INSUFISIENSI VENA

KRONIK
disusun oleh:
Intan Maulinar
Pembimbing:
dr. Yopie A. Habibie, Sp.BTKV

Definisi

Insufisiensi vena kronik (chronic venous

insufficiency, CVI) adalah suatu kondisi
dimana dinding atau katup vena tungkai tidak
bekerja secara efektif sehingga aliran darah
balik ke jantung menjadi terganggu.

Epidemiologi

5-30% pada populasi dewasa

Wanita : pria = 3 : 1

Anatomi

Etiologi

Insufisiensi vena kronik yang kongenital (present since birth)

Terdapat kelainan dimana katup yang seharusnya terbentuk di suatu
segmen ternyata tidak terbentuk sama sekali (aplasia, avalvulia), atau
pembentukannya tidak sempurna (displasia), berbagai malformasi vena,
dan kelainan lainnya.

Insufisiensi vena kronik yang primer (undetermined etiology)

Kelemahan intrinsik dari dinding katup, yaitu terjadi daun katup yang terlalu
panjang (elongasi) atau daun katup menyebabkan dinding vena menjadi
terlalu lentur tanpa sebab yang diketahui. Keadaan daun katup yang
panjang melambai (floppy, rebundant) sehingga penutupan tidak sempurna
yang mengakibatkan terjadinya katup tidak dapat menahan aliran balik,
sehingga aliran vena menjadi retrograd atau refluks.

Insufisiensi vena kronik yang sekunder (associated with post-thrombotic,

traumatic)

Faktor Resiko

Penambahan Usia

Jenis Kelamin

Family history of venous disease

Berdiri terlalu lama

Increased body mass index

Smoking

Inaktivitas fisik

Lower extremity trauma

Prior venous thrombosis (superficial or deep)

Hereditary conditions

High estrogen states

Pregnancy 2.

Patofisiologi

Refluks

CVI merupakan akibat dari disfungsi katup-katup vena yang

menyebabkan aliran darah vena yang anterograd untuk
mengalir dalam dua arah, yaitu secara antegrad dan
retrograde, sehingga terjadi refluks darah dalam pembuluh
darah (vena).
Hal ini menyebabkan vena tidak saja menerima darah yang
dipompa dari ventrikel kiri, tetapi juga aliran darah dari
dalam pembuluh darah yang gagal dipompa ke atrium kanan
(atau dari aliran vena yang tidak efisien)
Pembuluh darah vena berfungsi mengalirkan darah dari
seluruh tubuh kembali ke jantung. Untuk mencapai jantung,
darah pada vena tungkai harus mengalir ke arah atas. Otot
otot tungkai harus berkontraksi untuk memeras darah pada
vena tersebut. Vena memiliki katup satuarah untuk

CVI terjadi jika katup ini mengalami kerusakan

sehingga darah yang dipompa kembali ke arah
bawah dan tertumpuk sehingga tekanan dalam
vena meningkat. Kerusakan katup dapat terjadi
akibat proses penuaan, duduk atau berdiri
dalam jangka waktu lama, atau penurunan
mobilitas tungkai.
Obstruksi
Sumbatan pada vena profunda tungkai (deep
vein thrombosis, DVT), dapat akut maupun
kronis
Kombinasi

Manifestasi Klinis

ASYMPTOMATIC
SUPERFICIAL VENOUS DILATATION
Telangiectasis (intradermal)

Reticular veins (subdermal)

VARICOSE VEINS (subcutaneous)

Leg edema

Skin changes
Hyperpigmentation

Skin changes
Stasis dermatitis

Skin changes
Corona phlebectatica
a. venous cups (veins)
b. telangiectasis
c. reticular veins
d. stasis spots

(capillaries)

Lipodermatosclerosis
a form of panniculitis just above the ankles

Venous stasis ulceration

CLASSIFICATION OF VEIN
DISEASE

CEAP an international consensus conference initiated the Clinical-Etiology-AnatomyPathophysiology classification.

C 0 no evidence of venous disease.
C 1 telangiectasias/reticular veins.
C 2 varicose veins.
C 3 edema associated with vein disease.
C 4a pigmentation or eczema.
C 4b lipodermatosclerosis.
C 5 healed venous ulcer.
C 6 active venous ulcer.
E c congenital
E p primary venous disease.
E s secondary venous disorder.
E n not specified.
A s superficial veins.
A d deep veins.
A p perforating veins.
A n not specified.
P r venous reflux.
P o venous obstruction.
P n not specified.

Diagnosis

Anamnesis
Pemeriksaan fisik
Inspection dan palpation may reveal visual
evidence for CVI
Pemeriksaan penunjang

Pemeriksaan Penunjang

Venous Duplex Imaging

Photoplethysmography (PPG)
Air Plethysmography (APG)

VENOUS DOPPLER ULTRASOUND

Evaluate for deep and superficial venous
thrombosis.
Evaluate for incompetent veins with
significant reflux disease.
Evaluate for incompetent perforating
veins and tributaries.

