This document discusses varicose veins (VV), including their definition, anatomy, pathophysiology, etiology, clinical presentation, investigations, treatment options, and management approach. VV are dilated, tortuous superficial veins in the lower limbs. Treatment involves initial conservative measures for 3 months, including compression therapy and pharmacologic agents for symptomatic patients or those with reflux. Refractory patients may undergo ablative therapies like sclerotherapy, radiofrequency ablation, or laser ablation to treat refluxing veins. The goals of treatment are improved symptoms and appearance.

1. By
Mahmoud Zaghloul Raslan, MD
Consultant Surgeon, MGH
Madina

2. Definition
 Dilated tortuous superficial veins in
the lower limbs

3. Anatomy
 Venous drainage from LL is through 3 systems:
- Superficial veins:
- Long saphenous vein and tributaries
- Short saphenous vein and tributaries
- Deep veins: Ant. Tibial, post. Tibial,
peroneal, popliteal, deepF., superficial F.
and common F.
- Perforating veins: perforating deep fascia
to connect superficial with deep veins

9. Pathophysiology
Physiology:
_ Blood conductor:
- Muscular compression
- Negative ITP
- Calf Muscle pump
- Presence of valves

10. _ Blood reservoir:
- Dilatable
- Capacious

11. Etiology and Types
 Primary VV
_ High IVP: prolonged standing,
prolonged sitting with crossed
legs, chronic straining,
_ Weakness of vein walls:
- Obesity
- Pregnancy
- Hormonal

12.  Secondary VV:
- After previous DVT
- With pelvic tumours

13. Clinical Picture

14.  Thorough history taking:
- Occupation and prolonged standing
- Throbophlebitis or DVT
- Coaguation disorders
- Diabetes
- Results of previous treatment
- Pregnancy and contraceptive pills

15.  Symptoms:
- Pain: aching, throbbing, tingling
- Cramps, heaviness, tiredness of
legs, restless legs at night
- Of complications: Itching,
hyperpigmentation, skin ulceration
and bleeding
- Leg disfigurement

19. Trendlenberg test

20. Investigations

21.  General:
- Assess the general condition of the patient:
e.g. CBC,liver and kidney function tests
 Specific:
- Hand-held Doppler
- Duplex ultrasound: The best; gives both anatomical
and functional diagnosis
- Others: e.g. CT venography and MRI rarely needed

27. Treatment

28. Initial conservative
treatment
(I) General measures:
 Leg elevation
 Excerise
(II) Compression therapy:

29. (III) Pharmacologic therapy:
 Venoactive drugs
- Micronized purified flavonoid
MPFF e.g.Daflon
- Hydroxyethylrutoside

30.  Rheologic agents:
- Aspirin
- Stanozolol
- pentoxifylline
- prostacyclin analogues

31. (IV) Skin care:
 Skin cleansing e.g. Dove, Olay
 Emollients e.g. vaseline, cetaphil
 Barrier preparations e.g. zinc oxide
cream, Vaseline
 Topical corticosteroids

32. (V) Ulcer care
 Ulcer debridement
 Role of systemic antibiotics
 Topical agents:
- e.g. Silver sulfadiazine
- Other antiseptic agents

33.  Ulcer dressings
- Low-adherent gauze
- Hydrogels and alginate dressing
- Silver containing dressings
 Compressing dressing
 Skin grafting
 Others:
- Hyperbaric oxygen
- Electromagnetic therapy
- Therapeutic ultrasound

34. Vein ablative therapy
 Indications:
- Venous hemorrhage
- Superficial thrombophlebitis
- Venous reflux associated with
symptoms

35.  Contraindications:
- Pregnancy
- Acute superficial or deep venous
thrombosis
- Moderate to severe PAD
- Advanced generalized systemic
disease

36. Types of vein ablative
therapy
 Chemical:
- Sclerotherpy
 Mechanical:
- Surgical excision
 Thermal:
- Radiofrequency ablation RFA
- Endovenous laser therapy EVLA

37. Sclerotherapy
 Sclerosants:
_ Sodium tetradecyl sulphate
_ Sodium marrhuate
_ Polydocanol
_ Ethanolamine oleate
_ Hypertonic saline

40. Surgical stripping

42. Endoscopic subfascial
ligation of incompetent
perforators

44. Radiofrequency ablation
therapy
 By directing radiofrequency energy through a
vein, a narrow rim of tissue less than 1mm is
heated by an electrode.
 The amount of heating is modulated using a
microprocessor resulting in controlled
collagen contraction, thermocoagulation and
absorption of the vein.

49.  Endovenous laser ablation:
Initiates nonthrombotic occlusion by direct
thermal injury to vein wall causing
endothelial destruction, collagen
contraction and later fibrosis

54. Management by clinical category
 No visible or palpable signs of
venous dis. (CEAP category 0):
- If C/O venous symptoms:
Treated conservatively

55.  Telangiectasias and reticular veins
(CEAP category 1):
_ Asymptomatic patients with no
reflux: Treated by
- Sclerotherapy
- Laser light therapy
_ Symptomatic patients with reflux:
- Treat reflux first by surgical or
thermal ablation

56.  Varicose veins (CEAP category 2):
_ Isolated varicosities without trunkal
reflux are treated by:
- Sclerotherapy
- Surgical excision
Depending on size, location and
number of affected veins
_ With reflux: Treated by vein ablation

57.  Comparison of ablative therapies:
_ Recent studies reveal that minimally
invasive therapies are as effective as
surgical ablation with fewer
complications and rapid regain of daily
activities

58.  Advanced venous disease:
_ Patients with edema, skin changes or
ulceration (CEAP categories C3, C4,
C5, C6: Treated by initial conservative
measures
_ Refractory patients to conservative
measures: Treated by ablative therapy

59. Summary and conclusion

60.  Visibly dilated LL veins may indicate
underlying venous reflux, especially if
symptomatic, However, they can occur
in absence of symptoms or reflux
 Duplex US is essential to identify
superficial, deep or perforator vein reflux
and R/O DVT

61.  Patients with venous reflux and those
with complications should be referred to
venous or at least vascular specialist for
further evaluation and management
 Goals of treatment are improved
symptoms and appearance

62.  Most patients are treated by initial
conservative measures
 Patients refractory to conservative
measures for 3 months with documented
reflux (>0.5 second duration) are
candidates for vein ablative therapy

63.  Patients with telangiectasias, reticular
vein and VV with reflux should undergo
vein ablation before treating these
lesions
 Telangiectasias, reticular veins and
small VV large enough to admit 27 or 30
gauge needle are treated best by
sclerotherapy with good results

64.  Laser therapy is the only option for
telangiectasias too small to access,
allergy to sclerosants, patients afraid of
needles and after failed sclerotherapy
 Endovenous ablation techniques are
preferred for saphenous and other
trunkal veins over surgical ablation

65.  Persistent or recurrent perforators (by
duplex scan) after vein ablation are
treated by US-guided sclerotherapy or
endovenous methods
 Occasionally, surgical methods may be
required for recurrent or refractory
venous ulceration