Varicose Vein


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Dr Sajid Ali abbasi

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Varicose Vein

  1. 2. Dr. Sajid Ali Varicose Vein Topic Presentation
  2. 3. <ul><li>The collecting system of veins. </li></ul><ul><li>The conduits for blood to travel from superficial to the deep veins. </li></ul><ul><li>The channel through which blood is pumped out of the legs. </li></ul><ul><li>Contraction of leg muscles pumps blood through one-way valves up and out of the legs. </li></ul>Anatomy of V:System of leg A: Superficial venous system B: Perforating veins C: Deep venous system D: Musculovenous pump
  3. 4. <ul><li>Superficial System arises from foot & ends at Sapheno- femoral junction or Sapheno- popliteal junction. </li></ul><ul><li>Formed by union of dorsal digital vein of great toe & dorsal venous arch </li></ul><ul><li>Ascends ant: to medial malleolus, post: to medial condyle of femur. </li></ul><ul><li>Prox: it traverses saphenous opening in fascia to enter femoral vein. </li></ul><ul><li>Along its course, a variable number of named perforating veins may connect to deep system i.e. femoral, posterior tibial, gastrocnemius, & soleal veins. </li></ul>A:Superficial venous system 1: Great Saphenous Vein
  4. 5. <ul><li>Formed by union of dorsal digital vein of 5th digit & distal venous arch. </li></ul><ul><li>Runs post: to lateral malleolus, lateral to calcaneal tendon. </li></ul><ul><li>Runs superiorly medial to fibula and penetrates deep fascia of popliteal fossa, ascends b/w heads of gastrocnemius muscle to join popliteal vein. </li></ul>2: Small Saphenous Vein
  5. 6. <ul><li>These veins transverse deep fascia of lower extremity. </li></ul><ul><li>Valves are located just distal to penetration of deep fascia. </li></ul><ul><li>A number of named perforators are found at thigh, knee & leg. </li></ul><ul><li>Cockett perforators b/w ankle & knee are special group of perforating veins. </li></ul><ul><li>Rather than directly connecting sup: to deep venous systems they connect subfascial deep system with post: arch vein which then empties into GSV. </li></ul>B: Perforating Veins
  6. 7.   Named perforators along the greater saphenous distribution
  7. 8. <ul><li>Deep veins accompany the arteries. </li></ul><ul><li>Usually paired and run with named arteries inside a vascular sheath, this allows arterial pulsation to force blood proximally. </li></ul><ul><li>Popliteal vein joins femoral vein in popliteal fossa. </li></ul><ul><li>Femoral vein is joined by deep vein of thigh . </li></ul><ul><li>Femoral vein passes deep to inguinal ligament to become external iliac vein. </li></ul>C: Deep Venous System
  8. 9. <ul><li>Foot and calf muscles act to squeeze blood out of deep veins. </li></ul><ul><li>One way valve allow only upward and inward flow. </li></ul><ul><li>During muscle relaxation blood is drawn inward thru perforating veins. </li></ul>D: Musculovenous Pump
  9. 10. <ul><li>Valve leaflets allow unidirectional flow upward or inward. </li></ul><ul><li>Dilation of vein wall prevents apposition of valve leaflets,resulting in reflux. </li></ul><ul><li>Valvular fibrosis,destruction, or agenesis results in reflux. </li></ul>Venous Valvular Function
  10. 11. <ul><li>Long tortuous & dilated veins of superficial varicose system. </li></ul><ul><li>Varicose veins are bulging veins that are larger than spider veins i.e. typically 3 mm or more in diameter. </li></ul><ul><li>Force of gravity,pressure of body weight & task of carrying blood from bottom of body up to heart make legs primary location for varicose veins. </li></ul><ul><li>May also occur else where i.e. Abdominal Wall,Anus,Vulva, Oesophagus. </li></ul>What are varicose veins?
