This document discusses the venous drainage system of the lower extremities. It describes the three types of veins - deep, superficial, and perforating veins. It provides details on the long and short saphenous veins and deep veins like the femoral vein. Perforating veins that connect superficial and deep veins are also explained. Diagnosis of venous insufficiency involves physical exam, Doppler ultrasound, duplex ultrasound, and other tests. Management options for varicose veins and venous insufficiency include compression stockings, surgery like ligation and stripping, and minimally invasive procedures like sclerotherapy, radiofrequency ablation, and endovenous laser treatment.

1. Dr. GUNABHI RAM DAS
Associate Professor of Surgery
Assam Medical College and Hospital

3. Introduction
 The venous drainage system of the lower extremity
consists of three sets of veins:
 Deep veins,
 Superficial veins
 Perforating veins.
 All veins contain delicate one-way valves that
normally open to allow blood to flow toward the
heart and prevent blood from flowing in a
retrograde fashion after the valves close .

4. Veins of lower limb
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

5. Long saphenous vein (LSV)
 Longest and largest superficial vein in our body.
 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.
 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 2.5 cm below and lateral to the pubic
tubercle

7. Short saphenous vein(SSV)
 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 .

8. Deep veins
 This veins lie in deep fascial plane and are supported by
powerful muscles of leg.
 These are
1: Anterior and posterior Tibial veins
2: Peroneal vein
3: Popliteal vein
4: Femoral vein
 These veins accompany with Arteries.

10. Perforating veins
 These are communicating veins b/w superficial and deep
veins .
 Two type:
1} Indirect veins :-These consist of small superficial veins
which penetrate the deep fascia to connect with vessels in the
muscles and in turn end up in deep veins
2} Direct veins :-Directly connects superficial to deep veins
Direct perforators
 In thigh :
hunterian’s perforator connects LSV with femoral
vein in lower part of adductor canal

11.  In lower thigh: DODD’S Perforator on medial aspect
connects LSV with femoral vein
 Below knee :BOYD’S Perforator connects LSV or poserior-
Arch vein with posterior tibial vein
 In leg:
Lateral perforators: junction of mid &lower third of leg,
connects SSV with peroneal vein
Medially: COCKETT’S Perforator, three in number ,
connects posterior arch vein with posterior tibial vein
 Below ankle
May or kuster perforators

13. Venous insufficency
 Three categories:-
congenital-venous ectasias,absence of valves and
Klipple-Trenaunay syndrome
 primary- accquired idiopathic entity,largest clinical
category includes telangiectasias[thread veins or
hyphen webs],reticular veins and varicose veins
 Secondary- post thrombotic or obstructive state

14.  Defined as dilated usually tortuous subcutaneous veins
>3 mm in diameter measured in the upright position
with demonstrable reflux
Varicose Veins

15. EPIDEMIOLOGY
 More common in woman 25-30% ; in men 15%
 FACTORS affecting prevalence include :
 Gender - < in women
 Age - prevalence increases with age
 Ethnicity - influences the prevalence
 BMI and Height- directly proportional
 Pregnancy - increased risk
 Familial susceptibility present

16. 1. Dull aching,
2. Heaviness,
3. Itching,
4. Eczema and
Pigmentation
5. Ankle swelling
6. Bleeding
7. Superficial
Thrombophlebitis,
8. Lipodermatosclerosis
9. Ulceration
Symptoms:-

17. Signs
 Great saphenous vein involvement –60 %
 Small saphenous involvement 20 %
 According to distribution
 Medial Thigh and calf varicosity - Great SV incompetence
 Posterolateral calf varicosities - Small SV ncompetence
 Anterolateral Thigh and calf -isolated incompetence of the
Proximal anterolateral long saphenous tributary
Percussion over the varices may elicit an impulse tap by the
fingers placed over the dilated trunk.

18. Superfic (reticulial
spider veins ar
veins) only.
Simple varicose
veins only. Ankle edema (due
to venous
disease)
Skin pigmentation
lipodermatosclerosis
A healed venous ulcer An open venous ulcer.

