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VENOUS DISORDERS

VARICOSE VEINS

DVT

ANATOMY OF VENOUS SYSTEM

• SUPERFICIAL VENIS AND DEEP VEINS • LONG AND SHORT SAPHENOUS VEINS (LSV & SSV)

CARRY ONLY 10 % OF VENOUS RETURN• VENOUS DISORDER COMMON IN LOWER LIMBS• LSV – FROM DORSAL VENOUS ARCH MEDIALLY

ASCENDS – MEDIAL SIDE OF LEG- SUB CUTANEOUS PLANE – JOINS IN FEMORAL TRIANGLE WITH FEMORAL V.SAPHENO FEMORAL JUNCTION ( SFJ)

• SSV : FROM LATERAL DORSAL VENOUS ARCH ASCENDS LATERAL SIDE OF LEG JOINS POPLITEAL VEIN AT POPLITEAL FOSSA

• PERFORATORS V1. MID THIGH DODD’S2. GASTROCNEMIUS BOYD’S 3. LOWER LEG COCKETT’S I, II, III4. ANKLE MAY AND KUSTER

PATHO PHYSIOLOGYSUPERFICIAL VENOUS SYSTEM – LOW PRESSURE 20 mm HgDEEP V. HIGH PRESSURE – SUPPORTED BY MUSCLESVENOUS PUMPS: CALF MUSCLE, THIGH MUSCLES FOOT PUMP – WALKINGVALVES : BICUSPED VALVES – DIRECTS BLOOD TOWARDS HEARTFROM SUPERFICIAL TO DEEP VEINS

VARICOSE VEINS – CAUSE

• FAILURE OF VALVES IN LSV & SSV• 10 – 20 % OF ADULTS• DIET, INHERITANCE – WOMEN• VALVES - COMMISSURE -GAP – DEGENERATION• VEIN BELOW VALVE DILATES• PROLONGED STANDING • PREGNANCY - HORMONAL - SMOOTH MUSCLE

RELAXATION

Clinical features

• COSMETIC • DISCOMFORT AND ACHING • BLEEDING• PHLEBITLS• EZEMA, LIPO DERMATIC SCLEROSIS• ULCERATION

DEFINITIONDILATED TORTUOUS VEINS IN LEG LSV, SSVWITH DEFECTIVE VALVES5 -15 mm DIAMETER 0.5 mm VEINS IN SKIN - FLARE1 - 3 mm VEINS IN SUB-DERMAL RETICULAR

• SYMPTOMS - NOT RELATED TO SEVERITY OF VARICES

COMPLICATION OF VARICOSE VEINS• THROMBOSIS - THROMBOPHLEBITIS• HAEMORRHAGE• ULCERATION • ECZEMA AND PIGMENTATION

DEEP VEIN INCOMPETENCEFOLLOWING DVT - RECANALISATION -VALVES DESTROYEDVENOUS RETURN – SUPERFICIAL VEINSCALF MUSCLE INCREASE IN SIZE – “CHAMPAGNE BOTTLE LEG”ANKLE OEDEMA

ULCERATION, ECZEMA, PIGMENTATION HAEMOSIDERINLIPODERMATOSCLEROSIS

AMBULATORY VENOUS HYPERTENSION• REVERSAL FLOW DEEP TO SUPERFICIAL • VAVULAR INCOMPETENCE• DVT – SEVERE SYMPTOMS

CAUSE OF VENOUS ULCERATION• FIBRIN CUFF HYPOTHESIS

FIBRIN, COLLAGEN IV, FIBRONECTIN PREVENT DIFFUSION OF NUTRIENTS TO CELLS

• WHITE CELL TRAPPING HYPOTHESISLEUCOCYTE SEQUESTRATION - PROTEOLYTIC - ENZYMES

• INJURY TO CAPPILARY ENDOTHELIUM

INVESTIGATIONSa) CLINICAL TESTS1. TOURNIQUET TEST (BRODE – 1846)

