angiologiaVENOUS PATHOLOGY

VENOUS PATHOLOGY

Venous pathologies are often relegated to the background, as a minor disease. However, 7 out of 10 people in our society exhibit signs or symptoms of venous insufficiency, which can lead to a significant deterioration in their quality of life.

In the circulatory cycle, blood returns to the heart through the veins thanks to the pumping action of muscles, mainly the legs when walking and the abdomen when breathing. Unlike arteries, veins contain valves that prevent blood from settling in the lower limbs under the effect of gravity. When these valves work poorly, for whatever reason, the result is known as chronic venous insufficiency, which is one of the most common chronic illnesses.

The usual symptoms of this condition are pain, tingling, bloating and permanent fatigue in the legs accompanied by swelling, a burning sensation, redness, dryness and constant itching on the skin due to the accumulation of blood.

Depending on the severity of this malfunctioning venous return, the following complications may occur:

• Spider veins

These are dilated capillaries with a calibre of under 1 mm that tend to form in the shape of a spider web. They are usually red and are visible to the naked eye under the skin.

• Varicose veins

These are dilated subcutaneous veins, 3 or more millimetres in diameter with a bluish colour that can be seen under the surface of the skin.

• Skin disorders

Eczema can occur, which can present with vesicles and exudate. The pigmentation of the skin turns to a darker brown colour. Lipodermatosclerosis, white atrophy and even ulcers can form, which can compromise muscle tissue. They tend not to heal spontaneously.

• Deep vein thrombosis

This happens when a clot forms inside a vein, with the consequent danger of the clot, or part of it, detaching and moving to the lung (embolism). Although it is associated with genetic risk factors, the appearance of DVT, typically in the veins of the calf and thigh, can be caused by prolonged periods of immobilisation, so if you are on bed rest or in clinical recovery, for example, it is advisable to follow preventive anticoagulant treatment to keep these clots from forming.

angiologiaPELVIC VEIN PATHOLOGY

PELVIC VEIN PATHOLOGY

The venous system of the pelvis and lower limbs is regarded as comprising one functional unit that is difficult to separate anatomically and physiologically due to its great anatomical complexity, the diversity of connections in place between the two systems and the multiple factors (genetic, environmental, etc.) that may be involved.

Therefore, we must consider the classic symptoms of venous insufficiency and include those that present in pelvic venous insufficiency in what is known as:

• Pelvic congestion syndrome

(PCS). It is characterised by chronic pelvic pain with no known gynaecological cause, which increases with static postures (mainly standing) and which is usually present in women who have had several pregnancies. It is usually accompanied by bloating of the lower abdomen, pain during intercourse, painful menstruation and increased urinary frequency. In addition to these symptoms, it is very common for varicose veins to appear in the vulva and/or lower limbs. It is also found in men (testicular varicose veins), although it is more common in women.

Other causes of venous hypertension in the pelvis: compression syndromes

• May Thurner syndrome

This is a compression of the left iliac vein between the right iliac artery and the lumbar spine, a condition that increases venous pressure and hampers drainage of the left leg.
This syndrome is believed to be the main cause of most cases of deep vein thrombosis that develop in the left leg. The exact origin of this compression is unknown, but it is very common for it to occur in thin people, mainly women.

• Nutcracker Syndrome

This is defined as a compression of the left renal vein as it passes between the aorta and the superior mesenteric artery (mesoaortic compression), which hampers blood flow and may compromise the drainage of the left kidney.
It can cause left lumbar pain, haematuria (presence of blood in the urine) and an increase in venous pressure that leads to secondary varices in lower areas. This is why a distinction must be made between what this syndrome entails in terms of drainage of the left kidney and what it produces secondarily in other venous structures (venous hypertension).

angiologiaLYMPHATIC PATHOLOGY

LYMPHATIC PATHOLOGY

Lymphology is a medical discipline included in Vascular Pathology that is dedicated to studying the lymphatic system and its disorders.

