Varicose veins, pathophysiology, diagnosis and management

1. VARICOSE VEINS
Dr Kaushal Deep Singh
Lecturer,
Department Of Surgery,
UPUMS, Saifai

2. Venous Anatomy of Lower
Limbs
• Superficial venous
system
• Deep venous
system
• Perforator veins

3. The Long Saphenous VeinThe Long Saphenous Vein
The longest vein in the bodyThe longest vein in the body
Surface AnatomySurface Anatomy
•1 cm anterior to the medial malleolus
•One hand breadth posterior to the medial aspect of the patella
•Ends on the anteromedial side of the femoral vein 3.5 cm below &
lateral to the pubic tubercle
It receives the following tributaries near its termination:
•Superficial & deep external pudendal v.
•Superficial circumflex iliac v.
•Superficial inferior epigastric v.

4. The Short Saphenous VeinThe Short Saphenous Vein
AnatomyAnatomy
• Behind the lateral malleolus
• Pierces the deep fascia before it enters the
popliteal vein
• Variably terminates above or below the popliteal
fossa
• Communicates with the long saphenous vein by
several channels

5. Venous valves
• Venous valves are abundant in the
distal lower extremity and number of
valves decreases proximally, with no
valves in superior and inferior vena
cava
• Delicate structures
• Prevent reverse flow in the veins

6. Perforator Veins
• Connect superficial to deep veins at
various levels.
• Travel from superficial fascia through an
opening in the deep fascia before
entering the deep veins.
• Direction of blood flow - from superficial
to deep veins.
• Guarded by valves so that the flow is
unidirectional, i.e. Towards deep veins.
• Reversal of flow occurs due to
incompetence of perforators which leads
to varicose veins

7. Main sites of superficial to deep venous communicationMain sites of superficial to deep venous communication
Medial
malleolus
Sapheno-femoral junction
Mid thigh perforator
(Hunter’s canal)
Medial calf
perforators
Just below
Just above
10 cm above
Just below the knee
MayMay oror
KusterKuster ankleankle
perforatorsperforators
CockettCockett lowerlower
legleg perforatorsperforators(3)(3)
BoydBoyd
gastrocnemiusgastrocnemius
perforatorsperforators
Distal ThighDistal Thigh
PerforatorPerforator
(Dodd(Dodd perforator )perforator )

8. Venous returnVenous return
The heart pump
maintaining a pressure gradient across the veins
Gravity
Pooling in dependent limbs may reduce
cardiac output by 2 L/min & may cause fainting
Venomotor tone
Under control of sympathetic system
[Upright position -- dependant pooling – dec. cardiac output
-- inc. sympathetic discharge -- inc. venous tone -- inc.
venous return.]
With dependencyWith dependency
This is counter acted by:This is counter acted by:
With calf muscle contraction inWith calf muscle contraction in
walkingwalking
Calf muscle contraction
Blood is pushed upwards
and prevented from retrograde flow by competent venous
valves

9. CompetentCompetent Veno-muscularVeno-muscular
Pump is composed of:Pump is composed of:
1. Superficial & deep veins1. Superficial & deep veins
with competent valves.with competent valves.
2. Competent perforating2. Competent perforating
veins communicating theveins communicating the
deep & superficial systemsdeep & superficial systems
3. Powerful lower limb3. Powerful lower limb
muscles.muscles.

10. Varicose Veins
• Long, tortuous and
permanently dilated veins of
the superficial venous system
due to the pooling of blood in
the lower extremities.
• Risk factors
– Gender - Female sex
– Prolonged standing
– Raised intra abdominal
pressure
– Increased progesterone
– High heels
– Genetics
– Age
– Pregnancy
– Overweight and obesity

11. Classification Of Varicose Veins

14. Pathogenesis of Varicose Veins
Any risk factor/cause
↓
↑ced venous pressure
↓
Dilation of veins
↓
Valves stretched
↓
Incompetent valve
↓
Reverse blood flow
↓
Calf muscles fail to pump blood
↓
Venous distention

16. Clincial Features
• Dragging pain, postural discomfort
• Heaviness in the legs
• Night time cramps
• Oedema, itching
• Discolouration
• Ulceration

17. Cause Of Pain In Varicose Veins
• Chronic venous hypertension
• Anoxia
• Hyperviscosity of red cells
• Platelet aggregation
• Capillary functional disorder
• Altered cutaneous microcirculation

