2. DEFINITION
“Varicosity is the penalty for verticality against gravity”
In man, owing to his upright posture, blood has to flow from lower limbs to heart
against gravity.
• Varicose veins are defined as dilated, elongated, tortuous and palpable superficial
veins(>3mm in diameter measured in upright position with demonstrable reflux)
as a result of venous hypertension.
• It usually occurs due to permanent loss of valvular mechanism and
resultant venous hypertension.
3. VENOUS SYSTEM OF LOWER LIMB
Consists of:
• Deep system of veins which lies below the deep fascia.
• Superficial system of veins which lies outside the deep fascia (carry
10% blood)
• Perforating veins which pass through the deep fascia joining the
superficial to the deep system of veins.
4. Veins Of Lower Limb
1: Superficial veins: Long saphenous vein Short saphenous vein
2: Deep veins :
• Anterior & Posterior Tibial veins
• Peroneal vein
• Popliteal vein
• Femoral vein
3: Perforator veins
4. Communicating veins
5. Valves in the veins
• Valves present in superficial veins.
• Prevent flow of blood from proximal to distal and from deep to superficial
• Absent from above groin level
• Valves can resist pressure up to 300 mm of Hg
6. Long saphenous Vein (LSV)
• Largest and longest superficial vein of the limb.
• Begins on the dorsum of foot from medial end of dorsal venous arch.
• Run 1 to 1.5 inch anterior to the medial malleolus ,along the medial side
of the leg , and behind knee .
7. • At the ankle the position of the LSV is constant , lying in the groove b/w
the anterior border of the medial malleolus and tendon of tibialis
anterior.
• In the thigh it inclines forwards to reach the saphenous opening
where it pierces the cribriform fascia and opens into the
femoral vein 2.5 cm below and lateral to the pubic tubercle.
• LSV contains 12- 20 valves.
• In the lower part of leg, it is closely related to Saphenous nerve
8. • Tributaries of LSV in leg and thigh:
Posterior arch vein of Leonard
Anterior vein of leg
Anterolateral vein of thigh
Posteromedial vein of thigh
Tributaries of LSV at SFJ:
Superficial external pudendal vein
Superficial epigastric vein
Superficial circumflex iliac vein
9. Short Saphenous Vein (SSV)
• Lateral marginal vein of the foot below and behind the lateral malleolus continues
as SSV.
• It runs along the middle of the back of the leg between two heads of
gastrocnemius and runs upward up to the middle of the popliteal space, where
it passes deep to fascia to enter into popliteal vein .
• It has 6-12 valves
• Sural nerve runs closely with SSV
10. Perforating veins
• These are communicating veins b/w superficial and deep veins .
• Direction of blood flow is from superficial to deep veins.
• Two type:
1. Indirect veins
2. Direct veins
11. • Indirect perforating 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.
• Indirect perforating veins:
These directly connect superficial veins
with deep veins
12. • Location of named perforators:
1. Ankle perforator ( May or Kuster)
2. Bassi’s paraAchillian perforator- 5ch above calcaneum.
3. Cockett perforator- lower leg perforators, 2,4, and 6
inches above medial malleolus
4. Below knee ( Boyd’s ) perforator
5. Mid-thigh perforators ( Dodd’s )
6. Hunter’s perforator in the thigh
13. Communicating veins
• They are veins in the subcutaneous plane communicating between different
superficial veins of the leg
• They usually do not perforate the deep fascia.
• Communicating vein of Giacomini-Cruveilhier.- Between cranial extension of SSV
to join GSV.
14. VENOUS PATHOPHYSIOLOGY
• FACTORS HELPING IN VENOUS RETURN
1. Negative pressure in thorax during inspiration to -6 mm.
2. Calf muscle pump: Normal venous pressure in relaxed state 20 mm of Hg. Rises
to 200-300 mm of Hg during muscle contraction.
3. Vis-a-tergo : Arterial pressure transmitted to venous side through capillary bed
4. Competent valves
5. Venae commitants: lie by the side of artery, helped by arterial pulsation to
propel blood.
