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LIVE BLOG: New Approaches to the Lower Extremities & Venous Disease

In this live blog from the SDPA Summer Conference in St. Louis, Jeffery E. Petersen lectured on new approaches to treating skin diseases on the lower extremities.

 

Venous Anatomy

Deep venous system

+  Thigh

Common femoral

Femoral vein (superficial femoral) (deep vein)

Profunda

Popliteal

+ Calf

Posterior tibial

Anterior tibial 

Peroneal

Gastrocnemius

Below the muscle fascia

Up to 90% of the venous circulation

 

Physiology

Deep venous system is under high pressure while the superficial system is under low pressure. When valvular incompetence occurs this pressure is transmitted to the superficial system. (from 20-35mmhg)

 

Valvular Anatomy

+ Inferior vena cava and common illiac vein – no valves

+ External illiac and upper common femoral

         valve in 2/3 people (other third none)

         Valves absent on both sides 1/10 l Femoral 1-4 valves (variable)

+ Saphenous Vein

         1-2 valves in first 4 cm, up to 5 valves to knee (variable)

Below knee to ankle 8+ valves (variable)

+ Short Saphenous Vein- 1 upper valve, 5 below (variable)

Recent evaluation found that in 26 pts studied with CVI had 25 cm between valves in GSV vs 19cm in the control group. Also decrease in average number of valves.

Note: There is no standard anatomy

 

Venous Anatomy

+ Superficial venous system

Saphenous vein (greater)

Short saphenous vein (lesser)

Lateral (medial)subdermic venous system

(Giacomini – posterior thigh connection between GSV and LSV)

+ Major perforating veins with location

Huntarian – Mid thigh

Dodd – above medial knee

Boyd – below medial knee

Cockett’s – above the ankle

 

 

Importance of Venous Therapy

All of these diseases can be caused by venous insufficiency

All can be curatively treated with appropriate therapy

+ ulceration

+ lipodermatoclerosis

+ cellulitis

+ stasis dermatitis

+ atrophy blanche

+ medically recalcitrant edema

+ livedo vasculitis

+ painful varicosities

+ recurrent episodes of  ecsema

 

The Truth about Venous Anatomy

+ There is no standard anatomy.

+ Everyone is different

+ Each leg can be different

+ Ultrasound to diagram Venous anatomy is the only way to get most of the anatomy right

+ Anterior lateral and posterior medial

+ Diagram major branches at SFJ.

 

Importance of Venous Therapy

+ Where does venous disease begin?

+ Simple answer- on the inside

+ So what does that mean about the disease when it is seen on the skin?

+ That it has likely been causing injury for an extensive period of time, and what you see clinically is only the tip of the iceberg.

 

Previous Treatment Algorithm

Principals

+ NO TED HOSE.

+ Compression, compression, compression

+ Debride, debride, debride

+ Treat surrounding infection and eczema. 

 

After physical exam and if indicated ie ulcer, lipodermatosclerosis, ect

Suplex ultrasound examination to identigy junctional valvular incompetence and preforatior,…..

 

Treatment of Venous Disease

Treatment options based on duplex exam

Saphenofemoral reflux: R/F Laser Closure or Ligation +/- stripping

Saphenopopliteal reflux: As above

Varicosities (branches or perforators): Ambulatory Phlebectomy

    + S.E.P.S

    + Trivexa

    + Sclerotherapy

Varicose reticular veins: As above

Smaller veins: Sclerotherapy or Laser

 

Potential Side Effects

+ Paresthesias

7.4% for treatment extending to the ankle

2.5% for treatment of the thigh only

Usually resolves in 6-12 months; all cases resolve by 3 year follow-up

+Skin injury

         Prior to tumescent anesthesia 2.5%

+DVT

         Proximal greater saphenous vein 0.8%

+ One case of PE

+ Phlebitis

+Bruising

+ Erythema

 

Preventing Side Effects

+ Patient is awake throughout the procedures.(able to communicate comfort level)

+ Tumescent anesthesia provides cooling, protective barrier.

+ Feedback system provides information on impedance and temperature.

+ Patients are immediately ambulatory and allowed to exercise more vigorously in 3 days.

 

Treatment for Lipodermatosclerosis

+ Do not treat sclerotic plaque initially

+ Treat larger vessels initially and let skin soften prior to further treatment.

            Let the skin soften over 6-12 months

 

BE AWARE

+ Patients can have two diseases

+ Ulceration secondary to Hydroxyurea and severe venous disease

+ 4 months after venous therapy and discontinuation of hydroxea

Exmaple: Pt with saphenous vein harvest on left leg

Ultra sound shows no perforator disease on the left, saphenofemoral refuux on the right causing stasis.  Biopsy on the left leg show Morphea.

 

Takeaways: Things to Remember

+ Don’t be afriad of a challenge

+ Time heals most wounds, when they are treated appropriately

+ Venous disease starts years before you see the clinical manifestation

+ Correct diagnosis and early treatment can provide a cure

+ Compression is a life long way to maintain a disease free state

+ Putting your legs up and steroids will not solve the problem

 

[image Nicki Varkevisser]




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