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PART 1
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Basic Considerations of Venous
Disorders
1 Venous and lymphatic disease: Ahistoricalreview 3
Christine M. Dubberke and Ruth L. Bush
2 Development and anatomy of thevenoussystem 15
Peter Gloviczki
3 The physiology and hemodynamics of the normal venous circulation 27
Frank T. Padberg Jr.
4 Classification and etiology of chronic venousdisease 39
Robert L. Kistner and Bo Eklöf
5 The pathophysiology and hemodynamics of chronic venous insufficiency of the lower limb 51
John Blebea
6 Pathogenesis of varicose veins and cellular pathophysiology of chronic venous insufficiency 61
Deoranie N. Abdel-Naby, Walter N. Duran, Brajesh K. Lal, FrankT.PadbergJr.,and Peter J. Pappas
7 Venous ulcer formation and healing atcellularlevels 73
Joseph D. Raffetto
8 Acute and chronic venous thrombosis: Pathogenesis and new insights 91
Jose A. Diaz, Thomas W. Wakefield, and Peter K. Henke
9 Epidemiology and risk factors of acute venousthrombosis 107
Mark H. Meissner
10 Epidemiology of chronic venous disorders 121
Eberhard Rabe and Felizitas Pannier
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Venous and lymphatic disease:
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Ahistoricalreview
CHRISTINE M. DUBBERKE AND RUTH L. BUSH
1
1.1 Introduction 3
1.2 Varicose veins and chronic venous insufficiency 3
1.3 The lymphatic system and lymphedema 12
…it shows what a distance we have travelled in surgery during the last quarter of a century (19th) and nally it should make us
very careful of our written statements, for in a few years they look very ridiculous.
1.1 INTRODUCTION
is chapter is an updated historical overview that describes
the progression of discoveries and subsequent advancements
in both the diagnosis and treatment of venous and lymphatic
diseases. Reection on the historical evolution of medical
knowledge is important in order to appreciate how far we
have truly come and to realize how far we have le to go. As
with all scientic progress, our current understanding of
venous and lymphatic diseases is inextricably connected and
built upon the advancements of our predecessors. We have
the luxury of thousands of years of observation, scientic
trials, errors, and discoveries, which have sequentially culminated in creating our current expertise in the eld today.
We are in an unprecedented era of medical economic conscientiousness superimposed with exponential advancements
in technology and medical therapies. Comprehensive data
collection is utilized to instantaneously evaluate the unlimited variables in our concerted eorts to discern the ecacy
and eciency of medical interventions, and design the best
overall evidence-based, patient-centered therapies. How to
promote and execute the continuous improvement of patient
care, management, and prevention practices is the challenge
we currently face. We are at the frontier of knowledge, yet
medical uncertainties, unknown etiologies, and lack of denitive treatments for and prophylaxis of common venous disease is a true testament to how far we have le to go. Before we
can address how to produce signicant change in the future,
1.4 Conclusions 13
References 13
Jerry Moore
we will take a step back and review the major historical chronology in the medical management of venous diseases.
1.2 VARICOSE VEINS AND CHRONIC
VENOUS INSUFFICIENCY
1.2.1 Venous disease throughout antiquity
e rst descriptions of varicose veins and manifestations
of chronic venous insuciency date back thousands of
years. Since the human race has walked on two legs, gravity
opposed the venous return of blood to the heart, leading to
the development of acute venous thrombosis, varicose veins,
and chronic venous insuciency. us, the basic principles
underlying the treatment of varicose veins today are shockingly reminiscent of the methods used to treat varicosities
in ancient times.
e Ebers Papyrus was written by the ancient Egyptians
in around 1550 and is one of the oldest and most important medical papyri. It contains medical descriptions and
treatments of varices and describes them as “tortuous, [and]
solid with many knots, as if blown up by air.”1 Later, the
rst surgical textbook was written by Sushruta, an Indian
surgeon who lived between 800 and 600 . Several translations from the original Sanskrit reveal that he discussed
siragranthi or “aneurysms of the veins,” and that “straining
or exertion by pressure” caused the described varicosities to
develop. He also provided one of the rst recorded accounts
3
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on the diculty in treating the associated condition of
thrombophlebitis. In his attempts to cure varices, he developed phlebotomy, and described using tree bark-derived
astringents (sandhana), freeze-induced blood thickening
(skandana), ash-induced dehydration (pachana), and vein
cauterization-induced singeing (dahana) as ways of achiev-
ing hemostasis. Ultimately, he concluded that varices were
incurable.
