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Varicose Veins


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Teaching presentation on diagnosis and management of varicose veins.

Varicose Veins

  1. 1. Sarantos Kaptanis [email_address] Airedale General Hospital Department of Surgery Teaching Session 27 August 2009
  2. 2. <ul><li>“ In A Surgeon's Gown (Good) Physicians May Make Some Progress” </li></ul><ul><li>Incidence </li></ul><ul><li>Age </li></ul><ul><li>Sex </li></ul><ul><li>Geography </li></ul><ul><li>Genetics </li></ul><ul><li>Predisposing factors </li></ul><ul><li>Macroscopic appearance </li></ul><ul><li>Microscopic appearance </li></ul><ul><li>Spread </li></ul><ul><li>Prognosis: mortality and complications </li></ul>
  3. 3. <ul><li>25-50% of adult women </li></ul><ul><li>15-30% of adult men </li></ul><ul><li>Is it an industrialized country disease? </li></ul><ul><li>UK: 45 000 hospital admissions per year </li></ul><ul><li>Patrick H. Carpentier, Hildegard R. Maricq, Christine Biro, Claire O. Poncot-Makinen, Alain Franco, Prevalence, risk factors, and clinical patterns of chronic venous disorders of lower limbs: A population-based study in France, Journal of Vascular Surgery, Volume 40, Issue 4, October 2004, Pages 650-659, ISSN 0741-5214, DOI: 10.1016/j.jvs.2004.07.025. </li></ul><ul><li>Coon WW, Willis PW III, Keller JB. Venous thromboembolism and other venous disease in the Tecumseh community health study. Circulation 1973; 48: 839–846. </li></ul><ul><li>Franks PJ, Wright DD, Moffatt CJ, Stirling J, Fletcher AE, Bulpitt CJ et al. Prevalence of venous disease: a community study in west London. Eur J Surg 1992; 158: 143–147. </li></ul><ul><li>Bradbury A, Evans C, Allan P, Lee A, Ruckley CV, Fowkes FG. What are the symptoms of varicose veins? Edinburgh vein study cross sectional population survey. BMJ 1999; 318: 353–356 </li></ul>
  4. 4. <ul><li>Family history of varicose veins (current hypothesis: autosomal dominant with variable penetrance mode of genetic transmission) </li></ul><ul><li>History of thromboembolic disease </li></ul><ul><li>Number of pregnancies </li></ul><ul><li>Activity (prolonged sitting or standing) </li></ul><ul><li>Unskilled work </li></ul><ul><li>Exercise less than once a week </li></ul><ul><li>Height </li></ul><ul><li>Obesity </li></ul><ul><li>Cornu-Thenard A, Boivin P, Baud MM, et al: Importance of the familial factor in varicose disease: Clinical study of 134 families. J Derm Surg Oncol 20:318-326, 1994 </li></ul><ul><li>Patrick H. Carpentier, Hildegard R. Maricq, Christine Biro, Claire O. Poncot-Makinen, Alain Franco, Prevalence, risk factors, and clinical patterns of chronic venous disorders of lower limbs: A population-based study in France, Journal of Vascular Surgery, Volume 40, Issue 4, October 2004, Pages 650-659, ISSN 0741-5214, DOI: 10.1016/j.jvs.2004.07.025. </li></ul>
  5. 5. <ul><li>Dilated, tortuous, elongated superficial veins – Possible venous eczema – possible venous ulcers </li></ul>Venous eczema Images: Mr Neeraj Bhasin
  6. 6. <ul><li>Anatomy of the venous system of the leg </li></ul><ul><ul><ul><li>Deep veins </li></ul></ul></ul><ul><ul><ul><ul><li>Posterior tibial </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Anterior tibial </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Peroneal </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Soleal </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Gastrocnemius </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Popliteal </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Femoral </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Iliac </li></ul></ul></ul></ul><ul><ul><ul><li>Superficial veins </li></ul></ul></ul><ul><ul><ul><ul><li>Long saphenous (LSV) </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Short saphenous (SSV) </li></ul></ul></ul></ul>
  7. 8. <ul><li>It was previously thought that axial destruction of venous valves led to transmission of ambulatory venous hypertension, causing reflux and varix formation. </li></ul><ul><li>However, Labropoulos and associates reported that the most common location for initial varicose vein formation was in the below-knee great saphenous vein (GSV) and its tributaries, followed by the above-knee GSV, and the saphenofemoral junction. </li></ul><ul><li>Their study clearly indicates that vein wall degeneration with subsequent varix formation can occur in any segment of the superficial and deep systems at any time and suggests a genetic component to the disease. </li></ul><ul><li>Labropoulos N, Giannoukas AD, Delis K, et al: Where does the venous reflux start? J Vasc Surg 26:736-742, 1997. </li></ul>
