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Uthamalingam Murali, profile picture
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Varicose Veins - C/F, Investigations & Treatment

The document provides a comprehensive overview of varicose veins, covering their definition, classification, pathogenesis, clinical features, diagnostic methods, and treatment options. It discusses the venous anatomy of the lower limbs and details various complications associated with varicose veins. The text also highlights different clinical tests, investigative methods, and both conservative and surgical treatment modalities for managing varicose veins.

Health & Medicine◦
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Prof. U. Murali. Varicose Veins
Learning Objectives  Define & Classify varicose veins.  Explain the etio-pathogenesis & theories of VV.  Identify the clinical tests to diagnose VV.  Enumerate the C/F, complications & investigations of VV.  Mention the various treatment aspects of VV.
Venous Anatomy of Lower Limbs  Superficial venous system  Perforator veins  Deep venous system
Perforator veins  Connect superficial to deep veins at various levels.  Travel from superficial fascia through an opening in the deep fascia before entering the deep veins.  The direction of blood flow - from superficial to deep veins.  Guarded by valves so that the flow is unidirectional, i.e. towards deep veins.  Reversal of flow occurs due to incompetence of perforators which will lead to varicose veins.
Perforators – Types  Ankle perforators – May (or) Kuster  Lower leg – Cockett I / II / III  Gastrocnemius – Boyd’s  Mid-thigh – Dodd  Adductor canal – Hunterian
Venous valves  The venous valves are abundant in the distal lower extremity and number of valves decreases proximally, with no valves in SVC / IVC & Iliac veins.  Delicate structures.  Prevent reverse flow in the veins.  Ensure that the blood is pumped from the superficial to the deep system and back towards the heart when the patient is walking.
Introduction  Varicose veins are elongated, tortuous and dilated superficial veins usually of lower limb that arise due to faulty valves.  VV affects 20% and 10% of adult women & men, respectively.  Prevalence of varicose veins is 30-50%; severe varicose veins is 10%; chronic venous insufficiency (CVI) is 8%; ulcer is 2%.  In clinical practice, patients are normally categorized as having ‘varicose veins’ or ‘venous ulcer’. Cases of varicose veins may be uncomplicated (or) complicated.
Definition  Varicose vein is defined as dilated, tortuous, elongated subcutaneous veins > 3mm in diameter measured in the upright position with demonstrable reflux. E.g.  Vein in the lower limb.  Spermatic vein. ( Varicocele )  Oesophageal vein. ( Oeso. Varices )  Haemorrhoidal veins.
Pathogenesis Of Varicose Veins Venous insufficiency Valvular competence Calf muscle pump Venous patency Endothelial damage Shearing stress Increased MMP Alteration in relaxation and constriction Recurrent inflammation
Valve incompetence / Ch. Venous hypertension Defective microcirculation RBC diffusion/ lysis Hemosiderin deposition Dermatitis / capillary damage Chronic Venous ulceration Fibrin cuff Theory Inappropriate activation Trapped WBC’s Proteolytic enzymes Cell destruction & ulceration White cell trapping Theory
• Chronic venous insufficiency (CVI) is a syndrome resulting from continuous chronic venous hypertension / ambulatory venous hypertension [AVP] in the erect posture either on standing (or) exercise. • CVI consists of postural discomfort, varicose veins, oedema, pigmentation, induration, dermatitis, lipodermatosclerosis and ulceration. • CVI patients may be having SVI (30%) with or without PI or deep vein incompetence (30%) or having previous DVT with complete obliteration or partial recanalization with incompetence called as post-thrombotic syndrome (30%).
Clinical Features – Symptoms  Aching (or) heaviness  Itching & Ankle swelling  Discoloration  Ulceration  F O – Complications - LDS
Clinical Tests • Sapheno-femoral incompetence Brodie-Trendelenburg’s test I • Perforator incompetence Brodie-Trendelenburg’s test II • DVT Perthe’s test / Modified P T • Perforator incompetence Tourniquet’s test • Perforator site localisation Fegan’s test • Blow outs = perforators / S P I Pratt’s test / Ian – Aird test • S P I / Valvular incompetence Cough Impulse test / Schwartz test (BPT – F – PICS)
Complications  Haemorrhage  Eczema & Dermatitis  Lipodermatosclerosis  Periostitis  Marjolin’s ulcer  Equinavarus deformity  Calcification  Ulcer (Venous)  Thrombophlebitis (R) (HELP – ME – CUT)
Investigations  Venous Doppler Study  Duplex Scan  Venography  Plethysmography  Amb. Venous pressure  Ultrasound Abdomen  Blood Tests - PS / PC  X ray of the part  Varicography ‘Mickey Mouse’ sign
Treatment – Conservative  Elastic crepe bandage  From below upwards  Elevation of limbs  Above the level of heart  Graded Compression stockings  Improves deep venous return  Prevents reflux  Reduces edema - microcirculation
Contd..  Unna boot  Non-elastic compression  Zinc oxide, calamine & glycerine  Dressing changed once in a week  Medications - Drugs  Calcium dobesilate – 500mg bd  Diosmin – 450 mg bd  Toxerutin – 500mg bd
Injection Sclerotherapy  It is done under Ultrasound image guidance.  Mechanism of action Aseptic inflammation Peri-venous fibrosis Alters intravascular pH Approximation of intima
Contd…  Sclerosants - used are  S T D S – commonly used  Sodium morrhuate  Ethanolamine oleate  Polidocanol – 1% (or) 3%  Indications  Uncomplicated perforator incompetence  Smaller varices  Recurrent varices  Isolated varicosities  Aged / unfit patients
Sclerotherapy – Types  Fegan’s technique – By injecting sclerosants into the vein, complete sclerosis of the venous walls can be achieved.  Foam sclerotherapy – STDS taken in a syringe is passed rapidly into another syringe which contains air to result in formation of foam. 1 ml of STDS is mixed with 4 ml of air to make 5 ml of foam which is injected to vein.  Micro-sclerotherapy – is injected into the thread veins and reticular veins followed by application of compression bandage.
