varicose veins

VARICOSE VEINS

DEFINITION

Varicose veins are defined as dilated, tortuous, subcutaneous veins >3 mm in diameter

measured in the upright position with demonstrable reflux.

• ANATOMY • PHYSIOLOGY• CAUSES• PATHOGENESIS• SYMPTOMS • CLINICAL EXAMINIATION • TREATMENT

ANATOMY

Lower limb has 3 types of veins

1. superficial veins2. deep veins3. perforating veins

Superficial veins

Perforators

• Hunterian’s perforator • Dodd’s perforator • Boyd’s perforator• Cockett’s perforator - 3 groups

PHYSIOLOGY• Arterial blood reaches the leg by pumping of heart • Venous return to heart occurs with the help of MAINLY by 1. calf muscles hence it is called peripheral heart 2. valves are present in the veins, it prevents the

back flow

Important concept

PATHOGENESIS• When there is failure of normal unidirectional flow

in the leg veins , there is decreased venous return , it is called CHRONIC VENOUS INSUFFICIENCY (CVI).

• CVI can lead to stasis of blood in leg veins leading to AMBULATORY VENOUS HYPERTENSION .

• Due to venous hypertension , superficial veins may get dilated and tortuous , hence called VARICOSE VEIN.

CAUSES

• Congenital – absence of valves• Primary varicose veins • Secondary veins 1. Post thrombotic2. Pregnancy 3. Abdominal mass 4. Iliac vein thrombosis5. AV Fistula

SYMPTOMS

• Aching pain increases on prolonged standing

relieves on limb elevation• Ankle swelling • Pigmentation • Itching • Eczema • Ulceration - medial and lateral aspect of lower leg

“ GAITER AREA “

Hemoglobin

Hemosiderin biliverdin

2 hypothesis regarding venous ulcer : Fibrin Cuff Theory : due to raised capillary

pressure , there is leakage of plasma fibrinogen and form a cuff around the capillary thus reducing perfusion leading to venous ulcer .

White Blood Cell trapping theory : due to venous

stasis , WBC may get attached to the endothelial cell of capillaries and may extravasate into extracellular space , this is followed by release of proteolytic enzymes and damage of the cells leading to ulcer

CLINICAL EXAMINATION INSPECTION• TELANGECTASIA – DILATED INTRADERMAL VENULES < 1

mm DIAMETER• RETICULAR VEINS – DILATED SUBDERMAL VEINS 1-3

mm DIAMETER• PITTING ODEMA• ATROPHIC BLANCHE – WHITE ATROPHIC SKIN

SURROUNDED BY DILATED CAPILLARIES • CORONA PHLEBECTASIA \ ANKLE FLARE• LIPODEMATOSCLEROSIS – INVERTED WINE BOTTLE

APPEARANCE

• PIGMENTATION – HEMOSIDERIN DEPOSITION • ECZEMA• MORRISEY TEST • ULCERATION

Margin – thin and bluish showing growth of epithelium

Edge – sloping Floor – granulation tissue and

slough Base – fixed to deeper

structures

PALPATION

• TEMPERATURE • FEGAN METHOD• CRUVEILHIER’S SIGN• SCHWARTZ TEST • BRODIE TRENDLENBURG TEST – 2 METHODS 1ST – SAPHENO FEMORAL INCOMEPETENCE

2ND – PERFORATING VEIN INCOMPETENCE

• MULTIPLE TOURNIQUET TEST• PRATT’S TEST • PERTHES TEST • MODIFIED PERTHES TEST

• ANATOMY • PHYSIOLOGY• CAUSES• PATHOGENESIS• SYMPTOMS • CLINICAL EXAMINIATION• INVESTIGATION • TREATMENT

INVESTIGATIONDUPLEX ULTRASONOGRAPHY

Varicography• Rarely done in case of complex anatomy

MANAGEMENT

COMPRESSION HOISERY

class 1 – 14 – 17 mmHg class 2 – 18 – 24 mmHg {varicose vein} class 3 – 25 – 35 mmHg

ULTRASOUND GUIDED FOAM SCLEROTHERAPHY

• SODIUM TETRADECYL SULPHATE IS INJECTED INTO THE VEIN.

• IT DESTROYS THE ENDOTHELIAL CELL , HEALING OCCURS BY FIBROSIS AND BLOOD VESSEL GETS OBLITRATED.

ENDOVENOUS LASER ABLATION

RADIOFREQUENCY ABLATION

• Similar like endovenous laser ablation • But bipolar catheter is used to heat

SURGERY

TRENDLENBURG OPERATION :FOR SAPHENOFEMORAL INCOMPETENCY

PERFORATOR LIGATION AND SEPS(SUBFASCIAL ENDOSCOPIC PERFORATOR LIGATION SURGERY) :FOR PERFORATOR INCOMPETENCY

TRENDLENBURG OPERATION

INDICATION – SAPHENOFEMORAL INCOMPETENCY

STEP 1

• MARK THE VARICOSE VEIN BECAUSE THE VEIN MAY DISAPPEAR WHEN PT LIES DOWN

STEP 2

• SPINAL ANESTHESIA IS GIVEN

STEP 3

• BED IS TILTED IN HEAD DOWN POSITION OF ABOUT 10*TRENDLENBURG POSITION

STEP 4

• INCISION OBLIQUE INCISION

INCISION IS MADE 4 CM BELOW AND LATERAL TO PUBIC TUBERCLE OVER THE SAPHENOFEMORAL JUNCTION

STEP 5

• SAPHENOFEMORAL JUNCTION IS EXPOSED

STEP 6

• TRIBUTARIES ARE IDENTIFIED AND LIGATED AND CUT.

• FLUSH LIGATION IS DONE • IT IS LIGATION OF LONG SAPHENOUS VEIN

NEAR ITS TERMINATION .• AND IT IS CUT

STEP 7

• UPPER 10CM OF LONG SAPHENOUS VEIN IS LIGATED AND EXCISED.

COMPLICATIONS

• Haematoma

• Wound sepsis

• Edema of leg

• DVT

INDICATIONS OF PERFORATOR INCOMPETENCY

• PERFORATOR LIGATION -USING FEGANS METHOD .

THE PITS ARE FOUND IN THE DEEP FASCIA INCISION IS MADE OVER IT PERFORATOR IS IDENTIFIED AND LIGATED• SUBFASCIAL ENDOSCOPIC PERFORATOR

LIGATION SURGERY IN THIS METHOD AIR IS INFLATED DEEP TO DEEP

FASCIA

• NOW ENDOSCOPE IS INSERTED DEEP TO DEEP FASCIA

• PERFORATORS ARE IDENTIFIED AND THEY ARE LIGATED

THANK U

varicose veins

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