  11. 12. <ul><li>Visible, palpable veins in the subcutaneous skin greater than 3 mm </li></ul>Varicose veins
  12. 13. <ul><li>Also called spider veins, hyphen webs, or thread veins. </li></ul><ul><li>Dilated intradermal venules greater than 1 mm in diameter. </li></ul>Telangiectasias
  13. 14. <ul><li>Also called blue veins, subdermal varices or venulectasias. </li></ul><ul><li>Visible, dilated bluish subdermal, nonpalpable veins 1-3 mm . </li></ul>Reticular veins
  14. 15. <ul><li>Valvular insufficiency of the superficial veins, most commonly at the saphenofemoral junction. </li></ul><ul><li>Mainly caused by deep vein thrombosis (DVT) that leads to chronic deep venous obstruction or valvular insufficiency. </li></ul><ul><li>Catheter-associated DVTs are also included. </li></ul><ul><li>Pregnancy-induced and progesterone-induced venous valve weakness </li></ul><ul><li>Trauma. </li></ul><ul><li>This includes any venous malformations.i.eKlippel-Trenaunay variants,avalvulia etc. </li></ul>Secondary Congenital Primary Why do they occur?
  15. 16. Pathways leading to varicose veins and other clinical manifestations of venous hypertension.
  16. 17. <ul><li>Aging causes wear and tear on valves in veins that help regulate blood flow, that wear can cause valves to malfunction. </li></ul><ul><li>Women are more likely than men to develop condition. </li></ul><ul><li>Hormonal changes during pregnancy or menopause may be factor. </li></ul><ul><li>Female hormones tend to relax vein walls. </li></ul><ul><li>Taking hormone replacement therapy or birth control pills may increase risk. </li></ul>Risk factors Age Sex
  17. 18. <ul><li>If other family members had varicose veins,there's greater chance you will too. </li></ul><ul><li>Being overweight puts added pressure in veins. </li></ul><ul><li>Prolonged immobile standing impairs venous return. </li></ul><ul><li>Pregnancy,Abdominal/pelvic mass,Ascites,constipation etc inc: risk. </li></ul>Genetics Obesity Standing for long periods of time Anything that raises intra-abd:pressure
  18. 19. <ul><li>Achy or heavy feeling in legs. </li></ul><ul><li>Burning, throbbing & muscle cramping in lower legs. </li></ul><ul><li>Prolonged sitting or standing tends to make legs feel worse. </li></ul><ul><li>Restless” legs at night. </li></ul><ul><li>Appearance of spider veins in affected leg. </li></ul><ul><li>Skin ulcers near ankle, which represent severe form of vascular disease & require immediate attention. </li></ul><ul><li>Redness, dryness & itchiness of areas of skin - termed stasis dermatitis or venous eczema b/c of waste products building up in leg. </li></ul><ul><li>Skin above ankle may shrink (lipodermatosclerosis) b/c fat underneath skin becomes hard. </li></ul>Symptoms
  19. 20. <ul><li>A careful inspection & documentation of the site of varicosities is extremely important. </li></ul><ul><li>Look along distribution of Long saphenous vein i.e. Medial side along length of leg. </li></ul><ul><li>Next look along distribution of Short Saphenous vein i.e. Below knee, posterior & lateral aspects of leg. </li></ul>Signs
  20. 21. <ul><li>Varicosities can lead to major complications due to poor circulation thru affected limb. </li></ul><ul><li>Extremely painful ulcers may form on skin particularly near ankles. </li></ul><ul><li>Pigmentations & skin changes ie.brownish darkening of skin resulting from extravasated blood that causes lipodermatosclerosis. </li></ul><ul><li>Development of carcinoma or sarcoma in longstanding venous ulcers. </li></ul><ul><li>Blood clotting within affected veins termed sup:thrombophlebitis that can extend into deep veins becoming more serious problem. </li></ul><ul><li>Acute fat necrosis can occur, esp: at ankle of overweight pats with varicose veins. </li></ul>Complications
  21. 22. Venous stasis ulcer Lipodermatosclerosis
  22. 23. <ul><li>This is physical exam: technique to localise valves that are incompetent </li></ul><ul><li>Lie patient down & raise leg attempting to drain varicosities </li></ul><ul><li>Using either tourniquet or fingers put pressure over SFJ to occlude it & ask patient to stand </li></ul><ul><li>If varicosities don’t refill indicates SFJ incompetence & if do refill then leaky valve is lower down </li></ul><ul><li>Now try and locate incompetent perforators </li></ul><ul><li>Place tourniquet aprox: over area of each perforator i.e.mid thigh,sapheno popliteal,calf perforators </li></ul><ul><li>If varicosities don’t refill that perforator is incompetent & if varicosities do refill continue down leg </li></ul>Diagnostic Procedures A: Trendelenberg / Tourniquet Tests
