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3 Presentation of Chronic Venous Disease
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49
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R e fl ux Management
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Daniel F. Geersen and Eric Mowatt-Larssen
4
Contents
4.1 Introduction ................................................... 51
4.2 Differential Diagnosis .................................... 52
4.3 Medical Management .................................... 53
4.4 Interventional Strategies ............................... 56
4.5 Alternative Strategies .................................... 57
4.6 Ablation Techniques ...................................... 57
Conclusions ............................................................. 57
References ............................................................... 58
D. F. Geersen , MPAP, PA-C
Division of Vascular Surgery ,
Duke University Medical Center ,
Durham , NC , USA
e-mail: daniel.geersen@duke.edu
E. Mowatt-Larssen , MD, FACPh, RPhS (*)
Pacifi c Street 757, Suite C-2 , Monterey ,
CA 93940 , USA
e-mail: eric.mowatt.larssen@gmail.com,
veinspecs@gmail.com
Abstract
The most common cause of chronic venous
disease (CVD) is refl ux. Refl ux is abnormal
blood fl ow direction resulting from venous
valve dysfunction. In the lower extremity thigh
and calf, abnormal fl ow is from proximal to
distal in deep or superfi cial veins, or deep to
superfi cial in perforator veins. Refl ux is most
often primary (unknown etiology and not present at birth), is less often secondary (known
cause like thrombosis or trauma), and is rarely
congenital. This chapter will discuss how to
manage symptomatic venous refl ux disease.
4.1 Introduction
The most common cause of chronic venous disease (CVD) is refl ux. Refl ux is abnormal blood
fl ow direction resulting from venous valve dysfunction. In the lower extremity thigh and calf,
abnormal fl ow is from proximal to distal in deep
or superfi cial veins, or deep to superfi cial in perforator veins. To account for a normal valve closure time, refl ux is defi ned by consensus opinion
to be 0.5 s for veins generally, with the exception
of the femoropopliteal deep system, where the
value is 1.0 s [ 1 ]. Refl ux is most often primary
(unknown etiology and not present at birth), is
less often secondary (known cause like thrombosis or trauma), and is rarely congenital.
Obstruction, typically from thrombosis, is
also an important cause of CVD. Anatomic
E. Mowatt-Larssen et al. (eds.), Phlebology, Vein Surgery and Ultrasonography,
DOI 10.1007/978-3-319-01812-6_4, © Springer International Publishing Switzerland 2014
51
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Table 4.1 Common venous discomfort symptoms
Tingling
Aching
Burning
Muscle cramps
Swelling
Throbbing
Heaviness
Itching
Restless legs
Tiredness
Fatigue
obstructions, such as vein compression from an
artery, as in May-Thurner syndrome, or even a
tumor, can also cause CVD. Some unfortunate
patients may have combined refl ux and obstruction, which produces worse symptoms than either
condition alone. Both refl ux and obstruction in
the infrainguinal lower extremity are accurately
diagnosed by duplex ultrasound, and this test is
essential to management of potential CVD
patients.
This chapter will discuss how to manage
symptomatic venous refl ux disease. Not all refl ux
causes symptoms, and not all refl ux should be
treated. The differential diagnosis of potential
venous symptoms will be discussed. Then the
principles of conservative and procedural management will be outlined.
4.2 Differential Diagnosis
CVD can manifest itself in a variety of ways. The
hallmark symptoms of CVD are pain, discomfort,
spider veins, reticular veins, varicose veins, swelling, skin changes, and leg ulcers. Table 4.1 out-
lines common venous discomfort complaints.
Pain, discomfort, and swelling symptoms typically worsen with extremity dependence (i.e.,
standing) as the day progresses, since refl ux is
activated by gravity. The symptoms are also worse
when the weather is warm, as a result of venous
dilatation. Symptoms usually improve with
extremity elevation or compression. Swelling,
skin changes, and ulcers typically start at the ankle
Table 4.2 Differential diagnosis of lower extremity pain
and discomfort
Deep or superfi cial venous thrombosis
Peripheral arterial disease
Iliocaval obstruction
Pelvic congestion syndrome
Proximal venous refl ux (i.e., branches of the internal
iliac vein)
Vascular malformation
Nutcracker syndrome
Chronic compartment syndrome
Neuralgia (i.e., sciatica)
Complex regional pain syndrome
Restless legs syndrome
Musculoskeletal (i.e., muscle/tendon/ligament sprain,
muscle pain, osteoarthritis, rheumatoid arthritis)
Cellulitis
Table 4.3 Differential diagnosis of unilateral leg swelling
Chronic venous insuffi ciency
Deep venous thrombosis
Iliocaval obstruction
Lymphedema
Lipedema
Baker’s cyst
Cellulitis
Orthopedic trauma
area, where ambulatory venous pressure is highest, but may progress proximally up the calf and
thigh.