1,2
e rst illustration of varicose veins dates back to the
fourth century and is displayed on an ancient Greek
votive tablet (Figure 1.1). e stone carving discovered in
Acropolis (Athens) shows a twisted swelling extending up
the medial side of a massive leg and is believed to have been
dedicated to Doctor Amynos, one of the rst phlebotomists.
e ancient Greek Corpus Hippocraticum is evidence
that Hippocrates (460–377 ), the renowned “father of
medicine,” recognized a correlation between varicose veins
and ulceration. Even at a time when the understanding of
pathophysiology was extremely limited, he discouraged
standing for patients with lower extremity ulcers, explained
that varicosities represented “an inux of blood into the
veins,” and appreciated the importance of rm leg compression treatment by his prescription of bandages.
1,3–5
e
doctrine of the four humors (blood, phlegm, yellow bile,
and black bile) was the foundation of Hippocrates’ medicine and an extremely primitive understanding of circulation physiology, as both veins and arteries were believed to
carry air.3 He recommended alternative treatments, such
as small punctures in varicose veins and the use of cautery.
Hippocrates faced the same diculties in treating varices as
his predecessor, Sushruta, and wrote,
What cannot be cured by medications is cured
by the knife, what cannot be cured by the knife
is cured by the searing iron, whatever this cannot cure must be considered incurable.
3
One of the earliest attempts at compiling a complete history of medicine was completed in the rst century by
Aurelius Cornelius Celsus (25 –50 ), a famous Roman
encyclopedist. He described the use of compression linen
bandages and various types of plaster to treat leg ulcers,
and even performed operative phlebectomy via avulsion
with a blunt hook or cautery.
1,3
e widely accepted etiology
during this era was continuous bidirectional movement of
blood and its spirits, which resulted in varices that stored
the toxic humors safely outside of the body. e varicosities harboring evil spirits were believed to be benign unless
pressed back into the circulation.
1
Lack of anesthesia and a distorted view of blood circulation did not stop Claudius Galen, a rst century (130 )
Greek physician, from attempting surgical interventions
on unsightly varicose veins. Galen elaborated on Celsus’s
description of varicose vein surgeries, described venesection, and promoted operative avulsion with a blunt hook.
He is also credited with advancing the theory of humoral
dynamics in a text that would inuence Western medicine
and surgery for the next 1500 years.
1,5,6
An excerpt of his
writing explains:
In varicose veins of the legs we mark out the
whole extent of them by scratches on the out-
side, then put them on their backs, take hold of
the skin surface, and divide that first, then lift
up the varicosity with a hook and tie it off, and
do the same thing at all the incisions. Or we pull
them out with a varicocele hook and cut off the
ends, or we pass thread through the coil of the
veins with a probe and pull them up and take
them out.
2
If a vein is straight, or though crooked, is yet
not twisted, and if of moderate size, it is better
cauterized. If a vein is curved and twisted, as it
were into intricate coils and involutions, it is better to cut it out.
7
Figure 1.1 Votive offering leg with varicose veins.
Epidauros,Greece, third century BCE. (Available at
http://www.hkma.org.)
Byzantine physicians studied the medical treatments
and surgical techniques proposed by previous Greek and
Roman physicians at the famous Egyptian Alexandrian
school of medicine. Finding a surgical cure for varicose
veins was of great interest to ancient physicians, despite the
relatively limited knowledge concerning the pathophysiology of the disease process. Medical practice and surgery
were highly developed from the fourth to sixth centuries
. As Byzantine medical texts demonstrate, several surgical techniques for varices were widely studied, shared, and
practiced by all eminent Byzantine physicians, including
Oribasius, Aetius, Alexander of Tralles, and Paul of Aegina.
eir collective experiences through study and practice
1.2 Varicose veins and chronic venous insufficiency 5
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enabled them to establish the basic principles of vascular
surgery and develop new and innovative techniques.
