varicose veins

2. VARICOSE VEINS
Literature overview
AMBREEN AMNA
BMS02100005

3. DEFINATION
• VARICOSE VEINS are dilated , usually tortuous
subcutaneous veins greater than or equal to
3mm in diameter measured in upright
position with demonstrable reflux.

4. Varicose veins

5. ANATOMY OF VENOUS SYSTEM OF
LEGS
• The venous system of lower limb consists of
1) Superficial veins :-
They are GREAT & SMALL saphenous
veins.
2) Deep veins:-
They include tibial venae comitantes,
popliteal & femoral veins.
3 ) Perforators:-
May , Cockett , Boyd , Dodd

6. SUPERFICIAL VEINS

7. PERFORATORS

8. DEEP VEINS

9. PATHOPHYSIOLOGY
• The venous pressure in a foot vein on standing is
equivalent to the height of a column of blood
extending from the heart to the foot e.g. approx
100 mmHg.
• To enable blood to be returned against gravity
CALF MUSCLE PUMP(soleus muscle i.e. peripheral
heart) is essential.
• During calf muscle contraction e.g. walking deep
veins are compressed & they force blood into
popliteal & crural veins

10. PATHOPHYSIOLOGY (Contd..)
• The VALVES only allow blood to pass in the
direction of heart.
• Now, pressure rises to 200-300 mmHg during
muscle contraction.
• During muscle relaxation the pressure falls.
• Blood from the superficial veins pass into
deep veins through saphenous junction and
the perforating veins.

11. PATHOPHYSIOLOGY
Varicose veins may develop due to
1) PRIMARY VALVE INCOMPETENCE :-
congenital absence of venous valves
congenital defect in venous valve
due to dysfunctional smooth muscle cell
proliferation, collagen deposition, decreased elastin
content & increased matrix metalloproteinase's.
2) SECONDARY VALVULAR INCOMPETENCE :-
due to post thrombotic limb, and congenital
anomalies such as Klippel-Trenaunay syndrome,
multiple AV fistulae

12. EPIDEMIOLOGY
The adult prevalence of visible varicose vein is
25-30 % in women & 15% in men.
RISK FACTORS :-
 1) geographical : more common in
western population, may be diet related.
2) Gender :- Women > Men
3) Age :- Increase with age

13. EPIDEMIOLOGY (CONTD..)
4) Body mass & height :-
Increase body mass index & height
increases prevalence of varicose veins.
5) Pregnancy :- Increase risk[ hormonal effect }
6 )Family history :- Positive family history
increases the risk
7) Occupation & Lifestyle factors :- Increase risk
in smokers, patients who suffer constipation &
prolonged standing

14. CEAP CLASSIFICATION

15. CLINICAL FEAUTURES
• EARLY SYMPTOMS :-
Aching & heaviness
Ankle swelling
Itching
• LATE SYMPTOMS:-
skin changes
lipodermatosclerosis
venous ulceration
bleeding
marjulin ulcer{ignored prolonged ven ulcer
transforming malignant changes ,,,,,SCC }

16. SIGNS
• Tortuous dilated subcutaneous veins
• Telengectasia
• Reticular veins
• Saphena-varix
• Atrophic blanche
• Corona phlebectasia
• Pigmentation ; ulceration
• Eczema ; Lipodermatosclerosis
• Dependent pitting edema

17. CLINICAL EXAMINATION
• The patient should be standing , exposed from
umbilicus to foot.
• Look for the extent and distribution of varicose
vein.
• Long saphenous varicose veins
• Antero-lateral tributary of Long saphenous vein
• Short saphenous varicose vein
• Communicating vein varicosity

18. LOOK FOR :-
• Swelling (localized or general? )
• Color changes
• Pigmentation
• Eczema
• Scar marks
• Ulceration
• Hair distribution
• Toe nails
• Cough impulse for saphena-varix

19. PALPATION
• Temperature
• Tenderness
• Palpate along the distribution of long & short
saphenous veins
• Morrissey's Cough impulse test
• Brodie Trendelenburg test
• Multiple Tourniquet test
• Perth's test
• Fagan's test

20. PALPATION (Contd..)
• Arterial pulsations of both legs
• Nerves ( Dermatomal distribution ) of both
legs
• Ankle jerks of both legs
• Palpate the regional lymph nodes

