Webinar on Varicose Veins - Venous Disease : Hinduja Hospital

DR. ANAND SOMAYADR. ANAND SOMAYA
Consultant – Cardio Vascular SurgeonConsultant – Cardio Vascular Surgeon
1
VenousVenous
DiseaseDiseaseA Medical, CosmeticA Medical, Cosmetic
and sometimes a Life-threatening Conditionand sometimes a Life-threatening Condition
Dr. Anand SomayaDr. Anand Somaya
Consultant – Cardiothoracic and Vascular SurgeonConsultant – Cardiothoracic and Vascular Surgeon
MS FICA, FACP, FIACSMS FICA, FACP, FIACS
Hinduja Hospital, Mahim, MumbaiHinduja Hospital, Mahim, Mumbai
http://www.hindujahospital.com/dr-c-anand-somaya/http://www.hindujahospital.com/dr-c-anand-somaya/

2
VenousVenous

3
What is it ?
Venous disease is defined as the impairment
of blood flow towards your heart.
VenousVenous
DiseaseDisease legs are comprised of a network of
veins of varying sizes.
 Healthy veins have valves which open
and close to assist the return of blood
to the heart.
 If valves in the veins become damaged
they allow backward flow of blood in
the legs.
 gravity works on the legs more than on
other parts of the body, these vein
walls are under tremendous pressure.
Over time, this increased pressure can cause
additional valves to fail. If left untreated, it can lead
to leg pain, swelling, ulcers, and other health
problems.
 When blood cannot be properly
returned through the vein, it can pool,
leading to a feeling of heaviness and
fatigue, causing varicose veins and
other skin changes.

4
VenousVenous
DiseaseDisease
TREATMENT OF SPIDER VEIN OR VARICOSE
VEINS HAS OFTEN BEEN CONSIDERED
COSMETIC
TODAY, WE KNOW LEAVING
VENOUS ISSUES UNTREATED CAN LEAD TO
LARGER HEALTH PROBLEMS,
EVERYTHING IN THE BODY IS CONNECTED.
Common Types
 Varicose veins
 Spider veins
 Telangiectases
 Venous ulcers
 Deep vein thrombosis
(economy class syndrome)
 Pulmonary embolism
 Venous gangrene

Varicose veins
 VARICOSE derived from the
Latin root ‘varix’ meaning
TWISTED.
 Defined as:
An enlarged, gnarled blood
vessel carrying impure blood
from the extremities of the body
to the heart lying close to the
skin.
 Can affect any vein but
commonly those of leg and feet.
 Approximately 30% of the
population suffer from it.
When valve in vein
malfunctions, vein wall
becomes less elastic, dilates
like a balloon.
Backward bloodflow causes
eczema and ulceration.
Pregnancy also a cause as
uterus pressing on veins
causing pressure increase.

Varicose veins
Risk FactorsRisk Factors
 Age – usually appears between
30 to 70 years and progressively
gets worse.
 Sex – women are more prone
probably due to pregnancy, HRT
or birth control pills, which
relaxes the vein wall.
 Genetic – if other family members have it.
 Standing for long periods – this
also increases the pressure on the venous
system.
 Obesity – this adds pressure on the veins
SymptomsSymptoms
Aching legs – burning, throbbing and
cramping
Swelling of the legs
Enlarged veins seen under the skin
Brownish black discolouration of the ankles
Itching around one or more veins
Ulcers near the ankle – severe disease
requiring immediate attention
Severe bleeding

Varicose veins
CVICVI
CHRONICCHRONIC
VEINVEIN
INSUFFICIENCYINSUFFICIENCY
CVICVI is a distinctis a distinct
clinical syndrome of the lower limbclinical syndrome of the lower limb
SymptomsSymptoms
SwellingSwelling
PainPain
HeavinessHeaviness
CrampsCramps
 +/-+/- 
SignsSigns
OedemaOedema
VaricoseVaricose
veinsveins
SkinSkin
changeschanges
UlcerUlcer
There may be no signs, only symptomsThere may be no signs, only symptoms

Varicose veins
Pathogenesis of CVIPathogenesis of CVI – early stages– early stages
CHRONICCHRONIC
VEINVEIN
Macro vascularMacro vascular
basisbasis
InfectionInfection
SurgerySurgery
TraumaTrauma

Oral pillsOral pills
PregnancyPregnancy
ImmobilityImmobility

Genetic cause ?Genetic cause ?

