Our Vein treatment procedures have the least recovery time & give long term outstanding results. All our Vein Centers have in-house diagnostic Ultrasound and Colour Doppler facilities that gives us a precise roadmap to plan your Varicose veins treatment.

1. WELCOME TO
VARICOSE VEIN CENTER• By
• Dr. Himanshu Shah
• M.B.B.S. DMRD. VASCULAR RADIOLOGIST AND VARICOSE
CONSULTANT

2. VARICOSE VEINS
• Varicose veins are veins that have become
enlarged and twisted. The term commonly
refers to the veins on the leg, although
varicose veins can occur elsewhere. Veins
have pairs of leaflet valves to prevent blood
from flowing backwards (retrograde flow or
venous reflux). Leg muscles pump the veins
to return blood to the heart (the skeletal-
muscle pump), against the effects of gravity.
When veins become varicose, the leaflets of
the valves no longer meet properly, and the
valves do not work (valvular incompetence).
This allows blood to flow backwards and they
enlarge even more. Varicose veins are most
common in the superficial veins of the legs,
which are subject to high pressure when
standing. Besides being a cosmetic problem,
varicose veins can be painful, especially
when standing. Severe long-standing
varicose veins can lead to leg swelling,
venous eczema, skin thickening
(lipodermatosclerosis) and ulceration. Life-
threatening complications are uncommon,
but varicose veins may be confused with
deep vein thrombosis, which may be life-
threatening
DR. HIMANSHU SHAH
M.B.B.S.D.M.R.D., VARICOSEVEIN CONSULTANT

3. ULCER VARICOSE VEINS IN LEGS
• Non-surgical treatments include sclerotherapy, elastic
stockings, leg elevation and exercise. The traditional
surgical treatment has been vein stripping to remove the
affected veins. Newer, less invasive treatments which seal
the main leaking vein are available. Alternative techniques,
such as ultrasound-guided foam sclerotherapy,
radiofrequency ablation and endovenous laser treatment,
are available as well. Because most of the blood in the legs
is returned by the deep veins, the superficial veins, which
return only about 10% of the total blood of the legs, can
usually be removed or ablated without serious harm.
• Secondary varicose veins are those developing as collateral
pathways, typically after stenosis or occlusion of the deep
veins, a common sequel of extensive deep venous
thrombosis (DVT). Treatment options are usually support
stockings, occasionally sclerotherapy and rarely, limited
surgery.

4. SIGNS AND SYMPTOMS
1. Aching, heavy legs (often worse at night and after exercise).
2. Appearance of spider veins (telangiectasia) in the affected
leg.
3. Ankle swelling, especially in evening.
4. A brownish-yellow shiny skin discoloration near the affected
veins.
5. Redness, dryness, and itchiness of areas of skin, termed
stasis dermatitis or venous eczema, because of waste
products building up in the leg.
DR. HIMANSHU SHAH
M.B.B.S.D.M.R.D., VARICOSEVEIN CONSULTANT

5. 1. Cramps may develop especially when
making a sudden move as standing up.
2. Minor injuries to the area may bleed more
than normal or take a long time to heal.
3. In some people the skin above the ankle
may shrink (lipodermatosclerosis) because
the fat underneath the skin becomes hard.
4. Restless legs syndrome appears to be a
common overlapping clinical syndrome in
patients with varicose veins and other
chronic venous insufficiency.
5. Whitened, irregular scar-like patches can
appear at the ankles. This is known as
atrophie blanche.
DR. HIMANSHU SHAH
M.B.B.S.D.M.R.D., VARICOSEVEIN CONSULTANT

6. COMPLICATIONS
Most varicose veins are reasonably benign,
but severe varicosities can lead to major
complications, due to the poor circulation
through the affected limb.
DR. HIMANSHU SHAH
M.B.B.S.D.M.R.D., VARICOSEVEIN CONSULTANT

7. 1. Pain, tenderness, heaviness, inability to walk or stand for long hours, thus
hindering work
2. Skin conditions / Dermatitis which could predispose skin loss
3. Skin ulcers especially near the ankle, usually referred to as venous ulcers.
4. Development of carcinoma or sarcoma in longstanding venous ulcers. Over
100 reported cases of malignant transformation have been reported at a
rate reported as 0.4% to 1%.
5. Severe bleeding from minor trauma, of particular concern in the elderly.
6. Blood clotting within affected veins, termed superficial thrombophlebitis.
These are frequently isolated to the superficial veins, but can extend into
deep veins, becoming a more serious problem.
7. Acute fat necrosis can occur, especially at the ankle of overweight patients
with varicose veins. Females are more frequently affected than males.