21. PERCUSSION
• Schwarts test :-
In long standing case if a tap is made on
the long saphenous varicose vein on the lower
part of leg ,an impulse can be felt at the
saphenous opening with the other hand

22. AUSCULTATION
• For AV fistulae where a continuous machinery
murmur may be heard.
• Always examine both limbs.

23. GENERAL EXAMINATION
• Examination of abdomen is most important.
• Sometime a pregnant uterus or intrapelvic
tumor, fibroid, ovarian cyst, cancer of cervix or
rectum or abdominal lymph adenopathy may
cause pressure on the external iliac vein and
become responsible for secondary varicosities.
• Scrotal examination must be carried out to
rule out varicocele.

24. INVESTIGATION
Gold standard investigation is DUPLEX
ULTRASOUND IMAGING

26. INVESTIGATIONS ( CONTD…)
If duplex ultrasound scan
1) is not available OR
2) Is non diagnostic
Then go for Doppler ultrasonography.

27. INVESTIGATION (Contd..)
3) VARICOGRAPHY :-
It involves injection of contrast directly into
superficial varices which allows detailed
mapping of the varices to their termination.
This is helpful in patients with recurrent
varicose veins or with complex anatomy

28. VARICOGRAPHY

29. INVESTIGATION (Contd..)
4 ) Venography :-
Descending IV venography where contrast is
injected via the deep veins or magnetic
resonance venography is useful when lower
limb varicosities appear to arise from pelvic
vein incompetence.

30. VENOGRAPHY

32. Management
• Reassurance for asymptomatic patients
• Indication for referral to vascular surgeon
includes :-
C2 disease associate with bleeding
superficial thrombophlebitis
 symptoms which are impairing quality of life
 C3 to C6 disease.

33. Conservative:
1)Change life style(diet)
2)change standing occupation if
possible
3)Decrease long standing hours.
4)Compression hosieries.
5) Avoid smoking

34. COMPRESSION STOCKINGS

35. SURGICAL OPTIONS AVAILABLE
1 )MINIMAL INVASIVE SURGERY
• Ultrasound guided foam sclerotherapy
• Endovenous laser ablation
• Radiofrequency ablation

36. ULTRASOUND GUIDED FOAM
SCLEROTHERAPY

37. ULTRASOUNDED GUIDED FOAM
SCLEROTHERAPY
Ultrasound guided foam sclerotherapynvolves
the injection of detergent directly into
superficial veins , most commonly used is
SODIUM TETRA DECYL SULPHATE.
It destroy the lipid membrane of endothelial
cells causing them to shed leading to
thrombosis , fibrosis, and obliteration.

38. COMPLICATIONS OF UGFS
• Phlebitis
• Pigmentation
• Headache
• Visual disturbance
• Cough

39. ENDOVENOUS LASER ABLATION

40. RADIOFREQUENCY ABLATION

41. CONVENTIONAL SURGICAL
PROCEDURES
• Saphenofemoral flush ligation and long
saphenous stripping
• Saphenopopliteal junction ligation and lesser
saphenous stripping
• Perforator ligation
• phlebectomies

42. SAPHENOFEMORAL FLUSH LIGATION
AND LONG SAPHENOUS STIPPING

43. SAPHENOPOPLETEAL JUNCTION
LIGATION AND LESSER SAPHENOUS
STIPPING

44. PERFORATOR LIGATION

45. PHLABECTOMIES

46. Complication of standard vericose
surgery
• Recurrence
• Wound infections
• Nerve injury
• Venous thromboembolic complications

47. RECUURENT VARICOSE VEINS
• Approximately 10-20% of patients who
present to hospital with varicose veins have
had previous interventions.
• Significant clinical recurrence 5-10 years
following varicose veins surgery occurs in 10-
35 % of patients but duplex detected
recurrence is much more common being in
the order of 70%

48. Recurrent varicose veins
Conventional surgery> minimal invasive surgery
Short sap v surgery > long saphenous vein surgery
Increased BMI
WHAT ARE THE CAUSES OF RECURRUNCE
Neorevascularization
Reflux in residual axial vein
New reflux
Inadequate initial surgery
Thus endovenous intervention would seem to offer
an interactive alternative where feasible.