15. Venous hypertension
• The first source is hydrostatic pressure due to gravity, a result of venous blood
coursing in a distal direction. It is the weight of the blood column from the right
atrium
• The second source of venous hypertension is dynamic. It is the force of muscular
contraction, usually contained within the compartments of the leg
• If a perforating vein fails, high pressures of 150-200 mm Hg developed within the
muscular compartments during exercise are transmitted directly to the
superficial venous system
16.
17. Different types of classification
I. Classification 1
• Long/great saphenous vein varicosity.
• Short/small saphenous vein varicosity.
• Varicose veins due to perforator incompetence.
18. II. Clasiification 2-
• Thread veins/ teangiectasis/spider veins- 0.5- 1 mm size
• Reticular veins ( 1-3 mm in size)
• Varicose veins ( more than 3mm diameter)
• Combination of any above.
19. III. CEAP Classification of Lower limb varicose veins (2004) by American venous
forum:
C
Clinical signs (grade0-6), supplemented by
(A) for asymptomatic and (S) for
symptomatic presentation
E Etiologic Classification (Congenital, Primary, Secondary)
A Anatomic Distribution (Superficial, Deep, or Perforator, alone or in
combination)
P Pathophysiologic Dysfunction (Reflux or Obstruction, alone or in
combination)
20. Clinical classification-
• C0: no signs of venous disease;
• C1: telangectasia or reticular veins;
• C2: varicose veins;
• C3: oedema;
• C4a: pigmentation or eczema
• C4b: lipodermatosclerosis or atrophie blanche;
• C5: healed venous ulcer;
• C6: active venous ulcer.
Etiological Classification-
• Ec - Congenital
• Ep - Primary
• Es - Secondary (post-thrombotic)
• En - No venous cause identified
S- Symptomatic
A- Asymptomatic
21. Anatomic classification
As - Superficial veins
Ap - Perforator veins
Ad - Deep veins
An - No venous location identified
Pathophysiologic classification
Pr - Reflux
Po - Obstruction
Pr,o – Reflux and obstruction
Pn - No venous pathophysiology identifiable
22. Epidemiology of Varicose veins
Predisposing factors:
• Gender – more common in females (10:1)
• Age- increases with age
• Ethnicity
• Body mass and height
• Pregnancy
• Family history
• Occupation and lifestyle factors- smokers, patients who suffer from constipation, prolonged
standing
• Left > Right
23. Aetiology of Varicose veins:
PRIMARY:
• Congenital incompetence or absence of valves
• Weakness or wasting of muscles
• SYNDROMES-
• Klippel Trenuanay Syndrome, Avalvulia, Parkes- Weber syndrome- varices are of
atypical distribution
• GENETIC- Abnormalities in the FOXC2 gene
24. SECONDARY VV:
• Recurrent thrombophlebitis.
• Occupational-standing for long hours (traffic police, guards, sportsman).
• Obstruction to venous return like abdominal tumour, retroperitoneal fibrosis,
lymphadenopathy, ascites.
• Pregnancy (due to progesterone hormone), obesity, chronic constipation.
• AV malformations-congenital or acquired.
• Iliac vein thrombosis.
• Tricuspid valve incompetence.
25. Symptoms
• Dragging pain, postural discomfort
• Heaviness in the legs
• Night-time cramps- usually late night
• Oedema feet, itching
• Discolouration / ulceration in the feet/painful walk
26. Signs
• Visible dilated veins in the leg with pain, distress, nocturnal cramps, feeling of
heaviness, pruritus.
• Pedal oedema, pigmentation , dermatitis, ulceration, tenderness, restricted ankle joint
movement.
• Bleeding , thickening of tibia occurs due to periostitis.
• Positive cough impulse at the saphenofemoral junction.
• Saphena varix-a large varicosity in the groin which becomes visible and prominent on
coughing.
27. • Brodie-Trendelenburg test: Vein is emptied by elevating the limb and a tourniquet is tied just below the
sapheno-femoral junction (or using thumb, sapheno-femoral junction is occuluded). Patient is asked to
stand quickly. When tourniquet or thumb is released, rapid filling from above signifies sapheno- femoral
incompetence. This is Trendelenburg test I
In Trendelenburg test II, after standing tourniquet is not released. Filling of blood from below upwards
rapidly can be observed within 30-60 seconds. It signifies perforator incompetence.