Table 4.2 outlines differential diagnostic considerations for lower extremity pain and discomfort. Tables 4.3 and 4.4 outline the differential
diagnoses of unilateral and bilateral leg swelling, respectively. Table 4.5 outlines the differ-
ential diagnosis of leg ulcers. Skin changes in
the ankle area are often due to chronic venous
insuffi ciency, but each skin sign has a differential diagnosis of its own, and dermatology consultation should be considered if chronic venous
insuffi ciency cannot be ruled in. Leg ulcers can
also be caused by skin cancer, or venous ulcers
can become malignant [ 2 ]. It is not clear from
the literature when to biopsy, but skin biopsy
should be considered for leg ulcers which do
not heal despite appropriate management and
4 Refl ux Management
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Table 4.4 Differential diagnosis of bilateral leg swelling
Bilateral chronic venous insuffi ciency
Congestive heart failure
Pulmonary hypertension
Protein-losing nephropathy
Liver cirrhosis
Obesity
Table 4.5 Differential diagnosis of leg ulcer
Venous ulcer
Peripheral arterial disease
Neuropathic ulcer
Pressure ulcer
Skin cancer
patient compliance and for nonhealing leg ulcers
in unusual locations.
More advanced CVD, measured as increased
CEAP class, is associated with more areas
of refl ux. Saphenous refl ux is common in all
CEAP classes. The prevalence of perforator
and deep venous refl ux increases with increasing CEAP class [ 3 ]. The most common pattern
of saphenous refl ux involves the great saphenous vein (GSV) (Fig. 4.1 ). Refl ux in the small
saphenous vein (Fig. 4.2 ) or anterior accessory
GSV (Fig. 4.3 ) is also common. However, cross-
over involvement occurs, and each patient with
suspected CVD merits a duplex ultrasound to
determine if they meet the typical pattern [ 4 ].
Non-saphenous refl ux (Fig. 4.4 ) occurs in around
10 % of patients [ 5 ].
Venous symptoms can also be caused by
venous sources other than lower extremity
refl ux or obstruction. Iliocaval obstruction
should be considered in patients with venous
symptoms with minimal or no refl ux on infrainguinal ultrasound. Pelvic congestion syndrome
can present with pelvic pain or varicosities or
lower extremity varicosities which can be followed with ultrasound above the inguinal ligament. A vascular malformation usually presents
at birth or puberty (due to hormonal changes)
and can also be suggested by unusual anatomy
seen on ultrasound. Refl ux of tributaries of the
internal iliac vein can cause varicosities on the
buttocks or pelvic areas.
Fig. 4.1 The classic great saphenous vein ( asterisk ) pattern
4.3 Medical Management
Multiple conservative measures have been
recommended for patients with CVD, including compression, leg elevation, exercise, diet
and weight loss, and analgesics. Compression
options include elastic compression stockings,
inelastic bandaging, and pneumatic compression.
Prescription strength compression stockings
start at 20–30 mmHg (Class 1) and are followed by 30–40 mmHg (Class 2), 40–50 mmHg
(Class 3), and 50+ mmHg (Class 4). In general,
compression at 20–30 mmHg seems effective for
symptomatic varicosities, while 30–40 mmHg is
preferred if tolerated for those with venous ulcers
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D.F. Geersen and E. Mowatt-Larssen
Fig. 4.2 Classic small saphenous vein refl ux pattern
or leg swelling [ 1 ]. Knee-high length is often
used due to greater ease in getting the stocking on, but thigh and pantyhose styles are also
available. Compression therapy improves symptoms and quality of life in patients with simple
symptomatic varicosities, but it does not reverse
disease [ 6 ]. In patients with venous ulcers, com-
pression accelerates healing and reduces ulcer
recurrence risk [ 7 ]. Compression has not been
shown to reduce varicosity recurrence rates or
slow disease progression [ 6 ].
