with elevated venous pressure. Telengiectasias are linked to varicose veins. Spider Veins Varicose Veins Spider Veins Spider Veins Tretbar LL: The origin of reflux in incompetent blue reticular Telengiectatic veins. In, Davy A, StemmerR, (eds) Phlebology 89, Montrogue, France, John Libbey Eurotext, 1989, p95. Spider Veins Telengiectasias may receive venous hypertension from sub dermal reticular network associated with reflux demonstrated by Doppler study. Corona Phlebectatica Spider Veins

  5. 5 J Dermatol Surg. Oncol. 18:403, 1992 Bohler-Sommereger K., Karnel F., Schuller- Petrovic SS., Sautler R., “Do telengiectasias communicate with the deep venous system.” Telengiectasias may receive their pulse of venous hypertension directly through minute incompetent perforating veins. Spider Veins--relation to growth factors and embryological origins Embryological Basis of Varicose and Spider Veins Goren G, Yellin AE, Primary varicose veins: Topographic and hemodynamic correlations. J Cardiovasc Surg 31:672-677, 1990 A Doppler study of the distribution of varicose veins confirmed the presence of a distinct group of non-saphenous varicosities on the lateral aspect of the thigh and calf that represented the lateral venous system.

  6. 6 Embryological Basis of Varicose and Spider Veins Albanese AR, Albanese AM, Albanese, EF. Lateral subdermic varicose vein system of the legs. Its surgical treatment by the chiseling tube method. Vasc Surg 3:81-89, 1969 Based on anatomical dissections by Hochstetter, the initial venous system of the leg is characterized by a network of superficial veins from which the lateral venous system is derived. The deep venous system then develops in a rudimentary way, accompanied by development of a superficial external saphenous vein that is connected by small perforators to the deep system. When the deep system becomes predominant, the external saphenous vein disintegrates at the thigh, but not without leaving a few perforators intact. Albanese et al. speculated that, in areas where the superficial veins do not involute, superficial embryonic veins remain and may become easily and prematurely varicose. This change occurs for two reasons: (1) because of their superficial location, these veins are poorly supported by surrounding connective tissue; and (2) direct tansfascial perforators continue to connect these veins with the deep venous system. Angiogenic Factors and Spider Veins Bernard KG, Whimster J, Clemenson G, Thomas MI, Browse, NL. The relationship between the number of capillaries in the skin of the ulcer-bearing area of the lower leg and the fall in foot vein pressure during exercise. Br J surg 68:297-300, 1981 The vascular proliferation seen in the skin of patients with venous disease has been known for many years but has not been explained. In recent years many angiogenic factors that stimulate the growth of blood vessels have been recognized. Chapter 24 Page 519 Wickelgran I, Sci News 135:376-378,1989 Pennisi E, Sci News 140:220-223, 1991 Angiogenesis is poised to initiate rapid proliferation of new vessels, with entire cell populations turning over every 3 to 5 days following exposure to a wide variety of stimuli. These stimuli include: • Hypoxia •Venous Hypertension •Adaptive biochemical forces •Tissue trauma •Growth

  7. 7 The following articles from the medical literature show the symptoms caused by spider veins of the legs: Handbook of Venous Disorders 1996 Edition The symptoms may not be recognized by the patient as being due to the varicose veins so they must be asked for by the interested physician. Neither the patient nor the physician may understand that these symptoms arise from telangiectatic blemishes as well as venous varicosities. This is true and some 50% of patients with telangiectasias will have such symptoms and 85% will be relieved of them by appropriate therapy. Page 399 Current Therapy in Vascular Surgery 2001 Negative physician perception regarding availability and efficacy of treatment of varices deny the patient the precise care that is sought. Furthermore, symptoms of primary venous insufficiency may be present but not recognized by the patient until asked for during a thorough history taking. Chapter 4 VENOUS PHYSIOLOGY AND PATHOPHYSIOLOGY Page 28 Weiss RA et al, J Dermatol Surg Onc 1990; 16:333-336 Symptoms may be present in up to 98% of patients with “clinically relevant” alterations of venous circulation, but even small telengiectasias are often symptomatic: 53% of patients presenting with telengiectasias less than 1mm in diameter complain of symptoms that resolve with treatment.

