B36. Primary varicosity of the lower limbs.

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Chronic venous disorders

Definition and epidemiology

Chronic venous disorder (CVD) is an umbrella term for chronic disorders of the veins of the legs. It’s more common in women and includes disorders like varicose veins and chronic venous insufficiency. CVD is very common (as varicose veins are very common) but is mild in most cases.

Chronic venous insufficiency (CVI) is a severe form of CVD, where there is oedema, skin changes, or ulceration (clinical stage C3 or higher). CVI is relatively common and affects up to 5% of US adults.

Etiology

CVD can be primary or secondary:

  • Primary CVD
    • Family history
    • Sedentary lifestyle
    • Obesity
    • Smoking
  • Secondary CVD
    • Previous DVT (post-thrombotic syndrome)
    • Previous trauma

Pathomechanism

Venous hypertension, whether due to obstruction or reflux, impedes flow in the veins. Reflux occurs if the valves of the deep veins become incompetent, so that blood refluxes backwards instead of flowing back to the heart, increasing the pressure in the veins. Hypertension causes the lumen to dilate, eventually to the degree where the lumen is so dilated that the flaps of the valves can’t make contact in the lumen of the superficial veins, making them incompetent too, worsening the problem.

When walking, calf muscles pump blood from the deep veins toward the heart, reducing the pressure inside the veins. When the valves are incompetent, blood is pumped backwards into the superficial veins during walking instead of towards the heart, thereby increasing pressure in these veins rather than reducing it. Obstruction, e.g. due to a thrombus, also causes hypertension proximal to the obstruction.

Poor flow traps WBCs in the veins, which release proteolytic enzymes which damage the capillary basement membranes. This causes plasma to leak into the interstitium, causing oedema. Oedema decreases oxygen delivery to tissues, causing inflammation and hypoxia. Extravasation of RBCs causes haemosiderosis, causing pigmentation

Classification

Chronic venous disorders are classified according to the CEAP classification, which stands for Clinical, Etiological, Anatomical and Pathophysiological. The clinical part of it is the most important and shows the clinical manifestations of CVD from least severe to most.

  • C0 – No signs of venous disease
  • C1 – Telangiectasias
  • C2 – Varicose veins
  • C3 – Oedema
  • C4a – Pigmentation or eczema
  • C4b – Lipodermatosclerosis or white atrophy (atrophie blanche)
  • C5 – Healed venous ulcer
  • C6 – Active venous ulcer

Clinical features

There are many clinical stages of CVD, with different clinical manifestations. General symptoms include a feeling of heaviness in the leg, oedema, and pain. This pain is worsened when standing and having the leg below the body, but relieved by walking (which is, notably, opposite of that of PAD).

Telangiectasia, also called spider veins, are small dilated intradermal veins. Varicose veins are superficial veins which have become dilated and tortuous to the point where they’re visible and palpable on the legs.

Skin changes can occur and cause itching, stasis dermatitis, and pigmentation changes. Lipodermatosclerosis is a localised inflammation and fibrosis of the skin, which causes induration and pain. White atrophy refers to white atrophic plaques of skin, which are white due to the absence of capillaries in the fibrotic plaques.

Diagnosis and evaluation

Chronic venous disorders are mostly a clinical diagnosis, but duplex ultrasound can show retrograde flow (reflux) and/or obstruction in the veins. Ultrasound is especially important in those considered for surgery as the presence of reflux and/or obstruction influences the choice of treatment.

Treatment

Conservative treatment is indicated for all patients and includes:

  • Compression stockings
  • Frequent elevation of legs
  • Physical therapy
  • Manual lymphatic drainage by massage
  • Avoiding long periods of standing

Skin changes can be managed with moisturiser and topical corticosteroids. Ulcers require typical wound treatment, including debridement, skin care, and wound dressings. Skin grafts may be necessary in larger ulcers.

For most patients, conservative treatment is sufficient. Surgery is indicated if symptoms persist, or in case of severe symptoms. There are many options for surgical treatment:

  • For superficial veins
    • Injection sclerotherapy
    • Vein ligation
    • Vein stripping
    • Endovenous laser treatment
    • Radiofrequency ablation
  • For perforating veins
    • Subfascial endoscopic perforator surgery (SEPS)
    • Cockett operation
  • For deep veins
    • Palma operation (femoro-femoral crossover saphenous bypass)
    • Vein segment transplantation (of a segment containing intact valves)
    • Valvuloplasty (valve repair)
    • Vein transposition

The choice of procedure depends on the underlying pathomechanism (reflux, obstruction, or both) and which veins are affected (superficial, perforating, deep).


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Surgery – Traumatology

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