CHRONIC Venous Diseases JOEL ARUDCHELVAM MBBS (COL), MD (SUR), MRCS (ENG) CONSULTANT VASCULAR AND TRANSPLANT SURGEON Definition Clinical Classification Pathophysiology Varicose veins Venous anatomy Examination of varicose veins Investigations Detection of reflux Indications for treatment Treatment Options Deep Vein Thrombosis Definition Pulmonary embolism

1. DR JOEL ARUDCHELVAM
MBBS (COL), MD (SUR), MRCS (ENG)
CONSULTANT VASCULAR AND TRANSPLANT SURGEON

2.  A 40 year old female presented with the history
of heaviness and pain on calf region while
standing for long time, for 2 years duration.
The pain is not present while lying down. On
examination of her lower limbs, she had leg
swelling and there was pigmentation of the
lower half of the leg and the skin of the lower
leg was thickened. Dorsalis pedis pulse was
palpable. The most likely cause for the leg pain
is;

3. a) Acute deep vein thrombosis
b) Chronic compartment syndrome
c) Chronic venous hypertension
d) Lymphatic obstruction
e) Occlusive arterial disease causing ischemia

4.  A 60 year old female presented with history of
non-healing ulcer over the medial malleolus for
5 years duration. The ulcer was painless. There
was lot of fluid discharge from the wound. She
is a patient with diabetes mellitus for 10 years
duration but she does not have foot numbness.
There were varicose veins on the leg. The distal
pulses were palpable. And the surrounding
skin was dark in colour and thickened. The
most likely cause for the above wound is;

5. a) Arterial insufficiency
b) Chronic venous hypertension
c) Lymphatic obstruction and lymphedema
d) Neuropathy
e) Osteomyelitis on the medial malleolus

6.  spectrum of clinical manifestations occurring
due to venous hypertension

7. TelangiectasiaReticular veins

11.  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

12.  Venous hypertension
 Fibrin cuff theory
 decreases oxygen permeability
 White cell trapping
 Leukocytes get trapped in
capillaries releasing proteolytic
enzymes and reactive oxygen
metabolites causing endothelial
damage

13.  Varicose veins are abnormal,
dilated, tortuous, elongated
superficial veins
 Derived from the Greek word
"varix," - “grapelike”

14.  Superficial veins – great saphenous, Small Saphenous, etc.
 Deep veins – veins accompanying deep arteries (femoral,
popliteal, tibial )
 Perforators

15. Venous anatomy
 Named perforators
along
 Greater saphenous
distribution

16.  Short history
 Find out indications for intervention
 Exclude DVT in past
 Inspection
 Ask the patient to stand
 Expose
 Site (above or below knee)
 Affected veins (long / short saphenous veins)
 Edema
 Skin changes
 Palpation
 Tapping test

18.  Patient on supine position.
 Distal pulse
 Lipodermatosclerosis
 Palpate along the vein for any depression - fascial
defect (perforator incompetence) (button hole).
 Keep hand at SFJ. (Just medial to the femoral pulse.
3- 4 cms below and lateral to the pubic tubercle-
palpate cough impulse.

20.  Special test
 Tourniquet test

21.  Fills in less than 20 sec -
abnormal

22.  A 50 year old male presented with the history
of leg swelling for 2 months duration. He does
not have pain. The swelling reduces while
lying down and increases when standing for a
long time. On examination, there was pitting
edema at the ankle joint. There was dark
discoloration of the skin. There were few
varicose veins. The initial appropriate
investigation in this patient is;

23. a) Computed tomographic Venography
b) Conventional Venography
c) Duplex ultrasound scan
d) Lymphangiography
e) Magnetic resonance Venography

24.  To detect the presence of
venous insufficiency
 To find out the source
 To plan the intervention

25.  Non invasive
 Duplex scan
 Plethysmograhy
 CT Venography
 MR Venography
 Invasive
 Phlebography
 Ambulatory venous pressure
 Intravascular ultrasound

26.  USS + Doppler (+ Colour
(Colour Duplex)
 Preferred imaging
 High -frequency linear
array transducer of 7.5–
13 MHz

27.  Sites of reflux and size of refluxing segments
 Deep, superficial, perforator
 Abnormalities
 Duplicate GSV / SSV
 Hypoplastic femoral system
 DVT /Obstruction

28. • Above GSV – standing with
foot rotated outwards
weight taken on opposite
leg
• Below GSV and SSV –
seated

29. • Surrounded by
fascial layers
• “Egyptian eye” sign

30. • Surrounded by
fascial layers
• “Egyptian eye” sign

31. CFA/ CFV/SFJ
“Micky mouse”
sign

32. CFA/ CFV/SFJ
“Micky mouse”
sign

33.  Flow augmented and released
 Provocative maneuvers
 Distal limb compression
 Rapid inflation deflation cuff

34.  Significant reflux
 Superficial vein - > 0.5 s
 Deep - > 1s

35.  Reflux Augmentation

36.  Cosmetic
 Symptomatic
 Complicated
 Oedema
 C4 – skin changes
 C4a: pigmentation and eczema.
 C4b: lipodermatosclerosis and atrophie blanche.
 C5: healed ulcer.
 C6: active ulcer

