CHRONIC VENOUS

INSUFFICIENCY
ANATOMY

PHYSIOLOGY

DEFINITION

AETIOLOGY

RISK FACTOR

PATHOGENESIS

PATHOPHYSIOLOGY

MANIFESTATIONS
• VENOUS DILATATION
• OEDEMA
• SKIN CHANGES
• VENOUS ULCER FORMATION

HISTORY TAKING

PHYSICAL EXAMINATION

TESTS

MANAGEMENT
ANATOMY
• The two major superficial veins are the great
and small saphenous veins

• The great saphenous vein is formed by the

union of the dorsal digital vein of the great
toe and the dorsal venous arch of the foot
1. Ascends anterior to the medial
malleolus.
2. Passes posterior to the medial
condyle of the femur (about a
hand's breath posterior to the
medial border of the patella).
3. Anastomoses with the small
saphenous vein.
4. Traverses the saphenous
opening in the fascia lata.
5. Empties into the femoral vein.
 popliteal vein
• arises on the lateral side
of the foot from the
Posterior
union of the dorsal view
small saphenous vein
digital vein of the fifth
digit with the dorsal
venous arch
1. Ascends posterior to the lateral
malleolus as a continuation of the
lateral marginal vein

2. Passes along the lateral border of 5.

the calcaneal tendon.

3. Inclines to the midline of the 4.

fibula and penetrates the deep
fascia.

4. Ascends between the heads of the 3.

gastrocnemius muscle
2.
1.
5. Empties into the popliteal vein
in the popliteal fossa
• penetrate the deep fascia close to their
origin from the superficial veins

• contain valves that allow blood to flow only

from the superficial veins to the deep veins

• pass through the deep fascia at an oblique

angle
– when muscles contract and pressure inside
the deep fascia, the perforating veins are
compressed

• Its compression prevents blood from flowing

from the deep to the superficial veins
• Eg.Hunterian perforator
– Dodd's perforator
– Boyd’s perforator
– Cockett’s perforator
• in the lower limb accompany
all the major arteries

• usually paired, frequently

interconnecting veins

• are contained within a

vascular sheath with the
artery, whose pulsations also
help compress and move
blood in the veins

• drains into the popliteal vein

femoral vein
• as the arterial blood flow into the leg, distal superficial veins
constantly fills
• Venous blood is regularly emptied from the superficial
system into the deep venous system via SFJ,SPJ and
perforators
• This blood return to the right side of the heart through one-
way valves by calf muscle contraction
• Venous return occur uphill against gravity, against
fluctuating thoraco-abdominal pressure and sometimes in
the face of additional back-pressure such CCF
• This process of venous return depends on the patency of
the flow circuit and on the normal functioning of the calf
muscle pump and venous valve.
 Valvular system
• ‘One way’, bi-cuspid
• These valve permit blood
flow from the superficial
to deep and from distal to
proximal
• Located in the perforators
and major
junction(SFJ,SPJ)
• It is made up of thin sheet
of smooth
muscle/collagen covered
by endothelium.
Calf muscle pump
• When calf muscle are at
rest,the deep vein expand
and blood is drawn in
from the superficial vein
• Venous refilling will occur
via arterial inflow
• Contraction of muscles
compressed large venous
sinuses in the muscle,
• It will squeeze the blood
into popliteal vein and
back to heart
Definition: chronic venous insufficiency is CHRONIC VENOUS
termed apply to advanced chronic DISORDER: full spectrum
venous disorder(CVD). This is applied to of morphological and
functional abnormalities of the venous functional abnormalities
system causes by venous hypertension of the venous system
producing oedema, skin changes, or from telengiectasia to
venous ulcer. venous ulcer

Venous hypertension can result from:

1) Dysfunction of venous valve (90%)
• Venous reflux occur due to faulty valve function as a complication
of DVT
-DVT can happened due to postphlebitic and post-thrombotic damage
• Primary valvular incompetence without previous episode of DVT
-Floppy valves with redundant and leaky cups lead to communicating
veins involvement with varicose vein
2)Obstruction to venous flow
• Tumour compression in the pelvis,pregnancy, deep vein thrombosis
3)Failure of the “venous pump”
• Eg-dependent on adequate muscle contraction (stroke,muscular
weakness )
• Increase age
– Prevalence of venous disease
increase with age ( > 40 years )
• Family history
– Inherited defect is alteration in
vein wall collagen and / or elastin
• Orthostatic occupation
– Occupation that require prolonged
standing are thought to predispose
to venous insufficiency (e.g:
builder)
• Deep vein thrombosis (DVT)
– 50% people develop CVI within 5-
10 years of an episode of DVT due
to increased dilation of venous
system leading to reflux
• Female hormonal
– Produce dilatation and elongation
of veins
– e.g: Varicose vein develop in
pregnancy
• 70-80% cases in first trimester time
where corpus luteum releasing high
progesterone level
– Increase venous capacitance in
women who taking high dose
progesterone contraceptive pills
– Venous distensibilty is believed to
be greatest during luteal phase
• Obesity
– Veins struggle to withstand the
additional weight and increased
blood pressure --> vein valve
unable to function properly -->
varicose veins
Predisposing factors:
• Congenital abnormality
• Phlebitis
• Trauma
• Pregnancy
• DVT
• Age
• Family Hx
• Obesity
• Smoking
 PATHOPHYSIOLOGY
Venous
hypertension

Extravasation of Migration of Deposition of

plasma proteins leukocytes hemosiderin in
& fibrinogens 1. Capillary tissues
into soft tissue plugging Inflammation
2. Activate and fibrosis of
Fibrin cuff around
radicals and subcutaneous
capillaries
cytokines tissue
Restrict O2 diffusion
across vessel wall, Tissue damage HYPERPIGMENTED
macromolecular SKIN,
leakage and LIPODERMATOSCLER
trapping Skin changes OSIS

EDEMA &
DERMATOSCLEROTIC
CHANGES
 Venous dilatation
 Oedema
 Skin changes
 Venous ulcer formation
 Venous dilatation
1)Telengiectasia
• a confluence of dilated
intradermal venules less
than 1 mm in caliber
• Spider vein, hype webs,
and thread vein
2)Reticular vein
• Dilated bluish subdermal
tortuous veins 1-3 mm in
diameter
3)Varicosities
• Visible, dilated, tortuous superficial veins
formed by main tributaries of saphenous vein
• 3mm or more in caliber
• Medial thigh and calf varicosities suggest long
saphenous incompetence

• Posterolateral calf varicosities are suggestive

of short saphenous incompetence
4)Corona phlebectactica
• A network of small dilated
venules beneath the
lateral and or medial
malleolus with severe
venous hypertension
 Oedema
• Hallmark of CVI, Present in all cases but only the earliest stages
• Dependent pitting oedema as a result of increase in volume of fluid
in skin and subcutaneous tissue characteristically increases
throughout the day
• relieved by elevation and compression hosiery/bandaging.
• The oedema is usually confined to the ankle area but may extend to
the foot and rest of the leg
Skin changes
Hyperpigmentation

Atrophic blanche

Venous stasis eczema

Lipodermatosclerosis
 Hyperpigmentation

Hyperpigmentation is usually
a brown discolouration
(because of haemosiderin
deposition) of the skin

most frequently affecting the

gaiter (between knee and
ankle) area

and may be associated with

phlebitis and ulceration
 Atrophic blanche
• localised white atrophic skin • Atrophie blanche is characterised by:
• frequently surrounded by  Star-shaped or polyangular,
dilated capillaries and  Ivory-white depressed atrophic
hyperpigmentation plaques
• usually seen around the  Prominent red dots within the scar
ankle.
due to enlarged capillary blood vessels
 Venous stasis eczema

• Eczema is an
erythematous
dermatitis which
may progress to
blistering, weeping
or scaling eruption
of the skin
• not to be confused
with contact
dermatitis
 Lipodermatosclerosis
localised chronic inflammation and
fibrosis of the skin and subcutaneous
tissues of the leg
sign of severe chronic venous
disease.
Acute Lipodermatosclerosis
Episodes of painful inflammation
above the ankle, resembling cellulitis.
The affected area is red, warm , and
scaly.
Some thickening of the skin can be
felt but this is not sharply
demarcated as in chronic
lipodermatosclerosis.
Chronic lipodermatosclerosis

-may follow an acute episode

or develop gradually.
-Common findings in chronic
lipodermatosclerosis include:
• Pain
• Hardening of the skin
• Localised thickening
• Moderate redness
• Increased pigmentation
• Small white scarred areas
(atrophie blanche)
• Increased fluid in the leg
(oedema)
• Varicose veins
• Leg ulcers
 Venous Ulcer
• is a full thickness epidermal defect
• most frequently affecting the
gaiter area.
Marjolin’s ulcer
- Long standing squamous cell carcinoma
venous ulcer
- Ulcer had enlarged, painful, malodourous
- The edge of ulcer raised and thickened
- Enlarged inguinal lymph glands
 SYMPTOMS OF LOWER LIMB VENOUS DISEASE