THREE LEVELS : SAPHENO FEMORALABOVE KNEE

2. TRENDELENBURG TEST - BELOW KNEE3. PERTHE’S TEST

DOPPLER ULTRASOUND• BI DIRECTIONAL PROBE – REFLUX-• SFJ – INCOMPETENCE• SPJ – LESS RELIABLE• PRIMARY VARICOSE VEINS – EASY

PHOTOPLETHYSMOGRAPHY• PROBE TO ASSESS THE VENOUS FILLING OF SUPERFICIAL

VEINS• PATIENT LIES – DORSIFLEX ANKLE JOINT 10 TIMES

SUPERFICIAL VEIN EMPTY – PPG READING FALLS• PATIENT SITS UP : - SLOW FILLING 30 SECONDS

NORMAL- RAPID FILLING - VEIN INCOMPETANT

DUPLEX IMAGINGB - MODE ULTRASOUND WITH DOPPLERANATOMICA AND FLOW PATTERN WITH COLOUR CODINGDVT, PERFORATORS, REFLUX INCOMPETENCE OF VALVES

VENOGRAPHY• ASCENDING VENOGRAME DVT• DESCENDING VENOGRAPHY CANNULA FEMORAL V.

PATIENT STANDING• RECURRENT VARICOSE VEIN

MANAGEMENT PRIMARY OR SECONDARY

A. CONSERVATIVE1. ELASTIC GRADED PRESSURE STOCKING2. ELEVATION OF LIMB

B. SCLEROTHERAPY• NO MAJOR PERFORATING VEINS • NO SFJ INCOMPETENCE

Optimal indications TelangiectasiasReticular varicosities and reticular veinsIsolated varicosities *

Below-knee varicosities *

Recurrent varicosities

Indications for Sclerotherapy

■Anaphylaxis ■Allergic reactions ■ Thrombophlebitis ■ Cutaneous necrosis ■ Pigmentation ■ Neoangiogenesis

• STD → SODIUM TETRADECYL- EMPTY THE VEIN – INJECTION – COMPRESSION –

ENDOTHELIUM DESTROYED- HIGH RECURRENCE

• STD WITH FOAM• ECHO SCLEROTHERAPY• MULTIPLE SITTINGS REQUIRED

- SKIN PIGMENTATION- ULCERATION

• MICRO SCLEROTHERAPY

SURGICAL TREATMENTDVT – TO BE RULLED OUT

A. TRENDELENBERG PROCEDURESFJ: LIGATION ALONE WITH ITS THREE TRIBUTARIES1. SCI 2. SE 3. SP

Options available for surgical treatment of varicose veins are as follows:■Ankle-to-groin saphenous vein stripping (with stab avulsion) ■ Segmental saphenous vein stripping (with stab avulsion) ■ Saphenous vein ligation: high, low, or both ■ Saphenous vein ligation and sclerotherapy ■ Saphenous vein ligation (with stab avulsion) ■ Stab avulsion of varices without saphenous vein stripping (phlebectomy) ■ Endoluminal occlusion of the saphenous vein by radiofrequency (RF) or laser energy

B. WITH STRIPING LSV• TERMINATION SSV AT POPLITEAL FOSSA VARIABLE • IDEALLY ALL PERFORATORS MAPED WITH DUPLEX SCAN • POOT OPERATIVE COMPRESSION BANDAGE 3 DAYS• FOLLOWED BY GRADED STOCIKNGS

MANAGING PERFORATORS• HOOK PHLEBECTOMY• LINTON’S PROCEDURE • ENDOSCOPIC SUB FACIAL LIGATION

NEW TECHNIQUES• LASER • RF

COMPLICATIONS• BRUISING • LONG SAPHENOUS NERVE

SURAL NERVE INJURY• DVT – RARE

VENOUS RECONSTRUCTIVE SURGERYDEEP VEIN

• SPIRAL GRAFT OF SAPHENOUS VEIN• PALMA’S PROCEDURE : LSV FROM OPPOSITE LEG

REVERSED FROM ANASTAMOSED WITH FEMORALREPAIR OF VALVES

• VALVELOPLASTY• AXILLARY VEIN TRANSPLANT

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