1. Duplex ultrasound, plethysmography, and venography are common non-invasive and invasive tests used to investigate varicose veins. 2. Treatment options include conservative measures, injection sclerotherapy, and surgery. Surgery involves stripping the saphenous vein and removing tributaries and perforators. 3. Newer treatments include endovenous laser ablation which closes the vein using laser without removal and subfascial endoscopic perforator surgery to ligate perforators through a small incision.

1. VARICOSE VEINS-
INVESTIGATIONS AND
MANAGEMENT

2. INVESTIGATIONS
INVASIVE NON INVASIVE
VENOGRAPHY 1.DOPPLER USG
2.PLETHYSMOGRAPHY
3.COLOUR DOPPLER

3. DOPPLER ULTRASOUND
Procedure
With patient in standing position,the hand
held doppler probe is placed at the
saphenofemoral junction(SFJ)
With other hand,the examiner gently
squeezes the calf to propel blood forward-
this is heard as a ‘whoosh’from the
loudspeaker of the doppler machine

5. PLETHYSMOGRAPHY
This is a graphical representation of the
pressures in the superficial and deep veins at
rest and during exercise
various techniques include:
1. strain gauge plethysmography
2.photoplethysmography
3.impedance plethysmography
4.air plethysmography

6. VENOGRAPHY
Both ascending and descending
venography have to be done to give to
give the same information as colour
doppler
Good alternative in places where there are
no ultrasound facilities

7. ASCENDING VENOGRAPHY
USES
1.To diagnose perforator incompetence
2.To map out the deep venous system
3.To diagnose deep vein thrombosis-seen
as a filling defect

8. procedure
Tourniquet is tied just above the medial
maleoli to prevent blood flow into the
superficial veins
Non-ionic contrast is injected into the
dorsal venous arch
Normally,only the deep venous system
can be seen

9. DESCENDING VENOGRAPHY
Uses: To test for the competence of
Saphenofemoral Junction
Procedure

10. DUPLEX ULTRASOUND
IMAGING(COLOUR DOPPLER)
Involves use of higher resolution B-mode USG
with Doppler USG to obtain images of arteries,
veins and simultaneously measure flow in these
vessels.
The machine represents blood flow as a colour
map that is superimposed on the greyscale
image of the vessel.
Forward flow which occurs when the calf is
squeezed is seen as blue in the colour flow map.
When incompetent veins are present reverse
flow is seen as red when the calf is released.

11. Advantages
1)Is the most appropriate investigation to
obtain the anatomy and physiology of the
venous system.
2)All the lower limb vessels may be imaged.
3)The origin of varicose veins and venous
ulceration can be identified.
4)If DVT is present the thrombus can be
seen.

12. MANAGEMENT
TREATMENT OPTIONS
OPERATIVE NON-OPERATIVE
CONSERVATIVE
INJECTION-COMPRESSION RX

13. Conservative treatment:
Indications-
1)Uncomplicated Varicose veins
2)Patient unwilling or unfit for surgery
Bizzgards Regimen
• Avoid prolonged standing
• Foot end elevation at night
• Crepe bandage during the day
• Exercise to strengthen calf muscles

14. Injection-Compression treatment:
Used to treat Varicose veins in the absence of
Junctional incompetence.
Aim: To inject a small volume of effective
Sclerosant into veins lumen to destroy the
intima.
Solution: 3% Sodium Tetredecyl Sulphate
Procedure:
0.5ml of Sclerosant is injected into the empty
vein at points of control-Sites at which
incompetent perforators join the superficial
veins.
After injection external compression has to be
applied.

15. Disadvantages:
1)Local pain and Periphlebitis
2)Reccurence: Rates upto 30% have been
reported
Causes:
1)Presence of SFJ incompetence
2)Failure to apply external compression

16. SURGERY FOR VARICOSE
VEINS
Indications
1)Symptoms of aching heaviness and
cramps
2)Complications of venous stasis i.e.
Pigmentation, dermatitis, ulceration,
thrombosis
3)Large Varicosities subjected to trauma
4)Cosmetic concern

17. Objectives:
1)Releive symptoms
2)Alleviate stasis complications
3)Restore normal venous physiology
4)Improve cosmetic appearance

18. Principles of Surgery
• All incompetent superficial veins and perforators
to be thoroughly removed to prevent recurrence
• Veins having a potential to develop varicosities
should also be removed
• Special care to be taken not to damage or
destroy normal competent Greater or Lesser
Saphenous veins as they may be needed for
future Bypass procedures
• Superficial varices that follow DVT may be the
only route for the venous drainage of the lower
limbs hence should not be removed until the
patency of the deep veins are established

19. PROCEDURE OF STRIPPING OF VEIN
Pre Op – All veins have to be carefully and
accurately marked with an indelible pencil
Anesthesia - General/Regional
Position – Supine with legs elevated to 15 to 20°
to minimize bleeding
Incision:
1st - Groin incision just below the inguinal
crease medial to femoral artery pulsation
2nd – Small transverse incision placed anterior
and proximal to medial malleolus and transverse
incision on the distal Saphenous vein

20. Steps:
1. Ligation or removal of tributaries near the SFJ
• Medial femoral cutaneous
• Lateral femoral cutaneous
• Superficial external pudendal
• Superficial circumflex iliac
2. Flush ligation of SFJ –Modified Trendelenburg
operation
3. Insertion of a flexible intraluminal metallic
stripper into the Greater or Lesser Saphenous
veins
4. Resection of incompetent perforator veins
5. Stripping of Saphenous vein and closure

23. Precautions during stripping surgery
1.Tributaries of saphenous vein at the SFJ have to
be removed first
2.Stripper may encounter obstruction due to
tortuosities at the site of perforators
3.Stripper may enter the deep venous system
through one of the perforators
4.Care is taken to avoid damage to the Saphenous
nerve which lies adjacent to the vein from the
ankle to knee
Nerve damage causes sensory loss or traumatic
neuritis of medial aspect of ankle

24. MULTIPLE STAB AVULSION TECHNIQUE (Ambulatory
phlebectomy)
• This is done as an alternative to stripping of greater
saphenous vein after flush ligation of SFJ
• At the points of greatest tortuosity, tiny incisions are
made and the vein is picked up with a special hook and
clamped on both sides, then avulsed
• This is done at multiple points till the whole vein is
removed
• Advantages:
Complication of injury to the saphenous nerve is
prevented
Extremely useful for residual clusters after
Saphenectomy

25. Post Op:
1.Patient to ambulate on first post op day
2.Bandages are remove on second post op
day for inspection of wound
3.Aambulation is permitted only with elastic
external support for the first two weeks

26. PERFORATOR INCOMPETENCE
PROCEDURES
1. Cockett and Dodd’s subfascial ligation
2. Rob’s procedure
3. Felder-Rob’s procedure
4. Modified Felder-Rob’s procedure (by Dr.
Ananthakrishnan)

27. NEWER TREATMENTS
Endovenous Laser treatment (EVLT)
• Done under strict LA
• Permanently closes the vein while leaving it in place
• Laser is delivered into the vein via fine Fibreoptic probe
through a fine skin nick and the probe is guided via USG
• Successful treatment depends on heating of veins
• Lasers used are Diode, Nd-YAG, Alexandrite
• Precaution-The laser device is used with the cooling of
the skin with cool gel or chilled air to decrease risk of
injury to skin

29. Subfascial endoscopic perforator surgery
(SEPS)
• Entails placing of endoscope beneath
fascia of calf through a single small skin
incision
• Perforating veins traversing subfacial
space are ligated under direct vision