3,7
Oribasius was one of these notable fourth century
physicians who advanced the study of varicose veins by
consolidating the wisdom learned from the Alexandrian
medical school with his own observations, descriptions,
and experiences. He wrote two famous medical texts with
extensive chapters that meticulously depicted varices and
surgical treatment techniques. His works were some of the
earliest texts to dene varices and detail physical distribution patterns in the head, abdomen, scrotum, and the legs.7
In his chapter entitled “About the Diculty in Curing Ulcers
which are above Varicose Veins,” he suggested venesection
via incision along the vein in order to completely empty its
contents and allow inammation and resulting scar tissue
to eventually obliterate the vein. is procedure was then
followed by the administration of purgatives.
7
Succeeding Byzantine physicians evaluated the usefulness of previously proposed procedures and advanced
their own modications and observations, developing surgical techniques further. Aetius, a great sixth century
Byzantine medical writer, was the rst to ligate varicose
veins.1 In the seventh century , Paulus Aegineta (607–690
) improved Aetius’s ligation technique by recognizing
the importance of great saphenous vein (GSV) ligation and
removal.1 He also advanced other novel modalities, such as
the use of tourniquets in preparation for surgery.
3,7
He was
followed by Albucasis de Cordova (936–1013 ), a Muslim
surgeon, who was one of the rst to report the use of a rudimentary external stripper.
3,6
1.2.2 From the middle ages to the
Renaissance: Abandonment of the
humoral theory of disease
By the middle ages, the lack of successful surgical outcomes,
along with signicant associated morbidity, brought attention to the anatomy of the structures involved in pathophysiologic processes. Guy de Chalice (1298–1368), a French
Renaissance surgeon, studied anatomy through dissections,
led by Galen’s anatomy textbooks.
5
To treat leg ulcers, he
developed the predecessor of the modern-day multilayer
compression dressing using compression bandages composed of linen and an adhesive plaster made of lead oxide,
olive oil, and water.5 is process, described in his dissertation entitled Chirurgical Magna, remained a standard reference in Europe for almost four centuries.
8
Later, in his detailed anatomy drawings, Leonardo Da
Vinci (1452–1519) accurately illustrated the venous system
of the legs, including the supercial veins (Figure 1.2).
1.2.3 Sixteenth century
Jeronimus Fabricius d’Aquapendente (1533–1619), a renowned
professor of anatomy at the Padua medical school, provided one of the rst full descriptions of valves, which he
Figure 1.2 Leonardo da Vinci. (From da Vinci L. The major
organs and vessels c. 1485–1490 (RCIN 912597). Royal
Collection Trust/© Her Majesty Queen Elizabeth II 2016.)
demonstrated at public dissections in 1579. His formal work
on venous valves, De Venarum Ostiolis, was published in
3
1603.
In 1593, in another text entitled Opera Chirurgica, he
described the surgical approach to varicose veins. Jeronimus
reported the use of multiple ligations above and below the
varicosity, and since ligation alone was not adequate, he
advocated complete removal of the “gross” blood from the
vein via puncture to achieve a successful treatment.
3
A brilliant French Renaissance surgeon Ambroise Paré
(1510–1590) published texts about the treatment of varicose
veins.1 He was one of the rst aesthetically conscientious
surgeons, as he expressed concern regarding long scars.3 He
was also the rst to perform ligation of the internal saphenous vein, described the ligation of varicose veins and the
GSV in the thigh, and advocated the use of escharotics to
the skin overlying the varix in order to produce thrombosis.3 e immense pain and lethal complications of sepsis
signicantly aected the popularity of surgical treatment
during this era, so Paré came back to Galen’s strategy of
noninvasive compressive ulcer treatments. His modications included local debridement, topical treatment, and
cleaning of the ulcer, followed by bandaging of the leg from
the foot upwards with a lead plate in his dressing in order
5
to increase local compression.
He also incorporated a rigid
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diet, purgatives, bleeding, and bedrest into his treatments.
However, Paré expressed concern that the healing of an
ulcer may cause noxious humors to go elsewhere and cause
other serious diseases such as cancer, in contrast to open
ulcers, in which the harmful humors had the opportunity
to escape the body.
When Paré, the surgeon of Henri II of France, was taken
prisoner by Lord Vaudeville at the siege of Hesdin,
5,9
he was
promised freedom if he could cure Vaudeville’s leg ulcer
that had persisted for 6 or 7 years. Paré used his compression method to almost completely heal the ulcer in 15 days,
and he was released from captivity.
