1. MANAGEMENT OF VARICOSE VEINS WHEN & HOWBY
DR.G.THULASIKUMAR
M.S.(Gen.Surg) M.Ch. (Vascular Surgery)
Department of Vascular Surgery
Govt. Kilpauk Medical College Hospital
Chennai-10

2. Votive offerings such as these were given to physicians by grateful patients after successful treatment

3. Chronic venous disease
Most common vascular disorder
3 Billion US dollars spent a year for treatment
3 % of the total Heath care Budget
2 million USA work days lost per year

4. DEFINITION
A VEIN THAT BECOMES ELONGATED, DILATED, TORTUOUS, POUCHES AND THICKENED DUE TO DYSFUNCTIONING VALVES CAUSING CONTINOUS DILATATION UNDER PRESSURE .

5. Definition
Telangiectasias - are a confluence of dilated intradermal venules less than one millimeter in diameter.
Reticular veins - are dilated bluish subdermal veins, one to three millimeters in diameter. Usually tortuous.
Varicose veins - are subcutaneous dilated veins three millimeters or greater in size. They may involve the saphenous veins, saphenous tributaries, or nonsaphenous superficial leg veins.

6. Subcutaneous Veins When abnormal: - Telangiectasia (spider – 1mm)
- Reticular (1- 3 mm)
Varicose (>3mm)

7. Abnormal Veins
Telangiectasias
Reticular veins
Varicose vein

8. INCIDENCE MEN : 10-15% WOMEN : 20-25%
WHEN NON SAPHENOUS VARICOSITIES ARE INCLUDED
MEN : 45%
WOMEN : 50%

9. RISK FACTORS
FEMALE GENDER
ADVANCED AGE
CAUCASIAN RACE
FAMILY HISTORY
ACCELERATORS
PREGNANCY
OBESITY

10. VENOUS SYSTEM OF LOWER LIMBS
SUPERFICIAL VEINS
DEEP VEINS
PERFORATORS

11. SUPERFICIAL VEINS
LONG SAPHENOUS SYSTEM
SHORT SAPHENOUS SYSTEM

12. LONG SAPHENOUS SYSTEM
FROM MEDIAL LIMB THE DORSAL ARCH TO SAPHENOUS OPENING – SAPHENO FEMORAL JUNCTION
SFJ TRIBUTARIES
SUPERFICIAL EPIGASTRIC VEIN
SUPERFICIAL EXTERNAL PUDENDAL VEIN
SUPERFICIAL LATERAL CIRCUMFLEX
ILIAC VEIN.
THIGH TRIBUTARIES
ANTEROLATERAL VEIN
POSTEROMEDIAL VEIN
CALF TRIBUTARIES
ANTERIOR ARCH VEIN
POSTERIOR ARCH VEIN

14. VEINS CONNECTING LSV & SSV
SHORT SAPHENOUS SYSTEM
SAPHENO POPLITEAL JUNCTION
BRANCHES
LATERL CALF VEIN
MEDIAL CALF VEIN
VEINS CONNECTING LSV & SSV
LATERAL THIGH VEIN
INTER SAPHENOUS VEIN
ACCOMPANYING NERVES
LSV – SAPENOUS NERVE
SSV – SURAL NERVE

15. Perforators Connect deep and superficial systems
Flow normally from superficial to deep

16. PERFORATORS USUALLY DOUBLE 1-2mm IN DIAMETER
UPWARD DIRECTION FROM THEIR SUP.VEIN
LSV PERFORATORS
THIGH –
DODD’S GROUP
HUNTER’S PERFORATOR
DODD’S PERFORATING VEIN
HACH PERFORATING VEIN

17. PERFORATORS BELOW KNEE BOYD’S SHERMAN’S - 24cm COCKETT’S - III---18cm
CALF PERFORATORS
GASTROCNEMIUS (MAY’S)
SOLEUS PERFORATORS
BASSI’S VEIN- PERONEAL TO LSV
FIBULAR
FOOT PERFORATORS
KUSTER MARGINAL
BELOW MEDIAL + LATERAL
MALLEOLI

