Vol. 17 • Issue 6 • Page 49
Patients with venous insufficiency have clinical manifestations ranging from mild telangiectasias (spider veins) to varicose veins. In severe cases, venous insufficiency can produce lipodermatosclerosis or ulcerations. More than 90% of patients with venous insufficiency have superficial venous disease caused by valvular incompetence.1In the United States, superficial venous insufficiency affects 25% of women and 15% of men and can be potentially debilitating.2
Until recently, the gold standard treatment for superficial venous insufficiency was high ligation and stripping of the greater saphenous vein. This required a 2- to 3-day hospitalization and lengthy recovery time and was associated with frequent complications. Over the past 5 years, this traditional surgical approach has been replaced by minimally invasive treatments such as endovenous laser ablation therapy (EVLT), radiofrequency ablation (RFA), ultrasound-guided foam sclerotherapy (USGFS) and microambulatory phlebectomy (MAP). When used to treat varicosities caused by venous reflux, these therapies have been proven safe, effective and preferred by patients.3
Vein Anatomy
The venous anatomy of the lower extremities is divided into three systems: the deep system, the superficial system and the perforating veins. The primary veins of the deep system are located deep in the muscles and are the femoral vein and the popliteal vein. These veins drain the leg muscles and the muscular venous sinuses, transporting blood to the right atrium of the heart.
The primary veins of the superficial system are the greater saphenous vein, the lesser saphenous vein and the lateral venous system or tributary veins, which lie superficial to the muscle fascia. These veins drain the cutaneous system into the perforating veins that connect the superficial and deep venous systems.
The perforating veins, also called the communicating veins, perforate the deep fascia that separate the superficial and deep venous systems. These veins have one-way valves that direct the blood flow in a cephalad direction from the superficial system to the deep system. When these valves are weak or malfunctioning, a backflow of blood occurs and is called reflux.
When reflux is present, blood pools in the veins and causes venous distention that presents as varicose, reticular or spider veins.4These vein abnormalities are usually symptomatic.4
Etiology of Varicose Veins
Multiple factors contribute to varicose veins, and they include pathologic and environmental influences. Some of the more common causes of superficial venous insufficiency are heredity, pregnancy, hormones, aging, obesity and occupations that require prolonged standing.
In inherited varicose veins, an inborn defect in the vein wall collagen affects its elasticity. This weakens a focal area, causing an asymmetric abnormality.5During pregnancy, especially the first trimester, plasma volume increases and a surge in hormones occurs. An increase in progesterone particularly affects the vein wall and the ability of the valve leaflet to distend. In late pregnancy, the enlarged uterus compresses the inferior vena cava with venous hypertension, causing distention of varicosities. Female sex hormones, especially progesterone, inhibit smooth muscle contractility in the venous wall, allowing dilatation of veins and softening of valve leaflets.
During the aging process, veins atrophy, degenerate and weaken, leading to dilation over time.6Prolonged standing leads gravity to apply constant pressure on vein walls and valves. Over time, these hydrostatic forces cause progressive venous insufficiency. Obese patients develop varicosities due to the high intra-abdominal pressure caused by excess adipose tissue. This pressure is exerted on the iliac veins, leading to increased femoral pressures.5
Symptoms
Varicose veins may be symptomatic as well as cosmetically unpleasing, prompting patients to seek medical intervention. Skin ulceration, thrombophlebitis, dermatitis and abnormal pigmentation are common reasons patients seek care from a vein specialist. Common signs and symptoms of chronic venous insufficiency include lower extremity aching, throbbing, tiredness, heaviness, edema, pruritis, burning, cramping, tenderness or skin changes. These symptoms usually increase with standing and warm weather and are relieved with walking, elevation or compression.5-7
Examination
When a patient comes into the office with signs and symptoms of venous insufficiency, a thorough history and physical examination are necessary to rule out other diagnoses. The clinical history should include family history and any previous venous treatments. Patients who have had previous treatment for venous insufficiency may experience recurrence or recanalization of varicosities. Up to 27% of patients may experience a duplication of the greater saphenous vein, and up to 61% of patients with a history of ligation may have inadequate results.7It is important to distinguish between arterial and venous symptoms. In addition to the signs and symptoms of superficial venous insufficiency, venous pain is usually dull, vague and localized on the medial aspect (or where other varicosities are visible) of the affected lower extremity.7Pain is usually relieved with ambulation. With arterial disease, pain increases with ambulation and subsides with rest.7 erform this maneuver along the greater saphenous vein, and record where you detect retrograde flow.
