varicose veins of lower limbs

Varicose Veins Of Lower Limb

Venous System of Lower Leg

Superficial Veins Great saphenous vein Superficial inguinal

veins External pudendal

vein Superficial circumflex

vein Superficial epigastric

vein Accessory saphenous

vein Small saphenous vein Dorsal venous arch Plantar venous arch Lateral marginal vein Medial marginal vein

Deep Veins Femoral vein Profunda femoris vein Medial circumflex femoral Lateral circumflex femoral Perforating veins Sciatic vein Popliteal vein Sural veins Soleal veins Gastrocnemius veins Genicular venous plexus Tibial veins Fibular or peroneal veins

Superficial Veins Of Leg

External Iliac Vein

Cockett’s PerforatorMay & Kuster Perforator

“24 cm” Perforator

Boyd’s Perforator

Great Saphenous

Hunter’s Perforator

Dodd’s Perforator

Superficial Epigastric

Superficial External Pudendal

Femoral vein

Medial marginal

Greater Saphenous Vein

The greater saphenous vein, in close proximity to the saphenous nerve, ascends anterior to the medial malleolus.

Great Saphenous Vein

In the leg & thigh region, it crosses, and then ascends medial to the knee.

Great Saphenous Vein

Ascends in the superficial compartment and empties into the common femoral vein after entering the fossa ovalis.

Varicose Veins - Definition

Dilated, tortuous and elongated veins.Veins of lower limbs, spermatic, esophageal & haemorrhoidal show tendency for varicosity.

Etiology

Risk Factors:1. Age > 50 years2. Female sex hormones3. Heredity4. Gravitational hydro stasis5. Muscular hydrodynamics

Etiology

Primary:Cause not known.• Valves may be

incompetent.• Very rarely

valves may be congenitally absent.

Secondary:1. Obstruction to

venous outflow.PregnancyFibroidOvarian cystLymphadenopathyAscitesRetroperitoneal fibrosis

Etiology

2. Destruction of valves.

3. High pressure flow.

Usually follows Deep Vein Thrombosis

Arteriovenous fistula ( Parks-Weber Syndrome)Venous malformation (Klippel-Trenaunay Syndrome )

Clinical Features

Morphologically:1. Large vein

varicosity•Affecting Saphenous veins or their tributaries•Large in diameter (5 to 15 mm)•Usually symptomatic

Clinical Features

2. Tiny veins varicositya)Reticular Veins:

Lying immediately beneath the skin (1-3 mm diameter)

b) Thread veins :

Dilated skin vessels (0.5 mm)

Also called Dermal flares

Normal Venous Dynamics

Resting upright position

During muscle contraction

With muscle relaxation

Deep veins squeezed pushing blood upwards, without reflux

due to competent valves

Blood in deep veins can’t reflux due to valve closure

& blood is sucked from superficial veins

Blood flowing slowly from below

upwards

Venous Flow Dynamics in Varicose Veins

Upright position

Sluggish flow in normal direction but valves are

incompetent

Muscle contraction

Deep veins empty upwards

Muscle relaxation

Venous reflux into Superficial veins due to

incompetent valves

PathogenesisVaricose veins permit reverse flow

through it’s incompetent valves.This reflux adds extra work on veno-

muscular pump.As long as veno-muscular pump

copes with this extra work, patient remains asymptomatic.

Symptoms start only when pump fails to cope extra work.

Clinical Features

Common features:

1.Cosmetic

disfigurement

2.Heaviness

3.Limb fatigue

4.Pain

Clinical FeaturesPain Dull aching, continuous More towards end of the day Relieved by leg elevation Bursting calf pain during walking,

called, venous claudication

Clinical Features

Rare features:

1. Pigmentation

2. Itching & Eczema

3. Venous ulcer

4. Lipodermatosclerosis

Clinical Features

Past History:I. Operation for Varicose veinsII. Injection treatmentIII. Serious illnessIV. Complicated surgeryV. Deep vein thrombosis

Clinical FeaturesOn Examination:

• Phlegmasia alba dolens – White leg

• Phlegmasia cerulea dolens – Blue leg

• Eczema, pigmentation, scars, ulcers

• Saphena varix – Impulse on coughing

Clinical FeaturesTrendelenberg’s test

Localize the site of saphenous opening:

4cm below & lateral to the pubic tubercle

4

As the patient stands, the V.V. fill rapidly from above.

