Varicose VeinsBY

PROF/ GOUDA ELLABBAN

DEFINITION

Varicose Veins Are dilated, protruding, tortuous

saccular superficial veins in the subcutaneous tissues

ANATOMY The veins in the leg are

divided into two systems – the deep veins and the superficial veins. The two systems are linked periodically by perforating veins. A superficial vein can become varicose because a perforating vein is allowing blood to flow the wrong way (outwards).

Normal Physiology Normal Venous Pump Mechanism

The contraction of muscles compressing veins helps push blood up through the leg veins back to the heart. The valves allow the blood to flow towards the heart only.

Why do veins become varicose? Descending valvular incompetence

If the valve at the top of a vein becomes ‘incompetent’ and stops working properly, this allows a head of pressure to distend the section of vein below it. This stretches the vein’s wall, making it varicose, and this makes the next valve down incompetent, and so on down the leg.

Why do veins become varicose? Descending valvular incompetence

Why do veins become varicose? Descending valvular incompetence

Why do veins become varicose? Weakening of the vein wall

There is some evidence that the amount of collagen (which gives strength) and the quality of the elastin (which gives elasticity) are abnormal in the leg veins of people who develop varicose veins. It is therefore possible that weakening of the vein wall is the cause of varicose veins, but not all the studies done on vein walls are in agreement about these changes.

This theory applies to ‘primary varicose veins’ – the usual kind that develop for no very obvious reason. A very few people get ‘secondary varicose veins’ as a result of deep vein thrombosis blocking the deep veins, tumours in the pelvis pressing on the leg veins, or rare congenital problems with the arteries and veins.

PATHOPHYSIOLOGY

Which veins become varicose? The long saphenous vein

(LSV) and its tributaries most often form varicose veins. The short saphenous vein (SSV) and its tributaries can also become varicose but less often.

Who get varicose veins? Sex

Among the general population in the Western World, about 20 to 30 per cent of women have varicose veins. Most studies have found fewer men with varicose veins (7 to 17 per cent) but, in the recent Edinburgh Vein Study, 40 per cent of the men examined had varicose veins (compared with 32 per cent of the women).

Who get varicose veins? Geography and race

Studies on the incidence of varicose veins have been done in different ways, and have often concentrated on women. Nevertheless, they all seem to show that varicose veins are less common outside the countries of the Western World. For example, prevalences have been found of only two per cent in rural Indian women and about five per cent for women in central and east Africa

Who get varicose veins? Age

More people develop varicose veins as they get older – at least up to the age of about 40

Who get varicose veins? Heredity

It is not unusual for varicose veins to ‘run in the family’ to some extent, but there is no well-proven genetic basis for varicose veins

Who get varicose veins? Height and weight

Although very obese people and very tall people sometimes have particularly troublesome varicose veins, no significant correlation has ever been shown between height and varicose veins, and the evidence about obesity and varicose veins is inconsistent.

Who get varicose veins? Pregnancy

Varicose veins are more common in women who have had children, and the more pregnancies women have, the more likely they are to develop varicose veins. Varicose veins that develop in pregnancy are said to result partly from the pressure of the womb on the veins, but the evidence for this is poor, and relaxation of the vein walls by hormones may be more important.

Who get varicose veins? Diet and bowel habit

It has been suggested that lack of fibre in the diet and sitting straining on the lavatory (rather than squatting briefly to pass a bulky stool) might predispose to varicose veins. This idea has given rise to a lot of debate, but there is no real evidence to support it.

Who get varicose veins? Occupation and posture

A number of studies have found that varicose veins are more common in people who stand up at work – particularly those who stand still for long periods.

Etiology

Primary :

Familial Congenitally absent or incompetent

Secondary : Pregnancy and childbirth (most common) Pelvic tumor DVT AVM

Standing for long time Positive family history. Pregnancy. Abdominal tumors. Use of OCP. Physical inactivity. Obesity. Increased age.

