Management of Varicose Veins

Ranjith.R.ThampiIntern

Department of General Surgery

INTRODUCTION

“Varicosity is the penalty for verticality against gravity”In man, owing to his upright posture, blood has to flow

from lower limbs to heart against gravity.

Defined as Dilated, Tortuous and Elongated superficial veins of the lower limb.

Surgical Anatomy of Venous System of the Lower Limb

1. Superficial System-Long saphenous vein-Short saphenous veinplus their tributaries

2. Perforators3. Deep System of veins

Perforators There are about 5 constant perforators in

the lower limb on medial side which include:

-Ankle Perforators(Cockett) 3 in number (all related to medial malleolus)-Knee Perforator(Boyd)-Thigh Perforator(Dodd)

Surgical PhysiologyBlood flows in the leg because it is pumped by the heart

along the arteries. By the time it emerges from the capillaries, it is at a low pressure, but it is enough to return blood to the heart.

Factors helping blood return to heart include: -Calf muscle pump

-Competent valves-Vis-a-tergo-Negative intrathoracic pressure-Venae comitantes

ClassificationsClinical- 0-6 grades

Etiologic- congenital, primary, secondary

Anatomic- superficial, perforator, deep

Pathophysiologic- reflux, obstruction, both

ETIOLOGICAL TYPES

• CONGENITAL

• PRIMARY

• SECONDARY

CONGENITAL• Abnormality present since birth• Also due to muscular weakness or congenital

absence of valves• SYNDROME-

Klippel Trenuanay Syndrome (Valveless syndrome)- Complete absence of

valves in superficial and deep veins• GENETIC- Abnormalities in the FOXC2 gene

PRIMARY TYPE

• Venous dysfunction due to undetermined cause

• May be result of congenital weakness in the vein wall due to defective connective tissue and smooth muscle.

• Concomitant factors prolonged standing (occupational)

SECONDARY TYPE• Seen in people with an associated known cause

- Post Thrombotic, Post Traumatic, etc.

• In women, Pregnancy, Pelvic tumours, OC Pills, Progesterone intake

• Congenital AV fistula

• DVT secondary to RTAs or Post-op can result in destruction of valves resulting in varicose veins

Venous Pathophysiology

• Blood from the leg muscles returns through deep veins.

• Blood from skin and superficial tissues, external to deep fascia, drains via the long and short saphenous veins and communicating veins into deep veins.

*Valves prevent flow of blood from the deep to the superficial system

Venous Pathophysiology

• On standing, blood continues to circulate even in the absence of muscle activity.

• On walking and on exercising, foot pump and muscle pump come into play and maintain venous return

Venous Hypertension• The first source is hydrostatic pressure due to gravity, a

result of venous blood coursing in a distal direction. It is the weight of the blood column from the right atrium

• The second source of venous hypertension is dynamic. It is the force of muscular contraction, usually contained within the compartments of the leg

• If a perforating vein fails, high pressures of 150-200 mm Hg developed within the muscular compartments during exercise are transmitted directly to the superficial venous system

Clinical FeaturesSymptoms:

Patient with symptomatic varicose veins commonly has heaviness, discomfort, and extremity fatigue

Associated with Dragging pain, Night cramps, Eczema, Dermatitis, Pruritis, Ulceration, Bleeding

Pain is characteristically dull, and is exacerbated in the afternoon, especially after periods of prolonged standing

The symptoms are relieved by leg elevation or elastic support

Females complain of symptom exacerbation during the early days of the menstrual cycle

Signs1. Visible dilated veins in the leg with/ without blow

outs

2. Ankle flare, Pedal edema, pigmentation, dermatitis, ulceration, tenderness, restricted ankle joint movement.

3. Thickening of tibia due to periostitis

4. Positive cough impulse at the sapheno-femoral junction

Clinical Examination5. Brodie-Trendelenburg test: Vein is emptied by elevating

the limb and a tourniquet is tied just below the sapheno-femoral junction (or using thumb, sapheno-femoral junction is occuluded).Patient is asked to stand quickly. When tourniquet or thumb is released, rapid filling from above signifies sapheno- femoral incompetence. This is Trendelenburg test I

In Trendelenburg test II, after standing tourniquet is not released. Filling of blood from below upwards rapidly can be observed within 30-60 seconds. It signifies perforator incompetence.