This means that the incompetent connection between the deep & superficial system is NOT the sap-fem junction (which is controlled by the tourniquet), but it is below it.

Elevate the patients limb & empty the L.L. veins2

Apply the tourniquet below the saphenous opening

3

The site of incompetent perforator is suspected by a palpable fascial defect, multiple tourniquet & confirmed by Duplex

5

Classification of Chronic Lower Extremity Venous Disease

C Clinical signs (grade0-6)

E Etiologic classification

A Anatomic distribution

P Pathophysiologic

dysfunction

Classification of Chronic Lower Extremity Venous Disease

C Clinical Classification

Grade 0

Grade 1

Grade 2

Grade 3

Grade 4

Grade 5

Grade 6

No visible or palpable signs of venous diseaseTelangiectasia, reticular veins, malleolar

flareVaricose veins

Edema without skin changesSkin changes ascribed to venous disease (e.g.,

pigmentation, venous eczema, lipodermatosclerosis)

Skin changes as defined above with healed ulceration

Skin changes as defined above with active ulceration

Classification of Chronic Lower Extremity Venous Disease

E Etiologic Classification

Congeni

tal

Present at birth but may not be recognized

PrimaryUnknown cause, but not

Congenital

Second

ary

Associated known cause ( post-thrombotic, post-

traumatic )

Classification of Chronic Lower Extremity Venous Disease

A Anatomic

Classification

A(S) Superficial Veins

A(D) Deep Veins

A(P) Perforating Veins

Classification of Chronic Lower Extremity Venous Disease

P Pathophysiologic

Classification

P(R) Reflux

P(O) Obstruction

P(R,O) Reflux & Obstruction

Complications1.Thrombosis or Superficial

Thrombophlebitis

2.Hemorrhages

3.Ulceration

4.Malignancy (Marjolin’s)

5.Calcification

6.Periostitis

Investigations Clinical Tests

Doppler Study

Duplex study

Plethysmography

Venography

Treatment

1. Pain

2. Easy fatigability

3. Heaviness

4. Recurrent Superficial Thrombophlebitis

5. Bleeding

6. Cosmetic

Indications

Treatment Aim is to overcome venous congestion

Improving muscle pump by regular exercise can overcome venous hypertension

Compression Stockings

Compression stockings supports varicose veins abolishing the effect of venous reflux

They are especially suitable to control deep venous reflux and secondary varicose veins

Available in 3 Grades

Injection Sclerotherapy

•Cosmetic for reticular veins

•For residual varices after surgeryShould be given in an empty vein and compressed immediately afterwards.

Surgery Trendelenburg’s operation

Sub-fascial ligation of Cockett’s & Dodd’s

Sub-fascial Endoscopic Perforator Surgery

(SEPS)

VNUS Closure

TriVex

Radiofrequency ablation

Endovenous laser ablation

Trendelenburg’s Procedure

High juxta-femoral flush ligation of

the saphenous vein with division of ALL the

groin tributaries, with or without saphenous

vein stripping in the thigh is classically done

for documented sapheno-femoral reflux

Recurrence rates are higher with

ligation alone.

Vein stripping below the knee is not

needed (it is not varicosed, not connected to

perforators and may cause saphenous nerve

injury)

S E P S

Small port incisions are made

Carbon dioxide insufflation

done 2-6 perforators identified &

ligated

Indication: Below knee perforators

Newer TechniquesVNUS

Closure

TriVex

Ultrasound guided ablation catheter introduced into Sapheno-femoral junction & slowly withdrawnLow incidence of Hematoma & Pain

Veins identified by subcutaneous illuminationInjection of large volume of fluidsSuperficial veins are sucked out

Thank You

For your kind attention