 Transillumination microsclerotherapy – It is better imaging of the veins using light generated by halogen bulb with high quality fibre illumination over the skin uniformly.  Endosclerotherapy - Sclerotherapy is done under duplex ultrasound image guidance.  Catheter directed sclerotherapy – It is devised at Miami vein clinic with specific catheter for sclerotherapy. This catheter has got side holes all around the specific length for uniform contact of venous wall with the foam. Sclerotherapy – Types
Contd… • Sapheno-femoral incompetence • DVT • Peripheral arterial disease • Hypersensitivity Contraindications • OPD procedure • No anaesthesia Advantages • Anaphylaxis / shock • Abscess • Thrombophlebitis • Intravenous hematoma • Skin necrosis Disadvantages
Surgical management  Trendelenburg’s procedure  Juxta-femoral flush ligation of LSV with ligating tributaries.  Tributaries  Superficial circumflex  Superficial external pudendal  Superficial epigastric  Deep external pudendal  Unnamed tributaries
Contd… Stripping of LSV  Myer’s stripper is used  From below upwards  Avulses the vein &  Obliterates – tributaries  Saphenous nerve injury
Contd… Perforator incompetence  Sub-fascial ligation of perforators – Cockett & Dodd  Linton’s method  Stab avulsion method
Minimal Invasive methods  S E P S – Perforators are identified and fulgurated using bipolar cautery (or) clips can be applied into the perforators.  R F A - uses a bipolar catheter to generate thermal energy to ablate the vein.  E V L A - involves the insertion of a laser fibre into the lumen of an incompetent truncal vein, with subsequent thermal ablation of the vein.
Complications – VVS  Infection – most common  Haematoma / Oedema  Nerve injury Saphenous – LSV Sural – SSV Common peroneal – SSV  Recurrence – 20 - 30%  DVT – Rare - < 0.5%
References
Thank you
To Summarize  Surgical Anatomy of varicose veins.  Classification & Etiopathogenesis of VV.  Various clinical tests to diagnose VV.  Clinical features of VV.  Investigative methods & Complications of VV.  Various Treatment modalities to treat VV.  Complications following VV surgery.
Question Time  Define and Classify varicose veins.  Explain the pathogenesis of VV.  Mention the aetiology & C/F of VV.  List 5 clinical tests to diagnose VV.  Enumerate 5 complications of VV.  Name the non-surgical methods to treat VV.  Identify the 3 MIM & 3 surgical methods to treat VV.  List the complications following VV surgery.
Drug used for sclerotherapy of varicose veins are all the following, except –  a) Ethanolamine oleate.  b) Ethanol.  c) Polidocanol.  d) Sodium tetradecyl sulfate.
Brodie-Trendelenburg test – I is positive in –  a) Perforator incompetence below knee.  b) Deep vein incompetence.  c) Sapheno-femoral incompetence.  d) Both SFI & PI.
The pathophysiological classification of venous disorders is based on –  a) Edema.  b) Venous ulcer.  c) Pigmentation.  d) Obstruction.
Which of the following is the least likely complication of varicose veins ? –  a) Spontaneous bleeding through intact skin.  b) Skin pigmentation.  c) Deep vein thrombosis.  d) Leg ulcer.
A patient has undergone Trendelenburg procedure for his varicose vein of left lower limb. Later the patient developed sudden onset of pain along the medial border of the corresponding foot. Which nerve has been accidentally ligated? –  a) Sural nerve.  b) Deep peroneal nerve.  c) Saphenous nerve.  d) Popliteal nerve.
41 Pathogenesis – Varicose Veins
42 Pathogenesis – Venous Ulcer
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