  8. 8 Chapter 23 Painful Telangiectasias: Diagnosis and Treatment page 506 Table 23-1. Symptoms of painful telangiectasias* Patients with post- Symptom Overall Incidence% treatment Improvement % Fatigue, general ache 32 85 Pain in region of telangiectasias 31 86 or reticular vein Focal burning 27 93 Night Cramping 21 70 Local Edema 19 83 Throbbing sensation (focal or general) 17 86 Weiss RA et al, J Dermatol Surg Onc 1990; 16:333-336 Chapter 4 VENOUS PHYSIOLOGY AND PATHOPHYSIOLOGY Page 29 Weiss RA et al, J Dermatol Surg Onc 1990; 16:333-336 Table 4-3 Symptoms of Pain from Telagiectatic Webs ______________________________________ Fatigue Heaviness Focal burning or aching Focal pruritis Sharp intermittent stabbing pain (focal) Diffuse burning Night cramping Restless legs ___________________________ Chapter 23 Page 500 Chapter Painful Telengiectasias: Diagnosis and Treatment Lofgren KA, Postgrad Med 65:131-139, 1979 Pain associated with telengiectasias may be a consequence of stretching caused by pressure transmitted during reflux through reticular veins and venulectases. “the largest varicosities sometimes cause no complaints; other veins of small caliber may give rise to surprising discomfort.”

  9. 9 Symptoms Caused by Spider Veins Ibeghuna V, Delis K, Nicolaides AN. Effect of lightweight compression stockings on venous hemodynamics. Int Angiol 16:185-188, 1997 Many of our patients whose occupations involve long periods of standing have complained of muscle fatigue and aching or localized pain over group of telangiectasias and/or venulactases. Some relief of symptoms occurs by wearing lightweight support hose. Dermatol Surg 21:321-323, 1995 Isacs MN, Symptomatology of vein disease Aching/pain, excessive tiredness/fatigue, and throbbing in the legs correlate well with patients presenting with nonbulging reticular veins and telangiectasias compared with a matching control group. Furthermore, these symptoms were independent of the size of the veins. Why Minor Varicose Veins Cause More Leg Pain Than Larger Varicose Veins? Lofgren KA. Varicose veins : Their symptoms, complications, and management. Postgrad Med 65:131-139, 1979 The largest varicosities sometimes cause no complaints; other veins of small caliber may give rise to surprising discomfort. One theory that attempts to explain this phenomenon is that compliance of small veins may be greater than that of larger veins, with more dispensability and grater stretch resulting in greater stimulation of neural pain receptors.

  10. 10 How Minor Varicose Veins Cause Leg Pain Weiss MA, Weiss RA, Goldman MP. How minor varicose veins cause leg pain. Contemp Obstet Gynecol 36:113-125, 1991 Most patients experienced several symptoms. Frequently these symptoms were exacerbated during menses. A small percentage of our patients experienced pain or swelling only during menses. Venous Insufficiency--Superficial and deep Development of Venous Insufficiency Overflow of Blood Groin Level Deep Vein Late Stages Superficial Vein

  11. 11 Following articles demonstrate the relation of superficial and deep venous insufficiency-- superficial venous insufficiency leads to deep venous insufficiency; and, treatment of superficial venous insufficiency improves the deep venous incompetence: Ann Vasc Surg 1994;8:566-570 Femoral Venous Reflux Abolished by Greater Saphenous Vein Stripping In 27 of 29 limbs with preoperative femoral reflux, that reflux was abolished by greater saphenous stripping. In patients with popliteal reflux both femoral and popliteal reflux was abolished. Improvement of deep venous hemodynamics by ablation of superficial reflux supports the reflux circuit theory of venous overload. J Vasc Surg 1996;24:711-8 Hemodynamic and clinical improvement after superficial vein ablation in primary combined venous insufficiency with ulceration. Superficial and perforating vein incompetence accounts for a substantial and correctable component of venous insufficiency in limbs with combined deep and superficial vein reflux and venous ulceration. These data indicate that surgical correction of this component significantly improves clinical symptoms and venous hemodynamics. Superficial and perforator ablation is an appropriate initial step in the management of combined deep and superficial incompetence. Ann Vasc Surg 1996; 10:186-189 Correction of Lower Extremity Deep Venous Incompetence by Ablation of Superficial Venous Reflux Postoperative interrogation of the venous system revealed that in 16 (94%) of 17 patients, coexistent femoral venous insufficiency completely resolved. Thus ablation of superficial venous reflux eliminated incompetence in the deep venous system in patients with combined disease. These preliminary results suggest that superficial venous incompetence may be a cause of deep venous insufficiency.