• Most patients with venous disorders complain of

unsightly veins in their lower limbs, pain or discomfort
when standing and minor ankle swelling.
• They also may complain of skin changes
(lipodermatosclerosis, eczema, pigmentation and
ulceration) in the skin of the gaiter region.
• Superficial veins may occasionally bleed. Superficial
vein thrombosis causes painful lumps or cords.
• Deep vein thrombosis presents with calf pain and leg
swelling or pleuritic chest pain, haemoptysis and
dyspnoea if it is complicated by a pulmonary
embolism.
 HISTORY TAKING
1. Chief complaint (local)
 Itching and burning sensation of lower limb
 Swelling
 Leg cramps
 Leg fatigue / discomfort
 Heavy leg
2. History Of Presenting Illness

• skin burning and itching - Often associated with venous

stasis and eczema.
• leg swelling - unilateral or bilateral , when the swelling
occur ? confirm the suspicion of thrombosis are previous
deep vein thrombosis, an illness requiring bed rest and
recent limb immobilisation (the patient must be asked
about recent flight travel).
• leg cramps - Often at night ( nocturnal cough )
• leg fatigue, aching, and/or discomfort - Not present at the
start of the day. Develop and worsen towards the end of
the day and on prolonged standing, and improve on
elevation.
• heavy legs- Not present at the start of the day. Develops
and worsens towards the end of the day and on
prolonged standing, and improves on elevation.
3. Systems Reviews
-ASK COMPLICATIONS
• Ulceration
• Skin changes
• Venous dilatation
• Oedema – infection

4. Past Medical History

• Has patient undergoes any surgeries previously? ( hernia surgery might injure the nearby
femoral veins )
• Has patient involved in any MVA or trauma in past or recently ? ( pelvic fracture when
young might affect veins in the pelvic region which later cause venous problems )
• Past medical history of deep venous thrombosis ? ( give arise to post thrombotic CVI)
• Past medical history of pulmonary embolism ?

5.Drug History
• Is the patient on any anticoagulant drugs ? ( DVT )

6.Social History
• It is important to ask the patient regarding their functional status and employment such
as patient’s job,income , how the vein problem affecting their daily lives as this is
important for us ( the physician ) to decide the best treatment plan

7. Family History - history of bleeding disorder?

 PYHSICAL EXAMINATION
INSPECTION
• Expose lower limbs with patient standing erect
– ( Standing up brings out any reticular veins or varicose veins
if valves in those regions are incompetent )
• PRESENCE signs of CVI
– Venous dilatation
– oedema
– Skin changes
– Ulceration
• Look at COURSE of great saphenous or short saphenous vein for
varicosities
• Look at inguinal region - A blue-tinged bulge in the groin, which
disappears on lying down,is likely to be a saphena varix. .
PALPATION
• Feel any dilated varicosities , gently run over the course of the main
veins and their tributaries because dilated veins can sometimes be
more easily felt than seen, especially in fat legs.
• The termination of a distended short saphenous vein is easier to feel
if the patient is asked to bend the knees slightly to relax the deep
fascia covering the popliteal fossa.
• Carefully palpate the sapheno-femoral junction (2.5cm below and
lateral to the pubic tubercle) and the sapheno-popliteal junction,
which has a variable termination in the popliteal fossa (high or low).
• Palpate the inguinal region (saphenous varix)
• The patient should be asked to cough while the dilated veins are
palpated to see if there is any impulse or thrill (a cough impulse)
indicating that the valves at their junctions with the deep veins are
incompetent and the back flow is turbulent.
• Palpate the skin of the calf to define any areas of induration and
tenderness (lipodermatosclerosis).
AUSCULTATION
• Listen over any large clusters of veins, especially if they remain
distended when the patient lies down and the limb is elevated.
• A machinery murmur over such veins indicates that they are
secondary to an arterio-venous fistula.
 Non-invasive
Test for Venous
Insufficiency

1. Brodie–
Trendelenburg Test @
Tourniquet Test

2. Perthes Test
 Brodie–Trendelenburg Test @
Tourniquet Test
• Only performed in patients with varicose vein
• Purpose: To figure out if the cause of VV is due to
(a) Perforator valve insufficiency
(b) Superficial valve insufficiency