6. Perthe’s test: The affected lower limb is wrapped with elastic bandage and the patient is asked to walk around and exercise. Development of severe cramp like pain in the calf signifies DVT.

7. Modified Perth’s test: Tourniquet is tied just below the sapheno – femoral junction without emptying the vein. Patients is allowed to have a brisk walk which precipitates bursting pain in the calf and also makes superficial veins more prominent. It signifies DVT. DVT is contraindicated for any surgical intervention of superficial varicose veins. It is also contraindicated for sclerosant therapy.

8. Three tourniquet test: To find out the site of incompetent perforator, three tourniquets are tied after emptying the vein.1. at sapheno- femoarl junction2. above knee level3. another below knee level. Patient is asked to stand and looked for filling of veins and site of filling. Then tourniquets are released from below upwards, again to see for incompetent perforators

9. Schwartz test: In standing position, when lower part of the long saphenous vein in leg is tapped, impulse is felt at the saphenous junction or at the upper end of the visible part of the vein. It signifies continuous column of blood due to valvular incompetence.

10. Pratt’s test: Esmarch bandage is applied to the leg from below upwards followed by a tourniquet at sapheno – femoral junction. After that the bandage is released keeping the tourniquet in the same position to see the “blow outs” as perforators.

11. Morrissey’s cough impulse test: The varicose veins are emptied. The leg is elevated and then the patient is asked to cough. If there is sapheno- femoral incompetence, expansile impulse is felt at saphenous opening.

12. Fegan’s test: On standing, the site where the perforators enter the deep fascia bulges and this is marked. Then on lying down, button like depression in the deep fascia is felt at the marked out points which confirms the perforator site.

13. Ian- Aird test: On standing, proximal segment of long saphenous vein is emptied with two fingers. Pressure from proximal finger is released to see the rapid filling from above which confirms sapheno – femoral incompetence.

Summary of examination

System involved- LSV/SSVSFJ incompetent? Yes- T1 +/ No- T1 –Perforator incompetence? Yes- T2 +/ No- T2 –Group of perforators incompetent?-MTTIs there DVT? Yes- Perthes’ +/ No- Perthes’ –Any abdominal mass? Pelvic pathology/ tumorsAny complications? – Eczema/ Dermatitis/ UlcerUnilateral or Bilateral?

INVESTIGATIONS• THOROUGH HISTORY• BRODIE TRENDELENBERG TEST• TOURNIQUET TEST• ASSESS SKIN CHANGES• PERIPHERAL PULSES• ABDOMINAL EXAMINATION• DOPPLER ULTRASOUND• DUPLEX ULTRASOUND• VENOGRAPHY

Duplex Scan

Treatment

1. Conservative2. Injection line of treatment3. Foam Sclerotherapy4. Surgery

Conservative Management

• Limb Elevation + Elastic compression bandage

• Elastic compression stockings• Unna Boot

Unna Boot- Gauze impregnated with a thick, creamy mixture of zinc oxide and calamine to promote healing. It may also contain acacia, glycerin, castor oil and white petrolatum

Injection line of treatmentIndicated in Below knee varicosity and recurrent

varicosity after surgeryComplications:

Allergy, pigmentation, DVT, Thrombophlebitis, Skin necrosis

Sodium tetradecyl sulfate 1.5–3.0%Polidocanol 3–5%Polyiodinated iodine 2–12%Sodium morrhuate 5%Hypertonic saline 11.7 – 23.4%Chromated glycerin 50%

US Guided Foam Sclerotherapy

Foam sclerosant C (Polidocanol) used in few centres in the UK

Air mixed with sclerosant and injected into veins by US image

Complications:-Extravasation: Skin ulceration-Escape into deep veins: DVT-Entering brain: Stroke, Headache

Surgery

I. Trendelenburg’s Operation

II. Subfascial ligation of Cockett and Dodd

III. Subfascial endoscopic perforator surgery(SEPS)

Trendelenburg’s Operationa. Trendelenburg operation: It is a juxta femoral flush

ligation of long saphenous vein (i.e. flush with femoral vein), after ligating named (superficial circumflex, superficial external pudendal, superficial epigastric vein) and unnamed tributaries. All tributaries should be ligated, otherwise recurrence will occur.

b. Stripping of vein: Using Myer’s stripper vein is stripped off. Stripping from below upwards is technically easier. Immediate application of crepe bandage reduces the chance of bleeding and haematoma formation.