37.  Surgery
 Thermal Ablation
 LASER
 Radio Frequency Ablation - RFA
 Sclerotherapy

38.  SFI / SPL
 Surgery
 sapheno-femoral junction Ligation – SFL
 Sapheno popliteal junction Ligation – SPL
 Thermal ablation
 Endo venous laser ablation (EVLA)
 Radio Frequency Ablation
 LSV reflux
 Stripping
 Thermal ablation
 Varicosities /perforators
 Avulsions
 Sclerotherapy

39.  The whole table is tilted head down
(Trendlenberg position)

40.  Incision at groin
crease
 at Saphenous opening
3-4 cm below and
lateral to pubic
tubercle.

41.  Ligation of tributaries

42.  Stripping

43. • Multiple Stab Avulsions
• 2-3 mm stab
• No 11 blade

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

47.  Scleroscents used
 Sodium tetradecyl sulphate(std)
 Hypertonic saline
 Polydocanol
 Ethanolamine oleate

48.  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

49.  Mechanism of action
 Inflammation
 Endothelial damage
 Obliteration

50.  Multiple layers of various bandages
 Aimed at counteracting the
consequences of the venous
hypertension
 Applied in a way so that maximum
pressure is at the fore foot and the
pressure is gradually reduced when its
reaches the calf (graduated
compression)

51.  A 30 year old postpartum mother, developed
right leg swelling 5 days after delivery. She had
gradual onset pain at calf. Pain was constant.
He did not have fever. On examination there
was pitting edema of the leg. The distal pulses
were present. The calf was tender. The most
likely cause for the swelling is;

52.  Acute Deep vein thrombosis
 Cellulitis
 Lower Limb arterial thrombosis
 Myositis of the calf muscles
 Ruptured Bakers cyst

53.  Thrombosis – formation of solid material
within the circulation using blood components.
 Thrombophlebitis – due to infecction

55.  Leg swelling
 Pain

56.  D dimer
 Originate from clot lysis
 Duplex scan ( USS +
Doppler)
 Solid material inside vessel
 Non compressible
 Absent flow
 No augmentation
 No Phasic variation

59.  LMWH (low molecular weight heparin) – e.g.
Enoxaparin (1 mg/kg twice daily SC), dalteparin,
tinzaparin
 Advantages
 Does not require infusion
 Does not need frequent monitoring
 Unfractionated Heparin
o Loading dose 75 – 100 IU/Kg ( approx 5000 IU )
o Followed by Infusion of heparin -18U/kg (approx -
1000U/hr )
o Monitored with APTT. (Keep APTT between 60 to 80s)

60.  Also Start
o Warfarin
o10 mg D1
o10 mg D2
o5 mg D3
 Target INR - between 2 – 3
 When INR between 2 - 3 for 2 days omit
heparin.
 Continue warfarin for 3 months

61.  Other measures
 Analgesics
 Compression stocking
 Foot end elevation
 Hydration
 Young recurrent DVT – haematology
referral

62.  Occurs in 60 to 80% of patients with DVT
 Only half are symptomatic

63.  Clinical features depends on the size of the
embolus
 Small – lodges at peripheral pulmonary vessels
 Pain (pleuritic), effusion
 Pulmonary hypertension
 Larger – at branching points
 Wedge shaped infarction
 Pleuritic pain, effusion, tachypnoea
 Massive – occludes the bifurcation
 Haemodynamic instability
 Sudden onset pain
 SOB

64.  A 60 year old male underwent hemi
arthroplasty of the right hip joint. 5 days after
the surgery he developed painful swelling of
the right leg. On examination there was edema
of the leg. The distal pulses were present. One
day later he developed shortness of breath.
And the oxygen saturation reading on the
pulse oximeter was 92. He was suspected to
have pulmonary embolism. What is the most
appropriate investigation to confirm the
pulmonary embolism in this patient;

65. a) Catheter directed pulmonary angiography
b) Chest X Ray
c) Computed tomographic (CT) pulmonary
angiography
d) Magnetic resonance (MR) pulmonary angiography
e) ventilation–perfusion (VQ)Isotope scan

66.  Diagnosis
 CXR –wedge shaped
Oligaemic area/
infarction
 Dilated central vessels

67.  Diagnosis
 Gold standard – CT pulmonary angiogram

68.  Other tests
 Arterial Blood Gases
 Hypoxemia
 Hypocapnia
 Alkalosis
 ECG – only 20% has classic changes
 S1 Q3 T3
 Right heart strain
 Tall P waves in lead II (P
pulmonale), R axis deviation,
RBBB
 2D ECHO – R heart strain

70. Thank You