varicose veins
TRANSCRIPT
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
www.surgerycuracao.com
www.curacaoveininstitute.com
Chirurgen Maatschap Curacaowww.cmc.an