5,9
1.2.4 Seventeenth and eighteenth centuries
e monumental discovery that forever changed the understanding of venous physiology came from William Harvey
(1578–1657). Aer extensive study of anatomy under
Fabricius d’Aquapendente, he presented the rst accurate
description of the circulation in 1628. He proved that blood
circulates with the heart acting as a pump, and established
unidirectional blood ow, made possible by venous valves
(Figure 1.3).
theory of humors and inuenced further investigation into
more sound pathophysiological causes of varicose veins.
Like Hippocrates, Richard Wiseman (1622–1676)
believed in an association between varicose veins and ulceration, and is credited with coining the term “varicose ulcer”
in 1696.
3,5
is understanding essentially disproved the
3,5
He deviated from the tradition of writing about
A
B
C
A
E
F
D
D
5
the accredited work of preceding surgeons and focused on
describing his personal treatment methods and case histo-
5,10
ries.
Early in his career, he performed relatively simple
operations of the division and ligation of varicosities above
leg ulcers, but was greatly disturbed by the morbidity and
suering that patients endured from surgery. Wiseman realized that not all cases were appropriate for surgical operation, and generally opposed surgical treatment except for
extremely severe cases. By searching for noninvasive alternative treatments, he invented the rst permanent laced compression stockings, constructed from dog skin leather, which
was preferred for its soness and comfort (Figure 1.4). e
novelty of these stockings resided in the lace-up feature that
provided operator-controlled, variable degrees of compression pressure. Wiseman reported on several patients who
were successfully treated with his device, and recognized the
palliative nature of the treatment when ulcers recurred aer
discontinuation of the stockings.
3,5
An expansion of more sound pathophysiological theories
came from Jean Louis Petit (1674–1750), the rst director
of the Academy of Surgery in Paris. He believed that varicosities were caused by “anything that obstructed the rising blood in the veins.”6 e association of pregnancies as a
causative factor of varicosities was also an observation that
was made during this era.
3
1.2.5 Nineteenth century
Nineteenth-century scientists and surgeons expressed an
increasing need to investigate the underlying pathophysiological causes of varicose veins. Identied mechanisms became
the bases of newly developed surgical concepts and resulted
in rapid treatment evolution towards the end of the century.
e invention of the hypodermic needle facilitated the
very rst intravenous sclerotherapy reported by CharlesGabriel Pravaz in 1840. ese experiments, with injections
of absolute alcohol and ferric chloride into varicose veins,3
Figure 1.3 Harvey’s little vein experiment. (From De
Motu Cordis HW. Scientific Papers: Physiology, Medicine,
Surgery, Geology, with Introductions, Notes and
Illustrations, translated by Willis R. The Harvard Classics. P.
F. Collier and Son, New York, 1910, vol. 38.)
G
H
O
A
B
H
O
K
Figure 1.4 Richard Wiseman (1622–1676) and his laced
stocking. (From Royle J and Somjen GM. ANZ J Surg,
77(12), 1120–1127, 2007.)
were unsuccessful, being complicated by suppurative infec-
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tion, and were eventually banned. e idea was revisited
again at the turn of the twentieth century.
By 1867, the idea of the “varicose ulcer” was adamantly
refuted by a London surgeon, John Gay, who publically
criticized the causal relationship between varicose veins
and ulceration in his famous Lettsomian Lectures. During
his meticulous dissections of cadavers with varicose veins,
ulceration, pigmentation, and induration, he assimilated
considerable knowledge on venous insuciency. He concluded that ulcers were not invariably associated with visible
varicose veins, and emphasized the role of other abnormalities, including arterial disease, as well as the involvement
of the deep or communicating venous systems.
1,5
John Gay
wrote that the term “varicose ulcer” was misleading, subsequently reclassifying ulcers into three groups in 1868: simple ulcers, venous ulcers (a term he rst coined), and arterial
ulcers. He was also the rst to accurately describe perforating veins of the leg, which paved the way for the modern
treatment of varicose veins.