8. DIAGNOSIS
• Clinical tests that may be used include:
• Trendelenburg test–to determine the
site of venous reflux and the nature of
the sapheno femoral junction
• Multiple tournique test–to more
accurately localize the site of the venous
reflux
• Fegan's test–to assess the nature of any
perforating vein blow outs
• Perthes test–to check the patency of the
deep veins
• Other more historical/ academic tests
include Scwhartz test, and Morrisey's
cough impulse test.
• Lower limbs venous ultrasonography has
replaced most of the rest.
• Traditionally, varicose veins were
investigated using imaging
techniques only if there was a
clinical suspicion of deep venous
insufficiency, if they were recurrent,
or if they involved the sapheno-
popliteal junction. This practice is
not now widely accepted. Patients
with varicose veins should now be
investigated using lower limbs
venous ultrasonography. The
results from a randomised
controlled trial on patients with and
without routine ultrasound has
shown a significant difference in
recurrence rate and reoperation
rate at 2 and 7 years of follow up.
Clinical tests Investigations
DR. HIMANSHU SHAH
M.B.B.S.D.M.R.D., VARICOSEVEIN CONSULTANT

9. According to the CEAP classification:
C0 –no visible or palpable signs of venous disease
C1 – telangectasia or reticular veins
C2 –varicose veins.
C3 –edema
C4a –pigmentation or eczema
C4b –lipodermatosclerosis, atrophie blanche
C5 –healed venous ulcer
C6 –active venous ulcer •Each clinical class is further characterised by a
subscript depending upon whether the patient is symptomatic (S) or
asymptomatic (A) e.g. C2S.

10. CAUSES
Varicose veins are more common in women than in men, and are linked with
heredity. Other related factors are pregnancy, obesity, menopause, aging,
prolonged standing, leg injury and abdominal straining. Varicose veins are
unlikely to be caused by crossing the legs or ankles. Less commonly, but not
exceptionally, varicose veins can be due to other causes, as post phlebitic
obstruction or incontinence, venous and arteriovenous malformations.
More recent research has shown the importance of pelvic vein reflux (PVR) in
the development of varicose veins. Hobbs showed varicose veins in the legs
could be due to ovarian vein reflux and Lumley and his team showed
recurrent varicose veins could be due to ovarian vein reflux. Whiteley and his
team reported that both ovarian and internal iliac vein reflux causes leg
varicose veins and that this condition affects 14% of women with varicose
veins or 20% of women who have had vaginal delivery and have leg varicose
veins. In addition evidence suggests that failing to look for, and treat pelvic
vein reflux can be a cause of recurrent varicose veins.
DR. HIMANSHU SHAH
M.B.B.S.D.M.R.D., VARICOSEVEIN CONSULTANT

11. There is increasing evidence for the role of incompetent Perforator veins
(or "perforators") in the formation of varicose veins and recurrent varicose
veins.
Varicose veins could also be caused by hyperhomocysteinemia in the body,
which can degrade and inhibit the formation of the three main structural
components of the artery: collagen, elastin and the proteoglycans.
Homocysteine permanently degrades cysteine disulfide bridges and lysine
amino acid residues in proteins, gradually affecting function and
structure. Simply put, homocysteine is a 'corrosive' of long-living proteins,
i.e. collagen or elastin, or lifelong proteins, i.e. fibrillin. These long-term
effects are difficult to establish in clinical trials focusing on groups with
existing artery decline. Klippel-Trenaunay syndrome and Parkes-Weber
syndrome are relevant for differential diagnosis.
Another cause is chronic alcohol consumption due to the vasodilatating
side effect in relation to gravity and blood viscosity.

