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Varicose Vein
Varicose Vein
Varicose Vein
Varicose Vein
Varicose Vein
Varicose Vein
Varicose Vein
Varicose Vein
Varicose Vein
Varicose Vein
Varicose Vein
Varicose Vein
Varicose Vein
Varicose Vein
Varicose Vein
Varicose Vein
Varicose Vein
Varicose Vein
Varicose Vein
Varicose Vein
Varicose Vein
Varicose Vein
Varicose Vein
Varicose Vein
Varicose Vein
Varicose Vein
Varicose Vein
Varicose Vein
Varicose Vein
Varicose Vein
Varicose Vein
Varicose Vein
Varicose Vein
Varicose Vein
Varicose Vein
Varicose Vein
Varicose Vein
Varicose Vein
Varicose Vein
Varicose Vein
Varicose Vein
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Varicose Vein


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Dr Sajid Ali abbasi

Dr Sajid Ali abbasi

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  • 1.  
  • 2. Dr. Sajid Ali Varicose Vein Topic Presentation
  • 3.
    • The collecting system of veins.
    • The conduits for blood to travel from superficial to the deep veins.
    • The channel through which blood is pumped out of the legs.
    • Contraction of leg muscles pumps blood through one-way valves up and out of the legs.
    Anatomy of V:System of leg A: Superficial venous system B: Perforating veins C: Deep venous system D: Musculovenous pump
  • 4.
    • Superficial System arises from foot & ends at Sapheno- femoral junction or Sapheno- popliteal junction.
    • Formed by union of dorsal digital vein of great toe & dorsal venous arch
    • Ascends ant: to medial malleolus, post: to medial condyle of femur.
    • Prox: it traverses saphenous opening in fascia to enter femoral vein.
    • Along its course, a variable number of named perforating veins may connect to deep system i.e. femoral, posterior tibial, gastrocnemius, & soleal veins.
    A:Superficial venous system 1: Great Saphenous Vein
  • 5.
    • Formed by union of dorsal digital vein of 5th digit & distal venous arch.
    • Runs post: to lateral malleolus, lateral to calcaneal tendon.
    • Runs superiorly medial to fibula and penetrates deep fascia of popliteal fossa, ascends b/w heads of gastrocnemius muscle to join popliteal vein.
    2: Small Saphenous Vein
  • 6.
    • These veins transverse deep fascia of lower extremity.
    • Valves are located just distal to penetration of deep fascia.
    • A number of named perforators are found at thigh, knee & leg.
    • Cockett perforators b/w ankle & knee are special group of perforating veins.
    • Rather than directly connecting sup: to deep venous systems they connect subfascial deep system with post: arch vein which then empties into GSV.
    B: Perforating Veins
  • 7.   Named perforators along the greater saphenous distribution
  • 8.
    • Deep veins accompany the arteries.
    • Usually paired and run with named arteries inside a vascular sheath, this allows arterial pulsation to force blood proximally.
    • Popliteal vein joins femoral vein in popliteal fossa.
    • Femoral vein is joined by deep vein of thigh .
    • Femoral vein passes deep to inguinal ligament to become external iliac vein.
    C: Deep Venous System
  • 9.
    • Foot and calf muscles act to squeeze blood out of deep veins.
    • One way valve allow only upward and inward flow.
    • During muscle relaxation blood is drawn inward thru perforating veins.
    D: Musculovenous Pump
  • 10.
    • Valve leaflets allow unidirectional flow upward or inward.
    • Dilation of vein wall prevents apposition of valve leaflets,resulting in reflux.
    • Valvular fibrosis,destruction, or agenesis results in reflux.
    Venous Valvular Function
  • 11.
    • Long tortuous & dilated veins of superficial varicose system.
    • Varicose veins are bulging veins that are larger than spider veins i.e. typically 3 mm or more in diameter.
    • Force of gravity,pressure of body weight & task of carrying blood from bottom of body up to heart make legs primary location for varicose veins.
    • May also occur else where i.e. Abdominal Wall,Anus,Vulva, Oesophagus.
    What are varicose veins?
  • 12.
    • Visible, palpable veins in the subcutaneous skin greater than 3 mm
    Varicose veins
  • 13.
    • Also called spider veins, hyphen webs, or thread veins.
    • Dilated intradermal venules greater than 1 mm in diameter.
  • 14.
    • Also called blue veins, subdermal varices or venulectasias.
    • Visible, dilated bluish subdermal, nonpalpable veins 1-3 mm .
    Reticular veins
  • 15.
    • Valvular insufficiency of the superficial veins, most commonly at the saphenofemoral junction.
    • Mainly caused by deep vein thrombosis (DVT) that leads to chronic deep venous obstruction or valvular insufficiency.
    • Catheter-associated DVTs are also included.
    • Pregnancy-induced and progesterone-induced venous valve weakness
    • Trauma.
    • This includes any venous malformations.i.eKlippel-Trenaunay variants,avalvulia etc.
    Secondary Congenital Primary Why do they occur?
