Vascular diseases

1. DR.M.SHAHID SHABBIR
DPT.MS,NMPT
( N E U R O M U S C U L A R R E H A B S P E C I A L I S T )
D P T L E C T U R E R A N D C L I N I C A L I N C H A R G E
Z I H S
Varicose Veins

2. Definition of varicose vein
 Varicose veins are tortuous dilated veins more
common in lower limb due to incompetency of
saphenofemoral or sephanopopliteal junction or the
perforators

3. Pathophsiology
 Weak or damaged valves can lead to varicose veins. Arteries
carry blood from your heart to the rest of your tissues, and
veins return blood from the rest of your body to your heart,
so the blood can be recirculated. To return blood to your
heart, the veins in your legs must work against gravity.
 Muscle contractions in your lower legs act as pumps, and
elastic vein walls help blood return to your heart. Tiny
valves in your veins open as blood flows toward your heart
then close to stop blood from flowing backward. If these
valves are weak or damaged, blood can flow backward and
pool in the vein, causing the veins to stretch or twist.

4. Pathophysiology
 Venous hypertension, venous valvular incompetence, structural
changes in the vein wall, inflammation, and alterations in shear stress
are the major pathophysiological mechanisms resulting in varicose
veins. Venous hypertension is caused by reflux attributable to venous
valvular incompetence, venous outflow obstruction, or calf-muscle
pump failure. Venous reflux may occur in either or both the superficial
or deep venous system and results in venous hypertension below the
area of venous valvular incompetence. In patients with perforator vein
incompetence, high pressures generated in the deep veins during calf
muscle contraction may be directly transmitted to the superficial
system. Valvular incompetence may result from deformation, tearing,
thinning, and adhesion of the valve leaflets.

5. venous reflux.
 If a valve becomes damaged, it can't close
properly. Gravity takes over, and blood struggles
to flow upward toward your heart. It instead
flows backward, a situation known as venous
reflux.

6.  Overproduction of collagen type I, decreased
synthesis of collagen type III, and disruption of the
arrangement of smooth muscle cells and elastin
fibers have been observed in histological studies of
varicose venous segments

7. Pathophysiology

9. Symptoms
Varicose veins may not cause any pain. Signs you may
have varicose veins include:
 Veins that are dark purple or blue in color
 Veins that appear twisted and bulging; they are often
like cords on your legs

10. When painful signs and symptoms occur,
they may include:
 An achy or heavy feeling in your legs
 Burning, throbbing, muscle cramping and swelling
in your lower legs
 Worsened pain after sitting or standing for a long
time
 Itching around one or more of your veins
 Skin discoloration around a varicose vein

11. Risk factors
 These factors increase your risk of developing varicose veins:
 Age. The risk of varicose veins increases with age. Aging causes wear and tear on the
valves in your veins that help regulate blood flow. Eventually, that wear causes the valves
to allow some blood to flow back into your veins where it collects instead of flowing up to
your heart.
 Sex. Women are more likely to develop the condition. Hormonal changes before your
period or during pregnancy or menopause might be a factor because female hormones
tend to relax vein walls. Hormone treatments, such as birth control pills, might increase
your risk of varicose veins.
 Pregnancy. During pregnancy, the volume of blood in your body increases. This change
supports the growing fetus, but also can produce an unfortunate side effect — enlarged
veins in your legs. Hormonal changes during pregnancy may also play a role.
 Family history. If other family members had varicose veins, there's a greater chance
you will too.
 Obesity. Being overweight puts added pressure on your veins.
 Standing or sitting for long periods of time. Your blood doesn't flow as well if
you're in the same position for long periods.

12. Risk Factors
 Wearing constricting clothing
 Obesity
 Heredity risk?
 Both parents = 80%
 50/50 chance if one parent
 20% chance if neither parent

13. Presentation
 Telangiectasia (spider)

14. Reticular

19. Diagnosis
 To diagnose varicose veins, your doctor will do a physical
exam, including looking at your legs while you're standing
to check for swelling. Your doctor may also ask you to
describe any pain and aching in your legs.
 You also may need an ultrasound test to see if the valves in
your veins are functioning normally or if there's any
evidence of a blood clot. In this noninvasive test, a
technician runs a small hand-held device (transducer),
about the size of a bar of soap, against your skin over the
area of your body being examined. The transducer
transmits images of the veins in your legs to a monitor, so a
technician and your doctor can see them.

