Varicose veins

1. Dr Shivraj Sharma
2nd year MS resident
National Medical college ,Birgunj

2.  First in History
 ‘Siragranthi’-Varicose Veins
 Sushrutha-Indian surgeon of antiquity is the first in history to
document ‘Siragranthi=Varicose veins’ as aneurysmal dilation of
Veins in ‘Samhit
 Description of varicose vein as clinical entity can be traced back as
early as 5th century BC.
 Forefathers of medicine including Hippocrates and Galen
described the disease and treatment modalities, which are still used.
 Throughout centuries, surgical treatments have evolved from large, open
surgeries to minimally invasive approaches

3. • Varicose veins are defined as dilated, elongated, tortuous
and palpable superficial veins(>3mm in diameter
measured in upright position with demonstrable reflux) as
a result of venous hypertension.
• It usually occurs due to permanent loss of valvular
mechanism and resultant venous hypertension.

4. Consists of:
• Deep system of veins which
lies below the deep fascia.
• Superficial system of veins which lies
outside the deep fascia (carry 10%
blood)
• Perforating veins which pass through
the deep fascia joining the superficial
to the deep system of veins.

5.  1: Superficial veins:
Long saphenous vein
Short saphenous vein
2: Deep veins :
Anterior & Posterior Tibial veins
Peroneal vein
Popliteal vein
Femoral vein
3: Perforator veins

6. • Valves present in superficial veins.
• Prevent flow of blood from proximal to distal and from deep to
superficial
• Absent from above groin level
• Valves can resist pressure up to 300 mm of Hg.

7.  Largest and longest superficial
vein of the limb.
 Begins on the dorsum of foot
from medial end of dorsal venous
arch.
 Run 1 to 1.5 inch anterior to the
medial malleolus ,along the
medial side of the leg , and
behind knee .

8.  At the ankle the position of the LSV
is constant , lying in the groove b/w
the anterior border of the medial
malleolus and tendon of tibialis
anterior.
 In the thigh it inclines forwards to
reach the saphenous opening where
it pierces the cribriform fascia and
opens into the femoral vein 3-4 cm
below and lateral to the pubic
tubercle

9.  In the lower 2/3 of leg and in
upper 2/3 of the thigh vein lie on
deep fascia .
 Where the vein crosses the knee
joint it become more superficial
and often subcuticular .

10.  Just below knee LSV receive posterior arch vein (Leonardo's
vein) which collect the blood from post-medial aspect of calf .
 Anterior veins of leg(stocking vein) ascend across the shin
and join either LSV or posterior arch vein .
 There is a free anastomosis b/w tributaries of short
saphenous vein and venous arch connecting medial ankle
perforating vein and this medial ankle perforating veins are
connected with LSV in lower third of leg .

11. In the thigh before entering in the saphenous opening it recieves
1. Anterolateral vein
2. Posteromedial vein of thigh
3. Superficial external pudendal vein
4. Superficial epigastric vein
5. Superficial circumflex iliac vein
6. Deep External Pudendal Vein
 In the lower third of thigh long saphenous vein connect with
femoral vein in hunter’s canal by long perforating vein
( hunterian perforator)

13.  It begins by the fusion of
number of small veins below
and behind the lateral malleolus
. Here vein runs with the large
sural nerve up to lower third of
leg.
 SSV runs upward up to the
middle of the popliteal space,
where it passes deep to fascia
to enter into popliteal vein .

14.  These are communicating veins b/w superficial and deep
veins .
 Two type:
1 Indirect veins
2 Direct veins

15. 1. Indirect perforating veins:
 These consist of small
superficial veins which
penetrate the deep fascia to
connect with vessel in muscle
and in turn end in Deep vein.

16.  Direct perforating veins :
 These directly connect
superficial veins with deep
veins

17. Six Perforators joining the superficial
to deep venous system are located at
constant positions which are:
• 2, 4 and 6 inches above the
medial malleolus (Cockett’s
perforator)
• Just below the Tibial
tubercle(Boyd’s)
• In the adductor(Hunter’s) canal
of the thigh(Dodd’s perforator)
• Level of Mid-thigh
• Around 200 perforators are
described most of them
unnamed

18. • Negative pressure in thorax during inspiration to -6
mm.
• Calf muscle pump: Normal venous pressure in relaxed state 20mm of
Hg.Rises to 80-100 mm of Hg during muscle contraction.
• Vis a tergo : arterial pressure transmitted to venous side through
capillary bed
• Competent valves
• Venae commitants: lie by the side of artery, helped
by arterial pulsation to propel blood.