Risk Factors

CLINICAL PRESENTATION Symptoms

Asymptomatic “early disease” Cosmetic Dull aching discomfort in lower extremities Exacerbated with standing and hot weather Itching and tingling Dry and hard skin Ulcers

CLINICAL PRESENTATION Signs

Dilation and tortuosity of superficial veins Pigmented skin at site of varicosity Ulceration Edema can be present

Complications of V.Vs Thrombophlebitis

Complications of V.Vs Ulcer

Marjolin`s ulcer

Complications of V.Vs Talipes Equinovarus Hyperpigmentation &

Lipodermatosclerosis Bleeding

EXAMINATION Inspection

Brodie-Trendelenburg test

reveal the site of the incompetent valves elevate leg to ensure venous emptying. A tourniquet is placed on the thigh below the saphenofemoral

junction to block the superficial veins.

EXAMINATION The patient stands and venous

filling pattern is noted. Normal: veins do not fill within

30s, and there is not rapid refilling with removal of tourniquet.

If rapid refilling with removal of tourniquet occurs, suspect incompetent saphenous-vein valves.

If veins rapidly refill prior to removal of tourniquet, suspect incompetent valves in perforator veins

EXAMINATION

Multiple Tourniquet test Tapping test Homan’s test Pirth’s test “Exclude deep vein Thrombosis” Examine for signs of arterial insufficiency Percussion. Tapping test Auscultation.

Investigation Duplex US

Investigation Venography

Investigation Magenatic resonant Venography

CEAP ClassificationClinical picture:

Class Clinical signs

0 No visible or palpable signs of venous disease

1 Teleangiectases, reticular veins, malleolar flare

2 Varicose veins

3 Edema without skin changes

4 Skin changes ascribed to venous disease (pigmentation, venous eczema, lipodermatosclerosis ).

5 Skin changes (as defined above) in conjunction with healed ulceration

6 Skin changes (as defined above) in conjunction with active ulceration

Teleangictases

Varicose veins

Edema Without Skin Changes

Lipodermatosclerosis

Skin changes in conjunction with healed ulceration

Skin changes in conjunction with active ulceration

Treatment Part One

Get rid of the reflux

Part Two Get rid of the varicose veins

Treatment Compression stockings Surgical, vein stripping Endoluminal

Laser Radiofrequency ablation

Sclerotherapy Ultrasound guided Catheter delivered

Compression

Vein Stripping Typically requires general anesthesia Two incisions are need Can be painful post-operatively Requires 4-7 days off work

Ligation & Stripping Ankle-to-groin Segmental (groin to knee)

Ligation & Stripping Post Op. Care:

Elevate the leg. Observe for (Circulation, pain, bleeding). Ambulation next day.

Complications: Sural or Saphenous nerve damage.

EndoVenous treatment Laser ablation Radio-Frequency ablation

Perforator Interruption Open (ligation). Endoscopic.

Subfacial Endoscopic Perforator Surgery (SEPS)

Started in 1985 For active or healed ulcers.

Laser Ablation

Radiofrequency Ablation

Catheter Directed Foam Sclerotherapy

- Sclerotherapy: injection of 1% to 3% solution of sodium tetradecyl sulfate, or 5% morrhuate sodium. - Used alone for isolated varicosity or to supplement surgical

stripping

Part TwoRemoval of Varicosities

Stab phlebectomy and avulsion Sclerotherapy Suction phlebectomy

Superficial Phlebectomy

U/S Guided Sclerotherapy

Transilluminated power Phlebectomy TriVex

Endoscopic resection using a powered vein rejector and an illuminator.

The rejector has a powered oscillating ends which dislodges the veins and cut them.

The pieces of the vein are removed by suction.

Transilluminated Powered Phlebectomy (TriVex Technique)

Advantages: Large area of veins removed through only 2

small incisions.

Illumination allows removal under direct vision.

Spider veins Sclerotherapy

Sodium Tetradecyl (STS) 1%-3% Polidocanol 0.5%-1% Hypertonic Saline

Laser

Common Location of Spiders

Injection of Reticular Veins

Wound infection Hematoma DVT Recurrence

COMPLICATIONS

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