12. TREATMENT
Treatment can be either conservative or active. Active treatments can be
divided into surgical and non-surgical treatments. Newer methods
including endovenous laser treatment, radiofrequency ablation and foam
sclerotherapy appear to work as well as surgery for varices of the greater
saphenous vein.
DR. HIMANSHU SHAH
M.B.B.S.D.M.R.D., VARICOSEVEIN CONSULTANT

13. CONSERVATIVE
The National Institute for Health and Clinical Excellence (NICE)
produced clinical guidelines in July 2013 recommending that all
people with symptomatic varicose veins (C2S) and worse should be
referred to a vascular service for treatment. Conservative treatments
such as support stockings should not be used unless treatment was
not possible.
DR. HIMANSHU SHAH
M.B.B.S.D.M.R.D., VARICOSEVEIN CONSULTANT

14. The symptoms of varicose veins can be controlled to an extent with the
following:
Elevating the legs often provides temporary symptomatic relief.
Advice about regular exercise sounds sensible but is not supported by any
evidence.
The wearing of graduated compression stockings with variable pressure
gradients (Class II or III) has been shown to correct the swelling, nutritional
exchange, and improve the microcirculation in legs affected by varicose veins.
They also often provide relief from the discomfort associated with this disease.
Caution should be exercised in their use in patients with concurrent arterial
disease.

15. The wearing of intermittent pneumatic compression devices have been
shown to reduce swelling and increase circulation
Diosmin/Hesperidine and other flavonoids.
Anti-inflammatory medication such as ibuprofen or aspirin can be used as
part of treatment for superficial thrombophlebitis along with graduated
compression hosiery – but there is a risk of intestinal bleeding. In
extensive superficial thrombophlebitis, consideration should be given to
anti-coagulation, thrombectomy or sclerotherapy of the involved vein.
Topical gel application, helps in managing symptoms related to varicose
veins such as inflammation, pain, swelling, itching and dryness. Topical
application-noninvasive has patient compliance.
DR. HIMANSHU SHAH
M.B.B.S.D.M.R.D., VARICOSEVEIN CONSULTANT

16. SURGICAL
SURGERIES HAVE BEEN PERFORMED FOR OVER A CENTURY, FROM THE MORE
INVASIVE SAPHENOUS STRIPPING, TO LESS INVASIVE PROCEDURES LIKE
AMBULATORY PHLEBECTOMY AND CHIVA.
• Stripping consists of removal of all
or part the saphenous vein
(great/long or lesser/short) main
trunk. The complications include
deep vein thrombosis (5.3%),
pulmonary embolism (0.06%), and
wound complications including
infection (2.2%). There is evidence
for the great saphenous vein
regrowing after stripping. For
traditional surgery, reported
recurrence rates, which have been
tracked for 10 years, range from 5–
60%. In addition, since stripping
removes the saphenous main
trunks, they are no longer available
for use as venous bypass grafts in
the future (coronary or leg artery
vital disease)
• Other surgical treatments are:
• Ambulatory phlebectomy
• Veinligation is done at sephenofemoral
junction after ligating the tributeries at
sephanofemoral junction without
stripping the long sephenous vein
provided the perforater veins are
competent and absent DVT in the deep
veins.With this method long sephenous
vein is preserved.
• Cryosurgery- A cryoprobe is passed
down the long saphenous vein following
saphenofemoral ligation. Then the probe
is cooled with NO2 or CO2 to −85o F. The
vein freezes to the probe and can be
retrogradely stripped after 5 seconds of
freezing. It is a variant of Stripping. The
only point of this technique is to avoid a
distal incision to remove the stripper.
Stripping Other
DR. HIMANSHU SHAH
M.B.B.S.D.M.R.D., VARICOSEVEIN CONSULTANT

18. A 1996 study reported a 76% success rate at 24 months in treating
saphenofemoral junction and great saphenous vein incompetence with STS 3%
solution. A Cochrane Collaboration review concluded sclerotherapy was better
than surgery in the short term (1 year) for its treatment success, complication
rate and cost, but surgery was better after 5 years, although the research is
weak. A Health Technology Assessment found that sclerotherapy provided less
benefit than surgery, but is likely to provide a small benefit in varicose veins
without reflux. This Health Technology Assessment monograph included
reviews of epidemiology, assessment, and treatment, as well as a study on
clinical and cost effectiveness of surgery and sclerotherapy.
Complications of sclerotherapy are rare but can include blood clots and
ulceration. Anaphylactic reactions are "extraordinarily rare but can be life-
threatening," and doctors should have resuscitation equipment ready. There
has been one reported case of stroke after ultrasound guided sclerotherapy
when an unusually large dose of sclerosant foam was injected.

