Overview of Venous Disorders

  • Albeir Y. Mousa


There is growing recognition of the importance of venous pathology in our daily practice. With a better understanding of venous insufficiency distribution and its consequences, it is being proved that the main pathology of venous disease is not an obstructive process as previously thought. There are several methods to classify venous diseases, such as distribution and severity; however, the most effective way is to assess the severity based on clinical, etiological, anatomical, and pathophysiological aspects. This international classification is not only an efficient description, but is imperative in determining appropriate management. It is crucial to understand the new terminology, not only to keep up with the American Venous Forum updates, but also to serve as a common language among venous specialists. This chapter is an overview of venous disorders, both from anatomical and pathophysiological aspects, with a brief update on the new horizons in the management of venous disease.


Venous Superficial Deep Reflux CEAP Deep venous thrombosis Perforator Phlegmasia Incompetence 



The author records his special thanks to Dr. Mary Emmett for reviewing the content of this chapter.


  1. 1.
    Federative International Committee for Anatomical Terminology. Terminologia anatomica. Stuttgart: George Thieme Verlag; 1998.Google Scholar
  2. 2.
    Caggiati A, Bergan JJ, Gloviczki P, Jantet G, Wendell-Smith CP, Partsch H, International Interdisciplinary Consensus Committee on Venous Anatomical Terminology. Nomenclature of the veins of the lower limbs: an international interdisciplinary consensus statement. J Vasc Surg. 2002;36:416–22.PubMedCrossRefGoogle Scholar
  3. 3.
    Bundens WP, Bergan JJ, Halasz NA, Murrary J, Drehobl M. The superficial femoral vein: a potentially lethal misnomer. JAMA. 1995;274:1296–8.PubMedCrossRefGoogle Scholar
  4. 4.
    Ludbrook J. The musculovenous pumps of the human lower limb. Am Heart J. 1966;71:635–41.PubMedCrossRefGoogle Scholar
  5. 5.
    Eklof B, Rutherford RB, Bergan JJ, Carpentier PH, Gloviczki P, Kistner RL, et al. Revision of the CEAP classification for chronic venous disorders: consensus statement. J Vasc Surg. 2004;40(6):1248–52.PubMedCrossRefGoogle Scholar
  6. 6.
    Allegra C, Antignani PL, Bergan JJ, Carpentier PH, Coleridge-Smith P, Cornu-Thenard A, et al. The “C” of CEAP: suggested definitions and refinements: an International Union of Phlebology conference of experts. J Vasc Surg. 2003;37(1):129–31.PubMedCrossRefGoogle Scholar
  7. 7.
    Moneta GL. Regarding “the ‘C’ of CEAP: suggested definitions and refinements: an International Union of Phlebology conference of experts”. J Vasc Surg. 2003;37(1):224–5.PubMedCrossRefGoogle Scholar
  8. 8.
    Gillespie D, Glass C. Importance of ultrasound evaluation in the diagnosis of venous insufficiency: guidelines and techniques. Semin Vasc Surg. 2010;23(2):85–9.PubMedCrossRefGoogle Scholar
  9. 9.
    Labropoulos N, Leon Jr LR. Duplex evaluation of venous insufficiency. Semin Vasc Surg. 2005;18(1):5–9.PubMedCrossRefGoogle Scholar
  10. 10.
    Norris CS, Greenfield LJ, Herrmann JB. Free-floating iliofemoral thrombus. A risk of pulmonary embolism. Arch Surg. 1985;120(7):806–8.PubMedCrossRefGoogle Scholar
  11. 11.
    Kosir MA, Kozol RA, Perales A, McGee K, Beleski K, Lange P, et al. Is DVT prophylaxis overemphasized? A randomized prospective study. J Surg Res. 1996;60(2):289–92.PubMedCrossRefGoogle Scholar
  12. 12.
    McLeod RS, Geerts WH, Sniderman KW, Greenwood C, Gregoire RC, Taylor BM, et al. Subcutaneous heparin versus low-molecular-weight heparin as thromboprophylaxis in patients undergoing colorectal surgery: results of the Canadian colorectal DVT prophylaxis trial: a randomized, double-blind trial. Ann Surg. 2001;233(3):438–44.PubMedCrossRefGoogle Scholar
  13. 13.
    Clarke JL. DVT prophylaxis: confronting a public health menace. Am J Med Qual. 2010;25(1 Suppl):4S–15.PubMedCrossRefGoogle Scholar