19. C.E.A.P CLASSIFICATION
Clinical classification
 C0:-novenousdisease
 C1:-telangiectasiasorreticularveins
 C2:-varicoseveins
 C3:-odema
 C4a:-pigmentationoreczema
 C4b:-lipodermatosisoratrophic
blanche
 C5:-healdedvenousulcers
 C6:-activevenousulcers
Etiologic classification
Ec:-congenital
Ep:-primary
Es:-secondary
En:-novenouscauseidentified
Anatomic classification
As:-superficialveins
Ad:-deepveins
Ap:-perforators
An:-novenouslocationidentified
Pathophysiological
classification
Po:-obstruction
Pr:-reflux
Pr,o:-reflux andobstruction

20.  CEAP 1 — No Need to refer for medical treatment,
cosmetic problem only.
CEAP 2 — Refer routinely to Vein specialist for
duplex & photoplethysomography assessment.
CEAP 3-5 — Refer quickly to Vein specialist for
duplex ultrasound & photoplethysomography
assessment.
CEAP 6 — Refer urgently to Vein specialist for duplex
ultrasound & photoplethysomography assessment & to
Wound Care Center for ulcer assessment.

21.  Physical exam
 Appearance
 Trendelenburg test
 Palpation
 Hand Doppler
INVESTIGATIONS
 Doppler ultrasound
 Duplex ultra sound imaging
 Venography
 Mr venography(mrv)
 Plethismography(vrt)
 Maxm. Venous out flow(mvo)
 Muscle pump ejection fraction (mpep)
Diagnosis of venous disease

22. DOPPLER ULTRASOUND
 minimal level of investigation required
 used to exclude arterial disease, determine patency of
a vein, detect venous reflux
 to show flow is retrograde , antegrade or to & fro
 doppler transducer is positioned along the axis of a
vein at 45 degrees to the skin
 calf is compressed to produce an acceleration of blood
flow this is heard as WOOSH, if competent no sound
on release but ; if valve is incompetent retrograde flow
occurs and SECOND WOOSH is heard

23. DUPLEX ULTRASOUND
IMAGING
 standard imaging modality
 combines high resolution b-mode ultrasonography & doppler
ultrasound
 obtains images of vessels & measures flow
 Venous reflux is defined as retrograde flow reverse to
physiological direction >0.5 secs
 provides anatomical & fuctional information simultaneously
 A high frequency linear array transducer of 7.5-13 MHz is
used
 used to diagnose venous insufficiency; plan treatment ;
preoperative mapping

24. Duplex scan of femoral vein
showing thrombus n reverse flow
*Image via Bing

25. VENOGRAPHY (DIRECT
CONTRAST VENOGRAPHY
 x- ray equivalent of duplex u/s
 most combursome ,invasive imaging technique
 ASCENDING VENOGRAM
1. a vein in dorsum of foot is cannulated
2. tourniquet is applied over malleoli to direct blood
into deep veins
3. non ionic contrast is given
4. gives excellent anatomic information
5. less information when valves have failed

26. DESCENDING VENOGRAPHY
1. incompetent veins can be shown
2. cannula inserted into femoral vein
3. contrast injected with patient standing
4. contrast is heavier than blood & flows down through
incompetent veins
VARICOGRAM
1 to detect source of recurrent varicose veins
2 contrast is given into one of the varicose veins& followed
to identify source

28. MAGNETIC RESONANCE
VENOGRAPHY
 most sensitive & most specific for both superficial & deep
veins of lower limbs & pelvis where other modalities cannot
reach
 unsuspected nonvascular causes for leg pain & edema may
be observed on mrv scan when clinical presentation
erroneously suggests venous insufficiency/obstruction

29. PLETHYSOMOGRAPHY
 measures venous refilling time(vrt)
 probe attached to skin measures venous refilling time
by assesing light transmission of skin
 1st patient sits quitely until the trace stabilises
 then performs 10 to 20 tip toes /ankle dorsiflexions
 pressure in sup.veins falls & cutaneous venules empty
 the pt. then sits & veins refill
 vrt is the time necessary for the lower limb veins to
become fully suffused with blood after calf muscle
pump has comletely emptied lower leg as thouroughly
as poissible

30.  in perfect healthy limb it occurs only through arterial inflow
& requires 2 minutes
 vrt of 40-120 sec indicates mild / asymptomatic venous
insufficiency ,filling occurs through leaky valves
 vrt of 20- 40 sec significant high volume reflux through
retrograde flow in failed valves, associated with symptoms
 Vrt less then 20sec indicates high volume of retrograde flow
,always symptomatic