18. VALVES

20. PHYSIOLOGY
VIS A TERGO—LV CONTRACTION
VIS A FONTE---R A CONTRACTION

21. FOOT MUSCLE PUMP DEEP PLANTAR ARCH SUPERFICIAL DORSAL ARCH
BOW STRING EFFECT - FLATTENS BOTH ARCHES EMPTYING
VEINS PRESSURE > 100mg OF Hg
CONTRIBUTES > 50% BLOOD LEAVING CALF

22. Muscle Pump - superficial veins CALF MUSCLE PUMP 200 – 300 mm OF Hg
>80 ml OF BLOOD
Contractions propel blood towards heart
Relaxation draws blood from
- superficial veins
- lower deep veins

23. Thoracoabdominal Pump
Inspiration decreases intrathoracic pressure promoting venous return
Expiration reverses the process
Findings easily seen in US

24. REFILLING THE PUMP FROM ARTERIAL SYSTEM FROM SUPERFICIAL VENOUS SYSTEM
PRESSURE IN ERECT POSTURE >100mg OF Hg
INTRAVENOUS PRESSURE IN SUPINE POSTURE SELDOM < 5mm OF Hg
REFILLING TIME S

25. AMBULATORY VENOUS PRESSURE
RESIDUAL VENOUS PRESSURE
VIS –A-TERGO mm OF Hg
HYDROSTATIC PRESSURE 100mm OF Hg
AVP (MINIMUM PRESSURE. SHOWN DURING EXERCISE)
FALLS BY 60-80% IN FEW SECONDS.

26. IN CVI / CVH VALVULAR INCOMPETENCE CONTINUED REFLUX
INCREASED AVP DURING EXERCISE DUE TO INCOMPLETE EMPTYING
DECREASED REFILLING TIME <10S
INDEPENDENT(PRIVATE) CIRCULATION – BLOOD IN THE DEEP SYSTEM
FLOWS UP IN THE DEEP SYSTEM
FLOWS DOWN IN THE SAPHENOUS SYSTEM

27. PATHOPHYSIOLOGY OF MICROCIRCULATION CHANGES IN VENOUS HYPERTENSION
PRIMARY VARICOSE VEINS
DEEP VENOUS INSUFFICIENCY
AMBULATORY VENOUS HYPERTENSION
VENULAR AND CAPILLARY DILATATION
DECREASED CAPILLARY PERFUSION PRESSURE
INCREASED CAPILLARY PERMEABILITY
CHRONIC LYMPHATIC DAMAGE
DECREASED LYMPHATIC DRAINAGE

28. PATHOPHYSIOLOGY OF MICROCIRCULATION CHANGES IN VENOUS HYPERTENSION
DECREASED LYMPHATIC DRAINAGE
WBC TRAPPING, ADHESION, ACTIVATION
MACROMOLECULES ENTER CIRCULATION
IMPEDANCE OF MICROCIRCULATORY FLOW PLUS RELEASE FREE RADICALS, PROTEOLYTIC ENZYMES, CYTOKINES AND CHEMOTACTIC AGENTS
PERICAPILLARY FIBRIN CUFF
IMPAIRED TISSUE PERFUSION AND OXYGENATION
VENOUS ULCERATION

29. CLINICAL EVALUATION ASYMPTOMATIC SYMPTOMATIC PAIN & SWELLING
COSMETIC
SYMPTOMATIC
PAIN & SWELLING
COMPLICATION

30. SYMPTOMS PAIN ITCHING SKIN CHANGES COMPLICATIONS
THROBBING
ACHING
STINGING
BURNING
EXERCISE – VARIABLE EFFECT ON PAIN
NIGHT PAIN—CRAMPINESS
ITCHING
SKIN CHANGES
COMPLICATIONS
EFFECTS OF PREVIOUS TREATMENTS.

