This document discusses various venous disorders including varicose veins, chronic venous insufficiency, venous thrombosis, and venous ulcers. It describes the classification, anatomy, etiology, clinical features, investigations, and management of these conditions. The main types of venous thrombosis discussed are superficial thrombophlebitis and deep vein thrombosis. Superficial thrombophlebitis involves superficial veins and causes pain, tenderness and swelling along the vein. Deep vein thrombosis can dislodge and cause potentially fatal pulmonary embolisms.

1. Diseases of Veins
Dr. Alok Kumar
PhD, Shalya Tantra
NEIAH Shillong

2. Classification
Common Venous disorders are:
• Varicose veins
• Chronic venous insufficiency
• Venous thrombosis (superficial & deep)
• Venous ulcer
• Pulmonary embolism

3. Varicose veins
• Varicose Vein, a dilated, lengthened,
and often tortuous vein.
• If a vein becomes permanently dilated
it is called a varicose vein.
• The most common varicose veins are
the superficial leg veins.

4. VENOUS DRAINAGE OF LOWER LIMB
• The veins Consists of
three groups
• Deep vein – tibial.
Poplitial, femoral
• Superficial vein – long
saphenous vein, short
saphenous vein and their
tributaries
• Perforating or
communicating vein

6. Etiology
• Morphological factor
• Erect position
• Drain against gravity
• Superficial veins have loose fatty tissue support
• Predisposing factor
• Prolonged standing
• Obesity
• Pregnancy
• Old age
• Athletes

7. Classification
• Congenital varicose vein
• Primary varicose vein
• Secondary varicose vein

8. Congenital varicose vein
Due to congenital presence of
1. Arterio-venous fistula
2. Venous hemangioma

9. Primary varicose vein
Defect in the valves either due to thrombosis or
inflammation of vein.
• Sapheno-femoral valve defect – Varicosity of long saphenous vein.
• Sapheno-popliteal valve defect – Varicosity of short saphenous vein.
• Perforators valve defect – Varicosity of either long or short saphenous
vein.

10. Secondary varicose vein
Due to venous flow obstruction
1. Mechanical obstruction like pregnancy, Uterine Fibroid, ovarian cyst, pelvic
tumors.
2. Other factor like Deep vein thrombosis, progesterone, acquired artero-venous
fistula, venous hemangioma, iliac vein thrombosis, retroperitoneal
lymphadenitis or fibrosis.

11. Clinical feature
1. Tired & aching sensation in the affected limb at the end of the day.
2. Sharp bursting pain in grossly dilated veins.
3. Cramp in the calf shortly after retiring to bed.
4. H/O – prolong standing.
5. Presence of dilated & tortuous vein, along with
• Ankle swelling towards evening.
• Skin over varicosity may itch.
• Skin over varicosity may be pigmented.
• Eczema of the affected skin.
• Venous ulceration.

12. Examination
Inspection
• Veins become prominent when patient stands
up.
• Varicosity either of wide spread or single
(saphenavarix).
• single (saphenavarix) varicosity disappears
when patient lies down.
• Varicosity of long or short saphenous vein must
be assessed.
• Lower leg must be seen for oedema,
pigmentation, eczema & ulceration.

13. Palpation
• Coughing impulse +ve in saphena varix.
• Brodie – Trendelenburg test:- To determine incompetency of sapheno-femoral valve.
• Tourniquet test:- To determine incompetency of communicating vein.
• Pratt’s test:- To know the position of leg perforators.
•Perthes’ test:-To know the deep vein normalcy.
•Schwartz’s test.
•Morrisey’s test.
•Fegan’s method to indicate the site of perforators.
•Examination of abdomen to exclude pregnancy or other pelvic tumors & other dilated
vein of abdominal wall.
•P/R & P/V to exclude pelvic tumors