  12. 12 Haimovici’s Vascular Surgery Fourth Edition 1996 Chapter 87: Clinical Application of Objective Testing in Venous Insufficiency- page 1147 Improvement of deep venous hemodynamics by ablation of superficial reflux supports a reflux circuit theory of venous overload. It would be logical to suppose that ablation of such a reflux by superficial vein removal would correct the deep venous volume overload and allow diminution of the diameter of veins, thus producing valvular competence. Page 411 Page 412 1996 Earlier study of Phlebograms had shown that deep venous diameter was greatest in limbs with superficial reflux. Deep veins in limbs with proven prior deep venous thrombosis were actually found to be thinner in diameter than normal and those limbs with superficial reflux [46]. Now Doppler ultrasonography has shown that deep venous reflux in limbs with varicose veins proven not to have been the site of previous thrombosis is a startling 20.6%. Such deep venous reflux correlates with the severity of superficial reflux [47]. Using indirect parameters of venous pathophysiology, hemodynamics of the deep venous system were observed to improve after treatment of superficial venous incompetence [44]. Vascular Surgery A Comprehensive Review Edited by Wesley S. Moore, M.D. 1998 Chapter 42 Page 803-805 Niren angle and John J Bergan Varicose Veins: Chronic Venous Insufficiency We have recently studied 58 limbs with class 3 venous reflux. Ten limbs (17%) exhibited only superficial reflux, and superficial reflux was a major contributor to chronic venous dysfunction in an another 17 limbs. Of some importance is the fact that primary, nonthrombotic deep (superficial femoral and popliteal vein) incompetence may accompany superficial reflux. This is explained by reflux proceeding distally down the greater saphenous vein and overloading the deep venous system.(40) One would presume this causes dilatation and elongation of the deep vessels so that their valves become incompetent. Our own study of limbs following greater saphenous vein stripping in which superficial and popliteal venous incompetence was present has revealed correction of the deep reflux by superficial venous stripping in a vast majority of limbs.(41)

  13. 13 Page 298 Page 299 2001 Investigations of venous pathophysiology in continental Europe are influenced by the observations of Friederich Trendelenberg, Professor of Surgery in Bonn in the 1880s. In his 1891 publication advocating greater saphenous vein ligation, he coined the term ‘private circulation’ to describe the gravitational reflux down the saphenous vein which returns proximally through perforating veins and the deep venous system. 43 Later observers have noted that this private circulation is associated with primary deep venous valvular incompetence and this is the most important consequence of saphenous reflux. 44 Journal of Vascular Surgery (October 2000; 32:663-8) Prevalence of deep venous reflux in patients with primary superficial vein incompetence The prevalence of deep venous insufficiency in patients with primary superficial venous reflux and without history of DVT is 22%. J Am Coll Surg 2002;195:822-830 Comparative Evaluation of Duplex Derived Parameters in Patients with Chronic Venous Insufficiency: Correlation with Clinical Manifestations. This study has suggested the importance of superficial venous insufficiency in the development of advanced Chronic Venous Insufficiency (CVI). Superficial insufficiency is predominant in both early and advance CVI. These reports suggest that superficial incompetence produces an overflow of venous return through perforating veins into the deep system. Superficial venous insufficiency might play a major role in the development of advanced CVI.

  14. 14 Chronic venous insufficiency: Clinical and duplex correlations. The Edinburgh Vein Study of venous disorders in the general population. J Vasc Surg 2002 ;36:520-5 The prevalence of CVI rises steeply with age. There is a strong correlation between venous symptoms and the presence and severity of CVI. CVI is associated in approximately one third of the subjects with incompetence limited to the superficial system and in these a good therapeutic outcome could be expected from surgery to the superficial veins. The severity of clinical features correlates significantly with prevalence of valvular reflux in the deep and superficial systems. J Vasc Surg 2003; 38:517-21 How often is deep venous reflux eliminated after saphenous vein ablation In patients with concomitant deep and superficial venous reflux, saphenous vein ablation results in resolution of deep reflux in about a third of patients. Deep Venous Thrombosis and Superficial Venous Reflux J Vasc Surg 2000; 32:48-56 Superficial venous thrombosis frequently accompanies DVT and is associated with development of superficial reflux in most limbs. However, a substantial proportion of observed reflux is not directly associated with thrombosis and develops at a rate equivalent to that in uninvolved limbs. It can, therefore, be concluded that deep venous reflux is the result of superficial venous reflux.

