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Venous and
Lymphatic Diseases
edited by
Nicos Labropoulos
New Jersey Medical School
Newark, New Jersey, U.S.A.
Gerard Stansby
University of Newcastle upon Tyne
Newcastle upon Tyne, U.K.
Venous and
Lymphatic Diseases
Taylor & Francis is an imprint of the
Taylor & Francis Group, an informa business
Published in 2006 by
Taylor & Francis Group
270 Madison Avenue
New York, NY 10016
© 2006 by Taylor & Francis Group, LLC
No claim to original U.S. Government works
Printed in the United States of America on acid-free paper
10987654321
International Standard Book Number-10: 0-8247-2923-4 (Hardcover)
International Standard Book Number-13: 978-0-8247-2923-3 (Hardcover)
Library of Congress Card Number 2006040429
This book contains information obtained from authentic and highly regarded sources. Reprinted material is quoted with
permission, and sources are indicated. A wide variety of references are listed. Reasonable efforts have been made to publish
reliable data and information, but the author and the publisher cannot assume responsibility for the validity of all materials
or for the consequences of their use.
No part of this book may be reprinted, reproduced, transmitted, or utilized in any form by any electronic, mechanical, or
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For permission to photocopy or use material electronically from this work, please access www.copyright.com
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Trademark Notice: Product or corporate names may be trademarks or registered trademarks, and are used only for
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Library of Congress Cataloging-in-Publication Data
Venous and lymphatic diseases / edited by Nicos Labropoulos, Gerard Stansby.
p. ; cm.
Includes bibliographical references and index.
ISBN-13: 978-0-8247-2923-3 (alk. paper)
ISBN-10: 0-8247-2923-4 (alk. paper)
1. Veins--Pathophysiology. 2. Blood-vessels--Diseases. 3. Lymphatics--Diseases. I. Labropoulos, Nicos.
II. Stansby, Gerard.
[DNLM: 1. Veins--physiopathology. 2. Lymphatic Diseases. 3. Vascular Diseases. WG 600 V4632 2006]
RC695.V46 2006
616.1’4--dc22 2006040429
Visit the Taylor & Francis Web site at
http://www.taylorandfrancis.com
Taylor & Francis Group
is the Academic Division of Informa plc.
https://t.me/med1917
Preface
“The best preparation for tomorrow is to do today’s work superbly well.”
—William Osler (1849–1919)
The new millennium is an exciting time to be involved with the care of venous
disorders, and there have probably been more key advances in the last 20 years than in
the previous 200. Despite this, phlebology remains a relatively under-represented
specialty in many countries, and there is sometimes a lack of high-quality data and
access to training materials. As a result, sufferers of venous and lymphatic problems are
often inadequately investigated or mismanaged. This is a situation that cannot be
allowed to continue. Venous and lymphatic diseases are both common and distressing
for suffers. They also impose a large financial burden on the health services of most
industrialized countries. These alone are reasons why the topic is worthy of study, and
patients have the right to be seen by physicians and nurses with a special interest in the
management of their condition.
This book, Venous and Lymphatic Diseases, is an attempt to draw together a wide
range of experts in various aspects of venous disease to cover the full range of conditions
encountered in clinical practice. The aim has been to produce chapters that are both
definitive and readable, so that they will be of utility to both the expert in the subject and
the novice. To aid this, most chapters have a clear “key points” section. In addition, we
have deliberately chosen to invite a mixture of North American and European authors to
produce a genuinely international, multidisciplinary approach to the subject. The book
is subdivided and organized into related sections and includes sections on investigation
as well as treatment, including complex venous surgery and radiological therapies.
However, it has been the deliberate aim of the editors that this should not simply be a
surgical textbook; as a result, there are extensive sections on non-surgical topics,
including drug therapy, venous disorders in pregnancy, compression therapy, and
conservative therapies in lymphedema. The first three chapters set the scene by
reviewing the historical context, the anatomical terminology, and the physiology of the
veins and lymphatics.
If the book is useful to those involved in caring for patients with venous or lymphatic
disease, then we will have accomplished our aim.
iii
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ACKNOWLEDGMENT
The editors express their sincere thanks to the contributors who have given so
much of their valuable time to produce their sections. Thanks also go to Geoff Greenwood
who initially saw the need for such a book and who was pivotal in taking the idea forward
to fruition.