19.  Primary
• Long hours of standing,
which increase the
hydrostatic pressure of
gravity
• Family history
• Pregnancy
• Ageing
 Secondary
• Deep vein thrombosis
• Arterio venous
malformation- Parkes
Weber syndrome
• Hemangiomatous
malformation- Klippel
Trenaunay syndrome
• Pelvic mass
• Retro peritoneal fibrosis

21. • Varicose veins
• Limb hypertrophy
• Port wine Stains

22. • Valvular incompetence
• Perforator incompetence
• Venous obstruction in superficial veins
• Muscle dysfunction

23. • Bleeding
• Thrombophlebitis
• Venous Hypertension leading to
venous ulcer
• Calcification
• Talipes Equinovarus deformity of
foot
• Eczematoid dermatitis and
pigmentation
• Periostitis of subcutaneous
surface of tibia
• Carcinoma in long standing
venous ulcer-Marjolins ulcer

25.  Age : Any
 Sex : F:M 10:1
 Occupation : Jobs demanding prolong standing
person doing muscular work
 Leg heaviness, exercise intolerance, pain in lower limb.
However, bursting pain means DVT
 Ankle swelling usually at the end of day
 Tortous dilated visible vein
 Pruritus, restless legs, and paresthesias
 Skin changes : pigmentation, ulcer
 Dermal flare/thread veins
 Reticular vein

26. Aims:
• Finding the system involved
• Extent of involvement
• Skin changes/ulcer around malleolus
• Trendelenberg test for patency of Sapheno-
femoral junction
• Perthe’s test for patency of deep veins

27. C
C
Clinical signs (grade0-6), supplemented by
(A) for asymptomatic and (S) for
symptomatic presentation
E
Etiologic Classification (Congenital,
Primary, Secondary)
A
Anatomic Distribution (Superficial, Deep,
or Perforator, alone or in combination)
P
Pathophysiologic Dysfunction (Reflux or
Obstruction, alone or in combination)

28. Staging
 CEAP classification from American Venous Forum, last revised
2004
 Used to standardize recording of venous disease
Clinical
C0 - No visible or palpable signs of venous disease
C1 - Telangiectases or reticular veins
C2 - Varicose veins
C3 - Edema
C4a - Pigmentation or eczema
C4b - Lipodermatosclerosis or atrophie blanche
C5 - Healed venous ulcer
C6 - Active venous ulcer
S – Symptomatic, includes: ache, pain, tightness, skin irritation,
heaviness, and muscle cramps
A – Asymptomatic

29. Etiologic classification
Ec - Congenital
Ep - Primary
Es - Secondary (post-thrombotic)
En - No venous cause identified
Anatomic classification
As - Superficial veins
Ap - Perforator veins
Ad - Deep veins
An - No venous location identified
Pathophysiologic classification
Pr - Reflux
Po - Obstruction
Pr,o – Reflux and obstruction
Pn - No venous pathophysiology identifiable

30. • Ambulatory venous pressure studies
• Venous Doppler study
• Air plethysmography

31. Ambulatory venous pressure more than 90 mm of Hg is associated with
venous ulceration.
Also regarded as GOLD STANDARD for diagnosis of chronic venous
insufficiency
Ulcer never occurs at AVP lesser than 30 mmof Hg.
Invasive procedure hence ideally not suitable for screening

32. • Indicated for diagnosis of calf muscle dysfunction
• Measures changes in leg volume in response to exercise and posture.
• Leg placed in 40 cm tubular Vinyl air chamber Leg volume measured in
supine, elevated , standing on opposite leg and after 10 tip toe jumps.
• Venous volume(VV), venous filling time90(VFT 90) and venous filling
index(VFI) and ejection fraction (EF)calculted

35. • If venous volume > 350 ml (normal 100-150 ml) Indicates
chronic venous insufficiency(CVI)
• If VFI is 7 ml per second(normal < 2ml per second)
indicates CVI
• If ejection fraction venous blood of calf muscle is less than
60 percent after one tip toe indicates Calf Muscle
dysfunction
• If remaining venous fraction(RVF) after 10 tip toes is more
than 40 percent indicates calf muscle dysfunction
• If RVF more than 40 percent and Venous filling index(VFI) > 2
ml per second then it indicates reflux

36. • To find patency of deep veins.
• To define the site of incompetent perforators & to
mark them preoperatively.
• To find out the competence of Saphenofemoral
junction & Sapheno popliteal junction.
• If Sapheno-popliteal junction is incompetent it should
be marked preoperatively because of its highly variable
& inconstant position.
• Ankle brachial index should be measured to rule out any
concomitant arterial disease.