Tata Laksana

Conservative Management

LEG ELEVATION heart level for 30 minutes 3-4 times

daily improves micro-circulation reduces edema, and
promotes healing of venous ulcers.

EXERCISE daily walking and simple ankle flexion

exercises.

Compression therapy

Compression bandages elastic or non-elastic

with single or multi-layers.

Compression stockings

CLASS

PRESSURE

LEVEL OF
SUPPORT

INDICATION

CEAP

OTC

<15 mmHg

Minimal

Asymptomatic,
comfort only.

0, 1

15-20 mmHg

Mild

Minor varicosities,
tired aching legs,
minor swelling.

1, 2, 3

II

20-30 mmHg

Moderate

Moderate to severe
varicosities,
moderate swelling,
phlebitis, following
ablation.

3, 4

III

30-40 mmHg

Firm

Severe varicosities,
swelling,
management of
ulcerations,
following DVT, post
surgery.

4, 5, 6

IV

>40 mmHg

Extra firm

Lymphedema.

NA

MANAGEMENT OF CVI SKIN

CARE

Skin cleansing wash with a mild non-soap

cleanser (e.g. Dove, Olay, Caress).
Emollients provides a film of oil to lubricate
the skin (e.g. Vaseline, Lubriderm, Aveeno).
Barrier preparations physically block
chemical irritants and moisture (e.g. Zinc
oxide, Vaseline).
Topical corticosteroids often used to treat
stasis dermatitis.

MANAGEMENT OF CVI MEDICATIONS

Pentoxifylline more effective for complete or partial

ulcer healing.
Stanozolol an anabolic steroid that stimulates
fibrinolysis and improves lipodermatosclerosis and
possibly ulcer healing.
Escin (horseshoe chestnut) 50mg twice daily reduces
leg volume and edema. It stimulates the release of F
series prostaglandins which induce venoconstriction,
decreasing the permeability of vessel walls to low
molecular proteins, water, and electrolytes.

MANAGEMENT OF CVI VENOUS

STASIS ULCERS

Surgical debridement used to remove

devitalized tissue.
Enzymatic agents used to break down
necrotic tissue (e.g. Santyl).
Growth factors synthesized by many cell
types such as platelets, neutrophils, and
epithelial cells (e.g. Regranex).
Bioengineered tissue used for a variety of
non-healing ulcers (e.g. Apligraf, Dermagraft).
Skin grafting an option for non-healing ulcers.

MANAGEMENT OF CVI VENOUS

STASIS ULCERS

Dressings depend upon the ulcer characteristics,

frequency of dressing changes, and cost.
-Occlusive dressings may be fully occlusive
(impermeable to gases and liquids) or semiimpermeable (impermeable to liquids and partially
permeable to gases and water vapor).
It stimulates collagen synthesis, angiogenesis, and
speeds reepithelialization.
-Low adherent gauze dressings frequent changes but
inexpensive.
-Hydrogels and alginate dressings are highly absorbent
to handle heavily exudative ulcers, while hydrocolloids
can help with wound debridement and skin protection.
-Silver can be incorporated if the ulcer is infected.

MANAGEMENT OF CVI SCLEROTHERAPY

Chemical irritants injected to close unwanted

veins. Preparations include liquid and foam. It is
used primarily in the treatment of
telangiectasias, reticular veins, and small
varicose veins.
These substances cause endothelial damage by
their actions as either osmotic or detergent
agents. Osmotic agents achieve their effect by
dehydrating endothelial cells through osmosis.
Detergents are surface active agents which
damage the endothelium by interfering with cell
membrane lipids.
8.

MANAGEMENT OF CVI SCLEROTHERAPY

DETERGENT AGENTS
- Sodium tetradecyl sulfate
- Polidocanol
OSMOTIC AGENTS
- Hypertonic saline
- Glycerin

MANAGEMENT OF CVI ABLATION

THERAPY

Indications patients with persistent

signs/symptoms of venous disease after a
minimum of 3 months of medical therapy (e.g.
compression) and documented reflux (e.g.
>0.5 seconds of reflux GSV).
Absolute contraindications acute DVT or
phlebitis and pregnancy.

MANAGEMENT OF CVI
RADIOFREQUENCY ENDOVENOUS
ABLATION THERAPY

Radiofrequency devices generate a high

frequency alternating current for which the
energy heats the adjacent vein walls to the
probe which alters the protein structure of the
vein effecting its closure.
Superficial veins include Great Saphenous
Vein, Small Saphenous, and incompetent
perforator veins.

MANAGEMENT OF CVI
ENDOVENOUS LASER ABLATION
THERAPY

Lasers emit a single, coherent wavelength of light.

Laser therapy of venous structures is based upon
the concept of selective photothermolysis (ie,
selective thermal confinement of light induced
damage). Vein wall injury is mediated directly by
absorption of photon energy by the vein wall and
indirectly by thermal convection from steam
bubbles, and from heated blood.
Superficial veins include Great Saphenous Vein,
Small Saphenous Vein, incompetent perforator

Surgical Treatment
- Vein ligation/stripping
- Phlebectomy
- Valve reconstruction
- Open or endoscopic perforator ligation.

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