  • 16. Pathways leading to varicose veins and other clinical manifestations of venous hypertension.
  • 17.
    • Aging causes wear and tear on valves in veins that help regulate blood flow, that wear can cause valves to malfunction.
    • Women are more likely than men to develop condition.
    • Hormonal changes during pregnancy or menopause may be factor.
    • Female hormones tend to relax vein walls.
    • Taking hormone replacement therapy or birth control pills may increase risk.
    Risk factors Age Sex
  • 18.
    • If other family members had varicose veins,there's greater chance you will too.
    • Being overweight puts added pressure in veins.
    • Prolonged immobile standing impairs venous return.
    • Pregnancy,Abdominal/pelvic mass,Ascites,constipation etc inc: risk.
    Genetics Obesity Standing for long periods of time Anything that raises intra-abd:pressure
  • 19.
    • Achy or heavy feeling in legs.
    • Burning, throbbing & muscle cramping in lower legs.
    • Prolonged sitting or standing tends to make legs feel worse.
    • Restless” legs at night.
    • Appearance of spider veins in affected leg.
    • Skin ulcers near ankle, which represent severe form of vascular disease & require immediate attention.
    • Redness, dryness & itchiness of areas of skin - termed stasis dermatitis or venous eczema b/c of waste products building up in leg.
    • Skin above ankle may shrink (lipodermatosclerosis) b/c fat underneath skin becomes hard.
  • 20.
    • A careful inspection & documentation of the site of varicosities is extremely important.
    • Look along distribution of Long saphenous vein i.e. Medial side along length of leg.
    • Next look along distribution of Short Saphenous vein i.e. Below knee, posterior & lateral aspects of leg.
  • 21.
    • Varicosities can lead to major complications due to poor circulation thru affected limb.
    • Extremely painful ulcers may form on skin particularly near ankles.
    • Pigmentations & skin changes ie.brownish darkening of skin resulting from extravasated blood that causes lipodermatosclerosis.
    • Development of carcinoma or sarcoma in longstanding venous ulcers.
    • Blood clotting within affected veins termed sup:thrombophlebitis that can extend into deep veins becoming more serious problem.
    • Acute fat necrosis can occur, esp: at ankle of overweight pats with varicose veins.
  • 22. Venous stasis ulcer Lipodermatosclerosis
  • 23.
    • This is physical exam: technique to localise valves that are incompetent
    • Lie patient down & raise leg attempting to drain varicosities
    • Using either tourniquet or fingers put pressure over SFJ to occlude it & ask patient to stand
    • If varicosities don’t refill indicates SFJ incompetence & if do refill then leaky valve is lower down
    • Now try and locate incompetent perforators
    • Place tourniquet aprox: over area of each perforator i.e.mid thigh,sapheno popliteal,calf perforators
    • If varicosities don’t refill that perforator is incompetent & if varicosities do refill continue down leg
    Diagnostic Procedures A: Trendelenberg / Tourniquet Tests
  • 24.
    • This is also physical exam: technique in which tourniquet is placed over prox: part of leg to compress any sup: varicose veins while leaving deep veins unaffected.
    • Pat walks to activate calf-muscle pump which normally causes varicose veins to be emptied.
    • If obstruction of deep system exists then activation of calf-muscle pump causes paradoxical congestion of sup:venous system and engorgement of varicose veins resulting in positive test.
    • To verify pat is then placed supine & leg is then elevated (Linton test).
    • If varices distal to tourniquet fail to drain after a few seconds again deep venous obstruction must be considered.
    B: Perthes Maneuver / Linton Test
  • 25.
    • Doppler transducer is positioned along axis of vein with probe at angle of 45° to skin.
    • When distal vein is compressed audible forward flow exists .
    • If valves are competent no audible backward flow is heard with release of compression.
    • If valves are incompetent an audible backflow exists.
    • These compression-decompression maneuvers are repeated while gradually ascending limb to level at which reflux can no longer be appreciated .
    C: Doppler Auscultation
  • 26.
    • Duplex US with color-flow imaging sometimes called triplex ultrasound.
    • This is special type of 2-dimensional ultrasound that uses Doppler-flow information to add color for blood flow in image.
    • Vessels in blood are colored red for flow in one direction and blue for flow in other with graduated color scale to reflect speed of flow.
    • Venous valvular reflux is defined as regurgitant flow with Valsalva that lasts great than 2 seconds.
    D: Duplex US
  • 27.
    • This is a physiologic test,using plethysmography.
    • VRT is time necessary for lower leg to become infused with blood after calf-muscle pump has emptied lower leg.
    • In healthy subjects VRT is greater than 120 seconds
    • In pats with significant venous insufficiency VRT is abnormally fast at 20-40 seconds.
    • VRT of less than 20 seconds is markedly abnormal & is nearly always symptomatic.
    • If VRT is less than 10 seconds venous ulcerations are likely.
    E: Venous Refilling Time (VRT)
  • 28.
    • Most sensitive & most specific test to find causes of anatomic obstruction.
