Veins & Venous Disease

Veins are most commonly affected by thrombosis, or blood clots that develop within the vein, and insufficiency, which is the failure of the one- way valves present in veins which prevent the backward flow of blood within veins. In most vein practices, venous insufficiency is most common condition managed.

Venous Disease Overview & Treatment Options Anatomy & Venous System Review Types of Venous Disease Frequently Asked Questions Treatment Options for Venous Disease Arterial Screening

An understanding of venous disease and its treatment depends first upon an adequate understanding of venous anatomy and function. While venous anatomy has been known for years, there exists considerable variation from what might be considered the “normal” pattern. Knowledge of venous function, and particularly abnormal function, has grown considerably in recent years. The use of newer diagnostic tests, particularly ultrasound, has allowed physicians to better understand a given patient’s venous anatomy and function, and thereby tailor treatment for any venous disease present.

Anatomy & Venous System Review

Normal Venous Anatomy and Function

The venous system of the lower extremities is a complex of thin-walled and low-pressure vessels that return blood back to the heart after circulation to the tissues. This transport of blood is facilitated by several factors. Low central pressures in the chest cavity promote blood return to the heart. Active propulsion of blood by muscular contraction in the calves and thighs occurs during ambulation and functions as a “peripheral heart” driving blood return. Finally, the veins of the lower extremities usually contain venous valves that prevent the backward flow of blood.

The veins of the lower extremities can be conveniently divided into three types. The deep veins are those that are surrounded by muscular tissue and therefore can function as part of the “peripheral heart” noted above. The superficial veins include the greater and lesser saphenous veins, along with their major tributaries. The perforator veins penetrate the fascia that surrounds the muscle bundles and divert blood from the superficial to the deep venous system.

Deep Venous System

The deep veins include the gastrocnemius, peroneal and tibial veins in the calf, the popliteal veins behind the knee, and the femoral veins in the thigh. The deep veins are ultimately responsible for most of the venous drainage from the lower extremities. With the combination of active muscular contraction and normal venous valvular function, the deep veins provide the only active propulsion of venous return to the heart.

Superficial Venous System

The greater saphenous vein ascends along the inner aspect of the calf and thigh and ultimately drains into the femoral vein at the groin, through the saphenofemoral junction. Major tributaries (branches) include the posterior arch vein in the calf, the posteromedial vein and anterolateral vein in the thigh and the inferior epigastric vein in the groin.

The lesser saphenous vein lies on the posterior aspect of the calf and drains into the popliteal venous system behind the knee, through the saphenopopliteal junction. Not infrequently, the lesser saphenous vein drains into other venous channels, including the vein of Giacomini, which in turn drains into the greater saphenous vein.

Perforating Venous System

There are a number of perforating veins that communicate between the superficial and deep venous systems. It is important to keep two thoughts in mind when discussing the perforating veins; that they are quite variable in their location and prevalence, and that they are normal venous structures even in the absence of venous disease.

The function of perforating veins is to direct blood flow from the superficial venous system to the deep venous system. The perforating venous system can sometimes be the origin of venous disease but can also frequently be only indirectly affected by disease in the other systems. Classically defined perforating veins include the Hunterian and Dodd perforators in the thigh, the Boyd and Cockett perforators in the calf, and a number of perforators in the foot.

Anatomy Images

Deep Venous System

Superficial Venous System

Saphenofemoral Junction ( SFJ) Tributaries AL – Anterolateral PM – Posteromedial SEP – Superficial external pudendal SE – Superficial epigastric SCI – Superficial circumflex iliac

Small Saphenous Vein (SSV) Courses from the lateral ankle up the posterior calf Terminates in the popliteal fossa at the saphenopopliteal junction (SPJ) Confluence with the popliteal vein (PV) is variable Proximal portion lies between superficial & deep fascial layers

Perforators Connect superficial to deep veins Locations Proximal thigh - Hunterian Distal thigh - Dodd’s Knee - Boyd’s Ankle/Calf - Cockett’s Incompetent perforators often source of venous stasis ulcers at medial ankle

Types of Venous Disease

Broadly speaking, there are two major types of venous disease: obstruction and insufficiency.