Loss of venous toneLoss of venous tone

Deep vein thrombosis ofDeep vein thrombosis of
lower limblower limb

Valvular incompetenceValvular incompetence

Venous stasis of blood in lower limbVenous stasis of blood in lower limb

LOWER LIMBLOWER LIMB
normal venous returnnormal venous return
Normal veins
Standing at rest
Superficial venous
hypertension
present
Normal veins
Leg exercising
No superficial
venous
hypertension
Leg: posterior
lateral view
Short
Saphenous
vein
Mid calf
perforator
Lateral thigh
perforator
Soleal
perforator
Sapheno femoral
junction
Thigh perforators
Boyd’s perforator
Ankle perforators
PRIMARYPRIMARY
SECONDARYSECONDARY
Varicose veins
CVI typesCVI types

Varicose veins
CVI clinical evolution in IndiaCVI clinical evolution in India
Meanage-years
Early stage
Symptoms alone / oedema
41
7 yrs for7 yrs for
progressionprogression
48
Eczema
7 year interval in progression
from early to severe CVI
Implies ample opportunity to
treat early CVI and prevent
serious complications such as
eczema and leg ulceration

Varicose veins
The Ugly TruthThe Ugly Truth
 Patient with large tortuous
varicose veins, high-volume
venous reflux, and early stasis
changes of the medial ankle.
 Typical chronic medial leg
ulceration associated with long-
standing venous insufficiency.
 The ulcer had been present for
12 years and was refractory to
every treatment approach until
surgical extirpation of the
refluxing superficial varices was
DiagnosisDiagnosis
 Usually made by clinical examination by
vascular surgeon or in mild cases a
dermatologist.
 Confirmed by duplex ultrasound test with
colour Doppler, which shows the damaged
valves and enlarged veins.
 Could also be confirmed by venography –
now outdated due to improvement in
colour Doppler.

Varicose veins
TreatmentTreatment
CVI with varicose veins121
Laser therapy Sclerotherapy Drug treatment Compression Surgery
CVI without varicose veins
Treatment ofTreatment of
MildMild
Varicosities
 Lifestyle change – exercise,
losing weight, wearing lose
clothing, avoiding all periods
of standing or sitting.
 Pregnancy associated
varicosities heals
spontaneously within three
months of delivery.
 Class I & Class II stockings
should be worn during periods
of standing or prolong sitting.

Varicose veins
TreatmentTreatment
Oedema  Is there varicose veins or superficial
venous reflux?
 
Yes No
  
1st
Choice Alternative Flavonoids +
compression
 
Surgery/
Sclerotherapy
Laser therapy
Flavonoids +
compression

Varicose veins
TreatmentTreatment
Venoactive drugsVenoactive drugs
flavonoid compoundsflavonoid compounds
  Venous toneVenous tone
  WBC activation &  release ofWBC activation &  release of
inflammatory mediatorsinflammatory mediators
  Capillary hyper permeability andCapillary hyper permeability and
fragilityfragility
  Lymphatic drainageLymphatic drainage
 Effective in suppressing symptoms,Effective in suppressing symptoms,
reducing oedema and facilitatingreducing oedema and facilitating
ulcer healingulcer healing
 Well toleratedWell tolerated
Combined withCombined with Topical dressingsTopical dressings for ulcersfor ulcers
Preferably non adherent and which provide hydrationPreferably non adherent and which provide hydration
as well as gas exchangeas well as gas exchange