  8. 9. <ul><li>Asymptomatic </li></ul><ul><li>Unsightly cutaneous veins </li></ul><ul><li>Itching </li></ul><ul><li>Corona phlebectatica (ankle/malleolar flare) </li></ul><ul><li>Lipodermatosclerosis </li></ul><ul><li>Atrophie blanche </li></ul><ul><li>Varicose eczema </li></ul><ul><li>Edema </li></ul><ul><li>Hemorrhage </li></ul><ul><li>Chronic ulceration </li></ul>
  9. 11. <ul><li>Presenting Complaint: Varicosities, abdominal/groin lump – saphena varix </li></ul><ul><li>Symptoms </li></ul><ul><ul><li>Localized discomfort in the leg, Pain, Swelling, Venous claudication, Itching </li></ul></ul><ul><li>“ Risk” factors </li></ul><ul><ul><li>Female, age, ethnicity, occupation, pregnancy, obesity, smoking </li></ul></ul><ul><ul><li>ASK about history of abdominal complaints/cancer, DVT, previous & other venous complaints </li></ul></ul>
  10. 12. <ul><li>General OSCE tips: ICEPP </li></ul><ul><ul><li>I ntroduce – be polite and friendly </li></ul></ul><ul><ul><li>C onsent to examination </li></ul></ul><ul><ul><li>E xpose (adequately!) </li></ul></ul><ul><ul><li>P osition (standing initially) </li></ul></ul><ul><ul><li>P ain – ask before examining the patient </li></ul></ul><ul><li>Wash hands before examining the patient </li></ul><ul><li>Cover and thank patient, present findings </li></ul>
  11. 13. <ul><li>Look at the legs whilst patient is standing </li></ul><ul><li>Examine around the medial malleolus ‘gaiter area’ </li></ul><ul><li>VVV LAPS </li></ul><ul><ul><ul><li>V aricose veins – distribution (LSV, SSV) </li></ul></ul></ul><ul><ul><ul><li>V enous ulcers/eczema </li></ul></ul></ul><ul><ul><ul><li>V enous stars </li></ul></ul></ul><ul><ul><ul><li>L ipodermatosclerosis </li></ul></ul></ul><ul><ul><ul><li>A trophy blanche </li></ul></ul></ul><ul><ul><ul><li>P itting oedema </li></ul></ul></ul><ul><ul><ul><li>S cars </li></ul></ul></ul>
  12. 14. <ul><li>Venous ulcers/eczema </li></ul><ul><li>Venous stars (spider veins) </li></ul><ul><li>Atrophy blanche </li></ul><ul><ul><li>Ulceration: active and healed </li></ul></ul><ul><ul><li>Leaves a white patch </li></ul></ul><ul><li>Pitting oedema </li></ul>
  13. 15. <ul><li>Lipodermatosclerosis </li></ul><ul><ul><li>Literally &quot;scarring of the skin and fat“ </li></ul></ul><ul><ul><li>A slow process that occurs over a number of years and has 2 phases: </li></ul></ul><ul><li>Acute </li></ul><ul><ul><ul><li>Venous pooling ->chronic venous hypertension </li></ul></ul></ul><ul><ul><ul><li>RBC forced into surrounding tissue </li></ul></ul></ul><ul><ul><ul><li>Haemoglobin broken down into brown haemosiderin </li></ul></ul></ul><ul><li>Chronic </li></ul><ul><ul><ul><li>Chronic haemosiderin formation leads to fibrin deposition </li></ul></ul></ul><ul><ul><ul><li>Skin becomes thickened and shiny </li></ul></ul></ul><ul><ul><ul><li>Skin around ankle constricts and the inverted champagne-bottle shape is seen </li></ul></ul></ul>
  14. 16. <ul><li>Temperature </li></ul><ul><ul><li>Feel with back of hand, should be warm </li></ul></ul><ul><ul><li>If cold, arterial disease may co-exist </li></ul></ul><ul><li>Palpate the vein </li></ul><ul><ul><li>Feel the course of the vein </li></ul></ul><ul><li>Cough impulse </li></ul><ul><ul><li>Locate the saphenofemoral junction (SFJ) </li></ul></ul><ul><ul><li>Feel for the smooth swelling and palpable thrill of a saphena varix (cause of groin lump) </li></ul></ul><ul><ul><li>If present, cough test +ve </li></ul></ul><ul><li>Tap Test </li></ul><ul><ul><li>Place finger at any point along the varicose vein </li></ul></ul><ul><ul><li>Tap the vein proximally (above the finger) </li></ul></ul><ul><ul><li>Incompetent valves allow the transmission of a fluid thrill to the finger below </li></ul></ul><ul><li>Direction Test </li></ul><ul><ul><li>Empty a short section of the vein (place one finger on the vein and slide another finger firmly upwards). </li></ul></ul><ul><ul><li>If the valves are incompetent, the vein will refill when you release the top finger. </li></ul></ul><ul><li>Auscultation </li></ul><ul><ul><li>Over a large group of veins may indicate a bruit </li></ul></ul><ul><ul><li>Rare – indicates an underlying arteriovenous malformation </li></ul></ul>
