Varicose vein

Varicose Veins
Dr. Sudhir Kumar Jain, MS, FRCS
Professor of Surgery,
Maulana Azad Medical College,
New Delhi

Varicose Veins:
Presented By:
Dr. Sudhir. K. Jain, M.S, MBA(HCA), FRCS, FICS, FIAS.
Professor of Surgery,
Maulana Azad Medical College and Associated Lok
Nayak Hospital,
New Delhi.
With Credits to:
Dr. Vishnuraja, PG2, Dept of Surgery, MAMC.
Dr. Ronal Kori, PG2, Dept of Surgery, MAMC.

First in History
• ‘Siragranthi’- Varicose Veins
• Sushrutha- Indian surgeon
of antiquity is the first in
history to document
‘Siragranthi=Varicose veins’
as aneurysmal dilation of
Veins in ‘Samhit’
-History of Vascular surgery, Chapter 13, Page 147

First Surgery
• 2nd Century AD
• Galen describes the first surgery for Varicose
veins:
In varicose veins of the legs, we mark out the whole extent
of them by scratches on the outside, then put them on their
backs, take hold of the skin surface, and divide that first,
then lift up the varicosity with a hook and tie it off, and do
the same thing at all the incisions. Or we pull them out with
a varicocele hook and cut off the ends, or we pass thread
through the coil of the veins with a probe and pull them up
and take them out.

Definition
• Varicose veins are defined as dilated,
elongated, tortuous and palpable
superficial veins as a result of venous
hypertension.
• It usually occurs due to permanent
loss of valvular mechanism and
resultant venous hypertension.

Venous System of lower limb
Consists of:
• Deep system of veins which
lies below the deep fascia.
• Superficial system of veins
which lies outside the deep
fascia (carry 10% blood)
• Perforating veins which pass
through the deep fascia
joining the superficial to the
deep system of veins.

Deep veins
Three Pairs of venae commitantes accompanying
• anterior tibial ,
• posterior tibial and
• Peroneal arteries

Valves in the veins
• Valves present in superficial veins.
• Prevent flow of blood from proximal to distal and
from deep to superficial
• Absent from above groin level
• Valves can resist pressure up to 300 mm of Hg.

Long saphenous vein
• Originates at the medial border of the foot.
• It passes 1-1.5 inches anterior to the medial
malleolus over the distal 1/3rd of the tibia.
• It is accompanied by the saphenous nerve below the
knee joint
• Travels close to the deep fascia except at the knee
joint, where it may become subcuticular
• In the thigh it passes antero-superiorly to reach the
saphenous opening which is 3.75 cm below and
lateral to the pubic tubercle.
• The vein of Giacomini joins LSV to SSV in thigh ,
responsible for recurrences.

Location of perforators
Six Perforators joining the superficial
to deep venous system are located at
constant positions which are:
• 2, 4 and 6 inches above the
medial malleolus (Cockett’s
perforator)
• Just below the Tibial
tubercle(Boyd’s)
• In the adductor(Hunter’s) canal
of the thigh(Dodd’s perforator)
• Level of Mid-thigh
• Around 200 perforators are
described most of them
unnamed

Short Saphenous vein
• Arises on the lateral border of the foot by joining of
lateral marginal vein and lateral deep venous arch.
• Passes behind the lateral malleolus
• Runs up in the midline posteriorly in the intra fascial
compartment.
• Pierces the deep fascia in the upper part of the calf,
and terminates in the popliteal vein in the midline
4cm below the popliteal skin crease.
• It is accompanied by the Sural nerve, lymphatics and
popliteal nerve along its course.
• Derived from posterior axial vein of lower limb

Location of short saphenous
perforators
• Bassi’s perforator- 5 cm above calcaneous
• Soleus point perforator
• Gastroenemius point perforator

• Negative pressure in thorax during inspiration to -6
mm.
• Calf muscle pump: Normal venous pressure in
relaxed state 20mm of Hg.Rises to 80-100 mm of Hg
during muscle contraction.
• Vis a tergo : arterial pressure transmitted to venous
side through capillary bed
• Competent valves
• Venae commitants: lie by the side of artery, helped
by arterial pulsation to propel blood.
Factors Helping in Venous return