Nicos Labropoulos
Gerard Stansby
Prefaceiv
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Contents
Preface :::: iii
Contributors :::: xvii
SECTION A: BACKGROUND DATA
1. Historical Background . .................................. 1
Alberto Caggiati
The “Discovery” of the Venous Draining Systems ::::
1
Lymphatic Vessels :::: 2
The “Discovery” of the Circulation of the Blood :::: 3
Sclerotherapy :::: 5
Surgery :::: 6
2. Venous and Lymphatic Anatomy . .......................... 9
Alberto Caggiati
The Roots of the Draining Systems: The Microvascular Bed ::::
9
The Superficial Venous System of the Lower Limb :::: 9
Deep Veins of the Lower Limb :::: 14
Perforating Veins :::: 16
References :::: 22
3. Physiology of the Veins and Lymphatics ..................... 23
Philip D. Coleridge Smith
Introduction ::::
23
The Circulation and the Venous System :::: 23
The Venous Valves :::: 25
Superficial Venous System :::: 26
Communicating or Perforating Veins Associated with the
Long Saphenous Vein ::::
26
Deep Venous System :::: 26
Normal Venous Physiology of the Lower Limbs :::: 27
The Return of Blood to the Heart :::: 29
v
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The Calf Muscle Pump :::: 29
Lower Limb Venous Pathophysiology :::: 31
Valvular Reflux or Retrograde Flow :::: 31
Edema :::: 32
Lymphatic System :::: 33
Lymphedema :::: 34
References :::: 34
4. Epidemiology of Venous Disorders ......................... 37
F. G. R. Fowkes
Varicose Veins: Prevalence and Incidence ::::
37
Asymptomatic Venous Valve Incompetence: Prevalence :::: 40
Risk Factors for Varicose Veins :::: 41
Venous Skin Changes: Prevalence :::: 45
Venous Ulcer: Prevalence, Incidence, and Prognosis :::: 45
Risk Factors for Venous Ulcers :::: 47
Conclusion :::: 49
Key Points :::: 49
References :::: 50
5. Health Economics and Quality of Life—Impact of
Venous Disorders . . .................................... 53
Meryl Davis, Fiona J. Tsang, and Alun H. Davies
Introduction ::::
53
Health Economics :::: 53
Quality of Life :::: 55
Conclusion :::: 58
Key Points :::: 58
References :::: 58
6. Classification of Chronic Venous Disease and
Outcome Assessment .................................... 61
Gudmundur Danielsson and Bo Eklo
¨
f
Introduction ::::
61
The Creation of the CEAP Classification :::: 61
Other Developments Related to CEAP :::: 62
Revision of CEAP :::: 62
Terminology and New Definitions :::: 64
Refinement of C-Classes in CEAP :::: 65
Refinement of E, A, and P in CEAP :::: 66
Date of Classification :::: 66
Level of Investigation :::: 67
Basic CEAP :::: 67
Revision of CEAP: An Ongoing Process :::: 68
Revision of CEAP: Summary :::: 68
Outcome Assessment :::: 70
Contentsvi
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Conclusion :::: 74
Key Points :::: 74
References :::: 74
SECTION B: ASSESSMENT AND INVESTIGATION
7. Clinical Assessment of Venous Disease . ..................... 77
Sriram Subramonia and Tim A. Lees
Introduction ::::
77
Venous Anatomy :::: 77
Venous Physiology and Pathophysiology :::: 80
Risk Factors :::: 81
Symptomatology :::: 81
Skin Changes of Chronic Venous Insufficiency :::: 83
Acute Presentations of Venous Disease :::: 84
Outpatient Clinical Assessment :::: 85
Classification of Venous Disease :::: 89
Key Points :::: 90
References :::: 90
8. Noninvasive Evaluation of Venous Disease . . ................. 93
Ahmad Bhatti and Nicos Labropoulos
Introduction ::::
93
Physiologic Tests :::: 93
Air Plethysmography :::: 93
Photo Plethysmography :::: 94
Light Reflection Rheography :::: 94
Strain Gauge Plethysmography :::: 95
Foot Volumetry :::: 95
Continuous Wave Doppler :::: 95
Duplex Ultrasound :::: 95
Computed Tomographic Venography :::: 96
Magnetic Resonance Venography :::: 97
Key Points :::: 97
References :::: 97
9. Invasive Tests—Radiological and Pressure Measurements . . .... 101
Peter Negle
´
n and Seshadri Raju
Introduction ::::
101
Ambulatory Venous Pressure—A Global Hemodynamic Test :::: 101
Arm-Foot Venous Pressure Differential and Reactive Hyperemia
Foot Vein Pressure Elevation—A Hemodynamic Test for
Global Outflow Obstruction ::::
102
Femoral Venous Pressure—A Test for Focal Outflow
Obstruction ::::
104
Popliteal Venous Pressure—A Test for Focal Obstruction :::: 104
Contents vii
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