The treatment of Chronic Venous Insufficiency with Compression Types of veins There are 3 different types of veins: Superficial veins – close to skin Deep veins – lie in groups of muscles Perforating veins – connecting superficial and deep veins The deep veins lead to the vena cava, the body’s largest vein, directly to the heart What is Chronic Venous Insufficiency (CVI)? Arteries bring oxygen-rich blood from the heart to the rest of the body Veins return oxygen-poor blood back to your heart. When the leg veins cannot pump enough blood back to the heart, there is chronic venous insufficiency (CVI). When in upright position, blood in leg veins goes against gravity to the heart. The leg muscles squeeze the deep veins of the legs and feet to help move blood back to the heart. Valves in veins keep blood flowing in right direction. When leg muscles relax, the valves inside veins close, preventing blood from flowing in reverse. This Process is called the venous pump. While walking, the leg muscles squeeze, and the venous pump works well. When sitting or standing, especially for a long time, the blood in the leg veins can pool and increase the venous blood pressure. Deep veins and perforating veins are usually able to withstand short periods of increased pressures. However, sitting or standing for a long time can stretch vein walls because they are flexible. Over time, in susceptible individuals, this can weaken the walls of the veins and damage the vein valves, causing CVI. Overview of Vein Valves

Figure 1 Properly Functioning Valves merckmanuals.com

One-way valves consist of two flaps (cusps or leaflets) with edges that meet. These valves help veins return blood to the heart. Blood, as it moves toward the heart, pushes the cusps open like a pair of one way swinging doors (shown on the left). If gravity momentarily pulls the blood backward or if blood begins to back up in a vein, the cusps are immediately pushed closed, preventing backward flow (shown on the right). In a normal vein, the cusps of the valves close to prevent backward flow of blood. In a varicose vein, the cusps cannot close because the vein is abnormally widened. Consequently, blood can flow in the wrong direction.

Figure 2 Normal and Damaged vein merckmanuals.com

Spider Veins Fine blood vessels of a few millimeters or centimeters in length Visible as a spidery pattern just under the surface of the skin. Spider veins rarely cause complaints and are mostly only a cosmetic nuisance. However, they can be a warning signal of varicose veins.

Figure 3 Spider veins Vnus.com

Varicose veins When the vein wall becomes soft and distended, the venous valves no longer close properly. The blood stagnates and the veins give way even further. Without proper therapy, the varicose veins spread persistently. These veins can be seen through the skin. They often look blue, bulging, and twisted. Large varicose veins can lead to skin changes like rashes, redness, and sores.

Figure 4 Varicose Veins Veindoctor.com

Phlebitis Phlebitis occurs when a superficial or deep vein becomes swollen and inflamed. This inflammation causes a blood clot to form, which can also lead to Deep Vein Thrombosis, or DVT.

Figure 5 Phlebitis dallasveinspecialists.com

Deep vein thrombosis (DVT) DVT occurs when a thrombus blocks blood from flowing toward the heart, out of a deep or perforating vein. The blood trying to pass through the blocked veins can increase the blood pressure in the vein, which, in turn, overloads the valves. DVT is a potentially serious condition that causes leg swelling and requires immediate medical attention because sometimes the thrombus in the veins can break off and travel to the lungs and cause a pulmonary embolus.

Figure 6 Varicose Veins vascularsurgeonpune.com

Venous Ulcers Oxygen-deficient blood in the veins is not transported away, and the exchange of nutrients and waste products is impaired. This leads to cells being seriously damaged and tissue dying off, resulting in chronic leg ulcers, or venous ulcers.

Figure 7 Venous stasis ulcer unchealthcare.org

Symptoms of CVI Swollen ankles Calves may feel tight Legs may also feel heavy, tired, restless, or achy. You may feel pain while walking or shortly after stopping. CVI may be associated with varicose veins CVI can also cause problems with leg swelling because of the pressure of the blood pooling in the veins. Skin changes and dermatitis Your lymphatic system may also produce fluid, called lymph, to compensate for CVI. Your leg tissues may then absorb some of this fluid, which can increase the tendency for your legs to swell. Causes of CVI Over the long-term, blood pressure that is higher than normal inside your leg veins causes CVI. Deep vein thrombosis (DVT) Phlebitis Leg injury or surgery can damage the veins or valves Factors increasing risk of CVI Family history of varicose veins Being overweight Being pregnant Not exercising enough Smoking Standing or sitting for long periods of time. Extended bed rest Women older than 50 most often get CVI. Diagnostic Tests Physical examination and good history taking And for confirmation: Duplex ultrasound Venogram. Treatment of CVI Compression stockings

Compression bandaging Sclerotherapy Ablation Vein stripping Bypass Valve repair How does Compression Therapy work? External compression applies controlled pressure to the skin. This then supports the superficial venous system, reducing the increased pressure and restoring the balance between the deep and superficial veins. This helps in reducing edema and aiding venous return. Graduated compression hosiery applies external pressure which is greater at the ankle and reduces at the calf and thigh, thus increasing blood velocity within the deep venous system. The amount of pressure is dependent on the severity of the condition. Treatment of CVI tries to reduce edema (swelling), eliminate thickened, hardened tissues, and heal ulcers. Treatment used with Compression hosiery Leg elevation - Simple elevation of the legs above heart level for 30 minutes three or four times per day can reduce edema and improve circulation Exercises — Foot and ankle exercises are often recommended to reduce symptoms Intermittent pneumatic compression Drug therapy — A variety of drugs have been used for chronic venous insufficiency and venous ulcers Contra-indications for compression treatment Absolute Contraindications: Advanced peripheral arterial occlusive disease Congestive heart failure Septic phlebitis (inflammation of the vein caused by microorganisms) Relative Contraindication: Oozing dermatosis Intolerance of compression stoking material Sensory loss of the extremity Advanced peripheral neuropathy (E.g. diabetes mellitus) Rheumatoid arthritis Never wear a stocking over a open wound Classification Compression hosiery is classified as class I, II or III depending on the performance of the materials and its indication for use. The prescription of the correct class stocking is important, so please ensure that the prescribing doctor knows your entire medical history. Suitability for compression hosiery The patient should be diagnosed by a doctor or first line practitioner and the necessary test done. It is important for the Orthotist to assess the individual patient and each limb for suitability for compression treatment before application. Documentation of the patient's clinical history, physical examination and assessment of the individual's attitude and level of knowledge regarding their diagnosis and compression therapy, can help in the planning of individualized care.