  23. 24. <ul><li>This is also physical exam: technique in which tourniquet is placed over prox: part of leg to compress any sup: varicose veins while leaving deep veins unaffected. </li></ul><ul><li>Pat walks to activate calf-muscle pump which normally causes varicose veins to be emptied. </li></ul><ul><li>If obstruction of deep system exists then activation of calf-muscle pump causes paradoxical congestion of sup:venous system and engorgement of varicose veins resulting in positive test. </li></ul><ul><li>To verify pat is then placed supine & leg is then elevated (Linton test). </li></ul><ul><li>If varices distal to tourniquet fail to drain after a few seconds again deep venous obstruction must be considered. </li></ul>B: Perthes Maneuver / Linton Test
  24. 25. <ul><li>Doppler transducer is positioned along axis of vein with probe at angle of 45° to skin. </li></ul><ul><li>When distal vein is compressed audible forward flow exists . </li></ul><ul><li>If valves are competent no audible backward flow is heard with release of compression. </li></ul><ul><li>If valves are incompetent an audible backflow exists. </li></ul><ul><li>These compression-decompression maneuvers are repeated while gradually ascending limb to level at which reflux can no longer be appreciated . </li></ul>C: Doppler Auscultation
  25. 26. <ul><li>Duplex US with color-flow imaging sometimes called triplex ultrasound. </li></ul><ul><li>This is special type of 2-dimensional ultrasound that uses Doppler-flow information to add color for blood flow in image. </li></ul><ul><li>Vessels in blood are colored red for flow in one direction and blue for flow in other with graduated color scale to reflect speed of flow. </li></ul><ul><li>Venous valvular reflux is defined as regurgitant flow with Valsalva that lasts great than 2 seconds. </li></ul>D: Duplex US
  26. 27. <ul><li>This is a physiologic test,using plethysmography. </li></ul><ul><li>VRT is time necessary for lower leg to become infused with blood after calf-muscle pump has emptied lower leg. </li></ul><ul><li>In healthy subjects VRT is greater than 120 seconds </li></ul><ul><li>In pats with significant venous insufficiency VRT is abnormally fast at 20-40 seconds. </li></ul><ul><li>VRT of less than 20 seconds is markedly abnormal & is nearly always symptomatic. </li></ul><ul><li>If VRT is less than 10 seconds venous ulcerations are likely. </li></ul>E: Venous Refilling Time (VRT)
  27. 28. <ul><li>Most sensitive & most specific test to find causes of anatomic obstruction. </li></ul><ul><li>MRV is particularly useful b/c unsuspected nonvascular causes for leg pain and edema may often be seen on scan image when clinical presentation erroneously suggests venous insufficiency or venous obstruction. </li></ul><ul><li>This is expensive test used only as adjuvant when doubt still exists. </li></ul>F: Magnetic Resonance Venography (MRV)
  28. 29. <ul><li>Elevating legs often provides temporary symptomatic relief. </li></ul><ul><li>Wearing of graduated compression stockings with pressure of 30–40 mmHg has been shown to correct swelling, nutritional exchange & improve microcirculation in affected legs. </li></ul><ul><li>Caution should be exercised in patients with concurrent arterial disease. </li></ul><ul><li>They are offered in different levels of compression. </li></ul><ul><li>They are constructed using elastic fibers or rubber which help compress limb, aiding in circulation. </li></ul>Treatment 1: Compression Stockings A: Non-surgical Treatment
  29. 30. Compression stockings
  30. 31. <ul><li>It is commonly performed non-surgical treatment. </li></ul><ul><li>Often used for spider veins & varicose veins that persist or recur after vein stripping. </li></ul><ul><li>Sodium tetradecyl sulphate etc is inj: in veins to make them shrink. </li></ul><ul><li>Sclerotherapy can also be performed using foamed sclerosants under ultrasound guidance to treat larger varicose veins including GSV & SSV. </li></ul><ul><li>In U/S guided sclerotherapy u/s is used to visualize underlying vein so surgeon can deliver and monitor injection. </li></ul><ul><li>Microsclerotherapy is used to treat spider veins & other very small varicose veins. </li></ul>2: Sclerotherapy
  31. 32. <ul><li>GSV Saphenectomy </li></ul><ul><li>Surgical removal of GSV have evolved from large open incisions to less invasive stripping. </li></ul><ul><li>Stripping consists of removal of all or part of saphenous vein main trunk </li></ul><ul><li>Different devices are used in stripping i.e Mayo stripper, Babcock device, Keller device etc. </li></ul><ul><li>Perforation-invagination (PIN) stripper is mainly used now a days. </li></ul><ul><li>Technique of PIN stripping begins with 2-3cm incision made at groin. </li></ul>B: Surgical Treatment 1: Open Techniques Cont.......