14. Investigation
• Ascending venography
• Doppler USG

15. Management
A- Palliative treatment: (Indication)
• Pregnancy
• Avoid surgery
• Waiting for surgery
• Early cases
B- Operative treatment : (Indication)
• Positive Trendelenburg test
• Sapheno-femoral incompetence
(Contraindication)
• Pregnancy
• Women taking OCP
• Thrombophlebitis
C- Injection therapy:(Indication)
• Varicose vein confined to below knee
• Patient refuse to surgery
(Contraindication)
• Deep vein thrombosis
• Sapheno-femoral incompetence

16. Palliative treatment
Treatment consists of
1. Avoid prolonged standing
2. Crepe bandages or elastic stockings for continuous use
3. Elevation of limb from the level of heart
4. Exercise to strengthen the calf muscles

17. Operative treatment
• Ligation
• Ligation with stripping

18. Ligation
A- for sapheno-femoral incompetence
Procedure should be performed under GA. An Incision is
made just below the groin crease starting from femoral artery
pulsation to 5cm medially. The long saphenous vein is now
ligated with femoral vein. All other intervening tributaries are
also ligated to avoid later recurrence and formation of blind
loop. The long saphenous is now ligated distal to the flush
ligature and divided between the ligatures. Incision close with
interrupted suture with ASD.
B- sapheno-popliteal incompetence
The incision is made in popliteal fossa to expose short
saphenous vein and applied flush ligature with popliteal vein
and another ligature is applied distal to is . The short
saphenous vein is divided between ligature. Incision close
with interrupted suture with ASD

19. Ligation with striping
• Striping operation is performed on long saphenous veins. It is not popular in short saphenous as
incompetent perforating veins are hardly associated with short saphenous and it may cause the
damage to sural veins also.

20. Procedure:
1. Two small incision is made one medial malleolus and other at groin to expose saphenous vein, care
must be taken to avoid damage of saphenous nerve.
2. The distal part is ligated tight and ligature held with pair of artery forceps to lift the vein. Proximal tie
is kept loose. The vein is incised between two ligature and olive point of Myer’s vein is stripper is
inserted upward and emerge at groin incision.
3. The wire of stripper is about 73cm long.
4. Upper end is now pulled till acorn head is arrested at the medial malleolus incision.
5. Proximal ligature of distal incision is tightened around stripper. Now the vein is severed between two
ligature.
6. The ends of distal ligature is cut short.
7. Skin is sutured above acorn head .
8. Stripper is steadily pulled through the groin incision severing all the tributaries of long saphenous
vein.
9. The stripper is kept aside and skin margin at groin incision are closed.
10. ASD accompanies with crepe bandage.

22. Post-operative management
• At the end of operation compression bandage must bee applied to
limb to prevent bruising.
• The bandages may be replaced after 1or 2 days with elastic stocking.
• Advantage of stocking is that it can be removed before bath and put on
again.
• Mild analgesics may require to avoid pain and prophylactic antibiotics
to avoid infection.
• Rare possible complication may occur is the damage of accompanies
sensory nerve.

23. Fegan’s Injection therapy
• The principle of treatment is to inject sclerosant in the empty vein that
use to damage the intima and later on c.auses sclerosis in vein.
• The sclerosant used for therapy like ethanolamine oleate 5%hor sodium
tetradecyle sulphate 3%(Thrombovar).
• The quantity of sclerosant should not be more than 1 ml in one time at
one point.

24. Procedure
• First mark the dilated perforators in standing position with ink.
• A needle of syringe with slight withdrawn piston insert in vein and confirm
the position of needle inside vein.
• now ask the patient to lei down and empty the vein the push the 1ml of
sclerosant at every marked perforators.
• Applied compression bandage from groin to toe.
Postoperative care:
• Patient should encourage the walking as early as possible and avoid to
disturbed compression bandages for 3 weeks.
• Change bandage with less compression after 3 weeks.
• Ask patient for regular follow-up for recurrence or any complications.