    • MRV is particularly useful b/c unsuspected nonvascular causes for leg pain and edema may often be seen on scan image when clinical presentation erroneously suggests venous insufficiency or venous obstruction.
    • This is expensive test used only as adjuvant when doubt still exists.
    F: Magnetic Resonance Venography (MRV)
  • 29.
    • Elevating legs often provides temporary symptomatic relief.
    • Wearing of graduated compression stockings with pressure of 30–40 mmHg has been shown to correct swelling, nutritional exchange & improve microcirculation in affected legs.
    • Caution should be exercised in patients with concurrent arterial disease.
    • They are offered in different levels of compression.
    • They are constructed using elastic fibers or rubber which help compress limb, aiding in circulation.
    Treatment 1: Compression Stockings A: Non-surgical Treatment
  • 30. Compression stockings
  • 31.
    • It is commonly performed non-surgical treatment.
    • Often used for spider veins & varicose veins that persist or recur after vein stripping.
    • Sodium tetradecyl sulphate etc is inj: in veins to make them shrink.
    • Sclerotherapy can also be performed using foamed sclerosants under ultrasound guidance to treat larger varicose veins including GSV & SSV.
    • In U/S guided sclerotherapy u/s is used to visualize underlying vein so surgeon can deliver and monitor injection.
    • Microsclerotherapy is used to treat spider veins & other very small varicose veins.
    2: Sclerotherapy
  • 32.
    • GSV Saphenectomy
    • Surgical removal of GSV have evolved from large open incisions to less invasive stripping.
    • Stripping consists of removal of all or part of saphenous vein main trunk
    • Different devices are used in stripping i.e Mayo stripper, Babcock device, Keller device etc.
    • Perforation-invagination (PIN) stripper is mainly used now a days.
    • Technique of PIN stripping begins with 2-3cm incision made at groin.
    B: Surgical Treatment 1: Open Techniques Cont.......
  • 33.
    • Femoral vein and SFJ are exposed with dissection & all tributaries of SFJ must be identified and flush-ligated to minimize incidence of reflux recurrence.
    • Vessel is then inverted into itself tearing away from each tributary & perforator as stripper is pulled downward thru leg & out thru incision in upper calf.
    • Long epinephrine-soaked gauze or ligature may be secured to stripper before invagination allowing hemostatic packing to be pulled into place after stripping is complete.
  • 34. Perforation-invagination (PIN) stripping
  • 35.
    • SSV Saphenectomy
    • Removal of SSV is complicated by variable local anatomy and risk of injury to popliteal vein & peroneal nerve
    • Saphenopopliteal junction must be located by duplex exam: before beginning dissection.
    • After ligation and division of junction stripping instrument is passed downward into distal calf where it is brought out thru a small incision (2-4 mm).
    • Stripper is secured to proximal end of vein which is invaginated into itself as it is pulled downward from knee to ankle and withdrawn from below.
  • 36.
    • It is extremely useful for treatment of residual vein clusters after saphenectomy & for removal of nontruncal tributaries when saphenous vein is competent.
    • Microincision is made over vessel phlebectomy hook is introduced & vein is delivered thru incision.
    • With traction, as long a segment as possible is pulled out of body until vein breaks or cannot be pulled any further.
    • Another microincision is made and process is begun again and repeated along entire length of vein to be extracted.
    • Pat can go home same day after procedure is done.
    2: Stab or Ambulatory Phlebectomy
  • 37.
    • Laser fiber produces endoluminal heat that destroys vascular endothelium.
    • Seldinger technique is used to advance long catheter along entire length of truncal varicosity to be ablated.
    • Under U/S guidance tumescent solution with local anesthetic is inj: around entire length of vessel.
    • Firm pressure is applied to collapse vein around laser fiber & laser is fired generating heat leading to intraluminal steam bubbles,irreversible endothelial damage & thrombosis.
    • This process is repeated along entire course of vessel
    3: Endovenous (EV) laser Techniques
  • 38.
    • RF thermal energy is delivered directly to vessel wall causing protein denaturation, collagenous contraction & immediate closure of vessel.
    • Metal fingers at tip of RF catheter are deployed until they make contact with vessel endothelium.
    • RF energy is delivered both in and around vessel to be treated.
    • Thermal sensors record temp: within vessel & deliver just enough energy to ensure endothelial ablation.
    • RF catheter is withdrawn a short distance & process is repeated all along length of vein to be treated
    D: Radiofrequency (RF) ablation
  • 39.
    • Endovascular occlusion of Saphenous veins using VNUS ClosureTM Catheter
    A Minimally Invasive Alternative to Vein Stripping Surgery
  • 40.
    • Subcutaneous hematoma is a common complication.
    • Dysesthesias can occur from injury to sural or saphenous nerve.
    • At SFJ accidental treatment of femoral vein by inappropriate RF or laser catheter placement,spread of sclerosant or inappropriate surgical ligation can all lead to endothelium damage.
    • Hard tender lumps can sometimes form along the line of removed vein which usually disappears after few weeks.
    • Keloid scars can occur.
    Post operative Complications
  • 41. Thank You