DR. ASHOK PRADHAN DU, TU

2. Objective
• Anatomy of lower limb venous system
• Definition of varicose vein
• Etiolopathology
• Classification
• Clinical features
• Investigation
• Treatment modalities
• summary

3. LEG VEIN ANATOMY
Superficial Veins
• long saphenous vein
• Short saphenous vein
Deep Veins
• Femoral vein
• Popliteal vein
• Peroneal vein

4. Cont.
• Anterior tibial vein
• Posterior tibial vein
• Soleus sinuses
• Gastrocnemius sinuses

5. Cont.
Perforators
• Cockett’s perforators: which connect posterior
arch and posterior tibial veins
• Boyd’s perforators: connects great saphenous
vein and gastrocnemius veins
• Hunterian and dodd’s perforators: connect great
saphenous and superficial femoral veins

6. Saphenofemoral junction
Hunterian perforators
Dodd’s perforators
Boyd’s perforators
Cockett’s perforators

7. cont.
• Important characteristics- valves
• Capacitance of vascular tree
• Calf muscle augment venous return by
functioning as pump

8. Venous sufficiency
• Dilated, elongated, tortuous veins associated
with reversal of blood flow due to faulty
valve/incompetence of valve
• Congenital
• Primary
• Secondary

9. Cont.
Congenital
1. Venous ectasias
2. Absence of venous valves
3. Klippel-Trenaunay syndrome
Primary venous insufficiency- (
Telangiectasias, Reticular vein and Varicose vein)
Secondary venous insufficiency-
Deep vein thrombosis/post thrombotic syndrome

10. Pathology
Mechanical abnormalities
• Anatomic differences
1. Great saphenous vein
2. Small saphenous vein
• Venous hypertension( incompetence of valves)
1) Gravitational pressure
2) Dynamic pressure

11. Cont.
Cellular abnormalities
1 Fibrin cuff theory
2 White cell trapping theory
Molecular abnormalities

12. C Clinical sign(0-6)
A for asymtomatic
S for symptomatic
E Etiology
Congenital
Primary
secondary
A Anatomic distribution
Superficial
Deep
Perforator
Alone or in combination
P Pathophysiological dysfunction
Reflux
Obstruction
Alone or in combination
Classification of lower extrimity venous disease

13. CLASS FEATURES
0 No visible or palpable signs of venous disease
1 Telangiectasia, reticular veins, malleolar flare
2 Varicose veins
3 Edema without skin change
4 Skin changes(pigmentation, eczema,
lipodermatosclerosis)
5 Skin changes as defined above with helaed
ulceration
6 Skin changes as defined above with active
ulceration
Clinical Classification

14. Risk factor
• Advancing age
• Obesity
• Heredity
• H/O trauma to extrimity
• Hormonal changes
• Prolonged standing
• Increase intra-abdominal pressure
• Retroperitoneal mass

15. • Clinical feaures
Symptoms
• Heaviness, discomfort,
and extremity fatigue
• Night time cramps
• Oedema, itching
• Discolouration
• Ulceration
Signs
• Dilated veins
• Hyperpigmentation
• Lipodermatosclerosis
• Atropic blanche
• Corona phlebectica
• Venous stasis ulcer
• Venous stasis dermatitis

17. Clinical examination
• Bordie -Trendelenburg test
• Perthe’s test
• Three torniquet test
• Schwartz test
• Fegan’s test

18. SCORE 0 Asymtomatic
SCORE 1 Symtomatic but able to carry out
activities without any therapy
SCORE 2 Symtomatic- can do activities only
with compression/ limb elevation
SCORE 3 Symtomatic – unable to do daily
activities even with compression or
limb elevation
Venous Disability Scoring System

19. Diagnostic evaluation of venous dysfunction
• Venous Doppler
• Duplex scan
– High resolution B mode ultrasound imaging
– Doppler ultrasound
• Venography
– Ascending
– Descending

20. Treatment
Nonoperative managemant
External compression
Lower extrimity elevation
Encouraging patient to partcipate in activities that
activate calf musculovenous pump
Unna boot

21. Intervention
• Venous ablation of telangiectasias
–Injection sclerotherapy
–Laser treatment
• Surgery for axial venous incompetence
–Phlebectomy
–Stripping
–Endovenous therapy

25. Other venous disease
Deep Vein Thrombosis
• Causes
– Stasis
– Hypercoaguable state
– Venous trauma
• Clinical diagnosis
– Homans’s sign

26. Cont.
• Investigation
– Venography
– Duplex ultrasound
• Treatment
– Thrombolysis
– Endovascular reconstruction

27. Thank you