Examine the patient in an upright position under adequate lighting. Turn the affected extremity to enable visualization, and palpate completely to identify any abnormalities. Observe the skin of the lower extremities for the presence of discoloration, inconsistent pigmentation, skin breakdown, ulceration, bulging, edema, erythema, telangiectasias, reticular veins and varicose veins.5
Screening Tests
If available, use a handheld continuous-wave Doppler to identify reflux at the saphenofemoral junction at the proximal thigh (greater saphenous vein) and the saphenopoplitieal junction at the center of the midposterior knee (smaller saphenous vein). Reflux in these areas is an indicator of venous insufficiency. For this examination, the patient should wear a gown or loose-fitting shorts. Instruct the patient to stand with legs approximately shoulder width apart and to place his or her body weight on the leg not being examined. On the leg that is being examined, turn the toes away from the body, and have the patient bend the knee slightly.
Starting at the saphenofemoral junction, place the ultrasound gel and Doppler in the superior aspect of the groin crease to locate the pulsatile flow of the femoral artery. Once the pulsatile sound is located, grasp the patient's distal medial thigh with the opposite hand, and perform a brief manual compression. Listen for a swooshing or blowing sound during compression. Quickly release compression, and if you hear a reverse flow, reflux of the greater saphenous vein is most likely present.
The next site of Doppler examination is at the saphenopopliteal junction, which is located at the mid posterior knee. Place the ultrasound gel and Doppler at this site to locate the pulsatile flow of the popliteal artery.
Once the flow is detected, apply brief manual compression to the calf. Listen for a swoosh or blowing sound during compression. Quickly release the compression; if you hear a reverse flow, reflux of the small saphenous vein is likely present.
Whether audible reflux is present or absent during a handheld Doppler exam, refer any patient with signs and symptoms of venous insufficiency for a duplex Doppler ultrasound examination to assess the deep and superficial venous systems.7The Brodie-Trendelenberg test is a simple in-office screening tool for venous insufficiency that can be used when a Doppler is not available. Place the patient supine with the affected leg elevated. Massage the greater saphenous vein or smaller saphenous vein in a cephalad direction to empty the vein of blood. Keep the leg elevated, and apply a tourniquet on the mid to upper thigh.
When the patient resumes a standing position with the tourniquet in place, observe the veins for 30 seconds to note the presence or absence of venous distention. Remove the tourniquet after 30 seconds, and determine whether the patient develops venous distention. Distention before or after removal of the tourniquet is considered a positive result. Refer any patient with a positive result for an ultrasound. A duplex Doppler ultrasound will detect venous reflux caused by the absence or malfunction of venous valves. Once a diagnosis of venous insufficiency has been made, you can review treatment options with the patient.7
Treatment Options
Temporary conservative treatments for varicose veins include elevation and external compression with flexible ACE-type wraps or medical-grade graduated compression hose of at least 20 mm Hg to 30 mm Hg (but no more than 40 mm Hg).7Patients should wear these aids while awake or for prolonged standing.7 A minimally invasive choice is USGFS using the chemical sclerosing agent sodium tetradecyl sulfate (Sotradecol). This sclerosing agent is mixed with air to produce a foam solution. Under ultrasound guidance, the provider locates the vein and injects the foam solution into it, causing displacement of blood. The foam allows for a large surface area of the vein to come into contact with the sclerosant, resulting in a fourfold increase in thrombogenic activity. The detergent solution causes disruption of the vein endothelium, inducing rapid thrombus formation and leading to vascular sclerosis or scarring.7This occludes the vein.7
