VARICOSE VEINS

Bhavesh Bang
Under guidance of

Dr Shalu Gupta

INTRODUCTION

DEFINITIONS


Chronic Venous Insufficiency ( CVI ) Venous Hypertension in Lower limb Causing Symptoms like pain, swelling, edema & Skin Changes Varicose Veins -Any Dilated, tortuous, elongated vein of any caliber Telengiectasias - Intradermal Varicosities also c/as Spider veins/Thread veins or Dermal Flares Reticular veins Subcutaneous dilated veins

VENOUS ANATOMY
GREAT SAPHENOUS VEIN  Originates on dorsum from DVA


Relatively Constant anatomy Lies between the superficial & deep fascia

LESSER SAPHENOUS VEIN



From Lat. Side of DVA Ascends in Midline of calf Sapheno popliteal junction is inconstant Duplicated saphenous system present in 8 % population

PERFORATOR SYSTEM
Clinically Important Perforators  Cockett Perforator Medial Lower Leg Constant Perforators Post. Arch vein to Post. Tibial Vein  Boyds Perforators GSV to Deep veins Approx. 10 cm below Knee Usually first to become incompetent

Dodd Perforators  May be found anywhere along the saphenous pathway in the distal 3rd of thigh Hunter Perforators  Mid thigh  Inconstant  Absent in 10 15 %

PARATIBIAL PERFORATORS  Connect GSV directly to post tibial veins  Three groups are present at 24, 27 & 30 cm from Sole of foot ANTERIOR & LATERAL PERFORATORS  Imp in Pt. with Lateral Ulceration  Ant Perforators Connect GSV or LSV to ant Tibial Vein  Bassis Perforators in Distal calf connect LSV to Peroneal Veins

PATHOGENESIS

CALF PUMP
Calf Muscle Pump facilitates Venous return Max. Press In Muscles During Exercise 150 200 mm Hg

In Perforator Incompetence Pressure transmitted to Superficial veins

VENOUS HYPERTENSION
Responsible for valve failure  Two Reasons For venous Hypertension


Hydrostatic Pressure Due To Column of Blood Dynamic Pressure Due to Muscular Contractions

VENOUS VALVE REFLUX



Three main Causes of Reflux Congenital Aplasia of valve Dysplasias Like Avalvular duplication Conduit Structural Abnormality Primary valve Reflux Structurally normal Valves with redundant Leaflets Post Thrombotic Reflux Most Common Cause

RISK FACTORS
Age  Obesity  Female Sex  Increased Parity  Prolonged Standing  HRT/OCP  Family History  H/O DVT  Smoking


CLASSIFICATION
Primary Varicose veins Intrinsic vessel wall abnormalities Decreased Vein wall elasticity

Secondary Varicose Veins Antecedent event Preceding reflux m/c DVT

CLINICAL FEATURES
Symptoms Aching pain m/c symptom Unsightly Appearance Heaviness Early Fatigue Itching Edema Skin Changes  Worse at the End of day


Symptoms Result from irritation of superficial nerve fibers by Local Pressure  Marked Improvement After Overnight Rest  Worsening of Symptoms During Menstrual cycle  Distribution Long Saphenous Territory 90 % Short Saphenous Territory 15 %


DIAGNOSTIC WORKUP

CLINICAL EXAMINATION
Trendelenburg test  Tourniquet test  Pratts test  Perthes test  Schwartz test  Cough Impulse test  Fegans test


INVESTIGATIONS
DOPPLER ULTRASOUND  Minimum Level Investigation Required for T/t  Uses To Exclude Arterial Diseases Determine vein Patency Detect venous Reflux


Done with Patient Standing

DUPLEX ULTRASOUND Standard Imaging Modality for Diagnosis & Treatment Planning To Evaluate Reflux In Individual Venous segments of leg Transducer Placed Over the segment & Cuff inflated & rapidly deflated If Valve Closure takes > 0.5 sec, it is abnormal Can evaluate Deep Veins also