The most common lymphatic pathology is lymphoedema, a disease characterised by the presence of oedema or swelling in a specific region of the body, normally the limbs, due to the accumulation of water, salt, proteins, electrolytes and other substances in the interstitial space, as a consequence of a mechanical and/or dynamic alteration in the operation of the lymphatic system, either due to a congenital cause (primary lymphoedema) or secondary to other diseases and/or to their treatment (secondary lymphoedema).

Lymphoedema is a chronic and progressive disease that has no cure, but can be treated effectively.

A broad knowledge of vascular pathology is required for a correct diagnosis and to offer a comprehensive therapeutic approach. The aim is to reduce swelling, prevent complications and, ultimately, keep the disease from progressing.

The patient must actively participate in the treatment; guidance and education are essential to achieve greater therapeutic efficacy. In our experience, the results obtained both in the short and long term have been very satisfactory.

angiologiaDIAGNOSTIC TESTS

DIAGNOSTIC TESTS

The last 20 years have seen significant advances in the field of vascular and endovascular radiology, which has led to the emergence of new diagnostic and minimally invasive therapeutic techniques that have allowed us to determine and develop new horizons within vascular pathology.

Arterial exams

• Arteriography

Provides anatomical and dynamic information on arteries.It simply involves making a puncture in the patient's groin (or other regions such as the arm) and inserting a fine catheter through which to inject the contrast dye that fills the interior of the arteries, allowing the doctor to assess possible injuries to the arteries. Sometimes, the treatment can also be provided during the diagnostic process itself.

Venous exams

• Pelvic venous exam or pelvic phlebography

Also known as ilio-cavography or pelvic phlebography. This involves inserting a catheter through a puncture into a vein at the cubital fossa that travels to the veins of the abdomino-pelvic sector, through which a contrast dye is injected to obtain high-quality morphological images and measure pressure gradients, providing valuable information on the extent of the pelvic venous pathology. It also provides morphological information on the veins of the abdomen (iliac veins and inferior vena cava.)

• Ascending phlebography

EThis test provides complete and accurate information on the venous anatomy of the legs or any other anatomical region of interest. This is a very useful test for diagnosing and therapeutically assessing varices in the lower limbs, and especially venous thrombosis.

Other related procedures that sometimes also need to be carried out are dynamic phlebography (when studying thoracic outlet syndrome), selective descending phlebography or varicography.

Supplementary exams

• CT Angiogram

This is a non-invasive procedure that allows for a detailed examination of blood vessels, whether arteries or veins, and other adjacent anatomical structures (bones, muscles, viscera, etc.) without the need for catheterisation. It involves a high-speed, multi-slice, helical scanner that provides constant information on the area being scanned. This results in a much faster scan with a lower amount of radiation and a much higher quality, three-dimensional reconstruction.

• MR angiography

Magnetic resonance angiography is a diagnostic method that is used to obtain high-quality images without using X-rays. The images are obtained by exposing the patient to a magnetic field where radio frequency waves are applied that send a signal that is analysed by a computer, providing images of internal organs in two and three dimensions. It is a non-invasive technique, since the magnetic fields do not cause tissue damage. It is used to diagnose both arterial and venous diseases.

• Eco-doppler

This is the main tool in the vascular laboratory. It relies on the emission of sound waves (ultrasounds) that are transformed into images.The images received show if there are blockages in veins and arteries, as well as the volume and speed of blood flow. This is the main technique that we use in our service to diagnose and monitor venous and arterial diseases. It is a fast and harmless diagnostic method.

angiologiaTreatments

TREATMENTS

The procedures for treating the various pathologies involved in angiology have advanced enormously in just a few years. There are currently a large number of conditions that previously required open surgery

and that can now be treated using minimally invasive techniques.

Endovascular treatments

These procedures are performed using catheters that are inserted into the veins or arteries, guided by x-rays. This procedure normally requires access through the skin.

Endovascular procedures include:

• Radio frequency

This is the treatment that is normally used for varicose veins. The varicose veins are collapsed by applying the heat that is generated by the radio frequency catheter. It allows operating on varicose veins by making a small puncture in the leg. There is almost no post-operative discomfort and the recovery is very fast.

• Placement of stents

These are springs that are installed to correct narrowing arteries and veins or to treat aneurysms.

