This document provides information about varicose veins, including their anatomy, causes, risk factors, signs and symptoms, diagnosis, and treatment options. It begins by describing the structure and layers of veins, and defines varicose veins as dilated, elongated and tortuous veins. It then discusses the superficial and deep venous systems of the lower limbs, noting the long and short saphenous veins. Risk factors for varicose veins include prolonged standing, obesity, pregnancy, age, and certain sports. Signs include visible twisted veins and skin discoloration, while symptoms comprise aching, cramping, and itching. Diagnosis involves physical exams like Trendelenburg's test and imaging like Doppler ultrasound. Treatment

1. VARICOSE VEINS
By –
AKASH ARJUN
RATHOD

2.  Veins- These are blood vessels that carries blood
towards the heart
 Layers-1) Tunica externa
 2) Tunica media
 3) Tunica interna
 Veins consists of valves
 Superficial veins- Closer to the surface of body
and no corresponding arteries
 Deep veins- Deeper in body and have
corresponding arteries
 Perforated veins- drains from the superficial to
the deep veins
 Communicating veins- Directly connects
superficial veins to the deep veins

3.  Definition- when veins become dilated,
elongated and tortuous called as Varicose
Veins.
 Common sites-
 1) superficial venous system of lower
limb
 2) oesophageal varices
 3) varicosity in piles
 4) varicosity of spermatic veins

4.  Superficial veins of lower limb-lies in subcutaneous
fat.
 1) Long saphenous veins -it begins in medial
marginal vein of foot and ends in femoral vein 3 cm
below of inguinal ligament
 It runs upward post part of medial condyl of the
tibia and femur and along medial side of thigh to
the Saphenous opening.
 Short Saphenous vein- it begins behind the lateral
malleolus and along midline of the back of the leg.
 It perforate the deep facial and passes between two
heads of gastrocneumius in lower part popliteal
fossa

5. Superficial Venous System Of Lower Limb

6.  Deep venous system-drainage-
 Lateral and medial plantar vein
 Drains in post. Tibial vein
 Ant n Post. Tibial veins drain in popliteal vein
 It passes through adductor hiatus and comes anterioly
known as Femoral vein
 It passes through inguinal ligament known as external
illiac vein
 Ext illiac joins internal illiac and form common illiac
veins

7. Deep Venous System Of Lower Limb

8.  Direct perforators- these veins directly connect
the Saphenous vein to the deep vein.
 A) In thigh -between long Saphenous and femoral
vein in adductor canal.
 B) In the leg-
 1) Medial perforators- 3 in numbers in the line post
border of tibia
 2) Central perforators- in gastrocneumius and soles
muscle
 3) Lateral perforators- post border of fibula

9.  Aetiology-
 1) Morphological factor- varicose veins of the lower limbs are
the penalty the man has to pay for its erect posture.
 The veins has to drain against gravity.

 2) Primary varicose veins-
 A) defect in saphenofemoral valve-GSV incompetence
 B) defect in saphenopopliteal valve- SSV incompetence
 C) defect in perforators
 3)secondary varicose veins-
 A) pregnancy or tumors in pelvis
 B) DVT
 C) arteroivenous fistula
 D) hormonal causes- progesterone

11.  Predesposing favtors-
 1) prolonged standing- during prolonged standing long
column of blood along with gravity puts pressure on the
weekend valves of the veins.
 2) Obesity-Excessive fTty tissue in SC tissue offer poor
support to the veins.
 3) pregnancy- 1) progesterone cause dilation relaxation of
lower limb. This makes the valve incompetence.
 2) pregnant uterus cause INCLUDING, thus
obstruction to the venous flow.
 3) Old age-This cause weakness and atrophy of
the vein wall
 4) athlets-Forcible contraction of muscles may
force blood through Perfotating veins in reverse direction.

12.  Clinical features-
 Signs-1) tortuous vein
 2) elongated veins
 3) dilated veins
 4) bluish discoloration along the course of involved
vein
 5) Eczema
 6) venous ulcer
 Symptoms-
 1) aching sensation
 2) cramp in calf
 3) bursting pain while walking
 4) itching

13.  Physiology of varicose veins-
 Long standing n other causes

 Stagnation of blood in veins of lower limb
 Veins become dilated elongated n tortuous
 Stagnant blood causes tissue perfusion
 Break down of haemoglobin
 Release of ciderin, haemociderin
 Itching n bluish discoloration

15.  Physical Examination -
 1) Inspection-
 A) tortuousness seen in medial malleolus to the medial side of
knee and along the medial side thigh in case of GSV
 B) In case of SSV, dilated veins seen in leg from behind the lateral
malleolus upward to post aspect of the leg and ends in popliteal
fossa
 2) Swelling-
 A) Localised- superficial vein affected thrombophlebitis
 B) Generalised- DVT

16. 3) Skin-
1) Local redness- thrombophlebitis
2) Generalised change- white leg ( phlegmatic
Alba Dolans)
Due to lymphatic obstruction
4) Texture-a) shrink
b) dilated
c) venous ulcer
d) venous ulcer as

17.  2)Palpation-
 1) Brodie- Trendelenburg test- incompetency of
saphenofemoral, saphenopopliteal n communicating veins
 A) patient is first placed in recumbent position
 B)his legs are raised to empty veins
 C) the saphenofemoral junction is pressed with thumb of
the clinician or tourniquet is applied just below
saphenofemoral junction.
 D)pt is asked to stand quickly
 E) if the veins fill quickly- incompetence of
saphenofemoral valve
 F) the pressure is maintained for 1 min
 Gradual filling of veins - incompetence of
communicating valves.
 In case of SSV same test is done by pressing
saphenopoliteal junction.

