CHRONIC VENOUS

INSUFFICIENCY-(CVI)

Victoria Stirbu
Vascular Surgeon, PMSI CRH “T. Mosneaga” Cardiovascular Surgery
Department
CVI-DEFINITION

Medical condition where veins cannot pump enough

deoxy blood back to the heart

• “Impaired musculovenous pump”

• Mainly in Legs
CVI in Lower Limbs

Includes
 Telangectasias

 Reticular veins

 Varicose veins
Lower Limbs Venous System Anatomy

• Deep veins
• Superficial veins
• Perforator veins
Superficial Venous System

Great saphenous vein

• Begins from medial marginal vein on the

dorsum of foot
• Ascends in front of tibial malleolus
• In the medial aspect of leg
• behind medial condyles of tibia and femur
posteromedial surface of the knee
• In anteromedial aspect of thigh
• Terminates into femoral vein at fossa ovalis
2.5cm below and lateral to pubic
tubercle
 Tributary Veins
• Ankle-medial marginal vein

• Leg-anastomose with SSV

• communication-ant.& post.tibial veins
• receives post. & ant.arch veins

• Thigh-communicate with femoral vein

• receives accessory saphenous vein and other cutaneous
veins

• Fossa ovalis-superficial epigastric vein

• superficial iliac circumflex
• superficial external pudental vein
Superficial Venous System
Short saphenous vein
• Begins from the lateral marginal vein behind
lateral malleolous
• Lateral margin of tendocalcaneous
• Posterolateral aspect of calf
• Perforates the deep fascia of popliteal fossa
• Empties into popliteal vein
Tributary Veins

• Superficial circumflex vein,superficial inferior epigastric,ant.vein of

leg,post.arch vein

• Long intersaphenous communicating vein(comm.vein of Giacomini

Cruveilhier, Leonardo Vein)

• Ant.accesory great saphenous vein

Deep Venous System
1. Veins of conduits

2. Pumping veins/peripheral heart-soleal venous

sinus, gastrocnemial venous sinus of Gilot

• Located within the deep fascia

• Blood flow in greater pressure and volume

• Assures for 80 -90% of venous return flow

 Perforating Veins
Perforating veins, connect the DVS with the SVS, they pass through the deep fascia, guarded
by valves-unidirectional flow from superficial to deep veins (identified due to 40 )
1. Ankle perforators-may or Kuster

2. Lower leg perforators of Cockett-I,II,III

a)Posteroinferior to med malleolus
b)10cm above med.malleolus
c)15cm above med.malleolus

3. Gastrocnemius perforators of Boyd

4. Mid thigh perforators of Dodd

5. Hunter’s perforator in thigh

Physiology of venous blood flow

Venous return from leg is governed by

• Calf musculovenous pump

• Arterial pressure
• Gravity
• Thoracic pump
• Valves in veins
Musculovenous Pump

Foot and calf muscles act to squeeze

blood out of deep veins.

One way valve allow only upward and

inward flow.

During muscle relaxation blood is drawn

inward through perforating veins.
Valvular Function

Major valves
• ostial valve
• preterminal valve
Valve leaflets allow unidirectional flow upward
Pathophysiology in CVI

• Primary muscle pump failure

• Venous obstruction
• Venous valvular incompetance
1. Perforator vein incompetence- hydrodynamic reflux
2. SVS incompetence - hydrostatic reflux
3. DVS incompetence
Varicose veins Dilated, tortuous and elongated veins with reversal
of blood flow mainly due to valvular incompetence
 Etiology
o Congenital incompetence/absence of valves
o Inheritance with FOXC2 gene
o Klippel-Trenaunay Syndrome, Parks-Weber
o Deep vein thrombosis/ Recurrent thrombophlebitis (Post
thrombotic Sdr)
o Weakness/wasting of muscles
o Stretching of deep fascia
o External Obstruction to venous return
o Pregnancy
o Iatrogenic-in AV fistula
Etiology/Mechanism
Risk Factors

• Age
• Gender
• Height
• Heredity
• Pregnancy
• Obesity and overweight
• Posture
 Symptoms

o Dilated tortuous veins

o Dragging pain worsening on prolonged standing/sitting
o Bursting pain on walking
o Swelling of the ankle
o Itching, edema, thickening. Eczema
o Night cramps
o Appearance of spider veins in affected leg.
o Discoloration/ulceration
o Skin above ankle may shrink (lipodermatosclerosis)
o Bleeding blow outs
o Local gigantism
Signs (Positive for CVI)

o Special tests-positive
o Superficial thrombophlebitis
o Ankle flare
o Spider veins
o Reticular veins
o Saphena varix
o Champagne bottle sign
o Atrophic blanche
Saphena varix

 A saphena varix is a dilatation at the top of the long saphenous vein

due to valvular incompetence. It may reach the size of a golf ball or
larger.
 The varix is:
 soft and compressible
 disappears immediately on lying down
 exhibits an expansile cough impulse
 demonstrates a fluid thrill
Champagne bottle sign

o Inverted beer bottle look

o Contraction of ankle skin and s/c tissue with prominent edematous calf
 Special Tests