Obstructive venous disease is the less common form. It includes any cause that directly impedes the return of blood flow the heart, either due to intrinsic (inside the vein) or extrinsic (outside the vein) blockages. Intrinsic causes consist primarily of deep venous thrombosis (DVT), or blood clots, in the major veins of the thighs and/or pelvis. Causes of extrinsic obstruction, either actual or “functional” include large pelvic tumors, morbid obesity, chronic obstructive pulmonary disease (COPD or emphysema) and some types of heart disease such as severe tricuspid valve insufficiency or advanced congestive heart failure.

Venous insufficiency , or incompetence, is the more common form of venous disease. Rather than consisting of a actual obstruction to venous return, it involves a failure of the venous system, itself. Infrequently, this can be due to a failure of the muscular “peripheral heart”, but more frequently is due to structural failure of the veins. Structural failure of veins is either due to injury from a previous event, known as secondary venous insufficiency, or is due to disease of the veins not from an outside cause, known as primary venous insufficiency.

Secondary venous insufficiency is most commonly due to injury from a previous episode of deep venous thrombosis (DVT), in which the venous valves that would normally prevent the backward flow of blood have been damaged or destroyed. This is known as the post-phlebitic syndrome and is frequently associated with venous stasis disease which results in changes of the skin at the feet and ankles known as stasis dermatitis and can sometimes result in open sores, or venous stasis ulcers.

Primary venous insufficiency is the much more common cause of venous vascular disease. It is due to weakness and failure of the vein walls and venous valves. Primary venous insufficiency is frequently associated with a hereditary pattern of involvement. In female patients, it may also be associated with multiple pregnancies. And, regardless of gender, primary venous insufficiency may frequently be associated with body habitus (obesity), work environment and exercise habits.

Signs of Venous Insufficiency Edema Varicose Veins Skin Changes & Discoloration Skin Ulceration

Questions & Answers on Venous Disease

What are varicose veins?

Varicose veins – which afflict 10% to 20% of all adults but serve no useful purpose in the body – are swollen, twisted, blue veins that are close to the surface of the skin. Because valves in them are damaged, they hold more blood at higher pressure than normal. That forces fluid into the surrounding tissue, making the affected leg swell and feel heavy.

Unsightly and uncomfortable, varicose leg veins can promote swelling in the ankles and feet and itching of the skin. They may occur in almost any part of the body, but are most often seen in the back of the calf or on the inside of the leg between the groin and the ankle. Left untreated, patient symptoms are likely to worsen, with some possibly leading to venous ulceration.

What causes varicose veins?

The normal function of leg veins - both the deep veins in the leg and the superficial veins, which feed them - is to carry blood back to the heart. During walking, for instance, the calf muscle acts as a pump, contracting veins and forcing blood back to the heart.

To prevent blood from flowing in the wrong direction, veins have numerous valves. If the valves fail (a cause of venous reflux), blood flows back into superficial veins and back down the leg. This results in veins enlarging and becoming varicose. The process is like blowing air into a balloon without letting the air flow out again- the balloon swells.

To succeed, treatment must stop this reverse flow at the highest site or sites of valve failure. In the legs, veins close to the surface of the skin drain into larger veins, such as the saphenous vein, which run up to the groin. Damaged valves in the saphenous vein are often the cause of reversed blood flow back down into the surface veins.

Why does it occur more in the legs?

Gravity is the culprit. The distance from the feet to the heart is the farthest blood has to travel in the body. Consequently, those vessels experience a great deal of pressure. If vein valves can't handle it, the back flow of blood can cause the surface veins to become swollen and distorted.

Who is at risk for varicose veins?

Conditions contributing to varicose veins include genetics, obesity, pregnancy, hormonal changes at menopause, work or hobbies requiring extended standing, and past vein diseases such as thrombophlebitis (inflammation of a vein as a blood clot forms). Women suffer from varicose veins more than men, and the incidence increases to 50% of people over age 50.

