VARICOSE VEIN CAUSE AND TREATMENT

1. Vascular Intervention Radiology
Varicose Vein & Treatment
DR. NARENDRA SINGH PATEL
MBBS, MD - RADIODIAGNOSIS, FSVIR

2. WHAT IS VARICOSE VEIN ?
 Varicose veins are dilated tortuous superficial venous channels.

4. Perforating
veins
Indirect veins-
These consist of small
superficial veins which
penetrate the deep fascia
to connect with vessel in
muscle and in turn end in
Deep vein.

5. CAUSES – Pathology - RISK FACTORS
 1) Incompetent / malfunction/ diseased venous
valves
 2) dilation of vessels
 3) increase back pressure
 4) disorder - DVT

6. WHAT HAPPENS
 hemodynamic stress or valve agenesis.
 Decreased compliance and contractility and reduced smooth muscle content.
 Due to weakening of the vein wall, the vein dilates, stretching the valve cusp commissure and
separating the leaflets.
 Dilated saphenous veins undergo valvular remodelling with increased collagen and reduced elastin
content
 Consequently discolouration of skin , dryness, skin cracks then ulceration.

7. Who should be screened?
 Aching
 •Fatigue, heaviness in legs
 •Pain: throbbing, burning, stabbing
 •Cramping
 •Swelling (peripheral edema)
 •Itching
 •Restless legs
 •Numbness
 •Leg ulcerations –usually on the lower leg could be medial or lateral with typically
acceptable arterial circulation

9. CEAP classification stands for Clinical (C), Etiological (E),
Anatomical (A), and Pathophysiological (P).
Clinical classification
S: Symptomatic
A: Asymptomatic
C0 No visible or palpable signs of venous disease
C1 - Telangiectasies or reticular veins
C2 - Varicose veins; distinguished from reticular veins by a diameter of 3mm or more
C3 - Edema
C4 - Changes in skin and subcutaneous tissue secondary to CVD
C4a - Pigmentation or eczema
C4b - Lipodermatosclerosis or atrophie blanche
C5 - Healed venous ulcer.
C6 - Active venous ulcer.

10. The Etiological classification divides into:
Ec: - Congenital
Ep: - Primary
Es: - Secondary
En: - No venous cause identified
Anatomical classification divides into four categories:
As: superficial veins
Ap: perforating veins
Ad: deep veins
An: no venous location identified
pathophysiology classification, divided into four categories:
Pr: Reflux
Po: obstruction
Pr,o: reflux and obstruction
Pn: no venous pathophysiology identifiable

12. How can we make diagnose ?
 Mapping venous anatomy,
 Identifying anatomic variants ,
 Finding the sources of venous insufficiency.

13. What are the points to be proven ?
Find out cause of venous insufficiency .
 Points to be role out
 1) DEEP VEIN DISORDERS -
 a) external compression
 b) TOTUOUS ANATOMY
 c) Deep Vein reflux
 d) D V T
 2) superficial vein disorders
 A) dilation
 B) reflux
 C) disorder

14. Valves distribution
1) infrapopliteal segment
2) femoro-popliteal segment,
3) common femoral vein (CFV) near the inguinal ligament,
4) superficial femoral vein (SFV) just distal to the deep femoral vein (DFV) tributary,
5) popliteal vein (PV) near the adductor hiatus.

15. Technique
Patients are evaluated in the standing position to ensure maximum venous distention. The patient will need to be able to support
their weight on the opposite leg to participate in maneuvers to elicit reflux.
Slight limb flexion and outward rotation provides optimal visualisation of the great saphenous vein. The entire length of the GSV
is first examined using axial grayscale technique, noting the maximal vein diameter (normally <4 mm). Any varicose tributaries
are then identified and traced distally. Next, the SFJ is assessed for reflux. Color or power doppler imaging are used in
combination with sudden compression and release of distal venous segments (35) to identify sites of reflux. Since color Doppler
imaging often underestimates the degree of venous reflux, pulsed-wave doppler imaging is preferred while performing
compression and release (36).
For assessment of the short saphenous vein, the knee is slightly flexed and the muscles of the thigh are relaxed. Using axial
grayscale technique, the SSV is serially examined from the calf upwards until its termination at the SPJ, again noting the
maximal diameter, and assessing for venous competence of the SPJ. A thigh extension of the SSV is also assessed for reflux if
present. Comprehensive deep venous evaluation must also be performed for detection of DVT and reflux. Chronic DVT findings
may be subtle and manifest as webs, focal wall thickening, or calcification. Persistent or repeated venous obstructions can
contribute to venous hypertension. Perforating veins in the thigh and the leg are lastly examined in transverse and oblique planes
to identify the longitudinal axis of perforator.