1. The Trendelenburg test

o Used to assess the competence of SFJ
o Patient lies flat
o Elevate the leg and gently empty the veins
o Palpate the SFJ and ask the patient to stand whilst
maintaining pressure

o Findings:
o Rapid filling after thumb released→ SFJ is incompetent
o Filling from below upwards without releasing thumb
→presence of distal incompetent perforators
 Special Tests
2. Tourniquet test
 Uses a tourniquet to control the junction rather than fingers
 Advantage of moving the tourniquet lower (mid-thigh region)
 Test is unreliable below the knee

3. Delbet - Perthes Test

 Empty the vein as above, place a tourniquet around the thigh, stand the patient
up.
 Ask them to rapidly stand up and down on their toes – filling of the veins indicated
deep venous incompetence. This is a painful and rarely used test.
4. Schwartz test
 In standing position,tap the lower part of vein
 Impulse felt on saphenofemoral junction
Special Tests
 Special Tests

5.Pratt’s test-
 Esmarch bandage applied on the leg from below upward with tourniquet on
saphenofemoral junction
 Release of bandages
 Perforators seen as blow outs
 6.Morrissey’s cough impulse test
 limb elevated and veins emptied
 Patient is asked to cough
 Expansile impulse in saphenofemoral junction
7.Fegan’s test
 Line of varicosities marked
 Site where perforators pierce deep fascia-bulges on standing
circular depressions on lying
 Complications
o Hemorrhage
o Ulcerations
o phlebitis
o Pigmentations
o Eczema
o lipodermatosclerosis
o Periostitis
o Calcification of vein
o Equinus deformity
o Acute fat necrosis can occur, esp: at ankle
o Deep vein thrombosis
Complications
Complications
Classiffication-CEAP

C. (Clinical class):
- Class 0: No visible or palpable signs of
venous disease.
- Class I : Telangiectasis or reticular veins.
- Class 2: Varicose veins.
- Class 3: Edema.
- Class 4: Skin changes e.g. venous eczema, pigmentation and
lipodermatosclerosis.
- Class 5: Skin changes with healed ulceration
- Class 6: Skin changes with active ulceration
Classiffication-CEAP

E. (Etiology):
Congenital.
Primary (undetermined cause).
Secondary:- Post-thrombotic - Post-traumatic
A. (Anatomic distribution of veins):
Superficial.
Perforator.
Deep.
P. (Pathophysiologicmechanism):
Reflux.
Obstruction.
Reflux and obstruction.
Telangectasias

 Small(0.5-1mm) widened blood vessels in skin-small intradermal varicosities

“SPIDER VEINS”/”venulectasias"

 In anywhere on the body esp-leg

 Usually no severe symptoms

 Rarely heamorhagic
 “corona phlebectatica”-blue spiderveins on medial aspect ankle below
malleolus
Telangectasias
Reticular veins

 Subcutaneous dilated veins-enter tributaries of main axial/trunk

veins

 Size >spider veins (1-3mm)

<varicose vein
 “feeder veins”-
refluxing reticular veins spider veins

 Cause discomfort and is cosmetically undesirable

Reticular veins
Investigations
o Venous doppler
o Duplex scan
o Venography/phlebography
o Plethysmography
o AVP-ambulatory venous pressure
o Varicography
o Arm foot venous pressure
o Routine investigations
 Management
 Conservative treatment
o Elevation of limb
o Support hosiery-elastic crepe bandage /unna boots
o Drugs-diosmine (PHLEBODIA 600 mg, 1 pill per day)
 Surgical treatment
Trendelenburg procedure (High tie, ligation of Inferior Epigastric
vein, External Pudent vein, External Ilii Circumflex vein)
Babcock procedure (Long saphenous strip)
Narath- Mueller procedure (multiple destruction of incompetent
tributary veins)
Cokett-Linton procedure (Perforator vein incompetence solution,
by ligation)
Surgical Treatment
Surgical Treatment
Before/After Images (PMSI CRH “Timofei
Mosneaga” Vascular Surgery Department)

 B/A
Before/After Images (PMSI CRH “Timofei
Mosneaga” Vascular Surgery Department)

 B/A
 Management
 Sclerotherapy (Injecting sclerosants into veins.)
Sodium tetradecyl sulphate, destruction of lipid membranes of endothelial
cells, shedding of endothelial cells, thrombosis,fibrosis,obliteration of veins.
Sclerotherapy Results

 Results
EVLA or EVLT Ablation

 Light for heating the veins

EVLA Results

 B/A
EVLA Results

 B/A
Conclusion

 We here, stand for modernised, classic surgical treatment.

 Minimal scars –Radical solution, Maximum aesthetic, and personal
satisfaction.
Thank You, for your attention

Sincerelly, Dr. Victoria Stirbu