After USGFS, the patient must wear medical-grade compression hose. Length of time depends on provider preference. Although many chemicals are used for foam sclerotherapy, sodium tetradecyl sulfate is the only agent that has an FDA indication for the treatment of varicose, reticular and spider veins. When treated adequately with foam sclerotherapy, 80% to 90% of saphenous veins remain occluded after 3 years.8Complications are minimal, but skin pigmentation may occur as a result of hemosiderin deposits, and superficial thrombophlebitis is common.8EVLT is minimally invasive, cost effective and well tolerated. It is associated with minimal morbidity, and 85% of patients report clinical improvement. EVLT is an outpatient procedure performed under oral sedation and local anesthesia; patients can return to work in 1 or 2 days. In EVLT, the provider inserts a percutaneous laser catheter (under ultrasound guidance) into the saphenous vein, producing a focused heat that causes thrombotic vessel occlusion of the affected vein. The patient must wear medical-grade compression stockings for 3 weeks following the procedure. The procedure has a 93% to 97% occlusion rate and a 3% to 7% recanalization rate.9Complications are rare, but moderate ecchymosis, mild to moderate tenderness, transient numbness and thrombophlebitis are common side effects.9RFA is similar to EVLT, but an important difference is that the failure rate for RFA can be as high as 14% at 2 years.9The failure rate for EVLT is 7% or less after 3 years.9In RFA, the provider uses a catheter to direct radiofrequency energy from a generator, causing thermal ablation of the endothelium of the refluxing vein. It is performed in an outpatient setting under oral sedation and local anesthesia. Afterward, the patient must wear medical-grade compression stockings for 3 weeks. The most frequent complications are ecchymosis, tenderness, superficial thrombophlebitis and numbness.10After foam sclerotherapy, EVLT or RFA, patients may experience residual distended varicosities that do not decompress despite treatment. MAP performed the day of the procedure or at follow-up can address this.
In an outpatient setting under oral sedation and local anesthesia, the provider makes small incisions adjacent to any remaining distended veins and inserts small vein (crochet-type) hooks. The provider grasps the veins with the hooks and clamps them with mosquito clamps, then gently removes the veins in one or more segments. The provider then applies an adhesive strip, gauze, compression hose and compression wrap to the leg. These must be worn for several days to weeks, depending on provider preference. The patient may return to work in 1 or 2 days.
Putting It Into Practice
When correct screening and assessments are performed, chronic venous insufficiency can be diagnosed early. Patients can be treated using minimally invasive outpatient procedures that allow them to return to work quickly. If diagnosis is confirmed by ultrasound in the presence of symptoms, most insurance plans pay for these minimally invasive procedures. Nurse practitioners in venous treatment centers can perform these procedures as long as they fall with their state scope of practice. As with physicians, proper training is required.
References
1. Bergan J, et al. Venous disorders: treatment with sclerosant foam. J Cardiovasc Surg. 2006;47(1):9-18.
2. Berland T, et al. Thrombus extension into the common femoral vein after endovenous ablation of the greater saphenous vein for the treatment of venous insufficiency. J Vasc Ultrasound. 2006;30(3):129-131.
3. Raines J, et al. Abbreviated method of determining vein volume in balloon-controlled vein ablation. Phlebol. 2007;22(1):40-44.
4. Carr S. Current management of varicose veins. Clin Obstet Gynecol. 2006;49(2):414-426.
5. Gloviczki P, Yao J, eds. Handbook of Venous Disorders. 2nded. New York: Oxford University Press; 2001: 144, 270, 289-292.
6. Weiss R, et al. Vein Diagnosis and Treatment: A Comprehensive Approach. New York: McGraw-Hill; 2001: 4-5.
7. Goldman M, Bergan J. Sclerotherapy: Treatment of Varicose and Telangiectatic
Leg Veins. 3rded. St. Louis: Mosby; 2001: 36, 100, 104-105, 140-141, 174, 248.
8. Guex J, et al. Immediate and midterm complications of sclerotherapy: report of a prospective multicenter registry of 12,173 sclerotherapy sessions. Dermatol Surg. 2005;31(2):123-128.
9. Kavuturu H, et al. Endovenous laser ablation of saphenous vein in an effective treatment modality for lower extremity varicose veins. Am Surg. 2006;72(8):672-676.
10. Almeida J, Raines J. Radiofrequency ablation and laser ablation in the treatment of varicose veins. Ann Vasc Surg. 2006;20(4):547-552.
BJ Frey is a family nurse practitioner at Inland Aesthetic Institute in Spokane, Wash., where she is involved in the evaluation and treatment of varicose veins and other venous and skin presentations.
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