  15. 17. <ul><li>1. The Trendelenburg test </li></ul><ul><ul><li>Used to assess the competence of SFJ </li></ul></ul><ul><ul><li>Patient lies flat </li></ul></ul><ul><ul><li>Elevate the leg and gently empty the veins </li></ul></ul><ul><ul><li>Palpate the SFJ and ask the patient to stand whilst maintaining pressure </li></ul></ul><ul><ul><li>Findings: </li></ul></ul><ul><ul><li>If the veins do not refill-> SFJ is incompetent </li></ul></ul><ul><ul><li>If the veins do refill ->SFJ may or may not be incompetent, presence of distal incompetent perforators </li></ul></ul>
  16. 18. <ul><li>2. Tourniquet test </li></ul><ul><ul><li>Uses a tourniquet to control the junction rather than fingers </li></ul></ul><ul><ul><li>Advantage of moving the tourniquet lower (mid-thigh region) </li></ul></ul><ul><ul><li>Test is unreliable below the knee </li></ul></ul><ul><li>3. Perthes Test </li></ul><ul><ul><ul><ul><li>Empty the vein as above, place a tourniquet around the thigh, stand the patient up. </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Ask them to rapidly stand up and down on their toes – filling of the veins indicated deep venous incompetence. This is a painful and rarely used test. </li></ul></ul></ul></ul>
  17. 19. <ul><li>Use a Doppler ultrasound </li></ul><ul><li>Examine the abdomen for masses (+ DRE) to ascertain whether the varicose veins are primary or secondary </li></ul><ul><li>Complete a peripheral vascular exam for arterial supply of the lower limb, including ABPI </li></ul>
  18. 20. <ul><li>Conservative/Medical </li></ul><ul><ul><li>Graded compression bandaging, Compression hosiery </li></ul></ul><ul><ul><li>Paste Gauze (Unna) Boots </li></ul></ul><ul><ul><li>Diuretics? Zinc? Phlebotrophic/Hemorheologic agents? Aspirin/NSAIDs etc </li></ul></ul><ul><li>Robert B. Rutherford (editor). Vascular surgery 6th ed. 2005. Elsevier Saunders. ISBN 0-7216-0299-1 (set) </li></ul><ul><li>J. A. Michaels, J. E. Brazier, W. B. Campbell, J. B.MacIntyre, S. J. Palfreyman and J. Ratcliffe. Randomized clinical trial comparing surgery with conservative treatment for uncomplicated varicose veins. British Journal of Surgery 2006; 93: 175–181 </li></ul><ul><li>Surgical </li></ul><ul><ul><li>Ankle-to-groin saphenous vein stripping (with stab avulsion) </li></ul></ul><ul><ul><li>Segmental saphenous vein stripping (with stab avulsion) </li></ul></ul><ul><ul><li>Saphenous vein ligation: high, low, or both </li></ul></ul><ul><ul><li>Saphenous vein ligation and sclerotherapy </li></ul></ul><ul><ul><li>Saphenous vein ligation (with stab avulsion) </li></ul></ul><ul><ul><li>Stab avulsion of varices without saphenous vein stripping (phlebectomy) </li></ul></ul><ul><ul><li>Endoluminal occlusion of the saphenous vein by radiofrequency (RF) or laser energy </li></ul></ul>
  19. 22. Images: Mr Neeraj Bhasin
  20. 23. <ul><li>Day case procedure </li></ul><ul><li>Oral paracetamol as analgesia </li></ul><ul><li>Elastic bandaging for 2-3 days </li></ul><ul><li>Mobilization: Walking for 2-3 miles daily (ideally for 5 minutes every hour) </li></ul><ul><li>Compression stockings? </li></ul><ul><li>J.P. Houtermans-Auckel a, E. van Rossum b, J.A.W. Teijink c, A.A.H.R. Dahlmans a, E.F.B. Eussen a, S.P.A. Nicolaı¨a, R.J.Th.J. Welten. To Wear or not to Wear Compression Stockings after Varicose Vein Stripping: A Randomised Controlled Trial. Eur J Vasc Endovasc Surg (2009) 38, 387-391 </li></ul>
  21. 24. <ul><li>Major complications following VV surgery are relatively rare </li></ul><ul><li>Up to 20% morbidity </li></ul><ul><ul><li>Infection </li></ul></ul><ul><ul><li>Hematoma </li></ul></ul><ul><ul><li>Pain </li></ul></ul><ul><ul><li>Nerve damage </li></ul></ul><ul><ul><ul><li>Saphenous nerve (LSV surgery) </li></ul></ul></ul><ul><ul><ul><li>Sural, peroneal nerve (SSV surgery) </li></ul></ul></ul><ul><ul><li>Lymphatic leak - Venous thrombosis - Vascular injury </li></ul></ul><ul><ul><li>Recurrence </li></ul></ul><ul><li>W. B. Campbell, F. France & H.M. Goodwin, Medicolegal claims in vascular surgery. Annals of the Royal College of Surgeons of England, 84 (2002), 181–4. </li></ul><ul><li>W.G. Tennant, Medicolegal action following treatment for varicose veins. British Journal of Surgery, 8 (1996), 291–2. </li></ul>
  22. 25. <ul><li>Any Questions? </li></ul>