32. MANAGEMENT
 Conservative
 Flush ligation and stripping
 Extra fascial ligation of perforators
 Sub fascial endoscopic perforator surgery( SEPS)
 cryo stripping
 Micro phlebectomy
 Trans illuminated phlebectomy (TIPP)
 Sclerotherapy
 Micro sclerotherapy
 Endo venous laser treatment( EVLT)
 Radio frequency abalation
 Vein wave therapy

33. Compression hosiery
British classification
Class I - 14- 17 mm Hg
Class II - 18- 24 mm Hg
Class III - 25- 35 mm Hg

34. Surgery
Ligation and stripping of varicose vein :
Indication :
LSV /SSV incompetency
Perforating vein incompetency.
Contraindications:
DVT
Pregnancy
Thrombophlebitis
Peripheral vascular disease

36. Flush ligation and stripping
 After anesthesia proper position is given.
 The whole table is tilted head down to an angle of about 10
degree. (trendlenberg position)
 Oblique or hockey stick type incision is kept at groin at
Saphenous opening 3-4 cm below and lateral to pubic
tubercle
 After division of deep layer of fascia , saphenofemoral
junction is exposed
 Then flush saphenofemoral ligation (& tranfixation) done
with ligation of all tributaries of long SV ;then stripper is
passed down the saphenous vein and directed downward by
finger .Vein is tied with stripper and stripped out
retrogradely

37.  The residual veins are then ‘wormed out ‘ using multiple
stab avulsions using vein hooks ,from the preoperative
marked sites.
 Post operatively limb elevation and compression stockings
are given.
 Post operative care [during frist week]
1) Maintenance of firm elastic pressure over whole limb.The
original firm crepe bandage put on at the operation should
remain untouched for seven days
2) Regular movement and exercise of the legs
3 ) Elevation of the foot of the bed 6 to 9 inches so that the
legs are just above the heart level when the patient is in bed.

38. Extra fascial ligation of
perforators(Cocketts
procedure)
 Not commonly employed
 Aim is to clear all the extrafascial veins
 More traumatic due to adherence of subcutaneous fat
and connective tissue to the fascia

39. Subfascial Endoscopic Perforator
Surgery
People who suffer with leg ulcers
due to incompetent venous
perforators
Indication :
1) Incompetent perforating veins in
calf with no superficial venous
reflux or no evidence of DVT on
Doppler
2) Patient with LSV / SSV
varicosity with ulcer

40. PROCEDURE
Using spinal or general anesthesia a ¾ inch incision is made
on the inside of the calf.
An instrument is inserted deep to the fascia of the leg and a
large balloon is inflated with water to create a working space.
The balloon is then emptied and the space is insufflated with
air.
The camera is inserted and the perforator veins can be seen in
the space passing from superficial to deep layers.
Another small incision is made in the calf for passage of
another instrument.The perforator veins are carefully
dissected,Clips are applied and the veins are divided if
necessary.
All trocars are then removed and the wounds are closed.
The patient is generally sent home the same day of surgery
with elastic stocking.

41. CRYOSTRIPPING
 variation of traditional stripping
 limited to GSV
 vein freezes & adhers to the device which is stripped
less p0st operative bruising
 requires special instrumentation

42. Micro phlebectomy
 Minimally invasive method; office based procedure
 Small hook is used to remove veins from tiny incisions.
 Stiches are rarely needed;minimal or no scarring.
 Performed under local anaesthesia; by numbers of small
punctures.
 Comression bandage used for one week.
 Avoidance of sterous activities for one week

43. Transilluminated phlebectomy
1. Also called as TIVEX procedure
2. Alternative to avulsion phlebectomy for superficial vein
excision.
3. In this technique with the help of transcutaneous light,
veins are seen and extracted with the help of suction
dissector.
4. STEPS:- STEP 1
The Trivex procedure starts with a
cannula illuminator delivering
tumescent local anesthesia while
simultaneously hydrodissecting
the vein for easy removal.

44. STEP 2
Targeted veins are easily
identified for removal and a
clearly visualized end point.
STEP 3
Resector gently extracts veins by
suction and morcellation in a
controlled fashion.