25. Venous thrombosis
• Is very common surgical problem, having great influence on morbidity
and mortality of surgical patients.

26. Etiology
The factors that play major role in venous thrombosis are:
• Stasis
• Injury to vessel walls
• Hypercoagulability of blood

27. Predisposing factor
8. Shock
9. Long time sitting or bed rest
10. Pregnancy
11. Infection
12. Varicose vein
13. Obesity
14. Using OCP
1. Major injuries
2. Following major operations
3. Visceral cancer
4. Tobacco smoking
5. Diabetes
6. Congestive heart failure
7. Polycythemia vera

28. • Out of all these hypercoagulability is most important factor.
Process of thrombus formation
Damage to the endothelium
adherence of platelets
start of thrombotic process.

29. Outcome of thrombosis
1. Proximally : thrombus extends to large veins may cause pulmonary
embolism or infarction that may be fatal
2. Locally : clot organize as fibrous tissue. Later on it may calcified
and damage the valvular system of that vein leading to chronic
venous insufficiency.
3. Distally : thrombus causes venous obstruction, if the venous
pressure raises more than arterial pressure it may cause venous
gangrene.

30. Types of thrombosis
Superficial (Thrombophlebitis): here
mainly superficial veins involved. In this
cases venous thrombosis is associated with
local inflammatory response giving rise
pain, tenderness, swelling and redness.
Deep (Phlebothrombosis): here thrombus
produces local sign of inflammation and
the clot is loosely attached to wall that may
dislodge from it’s original site and may
cause fatal pulmonary embolism

31. Superficial vein thrombosis
(Thrombophlebitis)
• It occurs more often in superficial vein, particularly in varicose vein or after intra-
venous infusion.
• This may also seen with association with Plocythemia, Polyarteritis, Buerger’s
Disease and visceral cancer.
• In Buerger’s disease and visceral cancer thrombophlebitis may affect one after other
veins this particular condition is called thrombophlebitis migrans. Also known as
Trousseau’s sign.
Clinical feature : patients usually complains of a painful cord like inflamed area,
inflamed vein. There may be local redness, pain, tenderness and local induration.

32. Treatment
Mainly conservative management rarely required surgical treatment.
Conservative treatment includes:
• Hot bath or compress
• Elastic support or compress bandages
• Anticoagulants
• Aspirin is quit effective for anti-inflammatory.
• Rarely require antibiotics
Surgical treatment :
Only when there is evidence of ascent of thrombus into proximal veins,
ligation of vein is justified. Ligation of long saphenous vein at sapheno-
femoral junction using local anaesthesia. And short saphenous vein at
popliteal fossa.

33. Deep vein thrombosis (DVT) (Phlebothrombosis)
Calf is the most frequent site for deep vein thrombosis. Etiological factor
and predisposing factors are already discussed. Patient suspected for DVT
should be treat promptly to avoid propagation of clot and reduce fatality.
Clinical feature:
DVT is usually asymptomatic only 40% patient shows clinical picture. The
main symptom is dull aching pain at affected site. Muscular activity may
increase the pain. Sometime patient feel only heaviness in affected limb
that increases on standing position. Affected part may be have little
swelling and increase temperature.

34. Physical finding
There are three important sign
Swelling: not very obvious so must be measure with tape.
Tenderness: over thrombosis vein can be careful palpation of calf,
popliteal space and thigh.
Homan’s sign: the passive dorsiflexion of foot provoked pain in calf.
Passive elongation of gastrocnemius and soleus muscles causes irritative
pain in the calf.
Moses’ sign: squeezing of calf muscles from side to side is painful in
case of DVT.