Physiological effects of graduated compression Increases: • Blood flow velocity in deep veins • Prostacyclin production • Local capillary clearance • Transcutaneous oxygen pressure • Expelled calf volume on exercise • Release of plasminogen activator Decreases: • Capacity and pressure in veins • Visible superficial varicose veins • Capacity and pressure in veins • Edema • Lipodermatosclerosis • Ambulatory venous pressure • Contra Indications • Arterial insufficiency • Diabetic ulcers Measurement Measurements should be taken by a fully qualified Medical Orthotist and Prosthetist. Accurate measurement is essential to ensure that hosiery fits properly. A stocking that fits correctly will produce an effective graduation in pressure and will be comfortable to wear without forming tight bands at the ankles and knees. Incorrect measurement could result in trauma, discomfort and possible ulceration. Application and Care Time is taken to instruct every new client on the correct method of application and how to care for their hosiery. Applying the stocking is quite difficult and time consuming the first few times but gets easier with practice. Special care should also be taken washing and caring for these stockings not to damage the fibers and thereby impairing the effectiveness Instructions • Always use special SIGVARIS Rubber Gloves to don socks or stockings • Avoid sharp fingernails and toenails • Remove rings before applying • Do not cut off lose threads inside the stocking • Do not apply oily skin care lotion on your legs before wearing the product Care • Wash daily in a linen bag or wash by hand in cold/lukewarm water using normal bath soap/sunlight green bar soap • Lay flat to dry away from direct heat source • Do not use fabric softener • Do not machine dry • Do not dry clean • Do not iron Tips for Healthy Veins Move as much as possible Watch your weight

Keep digestion regular Strengthen veins with hydrotherapy Let legs decongest whenever possible Breathe deeply Do regular leg and foot exercises Wear suitable clothing and shoes Avoid heating the legs excessively Lying down and walking versus sitting and standing Wear compression stockings References ALEXANDER, G. G. 2008. Chronic Venous Insufficiency and Postphlebitic Syndrome Peripheral Venous and Lymphatic Disorders [Online]. Available from: [Accessed: 8/6/2010 2010]. CLINIC, C. 1995. Chronic Venous InsufficiencyVenous Insufficiency [Online]. Available from: http://my.clevelandclinic.org/disorders/venous_insufficiency/hic_venous_insufficiency.aspx.]. DODD, H., AND COCKETT, F.B. 1956. The Pathology and Surgery of the veins of the Lower Limb. 2nd ed. Edinburgh: Churchill Livingstone. EBERHARDT, R. T., RAFFETTO, D.J. . 2005. Chronic Venous Insufficiency. American Heart Association(111):2398-2409. ELLISON, L. J. 2008. Chronic venous insufficiency [Online]. Available from: http://www.ucdmc.ucdavis.edu/vascular/diseases/cvi.ht INNOVATIONS, V. 2005 Varicose and Spider Vein FAQsVein Innovations [Online]. Available from: http://www.veininnovations.com/terms.html. [Accessed: 8/6/2010 2010]. KAHN, R. S. 2009. Postthrombotic Syndrome After Deep Venous Thrombosis: Risk Factors, Prevention, and Therapeutic Options. Clinical Advances in Hematology & Oncology, 7(7):433-435. LEE A., D. M., M.D., DIONNE, S.I. 2001. Phlebography [Online]. Available from: http://www.surgeryencyclopedia.com/Pa-St/Phlebography.html. [Accessed: 10/6/2010 2010]. MARIANI, F. (Ed.). 2009. Compression: Consensus document based on scientific evidence and clinical experience. 1 st ed. Torino: Edizioni Minerva Medica. MARYLAND. 2010. Vein Disease and Treatment [Online]. Available from: http://mdveinprofessionals.com/treatment/phlebitis.cfm. [Accessed: 8/6/2010 2010]. MIN, S.-K., KIM, S.-Y., PARK, Y. J., LEE, W., JUNG, I. M., LEE, T., et al. 2010. Role of three-dimensional computed tomography venography as a powerful navigator for varicose vein surgery. Journal of Vascular Surgery, 51(4):893-899. SCHWARZ, T., VON HODENBERG, E., FURTWÄNGLER, C., RASTAN, A., ZELLER, T. & NEUMANN, F.-J. 2010. Endovenous laser ablation of varicose veins with the 1470-nm diode laser. Journal of Vascular Surgery, 51(6):1474-1478. SHANIK, D. G., MACERLAEAN, D.P. AND KEANVENY, T.V. 2009. The value of Doppler ultrasound in the diagnosis of deep vein thrombosis. Irish Journal of Medical Science, 146(1):97SIGVARIS. 2010. Sigvaris training manual. In SIGVARIS (Ed.), (pp. 16-41). Gallen. TURPIE,A.G.G. MD (2008), Overview of the Venous System, Merk Home Manuel, http://www.merckmanuals.com/home/heart_and_blood_vessel_disorders/venous_disorders/overview_of_the_venous_ system.html

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