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Varicose Vein
- 2. Venous Anatomy of Lower Limbs Superficial venous system Deep venous system Perforator veins
- 4. 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
- 5. Venous valves The venous valves are abundant in the distal lower extremity and number of valves decreases proximally, with no valves in superior and inferior vena cava 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
- 6. Ankle perforators Lower leg – Cockett perforators Boyd’s perforators Dodd perforators Hunterian perforators
- 7. Varicose Veins Permanently dilated , elongated veins with tortuous path causing pathological circulation. Risk factors Female sex Occupation-prolonged standing Immobility Raised intra abdominal pressure Increased progesterone High heels
- 8. Pathogenesis Of Varicose Veins Venous insufficien cy Valvular competence Calf muscle pump Venous patency Endothelialdamage Shearing stress Increased MMP Recurrent inflammation Alteration in relaxation and constriction
- 10. Clinicial Features Dragging pain, postural discomfort Heaviness in the legs Night time cramps Oedema, itching Discolouration Ulceration
- 11. Clinical Signs • Saphenofemoral incompetenceBrodie-trendelenberg’s test I • Perforator incompetenceBrodie-trendelenberg’s test II • DVT Perthe’s test / modified perthe’s • Perforator incompetenceTourniquet’s test • Valvular incompetenceSchwartz test • Perforator site localisationFegan test • Blow outs = perforatorsPratt’s test
- 12. Complications Haemorrhage Pigmentation,eczema ,dermatitis Periostitis Venous ulcer Marjolin’s ulcer Lipodermatosclerosis Talipes equinovarus DVT Recurrent thrombophlebitis
- 13. Other Examination Abdomen examination Ulcer Lymphnodal examination
- 14. Investigation In Varicose Veins Localise the anatomical location of the disease Nature of the lesion Rule out DVT
- 15. Contd… Venous Doppler DUPLEX scan Doppler combined with B mode Ultrasound Functional and anatomical information DVT well made out. Uniphasic signal – normal Biphasic signal – reversal flow
- 16. Contd… Venography Ascending venography • Dorsal venous arch – cannulated • Tourniquet at malleoli • Dye injected • X-rays taken • DVT/perforator status Descending venography • Ascending venogram nor possible • Contrast through femoral vein • Valvular incompetence
- 18. Conservative management Elastic crepe bandage – stockings 30-40mm Hg Elevation of limbs Above the level of heart Graded compression stockings
- 19. Contd.. Unna boot Nonelastic compression Zinc oxide, calamine, and glycerine Dressing changed once in a week Infection should not be there Compression methods Reduce ambulatory venous pressure Trans capillary leakage Improve cutaneous micro circulation
- 20. Medications Calcium dobesilate 500mg BD Improves lymph flow, reduce edema Diosmin 450mg + Hesperidin 50mg Relive night cramps Not proven much beneficial
- 21. Sclerotherapy Complete sclerosis of the venous wall Indications Uncomplicated perforator incompetence Smaller varices Recurrent varices Isolated varices Aged/unfit patients
- 22. Contd… Sclerosants used are Sodium tetradecyl sulphate Sodium morrhuate Ethanolamine oleate Polidocanol Mechanism of action Aseptic inflammation Perivenous fibrosis Endothelial damage Obliteration by intimal approximation
- 23. Technique 23 gauge needle in to vein and emptied 0.5 -1 ml of sclerosant Immediate compressio n bandage Proper endothelial apposition May have to be repeated after 2-4 weeks later
- 24. Contd… • Saphenofemoral incompetence • DVT • Peripheral arterial disease • Hypersensitivity Contraindication • OPD procedure • No anesthesia Advantages • Anaphylaxis/shock • Abscess • Thrombophlebitis • Intravenous hematoma • Temporary ocular disturbances Disadvantages
- 25. Surgical management Trendelenburg’s procedure Ligate the source of venous reflex(SFJ&SPJ) Remove incompetent saphenous trunks &ass.varices Flush ligation of tibutaries Superficial circumflex Superficial external pudendal Superficial epigastric Deep external pudendal Unnamed tibutaries
- 26. Contd… Stripping of long saphenous vein Upto knee joint Myer’s stripper Complications Saphenous nerve injury Hematoma Infection
- 27. Contd… Perforator incompetence Subfascial ligation of perforators Linton’s method Stab avulsion method
- 28. SEPS Subfascial endoscopic perforator surgery Minimally invasive method
- 29. Endovenous Laser Ablation - EVLA US guidance LSV canulated above knee joint Guide wire passed beyond SFJ Tip is placed 1cm distal to SF junction Laser fibre inserted upto the catheter Diode laser used for firing
- 30. Contd… Thermal damage of endothelium – occlusion of vein Laser energy acts on blood – in turn heats the vein wall. Complications Pain / ecchymosis Hematoma Skin burns DVT
- 31. Reference Bailey&love’s short practice of surgery Google S.Das
- 32. THANK YOU