17. GRADE I - incompetence found only during Valsalva’s maneuver on standing position;
GRADE II - incompetence found during Valsalva’s maneuver on standing and supine
positions;
GRADE III - incompetence found spontaneously on standing position;
GRADE IV - incompetence found spontaneously on standing and supine positions.
Choi, J, Hong, S, Park, S, Park, C, Seol, H, Cha, I,

18. TREATMENT OPTIONS
 VENASEAL CLOSER DEVICE
 LASER ABALATIONS ( BEST in category )
 SURGICAL REMOVAL OF SUPERFICIAL VEIN
 LIGATION OF THE VEIN AND PERFORATORS
 SCLEROTHERAPY
 RADIOFREQUNCY ABALATION

19. LASER ABALATIONS……….BEST WHY ?
 SHORTEST DURATION PROCEDURE - 2 HOURS WALKIN to WALKOUT
 DAY CARE PROCEDURE – No night emergency .
 NO ADMISSION / IPD -
 LESS COMPLICATED / POST PROCEDURE INFECTION
 LESS ASSOCIATED PERIPROCEDURAL MORBIDITY AND FASTER RECOVERY
 TREAT THE PERFORATORS

20. HOW DO WE DO IT ???
 HISTORY OF ILLNESS
 PRE- INTERVENTIONAL PREPARATION
 INVESTIGATIONS
 INTRA PROCEDURE CARE
 POST PROCEDURE CARE

21. HISTORY OF ILLNESS
 DURATION,
 PAST ILNESS,
 TREATMENT DONE BEFORE
 ANY OTHER ASSOCIATED DISEASE eg. DM
 TYPE OF DAILY ROUTINE

22. PRE - INTERVENTIONAL PREPARATION
 INVESTIGATIONS FOR DIAGNOSIS --
COLOR DOPPLER { REFLUX IN SFJ AND PERFORATORS, MAY BE SPJ,
DILATED GSV WITH SSV }
 COUNSELLING, { I DO NOT USE THE WORD OPERATION }.
 PT, INR, LA SENSITIVITY, OTHER ROUTINE PREPARATIONS, PAC

23. INTRA - PROCEDURE CARE
 TALK TO PATIENT DURING PROCEDURE
 SPINAL OR LOCAL BLOCK ANAESTHE SIA.
 CAN USE GA in SOS only
 MAKE SURE LUMEN OF VEIN COLLAPSE BY PERI VENULAR
ANAESTHESIA
 SPEED OF PULLING LASER FIBRE IS AS ABALATION
 DO NOT BE IN HURRY …………… TAKE YOUR TIME
 REPEAT USG IF ANY THING LEFT………… AND

26. POST PROCEDURE CARE
 ADEQUATE COMPRESSION DESSING 2 – 3 DAYS
 WOUND DRESSING ………..
 ADVICES TO THE PATIENT FOR EXERCISE, STOCKINGS
 FOLLOW UP AFTER 3 - 5 DAYS
 IF NEEDED MULTIPLE SITTINGS CAN BE DONE IN CHRONIC CASES.

27. RESULTS
MORE THAN 100 PATIENTS TREATED
WHEN PATIENT CAME WITH MULTIPLE
ULCERS,,,,,,,
CASE - 1

28. CASE - 2
WHEN PATIENT CAME WITH MULTIPLE ULCERS,,,,,,,

29. AFTER TREATMENT

30. WHEN PATIENT CAME WITH MULTIPLE
ULCERS,,,,,,,
CASE - 3

31. AFTER TREATMENT

32. WHEN PATIENT CAME WITH MULTIPLE ULCERS,,,,,,,
CASE - 4

34. CASE - 5