Chapter 173
The Growing Threat of
Chronic Venous Disease
Prakash Ramamoorthy
INTRODUCTION
India has made great strides in many aspects along with
industrialization. We are witnessing the emergence of many new
diseases. One of the underestimated causes of morbidity, workplace
absenteeism, increasing economic burden for the patient has been
the growing threat of chronic venous disease.
We do not have exact statistics for the Indian population figures
from the west make grim reading. India is likely to be only worse with
regards to venous disease.
Consider the following:
Chronic venous disease affects 40% of the US population
Chronic venous insufficiency (CVI) with ulceration affects up
to 2% of the population; an incidence comparable with the
incidence of diabetes
In UK almost 1 billion dollars equivalent is spent on managing leg
ulcers
Disease becomes more common with advancing age when other
issues in the family takes priority and these elderly patients may
not find support from the family members
Many employers do not wish to employ these patients with active
ulcers
A B
Figures 1A and B: Venous ulcer
Author has personally seen a patient whose wife divorced him
due to his chronic ulcers. Also many young male patients have
their marriage delayed due to ulcers.
Unfortunately, despite all of the above, physicians and the patients
do not consider CVI seriously as it is neither life nor limb threatening.
PRESENTATIONS OF VENOUS DISEASE
(FIGURES 1A AND B)
The presentation may be one of the following:
1. Varicose veins (dilated tortuous veins): Classification includes
trunk veins (varicosities of greater and lesser saphenous veins),
reticular veins (subcutaneous veins that begin at the tributary of
trunk veins) and telangiectasias (intradermal small varicose veins
which are asymptomatic)
2. Deep vein thrombosis (DVT): This may involve any deep vein
from tibial veins up to a totally occluded inferior vena cava (IVC)
symptoms, in an appropriate settings, includes unilateral leg
edema, pain, warmth, dilated veins
3. Superficial vein thrombosis or superficial thrombophlebitis
4. Sequelae of old chronic venous insufficiency: Heaviness,
pigmentation, discoloration venous eczema, ulcerations. These
 Surgery Section 25

groups of symptoms form what is called the post-thrombotic

syndrome.

RISK FACTORS FOR VARICOSE VEINS

Age: Incidence increases with age
Sex: More common in females. Pregnancy may be the most
important stress leading to varicose veins
Genetics: Individual with a genetic predisposition may develop
varicose veins when exposed to stress like obesity and pregnancy
Occupation: It conflicts reports. But incidence is definitely higher
in standing occupations like barbers
Parity: Women with multiple pregnancies may be at risk
Diet: Constipating diet may lead to straining, raised intra-
abdominal pressure and this leads to varicose veins
Other factors include obesity and heavy weight lifting.
Figure 3: Virchow triad
RISK FACTOR FOR DEVELOPING
DEEP VEIN THROMBOSIS
1. Stasis of blood flow: The first category, alterations in normal blood
These are summarized by what is called Virchows Triad. The origin
flow, refers to several situations. These include venous stasis,
of the term Virchows Triad is of historical interest, and has been
turbulence, mitral stenosis and varicose veins
subject to reinterpretation in recent years. While both Virchows and
2. Endothelial injury: The second category, injuries and/or trauma
the modern triads describe thrombosis, the previous triad has been
to endothelium includes vessel piercings and damages arising
characterized as the consequences of thrombosis and the modern
from shear stress or hypertension. This category is ruled by
triad as the causes of thrombosis.
surface phenomena and contact with procoagulant surfaces,
Rudolf Virchow elucidated the ethology of pulmonary embolism,
such as bacteria, shards of foreign materials, biomaterials of
whereby thrombi occurring within the veins, particularly those of
implants or medical devices, membranes of activated platelets
the extremities, become dislodged and migrate to the pulmonary
and membranes of monocytes in chronic inflammation
vasculature (Figure 2). He published his description in 1856 in
3. Hypercoagulability: The last category, alterations in the
detailing the pathophysiology surrounding pulmonary embolism;
constitution of blood, has numerous possible risk factors such
he alluded too many of the factors known to contribute to venous
as hyperviscosity, deficiency of antithrombin III, nephrotic
thrombosis. While these factors had already been previously
syndrome, changes after severe trauma or burn, disseminated
established in the medical literature by others, for unclear reasons
cancer, late pregnancy and delivery, race, age, whether the
they ultimately became known as Virchows triad. This eponym did
patient is a smoker, and obesity. All of these risk factors cause the
not emerge in the literature until long after Virchows death. One
situation called hypercoagulability.
estimate of the first use of the phrase dates it to the early 1950s.
Although the concept of the triad is usually attributed to
Virchow, he did not include endothelial injury in his description INVESTIGATIONS
(Figure 3). This has been attributed to a dispute Virchow had with Routine investigations include preoperative work up for varicose
Jean Cruveilhier, who considered local trauma of primary importance vein patients
in the development of pulmonary artery thrombosis. Color Doppler has become the gold standard in the evaluation of
the venous patient. A thorough evaluation of all the components
of the venous system from IVC to ankle will take almost 45 minutes
and may not be possible in a busy set up. This must be done with
patient in the lying down and erect position. All perforators
must be marked on the skin with indelible ink, as must be the
saphenopopliteal junction if incompetent. More challenging is the
evaluation of the patient with recurrent varicose veins (Table 1)
Other investigations include plethysmography, isotope studies,
venography and intravascular ultrasound which are not available
widely and also may not be much relevant from a practical point
of view
For the patient with DVT, apart from venous Doppler, other
investigations will include CBC (to evaluate Hb possible
leukemias), urea, creatinine, complete urinalysis to evaluate
proteinurias and liver function tests. Malignancy is an important
etiological factoridiopathic spontaneous thrombosis either
arterial or venous is never a diagnosisit is a symptom of some
underlying pathology. This may be malignancy. All possible
investigations must be considered as 10% of patients with
idiopathic DVT go on to manifest the underlying malignancy over
due course. This includes prostate, lymphomas, bronchogenic ca,
ovarian ca and so on
The role of evaluating the patient for hypercoagulopathies after first
Figure 2: Rudolf Virchow thrombotic episode is not very rewarding; it is very expensive, up
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 Section 25 Chapter 173 The Growing Threat of Chronic Venous Disease

