anatomy of the lower extremity veins, CVI , ambulatory venous hypertension, varicose veins , clinical examination and performance of various tests of the varicose veins

1. Varicose veins
By/ Mohamad Fathy Zaidan (MD)
Lecturer of General surgery

2. Venous Anatomy of Lower Limbs

3. The Long & Short Saphenous Veins
Superficial veins of the leg.
• 1-Sapheno-femoral junction
(SFJ),
• 2-Great saphenous vein (GSV),
• 3-Anterior accessory saphenous
vein (AASV),
• 4-Posterior accessory
saphenous vein (PASV),
• 5-Anterior thigh circumflex vein
(ATCV),
• 6- Posterior thigh circumflex vein
(PTCV)
• 7-Sapheno-popliteal junction
(SPJ),
• 8-Small saphenous vein (SSV),
• 9-Thigh extension of the small
saphenous vein (TE SSV),
• 10-Intersaphenous vein
(Intersaph. V)

4. Mainsitesofsuperficialtodeepvenouscommunication
Medial
malleolus
Sapheno-femoral junction
Mid thigh perforator
(Hunter’s canal)
Medial calf
perforators
Just below
Just above
10 cm above
Just below the knee
The lower
perforators
are joined to
form the
Posterior
arch vein
Thigh
perforators
connect to
the long
saphenous
main trunk
May or Kuster
ankle perforators
Cockett lower leg
perforators(3)
Boyd
gastrocnemius
perforators
Dodd
perforator

5. Valves
• Connects the deep
and superficial
system via the
perforators
• Divide the veins into
segments
• Unidirectional (from
below upwards ,, or
from superficial to
deep )

6. Venous return
• Venomotor tone
[Upright position -- dependant
pooling – dec. cardiac output -
- inc. sympathetic discharge --
inc. venous tone -- inc. venous
return.]
• Calf muscle contraction
Blood is pushed upwards and
from superficial to deep sys.
prevented from retrograde
flow by competent venous
valves

7. Competent Veno-muscular
Pump is composed of:
1. Superficial &
deep veins with
competent valves.
2. Competent
perforating veins
communicating
the deep &
superficial
systems
3. Powerful lower
limb muscles.

8. Ambulatory venous pressure
• The ankle venous pressure
during walking.
• (AVP) is the "gold standard"
test of the efficiency of the
calf musculovenous pump
• by placing a small needle into
one of the veins on the back
of the foot and connecting
the needle to a blood
pressure measurement
machine. The test has three
parts
• standing venous pressure is
around 90 mmHg , During
exercise this should fall to
around 30 mmHg.

9. "Ankle blow out" syndrome for
varicose veins
• Perforator vein incompetence in
the gaiter areas have been shown
to increase ambulatory venous
pressures (venous hypertension),
a phenomenon which has also
been referred to "ankle blow-
out" syndrome in the gaiter
areas.
• The combination of incompetent
perforator veins and
resultant venous hypertension
over time causes damage to
capillaries in the skin and
subcutaneous capillaries,
allowing protein rich fluid and
red blood cells to escape into the
subcutaneous tissue around the
ankle

10. CVI (chronic venous
insufficiency)
• CVI collectively
describes the
manifestations of
impaired venous return
due to abnormal
venous system
function.

11. CVI
• Whatever the cause of CVI, it will eventually cause
venous hypertension of the microcirculation,
giving the same symptoms & signs.
• The severity of symptoms & signs depend on the
degree & duration of venous hypertension
When veins fail,
the microcirculation
suffers.

12. CVI(symptoms and signs)
• Early
1-Posture related
discomfort
2-Lower limb
oedema
3-Muscle cramps
• Persistent & Sever
4. Ankle brown
pigmentation
5. Venous eczema
6.Lipodermatosclerosis
7. Venous ulcer
8- Talipes

13. Varicose veins
• Tortuous dilated
elongated veins.
• Defective connective
tissue and smooth
muscle in the vain
wall.
• Valve not working.
• Gathering of blood
within veins.

14. CLASSIFICATION
• (CEAP) classification from the American Venous Forum, last revised 2004.
Clinical
•C0 - No visible or
palpable signs of
venous disease
•C1 - Telangiectases or
reticular veins
•C2 - Varicose veins
•C3 - Edema
•C4a - Pigmentation or
eczema
•C4b -
Lipodermatosclerosis
or atrophie blanche
•C5 - Healed venous
ulcer
•C6 - Active venous
ulcer
Etiologic
•Ec – Congenital
•Ep – Primary
•Es - Secondary (post-
thrombotic)
•En - No venous cause
identified
Anatomic
•As - Superficial veins
•Ap - Perforator veins
•Ad - Deep veins
•An - No venous
location identified
Pathophysiologic
•Pr – Reflux
•Po – Obstruction
•Pr,o – Reflux and
obstruction
•Pn - No venous
pathophysiology
identifiable
EXAMPLE : C6, Ep, As,p,d, Pr

15. Inspection

16. 1-Superficial vein affected (long S. , short S.,
SFJ, SPJ , tributaries, stray V., perforators i.e
blow out ).
2-Describe the dilated superficial vein(s).
(Telangectasias-Reticular veins- varicose V.)
3-Look for signs of thrombophlebitis.
4-Inspect the ankle and look for signs of CVI.
5-Inspect the groin (static and dynamic)
,searching for masses, dilated V., Impulse, scar .
6-exclude ischemia.