18. The patient should be standingClinical ExaminationClinical Examination
Look for:Look for: The extent and distribution of VVThe extent and distribution of VV
Antro-lat. tributary
of LSV
Short saphenous VV Communicating
vein varicosity
Long saphenous
VV

19. Clinical Signs

20. Brodie –Trendelenburg test
Test for incompetenceTest for incompetence
Empty the
veins &
apply a mid
thigh
tourniquet
Let the patient stand
If the veins remain empty, but fill after
removal of tourniquet, the
incompetence must be above the
tourniquet
If the veins fill before removal of
tourniquet, the incompetence must
be below the tourniquet

21. Perthes’ walking testPerthes’ walking test
Place a tourniquet around the
thigh while the patient is
standing (note that the vv are
full)
Let the patient walk in place
If the veins empty with
walking, then the tourniquet is
preventing superficial reflux
from an incompetent valve
above, while deep veins are
patent with intact valves.

22. Investigations In Varicose Veins
• Identify the existence, site & degree of venous
reflux.
• Confirm deep venous patency to rule out DVT

23. Identification of venous reflux:Identification of venous reflux:
1.1. Doppler Ultrasound:Doppler Ultrasound: portable bedsideportable bedside
examinationexamination
It is accurate in detectingIt is accurate in detecting
sapheno-femoralsapheno-femoral reflux inreflux in
the groin.the groin.
•Hold the Doppler probe
on the groin and detect
the venous signal
•Squeeze the calf. This
will augment the signal
•If the SFJ is
incompetent, you will
hear a biphasic signal
due to retrograde flow

24. Identification of venous reflux:Identification of venous reflux:
Coloured Duplex Ultrasonography:Coloured Duplex Ultrasonography:
1. Doppler combined with B mode ultrasound
2. Functional as well as anatomical information
3. Visually demonstrates venous reflux into the
superficial and deep veins.
4. The degree of venous reflux
can be assessed. (Dynamic Study)
1. DVT can be ruled out.
2. Can detect incompetent perforators.
Uniphasic signal – normal
Biphasic signal – reversal flow

25. Identification of venousIdentification of venous
reflux:reflux:
Magnetic Resonance Venography
Photoplethysmography
Descending venography

26. Confirming Deep VenousConfirming Deep Venous
Patency:Patency:
As in patients with suspected post-phlebitic
syndrome (chronic complication of maltreated DVT)
1. Duplex Ultrasound1. Duplex Ultrasound
2. Ascending2. Ascending
VenographyVenography

28. Physiologic Testing of Venous
Function
• Venous refilling time
• Maximum venous outflow
• Calf muscle pump ejection fraction

29. Complications
• Hemorrhage
• Pigmentation/ eczema
• Periostitis
• Venous ulcer
• Lipodermatosclerosis
• Talipes equinovarus
• DVT
• Recurrent
thrombophlebitis
• Venous
thromboembolism

31. • Preventive measures C1
• Medical Measures C1-3
• Surgical/Ablative measures C3-6

32. Treatment of Venous Disorders Based
on Pathophysiology

33. Management of Varicose Veins
Minor VVMinor VV
Supportive
stocking
Injection
sclerotherapy,
compression
Trunk VV (long or short saphenous) with incompetenceTrunk VV (long or short saphenous) with incompetence
Endovenous Ablation (Radiofrequency/Laser) >>
Sapheno-femoral / sapheno-popliteal ligation with
stripping of the long or short saphenous vein.
(no need to strip the long saph. In the leg)
BranchBranch
VaricositiesVaricosities
Avulsion/ligation via multiple stabs
IncompetentIncompetent
perforatorsperforators
(detected by(detected by
Duplex)Duplex)
SEPS >> Individual ligation

34. Preventive
Measures
• Avoid prolonged sitting
& standing
• Elevation of limbs
• Weight reduction

35. Medical Management
1. Compression Therapy
– first-line therapy for symptomatic varicose
veins (prevention, treatment & post-op.)
•Elastic crepe bandage – 30-40mm Hg
•Unna boot
– Non-elastic compression
– Zinc oxide, calamine and glycerine
– Dressing changed once in a week
– Infection should not be there
•Graded compression stockings
– Reduce ambulatory venous pressure
– Trans capillary leakage
– Improve cutaneous micro circulation