  15. 15 December 2004 Vol. 40, No. 6:1184-9 Five-year outcome study of deep vein thrombosis in the lower limbs Akram M. Asbeutah, MS., Andrea Z. Riha, MBBS., James D. Cameron, MD Barry P. McGrath, MD December 2004 Vol. 40, No. 6 An important finding of this study was an unexpectedly high incidence of venous reflux in the apparently unaffected limb. Although these non-DVT limbs were not investigated at presentation, our data is consistent with the hypothesis that DVT may result in a more systemic disorder of venous function. This study points out the fact that deep venous insufficiency is usually the primary pathology that leads to deep venous thrombosis; therefore, it is very important to treat superficial venous insufficiency aggressively, including the treatment of saphenous venous reflux and complete elimination of all the varicose and spider veins, in order to improve DVI. November 1998 • Volume 28 • Number 5 Endoscopic perforator vein division with ablation of superficial reflux improves venous hemodynamics Jeffrey M. Rhodes, MD, Peter Gloviczki, MD, Linda Canton, RN, BSN, Tracy V. Heaser, RVT, Thom W. Rooke, MD Rochester, Minn SEPS with ablation of superficial reflux improved calf muscle pump function, reduced venous incompetence, and produced excellent midterm clinical results. However, functional improvement directly related to SEPS requires further investigation. This study supports adding SEPS to ablation of superficial reflux in patients with advanced chronic venous insufficiency. (J Vasc Surg 1998;28:83947.) This study shows that elimination of superficial venous reflux by treating perforator veins, with SEPS, reduces deep venous incompetence. Spider Veins Resulting in Ulceration and Bleeding

  16. 16 THE CONCEPT Spider veins and their connection to the deep veins

  17. 17  Color Duplex Scan with the patient in an upright position  Endovenous Closure  Ambulatory micro-phlebectomy in multiple sessions  Spider veins treated with trans-cutaneous intense pulse light (BBL) and/or ND:YAG laser in multiple sessions 2-3 weeks apart  Leg exercises—detailed instructions  Compression stockings  A thorough education in venous disease  Diet and supplements—detailed instructions(0ptional)  Every six months—a follow-up color Duplex scan

  18. 18 Guideline of American Venous Forum for the Treatment of Spider Veins Treatment algorithms for telengiectasias and varicose veins: Current Guidelines (Guidelines 4.12.0 of American Venous Forum on treatment algorithms for telengiectasias and varicose veins) Page 444 Grade of Recommendation 1, We recommend 2, We suggest Grade of Evidence A, high quality B, moderate quality C, low or very low quality Guideline No. 4.12.1 For class 1 venous disease we recommend treatment of symptomatic patients, but treatment can be considered in asymptomatic patients as well. We recommend sclerotherapy or laser for spider telengiectasias, and liquid or foam sclerotherapy for reticular veins. Class 1 Venous Disease—Spider Veins 1 A

  19. 19 Venous Duplex Scan--Criteria of reflux Duplex Scan Criterion currently used for the diagnosis of Venous Reflux: Duration of reflux-- 0.5 second or more, documented with Duplex scan November 1992 • Volume 16 • Number 5 Original Articles from the American Venous Forum A comparison between descending phlebography and duplex Doppler investigation in the evaluation of reflux in chronic venous insufficiency: A challenge to phlebography as the “gold standard” Peter NeglenMD, PhDSeshadri Raju, MD Al-Ain, United Arab Emirates, and Jackson, Miss. 1992;16:687–93. Reflux was considered significant if the duration of retrograde flow exceeded 0.5 second and was measured in the common femoral, superficial femoral, long saphenous, popliteal, and proximal and distal posterior tibial veins