Compression therapy is contraindicated in
patients with signifi cant peripheral arterial disease, congestive heart failure, or active infection
at the site. Patient compliance and diffi culty getting the stocking on can be a major problem, so
providers should carefully explain the benefi ts to
Fig. 4.3 The anterior accessory great saphenous vein
( asterisk ), when present, runs superfi cial to the femoral
vessels
patients. Interventional ablation of symptomatic
refl ux is more effective in improving quality of
life than compression and lifestyle modifi cation
[ 8 ]. Despite the data, third-party payers often
require a “trial” of conservative measures, such as
compression, before ablation can be performed.
Exercise has been advocated under the hypothesis that making the calf muscle stronger, even in
the presence of malfunctioning venous valves
from refl ux, may improve overall calf muscle
pump function. In patients with venous ulcers,
improving ankle range of motion and muscle
strength improves venous hemodynamic parameters but has not yet been clearly shown to affect
clinical outcomes [ 9 ].
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Gluteal vein Vulvar veinsPosterolateral
Sciatic
nerve vein
thigh perforator
vein
Lower
posterior
thigh vein
Popliteal
fossa
vein
Knee
perforator
vein
Fig. 4.4 Non-saphenous vein refl ux patterns (Used with permission) [ 5 ]
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Table 4.6 Venoactive medicines
Horse chestnut seed extract (aescin)
Flavonoids – rutosides, diosmin, hesperidin
Micronized purifi ed fl avonoid fraction (MPFF)
French maritime pine bark extract
Calcium dobesilate, naftazone
Benzarone
Table 4.6 lists venoactive medicines. Studies
on these medicines are limited, none are FDA
approved for venous refl ux disease, and many are
not available in the USA [ 1 ].
4.4 Interventional Strategies
In general, symptomatic and refl uxing veins are
treated in the following order: saphenous, then
epifascial (saphenous tributaries and localized
varicosities), then perforator veins, and then
deep veins. This order is based upon assessment
of benefi ts and risks. Ablation of symptomatic
saphenous refl ux has been shown to improve
quality of life in patients with symptomatic varicosities [ 10 ]. In patients with healed or active
ulcers, it has been shown to reduce ulcer recurrence by 25 % at 4 years, from 50 to 25 % [ 11 ]. It
is not clear if saphenous ablation improves ulcer
healing rates, with positive and negative results
reported [ 11 , 12 ].
Incompetent perforator vein (IPV) management is controversial. IPVs are associated with
worse venous disease, based on CEAP score [ 3 ].
The clinical benefi t with treatment of IPVs, however, has not been shown independent of saphenous vein treatment [ 13 ]. Clinical improvement
after IPV treatment may be hard to demonstrate
because isolated perforator refl ux is rare. The
ankle blowout syndrome of a leg ulcer with a
nearby incompetent perforator was described in
1953 [ 14 ]. Consensus opinion still favors treat-
ment in this setting [ 1 ].
Some deep vein treatments, such as iliocaval
stenting for obstruction or gonadal vein ablation
for pelvic congestion syndrome, carry a high
benefi t at low risk. Other deep vein disease treatments, such as those for mixed obstruction and
refl ux, carry signifi cant morbidity and require
specialized skills, allowing performance only at
specialized centers.
Relative contraindications to superfi cial vein
treatment include severe medical comorbidities
which limit patient quality of life benefi ts from
treatment. Inability to walk reasonably (i.e., at
least 5 min/h) may increase clot risk with
treatment. Although the opinion has been challenged, treatment of the superfi cial system in the
presence of deep venous obstruction is generally
considered contraindicated, since the superfi cial
system could be functioning as collateral circulation [ 15 ]. Acute thrombosis is generally a contra-
indication to superfi cial treatment, except in
cases like saphenofemoral junction ligation of
proximal GSV thrombosis in order to reduce
embolization risk. Anticoagulation, however, can
be considered in this case as well.
Some advocate concomitant instead of staged
therapies of saphenous and epifascial systems.
The main benefi t of the concomitant strategy is
that the patient can be treated in one session,
resulting in a faster improvement in quality of
life, although the improvement is not sustained in
the longer term [ 16 ]. This strategy may be par-
ticularly useful for patients who travel a long distance for their appointments, who lack the time
for repeated visits, or who are undergoing ambulatory phlebectomies.
