HOW I DOIT

TREATING CVI WITH CHRONIC ULCER

dr. Romzi Karim, Sp.B(K)V

Vascular Endovascular Surgeon
 Chronic Venous Insufficiency (CVI)
Prevalence vs. Number Treated
Note: Estimates are
for the U.S.

CVI
Prevalence*,1,2
30,000,000+

Seek Treatment *,3

1,900,000

Treated
500,0003
*Statistics based on individuals
over the age of 40

1. Gloviczki, P., MD., Comerota, A., MD., Dalsing, M., MD., Eklof, B., MD., Gillespie, D., MD., Gloviczki, M., MD.,… Wakefield, T., MD. The care of patients
with varicose veins and associated chronic venous diseases: Clinical practice guidelines of the Society for Vascular Surgery and the American Venous
Forum. J Vasc Surg. 2011 May; 53(5 Suppl): 2S-48S
2. “Age and sex composition: 2010.” In 2010 United States of America Census (c2010br-03). Web. <http://www.census.gov/prod/cen2010/briefs/c2010br-
03.pdf>
3. US Markets for Varicose Vein Treatment Devices 2011, Millennium Research Group 2011.
 INCIDENCE
 25-50% of adult women.
 15-30% of adult men.
 1-2% with active or healed ulceration.
 70 % chronic leg wound
 Ulcer is the most severe manifestation

Patrick H. Carpentier, Hildegard R. Maricq, Christine Biro, Claire O. Poncot-Makinen, Alain Franco, Prevalence, risk factors, and clinical patterns of chronic venous
disorders of lower limbs: A population-based study in France, Journal of Vascular Surgery, Volume 40, Issue 4, October 2004, Pages 650-659, ISSN 0741-5214, DOI:
10.1016/j.jvs.2004.07.025.
Coon WW, Willis PW III, Keller JB. Venous thromboembolism and other venous disease in the Tecumseh community health study. Circulation 1973; 48: 839–846.
Franks PJ, Wright DD, Moffatt CJ, Stirling J, Fletcher AE, Bulpitt CJ et al. Prevalence of venous disease: a community study in west London. Eur J Surg 1992; 158:
143–147.
Bradbury A, Evans C, Allan P, Lee A, Ruckley CV, Fowkes FG. What are the symptoms of varicose veins? Edinburgh vein study cross sectional population survey.
BMJ 1999; 318: 353–356
 BEAUTIFUL AND SEXY LEG

Dream of all woman in the

world
VARICOSE LEG

• Scarefull...

• Cause depression...

• Morbidity...

• Decrease quality of life...

PATOPHYSIOLOGY
REFLUX

Venous statis Venous dilatation

Raised distal venous pressure

Venous hypertension

MICROCIRCULATORY
DISORDER

ULCER
CEAP CLASSIFICATION

C1 C2 C3

C6 C4

C5
J Vasc Surg 2004;40:1248-52
INSPECTION
 Look at the legs while patient is standing.
 Examine around the medial malleolus ‘gaiter area’.
 VVV LAPS
 Varicose veins – distribution (GSV, SSV)
 Venous ulcers/ eczema
 Venous stars
 Lipodermatosclerosis
 Atrophy blanche
 Pitting oedema
 Scars
INSPECTION

 Venous ulcers/eczema  Atrophy blanche

 Ulceration: active and healed
 Leaves a white patch

 Venous stars (spider) veins)  Pitting oedema

VARICOSE VEIN – PRE-OP WORKUP
• Standard Venous Insufficiency Ultrasound Scan
• Classified into CEAP Groups
The goals of therapy
are :
- Relieve of the
complaint/ discomfort.
- Prevent recurrent
varicose veins.
- Shorter recovery period.
APPROACH TO THE VENOUS LEG ULCER
 Accurate diagnosis
 History
 Clinical
 US
 Compression
 Target the source of venou reflux
 Wound infection and antibiotics
 Debridemant
 Topical dressing
 Pharmacologic
 Surgical
COMPRESSION
SCLEROTHERAPY
Direct injection sclerosing agent into varicose vein to
eliminate small to medium size varicose veins by
transforming the wall of varicose vein into a fibrotic cord.

 permanent occlusion
Polidocanol (Aethoxysclerol)
Sodium tetradecyl sulfate (STD)
SCLEROTHERAPY
 SCLEROFOAM THERAPY-ULTRASOUND GUIDED

Tessari
Method

Almeida. Atlas of Endovascular Venous Surgery. Elsevier. 2012.

MEDICATION:

• As the phlebotropic drug is effective in the most severe

stage of the CVI.
• Diosmin Hesperidin, hidrosmin.
• Action at the level of the microcirculation, increases
venous tone, lymph drainage >>.
• Relieves all signs & symptoms.
DEBRIDEMENT
• Remove necrotic tissue
• Surgical or nonsurgical debridement
• Topical dressings
• NPWT
 SURGERY
• Saphenous vein stripping.
• High saphenous ligation.
• Ambulatory phlebectomy.
• Stab/avulsion phlebectomy.
• Thermal (laser or endovenous
ablation).
• Perforator ligation/ LINTON proc

Dwerryhouse, S, Davies, B, Harradine, K, Earnshaw, JJ. Stripping the long saphenous vein reduces the rate of reoperation for recurrent varicose veins: five-year results of a
randomized trial. J Vasc Surg 1999; 29:589.
Menyhei, G, Gyevnar, Z, Arato, E, et al. Conventional stripping versus cryostripping: a prospective randomised trial to compare improvement in quality of life and complications. Eur
J Vasc Endovasc Surg 2008; 35:218.
DEFEC CLOSURE
• Skin graft
• Flap
• Dressings