varicose veins

Varicose veins and treatment

• Jeannouel van Leeuwen , surgeon

• Chirurgen Maatschap Emma Care

• Courtesy of Servier• 25 january 2012

What we’ll cover

• Some Definitions• Anatomy• What are you looking for?• Examination techniques• Treatment options

Incidence

• annual incidence of varicose veins is about 2%

• life-time prevalence of varicose veins approaches 40%

• Varicosities are more common in women (about 2-3 times as prevalent in women than in men)

• 10-20% actually are symptomatic enough to complain about their lower leg varicose veins and seek treatment.

What is a varicose vein?

• Long, tortuous and dilated vein of the superficial varicose system

• Commonly legs but where else?• Abdominal Wall • Anus• Vulva • Oesophagus• Scrotum

Why do they happen?

• increased pressure in the superficial venous system

• normally blood flows from superficial system to deep

• if the valves protecting the superficial veins become incompetent there is higher pressure in the superficial veins and they become varicose

Normal venous flow in the Leg

Normal Flow • Superficial veins drain into the deep veins• From the foot up to the heart

Superficial vein disease always starts with abnormal valves and interruption to normal flow called venous reflux

Abnormal flow = Venous Reflux

Damaged Valves

1. Blood flows to the skin

2. Blood is pushed distally and proximally

3. Close loop recirculation

4. Blood is retained in the leg• Increased volume of blood

(heaviness Fatigue)

• Increased venous pressure• Veins Dilate (varicose veins)

Taking the history

Presenting Complaint: Varicosities, abdominal/groin lump – saphena varix

Symptoms Localized discomfort in the leg, Pain, Swelling,

Venous claudication, Itching “Risk” factors

Female, age, ethnicity, occupation, pregnancy, obesity, smoking

ASK about history of abdominal complaints/cancer, DVT, previous & other venous complaints

So the examination

• Inspection• Auscultation• Palpation

• cough test• tap test

• Tourniquet Tests• Trendelenberg• Tourniquet test• Perthes

• Doppler• Sapheno-femoral junction• Sapheno-popliteal junction

Diagnosis of venous disease

• Physical exam• Appearance• Trendelenburg test• Palpation• Hand Doppler

• Duplex Examination• R/O DVT• Size of veins• Map out superficial veins• Locate the site of reflux• Reflux 0.5 sec in GSV and 1 sec in

deep system• Find refluxing perforators

Clinical picture - symptoms

• Cosmetic disfigurement• Pain and discomfort• Night cramps• Mild swelling at night• Pigmentation• Itching• Ulceration

Anatomy• Superficial System arises from foot and ends at Sapheno- femoral

junction (spiderhead)• Long saphenous vein- medial leg up to SFJ• Short saphenous vein- lateral malleolus , up calf to meet popliteal

vein behind knee• Sapheno- femoral junction- 4 cm lateral and 4cm below the pubic

tubercle • Communication veins: connecting deep and superficial system

through piercing deep fascia, with valves to direct blood from superficial to deep viens.

• Perforator veins: there are 3 perforators on the medial side and 1 on the lateral side of the leg

Inspection- other features

1. Spider Veins- blueish vessels that distend above the skin surface

2. Thrombophlebitis- superficial red painfull lump

3. Brown pigmentation- haemosiderin deposition

4. Venous Eczema5. Venous Ulcers- over medial ankle 6. Lipodermatosclerosis-progressive sclerosis

of cutaneous fat- ankle becomes thin and hard- area above becomes oedematous

7. Scars from previous surgery

Inspection Venous

ulcers/eczema

Spider veins

Atrophy blanche Ulceration: active and healed Leaves a white patch

Pitting oedema

Inspection

Lipodermatosclerosis Literally "scarring of the skin and fat“ A slow process that occurs over a

number of years and has 2 phases:1. Acute

Venous pooling →chronic venous hypertension

RBC forced into surrounding tissue Haemoglobin broken down into brown

haemosiderin

2. Chronic Chronic haemosiderin formation leads to

fibrin deposition Skin becomes thickened and shiny Skin around ankle constricts and the

inverted champagne-bottle shape is seen

Stages of chronic venous insufficiency (Expert meeting in Moscow, 2000.)

• 0 - no symptoms;• 1 - heavy feet syndrome;• 2 - intermittent edema;• 3 - persistent edema, hyper- or

hypopigmentation, lipodermatosclerosis, eczema;

• 4 - venous ulcer.

CausesPrimary• Theories of Aetiology:

• Weak wall theory• Congenital valvular incompetence

• Aggravating factors:• Female sex• High parity • Occupation requiring prolonged standing• Marked obesity• Constricting clothes• Estrogen intake• Deep venous thrombosis

SecondaryAnything that raises intra-abdominal pressure or raises pressure in superficial/deep venous systemso…:

• Pregnancy• Abdominal/pelvic mass• Ascites• obesity• constipation• thrombosis of leg veins (DVT)• AV fistula• Vena cava thrombose• Large liver cysts

Auscultation

• Auscultate over any varicosities for bruits• due to A-V malformation

Palpation• Palpate the veins to confirm they are infact veins-

will refill if if gently pressed and released• Next- find the sapheno-femoral junction (SFJ)