Complication is injury to saphenous nerve causing saphenous neuralgia.

Trendelenburg’s Operation

Stripping is not usually done for the veins in the lower part of the leg.Stripping of the vein is more effective.‘Inverting or invaginating stripping’ using rigid Oesch pin stripper is better as postoperative pain and haematoma is less common and also there is tissue damage. Vein should be very firmly fixed to the end of the stripper and pulled out to cause the inverting of the vein.Stripping of short saphenous vein is more beneficial than just ligation at sapheno popliteal junction. It is done from above downwards using a rigid stripper to avoid injury to sural nerve.

Subfascial Ligation of Cockett and Dodd

Perforators are marked out by Fegan’s method. Perforators are ligated deep to the deep fascia through incisions in antero medial side of the leg.

SEPS• Video techniques that allow direct visualization through

small-diameter scopes have made endoscopic subfascial exploration and perforator vein interruption possible

• Minimal morbidity and wound complications• The connective tissue between the fascia cruris and the

underlying flexor muscles is so loose that this potential space can be opened up easily and dissected with the endoscope

• This operation, done with a vertical proximal incision, accomplishes the objective of perforator vein interruption on an outpatient basis

SEPS

Recent Techniques in management

• VNUS closure- Ablation catheterComplications: DVT, recurrence, damage to overlying skin

• TriVexComplications: Induration, Bruising, Subcutaneous grooves

• Radiofrequency ablation- Metal prongs• Endovenous laser ablation- Laser probe

VNUS Closure Also known as endovenous radiofrequency

ablation, it is a minimally-invasive procedure used to treat the great saphenous vein (GSV), small saphenous vein (SSV) and other superficial veins. It uses a patented radiofrequency catheter inserted into the vein, which applies RF energy to heat the vein. This causes the vein to collapse and seal shut.

VNUS closure

TRIVEXInvolves a novel technique called transilluminated powered

phlebectomy. While most varicose vein surgery is done without directly visualizing the varicose veins, the TRIVEX system transilluminates the veins requiring removal via advanced fiberoptic technology (much like a flashlight can shine through your skin).

Once the surgeon has visually confirmed the location of the diseased varicose vein(s), a local anesthetic is delivered under pressure into the area. A powered vein resector is then guided next to the vein and suction is used to draw up and remove the vein (much like ‘liposuction’). This varicose vein treatment allows accurate removal of large clusters of varicose veins with a minimal number of incisions.

TriVex Disadvantages:It may cause bruising,grooves, skin induration.

Radiofrequency Ablation

Complications of Varicose Veins

i. Eczema & Dermatitisii. Lipodermatosclerosisiii. Haemorrhageiv. Thrombophlebitisv. Venous Ulcer- Fibrin cuff hypothesis & White cell

trapping hypothesisvi. Calcificationvii. Periostitisviii. Equinovarus deformityix. Marjolin’s ulcer

Lipodermatosclerosis

Marjolin’s Ulcer

Doctors at the China Rehabilitation Research Centre in Beijing have developed an egg cup-like casing for a miracle survivor who was cut in half in a freak accident back in 1995. It took 20 doctors to save his life and nobody thought he'd be able to do anything again, but when doctors at the CRRC heard about his case, they created these robotic

legs for him.

Thank You

References• Bailley & Love

Textbook of Surgery• The Mayo Clinic- Vascular Surgery• The Merck Manual of Diagnosis & Therapy, 18th

Edition• Oxfor Handbook of Clinical Surgery,

3rd Edition• The Internet• Learning SurgeryThe Surgery Clerkship ManualStephen F. Lowry, MD, FACS, FRCS Edin (Hon.)