varicose veins of lower limbs
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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
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For your kind attention