Following Indices can be calculated Valve Closure Time Venous Diameters Peak Reflux velocities Volume Flow at Peak reflux ( VFPR )

VFPR value > 10 ml/sec correlates with increased incidence of Lipodermatosclerosis

PLETHYSMOGRAPHY

Based on Measurement of changes in Blood Flow  Two types of Venous Plethysmography are used Photo Plethysmography Evaluates Venous


function through Infrared Light Measures Overall Venous function AVP Pressure in the Deep Veins of Leg Measured after Light Excersise VRT Time req. for Venous Pressure to Return to 90 % baseline From AVP

Air Plethysmography - Calf Pump Function Venous Reflux Overall Venous Function Following Indices are Calculated VFI Max Venous Volume / Time. Measure of Reflux EF Change In recorded Blood volume In a Tip Toe Maneuver. Measure of Calf Function RVF - Change in Blood Volume after 10 Maneuver. Measure of Overall Function

CONTRAST STUDIES MR Venography ( MRV )  Most Sensitive & Specific Investigation for Venous diseases of lower limb  Rule out other nonvascular causes of Leg pain & edema DIRECT CONTRAST VENOGRAPHY  Used in Inconclusive cases Ascending Phlebography Deep Vein Status Descending Phlebography Identifies Specific Valvular Incompetence

COMPLICATIONS
Thrombophlebitis  Hyperpigmentation  Lipodermatosclerosis  Varicose Ulcers  Bleeding  Eczema  Periostitis  Equinus Deformity


MANAGEMENT

INDICATIONS FOR INTERVENTION  Unsightly Appearance  Aching pain  Easy Fatigue  Superficial Thrombophlebitis  External Bleeding  Ankle Hyper pigmentation  Lipodermatosclerosis  Venous Ulcer

C/I FOR INVASIVE INTERVENTION Acute Inflammatory Thrombophlebitis At least 3 mo time should be allowed to pass  DVT  Pregnancy  Pelvic tumors  Oral Contraceptive Pills  Arterial Occlusive Disease


Non Operative
COMPRESSION THERAPY


First line therapy in the T/t of varicose veins Highly effective in controlling Symptoms & promoting Healing of Venous Ulcers Acts by increasing the interstitial pressure & thereby promoting fluid resorption

Elastic Compression Stocking  20 30 mm Hg pressure Stockings are used initially f/b High Pressure stockings if these are not effective  Worn throughout day & taken off at night  Primary therapy in cases of venous ulcers along with wound care  Problems of Poor Patient Compliance Hypersensitivity Exacerbating concomitant Arterial Insufficiency

UNNA BOOTS ( Paste Gauze Boots )  Used in cases of Varicose Ulcers  It provides both Compression as well as topical therapy for the ulcers  Consists of three layer dressing 1st Layer Dome Paste Containing Calamine, Zinc Oxide, Glycerin, Sorbitol, Gelatin & Magnesium Aluminum Silicate 2nd Layer 4 wide Continuous Gauze Dressing 3rd Layer Elastic Compression bandage  Changed Weekly

Advantages Improved Patient Compliance Better Wound healing Disadvantages Need for trained personnel to apply Discomfort Inability to monitor Ulcer between Dressing Contact dermatitis

ADJUNCTIVE COMPRESSION DEVICES CircCirc-Aid Orthosis Multiple rigid compression bands held with Velcro tape

Pneumatic Compression Devices Useful in Patients with massive edema & Morbid obesity who have Varicose ulcers

Sclerotherapy
 

  

For varicosites < 3 mm Optimal Indications Telengiectasias Reticular Veins Below knee Varicosities Recurrent Varicosities Non Surgical candidates Contraindication Allergy to sclerosant SF Reflux & Venous HTN must be corrected first Destroys Vascular Endothelium

Sclerosing Agents Include Sodium Tetradecyl sulfate 0.125 to 0.75 % Polidocanol 0.5 to 1 % Hypertonic saline 11.7 to 23 %  Post therapy Pressure dressing for 24 72 hrs  Post therapy Drainage of entrapped blood at 14 21 days  Complications Allergic Reaction Pigmentation Thrombophlebitis Skin necrosis


