clinical presentation on varicose vein.

1. Weekly Presentation
Dr Md. Tafazzul Hossain Bhuiyan
FCPS Trainee
Dept of surgery
DMCH

2. Varicose vein

3. Introduction
• Up to 40% of adult in resource rich countries have disease of veins
• Usually affects saphenous vein and its branches
• Associated impairment in health related quality of life made it very
important area of surgical practice
• Surgical interventions has been revolutionized by the development of
endovenous techniques

4. Anatomy

5. Definition
• Elongated, tortuous, subcutaneous dilated vein 3 mm in diameter or
larger with intermittent blowouts is varicose vein
• Ref: Bailey & Love’s Short Practice of Surgery 28ed

6. Picture

7. Epidemiology
• Age: Prevalence increases with age
• Gender: Higher prevalence in female
• Ethnic groups: less common in Africa and far east than Europe and
North America
• Occupation: Involves occupations that require prolong standing
• Lifestyle: more in smokers and who suffers from constipation
• Body mass: increasing body mass has higher prevalence
• Pregnancy: increases the risk of varicose veins

8. Pathophysiology

9. Pathophysiology

10. Causes of varicose vein
• Primary
• Cause not known
• Often familial
• Weakness of vein wall, valve ring dilatation
• Congenital absence of valve

11. Causes
• Secondary
• Obstruction to venous outflow by
• Pregnancy
• Fibroids/ ovarian cyst
• Abdominal lymphadenopathy
• Pelvic cancer
• Ascites
• Iliac vein thrombosis
• Retroperitoneal fibrosis
• Valve destruction
• Deep vein thrombosis
• Arteriovenous fistula

12. Complications
• Hemorrhage
• Eczema and dermatitis
• Periostitis
• Venous ulcer
• Lipodermatosclerosis
• Deep vein thrombosis
• Thrombophlebitis
• Talipes equinovarus
• calcification

13. Classification
• The descriptive CEAP classification is widely utilized
• CEAP stands for C- Clinical, E- Etiology, A- Anatomy and P-
Pathophysiology

14. Clinical classification
• C0: no signs of venous disease
• C1: telangiectasia or reticular veins
• C2: varicose veins
• C3: oedema
• C4a: pigmentation or eczema
• C4b: LDS or atrophie blanche
• C4c: Corona phlebectatica
• C5: healed venous ulcer
• C6: active venous ulcer

15. • Clinical class can be further characterized as symptomatic (s),
asymptomatic (a), or recurrent (r).
• e.g C2a, C2s, C6r

16. Etiological classification
• Ec: congenital
• Ep: primary
• Es: secondary (post thrombotic)
• En: no venous cause identified

17. Anatomical classification
• As: superficial veins
• Ap: perforator veins
• Ad: deep veins
• An: no venous location identified

18. Pathophysiological classification
• Pr: reflux
• Po: obstruction
• Pr,o: reflux and obstruction
• Pn: no venous pathophysiology identifieable

19. Symptoms
• Aching
• Heaviness
• Throbbing
• Burning
• Bursting
• Itching
• Swelling of ankle

20. Symptoms

21. Investigation
• Torniquet test and use of hand held doppler have now been
abandoned
• Duplex ultrasound scanning for all patients
• Pelvic and iliac veins by trans abdominal duplex
• MR venography
• Contrast venography
• Intravenous ultrasound

22. Management
• Compression: compression hosiery improves symptoms
• Endothermal ablation:
• Laser ablation: EVLA
• Radiofrequency ablation
• Non endothermal, non tumescent ablation
• Ultrasound guided foam sclerotherapy
• Catheter directed sclerotherapy
• Endovenous glue

23. EVLA

24. EVLA

25. RFA by closurefast

26. Endovenous glue

27. Surgery
• Open surgery
• Saphenofemoral ligation and great saphenous stripping
• Saphenopopliteal ligation and small saphenous stripping
• Adjunctive surgical techniques
• Phlebectomy
• Perforator ligation

28. Saphenofemoral ligation and great saphenous
stripping

29. Phlebectomy

30. Complication of surgery
• Wound infection
• Nerve injury
• Saphenous nerve injury following GSV stripping
• Sural nerve injury following SSV surgery
• Venous thromboembolic complication

31. References
• Bailey and love’s short practice of surgery, 28e
• Browse’s introduction to the symptoms and sign of surgical disease, 6e
• https://www.astraveinvascular.com/endovenous-laser-ablation-evla-evlt/
• https://www.cedarsheart.com/radiofrequency-ablation-treatment-varicose-veins/
• https://www.veinclinicperth.com.au/treatments/glue-treatment-for-veins/
• https://clinicadrmolina.es/en/tratamientos-varices-iv-cirugia-clasica-en/

32. Thank you