Varicose veins
TreatmentTreatment
CompressionCompression
Bandages and MaterialsBandages and Materials
 Compression bandages: Mode of actionCompression bandages: Mode of action
  Ambulatory venousAmbulatory venous
hypertensionhypertension
 Improve microcirculation flow,Improve microcirculation flow,
filtration and exchange dynamicsfiltration and exchange dynamics
 Compression materialsCompression materials
 Inelastic - for continuous use inInelastic - for continuous use in
severe CVIsevere CVI
 Elastic - self applied for day timeElastic - self applied for day time
useuse
 Short stretch (< 70%)Short stretch (< 70%)
 Medium stretch (70-140%)Medium stretch (70-140%)
 Long stretch (>140%)Long stretch (>140%)
Application pressure is correct when:Application pressure is correct when:
it isit is uncomfortableuncomfortable to sit for >20 minutesto sit for >20 minutes

Varicose veins
TreatmentTreatment
SclerotherapySclerotherapy
 Sclerotherapy is a minor procedure
in the doctor’s office – injecting
small and medium veins with a
special solution that thromboses the
vein instantly.
 Does not require general
anaesthesia, is effective and
complication free in experienced
hands.
 Now microsclerotherapy, an
improved injection technique under
magnification increases success
rate and reduces complications..

Varicose veins
TreatmentTreatment
SurgerySurgery
 Vein stripping – removing under
GA the entire length of the diseased
vein and its branches. This is the
age old method
 Requires hospital stay of two to
three days with multiple scars and
normal activities in two weeks or
less.
 Vein removal does not affect
circulation as the deep veins in the
leg takes over.

Varicose veins
TreatmentTreatment
LASER SURGERYLASER SURGERY
 Most modern and effective
method of treatment of varicose
veins.
 Day-care hospital procedure
 Cost effective
 Immediate return to normal
activities
 Minimal scarring

Varicose veins
TreatmentTreatment
ELVeSELVeS
Endo-LaserEndo-Laser
VeinVein
SystemSystem
Following percutaneous entry into the
greater saphenous vein, a fine ELVeS laser
fiber is inserted into an introducer sheath
and advanced towards the sapheno-femoral
junction.
Once in position (confirmed by ultrasound
and the laser aiming beam), the near infrared
laser energy is delivered in short pulses,
causing thermal damage and contraction of
the vein wall. Due to the application of
tumescent local anaesthesia damage of
surrounding structures is inhibited.
The laser treatment is performed along theThe laser treatment is performed along the
entire vessel length. The irreversible thermalentire vessel length. The irreversible thermal
damage induced by the laser energy thendamage induced by the laser energy then
leads to a complete occlusion of the vein.leads to a complete occlusion of the vein.
Fiber position at SFJ
Perivenous anaesthesia
and laser energy delivery
Treatment using fine
ELVeS laser fiber

Varicose veins
TreatmentTreatment
ELVeSELVeS
VeinVein
SystemSystem
Unaesthetic TelangiectasiaUnaesthetic Telangiectasia andand Spider VeinsSpider Veins are frequentlyare frequently
observed in patients presenting varicose veins. These tiny veinsobserved in patients presenting varicose veins. These tiny veins
can becan be treated with the ELVeS focusing hand-piecetreated with the ELVeS focusing hand-piece..
The near infrared laser energy is well absorbed by haemoglobin.The near infrared laser energy is well absorbed by haemoglobin.
The surface tissue is unaffected by the laser energy.The surface tissue is unaffected by the laser energy.

Varicose veins
PreventionPrevention
Regular exerciseRegular exercise helps to pump blood up the legshelps to pump blood up the legs
and back to the heart against gravityand back to the heart against gravity
Getting enoughGetting enough restrest
Eating aEating a healthy diethealthy diet
Keeping yourKeeping your weight downweight down..
Support stockings and herbal supplementsSupport stockings and herbal supplements havehave
been shown to improve pain and swelling frombeen shown to improve pain and swelling from
varicose veins but have never been proven to healvaricose veins but have never been proven to heal
bad veins or prevent healthy ones frombad veins or prevent healthy ones from
deteriorating.deteriorating.
Unfortunately, time and gravity
cause veins in susceptible people
to wear out over time.
Once a vein has become varicose
it will never function properly and
should be eliminated.