1,5 ,11
Until the end of the nineteenth century, the most eective therapy for all forms of venous disease remained leg elevation and compression, as advocated by Wiseman.12 Even
the simplest surgical varicosity operations carried signicant danger of infection, commonly followed by septic complications and venous thrombosis. Evaluation of proposed
surgical procedures became possible aer the acceptance
of aseptic surgical techniques and the introduction of safe
anesthesia.5 In 1867, Joseph Lister developed surgical antisepsis, which greatly increased the safety of groin incision
by substantially reducing the risk of infection.3 Around the
same time, anesthesiology had greatly improved, with the
introduction of spinal and gas anesthesia. e progress of
anesthesia and antiseptic techniques advanced the surgical
treatment of varicose veins at an unprecedented pace.
3
Friedrich Trendelenburg (1844–1925), a famous German
surgeon, published the original landmark paper on the GSV
ligation in 1890, establishing the foundation for modern-day
venous surgery.5 He identied the incompetent GSV as the
source of reux and resultant venous hypertension, which
could be eliminated by ligation of the GSV (Figure 1.5).
Early ambulation was not enforced due to a fear of mobility causing pulmonary emboli, thus Trendelenburg kept his
patients in bed for more than 10 days. Patients were oen
hospitalized for 5–6 weeks aer the procedure, oen due to
frequent thrombophlebitis and infectious complications.
3,6
William “Jerry” Moore (Figure 1.5), a surgeon from
Melbourne, Australia, modied Trendelenburg’s original
GSV ligation procedure to a high ligation and division of the
GSV just distal to the saphenofemoral junction (SFJ), which
is very similar to how it is still performed today (Figure 1.6).
He also recommended a short transverse incision 1–2 inches
below the Poupart ligament, where the anatomical position
of the GSV is relatively constant. He was one of the rst surgeons to faithfully use Lister’s aseptic surgery principles in
order to perform his operations with minimal infectious
complications. In 1896, he published an extraordinary paper
1.2 Varicose veins and chronic venous insufficiency 7
Figure 1.5 William Moore, circa 1903. (From Royle J and
Somjen GM. ANZ J Surg, 77(12), 1120–1127, 2007.)
Moore
AASV
GSV
Trendelenburg
AVL
PAV
Figure 1.6 The recommended levels of great saphenous
vein ligation according to Trendelenburg and Moore.
AASV, anterior accessory saphenous vein; AVL, anterior
vein of the leg; GSV, great saphenous vein; PAV, posterior
arch vein. (From Royle J and Somjen GM. ANZ J Surg,
77(12), 1120–1127, 2007.)
8 Venous and lymphatic disease
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in which he quoted Trendelenburg’s procedure as an inspiration for his intervention. e article was a comprehensive
description of the etiology of varicose veins, listing venous
reux, gravitational force leading to vein dilation, and incompetent, faulty valves of the saphenous vein as factors in the
development of varicosities. An important question on of the
pathological process was also raised: do faulty valves lead to
venous dilatation or does venous dilatation lead to valvular
incompetence?
5,12
He reported successful results in the healing of leg ulcers, and that previously engorged veins nearly
vanished when surgical elastic bandages were employed aer
the interventions.
5
1.2.6 Twentieth century
By the twentieth century, saphenous vein ligation at the SFJ,
known as “crossectomy,” was routinely practiced, but it was
soon realized that recurrence rates were high. In the early
1900s, interest was again peaked in terms of the development
of sclerosing agents, and many concoctions were tried but
abandoned, due side eects such as allergic reactions, skin
sloughing, pain, and even death. Eventually, saphenous vein
stripping was added to proximal GSV ligation, which was
found to signicantly reduce the number of recurrences.
In 1916, John Homans further advanced the pathophysiological classication system of venous diseases originally
proposed by Gay. Contrary to popular belief, Homans
believed that the surgical treatment of varicose veins and
ulcers should be based upon the specic causative anatomical defect.3 He wrote:
Surface varix complicated by varicosity of the
perforating veins requires for its cure not only
eradication of the great saphenous vein, but a
thorough exploration of the lower leg in order
to ligate varicose perforating veins.
1
In the 1930s, an engineer named Conrad Jobst, who suffered from varicose veins and chronic ulcerations refractory
to sclerotherapy, noticed that his symptoms improved considerably while standing in a pool of water. He realized that
graduated pressure counteracted excessive hydrostatic pressure, relieving his symptoms. He designed his own ambulatory gradient compression stockings, and to this day, his
invention remains the most important treatment for venous
insucienc y.
