Varicose Veins


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Teaching presentation on diagnosis and management of varicose veins.

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  • Chronic Venous Insufficiency (CVI) is the general term for a group of disorders including varicose veins (VVs), skin changes (corona phlebectatica, lipodermatosclerosis, varicose eczema, atrophie blanche), and chronic venous ulceration (CVU).
  • It has been noted that men are less troubled by the cosmetic appearance, so they present less often with the problem. However population-based studies also indicate that varicose veins are more common in women, about 2:1. Chronic venous disorders are an important cause of discomfort and disability that is widespread in the industrialized countries and that result in a substantial medical and economic problem. The health care demand is massive, ranking in France as the seventh most often declared reason for consulting a general practitioner. Edinburgh vein study reported a higher prevalence of mild disease in men.
  • Yes, you must know this!!! Part of the examination involves identifying which vein is involved and level of incompetence . Three paired stem veins (no valves): Posterior tibial, Anterior tibial, Peroneal. Two muscular veins (with valves): Soleal, Gastrocnemius. Join with short saphenous vein in popliteal fossa to form popliteal vein, which becomes femoral vein and joins with long saphenous vein in saphenofemoral junction, then becomes iliac vein. Note mid-thigh perforator + 3-4 middle-calf perforators.
  • Corona phlebectatica (ankle/malleolar flare): One of the earliest skin manifestations of CVI comprises dilated intra/subdermal veins at or just below the medial malleolus. Overlying skin is thin and fragile leading to a blue-bleb appearance. Trauma frequently leads to hemorrhage and ulceration. Lipodermatosclerosis: The skin is brown (red or purple) and indurated due to hemosiderin and plasma protein deposition, leading to dermal fibrosis. Atrophie blanche: Thin and pale skin due to the thrombotic obliteration of papillary capillaries; often at the site of previous ulceration. Varicose eczema: Scaly dry (or weeping) skin that is often intensely pruritic and can demonstrate blanching erythema (mimicking cellulitis). Edema: A common presentation in patients with CEAP class 3 or greater CVI. Chronic venous insufficiency may coexist with other diseases that cause edema, such as congestive heart failure, and must be considered when evaluating CVI patients . Hemorrhage: Can be alarming, even life threatening,may be spontaneous or follow trauma. Direct pressure and elevation always arrest venous hemorrhage. As recurrent bleeding is almost inevitable, the patient should be hospitalized for definitive treatment. Ulceration: Most CVUs can be easily differentiated from other forms of ulceration.
  • Localized discomfort in the leg: Usually at the site of the visible VV, particularly after prolonged standing. Prominent varices may be tender, particularly in menstruating w omen. Pain: Severe pain is unusual and suggests infection or arterial insufficiency. Swelling: A feeling of swelling is common. Venous claudication: This is unusual and due to extensive postthrombotic iliofemoral venous occlusion. There is bursting pain in the calf on walking, which is relieved only by elevating the leg. In addition, patients often complain of heaviness in the calf with ambulation. Itching: This is common and may lead to scratching, infection, and ulceration. heaviness, tension, aching, itching commonly after standing
  • Fortunately, major complications following VV surgery are relatively rare. However, up to 20% of patients may suffer some form of minor morbidity, such as hematoma, lymphatic leak, pain, saphenous neuritis, and venous thrombosis. In the U.K., VV surgery is the commonest cause of litigation against general and vascular surgeons. This not a field for the unsupervised, inexperienced surgeon and it behooves surgeons who undertake VV surgery to carefully audit their management, techniques, and outcomes. Surgery is for recurrence in 20% of patients.
  • 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>