January 2020

Valves, Varices and Voodoo - Understanding Venous Disease

Manu Aggarwal, MD

Dr. Aggarwal is a Board Certified and Aesthetic Laser Certified Family Physician specializing in vein disease at the Vein Care Center in Ohio. She is the Medical Director of the center’s IAC Accredited Ultrasound Laboratory and a Preceptor for the American Vein And Lymphatic Society and the American Society for Laser Medicine & Surgery. Dr. Aggarwal received her medical degree from West Virginia University School of Medicine.

Valves, varices and voodoo? There are many terms that you may hear or read about when visiting your vein specialist. It can be overwhelming! Venous disease is not uncommon and therefore we all should become more familiar on how this disease is diagnosed and treated.

The first step in diagnosing venous disease is to recognize the symptoms. The most common symptom is swelling in the legs, called edema. Edema, usually is limited to the ankle and above. However, it can also sometimes involve the foot and toes. Often times, in these cases, this is called lymphedema. When you have lymphedema combined with venous disease, this is called phlebolymphedema. These two diagnoses can occur simultaneously or separately, and it is important to be able to differentiate the two.

Symptoms can also include skin pigmentation (discoloration to the skin that is usually darker than the normal skin color), pain, presence of varicose veins, ulcerations, inflammation (redness and irritation to the skin) and induration (hardened skin from inflammation).

The next step is the ultrasound, a tool used in the venous setting to determine if blood is flowing towards the heart. The venous system is responsible for this task. Arteries carry blood to the body parts and veins collect and carry the blood back to the heart for recirculation. A Registered Vascular Technologist (RVT) or a Registered Phlebology Sonographer (RPhS) is a medical professional who specializes in ultrasound examination of the vascular system (RVT) or venous system (RPhS). The sonographer does venous mapping. Mapping the venous system is not the same for each patient. It can be tedious and usually takes about an hour. Veins have one-way valves that work against gravity and other forces to allow blood flow to go up towards the heart. When these valves and vein walls do not work properly, it is called venous insufficiency — the venous system is not sufficient. Specifically, the sonographer looks for reflux.

Reflux is a measurement of time where the blood flow is flowing down the vein rather than up the vein towards the heart. Reflux is measured while the patient is standing. This is important during your examination to insure accurate findings. When the flow is going back down the leg, the time spent coming down the leg is measured as reflux. Reflux can be in the normal range, of less than 500ms. However, if a superficial vein has a greater than 500ms of reflux, that is considered abnormal and the patient is diagnosed with venous insufficiency. Other veins have specific reflux time criteria to be considered incompetent, such as perforator veins (greater than 350ms) and deep veins (greater than 1000ms).

As you can see, the exam findings and ultrasound findings can be very variable. Therefore, there are criteria we use when determining the severity of one’s disease. The two most commonly used are the CEAP (Clinical, Etiology, Anatomy and Pathophysiology) and VCSS (Venous Clinical Severity Score). CEAP was created in 1994 and the VCSS was designed in 2000 to serve as an adjunct to the CEAP score; both scoring systems were developed by the American Venous Forum (AVF).

The CEAP score indicates the patient’s physical findings of varicose and spider veins, ulcers and swelling (Clinical). The next is the Etiology: congenital (born with venous anomalies), primary (most common cause) or secondary (due to previous history of a blood clot or other cause). The A for Anatomy tells us if the veins involved are in the superficial, deep or perforator veins. The P tells us if the cause of the venous disease is reflux or obstruction, or both.

The VCSS score takes into consideration many patient symptoms as mentioned above, such as pigmentation, pain, ulceration and varices. However, the other consideration is the use of compression stockings and progression of the disease over a 3-month period shown below.

These scoring systems allow you and your vein specialist to monitor your progression — with or without a venous procedure. It is important to recognize that these are criteria to determine the presence or absence of venous disease. It doesn’t absolutely determine procedures. However, you can use these criteria to monitor your progression and work with your vein specialist to determine a treatment plan that best suits you.


Learn which Juzo products can help improve circulation if you have venous disease or the symptoms Dr. Aggarwal describes above.

M. Kren commented on Jan 23, 2020

Reply

Great information. The key is the first line of practitioner contact- the IM or GP. Educating them to ask two simple questions on health forms would go a long way in getting CVI sufferers into a specialist's office and then into the proper therapeutic options to alleviate their symptoms and gaining relief.