Varicose veins
CVICVI
…… as with any chronic diseaseas with any chronic disease
CHRONICCHRONIC
VEINVEIN
It causes significant impairment of quality of life.
Patients demand relief from symptoms.
Correct diagnosis and treatment does:
 relieve symptoms and
 delay progression.
...the physician is the first contact
and can make the maximum impact on its
control in the population.

Varicose veins
Venous Ulcer – wound healingVenous Ulcer – wound healing
ELVeSELVeS
VeinVein
SystemSystem
ELVeS hasELVeS has beneficial effectsbeneficial effects
on healing woundson healing wounds. The. The
treatment of woundstreatment of wounds
encourages the wound healingencourages the wound healing
process, significantly reducingprocess, significantly reducing
the healing time.the healing time.
TheThe laser treatment induces a positive effect:laser treatment induces a positive effect:
 in conditions of reduced microcirculation, andin conditions of reduced microcirculation, and
 results in the stimulation and proliferation of theresults in the stimulation and proliferation of the
patient’s own cells.patient’s own cells.

FromFrom
medicalmedical
and cosmeticand cosmetic
TOTO
a life-threateninga life-threatening
condition…condition…

Thrombophlebitis
Deep vein thrombosis -DVTDeep vein thrombosis -DVT
 ThromboThrombo means "means "clotclot."."
 PhlebitisPhlebitis isis inflammation of a veininflammation of a vein..
 ThrombophlebitisThrombophlebitis (throm-bo-fluh-BI-tis) occurs when(throm-bo-fluh-BI-tis) occurs when
aa blood clot and inflammation develop in one or more ofblood clot and inflammation develop in one or more of
your veinsyour veins, typically in your legs. On rare occasions,, typically in your legs. On rare occasions,
thrombophlebitis (often shortened tothrombophlebitis (often shortened to phlebitisphlebitis) can affect) can affect
veins in your arms.veins in your arms.
 The affected vein may be near theThe affected vein may be near the surface of your skinsurface of your skin
(superficial thrombophlebitis) or(superficial thrombophlebitis) or deep within a muscledeep within a muscle
(deep vein thrombosis).(deep vein thrombosis).

Thrombophlebitis
SEVERE Deep vein thrombosisSEVERE Deep vein thrombosis
The incidence of post operative DVT in
Indian patients undergoing major lower
limb surgery is as high as seen in the
western world
The most common distribution of DVT in
Indian patients appears to be distal, similar
to their Asian counter parts.

Thrombophlebitis
Pathophysiology ofPathophysiology of
DVTDVT
In 1856, Rudolf Virchow's proposed three
risk factors for thrombosis which were
subsequently termed Virchow’s Triad
Virchow’s triad
Hypercoagulability
Endothelia
linjury
Stasis
The strong relationThe strong relation
between DVT and PEbetween DVT and PE
Approximately 50% of patients with proximal
DVT of the leg have asymptomatic PE
DVT (mainly asymptomatic) is found in around
80% of patients with PE
Thrombus
Migration
Embolus

Thrombophlebitis
DVTDVT
Often goes undetectedOften goes undetected
till its too late…till its too late…
The strong relationThe strong relation
between DVT and PEbetween DVT and PE
Approximately 50% of patients with proximal
DVT of the leg have asymptomatic PE
DVT (mainly asymptomatic) is found in around
80% of patients with PE
Thrombus
Migration
Embolus
Less than half of all cases of fatal PE are
detected prior to death
Approximately 80% of
DVT are clinically
silent