What are the symptoms?

Varicose veins may ache, and feet and ankles may swell towards day's end, especially in hot weather. Varicose veins can become sore and inflamed, causing redness of the skin around them. In some cases, patients may develop venous ulcerations.

What are venous leg ulcers?

Venous ulcers are areas of the lower leg where the skin has died and exposed the flesh beneath. Ulcers can range from the size of a penny to completely encircling the leg. They are painful, odorous open wounds, which weep fluid and can last for months or even years. Most leg ulcers occur when vein disease is left untreated. They are most common among older people but can also affect individuals as young as 18.

What is the short-term treatment for varicose veins?

“ESES” (pronounced SS) is an easy way to remember the conservative approach. It stands for “Exercise, Stockings, Elevation and Still.” Exercising, wearing compression hose, elevating and resting the legs will not make the veins go away, or necessarily prevent them from worsening because the underlying disease (venous reflux) has not been addressed. However, it may provide some symptomatic relief. Weight reduction is also helpful.

If there are inflamed areas or an infection, topical antibiotics may be prescribed. If ulcers develop, medication and dressings should be changed regularly.

There are also potentially longer-term treatment alternatives for visible varicose veins, such as sclerotherapy and phlebectomy.

What is sclerotherapy?

A chemical injection, such as a saline or detergent solution, is injected into a vein, causing it to "spasm" or close up. Other veins then take over its work. This may bring only temporary success, and varicose veins frequently recur. It is most effective on smaller surface veins, less than 1-2mm in diameter.

What is ambulatory phlebectomy?

As with sclerotherapy, ambulatory phlebectomy is a surgical procedure for treating surface veins. Multiple small incisions are made along a varicose vein and it is "fished out" of the leg using surgical hooks or forceps. The procedure is done under local or regional anesthesia, in an operating room or an office procedure room.

What is vein stripping?

If the source of the reverse blood flow is due to damaged valves in the saphenous vein, the vein may be removed by a surgical procedure known as vein stripping. Under general anesthesia, all or part of the vein is tied off and pulled out. The legs are bandaged after the surgery, but swelling and bruising may last for weeks.

When is the Closure® procedure used?

Closure is used like vein stripping to eliminate reverse blood flow in the saphenous vein, but without physically removing the vein, and can be performed without general anesthesia. Like other venous procedures, the Closure procedure involves risks and potential complications. All patients should consult their doctors to determine whether or not they are candidates for this procedure, and if their conditions present any special risks. Complications reported in medical literature include numbness or tingling (paresthesia), skin burns, blood clots and temporary tenderness in the treated limb.

What is the main difference between arteries and veins?

In simplest terms, arteries pump oxygen-rich blood FROM the heart; veins return oxygen-depleted blood to the heart.

What are the three main categories of veins?

“Deep” leg veins return blood directly to the heart and are in the center of the leg, near the bones. “Superficial” leg veins are just beneath the skin.  They have less support from surrounding muscles and bones than the deep veins and may thus develop an area of weakness in the wall. When ballooning of the vein occurs, the vein becomes varicose. “Perforator” veins serve as connections between the superficial system and the deep system of leg veins

Treatment Options for Venous Disease

Conservative Measures

These are non-surgical options to address the symptoms of venous disease. While they do not result in a correction of the underlying problem, they may adequately treat the presenting symptoms. Conservative measures
are useful by themselves, and are often useful even during and after undergoing more definitive surgical care.

The acronym ACE is useful in remembering the conservative measures useful in the management of venous insufficiency. ACE stands for analgesics (pain relievers such as Ibuprofen), compression (stockings), and elevation (of the affected leg when possible). An additional A or E is commonly used to mean either activity or exercise, as this is frequently useful in decreasing the severity of symptoms due to venous insufficiency.