OPERATIVE
Goals Of Surgery Permanent removal of varicosities with the source of venous HTN Cosmetic acceptability Minimum Complications  Appropriate for Large varicose clusters Axial Veins with gross reflux Varicosities above knee  Presence of DVT is an absolute C/I for Surgery


OPTIONS FOR SURGICAL TREATMENT Groin to Ankle Saphenous Vein Stripping  Segmental Saphenous Vein Stripping  Saphenous vein Ligation  Saphenous Vein Ligation With Sclerotherapy  Saphenous Vein Ligation with stab avulsion of varices  Stab Avulsion of Varices without vein Stripping


SFJ LIGATION  Also c/as Trendelenburg Procedure  Procedure removes gravitational reflux across SFJ  Advantages Simple Procedure Decreased Bleeding & Pain Lower Incidence of Wound infection Preserves GSV  Disadvantages Very High Recurrence rate

SAPHENOUS VEIN STRIPPING

Removes Gravitational reflux & therefore hydrostatic element of venous hypertension  Below knee Stripping not advocated b/se Below knee Perforators are part of Post Arch circulation Associated Saphenous Nerve Injury


All Inguinal Tributaries Should be tied & Cut  Incisions at groin, thigh & ankle are Transverse  Other Incisions Should be Longitudinal


Stripper is Introduced from Groin Stripping Should be done from above Downwards Complications Saphenous Nerve Injury Injury to Vessels & Nerve Of Femoral Seroma Formation

STAB AVULSION


Also c/as Ambulatory Phlebectomy / Micro Extraction Phlebectomy Saphenous vein reflux Should be absent Detaches Perforating Veins from Varicose Clusters If Combined Stab Avulsion & Stripping is to be done, Stab Avulsion Should be done 1st

Done

LA

1- 2 mm Vertical Incisions are made Retained Vein ends need not be Ligated or Clipped as leg elevation, Venospasm & Direct Pressure will ensure Hemostasis Incisions Do Not require stitch closure Compression Stocking worn for 1 mo

PERFORATOR MANAGEMENT
Perforator incompetence is present in approx. 2/3rd patients with Venous Ulceration  Gaiter area of leg is the most common site of Venous Ulceration & Skin changes  Perforator Surgery is indicated when there are Incompetent perforators in presence of skin changes  Three Approaches Lintons Procedure Laparoscopic Procedure Single Scope Procedure


CONTRAINDICATIONS Chronic Arterial Occlusive Disease  Ulcer in Diabetics, RF patients, CTD Patients  Morbid obesity  Nonambulatory Patient  Lateral Ulcerations  Previous Perforator Surgery  Extensive skin Changes  Infected ulcer


OPEN PERFORATOR SURGERY



Also c/as Lintons procedure Associated with Wound Complications d/t incisions in the lipodermatosclerotic skin Edwards Procedure involves use of an instrument c/as Phlebotome introduced proximally from knee

RECONSTRUCTIVE VEIN SURGERY

Used for Cases where valve Structure is abnormal m/c in Cases of Post Phlebitic Reflux & Some cases of primary reflux  Uppermost Superficial femoral valve is m/c repaired valve  In Cases Of Primary Reflux, Single valve repair is sufficient in most cases  In Post Phlebitic cases Multiple Valve Repair is needed


VENOUS OBSTRUCTION PALMA OPERATION Inserting The Long Saphenous Vein Of Diseased leg into Opposite Femoral Vein MAY MAYHUSNI PROCEDURE In case of Sup. Femoral vein Obstruction, GSV is Connected to Popliteal Vein VENOUS INCOMPETENCE INTERNAL VALVULOPLASTY PROSTHETIC SLEEVE IN SITU AXILLARY VEIN TRANSFER