Thrombophlebitis
YourYour RISKRISK of DVTof DVT increasesincreases if you:if you:
AreAre inactiveinactive for a long period of time, such as sitting in a car or anfor a long period of time, such as sitting in a car or an
airplane (economy class syndrome).airplane (economy class syndrome).
AreAre confined to bedconfined to bed for a prolonged time, such as after surgery, a heartfor a prolonged time, such as after surgery, a heart
attack or a leg fracture.attack or a leg fracture.
Have certain types ofHave certain types of cancercancer, such as pancreatic cancer, which may, such as pancreatic cancer, which may
result in an increase in your blood of procoagulants, substancesresult in an increase in your blood of procoagulants, substances
necessary for blood clotting (coagulation).necessary for blood clotting (coagulation).
Have had aHave had a stroke resulting in paralysisstroke resulting in paralysis of your arms or legs.of your arms or legs.
AreAre pregnantpregnant or haveor have just given birthjust given birth, which may mean you have, which may mean you have
increased pressure in the veins of your pelvis and legs.increased pressure in the veins of your pelvis and legs.
UseUse oral contraceptives or hormone replacement therapyoral contraceptives or hormone replacement therapy, which may, which may
increase the clotting factors in your blood.increase the clotting factors in your blood.
Have aHave a family historyfamily history of a tendency of blood clots.of a tendency of blood clots.
HaveHave varicose veinsvaricose veins. Clots may develop in dilated superficial veins. Clots may develop in dilated superficial veins
(varicose veins), causing superficial thrombophlebitis and DVT(varicose veins), causing superficial thrombophlebitis and DVT..
DVTDVT
Very large population at riskVery large population at risk
Prevalence of DVT risk in a typical hospital population:
Percentage of patients with at least 3 DVT risk factors
20% of hospital patients have at
least three risk factors
Patients with at least three risk factors (%)
0 10 2
0
3
0
4
0
5
0
6
0
7
0
8
0
All
hospitalized
All major
surgery
Abdominal
surgery
Vascular surgery
Neurosurger
y
Urology
Cardiac
surgery
Up to 70%
in some wards

Thrombophlebitis
DVTDVT
Dr. Rajagopalan’s DataDr. Rajagopalan’s Data
Patients with recent surgery has
a 22-fold increased risk of DVT
In the absence of prophylaxis,
about 50% of hip replacement
patients and over 60% of knee
replacement patients develop DVT
Risk ClassificationRisk Classification
Low RiskLow Risk Minor surgery, Age <40 yrs,Minor surgery, Age <40 yrs,
No other risk factorsNo other risk factors
Moderate RiskModerate Risk Major surgery, Age >40 yrs, No otherMajor surgery, Age >40 yrs, No other
risk factorsrisk factors
High RiskHigh Risk Major surgery, Age >40 yrs, MI,Major surgery, Age >40 yrs, MI,
Additional risk factorsAdditional risk factors
Very high RiskVery high Risk Major surgery, Age >40 yrs, HistoryMajor surgery, Age >40 yrs, History
of VTE, Hip or total joint procedure,of VTE, Hip or total joint procedure,
Stroke, Spinal cord injury, Trauma,Stroke, Spinal cord injury, Trauma,
MalignancyMalignancy

Thrombophlebitis
Pulmonary Embolism - PEPulmonary Embolism - PE
Clinical FeaturesClinical Features
 Dyspnoea
 Tachypnoea
 Pleuritic pain
 Rt sided heart failure
 Cardiovascular collapse
Pulmonary embolismPulmonary embolism
occurs when aoccurs when a bloodblood
clot becomes lodged inclot becomes lodged in
a lung artery, blockinga lung artery, blocking
blood flow to lungblood flow to lung
tissue.tissue. Blood clotsBlood clots
often originate in theoften originate in the
legs.legs.