45. SCLEROTHERAPY
 Used for:-
small non saphenous varices <5mm; telangiectasia;
reticular veins; perforator veins; residual or recurrent
veins; frail with resistant or healed ulcers
 Solutions used:-
1. Sodium tetra decyl sulphate
2. hypertonic saline sol.
3. polydocanol,sotradecol
4. ethanolamine oleate
5. glucose combinations

46. Foam Sclerotherapy
 Principal : By injecting sclerosant into a varicose vein,
destroy its endothelium in that area , and thus induce an
aseptic thrombosis which organises and closes the vein.
 Indications :
1. Treating spider veins
2. Residual vein after surgery
3. Large venous telangiectases.
4. Isolated small dilated veins
 Contraindications
1. Pelvic tumor
2. Sup thromboplebitis at the time of procedure
3. DVT
4. Previous history of reaction to sclerosant

47. `
 PROCEDURE : tessari method
 Depending upon the size of vein, sclerosant is taken in 20 ml
syringe and connected to another syringe with 4 times the
amount of air.
 By repeated to and fro motion of the solution and air into
syringes , dense white foam is prepared .
 After giving position under USG guidance needle is inserted
into the vein and sclerosant is injected into the vein .
 Not more than 10 ml foam should be injected at one sitting ,
 Multiple sitting may be required for successful obliteration
of vein
 Immediately after foam injection compression stocking is
applied and patient is mobilized

48. Advantage
Cheap
Easy to learn
Truly an OPD
procedure
Can be repeated many
times
No anesthesia required
Disadvantage
Not suitable for SFJ/SPJ
obliteration
Thrombophebitis
Pigmentation over skin
More than 3 wks compression
is required

49. MICROSCLEROTHERAPY
 30 g butterfly needle
 0.2%sts& polidocanol
 several courses are required
 for thread or reticular veins
 compression bandage for 1- 5 days

50. Endovenous Laser Treatment (EVLT)
EVLT initiate a non-thrombotic occlusion by direct thermal
injury to vein wall, causing endothelial denudation,
collagen contraction and later fibrosis.
 Indication :
Long saphenous vein varicosity
Short saphenous vein varicosity
 Contraindication :
 Superficial vein thrombophlebitis
 DVT

51. Procedure
 EVLT is done under local anesthesia under USG guidance.
 Vein is canulated with 0.035” J guide-wire via 19G needle
 An 810 nm diode laser is used.
 The Laser fiber is then introduce over it under USG guidance
upto 2-3 cm distal to SF junction. Fiber is withdrawn at the
rate 1-3mm / sec under USG guidance .
 This laser fiber causes thermal damage to the venous
endothelium(1000 c) and occlusion of lumen by fibrosis.
 Immediately after procedure compression stockings are given
f0r 2 days
 Patient can be discharge on same day with good analgesics
and with compression stockings.

53.  ADVANTAGE
Minimal invasive procedure
No post op scar
Done with local anesthesia
Minimal post-op pain
Recurrence rate (at 2 year f/u
only 3%)
 DISADVANTAGE
Costly procedure
High technical skills req
Color Doppler and
Radiologist is req
Skin burns
Thrombophebitis
COMPLICATIONS
pain,bruising&hematoma
skin changes
burns
induration
pigmentation
matting
dysesthesia,sup.throm
bophlebitis
nerve injury
dvt
wound infection

54. Radiofrequency Ablation
 This technique based on same
principal of EVLT
 Here instead of laser fiber , special
heater probe is inserted which work at
85 -120 degree centigrade
 Probe directly comes in contact with
vein wall & causes tissue damage .
 A 45 cm of vein segment takes only 3-5
min
 Patient can directly go to home after
procedure after rest of 90 mins
 works well on tissues composed of
collagen
 special probes to manage non-
saphenous & perfortators

56. VEIN WAVE THERAPY
 Based on unipolar thermocoagulation
 Utilize radiofrequency energy delivered through a ultra
fine insulated needle which causes veins to collapse
 Hard areas eg nose and cheeks can be treated with high
precesion
 Veins treated with system usally do not return
 Anesthetic creams,pain medications,bandasges not
required
 Session last for 30 mins,patients can resume their work
immediately
 Caution in patients with nickle allergy and permanent
pacemakers

58. Thank-You