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Varicose veins
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  • 1. Varicose veins
    • Dilated tortuous superficial veins - either main trunk (long or short sapehnous) or tributaries
    • distinct from
    • spider veins/telangiectasia
    “ What are they?”
  • 2. Varicose veins
    • chronic inflammation
    • lysosymal enzymes
      • MMP
    • collagen
    • elastin
    • cause and effect
    • micro AV fistulae
    “ Why did I get them?”
  • 3. Varicose veins
    • Primary
    • 27% US adults
    • “ Secondary”
    • DVT/obstruction
    • Pelvic mass
    • Cross groin varicosities
  • 4. Varicose Veins
    • Appearance (Quality of Life)
    • Ache or pain
    • Itching
    • Swelling
    • Skin changes
      • lipodermatosclerosis
      • eczema
      • ulceration
    “ Do they cause this pain, itching, burning ... ?”
  • 5. Varicose veins - symptoms Edinburgh vein study
  • 6. Varicose veins
    • Progression
    • Skin changes  ulceration
    • superficial thrombophlebitis
    • bleeding (trauma)
    • NO increased risk of DVT
    “ Are they dangerous? What complications might I get?”
  • 7. Varicose Veins
    • Appearance
    • Skin changes or ulceration (esp if deep veins normal)
    • Superficial thrombophlebitis
    • Fit for day case surgery
    • Compression hosiery
    “ Do I have to have surgery?”
  • 8. Varicose veins - Quality of life Men Women Pre OP * * * * * *
  • 9. Quality of life - Change All Post OP * * General Health vs 1 year ago
  • 10. Role of Surgery * Gohel et al. British Journal of Surgery 2005; 92: 291–297
    • open or recently healed ankle ulceration (>4 weeks)
    • ABI < 0·85
    • Either
      • superficial venous reflux
      • mixed superficial and deep venous reflux
    • Excluded
      • No reflux, deep reflux only, deep occlusion
  • 11. Role of Surgery * Gohel et al. British Journal of Surgery 2005; 92: 291–297 Healing Recurrence
  • 12. Varicose veins
    • Clinical
    • Hand-held doppler (CWD)
    • Duplex
      • recurrent
      • suspected deep venous disease
      • evidence of SV disease
    “ What tests do I need to have done?”
  • 13. Varicose veins
    • Clinical assessment
    • Distribution of varicosities
    • Trendelenburg test
    • Tourniquet test
    • Perthés test
    • Reliable (>90%) if clinical shows LSV only but if ?SSV <50%.
  • 14. Varicose Veins
    • Trendelenburg test
      • Lie patient down
      • identify SFJ*
      • apply pressure (tourniquet)
      • stand up
    LSV
  • 15. Trendelenburg
  • 16. Trendelenburg
  • 17. Varicose Veins
    • Trendelenburg test
      • Lie patient down
      • identify SFJ*
      • apply pressure (tourniquet)
      • stand up
    • If veins do not fill
      • SFI confirmed
    • IF veins do fill
      • perforators
      • SFI
    LSV
  • 18. Varicose Veins
    • Tourniquet test
      • Lie patient down
      • apply three tourniquets
      • stand up
      • release serially
  • 19. Modified Trendelenberg
  • 20. Modified Trendelenberg
  • 21. Modified Trendelenberg
  • 22. Modified Trendelenberg
  • 23. Varicose Veins
    • Perthés test
      • apply tourniquet below knee
      • stand up
      • tip toe manoeuvres
      • if veins fill
      • perforators incompetent
    normal abnormal
  • 24. Varicose veins
    • Long saphenous
    • Groin exploration
      • saphenofemoral ligation
    • Stripping (to knee)
    • Short saphenous
    • ligation of SSPV
    • Both
    • multiple avulsions
    “ What does the operation consist of ?” SSV LSV
  • 25. Varicose Veins
    • Recurrent/residual varicosities (22% by 6 years)
      • inadequate primary surgery
      • avulsion (LA)
      • sclerotherapy
    • Compression stockings
    “ Will I be cured - can they come back? ”