  14. 14.
    Schumann SA, Ewigman B. Is it DVT? Wells score and D-dimer may avert costly workup. J Fam Pract. 2007;56(12):1010–2.PubMedGoogle Scholar
  15. 15.
    Villemur B, Bosson JL, Diamand JM. Deep venous thrombosis (DVT) after hip or knee prosthesis. Evaluation of practices for prevention and prevalence of DVT on Doppler ultrasonography. J Mal Vasc. 1998;23(4):257–62.PubMedGoogle Scholar
  16. 16.
    Guptan RC. Regarding “is there an increased risk for DVT with VNUS closure procedure?”. J Vasc Surg. 2003;38(5):1140.PubMedCrossRefGoogle Scholar
  17. 17.
    Komenaka IK, Nguyen ET. Is there an increased risk for DVT with the VNUS closure procedure? J Vasc Surg. 2002;36(6):1311.PubMedGoogle Scholar
  18. 18.
    Lindholm C. DVT: the forgotten factor in leg ulcer prevention. J Wound Care. 2002;11(1):5.PubMedGoogle Scholar
  19. 19.
    Neumann V, O’Connor RJ, Bhakta BB, Tennant A. DVT and pulmonary embolism after acute infection. Lancet. 2006;368(9531):201; author reply 201.PubMedCrossRefGoogle Scholar
  20. 20.
    Hingorani AP, Ascher E, Markevich N, Schutzer RW, Kallakuri S, Mutyala M, et al. Prospective evaluation of combined upper and lower extremity DVT. Vasc Endovascular Surg. 2006;40(2):131–4.PubMedCrossRefGoogle Scholar
  21. 21.
    Kline JA, Courtney DM, Kabrhel C, Moore CL, Smithline HA, Plewa MC, et al. Prospective multicenter evaluation of the pulmonary embolism rule-out criteria. J Thromb Haemost. 2008;6(5):772–80.PubMedCrossRefGoogle Scholar
  22. 22.
    Hirsh J, Guyatt G, Albers GW, Harrington R, Schunemann HJ, American College of Chest Physician. Antithrombotic and thrombolytic therapy: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (8th edition). Chest. 2008;133(6 Suppl):110S–2.PubMedCrossRefGoogle Scholar
  23. 23.
    Sales CM, Haq F, Bustami R, Sun F. Management of isolated soleal and gastrocnemius vein thrombosis. J Vasc Surg. 2010;52(5):1251–4.PubMedCrossRefGoogle Scholar
  24. 24.
    Ault M, Artal R. Upper extremity DVT: what is the risk? Arch Intern Med. 1998;158(17):1950–2.PubMedCrossRefGoogle Scholar
  25. 25.
    Monreal M, Raventos A, Lerma R, Ruiz J, Lafoz E, Alastrue A, et al. Pulmonary embolism in patients with upper extremity DVT associated to venous central lines–a prospective study. Thromb Haemost. 1994;72(4):548–50.PubMedGoogle Scholar
  26. 26.
    O’Brien PJ, Ramasunder S, Cox MW. Venous thoracic outlet syndrome secondary to first rib osteochondroma in a pediatric patient. J Vasc Surg. 2011;53(3):811–3.PubMedCrossRefGoogle Scholar
  27. 27.
    Molina JE. Regarding “combination treatment of venous thoracic outlet syndrome: open surgical decompression and intraoperative angioplasty”. J Vasc Surg. 2005;42(3):593; author reply 593.PubMedCrossRefGoogle Scholar
  28. 28.
    Schneider DB, Dimuzio PJ, Martin ND, Gordon RL, Wilson MW, Laberge JM, et al. Combination treatment of venous thoracic outlet syndrome: open surgical decompression and intraoperative angioplasty. J Vasc Surg. 2004;40(4):599–603.PubMedCrossRefGoogle Scholar
  29. 29.
    Lozano P, Doaz M, Riera R, Gomez FT. Venous thoracic outlet syndrome secondary to congenital pseudoarthrosis of the clavicle. Presentation in the fourth decade of life. Eur J Vasc Endovasc Surg. 2003;25(6):592–3.PubMedCrossRefGoogle Scholar
  30. 30.
    Glass BA. The relationship of axillary venous thrombosis to the thoracic outlet compression syndrome. Ann Thorac Surg. 1975;19(6):613–21.PubMedCrossRefGoogle Scholar
  31. 31.
    Marsh P, Price BA, Whiteley MS. Prevalence and management of ovarian venous insufficiency in the presence of leg venous insufficiency. Phlebology. 2007;22(4):192.PubMedCrossRefGoogle Scholar
  32. 32.
    Sutaria R, Subramanian A, Burns B, Hafez H. Prevalence and management of ovarian venous insufficiency in the presence of leg venous insufficiency. Phlebology. 2007;22(1):29–33.PubMedCrossRefGoogle Scholar
  33. 33.
    Mahorner H. Diagnosis and treatment of phlegmasia alba dolens and phlegmasia cerulea dolens. Am Surg. 1968;34(3):210–2.PubMedGoogle Scholar