• Perthe’s test: The affected lower limb is wrapped with elastic bandage and the patient is asked to walk
around and exercise. Development of severe cramp like pain in the calf signifies DVT.
• Modified Perth’s test: Tourniquet is tied just below the sapheno – femoral junction without emptying the
vein. Patients is allowed to have a brisk walk which precipitates bursting pain in the calf and also makes
superficial veins more prominent. It signifies DVT.
DVT is contraindicated for any surgical intervention of superficial varicose veins. It is also contraindicated for
sclerosant therapy.
28. • Three tourniquet test: To find out the site of incompetent perforator, three
tourniquets are tied after emptying the vein.
a) at sapheno- femoral junction
b) above knee level
c) another below knee level.
Patient is asked to stand and looked for filling of veins and site of filling. Then
tourniquets are released from below upwards, again to see for incompetent
perforators
• Schwartz test: In standing position, when lower part of the long saphenous vein
in leg is tapped, impulse is felt at the saphenous junction. It signifies continuous
column of blood due to valvular incompetence.
29. • Fegan’s test: On standing, the site where the perforators enter the deep fascia
bulges and this is marked. Then on lying down, button like depression in the deep
fascia is felt at the marked out points which confirms the perforator site.
• Pratt’s test: Esmarch bandage is applied to the leg from below upwards followed by
a tourniquet at sapheno – femoral junction. Then the bandage is released keeping
the tourniquet in the same position to see the “blow outs” as perforators.
• Morrissey’s cough impulse test: The varicose veins are emptied. The leg is elevated
and then the patient is asked to cough. If there is sapheno- femoral incompetence,
expansile impulse is felt at saphenous opening.
30. • Ian- Aird test: On standing, proximal segment of long saphenous vein is emptied
with two fingers. Pressure from proximal finger is released to see the rapid filling
from above which confirms sapheno – femoral incompetence.
• Examination of the abdomen has to be done to look for pelvic tumours, lymph
nodes etc.
31. Complications of varicose veins
• Bleeding
• Thrombophlebitis
• Venous Hypertension leading to venous ulcer
• Calcification
• Talipes Equinovarus deformity of foot
• Eczematoid dermatitis and pigmentation
• Periostitis of subcutaneous surface of tibia
• Carcinoma in long standing venous ulcer- Marjolins ulcer
• Deep vein thrombosis
32. Investigations
• Venous Doppler study
• Duplex scan – Doppler + B Mode USG
• Air plethysmography
• Ambulatory venous pressure studies.
• Venography – to r/o DVT
33. • To find patency of deep veins.
• To define the site of incompetent perforators & to mark them
preoperatively.
• To find out the competence of Saphenofemoral junction &
Sapheno popliteal junction.
• If Sapheno-popliteal junction is incompetent it should be marked
preoperatively because of its highly variable & inconstant position.
• Ankle brachial index should be measured to rule out any
concomitant arterial disease.
34. • Ambulatory venous pressure more than 90 mm of Hg is associated with
venous ulceration.
• Also regarded as GOLD STANDARD for diagnosis of chronic
venous insufficiency
• Ulcer never occurs at AVP lesser than 30 mmof Hg.
Invasive procedure hence ideally not suitable for screening
35. • Indicated for diagnosis of calf muscle dysfunction
• Measures changes in leg volume in response to exercise and posture.
• Leg placed in 40 cm tubular Vinyl air chamber Leg volume measured in
supine, elevated , standing on opposite leg and after 10 tip toe jumps.
• Venous volume(VV), venous filling time90(VFT 90) and venous
filling index(VFI) and ejection fraction (EF)calculted
37. Management of varicose veins
Conservative management:
• Avoiding prolonged standing, weight loss ,excercise
• Crepe bandaging and elastic stockings from toe to thigh, which causes
decreased edema, venous volume and reflux and increases venous
return.
