Varicose veins it's risk factor's staging multiple treatment options

1. VARICOSE VEINS

3. Venous Anatomy of Lower Limbs
▶ Superficial venous system
▶ Deep venous system
▶ Perforator veins

4. Deep Veneous system

6. Perforator veins
▶ Connect superficial to deep veins at various
levels.
▶ Travel from superficial fascia through an
opening in the deep fascia before entering the
deep veins.
▶ The direction of blood flow - from superficial to
deep veins.
▶ Guarded by valves so that the flow is
unidirectional, i.e. Towards deep veins.
▶ Reversal of flow occurs due to incompetence of
perforators which will lead to varicose veins

7. Venous valves
▶ The venous valves are abundant in the distal lower
extremity and number of valves decreases
proximally, with no valves in superior and inferior
vena cava
▶ Prevent reverse flow in the veins
▶ Ensure that the blood is pumped from the superficial
to the deep system and back towards the heart when
the patient is walking

8. ▶ Ankle perforators
▶ Lower leg – Cockett perforators
▶ Boyd’s perforators
▶ Dodd perforators
▶ Hunterian perforators

9. Varicose Veins
▶ Permanently dilated , elongated veins with
tortuous path due to incompetent valves.
▶ Risk factors
▶ Female sex
▶ Occupation-prolonged standing
▶ Immobility
▶ Raised intra abdominal pressure
▶ Increased progesterone
▶ High heels

10. Valve
incompetence
/Ch. Venous
hypertension
Defective
microcirculati
on
RBC
diffusion/
Lysis
Hemosiderin
deposition
Dermatitis /
capillary
damage
Chronic
Venous
ulceration

12. Clinicial Features
▶ Dragging pain, postural discomfort
▶ Heaviness in the legs
▶ Night time cramps
▶ Oedema, itching
▶ Discolouration
▶ Ulceration

13. Clinical Signs
• SFJ & Perforator incompetence
Trendelenberg’s test
• DVT
Perthe’s test / modified
perthe’s
• valvular incompetence
Tap test

14. TAP TEST

15. Trendelenberg’s Test

16. PERTHE’S TEST

17. Complications
▶ Haemorrhage
▶ Pigmentation,eczema ,dermatitis
▶ Venous ulcer
▶ Lipodermatosclerosis
▶ DVT
▶ Recurrent thrombophlebitis

18. Investigation In Varicose Veins
▶ Localise the anatomical location of the disease
▶ Nature of the lesion
▶ Rule out DVT

19. Duplex Scan
▶ Venous Doppler
▶ DUPLEX scan
▶ Doppler combined with B mode Ultrasound
▶ Functional and anatomical information
▶ DVT well made out.
▶ Uniphasic signal – normal
▶ Biphasic signal – reversal flow

20. Contd…
Venography
Ascending venography
• Dorsal venous arch – cannulated
• Tourniquet at malleoli
• Dye injected
• X-rays taken
• DVT/perforator status
Descending venography
• Ascending venogram nor possible
• Contrast through femoral vein
• Valvular incompetence

22. Conservative management
▶ Elastic crepe bandage – stockings
▶ 30-40mm Hg
▶ Elevation of limbs
▶ Above the level of heart
▶ Graded compression stockings

23. Sclerotherapy
▶ Complete sclerosis of the venous wall
▶ Indications
▶ Uncomplicated perforator incompetence
▶ Smaller varices
▶ Recurrent varices
▶ Isolated varices
▶ Aged/unfit patients

24. ▶ Sclerosants used are
▶ Sodium tetradecyl sulphate
▶ Mechanism of action
▶ Aseptic inflammation
▶ Perivenous fibrosis
▶ Endothelial damage
▶ Obliteration by intimal approximation

25. Technique
0.5 -1 ml
of
sclerosant
23 gauge needle
in to vein and
emptied
Immediate
compressio
n bandage
Proper
endothelial
apposition
May have
to be
repeated
after 2-4
weeks later

26. Contd…
• Saphenofemoral incompetence
• DVT
• Peripheral arterial disease
• Hypersensitivity
Contraindication
• OPD procedure
• No anesthesia
Advantages
• Anaphylaxis/shock
• Abscess
• Thrombophlebitis
• Intravenous hematoma
Disadvantages

27. Surgical management
▶ Trendelenburg’s procedure
▶ Ligate the source of venous reflex(SFJ&SPJ)
▶ Remove incompetent saphenous trunks &ass.varices
▶ Flush ligation of tibutaries
▶ Superficial circumflex
▶ Superficial external pudendal
▶ Superficial epigastric
▶ Deep external pudendal
▶ Unnamed tibutaries

28. ▶ Stripping of long saphenous vein
▶ Upto knee joint
▶ Complications
▶ Saphenous nerve injury
▶ Hematoma
▶ Infection

29. ▶ Perforator incompetence
▶ Subfascial ligation of perforators
▶ Stab avulsion method

30. SEPS
▶ Subfascial endoscopic perforator surgery
▶ Minimally invasive method

31. Endovenous Laser Ablation - EVLA
▶ US guidance LSV canulated above knee joint
▶ Guide wire passed beyond SFJ
▶ Tip is placed 1cm distal to SF junction
▶ Laser fibre inserted upto the catheter
▶ Diode laser used for firing

32. ▶ Thermal damage of endothelium – occlusion of vein
▶ Laser energy acts on blood – in turn heats the vein wall.
▶ Complications
▶ Pain / ecchymosis
▶ Hematoma
▶ Skin burns
▶ DVT

33. Reference
▶ Bailey&love’s short practice of surgery
▶ Google
▶ S.Das

34. THANK YOU