Chronic Venous

Disease:
High prevalence but low
awareness to
diagnose and manage CVD
patients

Dr Shahzad Alam
Shah
1
2
 Chronic Venous Disease:
A highly prevalent disease

8 out of 10 patients suffer from chronic

venous disease Vein Consult Programstatistical results. March 2011.
 Prevalence & presentation of
chronic venous disease in
Pakistan
Presence of
symptoms

Prevalence and presentation of chronic venous disease in Pakistan.

Phlebology Journal Vol. 28(2)March, 2013.
1. Pathophysiology

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Superficial veins & deep veins,
saphenous veins

6
 Saphenous veins
Great saphenous vein (GSV)

Anterior accessory
Saphenous vein of the thigh
(AASV)

Small saphenous vein

(SSV)
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8
 Pathophysiological process of chronic
venous disease: leukocyte activation

Genetic predisposition, obesity, Venous hypertension

pregnancy, ..
Environmental factors repeated Altered blood flow and
over time shear stress

Leukocyte activation and

expression of adhesion molecules

Adhesion and infiltration of the leukocytes into the venous valves and walls

Leukocyte degranulation and

release of inflammatory mediators PAIN

Degradation of the venous valves and walls

Increase hypertension leading to chronic hypertension

9
Adapted from Danziger N. J Mal Vasc. 2007;32:1-7 and Bergan JJ et al. N Engl J Med. 2006;355:488-498.
 Risk or Predisposing
Factors
Heriditary
Prolonged Standing
Obesity
History of DVT, DM,
Chronic heart failure or
recent edema
Number of Pregnancies
2. Symptoms & signs

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Chronic venous disease symptoms

Except in the case of thrombosis

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Symptom frequency VEIN CONSULT PROGR
in the
Example of the results in France48.9%
40.9%

37.4%

28.3%

13.4%

15
14.4% %

Guex JJ, Allaert FA. Observatoire du dpistage et de la prise en charge de14la

maladie veineuse en mdecine gnrale. Phlbologie. 2012;65(2):1-10.
 Which symptoms?
Symptoms:
Leg pain
Nighttime leg cramps
Restless legs
Heavy legs Edema
Itching
Left leg? Right leg? Both legs?

When:
Not aggravated by walking except after deep thrombosis in
the case of a postthrombotic syndrome (venous claudication).
Aggravated at night, by heat and prolonged standing, in the
summer, or during menstration.
Calmed by walking, walking on a cold floor, taking a cold
shower, elevating the legs, and playing water sports.

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 Signs of chronic venous
disease
Visible by an examiner

Help establish a descriptive classification of the

disease

Clinical classification, divided into 7 stages

These stages may be symptomatic or asymptomatic

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3. Clinical stages
of CEAP
classification
&
Clinical cases

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 Stages of CEAP classification

C0s C1 C2 C3 C4 C5-C6

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 Signs of the CEAP
Dilatation

C0 C1 C2

Increase of venous permeability and capillary fragility

C4
C3 C4 C5 C6

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 Stage C0

24-year-old female:
Pain
Heaviness
Nighttime leg cramps

C0s (symptomatic)

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 Stage C0

C0s
Doppler

Incompetent GSV Normal

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 Stage C1

43-year-old female

No symptoms!

Tributary veins:
C1as (asymptomatic) <3 mm

Telangiectasia

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Stage C1: Corona Phlebectatica

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 Stage C2

55-year-old mother:
Three daughters
Nighttime leg cramps
"My mother has the C2 Varicose vein >3
same !
mm
C2s

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Stage C2: Hemorrhagic bubbles (1/2)

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Stage C2: Hemorrhagic bubbles (2/2)

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Stage C3: Edema and bucket sign
(1/2)

39-year-old female:
Time of the exam: 11 AM
Ankle sprain when she was
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Exercises infrequently
Cramps are preventing
sleep

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Stage C3: Edema and bucket sign
(2/2)

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 Digital pressure method

Persistence of a skin depression after pressure

Do not confuse with

a lipoedema

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 When the venous disease
worsens,
the skin suffers C4, C5 and C6

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 Stage C4
C4a---Dermatitis-Eczema-
Hypodermatitis

C4bDermatosclerosis

C4c--- White Skin Atrophy

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 4a

dermatitis - Eczema -
hypodermatitis

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 Stage C4b: Dermatosclerosis