35. Common site of DVT
• Calf vein thrombosis (50%)
• Femoral vein thrombosis
• Iliofemoral vein thrombosis
• Pelvic vein thrombosis

36. Special investigation
• Phlebography
• Radiological fibrinogen test
• Doppler ultrasonography
• Plethysmography
• Venous pressure measurement
• Duplex ultrasound imagine

37. Prevention
• DVT is the condition which may prevented if proper precautions taken
during the major surgical procedure. Because most of the DVT occur
in the post operative periods. The major three points should be keep in
mind-
1. To Minimize venous stasis
2. To avoid venous intima injury
3. To reduce hypercoagulability
To achieve all these point some steps must be taken before, during and
after surgery

38. Care of surgical patients to avoid DVT
Before operation:
• Reduce time of waiting in hospital
• Leg elevation above heart level
During operation:
• Leg elevation above heart level during surgery
• Hypertonic irritant intravenous solutions should not be given in lower extremities.
• Use anti-coagulants in small doses. 5000 unit of heparin subcutaneously 2 hr. prior to
surgery.
• Intermittent pneumatic compression of calf muscles
After operation:
• Leg elevation above heart level
• Aspirin in small dose helps both in pain and avoid DVT
• Elastic compression stocking for continuous use.

39. Management of stablished cases
• Conservative treatment
• Operative treatment

40. Conservative treatment (ABCDEF &H)
1. Bed rest for 7 days to allow thrombus to settle down at one place
that reduces chance of pulmonary embolism.
2. Elevation of leg relieve odema and pain in leg, increase blood flow
with gravity.
3. Heparin act as anti-thrombin.
4. Coumarin derivatives reduce plasma conc. of prothrombin
5. Fibrinolytic drugs e.g. streptokinase to dissolve clot.
6. Asprin, Dipyridamile and sulphinpyrazone drugs to
inhibit/reduce platelet function.

41. Operative treatment
• By-pass procedure (Palma operation, May-Husni procedure)
• Valvular repair
• Valve transplant by autograft

42. Chronic venous insufficiency
Means then vein is not enough sufficient to drain the blood from
affected part that causes various sign and symptoms.
Etiology:
There are mainly three cause of chronic venous insufficiency:
1. Varicose vein.
2. Incompetent perforators.
3. Deep vein abnormalities.

43. Clinical features
1. Odema with browny
induration
2. Varicose vein
3. Pain and heaviness in
limb
4. Local dermatitis
5. Itching in skin
6. Venous ulcer

44. Pathophysiology
Due to varicose vein, DVT, incompetent perforators and other deep vein abnormalities
Serious stasis of venous blood in deep venous system
Fibrinogen escapes through large venules of skin
Accumulated fibrin cannot removed due to inadequate blood flow
This develops a pericapillary cuff which act as barrier in oxygen and nutrient transfer
As results this subcutaneous tissue became thick, hard and tendor known as liposclerosis.
These changes along with stasis dermatitis produces brawny edema, cutaneous atrophy and pigmentation
ultimately tissue death and ulceration.

45. Management
• Conservative treatment:
• Elevation of limb
• Active exercise
• Elastic compression stocking
• Avoid longtime standing or walking
• Treatment of venous ulcer
• Surgical treatment:
• Ligation and striping of long saphenous vein
• Fegan’s injection therapy
• Ligation of incompetent perforators
• By-pass operation of veins

46. Venous ulcer
• Venous Ulcers usually develops in
lower part of lower limb. These
develops due to improper
functioning of the adjoining vein.
• There two types of venous ulcers.
Firstly, ulceration may be
associated with visible varicose
vein and secondly ulceration
followed with thrombosis and
phlebitis of deep vein.

48. Special investigation
• Ascending functional phlebography
• Doppler ultrasonography

49. Management
• Conservative
• Elevation of limb
• Active exercise
• Avoid longtime standing or walking
• Elastic compression stocking
• Effective antibiotic after C/S
• Daily C&D
• Absorbent dressing
• Surgery
• The procedure require for incompetent perforator, varicose vein may be useful.
• Skin graft may require if wound area is large.
• Bypass may be performed for thrombosed deep veins.
• Valvular repairs may be performed if required.