varicose veins, causes for recurrence, diagnosis, indication, treatment options

1. DR JOEL ARUDCHELVAM
CONSULTANT VASCULAR AND TRANSPLANT
SURGEON

2.  Dilated tortuous superficial veins (derived
from the Greek word "varix," - “grapelike”)
 Old disease
 Hippocrates and Galen described the disease

3.  Prevalence of varicose veins - 2% to over 60% in
population studies
 Recurrence rate of 20%-60% after 5 years
 Epidemiology of chronic venous disease.Robertson L, Evans C, Fowkes FG Phlebology. 2008; 23(3):103-11
 Allaf N, Welch M. Recurrent varicose veins: Inadequate surgery remains a problem. Phlebology. 2005;20:138–
40.

5. Venous anatomy
Named perforators along
Greater saphenous
distribution

6. New perforator vein terminology

7.  Inadequate initial procedure
 Not stripping
 Neo vascularisation -new veins appearing in the granulation
tissue connecting the end of the ligated sapheno-femoral
junction (SFJ)
 Recanalisation – after thermal, chemical ablation
 New source of reflux
 Accessory Long Saphenous Vein (LSV)
 Accessory Short Saphenous Vein (SSV)
 Deep venous disease

9.  Inadequate initial procedure
 Not stripping
 Neo vascularisation -new veins appearing in the
granulation tissue connecting the end of the SFJ
 Recanalisation – after thermal, chemical ablation
 New source of reflux
 Accessory Long Saphenous Vein (LSV)
 Accessory Short Saphenous Vein (SSV)
 Deep venous disease

11.  Inadequate initial procedure
 Not stripping
 Neo vascularisation -new veins appearing in the
granulation tissue connecting the end of the SFJ
 Recanalisation – after thermal, chemical ablation
 New source of reflux
 Accessory Long Saphenous Vein (LSV)
 Accessory Short Saphenous Vein (SSV)
 Deep venous disease

13.  C0: No Varicose Veins
 C1: Telangiectasia ( reticular veins , spider veins)
 C2: Varicose veins
 C3: Edema
 C4: Skin changes
 C4a: pigmentation and eczema
 C4b: lipodermatosclerosis and atrophie blanche
 C5: Healed venous ulcer
 C6: Active venous ulcer

15.  C0: No Varicose Veins
 C1: Telangiectasia ( reticular veins , spider veins)
 C2: Varicose veins
 C3: Edema
 C4: Skin changes
 C4a: pigmentation and eczema
 C4b: lipodermatosclerosis and atrophie blanche
 C5: Healed venous ulcer
 C6: Active venous ulcer

17.  C0: No Varicose Veins
 C1: Telangiectasia ( reticular veins , spider veins)
 C2: Varicose veins
 C3: Edema
 C4: Skin changes
 C4a: pigmentation and eczema
 C4b: lipodermatosclerosis and atrophie blanche
 C5: Healed venous ulcer
 C6: Active venous ulcer

20.  To identify the cause of recurrence
 SFJ incompetence (SFI), Sapheno poplieal junction
incompetence (SPI)
 Acc LSV, Acc SSV
 DVT
 Perforators / site
 Neo vascularisation

21.  COSMETIC
 SYMPTOMATIC
 COMPLICATED
 Oedema
 C4 – skin changes
 C4a: pigmentation and eczema.
 C4b: lipodermatosclerosis and atrophie blanche.
 C5: healed venous ulcer.
 C6: active venous ulcer

22.  Surgery
 Thermal Ablation ( Radio frequncy ablation
/LASER )
 Sclerotherapy

23.  Dangers
 Risk of injury to femoral vein
 Lymphatic leak
 Expose artery first and approach vein from
lateral side

24. • Energy source
• Gain medium
• Resonant cavity
• LASER
• Monochromatic – same wave
length
• Coherent – unidirectional
• Collimated - parallel

26. Laser energy is absorbed
by vein wall and
hemoglobin producing heat
and vein wall destruction

27.  Scleroscents used
 SODIUM TETRADECYL SULPHATE(STD)
 HYPERTONIC SALINE SOL
 POLYDOCANOL
 SOTRADECOL
 ETHANOLAMINE OLEATE
 GLUCOSE COMBINATIONS

28. • sclerosant is taken in 20 ml
syringe ,another syringe with
4 times the amount of air
• By repeated to and fro motion
,dense white foam prepared

29.  Mechanism of action
 Endothelial damage
 Inflammation
 obliteration

30.  Recurrent SFJ /SFI
 Surgical,Laser
 neovascularisation
 Sclerotherapy, surgery
 LSV
 Thermal ablation (LASER, RFA), Stripping
 Varicosities
 Sclerotherapy, Avulsion, thermal ablation (LASER,
RFA)
 Pelvic DVT - Venous Angioplasty

31.  Duplex scanning and identifying the right
source - accessory LSV, (Giacomini vein),
correct site of reflux of SSV. Ect
 Stripping of Long Saphenous Vein
 Duplex scanning and Avoiding varicose vein
intervention in patients with past DVT

33.  Duplex scanning and identifying the right
source - acc LSV, (Giacomini vein), correct site
of reflux of SSV. Ect
 Stripping of Long Saphenous Vein , Ligation of
tributaries
 Duplex scanning and Avoiding varicose vein
intervention in patients with past DVT

34. Thank You