Deep Venous Disease

Condition

Deep Venous Disease is caused by either blockage to flow in the deep veins or leaking valves. Most patients develop problems with blockage after suffering from a deep vein thrombosis (DVT). Leaky valves may also follow DVT but may also be congenital as with Varicose Veins. One of the most common causes of DVT high up in the leg is May-Thurners syndrome (or Cocketts syndrome). This is were the main arteries in the leg compress the veins and cause a blockage. It most commonly occurs in the left leg.

For may people the only option for managing DVT has been long term anticoagulation (blood thinning with drugs such as Warfarin) however emerging evidence has increased the possible options for treatment to include clot busting drugs and stents.

Treatment has been largely confined to those with disease associated with advanced chronic venous insufficiency and has been compounded by the lack of reliable diagnostic tests that are able to quantify the extent of disease independent of the clinical manifestations. Understanding of this is gradually improving.

Patients with symptoms of chronic venous insufficiency should be managed through a careful treatment protocol that addresses each component of the venous system in turn. This allows for a patient to be treated in stages with the more complex procedures reserved for those in whom the more simple techniques have failed.

Signs and Symptoms

The classical presenting features of chronic venous insufficiency are oedema, skin changes and lipodermatosclerosis (blackening and hardening of the skin around the ankles) in the presence of underlying deep or superficial venous disease. These are allied with pain, typically described as a bursting pain in the thigh or calf, which is called venous claudication.

Several scoring systems for the assessment of venous disease based on a combination of signs and symptoms exist. Those most commonly used in clinical practice are the CEAP classification, Villalta Score and Venous Severity Score whichallow for grading severity of disease.

The CEAP score is a descriptive score which can be represented in either simple or advanced form. The Villalta Scores and Venous Severity Score allows for longitudinal assessment of outcome.

Several consensus documents have been published which have revised both the scoring systems and nomenclature of descriptive terms for venous disease to attempt to standardize reporting.

Diagnosis of Deep Venous Disease

Diagnosis rests on the establishment of either reflux or obstruction in the patient presenting with symptoms and signs of chronic venous insufficiency.

The initial diagnostic test performed is a duplex ultrasound. Duplex allows for the detection of obstruction and reflux as well as some degree of quantification of the extent of reflux.

There are no completely accurate tests for the presence of significant outflow obstruction.The diagnosis of outflow obstruction therefore rests largely on morphological tests (tests which provide detail of anatomy) which identify a lesion.The morphological data is typically obtained through a combination of imaging modalities, principally CT venography MR venography, duplex ultrasonography and venography.

Intra-vascular ultra sound (IVUS) has been shown to be the most sensitive system for detecting stenosis. IVUS may help to reduce the contrast dose of patients, many of whom are young, undergoing venous interventions.

A combination of modalities is required to completely assess venous disease given the relative limitations of each.


Treatments


The medical information provided here is intended solely for patients of the London & Surrey Vascular Clinic, it is general information only and should not be used as a substitute for personal advice received when consulting your own surgeon face-to-face.

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