CVI

Question 1

When does chronic venous insufficiency occur?

Answer 1

post DVT so its called post-phlebitic syndrome (post-thrombotic leg)

Question 2

What is CVI?

Answer 2

sustained venous hypertension due to inadequate drainage of venous system caused by obstruction or valvular incompetence

Question 3

What are the causes of CVI?

Answer 3

PRIMARY CVI due to decreased venous tone

SECONDARY to venous thrombosis (late complication of DVT)

• incomplete resolution of the thrombus by means of recanalization
• lumen becomes patent but with destruction of valves & incompetent perforator
• high pressure reflux from deep system to superficial (BLOW OUT)
• regional increased venous pressure
• venous hypertension

Question 4

What are the compensatory mechanisms that are supposed to decrease venous hypertension?

Answer 4

• lymphatic drainage
• body’s natural fibrinolytic activity removing pericapillary cuff

IF VENOUS DEFECTS OVERCOME THEM –> CVI IS DEVELOPED

Question 5

What is the pathophysiology of CVI?

Answer 5

1- increase in skin flow on gaiter’s area & increase in capillary dilatation
2- increase of leakage of plasma, plasma proteins, WBCs & RBCs
3- increase in interstitial fluid
4- overloaded lymphatics
5- edema occurs

RBC leakage -> hemosidrin deposition leads to brown pigmentation of gaiter area
FIBRIN CUFF theory -> fibrin depositions impairs O2 transport -> hypoxia, ischemia, fat necrosis, skin pigmentation & ulceration
WHITE CELL TRAPPING hypothesis -> white cells are trapped in high flow capillaries releasing free radicals

Question 6

What is the typical clinical picture of CVI?

Answer 6

1- history of DVT (2-7 years ago)
2- pain
- aching & night cramps
- venous claudication
3- edema (of lower limb especially at the end of day)
- initially soft & pitting but relieved by elevation
- later it becomes firmer & woody feeling (brawny induration)
4- brown pigmentation
5- dermatitis, eczema & lipodermatosclerosis
6- secondary varicose veins (due to obstruction of deep system)
7- venous ulcer (in Gaiter’s area)

Question 7

What is the most important method of investigation of CVI?

Answer 7

VENOUS DUPLEX

• site, extent & degree of obstruction
• presence of reflux

Question 8

What does ascending phlebography show?

Answer 8

vein obstruction

Question 9

What does descending phlebography show?

Answer 9

incompetent valves

Question 10

how can we measure walking venous hypertension?

Answer 10

using AMBULATORY VENOUS PRESSURE

Question 11

What is the main line of treatment in CVI?

Answer 11

CONSERVATIVE TREATMENT

• bed rest
• limb elevation
• avoid prolonged standing
• graduated elastic or pneumatic compression (ONLY if deep system is competent)
• antibiotics if associated with cellulitis
• adjunctive treatments

Question 12

What are the indications for operative treatment?

Answer 12

• patients with CEAP clinical class 5 or 6
• failure of non-operative therapy
• recurrent disease after non-operative therapy

Question 13

What are the types of operative treatment in CVI?

Answer 13

SUBFASCIAL LIGATION OF PERFORATORS

• helps in healing resistant ulcers
• OPEN: long medial calf incision
• SEPS (subfascial endoscopic perforator surgery )

Deep Venous Reconstruction