17. Site and extent of the affected vein (in
the standing position)

18. Telangectasias
• Small(0.5-1mm)
widened blood vessels in
skin-small intradermal
varicosities
“SPIDER
VEINS”/”venulectasias"
• In anywhere on the body
esp-leg
• Usually no severe
symptoms

20. Reticular veins
• Subcutaneous dilated
veins-enter
tributaries of main
axial/trunk veins
• Size >spider veins
<varicose vein

21. Blow out
• Defect in the deep
fascia at the site of
incompetent
perforator

22. Ankle flare

23. Pigmentation & eczema
• The skin
pigmentation of
chronic venous
insufficiency is
associated both with
increased melanin
production and also
with deposition of
haemosiderin

24. Lipodermatosclerosis
• Progressive
scaring of skin
and subcutaneous
fat due to venous
insufficiency, area
affected becomes
thin and hard- area
above becomes
oedematous
(Champagne bottle
appearance)

25. Venous ulcer
• As a complication of
CVI and ankle
blowout syndrome
(due to increase the
AVP)
• At the gaiter area
(site of ankle
perforators)

27. Clinical
features
Ischemic ulcer Venous ulcer
Gender Men > women Women > men
Age Usually presents > 60 years Typically develops 40-60 years
Risk factors Smoking, diabetes, hyperlipidemia and
hypertension
Previous DVT, thrombophilia, varicose
vein
Symptoms Severe pain unless there is diabetic
neuropathy
Pain but not severe, relieved by
elevation
Site Pressure area (heel, metatarsal head
and base)
Medial and lateral malleoli
Edge Regular, punched out Irregular, with neo-epithelium
Base Deep, green (sloughy) or black
(necrotic) with no granulation tissue,
may involve tendon, bone and joint
Pink and granulating
Surrounding
skin
Shows signs of ischemia (cold, pale,
atrophic….)
Varicose eczema, indurations,
pigmentation, redness.
Veins Empty Full, usually varicosed
Swelling Usually absent Often present

28. Talipes equinovarus
• Progressive scaring
around the ulcer
leads to permanent
deformity

29. Scars of previous operations

30. Inspection of the groin

31. Morrissey’s Cough Test

32. Thrombophlebitis

33. Palpation

34. Items of palpations
• Tenderness
• Temperature
• Thrombophlebitis (Tenderness-cord like
structure)
• Defect in the deep fascia (Fegan’s method )
• Ulcer (base)
• Calf muscles (DVT)
• Groin (LNs.- cough impulse )
• Abdomen (masses)
• Special tests

35. Comments

36. Schwartz’s test

37. For DVT
• Tender calf
• Mose’s sign
• Homan’s sign

39. Special tests
1.Brodie Trenedlenburg
test
2.Multiple Tourniquet test
3.pratt’s test
4.Perthe’s test
5.Modified Perthe’s test

40. Brodie Trenedlenburg test

41. Brodie Trenedlenburg test

42. Brodie Trenedlenburg test

43. Do Multiple Tourniquet test
pratt’s test
only if Brodie
Trenedlenburg test
positive with maintained
pressure

44. Multiple Tourniquet test

45. pratt’s test

46. Perthe’s test & Modified
Perthe’s test
Modified Perthe’s testPerthe’s test

48. Auscultation
• ??????

50. Investigations
•Doppler
•Duplex
•Biopsy

51. Doppler

52. Doppler ultrasound
• The transducer sends and
receives sound waves that
are amplified through a
microphone.
• The sound waves bounce
off solid objects, including
blood cells.
• The movement of blood
cells causes a change in
pitch of the reflected
sound waves (called the
Doppler effect).
• If there is no blood flow,
the pitch does not change.

53. Duplex
• Combines Doppler flow
information and
conventional imaging
information.
• Sometimes called B-
mode, to allow physicians
to see the structure of
your blood vessels.
• It can also be useful to
estimate the diameter of a
blood vessel as well as the
amount of obstruction, if
any, in the blood vessel

54. Management
• For incompetent perforator
1-Trendelenburg operation (saphenofemoral disconnection)
2- saphenopoplitial disconnection
3-Subfascial ligation (OPEN OR ENDOSCPPIC= SEPS)
4-endovasculer occlusion
• For incompetent dilated vein
1-Stripping
2-Endoluminal occlusion of the saphenous vein by radiofrequency
(RF) ,laser energy or foam injection.
3-Stab avulsion of varices with or without saphenous vein stripping
(phlebectomy)
• For valve incompetence ??
• For the ulcer
1-biopsy if suspicious
2-Compression dressings (4 layer , Unna’s boot…atc)
3-coverage

55. Trendelenburg operation
(Saphenofemoral disconnection)

56. • Brodie–Trendelenburg percussion test (also accredited to Sir
Benjamin Collins Brodie) is a test for incompetent valves
in superficial veins
• Trendelenburg's cannula: a cannula used during surgery of
the larynx to prevent the patient from swallowing blood during
surgery involving the head and neck
• Trendelenburg gait: an abnormal gait caused by weakness of
the abductor muscles of the lower limb, including the gluteus
medius and gluteus minimus muscles.
• Trendelenburg operation: ligation of the great saphenous vein, for
the treatment of varicose veins. This term may also apply
to pulmonary thrombectomy
• Trendelenburg position, in which the patient is placed on a bed
which is put into incline such that the patient's head is lower than
his feet
• Trendelenburg's sign: a sign of congenital dislocation of the hip
• Trendelenburg's test: a test for varicose veins as well as a test to
assess hip mobility

57. Stripping

58. Subfascial ligation (SEPS)

59. Endovascular occlusion

60. Stab avulsion (phlebectomy)

61. Profore system (four layers
compression)
• orthopaedic wadding
(Velband) was
applied over the
primary dressing
• crepe bandage
• Elset bandage
• final layer of a
cohesive bandage
(Coban)

62. UNNA boot

63. Thank you