• Compression stocking of the pressure of 30-40 mmhg is preferred for
varicose veins.
• Limb elevation above the level of heart while lying down
• Unna boots
39. Unna Boot- Gauze impregnated with a thick, creamy
mixture of zinc oxide, calamine and Glycerine to
promote healing. Provides Non- elastic compression
therapy
40. Medical management
• MICRONIZED PURIFIED FLAVONOID FRACTION (MPFF)/ DIOSMIN:
DAFLON 500MG oral phlebotropic drug consisting of 90 % micronized diosmin and 10%
flavonoids expressed as hesperidin.
Shown to improve venous tone and lymphatic drainage and reduce capillary
hyperpermeability by protecting the microcirculation from inflammatory process.
• CALCIUM DOBESILATE
• PENTOXIFYLLINE : inhibits platelet aggregation hence reduce blood viscosity and improves
microcirculation
• ASPIRIN
41. Injection- Sclerotherapy
• Under Ultrasound guidance.
• Polidocanol is used( Sodium tetradecyl sulphate 3%, can also be used)
• Polidocanol converted in foam by mixing air using three way tap.
• Spread of foam monitored under USG guidance as it spreads.
• Apex of saphenous opening compressed by probe to prevent foam entering
deep veins.
• Leg also elevated and pressure bandage applied
45. Surgery
1. Flush ligation of Sapheno femoral junction with ligation of all tributaries
ending at SFJ.
2. Stripping of long saphenous upto the knee joint.
3. Flush Ligation of Short Saphenous vein.
4. Subfascial ligation of perforators
46. Flush ligation of saphenous vein
• Curved or Hockey stick incision.
• Alternatively a 7-8 cm long Oblique incision .
• Femoral Vein is exposed 1 cm above and below the Sapheno femoral junction.
• The all tributaries joining the termination of saphenous vein are defined and ligated
• The end of the long saphenous vein is flush ligated at Saphenofemoral junction with
silk and a second ligature is transfixed to avoid haemorrhage.
• Femoral vein is inspected above and below the junction and long saphenous divided.
47.
48. Stripping of vein
• A Myer’s stripper is passed from the groin Incision into the long
saphenous vein.
• A vertical incision is made just below knee and vein exposed
• The stripper is extruded from the vein and the acorn head is firmly tied
in the vein.
• The stripper is firmly withdrawn with the vein telescoped over it.
• The track is compressed with a large sterile pad for 3 to 5 minutes.
49. Stripping of vein
• Complications of surgery
• Haemorrhage from torn varix
• Division or injury to the common Femoral Vein
• Sural Nerve or Saphenous nerve injury
• Postoperative Complications:
• Haematoma and bruising
• Wound infection
• Neuritis
• Lymphoedema
• Induration of stripper track
• Lymphatoma
• Deep Venous Thrombosis
50. Post-operative care
• Maintain firm pressure over the limb
• Regular movement of the operated limb
• Limb elevation above heart level to reduce venous pressure
• Removal of primary dressing after 7 to 10 days
51. Subfascial Ligation of Cockett and Dodd
• Perforators are marked out by Fegan’s method.
• Perforators are ligated deep to the deep fascia through incisions in antero medial
side of the leg.
52. Subfascial Endoscopic Perforator Surgery (SEPS)
• Subfascial Endoscopic Perforator Surgery is a minimally invasive procedure where
in Incompetent perforators are ligated below the deep fascia by creating
space with CO2.
• Contraindications
• Secondary varicose veins
• Arterial Insufficiency
• Deep Vein Thrombosis
53. Insertion Of Ports for SEPS
• A single 10 mm port for camera is inserted below the deep fascia at the medial end of upper
part of tibia. Another 5mm port inserted at junction of upper 1/3rd and lower 2/3rd of the
calf.
55. VNUS Closue
• Also known as endovenous radiofrequency ablation,
• It is a minimally-invasive procedure used to treat the great saphenous vein
(GSV), small saphenous vein (SSV) and other superficial veins. It uses a patented
radiofrequency catheter inserted into the vein, which applies RF energy to heat
the vein. This causes the vein to collapse and seal shut.