36. Medical Management contd…
2. Oral medication
•No evidence for monotherapy (only in addition effect on
ulcer healing)
•Calcium dobesilate
– Improves lymph flow, reduce edema
•Daflon, Pentoxifylline (Trental), Aspirin

37. Medical Management (contd)…
Рhlebo/Venotropic drugs
a)Diosmin –
• Semisynthetic flavonoid (modifies hesperidin)
• Venotonic, lymphotonic, Improves microcirculation
• Improves edema, dermatitis, venous ulcers
a)Hesperidin –
• Flavonoid
• Venotonic
• Used along with diosmin
a)Rutoside –
• Glycoside
• Inhibits platelet aggregation, decreases capillary
permeability, anti-inflammatory
• Less certain role

38. Medical Management (contd)…
d) Sulodexide –
• Highly purified glycosaminoglycan consisting of 80% low-
molecular-weight heparin and 20% dermatan sulfate
• Anti-inflammatory, endothelial-protective
• Improves venous ulcers
e) Micronized purified flavonoid fraction (MPFF) (Daflon) –
• 90% micronized diosmin and 10% flavonoids as hesperidin
• Veno and lymphotonic, decreases capillary permeability,
anti-inflammatory
• Improves venous ulcers, reduces edema
• Horse chestnut seed extract

39. Exercise
•Graded exercise programs rehabilitate the muscle
pump and improve the symptoms of CVI.
•Structured exercises re-establishes calf muscle
pump function.
Medical Management (contd)…

40. Sclerotherapy
• For obliterating telangiectases, reticular veins, varicose
veins, and saphenous segments with reflux.
• Complete sclerosis of the venous wall.
• Indications
– Uncomplicated perforator incompetence
– Smaller varices
– Recurrent varices
– Isolated varices
– Aged/unfit patients

41. Sclerotherapy (contd.)…
• Sclerosants used are
– Hypertonic solution of sodium chloride
(23.4%)
– Sodium tetradecyl sulphate
– Sodium morrhuate
– Ethanolamine oleate
– Polidocanol
– Glycerin
• Mechanism of action
– Aseptic inflammation
– Perivenous fibrosis
– Endothelial damage
– Obliteration by intimal approximation

42. Sclerotherapy (contd.)…
• Sclerotherapy with polidocanol foam under duplex
ultrasound guidance has become standard in the
treatment of –
• Intracutaneous telangiectases
• Subcutaneous varicose veins
• Transfascial perforating veins
• Venous malformations
• Complication -
Hyperpigmentation of the surrounding skin from deposition of
hemosiderin.

43. Sclerotherapy Technique

44. Sclerotherapy Contd…

45. Surgical Management
• Trendelenberg’s
procedure
– Juxtafemoral flush ligation
of long saphenous vein
Flush ligation of tibutaries
Superficial circumflex iliac
Superficial external pudendal
Superficial inferior epigastric
Deep external pudendal

46. Surgical Management Contd…
• Stripping of long saphenous vein
• Upto knee joint
• Myer’s stripper
• Complications
– Saphenous nerve injury
– Hematoma
– Infection

47. Surgical Management Contd…
• Perforator incompetence
– Subfascial ligation of perforators
– Linton’s method
– Stab avulsion method

48. SEPS
• Subfascial endoscopic perforator surgery
• Minimally invasive method

49. Endovenous Laser Ablation - EVLA
• US guidance LSV canulated above knee jt
• Guide wire passed beyond SFJ
• Tip is placed 1cm distal to SF junction
• Laser fibre inserted upto the catheter
• Diode laser used for firing

50. EVLA Cotd…
• Office based procedure
• Done under local anesthesia
• One needle puncture at the level of the knee
• Takes about 1 hour
• Patient resumes normal activity same day

51. • Skin grafting can be
put on a non
infected granulating
skin defect of a
venous ulcer

52. • Major complications following VV surgery are relatively
rare.
• Up to 20% morbidity
– Infection
– Hematoma
– Pain
– Nerve damage
• Saphenous nerve (LSV surgery)
• Sural, peroneal nerve (SSV surgery)
– Lymphatic leak - Venous thrombosis - Vascular injury
– Recurrence

53. Recurrent Varicose Veins
A. Are more common if the long saphenous vein is
not tied flush in the first procedure
B. Are more common if incompetent perforators are
not identified at the first procedure
C. Should be investigated by duplex ultrasound
D. Can be treated with sclerotherapy

54. THANK YOU