Chronic Venous Disease (CVD) & Deep Vein Thrombosis Treatment

CVD covers the whole spectrum of venous disorders from small telangiectasia to the venous ulcer. The most common presentation is primary varicose veins.

Primary varicose veins –
These can be complicated by bleeding, pigmentation, ulceration, pain, swelling etc. Everyone with varicose veins deserves assessment including ultrasound scan and based on the findings he or she can be offered adequate treatment. Uncomplicated varicose veins can be treated at any point of time and treatment should be minimally invasive and cosmetically acceptable. The recommended treatment is endovenous laser ablation or radiofrequency ablation of the major subcutaneous vein (Great or Short Saphenous Veins) with or without additional phlebectomy or sclerotherapy (veins are either removed from the leg via small stab incision not larger then few millimetres or are injected with a special substance that makes them shrink).

Varicose veins a day-surgery procedure

Patients with more advanced CVD (significant leg swelling not improving with stockings, skin pigmentation or even skin ulcer) should be treated as soon as possible. Leg ulcers are very difficult to heal and if they heal they tend to reoccur (in up to 70% of cases they reopen again). The causes for these ulcers may range from large varicose veins and previous deep vein thrombosis (DVT) to even a vein compression which was not symptomatic for most of the patient’s life, therefore being unrecognised. For all patients with advanced CVD there is a realistic chance to improve their quality of life by healing the ulcer with only a key-hole surgery (or mini-invasive surgical procedure under local anaesthetic) with no overnight hospital stay. The results showed us that it is very safe and very reliable treatment.

The concept of treatment of chronic venous insufficiency is to
1. Reduce (eliminate) obstruction
2. Reduce (eliminate) reflux
– By the least invasive way possible with as short hospital stay as feasible

The obstruction can be found in the venous system after DVT quite often. This is partially due to the fact that in some segments of the venous system the vein after DVT often reopens incompletely in spite of adequate medical management (anticoagulation medication). Typical example is iliac (pelvic) or femoral (groin) veins.

The concept of obstruction

Why is obstruction important – it increases venous pressure (Venous Hypertension) and is responsible for tissue damages.

Concept of “permissive” iliac vein lesion otherwise asymptomatic “silent” blockage waiting for a trigger like heart failure, inflammation, dehydration, etc. to become symptomatic – causing a non-thrombotic obstruction or acute DVT.

Diagnosis
– Ultrasound assessment (by expert technician)
– CT Venogram – up to 50% of blocked veins are underdiagnosed due to number of issues (shape of the vein, non-contrast blood etc.)
– Formal venogram(or angiogram) – similar rate of underdiagnosed blockages
– IVUS (intravascular ultrasound) – golden standard (not funded, not always available)

Acute DVT (acute blood clot in the deep vein)

blood clot removed from large vein
Full recovery is seen in only minority of cases if pelvic vein is affected but calf or thigh veins usually do reopen after several weeks. Therefore we advocate an intervention for pelvic vein thrombosis (Iliofemoral DVT) within 2 weeks following the onset of symptoms. This window of opportunity is good enough for patients to seek adequate medical attention of general practitioner who should put the patient on anticoagulation medication refer them to a physician specialising in venous disease. Treatment method of choice is a pharamaco-mechanical thrombolysis where a small catheter is placed into a vein and the clot is sprayed with a drug that allows it to dissolve. The clot is then sucked out clearing the vein. In most cases there will be an underlying blockage in the vein which might have triggered the DVT in the first place and this obstruction needs to be repaired by placing a stent in the vein. The stent is a flexible but strong (usually nitinol) spring that will keep the vein open. This procedure also can be done as an outpatient with no hospital stay.

venous ulcers

Patient with chronic swelling or leg ulcers should also seek vascular specialist as their venous system is not working correctly. There is an intervention that dramatically improves healing (usually within 12 weeks after intervention). It is most of the time a key-hole procedure requiring only a local anaesthetic and sedation and patients can be discharged home few hours after the procedure. In our centre we have achieved healing rate around 70% within 12 weeks post intervention (presented at ANZSVS meeting, 2016).

In certain complex situations where both reflux and obstruction play role we treat one problem first and wait. If the healing is satisfactory then no more intervention is required. If on the other hand, the healing is not as fast as we would have liked, another procedure is considered. It is mostly a combination of key-hole stenting (angioplasty) and phlebectomy (with or without laser surgery) that is usually opted for. In majority of cases this is regarded as a day-procedure.

skin damage including pigmentation and ulcers

Redressing of the wounds in cooperation with a general practitioner or wound nurse is necessary for a certain period of time. Elastic compression stocking might not be necessary if the obstruction (and/or reflux) was successfully removed. There is a chance for people who were wearing stocking, not to wear them afterwards at all. Anticoagulation medication (warfarin, dabigatran, etc) in some situations is required and also aspirin (or Plavix) can be prescribed due to a previous DVT or stent placement but in certain cases even those medications might be ceased and patient might not take any of them following successful operation.

Cooperation with haematologists, dermatologist, wound nurses, general practitioner is necessary during and after treatment of CVD. Patients are also encouraged to look for a second opinion always.

Technology is very advancing every year and there are number of new devices on the market that may change patient’s quality of life. If previous physician’s intervention failed several years ago it does not mean that the next intervention will fail again. It might be the right time to discuss your leg problems with a different vascular specialist in Perth again.

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