  32. 33. <ul><li>Femoral vein and SFJ are exposed with dissection & all tributaries of SFJ must be identified and flush-ligated to minimize incidence of reflux recurrence. </li></ul><ul><li>Vessel is then inverted into itself tearing away from each tributary & perforator as stripper is pulled downward thru leg & out thru incision in upper calf. </li></ul><ul><li>Long epinephrine-soaked gauze or ligature may be secured to stripper before invagination allowing hemostatic packing to be pulled into place after stripping is complete. </li></ul>
  33. 34. Perforation-invagination (PIN) stripping
  34. 35. <ul><li>SSV Saphenectomy </li></ul><ul><li>Removal of SSV is complicated by variable local anatomy and risk of injury to popliteal vein & peroneal nerve </li></ul><ul><li>Saphenopopliteal junction must be located by duplex exam: before beginning dissection. </li></ul><ul><li>After ligation and division of junction stripping instrument is passed downward into distal calf where it is brought out thru a small incision (2-4 mm). </li></ul><ul><li>Stripper is secured to proximal end of vein which is invaginated into itself as it is pulled downward from knee to ankle and withdrawn from below. </li></ul>
  35. 36. <ul><li>It is extremely useful for treatment of residual vein clusters after saphenectomy & for removal of nontruncal tributaries when saphenous vein is competent. </li></ul><ul><li>Microincision is made over vessel phlebectomy hook is introduced & vein is delivered thru incision. </li></ul><ul><li>With traction, as long a segment as possible is pulled out of body until vein breaks or cannot be pulled any further. </li></ul><ul><li>Another microincision is made and process is begun again and repeated along entire length of vein to be extracted. </li></ul><ul><li>Pat can go home same day after procedure is done. </li></ul>2: Stab or Ambulatory Phlebectomy
  36. 37. <ul><li>Laser fiber produces endoluminal heat that destroys vascular endothelium. </li></ul><ul><li>Seldinger technique is used to advance long catheter along entire length of truncal varicosity to be ablated. </li></ul><ul><li>Under U/S guidance tumescent solution with local anesthetic is inj: around entire length of vessel. </li></ul><ul><li>Firm pressure is applied to collapse vein around laser fiber & laser is fired generating heat leading to intraluminal steam bubbles,irreversible endothelial damage & thrombosis. </li></ul><ul><li>This process is repeated along entire course of vessel </li></ul>3: Endovenous (EV) laser Techniques
  37. 38. <ul><li>RF thermal energy is delivered directly to vessel wall causing protein denaturation, collagenous contraction & immediate closure of vessel. </li></ul><ul><li>Metal fingers at tip of RF catheter are deployed until they make contact with vessel endothelium. </li></ul><ul><li>RF energy is delivered both in and around vessel to be treated. </li></ul><ul><li>Thermal sensors record temp: within vessel & deliver just enough energy to ensure endothelial ablation. </li></ul><ul><li>RF catheter is withdrawn a short distance & process is repeated all along length of vein to be treated </li></ul>D: Radiofrequency (RF) ablation
  38. 39. <ul><li>Endovascular occlusion of Saphenous veins using VNUS ClosureTM Catheter </li></ul>A Minimally Invasive Alternative to Vein Stripping Surgery
  39. 40. <ul><li>Subcutaneous hematoma is a common complication. </li></ul><ul><li>Dysesthesias can occur from injury to sural or saphenous nerve. </li></ul><ul><li>At SFJ accidental treatment of femoral vein by inappropriate RF or laser catheter placement,spread of sclerosant or inappropriate surgical ligation can all lead to endothelium damage. </li></ul><ul><li>Hard tender lumps can sometimes form along the line of removed vein which usually disappears after few weeks. </li></ul><ul><li>Keloid scars can occur. </li></ul>Post operative Complications
  40. 41. Thank You