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 Chronic Venous Insufficiency

John F. Eidt , M.D., Dhiraj M. Shah, M.D., James N. Thomas, M.D.

Includes:

  • Noninvasive Diagnosis
  • Medical Treatment
  • Sclerotherapy
  • Surgical Reconstruction including Subfascial Ligation of Perforators, Valvular
  • Repair/Transposition, Vein Stripping/ Ligation

Congenital Causes I. Anatomy & Pathophysiology

1. To review normal venous anatomy: superficial, deep and perforatoring veins, greater saphenous vein (GSV), lesser saphenous vein (LSV), femoral, popliteal & tibial vessels.

2. To describe the major venous anatomic variants of clinical importance including left sided inferior vena cava, retroaortic and circumaortic left renal vein.

3. To understand normal venous hemodynamics and the derangements associated with chronic venous insufficiency.

4. To review the epidemiology of chronic venous insufficiency.

5. To understand the function of normal venous endothelium and its alteration in chronic venous insufficiency (e.g. production of prostacyclin , plasminogen activator, heparans and thrombomodulin ).

6. To outline the major risk factors for venous thrombosis including acquired and hereditary hypercoagulable conditions.

7. To review the postulated consequences of venous thrombosis on normal venous patency and valve function.

8. To explain the relationship between acute deep vein thrombosis and the eventual development of chronic venous insufficiency.

9. To define: Chronic venous insufficiency

Varicose veins

Perforating veins

Telangiectasia

Sclerotherapy

Lipodermatosclerosis

Venous claudication

Phlegmasia cerulea dolens

10. To review the postulated chain of events that leads to lipodermatosclerosis and venous ulceration.

11. To understand that chronic venous disease is defined as an abnormally functioning venous system caused by venous valvular incompetence with or without venous outflow obstruction which may affect the superficial venous system, the deep venous system or both.

12. To understand that the term post - thrombotic may be used if the patient has experienced an objectively documented episode of DVT. The term postphlebitic syndrome should not be used because this implies the presence of an inflammatory component that is infrequently confirmed.

13. To review the role of inflammatory cells in the development of venous stasis ulcers.

14. To understand that chronic venous insufficiency can lead to significant morbidity and may be disabling.

15. To differentiate congenital from acquired forms of venous insufficiency.

II. Diagnostic Evaluation

1. To review the "CEAP" classification system of chronic venous insufficiency: Clinical condition, Etiology, Anatomic distribution and Pathophysiology .

2. To understand and differentiate the three etiologic categories of venous dysfunction: congenital, primary (acquired, undetermined cause) and secondary (acquired, e.g. post - thrombotic or post traumatic).

3. To differentiate the clinical features of superficial venous insufficiency from deep vein (or combined) insufficiency.

4. To review the noninvasive and invasive evaluation of the venous system including ascending & descending venography , photoplethysmography , air plethysmography , and duplex scanning.

5. To describe the characteristics of venous stasis ulcers and differentiate from other types of ulcers including arterial, neuropathic , malignant, infectious and inflammatory ( vasculitis ).

6. To differentiate stasis dermatitis from other causes of dermatitis in the lower leg.

III. Treatment

1. To describe the types of available therapy for superficial venous insufficiency (varicose veins) including elastic stockings, elevation, sclerotherapy , laser treatment, stab evulsion , stripping.

2. To review the strengths and drawbacks of agents used in sclerotherapy including hypertonic saline, sodium tetradecyl sulfate, polidocanol etc.

3. To recognize the relative risks and benefits associated with treatment of varicose veins including DVT, infection, skin slough, etc.

4. To define the principles of non - operative management of lower extremity chronic venous insufficiency: ambulation, elevation, elastic support.

5. To review the technique of ambulatory phlebectomy ( microstab evulsion ) for varicose veins including the use of tumescent (large volume, low strength) local anesthesia.

6. To review the indications for surgery and surgical options in the treatment of chronic venous insufficiency, varicose veins, venous obstruction and stasis ulceration.

7. To describe the procedures for treatment of valve reflux including valvuloplasty , vein valve autotransplantation and vein segment transposition.

8. To discuss the relative risks and merits of procedures designed to decrease the degree of valve reflux.

9. To describe the procedures designed to treat venous outflow obstruction including autogenous or prosthetic bypass and venous disobliteration .

10. To describe the non - operative management of venous stasis ulcers including UNNA Boot, etc.

11. To review the operative procedures for venous ulceration including subfascial ligation .

12. To outline the technical features of 1) endoscopic subfascial ligation of incompetent ankle perforating veins in the treatment of chronic venous insufficiency and 2) endoscopic excision of varicose veins.

13. To describe the proposed pharmaceutical treatment of venous stasis ulcers: pentoxyphyllines , prostaglandins, antibiotics, growth factors, etc.

References

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Posted June 2010