Kingdom of Saudi Arabia Ministry of Higher Education King Faisal University College of Medicine VENOUS DISEASES Fahad H. Al-Hulaibi 208004222 Ahmed K. Al Khalifah 2080286522012 General Surgery Course
objectives Anatomy of the lower limb veins. Physiology of venous flow and its alterations. Varicose veins definitions and classifications. Clinical presentation of varicose vein. Diagnosis of varicose vein. Complications/venous ulcer. management
Deep veins: Anterior & external iliacposterior tibial Polpiteal vains Femoral vains vain. & peronealwithin the muscle tissue and usually are paired with an artery
Superfacial vains:- Above muscle fascia of the limb.- Greater saphinous Join to femoral vain.- Lesser saphinous varible site on popliteal fossa. Perforating “communicating”:- - in the calf & thigh.
Physiology of venous flow and its alterations The venous system must move blood against the force of gravity in the standing position . The pressure at the venular end of capillary is 12mmHg. Continue to fall till it reach Rt. Atrium. Calf muscle pump +/- foot & thigh pump.
During relaxation: During contraction :The pressure fall and the blood from The veins which has valves pump superficial veins enter to the deep the blood to the heart.
The pump mechanism mainly results from a combination of different forces:1. Calf muscle pump .2. anti-reflux valves and the resistance of the vein walls.3. The beating of the heart and the negative pressure .
DEFINITION Tortuous dilated veins. Defective connective tissue and smooth muscle in the vain wall. Valve not working. Gathering of blood within veins.
CLASSIFICATION (CEAP) classification from the American Venous Forum, last revised 2004. Pathophysiologic Clinical Etiologic Anatomic• C0 - No visible or • Ec – Congenital • As - Superficial veins • Pr – Reflux palpable signs of venous disease • Ep – Primary • Ap - Perforator veins • Po – Obstruction• C1 - Telangiectases or reticular veins • Es - Secondary (post- • Ad - Deep veins • Pr,o – Reflux and• C2 - Varicose veins thrombotic) obstruction• C3 - Edema • An - No venous• C4a - Pigmentation or • En - No venous location identified • Pn - No venous eczema cause identified pathophysiology• C4b - identifiable Lipodermatosclerosis or atrophie blanche• C5 - Healed venous ulcer• C6 - Active venous ulcer EXAMPLE : C6, Ep, As,p,d, Pr
CAUSES Primary:- Familial (weakness of vain wall).- Congenital absence of valve (rare). Secondary:- Obstruction of venous flow. Obesity, pelvic cancer, ascites.- Valve destruction. DVT- Increase flow & pressure by arteno-venous fistula.- Occupational and prolong standing.- Lower leg fracture calf vain thrombosis
CLINICAL FEATURES Many patient are asymptomatic. Most common complain is :Aching in the veins after prolong standing. Other symptoms:Ankle swelling, itching, bleeding, superfacial thrombophlebitis, eczema lipodermatosclerosis and ulceration. Common site:- In greater and lesser saphenous veins.
VenographyWith tourniquet to direct contrast injectionIn present of post- thrombotic changes
COMPLICATIONSBleedingVaricose veins near the surface of your skin can sometimes bleed if you cut or bump your leg.Varicose veins bleed more than healthy veins because of abnormally high pressure within the damaged veins. Thrombophlebitis
VENOUS ULCER The edema is insidious, often beginning in the foot and ankle, worsening with activity and resolving with or elevation bedrest. Patients often describe the pain as an aching heaviness.
Clinical Ischemic ulcer Venous ulcer features Gender Men > women Women > men Age Usually presents > 60 years Typically develops 40-60 yearsRisk factors Smoking, diabetes, hyperlipidemia Previous DVT, thrombophilia, and hypertension varicose veinSymptoms Severe pain unless there is diabetic Pain but not severe, relieved by neuropathy elevation Site Pressure area (heel, metatarsal Medial and lateral malleoli head and base) Edge Regular, punched out Irregular, with neo-epithelium Base Deep, green (sloughy) or black Pink and granulating (necrotic) with no granulation tissue, may involve tendon, bone and jointSurroundin Shows signs of ischemia (cold, Varicose eczema, indurations, g skin pale, atrophic….) pigmentation, redness. Veins Empty Full, usually varicosed Swelling Usually absent Often present
TREATMENT Patient without symptoms or signs of lipodermatsclerosis or ulceration, simply reassurance. Elastic compression stockings
Work up: 1. Injection sclerotherapy. 2. US guided foam sclerotherapy 3. surgery.
1. Injection sclerotherapy. Inject directly to the superfacial vein the 3% sodium tetradecyle sulphate. And compression are applied. It destroy the lipid membrane of endothelial cells causing them to shed, leading to thrombosis, fibrosis and obliteration ( sclerosis ). It is not suitable for major saphinous incompetence.
A. saphino-femoral junction ligation & greater saphenous stripping.
B. saphino-popliteal junction ligation & lesser saphenous stripping.risk of injury to the popliteal vein and peroneal nerve
New techniques:Radiofrequency ablationThermal energy is delivered directly to the vessel wall Destroy the endothelial lining.Endovenous laser ablasionA laser fiber produces endoluminal heat that destroys the vascular endothelium Collapse.
COMPLICATIONS OFSURGERY Bruising. Sensory Nerve Injury Deep vain thrombosis (rare). If so, give LMW Heparin Most common is Recurrence .
References Varicose Vein Surgery Workup Medscape Link: http://emedicine.medscape.com/article/462579-workup#showall http://www.urgo.co.uk.