20. Investigations
 Duplex Ultrasound is the gold standard

21. Scenario
 A 35 year old mother of 2 children , banker ,
presents with dilated veins on her left calf. She has
severe discomfort due to these dilated tortuous veins.
 How would you manage this patient?

22. Treatment
 Self-care
Self-care — such as exercising, losing weight, not
wearing tight clothes, elevating your legs, and avoiding
long periods of standing or sitting — can ease pain and
prevent varicose veins from getting worse.

23. Compression stockings
 Wearing compression stockings all day is often the
first approach to try before moving on to other
treatments. They steadily squeeze your legs, helping
veins and leg muscles move blood more efficiently.
The amount of compression varies by type and
brand.
 You can buy compression stockings at most
pharmacies and medical supply stores. Prescription-
strength stockings also are available, and are likely
covered by insurance if your varicose veins are
causing symptoms.

24. If you don't respond to self-care or compression stockings, or if
your condition is more severe, your doctor may suggest one of
these varicose vein treatments:
 Sclerotherapy.
Injection of a large vein with a foam solution is also a
possible treatment to close a vein and seal it.
 Laser treatment. Doctors are using new
technology in laser treatments to close off smaller
varicose veins and spider veins. Laser treatment
works by sending strong bursts of light onto the vein,
which makes the vein slowly fade and disappear. No
incisions or needles are used.

25.  Catheter-assisted procedures using
radiofrequency or laser energy. In one of these
treatments, your doctor inserts a thin tube (catheter)
into an enlarged vein and heats the tip of the
catheter using either radiofrequency or laser energy.
As the catheter is pulled out, the heat destroys the
vein by causing it to collapse and seal shut. This
procedure is the preferred treatment for larger
varicose veins.

26. ligation and vein stripping
 Sephanofemoral junction ligation, stripping and avulsion of
veins
 Sephanopoploiteal junction ligation, stripping and avulsion of
veins
Ambulatory phlebectomy
(fluh-BEK-tuh-me). Your doctor removes smaller varicose veins
through a series of tiny skin punctures. Only the parts of your leg
that are being pricked are numbed in this outpatient procedure.
Scarring is generally minimal.

27.  Endoscopic vein surgery. You might need this
operation only in an advanced case involving leg
ulcers if other techniques fail. Your surgeon uses a
thin video camera inserted in your leg to visualize
and close varicose veins and then removes the veins
through small incisions.
 Varicose veins that develop during pregnancy
generally improve without medical treatment within
three to 12 months after delivery.

29. Injection sclerotherpy of reticular veins

30. Laser therapy of varicose veins

33. Before and after laser therapy

34. Complications
 Ulcers. Painful ulcers may form on the skin near varicose
veins, particularly near the ankles. A discolored spot on the
skin usually begins before an ulcer forms. See your doctor
immediately if you suspect you've developed an ulcer.
 Blood clots. Occasionally, veins deep within the legs
become enlarged. In such cases, the affected leg may
become painful and swell. Any persistent leg pain or
swelling warrants medical attention because it may indicate
a blood clot — a condition known medically as
thrombophlebitis.
 Bleeding. Occasionally, veins very close to the skin may
burst. This usually causes only minor bleeding. But any
bleeding requires medical attention.

35. Prevention
There's no way to completely prevent varicose veins. But
improving your circulation and muscle tone may reduce your
risk of developing varicose veins or getting additional ones.
The same measures you can take to treat the discomfort from
varicose veins at home can help prevent varicose veins,
including:
 Exercising
 Watching your weight
 Eating a high-fiber, low-salt diet
 Avoiding high heels and tight hosiery
 Elevating your legs
 Changing your sitting or standing position regularly

36. Be Happy