1,13
Later, in 1938, Robert Linton signicantly advanced the
understanding of venous diseases by describing communicating veins and incompetent perforators and their roles in
venous ulcer development. He ardently studied the anatomy
of these veins, and developed the surgical approaches for
the subfascial ligation of medial lower leg communicating
veins, known as the “Linton procedure.”
1,3
His technique
was eventually abandoned due to the unacceptable morbidity associated with the necessary extensive skin incisions.
e rst use of phlebography by Beberich and Hirsch
in 1923 was an important breakthrough in the diagnosis of
3
1,3
venous disorders. e rst attempt to quantify the degree
of venous insuciency was made using Barber’s “blood
manometer” in 1925. In this method, an 18-gauge needle
was used to obtain direct measurements of lower extremity
venous pressure. In 1948, Gunnar Bauer of Sweden developed descending phlebography, which conrmed the high
incidence of deep venous system abnormalities in patients
with varicose veins and leg ulcers, and showed that abnormalities other than varicosities predisposed individuals to
venous insuciency.
1
e use of foamed sclerosing agents was introduced in
1939 by Stuard McAusland, when he accidentally produced
foam by shaking a bottle that was lled with sodium morrhuate and treated spider veins and telangiectasias with the
froth.3 Sclerotherapy became an accepted treatment for
venous insuciency aer his report on using sclerotherapy
in 10,000 patients.1 Egmont James Orbach’s 1944 publication entitled Air-block Technique described the injection of a
small amount of air into the venous segment, displacing the
blood in the vein that was to be treated, and inspired today’s
“foam-block” (air-block with large-bubbled foams), which
is still used to treat small veins. e ensuing several decades
were peppered with several variations and improvements
on sclerosing foams.
3
Since initial attempts in 1906 by Carrel and Guthrie, the
evolution of venous reconstructive surgery remained relatively stagnant until the 1950s, during which arterial surgical techniques were developed, but its progress was still
much slower than arterial surgery. Venous disorders have a
relatively tolerable insidious development, making them less
acute, and not urgently life or limb threatening. Additionally,
the pathophysiology of venous insuciency is complicated
and varies with each individual patient, oen requiring more
than a single, simple procedure. Furthermore, the delicate
venous anatomy (collapsible thin-walled vessels with paperne valves) added to the complexity and diculty encountered in venous reconstructive surgery. e rst gra using
a saphenous vein to bypass an obstructed external iliac vein
was performed in 1952. It thrombosed aer 3 weeks, but was
followed by various other attempts throughout the 1960s.
In 1968, Psathakis transformed a segment of the gracilis
tendon in order to construct what he called a “substitute
valve” for the popliteal vein. is inspired the rst reported
attempt by Kistner to directly repair incompetent femoral
valves in 1975, with successful long-term results. Eventually,
in 1979, prosthetic gras were used in the venous system.
Surgeons also began to transplant segments of veins with
normal valves in order to replace the diseased veins in the
1980s. Prosthetic gras were used in the 1990s to reconstruct
large veins, including the superior vena cava and iliac veins.
1
Today, venous valve reconstruction treatments, such as valve
transplant, valvuloplasty, and endogra valves, are used only
selectively. However, surgical vein bypass is an option for
patients with severe proximal venous reux or obstruction
aer percutaneous intervention has failed, or if percutaneous
intervention is not possible. Sclerosing agents became popular again in the 1960s due to the failings and invasiveness
1.2 Varicose veins and chronic venous insufficiency 9
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of surgery. e technique of sclerotherapy continued to be
adapted and improved upon; however, the lack of consistently reproducible techniques and the variety of preparations made it dicult to compare results and determine the
ideal technique.
3
e treatment of residual varicosities aer surgery
remained an issue, inspiring Robert Muller, a Swiss dermatologist, to reinvent the stab avulsion phlebectomy technique using instruments that he developed in 1967, initially
from half of a broken hemostat. is procedure, known as
the “Mullerian ambulatory phlebectomy,” was taught to
hundreds of physicians. Robert Muller is regarded as the
father of modern-day ambulatory phlebectomy and his
hooks are still used today.