TABLE 1Stages of hypercoagulability

Hypercoagulable states General Patients with Thrombophilic
population (%) single VTE families
Factor V Leiden 37 20 50
Prothrombin G20210A 13 6 18
Antithrombin deficiency 002 1 48
Protein C deficiency 0.20.4 3 68
Protein S deficiency N/A 12 313
Hyperhomocystenemia 510 1025 N/A
Antiphospholipid antibodies 07 515 N/A

to 40% of the patients may not test positive for hypercoagulability Sclerotherapy: Another procedure which has found wide spread
despite manifesting venous thromboembolism (VTE). acceptance has been the use of sclerosants. This is particularly
widespread in Europe and has given rise to group of specialists
CEAP CLASSIFICATION called sclerotherapists who do only sclerotherapy
(AMERICAN VENOUS FORUM 1994) Dermal laser and sclerotherapy have been used for treating
thread veins
In order to standardize reporting of venous diseases Clinical, Drugs which have been used to treat venous insufficiency include
Etiological, Anatomical, Pathophysiological (CEAP) classification flavonoid plant extracts (e.g. Daflon), anabolic steroids, aspirin, etc.
as defined by the American venous forum in 1994 has been adapted
worldwide. This underwent further modification in 2004. In order
TREATMENT OF DEEP VEIN THROMBOSIS
to encourage widespread acceptance a Basic CEAP has also been
defined. This involves initial treatment with heparin, either unfractionated or
low molecular weight, and then converting to oral anticoagulation.
Clinical Classification Proper advice must be given regarding duration, wearing proper
graduated compression stockings, dos and donts with regards to
C0: no visible or palpable signs of venous disease diet, intramuscular injections, other drug interaction, etc.
C1: telangiectasias or reticular veins
C2: varicose veins
PROBLEMS PECULIAR TO INDIAN SCENARIO
C3: edema
C4a: pigmentation or eczema Many patients regard varicose veins as nerves and are scared of
C4b: lipodermatosclerosis or atrophie blanche treatmentthey fear that they may not be able to walk again. In
C5: healed venous ulcer fact, many patients go to a neurologist for treatment
C6: active venous ulcer There is a misconception that even after surgery, varicose veins
will recursurgeons have to mention a recurrence rate of 5%
Etiologic Classification when getting consent
Patients present only advanced state in fact, it is one of the
Ec: congenital complications of varicose veins which brings the patient to
Ep: primary the surgeon-ulcer, bleeding from varicose, superficial vein
Es: secondary (post-thrombotic) thrombosis which can lead to DVT in about 1015%
En: no venous cause identied Unlike west, request for surgery from a cosmetic point of view
does not happen in India due to full length dresses worn by
Anatomic Classification patients with even advanced cases
As: supercial veins Even specialist doctors like dermatologist do not refer the patient
Ap: perforator veins at the appropriate time for some reason best known to them
Ad: deep veins Some of the worst sufferers come from the group involved in long
An: no venous location identied standing occupations like grocery shop, bakery, hotel, police who
do not have the awareness nor the means to change occupation
Pathophysiologic Classification Deep vein thrombosis has always been under recognized, under
diagnosed and under treated in India. These patients present very
Pr: reux late due to severe stasis changes. Physicians should remember
Po: obstruction that the post-thrombotic syndrome of today is the neglected DVT
Pr,o: reux and obstruction of yesterday
Pn: no venous pathophysiology identiable There is a very high incidence of pro-thrombotic state in the
Indian population; one condition which is easy to diagnose and
TREATMENT OF VARICOSE VEINS treat is secondary polycythemia due to smoking
Classical operation of Trendelenburg: It involves dissection in the Fear of surgery, fear of recurrence, neighbors and relatives are the
groin, disconnecting all the named tributaries of long saphenous main reasons why the Indian patient typically comes very late
vein, stripping up to ankle. This may be combined with perforator Employers attitude: A famous textile chain in south forbids
ligation its employees from sitting throughout the dayno chairs are
Thermal ablation: Current minimally invasive alternatives available and they are forced to stand throughout their duty
include radiofrequency ablation (RFA), laser ablation, steam which may be between 8 and 10 hours. This is unheard of and
ablation. These are currently very expensive unacceptable in a western society.
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CONCLUSION
Patient and doctors are to be educated regarding morbidity
caused by chronic venous problems and persuaded to seek
surgical treatment at the earliest. Skin changes, once they set in,
almost become permanent
Have a low threshold for getting a venous Doppler for any patient
with a unilateral swelling in an appropriate clinical setting to rule
out DVT-post-thrombotic syndrome of today is neglected DVT of
yesterday
In all patients with idiopathic DVT suspect and rule out underlying
malignancy and thrombophilias by ordering appropriate tests
Proper compression stockings are essential to prevent post-
thrombotic syndrome
Varicose veins and venous eczema must be aggressively treated,
especially in the diabetics as they run a high risk of developing
limb threatening cellulitis.
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