  34. 34.
    Mousa A, Henderson P, Dayal R, Bernheim J, Kent KC, Faries PL. Endoluminal recanalization in a patient with phlegmasia cerulea dolens using a multimodality approach. Vascular. 2005;13(5):313–7.PubMedGoogle Scholar
  35. 35.
    Bird RL, Hamilton G. Treatment options for phlegmasia cerulea dolens. J Vasc Surg. 1995;21(6):998–9.PubMedCrossRefGoogle Scholar
  36. 36.
    Harris Jr EJ, Kinney EV, Harris Sr EJ, Olcott CT, Zarins CK. Phlegmasia complicating prophylactic percutaneous inferior vena caval interruption: a word of caution. J Vasc Surg. 1995;22(5):606–11.PubMedCrossRefGoogle Scholar
  37. 37.
    Jazayeri S, Tatou E, Cheynel N, Becker F, Brenot R, David M. A spontaneous rupture of the external iliac vein revealed as a phlegmasia cerulea dolens with acute lower limb ischemia: case report and review of the literature. J Vasc Surg. 2002;35(5):999–1002.PubMedCrossRefGoogle Scholar
  38. 38.
    Kuo I, Smith J, Abou-Zamzam Jr AM. A multimodal therapeutic approach to phlegmasia cerulea dolens in a pediatric patient. J Vasc Surg. 2011;53(1):212–5.PubMedCrossRefGoogle Scholar
  39. 39.
    Allegra C, Bergan J. Update on fundamental causes and management of chronic venous insufficiency. Executive summary. Angiology. 2003;54 Suppl 1:S1–3.PubMedCrossRefGoogle Scholar
  40. 40.
    Bergan JJ. Venous insufficiency and perforating veins. Br J Surg. 1998;85(6):721–2.PubMedCrossRefGoogle Scholar
  41. 41.
    Delis KT, Ibegbuna V, Nicolaides AN, Lauro A, Hafez H. Prevalence and distribution of incompetent perforating veins in chronic venous insufficiency. J Vasc Surg. 1998;28(5):815–25.PubMedCrossRefGoogle Scholar
  42. 42.
    Aita DJ, Kvamme P, Rice JC, Kerstein MD. Venous insufficiency: a late sequelae of four-compartment fasciotomy in the lower extremity? Am Surg. 1993;59(9):574–7.PubMedGoogle Scholar
  43. 43.
    Thurston OG, Williams HT. Chronic venous insufficiency of the lower extremity. Pathogenesis and surgical treatment. Arch Surg. 1973;106(4):537–9.PubMedCrossRefGoogle Scholar
  44. 44.
    Cranley JJ, Krause RJ, Strasser ES. Chronic venous insufficiency of the lower extremity. Surgery. 1961;49:48–58.PubMedGoogle Scholar
  45. 45.
    Manfredini R, Zamboni P. Regarding “chronic venous insufficiency is associated with increased platelet and monocyte activation and aggregation”. J Vasc Surg. 2000;32(3):622.PubMedCrossRefGoogle Scholar
  46. 46.
    Pappas PJ, You R, Rameshwar P, Gorti R, DeFouw DO, Phillips CK, et al. Dermal tissue fibrosis in patients with chronic venous insufficiency is associated with increased transforming growth factor-beta1 gene expression and protein production. J Vasc Surg. 1999;30(6):1129–45.PubMedCrossRefGoogle Scholar
  47. 47.
    Powell CC, Rohrer MJ, Barnard MR, Peyton BD, Furman MI, Michelson AD. Chronic venous insufficiency is associated with increased platelet and monocyte activation and aggregation. J Vasc Surg. 1999;30(5):844–51.PubMedCrossRefGoogle Scholar
  48. 48.
    Raffetto JD, Mendez MV, Marien BJ, Byers HR, Phillips TJ, Park HY, et al. Changes in cellular motility and cytoskeletal actin in fibroblasts from patients with chronic venous insufficiency and in neonatal fibroblasts in the presence of chronic wound fluid. J Vasc Surg. 2001;33(6):1233–41.PubMedCrossRefGoogle Scholar
  49. 49.
    Raju S, Owen Jr S, Neglen P. The clinical impact of iliac venous stents in the management of chronic venous insufficiency. J Vasc Surg. 2002;35(1):8–15.PubMedGoogle Scholar
  50. 50.
    Fukuoka M, Okada M, Sugimoto T. Foot venous pressure measurement for evaluation of lower limb venous insufficiency. J Vasc Surg. 1998;27(4):671–6.PubMedCrossRefGoogle Scholar
  51. 51.
    Treiman GS, Copland S, McNamara RM, Yellin AE, Schneider PA, Treiman RL. Factors influencing ulcer healing in patients with combined arterial and venous insufficiency. J Vasc Surg. 2001;33(6):1158–64.PubMedCrossRefGoogle Scholar
  52. 52.
