Chronic Venous Insufficiency
Chronic venous insufficiency (CVI) is a pervasive and problematic disorder thought to affect between 10 and 35 % of the American population [1]. It encompasses a full spectrum of chronic venous disorders ranging from uncomplicated telangiectasies to debil
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Mary So, Namrata Khimani, and Michael Ngyuen
Introduction
Pathophysiology
Chronic venous insufficiency (CVI) is a pervasive and problematic disorder thought to affect between 10 and 35 % of the American population [1]. It encompasses a full spectrum of chronic venous disorders ranging from uncomplicated telangiectasias to debilitating venous ulcers.
The underlying pathophysiology of CVI is not well-understood. Early theories proposed that CVI arose from incompetent venous valves (reflux), obstruction, and inadequate muscle pump function leading to elevated venous pressure. Recent theories have focused on structural and histologic abnormalities, including underlying connective tissue defects [1].
Etiology CVI can be broadly divided into three categories based on etiology: primary, secondary, and congenital. Primary CVI includes patients without an underlying mechanism for venous dysfunction. Secondary CVI is a result of venous malfunction precipitated by an event such as a deep vein thrombosis [2]. Congenital CVI include those born with venous malformations at birth [3].
Risk Factors Risk factors for chronic venous disorder include female gender, obesity, advanced age, family history, pregnancy, prolonged standing, and urban residence [1].
History and Physical Exam M. So, MD (*) Department of Anesthesiology and Pain Medicine, New York Presbyterian Hospital-Weill Cornell Medical Center, 1300 York Ave, 19th Floor, New York, NY 10022, USA e-mail: [email protected] N. Khimani, MD • M. Ngyuen, MD Department of Anesthesia and Perioperative Medicine, Brigham and Women’s Hospital/Harvard Medical School, 75 Francis Street, Boston, MA 02115, USA e-mail: [email protected]; mnguyen@ miamiskinandvein.com
Presenting symptoms include pain, aching, cramping, sensation of “heaviness” in the leg, itching, swelling, edema, and skin changes. Physical exam findings can include reticular and varicose veins, telangiectasias, skin pigmentation, lipodermatosclerosis, dermatitis, and ulcerations [3]. Differential diagnoses include arterial occlusive disease, vasculitis (small vessel disease), infection, and carcinoma [1].
© Springer International Publishing Switzerland 2017 R.J. Yong et al. (eds.), Pain Medicine, DOI 10.1007/978-3-319-43133-8_132
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CEAP Classification An international committee of the American Venous Forum developed a universal and systematic classification system for chronic venous disorders. The classification “CEAP” was based on (C) clinical manifestations, (E) etiologic factors, (A) anatomic distribution of disease, and (P) underlying pathophysiologic findings (Table 132.1).
Diagnosis History and physical examination are integral to the diagnosis of CVI and can be aided with noninvasive testing, such as Venous Duplex Imaging. Venous
Duplex Imaging can detect acute and chronic thrombosis, post-thrombotic changes, obstructive flow, and reflux. The presence of reflux is determined by the direction of flow and its duration is known as the reflux time. A reflux time of gre
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