19. SCLEROTHERAPY
A commonly performed non-surgical treatment for varicose and "spider" leg
veins is sclerotherapy, in which medicine (sclerosant) is injected into the veins to
make them shrink. The medicines that are commonly used as sclerosants are
polidocanol (POL branded Asclera in the United States, Aethoxysklerol in
Australia), sodium tetradecyl sulphate (STS), Sclerodex (Canada), Hypertonic
Saline, Glycerin and Chromated Glycerin. STS (branded Fibrovein in Australia)
liquids can be mixed at varying concentrations of sclerosant and varying
sclerosant/gas proportions, with air or CO2 or O2 to create foams. Foams may
allow more veins to be treated per session with comparable efficacy. Their use in
contrast to liquid sclerosant is still somewhat controversial. Sclerotherapy has
been used in the treatment of varicose veins for over 150 years. Sclerotherapy is
often used for telangiectasias (spider veins) and varicose veins that persist or
recur after vein stripping. Sclerotherapy can also be performed using foamed
sclerosants under ultrasound guidance to treat larger varicose veins, including
the great saphenous and small saphenous veins.
DR. HIMANSHU SHAH
M.B.B.S.D.M.R.D., VARICOSEVEIN CONSULTANT

20. ENDOVENOUS THERMAL
ABLATION
There are three kinds of endovenous thermal ablation treatment possible
laser, radiofrequency and steam.
The Australian Medical Services Advisory Committee (MSAC) in 2008
determined that endovenous laser treatment/ablation (ELA) for
varicose veins "appears to be more effective in the short term, and at
least as effective overall, as the comparative procedure of junction
ligation and vein stripping for the treatment of varicose veins." It also
found in its assessment of available literature, that "occurrence rates of
more severe complications such as DVT, nerve injury and paraesthesia,
post-operative infections and haematomas, appears to be greater after
ligation and stripping than after EVLT". Complications for ELA include
minor skin burns (0.4%) and temporary paraesthesia (2.1%). The
longest study of endovenous laser ablation is 39 months.
DR. HIMANSHU SHAH
M.B.B.S.D.M.R.D., VARICOSEVEIN CONSULTANT

21. BEFORE AFTER
BEFORE AFTER
DR. HIMANSHU SHAH
M.B.B.S.D.M.R.D., VARICOSEVEIN CONSULTANT

23. Two prospective randomized trials found speedier recovery and fewer
complications after radiofrequency ablation (ERA) compared to open surgery.
Myers wrote that open surgery for small saphenous vein reflux is obsolete.
Myers said these veins should be treated with endovenous techniques, citing
high recurrence rates after surgical management, and risk of nerve damage up
to 15%. By comparison ERA has been shown to control 80% of cases of small
saphenous vein reflux at 4 years, said Myers. Complications for ERA include
burns, paraesthesia, clinical phlebitis and slightly higher rates of deep vein
thrombosis (0.57%) and pulmonary embolism (0.17%). One 3-year study
compared ERA, with a recurrence rate of 33%, to open surgery, which had a
recurrence rate of 23%.
Steam treatment consists in injection of pulses of steam into the sick vein.
This treatment which works with a natural agent (water) has similar results
than laser or radiofrequency. The steam presents a lot of post-operative
advantages for the patient (good aesthetic results, less pain, etc.)

24. ELA and ERA require specialized training for doctors and special equipment.
ELA is performed as an outpatient procedure and does not require an
operating theatre, nor does the patient need a general anaesthetic. Doctors use
high frequency ultrasound during the procedure to visualize the anatomical
relationships between the saphenous structures. Some practitioners also
perform phlebectomy or ultrasound guided sclerotherapy at the time of
endovenous treatment. Follow-up treatment to smaller branch varicose veins
is often needed in the weeks or months after the initial procedure. Steam is a
very promising treatment for both doctors (easy introduction of catheters,
efficient on recurrences, ambulatory procedure, easy and economic procedure)
and patients (less post-operative pain, natural agent, fast recovery to daily
activities).
THANK YOU
DR. HIMANSHU SHAH
M.B.B.S.D.M.R.D., VARICOSEVEIN CONSULTANT