    Taheri SA, Williams J, Powell S, Cullen J, Peer R, Nowakowski P, et al. Iliocaval compression syndrome. Am J Surg. 1987;154(2):169–72.PubMedCrossRefGoogle Scholar
  53. 53.
    Asbeutah AM, Riha AZ, Cameron JD, McGrath BP. Reproducibility of duplex ultrasonography and air plethysmography used for the evaluation of chronic venous insufficiency. J Ultrasound Med. 2005;24(4):475–82.PubMedGoogle Scholar
  54. 54.
    Ruckley CV, Evans CJ, Allan PL, Lee AJ, Fowkes FG. Chronic venous insufficiency: clinical and duplex correlations. The Edinburgh vein study of venous disorders in the general population. J Vasc Surg. 2002;36(3):520–5.PubMedCrossRefGoogle Scholar
  55. 55.
    Criado E, Farber MA, Marston WA, Daniel PF, Burnham CB, Keagy BA. The role of air plethysmography in the diagnosis of chronic venous insufficiency. J Vasc Surg. 1998;27(4):660–70.PubMedCrossRefGoogle Scholar
  56. 56.
    Fukuoka M, Sugimoto T, Okita Y. Prospective evaluation of chronic venous insufficiency based on foot venous pressure measurements and air plethysmography findings. J Vasc Surg. 2003;38(4):804–11.PubMedCrossRefGoogle Scholar
  57. 57.
    Padberg Jr FT, Johnston MV, Sisto SA. Structured exercise improves calf muscle pump function in chronic venous insufficiency: a randomized trial. J Vasc Surg. 2004;39(1):79–87.PubMedCrossRefGoogle Scholar
  58. 58.
    Partsch H, Menzinger G, Borst-Krafek B, Groiss E. Does thigh compression improve venous hemodynamics in chronic venous insufficiency? J Vasc Surg. 2002;36(5):948–52.PubMedCrossRefGoogle Scholar
  59. 59.
    Felty CL, Rooke TW. Compression therapy for chronic venous insufficiency. Semin Vasc Surg. 2005;18(1):36–40.PubMedCrossRefGoogle Scholar
  60. 60.
    Agu O, Baker D, Seifalian AM. Effect of graduated compression stockings on limb oxygenation and venous function during exercise in patients with venous insufficiency. Vascular. 2004;12(1):69–76.PubMedCrossRefGoogle Scholar
  61. 61.
    Gloviczki P, Bergan JJ, Rhodes JM, Canton LG, Harmsen S, Ilstrup DM. Mid-term results of endoscopic perforator vein interruption for chronic venous insufficiency: lessons learned from the North American subfascial endoscopic perforator surgery registry. The North American Study Group. J Vasc Surg. 1999;29(3):489–502.PubMedCrossRefGoogle Scholar
  62. 62.
    Huang Y, Jiang M, Li W, Lu X, Huang X, Lu M. Endovenous laser treatment combined with a surgical strategy for treatment of venous insufficiency in lower extremity: a report of 208 cases. J Vasc Surg. 2005;42(3):494–501; discussion 501.PubMedCrossRefGoogle Scholar
  63. 63.
    Kundu S, Lurie F, Millward SF, Padberg Jr F, Vedantham S, Elias S, et al. Recommended reporting standards for endovenous ablation for the treatment of venous insufficiency: joint statement of the American Venous Forum and the Society of Interventional Radiology. J Vasc Surg. 2007;46(3):582–9.PubMedCrossRefGoogle Scholar
  64. 64.
    Mendes RR, Marston WA, Farber MA, Keagy BA. Treatment of superficial and perforator venous incompetence without deep venous insufficiency: is routine perforator ligation necessary? J Vasc Surg. 2003;38(5):891–5.PubMedCrossRefGoogle Scholar
  65. 65.
    Merchant RF, Pichot O. Long-term outcomes of endovenous radiofrequency obliteration of saphenous reflux as a treatment for superficial venous insufficiency. J Vasc Surg. 2005;42(3):502–9; discussion 509.PubMedCrossRefGoogle Scholar
  66. 66.
    Neglen P, Eklof B, Kulwicki A, Davies A, Deschamps T, Garcia M, et al. Prevention and treatment of venous ulcers in primary chronic venous insufficiency. J Vasc Surg. 2010;52(5 Suppl):15S–20.PubMedCrossRefGoogle Scholar
  67. 67.
    Tawes RL, Barron ML, Coello AA, Joyce DH, Kolvenbach R. Optimal therapy for advanced chronic venous insufficiency. J Vasc Surg. 2003;37(3):545–51.PubMedCrossRefGoogle Scholar

Copyright information

© Springer-Verlag London 2013

Authors and Affiliations

  1. 1.Department of Surgery, Robert C. Byrd Health Sciences CenterWest Virginia UniversityCharlestonUSA

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