Pathology
Primary
• Long hours of standing,
which increase the
hydrostatic pressure of
gravity,
• Family history
• Pregnancy
• Ageing
Secondary
• Deep vein thrombosis
• Arterio venous
malformation- Parkes
Weber syndrome
• Hemangiomatous
malformation- Klippel
Trenaunay syndrome
• Pelvic mass
• Retro peritoneal fibrosis

Klippel Trenaunay syndrome
• Varicose veins
• Limb hypertrophy
• Port wine Stains

Factors in Primary Varicose veins
• Valvular incompetence
• Perforator incompetence
• Venous obstruction in superficial veins
• Muscle dysfunction

Complications
• Bleeding
• Thrombophlebitis
• Venous Hypertension leading to
venous ulcer
• Calcification
• Talipes Equinovarus deformity of
foot
• Eczematoid dermatitis and
pigmentation
• Periostitis of subcutaneous
surface of tibia
• Carcinoma in long standing
venous ulcer-Marjolins ulcer

Varicose presentation
• More common in males in India
• Left lower limb more commonly involved
• Long saphenous system affected in 2/3 rd of cases

Examination
Aims:
• Finding the system involved
• Extent of involvement
• Skin changes/ulcer around malleolus
• Trendelenberg test for patency of Sapheno-
femoral junction
• Perthe’s test for patency of deep veins

Investigations
• Ambulatory venous pressure studies
• Venous Doppler study
• Air plethysmography

Ambulatory venous pressure study
Ambulatory venous pressure more than 80 mm
of Hg is associated with venous ulceration.

Air Plethysmography
• Indicated for diagnosis of calf muscle dysfunction
• Measures changes in leg volume in response to
exercise and posture.
• Leg placed in 40 cm tubular Vinyl air chamber Leg
volume measured in supine, elevated , standing on
opposite leg and after 10 tip toe jumps.
• Venous volume(VV), venous filling time90(VFT 90)
and venous filling index(VFI) and ejection fraction
(EF)calculted

Interpretation API
• If venous volume > 350 ml (normal 100-150 ml) Indicates
chronic venous insufficiency(CVI)
• If VFI is 7 ml per second(normal < 2ml per second)
indicates CVI
• If ejection fraction venous blood of calf muscle is less
than 60 percent after one tip toe indicates Calf Muscle
dysfunction
• If remaining venous fraction(RVF) after 10 tip toes is
more than 40 percent indicates calf muscle dysfunction
• If RVF more than 40 percent and Venous filling index
(VFI) > 2 ml per second then it indicates reflux

Color Doppler Study
• To find patency of deep veins.
• To define the site of incompetent perforators & to
mark them preoperatively.
• To find out the competence of Saphenofemoral
junction & Sapheno popliteal junction.
• If Sapheno-popliteal junction is incompetent it
should be marked preoperatively because of its
highly variable & inconstant position.
• Ankle brachial index should be measured to rule out
any concomitant arterial disease.

Venous disease-Classification
Class Description
0 No visible or palpable signs of venous disease
1 Telangiectasia (intra dermal vein upto 1 mm) or
reticular veins (Subdermal upto 4 mm non palpable)
2 Varicose veins-Palpable more than 4 mm
3 Edema
4 Skin changes-Pigmentation, eczema,
lipodermatosclerosis
5 Skin changes with healed ulceration
6 Skin changes with active ulceration
• CEAP-Clinical, etiological, anatomical and pathological signs

Conservative management:
• Avoiding prolonged standing
• Crepe bandaging and elastic
stockings from toe to thigh, which
causes decreased edema, venous
volume and reflux and increases
venous return.
• Limb elevation above the level of
heart while lying down

Conservative Management
Indications
• Refusal for surgery
• Capillary veins, Venous
Stars (C1)
• Pregnant patients
• Waiting for surgery
• Early cases
Contraindications
• Arterial Insufficiency

Ultrasound guided foam
sclerotherapy
• Under Ultrasound guidance.
• Polidocanol is used
• Polidocanol converted in foam by mixing air using
three way tap.
• Spread of foam monitored under USG guidance as it
spreads.
• Apex of saphenous opening compressed by probe to
prevent foam entering deep veins.
• Leg also elevated