18.  2) perthes test-
 The affected lower extremities is wrapped with
elastic bandage. With the elastic bandage on the
patient is instructed to move around and exercise.
 Severe cramps pain is complained of if there is DVT.
 3)Parthes test classic- A tourniquet is tied round
the upper part of thigh tight enough to prevent any
reflux down the vein
 The pt is asked to walk quickly with tourniquet
 If the communicating and deep vein are normal,
varicose vein will shrink and if they are blocked the
varicose veins will more distended.

19.  4)Schwartz test- In long standing case, if tap is made
on the long Saphenous varicose vein in the lower part
of leg, an impulse can be felt Saphenous opening with
the other hand.
 5) Pratt's test-This test is performed to know the
position of leg perfoartors.
 Firstly elastic bandage is applied from toes to the
groin.
 A torniquet is them applied at the groin. This cause
emptying of Varicose vein.
 The torniquet is kept in position and elastic bandage
is taken off. The same elastic bandage is now applied
from groin downward.
 At the position of perforators blow out can be seen.

20.  6) Morrissey's cough impulse test -
 The limb is elevated to empty the varicose vein.
 The limb is then put to bed and the pt is asked to cough forcibly.
 An expansile impulse is felt in the long Saphenous vein at Saphenous
opening if saphenofemoral valve is incompetent.

 7)Fegans method- in standing posture the places of excessive bulges
within the varicosities are marked.
 The pt now lies down. The affected limb is elevated to empty varicose
veins.
 The examiner palpates along the line of marked varicosities.
 Find out gaps or pits in deep facial.
 8) Multiple torniquet test-
 3 tourniquet are tied after emptying the veins at
1) below saphenofemoral junction
2) above the knee
3) below the knee
 N den examine the filling of veins to inspect incompetency of
petforators.

21.  3) Percussion- if the most prominent parts of the
varicose veins are tapped, an impulse can be felt by
the finger at Saphenous opening. In Schwartz test.
 4) Auscultation-The importance of auscultation is
limited to the Arteriovenous fistula, where a continues
machinery murmur is heard.

22.  Special investigation-
 1)Radioactive fibrinogen test
 2)Phlebography

23.  3)Doppler Ultrasound- The sensing probe is places
over the femoral vein the groin.
 This normally transmit a venous him.
 If the calf is squeezed, it changes hum into roar due to
increased blood flow.
 If there is DVT between the calf and the groin, the
roar does not occur.
 4) Duplex Imaging- it allows direct visualisation of the
deep veins.
 5) Ultrasound and CT scan- when secondary varicose
vein is suspected.

24.  Complications-
 1)Thrombophlebitis- Inflammation of superficial veins.
 2) Pigmentation- brownish to black pigmentation is
noticed.
 3) Eczema- due to extravasation and breaking down of
RBCs causes itching. The pt scratches causes eczema.
 4) Hemorrhage- any minor trauma to affected veins may
lead to rupture of vessel.
 5) Periostitis- inflammation of periostium.
 Mostly if venous ulcer is formed at medial malleolus of
tibia.
 6) Venous ulcer- common in DVT.
 Mostly found near medial malleolus.
 7) Equines deformities- this is due to bad practice of pt
walking on the toes for pain relief due to Varicosity.

25.  Treatment-
 Three modes of treatment are available.
 A. Palliative treatment
 B. Operative treatment
 C. Fegan's injection and compression treatment.
 A. Palliative treatment:
 The treatment has limited scope and it's indications
are:
 1. Those who are pregnant
 2.those who don't want operations
 3.those who are waiting for operations.
 4.very early cases of Varicosity.

26.  This treatment consists of:
 1) Avoidance of prolonged standing.
 2) A crepe bandage or elastic stockings are applied
from goes to thigh.
 This should be applied before going out of bed in
the morning and should be kept till after getting
into the bed at night. So it should be worn
throughout the day and only taken off during
sleep.
 3) Whenever the patient sits or sleeps the limb
should be preferably above the heart level. At least
it should always raised.
 4) Exercise like bicycle riding in the air while lying
on the back, walking etc. should be performed to
strengthen the calf muscle.

27. Stockings In Varicose Veins

28.  Operative treatment-
 Indications- 1) positive trendelenburg test
 2) saphenofemoral incompetence
 Operation- A) LIGATION-
 Saphenofemoral incompetence-
 Operation is performed under G. A.
 An oblique incision is made just below the groin starting
from femoral artery pulsation to 5 cm medially.
 All the tributaries of the long saphenofemoral vein are
ligated
 The long saphenous vein is ligated flush with femoral vein.
 In the process, superficial epigastric
 Superficial circumflex illiac
 External pudendal tributaries are ligated.
 Saphenopopliteal incompetence- a ligature is applied at SSI

29.  B) Ligation with stripping-
 Mainly it is performed in LSV.
 A transverse incision is made over the long saphenous
vein in front of medial malleolus.
 The LSV is cleared from surrounding structure and
lifted with an aneurysm needle.
 The distal part is ligated tightly
 Proximal tie is kept loose.
 Vein is invited between the two ligatures and olive
point of the Myers stripper is pushed pushed up
through to emerge through that distal cut end of LSV
Athens the groin incision.
 The upper end is now pulled till the acorn head is
arrested at the medial malleolus incision.

30.  The proximal ligature here is tightened around the
stripper and the LSV is severed between the
ligatures.
 The ends of the distal ligature are cut short.
 The skin is sutures above the acorn head. Stripper is
steadily pulled through groin incision severing all
the tributaries and performing veins up to groin
incision.

31.  THANK YOU