1. Elevate the leg 30 to 45 degree angle for 10 to 15 s

( To drain blood from the superficial veins)
2. A tourniquet is placed at the saphenofemoral junction (SFJ- 4
cm below & lateral to pubic tubercle)
3. The patient then stands erect with the tourniquet still tight
4. Observe any changes occuring above and below the
tourniquet
for the varicosities.
 Possible Outcomes
1. If the perforator valves distal to the tourniquet
(a) Competent - the varicosities will refill slowly
- Varicosities secondary to superficial vein valves incompetence
- To confirm superficial valves are incompetent , repeat the
procedure but only this time , TAKE OFF THE TOURNIQUET IMMEDIATELY
AFTER THE PATIENT UP - varicosities will immediately fill up if the
superficial vein valves are incompetent
(a) Incompetent – the varicosities will refill immediately
- Varicosities secondary to perforator valves incompetence

2. If the main Saphenofemoral Junction (SFJ) valve incompetent

– the varicosities will fill immediately above the tourniquet

3. If the test was positive , repeat the entire procedure , only

relocate the tourniquet more distally – mid thigh , if test is still positive ,
repeat the procedure again , only more distally , keep repeating the
procedure until the test become negative
- By doing so ,you can pinpoint exactly which perforators are
incompetent
 Perthes Test
• To checks for DVT
1. Don’t have to empty the superficial veins
2. Place tourniquet below the SFJ
3. Have patient stand up with tourniquet on
and ask them to either WALK BRISKLY FOR
5 MIN or DO 10 CALF RAISES
4. Positive Perthes Test if patient experince
significant pain in the lower extremities
during the exercise – confirms DVT
Investigations
• Venous Duplex
Ultrasound
- Usually to diagnose
DVT.
- Extend to detect
obstruction or reflux
and to determine
their anatomic
extent in CVI.
 MANAGEMENT
• Conservative
- Avoid long periods of standing or sitting
- Exercise regularly
- Weight reduction
- Elevate your legs at night
- Wear graduated compression stockings
- Skin care and hygiene
• Non-surgical treatment
– Sclerotherapy
– Endovenous thermal ablation
• Surgical treatment
– Ligation and stripping
– Microincision/ambulatory phlebectomy
– Vein bypass
 Nonsurgical treatment
Sclerotherapy
• A medical procedure used to eliminate varicose
veins and spider veins.
• An injection of a detergent (generally a salt
solution) directly into the SUPERFICIAL vein.
• The detergent destroys the lipid membranes of
endothelial cells causing them to shed, leading
to thrombosis, fibrosis and obliteration
(sclerosis).
• The procedure commences with the patient
standing
• Sclerotherapy improves varicose vein-related
symptoms, but recurrence rates and the need
for reintervention are relatively high. Foam is
superior to liquid sclerotherapy,
• Some complications (phlebitis, pigmentation,
headache, visual disturbance, chest tightness,
cough) are relatively common.
 Endovenous thermal ablation (EVLA)
• Treatment of varicose vein
• ultrasound-guided marking
• involves the insertion of a laser fibre into the lumen
of an incompetent truncal vein, with subsequent
thermal ablation of the vein.
• treats only junctional and truncal incompetence,
management of varicosities concomitantly or
sequentially by either phlebectomy or
sclerotherapy.
• Less painful compare to surgical method and
permits faster return to normal activities.
• Leaves no scar
 Surgical treatment
Ligation and stripping
• An oblique groin incision is made.
The long saphenous vein is identified
and dissected to the SFJ.
• SFJ ligation is then peformed and the
Vein ligation is a procedure in which a
vascular surgeon cuts and ties off the
problematic veins.
• LSV retrogradely stripped to the
knee.
• Stripping is the surgical removal of
larger veins through two small
incisions.
• Done in combination.
Microincision / ambulatory
phlebectomy
• Minimally invasive procedure in
which small incisions or needle
punctures are made over the
veins, and a phlebectomy hook is
used to remove the problematic
veins.
• Usually to remove secondary
varicose veins.
• Patient under local anaesthesia.
• Skin closed with surgical glue and
sutures are not required.
Vein bypass
• Similar to heart bypass
surgery, just different
location.
• Procedure that use a
portion of healthy vein
transplanted from
elsewhere in your body to
redirect blood around the
vein affected by CVI.
• Used for treatment of CVI
in the upper thigh and
only in the most severe
cases, when no other
treatment is effective.