Sclerotherapy
Indications Contraindications
• Varicosity confined below
knee and caused by
incompetent perforators
• Recurrent/ residual
varicosities post-surgery
• Large Venous telangiectasia
• Dilated branch veins around
the knee following early long
saphenous incompetence
• Refusal for surgery
• Deep Venous thrombosis
• Sapheno Femoral
Incompetence
• Veins in lower 1/3rd of leg
• Veins on the foot
• Veins in elderly
• Veins in fat legs
• Immobile patient
• Post thrombotic syndrome
• Dirty ulcer or extensive
eczema

Complications
• Complications:
• Extravenous Injection
• Deep vein thrombosis
• Hypersensitivity
• Skin pigmentation
• Gangrene of distal limb

Agents used for sclerotherapy
• 5% monoethanolamine
with 2% benzyl alcohol
• 3% sodium
tetradecylsulphate in 2%
benzyl alcohol
• 25% glycerine with 2%
phenol

Surgical Management
Types of surgeries done:
• Flush ligation of Sapheno femoral junction
with ligation of all tributaries ending at SFJ.
• Stripping of long saphenous upto the knee
joint.
• Flush Ligation of Short Saphenous vein.
• Subfascial ligation of perforators

Flush Ligation Of Saphenous Vein
• Curved or Hockey stick incision.
• Alternatively a 7-8 cm long Oblique incision .
• Femoral Vein is exposed 1 cm above and below the
Sapheno femoral junction.
• The all tributaries joining the termination of saphenous
vein are defined and ligated
• The end of the long saphenous vein is flush ligated at
Saphenofemoral junction with silk and a second
ligature is transfixed to avoid haemorrhage.
• Femoral vein is inspected above and below the
junction and long saphenous divided.

Stripping of veins
• An Oliers stripper is passed from the
groin Incision into the long saphenous
vein.
• A vertical incision is made just below
knee and vein exposed
• The stripper is extruded from the vein
and the acorn firmly tied in the vein.
• The stripper is firmly withdrawn with
the vein telescoped over it.
• The track is compressed with a large
sterile pad for 3 to 5 minutes.

Introduction of Stripper
from Groin Incision
Stripper is extruded
from the vein below
Knee

Complications of Surgery
• Haemorrhage from torn varix
• Division or injury to the common Femoral Vein
• Sural Nerve or Saphenous nerve injury
• Postoperative Complications:
• Haematoma and bruising
• Wound infection
• Neuritis
• Lymphoedema
• Induration of stripper track
• Lymphatoma
• Deep Venous Thrombosis

Post Operative Care
• Maintain firm pressure over the limb
• Regular movement of the operated limb
• Limb elevation above heart level to reduce
venous pressure
• Removal of primary dressing after 7 to 10 days

SEPS
Indications Contraindications
 Chronic Venous
Insufficiency (C4-6)
 Secondary varicose
veins
 Arterial Insufficiency
 Deep Vein Thrombosis
Subfascial Endoscopic Perforator Surgery is a
minimally invasive procedure where in Incompetent
perforators are ligated below the deep fascia by
creating space with CO2.

Insertion Of Ports for SEPS
A single 10 mm port for camera is inserted below the deep fascia at the
medial end of upper part of tibia. Another 5mm port inserted at junction
of upper 1/3rd and lower 2/3rd of the calf.

View of the Subfascial Space
All perforators traversing the subfascial space are identified and ligated
using ultrasonic dissecting shears.

Radiofrequency Ablation
• The intima of smaller veins can be destroyed by heat
generation and denaturation of collagen using a probe
consisting of a bipolar heat generator.
• Performed under ultrasound guidance and position of
the probe is confirmed near the Saphenofemoral
junction.
• Probe is heated to 85 degrees and gradually retracted
down at a constant rate of 2-3cm/minute.
• must be avoided in presence of dilated veins, veins
with aneurysms and thrombosed veins.

Endovenous Laser Therapy
• Employs diode laser for the destruction of
endothelial lining of the target vein.
• The ultrasound guides the location of probe,
which is placed 2 cm distal to the
Saphenofemoral junction.
• The probe is gradually withdrawn and ablates the
lumen as it regresses down the vein by boiling
the blood present within the lumen.
• Veins of all sizes can be treated with this
procedure.

Varicose vein

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