NEWER APPROACHES

SAPHENOUS REFLUX
Radiofrequency Ablation of SFJ  Bipolar endothermal energy is used which causes heat contracture of collagen in the vein wall  Vessel occludes d/t formation of thrombus plug within the reduced vein lumen  System used is VNUS system  Treatment time 12 to 16 min approx  Access to veins is via Percutaneous route or Cut down

Short GA is used  Vein Characteristics Straight Free of Thrombus Without Aneurysms



C/I Postphlebitic vein Mega saphenous vein ( > 12 mm ) Aneurysmal SFJ

ENDOVENOUS LASER THERAPY ( EVLT )

Laser energy @ 810 nm is delivered via a fiber  Laser causes boiling of blood & steam bubbles  There is thickening of vessel wall with Collagen contraction & thrombosis of lumen  Diode Laser is used  Local Anesthesia  Compression Stockings used for 1 week


VARICOSITIES
Transilluminated Power Phlebectomy ( TIPP )  Trivex System  A light source beneath the skin is used for varicose vein visualization & Suction resector to perform Phlebectomy  Resector aspirates varicosities, morcillates them & then removes by suction  Complications include Ecchymosis Most common DVT

FOAM SCLEROTHERAPY  Standard Sclerotherapy is effective only for smaller veins  In foam Sclerotherapy, a mix of standard sclerosant with air is used  Surface area of the sclerosant is increased  LA is used  External compression at SFJ prevents entry of Sclerosant in Deep Venous System  Minor Complications Pigmentation & Superficial thrombophlebitis  Major Complications Anaphylaxis & IA Injection

PERFORATOR SURGERY
SUBFACIAL ENDOSCOPIC PERFORATOR SURGERY ( SEPS ) Two techniques Single Scope Laparoscopic Technique Two 10 mm Ports are placed 6 10 cm apart in proximal Calf CO2 at 30 mm Hg pressure is insufflated Perforators are divided between Clips ( > 2mm ) or Harmonic Scalpel ( < 2mm )

VENOUS ULCER
In association with Varicose Veins 40 % DVT 20 % Venous Stasis Favors Local anoxia & Edema Varicose Ulcers Respond to ambulatory T/t & Ligation Thrombotic ulcers are refractory & require rest curettage & skin Grafting Ascending Venogram helps in identifying patency & lumen of deep veins & also presence of Incompetent valves

MANAGEMENT OF VENOUS ULCERS  BISGAARD METHOD Massage in elevation Passive Movement Active Movement Bandage Application  Bandaging & Limb elevation are used when Pt. compliance is not proper  Subfascial Ligation ( Cockett & Dodd Op ) After Ulcer healing Perforators are identified & Divided by Lower Leg incision  PHARMACOTHERAPY Zinc Fibrinolytic Agents Stanazol

Phlebotrophic Agents Hydroxyrutosides Calcium Dobesilate Rheological Agents Pentoxifylline Aspirin Free Radical Scavengers Dimethyl Sulfoxide Prostaglandins PGE1 , PGF Topical Agents Iodosorb Ketanserin Growth Factors & Cytokines

RECURRENT VARICOSE VEINS



Incidence 15 20 % in 3 5 Yrs

SITE OF RECURRENCE  Saphenous junction SFJ or SPJ Major Cause  Perforating Veins in the thigh & Calf  Previously Unoperated Saphenous system RECURRENT SFJ REFLUX  Neovascularisation  Technical Error

CLINICAL EVALUATION  Early age at onset of original Varicose Vein  Family History  Rapid Recurrence All Suggest Strong Tendency for recurrence  Aching & Discomfort are less common  Skin Changes & ulceration respond poorly to Surgery  Varicography or Venography is required to clear venous anatomy

OPERATIVE STRATERGY  Aim is to find common femoral vein above reconstituted junction  Common femoral vein should be free of any tributary including residual Saphenous System  Measures to prevent further recurrence Pectineus Muscle Fascia Flap Prosthetic ( PTFE ) Patch can be applied over Denuded CFV

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