Others advocate staged treatments. After
GSV ablation, attached varicosities often
become smaller, and some disappear [ 17 ]. Even
small saphenous vein (SSV) refl ux sometimes
corrects after GSV ablation [ 18 ]. Presumably
these improvements are due to reduction of the
volume of refl ux moving distally into these veins
after successful ablations. Remaining varicosities are then easier to treat [ 19 ]. Some have even
recommended waiting 4 months after saphenous
ablation before treating remaining varicosities
due to less need for treatment with this waiting
period [ 20 ].
It is important for patients to understand that
any chronic venous disease management strategy
does not cure vein disease, but can often make a
big difference in clinical endpoints such as quality of life and ulcer recurrence. Still, varicosity
or ulcer recurrence remains a risk. The patient
4 Refl ux Management
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57
who presents with recurrent chronic venous
disease needs a reassessment, including duplex
ultrasound, to determine the cause of recurrence
before a successful treatment strategy can be
implemented.
4.5 Alternative Strategies
Some advocate treatment of the superfi cial
tributaries before the saphenous in many cases.
The saphenous-fi rst strategy was based on a
pathophysiologic model that refl ux begins at
saphenous- deep junctions, such as the saphenofemoral junction, and then progresses distally
gradually, usually over several years. More recent
ultrasound studies challenge that belief [ 21 ].
Based on this new information, some advocate
treating the refl uxing tributaries and localized
varicosities fi rst, before the refl uxing saphenous
vein, in many cases. Retrospective data on this
technique, termed ASVAL (ambulatory selective varices ablation under local anesthesia), is
intriguing [ 22 ].
An additional challenge to the standard saphenous then tributaries model comes from some
who advocate disconnecting points where refl ux
crosses from deep to saphenous (like the saphenofemoral junction) or from saphenous to epifas-
cial (like the saphenous-tributary junction) but to
otherwise preserve these refl uxing veins in order
to preserve venous drainage and thus prevent disease recurrence [ 23 ]. CHIVA (for the French,
“cure conservatrice et hemodynamique de
l’insuffi sance veineuse en ambulatoire” and in
English, “conservative hemodynamic treatment
for chronic venous insuffi ciency”) utilizes surgical ligations for disconnection [ 24 ]. CHIVA has
been shown in two randomized, controlled trials
to reduce recurrence in comparison to surgical
high ligation and stripping [ 25 , 26 ].
4.6 Ablation Techniques
Thermal (endovenous laser or radiofrequency),
surgical (high ligation with or without stripping), and chemical (ultrasound-guided foam
sclerotherapy) are all safe and effective techniques to ablate a symptomatic saphenous vein.
There are few studies comparing clinical endpoints between these options. The American
Venous Forum and Society for Vascular Surgery
recommend thermal ablation as fi rst choice in a
consensus opinion because it is minimally invasive and has similar or better early-term results,
and equivalent midterm results, as surgery [ 1 ].
Techniques for ultrasound- guided foam sclerotherapy are rapidly improving, but results are
not yet as good as those seen with thermal ablation and surgery [ 1 ].
Ablation techniques for epifascial veins
include chemical (sclerotherapy with or without ultrasound guidance) and surgical (microphlebectomy or powered phlebectomy) [ 19 ].
Chemical ablation is fully reviewed in Chap. 11
and surgical techniques in Chap. 12 . Thermal
ablation (laser or radiofrequency), reviewed in
Chap. 10 , can also be used in some cases if the
vein is straight and long enough for technical
success, but this technique is less commonly used
for these veins [ 19 ].
Surgical endoscopic perforator surgery
(SEPS), thermal ablation, and ultrasound-guided
foam sclerotherapy are all technically successful
therapies for incompetent perforating veins [ 1 ].
Some deep vein problems, such as iliocaval
obstruction and pelvic congestion syndrome, are
now also amenable to endovascular treatments.
Other deep vein diseases require sophisticated
techniques like valvuloplasty or even venous
bypass, which are performed only at specialized
centers.
Conclusions
Venous disease occupies a wide spectrum of
severity and possible treatments. The keys
to success remain the same: identify the
source of the symptoms; treat in order to
achieve a durable improvement in quality of
life for patients; and minimize venous dis-
ease recurrence. The history of phlebology
is far from written. New technologies,
instrumentation, and knowledge of the sub-
ject continue to alter our understanding of
the disease.
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