Conservative measures, while sometimes cumbersome (particularly wearing compression stockings during the hot summer months), are useful, particularly in certain situations. For example, some venous insufficiency is simply not easily correctible, such as advanced deep venous insufficiency from prior deep vein thrombosis (DVT), in which case conservative measures may be the best option available. Conservative measures, especially compression stockings, are also frequently utilized as an aid during healing from surgical procedures.

However, for many people, when a surgical correction of their venous insufficiency is possible, the thought of lifelong use of conservative measures instead isn’t attractive. Comparably, in this age of safe and reliable hernia repairs, does it make sense to ask a patient to wear a truss, instead? Still, insurance companies are frequently unwilling to finance a definitive surgical treatment unless it has been documented that an adequate trial of conservative measures has failed to control the presenting symptoms. The definition of what constitutes and “adequate” trial differs between insurance companies, with some having no clearly defined criteria and some demanding weeks or months of documented compression stocking use.

At Iowa City Thoracic & Vascular, we make every attempt to ensure that any specific requirements for a given patient’s insurance provider have been met, and that clearance from their insurance provider has been obtained, when necessary, prior to proceeding with any surgical treatments.

High Ligation

This procedure involves the surgical ligation, or tying-off, of the diseased vein at its proximal end, most frequently at the groin. While not terribly invasive (it can be performed under local anesthesia in a physician office in some cases), it does not frequently result in a long-term cure for many patients. At Iowa City Thoracic & Vascular, we occasionally do perform high ligations, but typically only as an adjunct to other procedures, and/or in patients who have limited options due to prior surgical procedures.

Vein Stripping

This procedure involves the surgical removal (stripping) of the diseased vein, most commonly the greater saphenous vein, via incisions at the groin and knee or groin and ankle. While more effective than high ligation alone, it is a more invasive procedure that must be performed in a hospital setting, and requires the administration of either general or spinal anesthesia. And, for many patients, the early recovery period is fairly uncomfortable. In addition, for a variety of reasons beyond the scope of discussion here, recurrence is not at all uncommon, as evidenced by a number of patients we see at Iowa City Thoracic & Vascular who have returned years and decades after a prior stripping procedure.

Radiofrequency Ablation (Closure Procedure)

This is a less invasive and more effective alternative to vein stripping for the vast majority of patients. Endovenous ablation involves the destruction of the diseased vein with the use of a specialized catheter placed into the target vein under ultrasound guidance, and the subsequent destruction of the vein with heat energy after the administration of local anesthetic. The specialized catheters that have been developed by various companies include those powered by radiofrequency energy and by laser. At Iowa City Thoracic & Vascular, we have utilized both modalities, and have come to believe that radiofrequency ablation (the Closure procedure developed by VNUS) to be the most effective, safe and comfortable for our patients. Radiofrequency ablation is also a more versatile technique, in that it can be used not only to treat long axial veins such as the saphenous veins, but also shorter perforator veins that are often times important for patients with advanced skin changes and/or ulcerations.

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Ambulatory Microphlebectomy

This procedure involves the removal of superficial branch varicose veins through small incisions made in the skin under local anesthesia. Each incision is roughly 1/8 of an inch long, and they generally heal with a very good cosmetic result. Ambulatory microphlebectomy may be performed as a stand-alone procedure or as an adjunct to other procedures, which are sometimes done in stages.

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Sclerotherapy and Ultrasound-Guided Sclerotherapy

Sclerotherapy involves the injection of a chemical (the sclerosant) into a target vein with the goal of causing chemical injury to the inner lining of the vein resulting in closure of the vein. In our clinic, this procedure may be aided by the use of several techniques, to include magnification, transillumination of the skin with a VeinLite, or the use of ultrasound guidance.

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Subfascial Endoscopic Perforator Surgery (SEPS)

This procedure is designed to surgically ligate diseased perforator veins in a less invasive manner than had been available previously. It is useful in occasional circumstances where radiofrequency ablation of the target perforator veins has not been successful or is not feasible. While less invasive than its predecessor, known as the Linton procedure, it must still be performed in a hospital setting under general or spinal anesthesia. In our experience, it is rarely necessary, but is a useful option to have available, if needed.

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