Edema masks the varicose veins

Dermatitis and cutaneous

sclerosis

Image of skin retraction

Leg appears shaped like a funnel

Skin becomes rigid

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 Edema is not fatal
Pretreatment 1 month
posttretreatment

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 Inflammation is not fatal
1 month 3 months 1 year
Pretreatment posttretreatm posttretreatm posttretreatmen
ent ent t

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Stage C4b: White skin atrophy

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Stage C5 and C6: Healed or active
ulcer

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 Treatment Options
Life Style Modification
Venoactive Drugs
Compression Therapy
Foam Injection Sclerotherapy
Endovascular Procedures
Endovenous Laser Ablation
Radiofrequency Ablation
Surgery
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 Treatment Options
SURGERY
Ligation of Incompetent Saphenopopliteal
and Saphenofemoral Juntions
LSV Stripping
Phelebectomies
Perforator Ligation
ENDOSCOPIC
Subfascial Endoscopic Perforator Surgery

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Treatement with
Venoactive Drugs

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 Pathophysiological process of chronic
venous disease: leukocyte activation

Genetic predisposition, obesity, Venous hypertension

pregnancy, ..
Environmental factors repeated Altered blood flow and
over time shear stress

Leukocyte activation and

expression of adhesion molecules

Adhesion and infiltration of the leukocytes into the venous valves and walls

Leukocyte degranulation and

release of inflammatory mediators PAIN

Degradation of the venous valves and walls

Increase hypertension leading to chronic hypertension

42
Adapted from Danziger N. J Mal Vasc. 2007;32:1-7 and Bergan JJ et al. N Engl J Med. 2006;355:488-498.
 Daflon acts at the heart of venous
inflammation in the venous valves and
walls
CD11b/CD18

Leucocyte VLA-4
DAFLON

L-selectin
Venous wall
endothelium
VCAM-1 E-selectin ICAM-1

Adapted from Shoab SS et al. Endothelial activation response to oral Micronized Flavonoid therapy in patients with 43
chronic venous disease a prospective study. Eur J Vasc Endovasc Surg. 1999;17:313-318.
 Accentuation of the inflammatory
process and impact on all the
elements of venous disease
MACROcirculation MICROcirculation

Valve Venous wall Capillary Capillary

damage remodeling leakage damage

Symptoms Varicose Skin

Reflux Edema (C3) changes (C4)
C0s veins (C2)

Venous
ulcer (C5,6)

Symptoms Symptoms Symptoms Symptoms

Inflammation

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Adapted from Bergan JJ et al. N Engl J Med. 2006;355:488-498 and from Eberhardt RT et al. Circulation. 2005;111:2398-2409.
 Daflon reduces leukocyte infiltration into
the venous valves

Fluorescent leukocytes

Valves without Daflon at 21 days

Valves with Daflon at 21 days

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Pascarella L et al. Mechanisms in experimental venous valve failure and their modifications by Daflon 500 mg. Eur J Vasc Endovasc Surg. 2008;3
 Daflon preserves the valves structure
1
2

1. Valve diameter
2. Valve height

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Pascarella L et al. Mechanisms in experimental venous valve failure and their modifications by Daflon 500 mg. Eur J Vasc Endovasc Surg. 2008;3
 Daflon 500 mg relieves patients
symptoms

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2 Lishov D et al. Patients seeking treatment for chronic venous disorders: Russian results from the Vein Act Program. Phlebolymphology. 2016;
Dose of Venoactive
Drugs (Daflon 500)
in Chronic Venous
2 tab./day
diseasefor 6
months
 DAFLON 500
in patients undergoing
Surgery
or
Endovosavcular
procedures
 Complicated CVD

Role of Venoactive Drugs ?

DAFLON 500
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 Can Daflon 500 improve
outcomes of
lower extremity varicose vein
endovenous treatment?
Results from the DECISION study
 Results from the DECISION study

Daflon 500 mg is significantly effective in

reducing post operative pain and clinical
severity
Phlebolymphology. Vol 20. No. 4. 2013
 Stripping of the great saphenous vein
under Daflon 500 protection

DEFANCE
(Daflon 500 mg assEssment of eFficacy
ANd safety for
Combined phlEbectomy)
Subfascial Endoscopic Perforator
Surgery

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Q&A Session

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