• Balloon angioplasty

Instead of placing a stent, a small "balloon" is used which is inflated once the final location is reached in order to correct/dilate the constriction.

• Thrombolysis/thrombectomy

This involves administering a medication, which is guided to the blockage with the help of a catheter, to dissolve the clot. In other cases, a special catheter is used to dissolve and remove the clot using mechanical and pharmacological methods. It is very useful for treating acute thrombosis.

• Embolisation

Sometimes it will be necessary to deliberately cut off blood vessels for various purposes, such as to interrupt blood flow in a specific vessel that is broken, or to treat pelvic varices.

Open surgery treatments

Whenever possible, pharmacological or endovascular procedures will be used to treat vascular diseases, but there are many cases in which "open surgery" will be required.

• Varicose vein surgery

The classical technique for treating varices is known as saphenectomy. This involves disconnecting the main branch that generates the varices in one leg, the internal or external saphena, through an incision in the groin or in the hamstring and another in the ankle. Once disconnected, it is removed. Microincisions are made to remove the remaining varicose branches.

• Revascularisation surgeries

to return functionality to the following areas:

• • Of the supra-aortic trunks and the upper limbs

    • Carotid endarterectomy: The goal is to remove the "plaque" (accumulated fatty substance) from the carotid artery. A portion of the vessel is cut lengthwise and the plaque is removed with tweezers. Finally, the opening in the artery is closed with a suture or patch.

  • Axillary bypasses or upper limb bypasses

    • Of the aortoiliac sector
      • Aortobifemoral bypass: A tube is inserted between the aorta and one or both femoral arteries in the legs to save the blocked areas.
      • Iliofemoral bypass: In this case, the iliac artery (in the pelvis) is linked to the femoral artery in the leg.

• • • Of the femoral popliteal sector

▪ Femoral endarterectomy and profundaplasty: The plaque in the femoral artery is removed. When removed from the deep femoral artery, it is called a profundaplasty.

▪ Femoral popliteal bypass: The popliteal artery is an extension of the femoral artery. This bypass is intended to go around a blockage that prevents blood flow to the lower legs.

Aesthetic treatments of varices

Vascular spiders and small-calibre varices can be treated without surgery by using microfoam. The treatment consists of injecting a drug with a very fine needle into the small varices that are to be removed.

This is a safe treatment with excellent short-term results.

It is also sometimes used as a supplement when treating higher calibre varicose veins, vascular malformations or recurrent varicose veins.

angiologiaPREVENTION

PREVENTION

Prevention in angiology as in many other medical disciplines is often the best treatment against vascular pathologies.

Checkups

Checkups are a good tool especially when we get older to detect early arteriopathies in general and especially cerebral, arterial aneurysms, atheromatous diseases or patients at high risk of venous thrombosis, among other vascular pathologies.

In the checkups we perform hemodynamic and physical exams. In addition, the patient will be consulted about his life habits in order to collect the necessary information to assess his risk factors. The doctor might indicate both pharmacological measures or change of habits.

Risk factor's

The main risk factors for arterial, venous and lymphatic systems are the following:

• Tobacco
• Obesity

• Hypertension

• Sedentary lifestyle

• Cholesterol
• Diabetes

Not to mention others such as stress, high triglycerides, etc.

Special cases

There are patients who are exposed to vascular problems in a timely or constant manner:

• Pregnancies

Pregnant women will have their legs heavier and at risk of edema. It´s essential to take special measures, such as massages, keeping physical activity, control over-weight, etc. In case of varicose veins they will have to wear compression stockings.

After childbirth, vascular problems usually disappear, but it is also normal that they persist sometimes due to hormonal alterations.

• Office and sedentary jobs

Any job that requires long time seating will be necessary to care legs circulation. It is important that they seat properly, without crossing their legs, for example, wearing loose clothes or avoid sources of heat, as well as to eat lighter than if they had physical work.

• The plane

The reduced space and the forced postures in large intervals of time can get worse vascular pathologies, so it is highly recommended carry out a vascular check before a long flight. If necessary, the specialist may prescribe a drug that helps in these cases.