Varicose Veins

1. Varicose Veins
By: Dr. Noshirwan P. Gazder

2. • Varicose veins are defined as dilated subcutaneous veins ≥ 3 mm in
diameter in which there is back flow of blood caused by incompetent
valve closure.
• Which results in venous congestion and venous enlargement.
• Most commonly occur in the lower limbs.

4. Blood of Supply of Lower Limb
• Deep Veins.
• Superficial Veins.
1. Great Saphenous Vein.
2. Lesser Saphenous Vein.
• Perforators.

5. Superficial Veins of
Lower Limb
Greater Saphenous Vein:
• Formed by the union of the dorsal
vein of the big toe and dorsal
venous arch of the foot.
• Passes anterior to the middle
malleolus.
• Terminates into the femoral vein
at fossa ovalis 2.5cm below and
lateral to pubic tubercle.

6. Superficial Veins of
Lower Limb
Lesser Saphenous Vein:
• Formed by the union of the dorsal
vein of the little toe and dorsal
venous arch of the foot.
• Passes posterior to the lateral
malleolus
• Empties into popliteal vein within
the popliteal fossa.

7. Deep Veins
• The deep veins are located beneath the deep fascia of the lower limb.
• Most of the deep veins of the lower limb are binary and they
accompany the corresponding arteries sharing their name
1. Femoral vein.
2. Popliteal vein.
3. Anterior tibial vein.
4. Posterior tibial vein.

8. Perforators
• Network of veins that connect superficial veins with the deep veins.
• Allows blood to flow only from the superficial to deep veins.
• Lower Leg Perforators:
1. Ankle perforators (May or Kuster).
2. Lower leg perforators: I, II, III (of Cockett).
3. Gastrocnemius perforators (of Boyd).
4. Mid thigh perforators (Dodd).
5. Hunter’s perforator in the thigh.

9. CEAP classification for Chronic Venous
Insufficiency (CVI)

11. Risk Factors
• Age.
• Sex.
• Pregnancy.
• Family history.
• Obesity.
• Standing or sitting for long periods of time.

12. Causes
• Primary Varicose Veins.
• Secondary Varicose Veins:
1) Pelvic mass (tumors or Uterine Fibroids).
2) Pregnancy.
3) After Pelvic surgery or irradiation.
4) Multiple Arteriovenous Fistulae.

13. Pathophysiology

14. Symptoms
Varicose veins may not cause any pain. So the patient may complain of:
• Veins that are dark purple or blue in color
• Veins that appear twisted and bulging.
When painful the patient may complain of:
• An achy or heavy feeling in the legs.
• Burning, throbbing, muscle cramping and swelling in the lower legs.
• Worsened pain after sitting or standing for a long time.
• Itching around one or more of your veins.
• Skin discoloration around a varicose vein.

15. Signs
• Telangectasia.
• Ankle flare.
• Reticular veins.
• Saphena varix.
• Champagne bottle sign.
• Atrophic Blanche.
• Special tests-positive.

18. Brodie-Trendelenburg Test
• The vein is emptied by elevating the
limb and a tourniquet is tied just
below the sapheno-femoral junction
which occludes the sapheno-femoral
junction.
• The patient is asked to stand quickly.
When the tourniquet is released,
rapid filling from above signifies
saphenofemoral incompetence. This
is Trendelenburg test I.
• In Trendelenburg test II, after
standing tourniquet is not released.
Filling of blood from below upwards
rapidly can be observed within 30-60
seconds. It signifies perforator
incompetence.

19. Three Tourniquet Test
• To find out the site of incompetent perforator, three tourniquets are
tied after emptying the vein
1. At sapheno-femoral junction.
2. Above knee level.
3. Another below knee level.
• The patient is asked to stand and is observed for filling of veins and
the site of filling. Then the tourniquets are released from below
upwards, again to see for incompetent perforators.

20. Schwartz test
• In the standing position, when
the lower part of the long
saphenous vein in leg is tapped,
an impulse is felt at the
saphenous junction or at the
upper end of the visible part of
the vein.
• It signifies continuous column of
blood due to valvular
incompetence.

21. Morrissey’s Cough Impulse Test
• The varicose veins are emptied.
• The leg is elevated and then the patient is asked to cough.
• If there is sapheno- femoral incompetence, expansile impulse is felt
at saphenous opening.
• It is a venous thrill due to vibration caused by turbulent backflow.

22. Perthe’s test
• The affected lower limb is wrapped with an elastic bandage and the
patient is asked to walk around and exercise.
• Development of severe cramp like pain in the calf signifies deep
venous incompetence.
• This is a painful and rarely used test.

23. Complications
• Hemorrhage.
• Ulcerations.
• Pigmentations/Eczema.
• Calcification of vein.
• Equinus deformity.
• Recurrent Thrombophlebitis.
• Deep vein thrombosis.

24. Thank You