37. • Avoiding prolonged standing, weight loss ,excercise
• Crepe bandaging and elastic stockings from toe to thigh, which
causes decreased edema, venous volume and reflux and
increases venous return.
• Compression stocking of the pressure of 18-24 mm is preferred
for varicose veins.
• Limb elevation above the level of heart while lying down

38. • Refusal for surgery
• Capillary veins, Venous
Stars (C1)
• Pregnant patients
• Waiting for surgery
• Early cases
Indications Contraindications
• Arterial Insufficiency

39.  MICRONIZED PURIFIED FLAVONOID FRACTION: (MPFF)
DAFLON 500MG oral phlebotropic drug consisting of 90 %
micronized diosmin and 10% flavonoids expressed as
hesperidin.
Shown to improve venous tone and lymphatic drainage and
reduce capillary hyperpermeability by protecting the
microcirculation from inflammatory process.
 CALCIUM DOBESILATE
 PENTOXIFYLLINE : inhibits platelet aggregation hence reduce
blood viscosity and improves microcirculation
 ASPIRIN

40. • Under Ultrasound guidance.
• Polidocanol is used
• Polidocanol converted in foam by mixing air using
three way tap.
• Spread of foam monitored under USG guidance as it
spreads.
• Apex of saphenous opening compressed by probe to prevent
foam entering deep veins.
• Leg also elevated

42. Indications Contraindications
• Varicosity confined below
knee and caused by
incompetent perforators
• Recurrent/ residual
varicosities post-surgery
• Large Venous telangiectasia
• Dilated branch veins around
the knee following early long
saphenous incompetence
• Refusal for surgery
• Deep Venous thrombosis
• Sapheno Femoral
Incompetence
• Veins in lower 1/3rd ofleg
• Veins on the foot
• Veins in elderly
• Veins in fat legs
• Immobile patient
• Post thrombotic syndrome
• Dirty ulcer or extensive
eczema

43. • Complications:
• Extravenous Injection
• Deep vein thrombosis
• Hypersensitivity
• Skin pigmentation
• Gangrene of distal limb

44. • 5% monoethanolamine
with 2% benzyl alcohol
• 3% sodium
tetradecylsulphate in 2%
benzyl alcohol
• 25% glycerine with 2%
phenol

45. Types of surgeries done:
• Flush ligation of Sapheno femoral junction
with ligation of all tributaries ending at SFJ.
• Stripping of long saphenous upto the knee
joint.
• Flush Ligation of Short Saphenous vein.
• Subfascial ligation of perforators

46. • Curved or Hockey stick incision.
• Alternatively a 7-8 cm long Oblique incision .
• Femoral Vein is exposed 1 cm above and below the
Sapheno femoral junction.
• The all tributaries joining the termination of saphenous
vein are defined and ligated
• The end of the long saphenous vein is flush ligatedat
Saphenofemoral junction with silk and a second
ligature is transfixed to avoid haemorrhage.
• Femoral vein is inspected above and below the
junction and long saphenous divided.

48. • An Oliers stripper is passed from the
groin Incision into the long saphenous
vein.
• A vertical incision is made just below
knee and vein exposed
• The stripper is extruded from the vein
and the acorn firmly tied in the vein.
• The stripper is firmly withdrawn with
the vein telescoped over it.
• The track is compressed with a large
sterile pad for 3 to 5 minutes.

50. • Haemorrhage from torn varix
• Division or injury to the common Femoral Vein
• Sural Nerve or Saphenous nerve injury
• Postoperative Complications:
• Haematoma and bruising
• Wound infection
• Neuritis
• Lymphoedema
• Induration of stripper track
• Lymphatoma
• Deep Venous Thrombosis

51. • Maintain firm pressure over the limb
• Regular movement of the operated limb
• Limb elevation above heart level to reduce
venous pressure
• Removal of primary dressing after 7 to 10 days

52. Indications Contraindications
 Chronic Venous
Insufficiency (C4-6)
 Secondary varicose
veins
 Arterial Insufficiency
 Deep Vein Thrombosis
 Subfascial Endoscopic Perforator Surgery is a
minimally invasive procedure where in
Incompetent perforators are ligated below the
deep fascia by creating space with CO2.

53. Insertion Of Ports for SEPS
A single 10 mm port for camera is inserted below the deep fascia at the
medial end of upper part of tibia. Another 5mm port inserted at junction
of upper 1/3rd and lower 2/3rd of thecalf.

54. • The intima of smaller veins can be destroyed by heat
generation and denaturation of collagen using a probe
consisting of a bipolar heat generator.
• Performed under ultrasound guidance and positionof
the probe is confirmed near the Saphenofemoral
junction.
• Probe is heated to 85 degrees and gradually retracted
down at a constant rate of 2-3cm/minute.
• must be avoided in presence of dilated veins, veins
with aneurysms and thrombosed veins.

55. • Employs diode laser for the destruction of
endothelial lining of the target vein.
• The ultrasound guides the location of probe,
which is placed 2 cm distal to the
Saphenofemoral junction.
• The probe is gradually withdrawn and ablates the
lumen as it regresses down the vein by boiling
the blood present within the lumen.
• Veins of all sizes can be treated with this
procedure.