3
Duplex scanning, which was introduced in the mid1980s, rapidly surpassed phlebography as the gold standard for investigating venous reux. Color duplex imaging
arrived in the early 1990s, which required less time for performing scans and demonstrated improved reliability. It
facilitated the noninvasive diagnosis and study of the natural history and pathophysiology of venous disease.3 In 1994,
the CEAP classication was developed, with the recognition
of the dierent etiologies and locations of lower extremity
venous disease. is classication system dened seven
clinical classes according to the clinical signs (C), the etiology (E), the anatomic (A) distribution, and the pathologic
(P) mechanism of the venous disease. Severity and disability
rating scales were also designated.
1
1.2.7 Modern varicose vein treatment
Prior to the twenty-rst century, varicose veins were conventionally treated with open operations. Today, most
venous disorders and resultant venous insuciency are
treated without the need for open procedures. Minimally
invasive techniques have forever changed the clinical landscape of varicose vein surgery, and include ultrasoundguided foam sclerotherapy, endovenous laser therapy, and
radiofrequency ablation. Newer interventions are continually being developed and will be discussed in later chapters.
ese procedures can be performed on an outpatient basis
and do not require general anesthesia. High patient satisfaction rates are related to the improved quality of life, reduced
postoperative pain, fewer complications, and quicker return
to work and normal activities.
core surgical principles in the treatment of varicose veins
and venous ulcers are applied today in much the same way
as they were over 100 years ago. On occasion, traditional
surgical methods may be required for patients with recurrent or refractory venous ulceration.15 Use of foamed sclerotherapy resumed in the late 1990s. Today, sclerotherapy is
the treatment of choice for lower extremity telangiectasias,
reticular veins, and small varicose veins. e modern sclerosing agents include sodium tetradecyl sulfate, polidocanol, and, occasionally, hypertonic saline.
is also used for the treatment of small or facial (cosmetic)
telangiectasias.
15
14
Albeit slightly adjusted, the
16
Laser therapy
1.2.8 Modern economic implications of
varicose veins and chronic venous
insufficiency
e management of venous diseases and their associated
sequelae consumes a signicant proportion of today’s health
care budget. Venous diseases should not be considered to
be a benign, cosmetic issue. e enormous costs associated with venous diseases are associated with the management of subsequent venous ulceration and complications.
Minimally invasive procedures have greatly improved the
therapeutic eciency and health-related quality of life by
reducing serious side eects, costs, and postoperative pain.3
e importance of venous reux treatment for reducing the
risk of recurrent venous ulceration has been clearly demonstrated, and subsequent systematic reviews of health
economic analyses have suggested that the early treatment
of varicose veins using endovenous procedures performed
under local or tumescent anesthesia in the outpatient setting
is more cost eective than conservative management in the
long run.
17,18
Continued research and economic analyses in
this area are needed to conrm this assessment and deliver
cost-eective, quality treatment options for patients.
17
1.2.9 Venous thromboembolism
Venous thromboembolism (VTE) includes both deep vein
thrombosis (DVT) and pulmonary embolism (PE). Unlike
the long history of varicose veins and chronic venous insufciency, the identication, diagnosis, and treatment of
VTE have been relatively recent in the history of medicine.
Due to its equivocal clinical ndings and its rapidly lethal
nature, VTE was unrecognized and untreated for thousands
of years, and continues to be a diagnostic and therapeutic
challenge today. Although humans have undoubtedly suffered from VTE for thousands of years, the recorded history
of DVT treatment begins much more recently in the past
700 years, with major discoveries and progress occurring
within the past 100 years.
2,8
1.2.10 First cases and treatments of DVT:
1271–1700s
It is speculated that the earliest reference to venous thrombosis came from Avicenna (980–1037), an oriental scientist
who noted a risk of “particle migration” during vein surgery.8 In 1271, the rst formal description of DVT was written by Guillaume de Saint Pathus. His manuscript describes
a 20–year-old Norman cobbler, named Raoul, who presented to a surgeon, Henri de Perche, with unilateral pain
and swelling of the right calf. He was initially advised to
wait for clinical improvement; however, the pain and swelling progressively extended up to his thigh. Aer several
unsuccessful treatment attempts, the symptoms continued to worsen until the patient eventually developed a leg
ulcer. Finally, he was advised to visit the tomb of King Saint
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