• Find Pubic Tubercle just lateral to pubic symphisis• 4 cm lateral then 4cm below• Palpate for a sapheno varix- localised distension of the

long saphenous vein in the groin• Cough Test- Fingers over SFJ, ask patient to cough

can you feel a thrill, if yes suggest incompetence• Tap Test- tap over the SFJ and feel further down

long saphenous vein for any transmitted sounds, if yes suggest incompetence

Trendelenberg/Tourniquet tests

Aim- to localise the valve/s that are incompetent

Trendelenberg• Lie patient down and raise leg attempting

to drain varicosities of blood.• Using either a tourniquet or fingers put

pressure over SFJ to occlude it• Ask patient to standIf varicosities DO NOT refill indicates SFJ

incompetenceIf DO refill the leaky valve is lower down‘I will now try and locate the incompetent

perforator using the tourniquet test’

Tourniquet test continued

• Same as before- lie down, raise and drain leg

• Place tourniquet approximately over area of each perforator( mid thigh, sapheno popliteal, calf perforators)

• If varicosities DO NOT refill that perforator is incompetent

• If varicosities DO refill continue down leg

To complete my examination I would like to…

• Perform a full Abdominal Examination• Scrotal examination ( on males!)• Arterial Examination

Investigations• Duplex Ultrasonography- maps valve

incompetence• Phlebography not done anymore

Spider Veins

The proper term is Telangiectasia

• These are non raised dilated veins located in the Dermis (deep layer of the skin)

• Single layer endothelium, minimal muscle

• Can be Red or Blue in color depending on the origin

• Do not cause major medical complications

• Appears earlier than varicose veins (4% of teenagers , and 13 % in 18 to 20 year olds

• More common in females

• Reticular Veins are lager feeding veins

Spider Veins

Etiology: Multifactorial • Venous Hypertension associated with varicose

veins

• Congenital: vascular nevi, neonatal hemangiomatosis, others..

• Collage Vascular Disease: lupus,

• Hormonal factors: pregnancy, estrogen therapy, topical steroids

• Trauma: contusion, incisions

• Infections

Venous Stasis Ulcers

• Differential Diagnosis1. Venous ulcerations 50% on non healing ulcers

2. Arterial ulcers in about 10%

3. Malignancy : basal and squamous cell, lymphoma

4. Infections: HIV, fungal

5. Collagen vascular disorders: Lupus ec.

6. Lymphatic obstruction

•Affects over 1 million people in the US•100,000 are disabled from this•More common in elderly population

Ulcus cruris venosum

Venous Stasis Ulcers• Etiology

1. Venous Hypertension• Venous reflux• DVT• Varicose veins

2. Edema

3. Biological factors• Leakage of proteins impedes

diffusion O2

• Aggregation of white cells • Block capillary flow• Release on inflammatory proteins

Management

Conservative/Medical Graded compression

bandaging, Compression hosiery

Paste Gauze (Unna) Boots

Diuretics? Zinc? Phlebotrophic/Hemorheologic agents? Aspirin/NSAIDs etc

Surgical• Ankle-to-groin saphenous vein

stripping (with stab avulsion)• Segmental saphenous vein

stripping (with stab avulsion)• Saphenous vein ligation: high,

low, or both• Saphenous vein ligation and

sclerotherapy• Saphenous vein ligation (with

stab avulsion)• Stab avulsion of varices

without saphenous vein stripping (phlebectomy)

• Endoluminal occlusion of the saphenous vein by radiofrequency (RF) or laser energy

Surgical ligation and Stripping

• Standard treatment for a century

• General anesthesia• Pain• Long recovery• Some complications• Good cosmetic

results

Surgical treatment

• Crossectomy or/and vein stripping till below knee better than compressive therapy alone

• Other techniques : Endovas.burning or foam injection

Vein Ablation• Laser Ablation (EVLA )

• Uses light to heat the vein • Radio Frequency (VNUS Procedure)

• Uses radio frequency to heat the vein

• Office based procedure• Done under local anesthesia• One needle puncture at the level of the

knee• Takes about 1 hour• Patient resumes normal activity same day

EVLA Results

Images from http://venacure-evlt.com/

Sclerotherapy

• Cumulate vein with needle• Inject Sclerosing Solution

• Ethoxysclerol• Hyper tonic Saline• Foam (Mix STS with air and make

bubbles)

• Intravenous injection causes intima inflammation and thrombus formation

Sclerotherapy Use

• Neovascularization• Perforators• Clean up after Phlebectomies• Spider veins• Reticular veins• GSV: can closure the, but has

high recurrence rate

Sclerotherapy results

UNNA boot result

• Weekly change with UNNA boot bandage gives nice result

• Compressive bandages first choice with simple small vein ulcer

• Skin grafting can be put on a non infected granulating skin defect of a venous ulcer

Treatment complications

• Major complications following VV surgery are relatively rare• Up to 20% morbidity

• Infection• Hematoma• Pain• Nerve damage

• Saphenous nerve (LSV surgery)• Sural, peroneal nerve (SSV surgery)

• Lymphatic leak - Venous thrombosis - Vascular injury• Recurrence

Oral medication

• Effect on edema , hematocrit , augmentation capillary permeability , inflammation , less fibrinolysis , leukocyte function en erythrocytes

• No evidence for monotherapy only in addition effect on ulcer healing

• Daflon , Trental , Aspirine

Рhlebotropic drugs

• Daflon • Venal • Venoruton • Doxium

Rheologic hemocorrectors

• acetylcalicylic acid, • dipiridamol • pentoxyphylline • low-molecular dextranes

Thank you for your attention

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www.curacaoveininstitute.com

Chirurgen Maatschap Curacaowww.cmc.an