  20. 20 May 2003 • Volume 37 • Number 5 Quantified duplex augmentation in healthy subjects and patients with venous disease: San Diego population study Arnost FronekMD, PhD Julie O. DenenbergMA Michael H. CriquiMD, MPH Robert D. LangerMD, MPH San Diego, Calif 2003;37:1054-8 Subjects were examined on a tilt table in a reversed 15-degree Trendelenburg position with the legs slightly flexed in minimal external rotation for maximum comfort. The duplex probe was used to determine vein compressibility5-7 in all examined veins. An automatic cuff inflator (Hokanson, Bellevue, Wash) was connected to cuffs placed at mid-thigh to examine the common femoral vein, superficial femoral vein, and sapheno-femoral junction; at mid-calf to examine the popliteal vein and sapheno-popliteal junction; and at foot level to examine the posterior tibial vein. Standard rapid inflation (100 mm Hg) and deflation were performed, and response in the examined veins, ie, augmentation of flow velocity, was determined. Duration of inflation was 3 seconds, and reflux longer than 0.5 seconds was considered a positive result Positive Indicators of Reflux: GSV: reflux >= 0.5 seconds size: > 6.0 mm SSV: reflux >= 0.5 seconds size: > 3.0 mm CFV: reflux >= 0.5 seconds Popliteal: reflux >= 0.5 seconds Perforator: reflux >= 0.3 seconds size: > 3.0 mm

  21. 21 Patient Positioning for Venous Duplex Scanning: Change of Vein Size with Patient Position Effects of Position on vessel Size Vein size—0.75 cm Vein size—1.0 cm Standing Leg Elevated Supine e Vein size—0.5 cm Patient Positioning for Venous Duplex Scan Ideal Position Small Saphenous Veins Incorrect Position Great Saphenous Veins Correct Position (until recently)

  22. 22 Revised CEAP Clinical Classification of Venous Disease C--Clinical E--Etiology A--Anatomical P--Pathophysiology Clinical Classification C0: No visible or palpable signs of venous disease C1: Telangiectasias or reticular veins C2: Varicose veins C3: Edema C4a: Pigmentation or eczema C4b Lipo-dermatosclerosis or atrophie blanche C5: Healed venous ulcer C6: Active venous ulcer S: Symptomatic (including ache, pain, tightness, skin irritation, heaviness, muscle cramps, and other complaints attributable to venous dysfunction) A: Asymptomatic

  23. 23 VENOUS VENOUS NOMENCLATURE NOMENCLATURE Old Terminology Femoral Vein Long Saphenous Vein Greater Saphenous Vein Superficial Femoral Vein Lateral Accessory GSV Medial Accessory GSV Short Saphenous Vein Lesser Saphenous Vein Perforators (Hunter, Boyd, Dodd, Cockett-1,2,3) Giacomini Vein New Terminology Common Femoral Vein Great Saphenous Vein Femoral Vein Anterior Accessory GSV Posterior Accessory GSV Small Saphenous Vein Perforators (Femoral, Paratibial, Posterior Tibial) Intersaphenous Vein Thigh extension of Small Anterior Accessory Posterior Accessory Intersaphenous Vein Great Saphenous Vein Small Saphenous Vein

  24. 24 Femoral Vein Great Saphenous Vein Re-entry Perforator Classification of Saphenous Refluxes Type 1: Varices with competent GSV Type 2: GSV Reflux Without Varices Type 3: Varices with Incompetent GSV and Competent Saphenous Junction Type 4: Varices with Incompetent GSV and Saphenous Junction Type 5: Varices with Reflux Limited at the Saphenous Junction

  25. 25 Chapter 20: Laser And High Intense Pulse Light No. of Treatments Needed For Each Area

  26. 26 Chronic Venous Insufficiency Sclerotherapy

  27. 27 Compression Therapy Compression Strength 8-15mm Indications Leg fatigue, mild swelling, stylish Mild aching, swelling, stylish 15-20mm Aching, pain, swelling, mild varicose veins Aching, pain, swelling, varicose veins, post-ulcer Recurrent ulceration, lymphedema 20-30mm 30-40mm * 40-50, 50-60mm * * Requires a prescription 2009 by American College of Phlebology 64 21stAnnual Congress of the American College of Phlebology 8-11 November 2007 Paper 1.6 The effect of three– month mandatory conservative treatment with compression hose therapy on quality of life issues and great saphenous vein reflux . Kenneth E. Harper, Elizabeth Hall, Barbara Loyd, Sanjae Hyun, and Melanie Chastain. Vein specialists of the South, LOLC, 556 Third Street, Suite A, Macon 31211; Mercer University, Macon, GA, USA Presented by: Kenneth E. Harper 43 patients (77% female) with reflux and studied for the effect of three months of conservative therapy with compression hose. There was no statistically significant improvement in the GSV reflux and other QOL issues to warrant mandatory conservative therapy prior to correction of venous reflux.