Thrombophlebitis
PREVENTIONPREVENTION
‘‘umbrella’umbrella’

Thrombophlebitis
Case 1Case 1
 A 33 year old male
 C/o severe headache and
vomiting for two days
 Vital signs – normal
 MRI - sup sagittal sinus
thrombosis

Thrombophlebitis
Case 1Case 1
Clinical ProgressionClinical Progression
 10th day 7am – acute left sided
chest pain
 Rushed to cath lab – complete cut
off LPA
 Wheeled into O R
 Crashed on induction
 Emergent CPB
 PA opened and thrombus
extracted
 Weaned off CPB with minimal
Culprit ThrombusCulprit Thrombus

Thrombophlebitis
Case 1Case 1
Post-operative CarePost-operative Care
 Doppler showed multiple floating
thrombi – both legs
 Emergency laparotomy second
post op day
 Plication of IVC done
 Sodium nitroprusside test +ve-
diagnostic of homocysteineuria
 Post op – Vitamin B and oral
anticoags for six months
Alive and well –
twenty years later!
Homocysteineuria -ve

Thrombophlebitis
Case 2Case 2
 A 33 year old man
 Acute dyspnoea on exertion
three days
 XX: ray chest: severe
oligemia both lungs
 2D echo: large myxoma in
RA
 Large mass in MPA with total
obliteration of LPA
RAMyxomaonCPBRAMyxomaonCPB
SurgerySurgery
TumourMassinMPATumourMassinMPA

Thrombophlebitis
Case 2Case 2
 A 33 year old man
 Acute dyspnoea on exertion
three days
 XX: ray chest: severe
oligemia both lungs
 2D echo: large myxoma in
RA
 Large mass in MPA with total
obliteration of LPA
Culprit ThrombiCulprit Thrombi
AndAnd
MyxomaMyxoma

Thrombophlebitis
Case 3Case 3
 48 year old male
 Chronic rheumatoid arthritis
 10th day post operative total
hip replacement
 Nil Risk factors
 Mobilised day 3 post
operative
 No DVT prophylaxis
Case of Acute PECase of Acute PE

Thrombophlebitis
Case 3Case 3
 AM - tense calf
 PM - Sudden onset dyspnoea
 Cold clammy peripheries
 Seen by physician
 Immediate HRCT scan
 Diagnosed within 30 minutes
 Resuscitated with fluids,
inotropes
CardiopulmonaryBypassCardiopulmonaryBypass
……first glimpse of thrombusfirst glimpse of thrombus

Thrombophlebitis
Case 3Case 3
 AM - tense calf
inotropes
and it kept coming…and it kept coming…
CardiopulmonaryBypassCardiopulmonaryBypassThe culprit! – world’s largest!The culprit! – world’s largest!

Thrombophlebitis
Case 3Case 3
 AM - tense calf
inotropesDR. ANAND SOMAYADR. ANAND SOMAYA

42
DVT prophylaxis!!DVT prophylaxis!!
Role of surgicalRole of surgical
managementmanagement
As good?As good?
Maybe better!Maybe better!

Dr. Anand SomayaDr. Anand Somaya
Consultant Cardiothoracic and Vascular SurgeryConsultant Cardiothoracic and Vascular Surgery
OPD Schedule:OPD Schedule: Wednesday, 12:00 to 01:30 pmWednesday, 12:00 to 01:30 pm
Appointment Helpline:Appointment Helpline: 022-39818181/67668181/24451515022-39818181/67668181/24451515
For any Queries, please write us on:For any Queries, please write us on:
info@hindujahospital.cominfo@hindujahospital.com
Thank YouThank You

Webinar on Varicose Veins - Venous Disease : Hinduja Hospital

Recommended

Recommended

More Related Content

What's hot

What's hot (20)

Viewers also liked

Viewers also liked (20)

Similar to Webinar on Varicose Veins - Venous Disease : Hinduja Hospital

Similar to Webinar on Varicose Veins - Venous Disease : Hinduja Hospital (20)

More from Hinduja Hospital

More from Hinduja Hospital (14)

Recently uploaded

Recently uploaded (20)

Webinar on Varicose Veins - Venous Disease : Hinduja Hospital