31. Complications
EXTREMELY PAINFUL ULCERS - NEAR VARICOSE VEINS, PARTICULARLY NEAR THE ANKLES.
BROWNISH PIGMENTATION USUALLY PRECEDES THE DEVELOPMENT OF AN ULCER.
OCCASIONALLY, VEINS DEEP BECOME ENLARGED.
BLEEDING
SUPERFICIAL THROMBOPHLEBITIS

32. PERSONAL HISTORY PREGNANCY MENSTURAL CYCLE PELVIC CONGESTION SYNDROMES
(VULVOPUDENDAL VARICES ASSOCIATED WITH PELVIC & OVARIAN VARICES

33. PAST MEDICAL HISTORY CONGESTIVE FAILURE RENAL & CIRCULATORY FAILURE
AUTOIMMUNE DISEASES
ALLERGIC HISTORY
HOSPITALISATION AND IMMOBILISATION

34. STRONG FAMILIAL COMPONENT
Not well studied
Twin studies 75% identical, 52% non identical
If both parents VVS - 90% of children VVs
If one parent was affected 25 percent for men and 62 percent for women
Cornu-Thenard, A, Boivin, P, Baud, JM, et al. Importance of the familial factor in varicose disease. Clinical study of 134 families. J Dermatol Surg Oncol 1994; 20:318.

35. PHYSICAL EXAMINATIONS
STANDING POSITION
SKIN SHOULD BE INSPECTED,TAPPED, TOUCHED, PRESSED & SQUEEZED
EVALUATION FOR:
COLOR
TEMPERATURE
TEXTURE
TURGOR
MOISTURE
HAIR QUALITY

36. SKIN CHANGES CORONAPHLEBECTATICA VENOUS ECZEMA
BROWN HAEMOSIDERIN DEPOSITION
ACUTE/CHRONIC LIPODERMATO SCLEROSIS
INDURATION
ATROPHIC BLANCHE
OEDEMA
VENOUS ULCERATION
CONTRACTURES
MARJOLINS ULCER

37. VARICOSITIES SPIDER NAEVI—TELENGIECTASIA RETICULAR VEIN—VENULECTASIS
TRUNCAL VARICOSITIES

38. CLINICAL TESTS TO KNOW WHICH SYSTEM WHICH PERFORATOR
PATENCY OF DEEP VEIN

39. TRENDELENBURG TEST I & II

40. SCHWARTZ TEST (CRUVHEILLIER’S SIGN)

41. MORISSEY’S COUGH IMPULSE

42. FEGAN’S METHOD. (PHALEN’S TEST)

43. PRATT’S TEST

44. THREE TOURNIQUET TEST (Mahorne-ochsner )

45. PERTHE’S TEST

46. PHYSICAL EXAMINATION
ABDOMINAL PELVIC EXAMINATION.
AUSCULTATION.

47. CEAP CLASSIFICATION
CLINICAL
ETIOLOGIC
ANATOMIC
PATHOPHYSIOLOGIC

48. CLINICAL CLASSIFICATION
CO NO SIGN OF VENOUS DISEASE
C1 TELENGIECTASIA AND SPIDER VEINS
C2 VARICOSE VEINS
C3 EDEMA DUE TO VENOUS DISEASE
C4 SKIN CHANGES; LIPODERMATOSCLEROSIS
C5 HEALED ULCERS
C6 ACTIVE ULCERS

49. ETIOLOGIC CONGENITAL EC PRIMARY EP SECONDARY ES POST THROMBOTIC
POST TRAUMATIC
OTHERS

50. ANATOMIC SEGMENTS 18 SUP VEINS As 1. LSV 2. ABOVE KNEE 3. BELOW KNEE
4. SSV
5. NON SAPHENOUS
DEEPVEIN Ad
6. IVC
16. MUSCULAR
PERFORATING VEIN Ap
17. THIGH
18. CALF

51. PATHOPHYSIOLOGIC CLASSIFICATION
REFLUX Pr
OBSTRUCTION Po
REFLUX & OBSTRUCTION Pro

52. INVESTIGATIONS CONTINUOUS WAVE DOPPLER
TO ASSES FLOW DIRECTION
QUALITATIVE ASSESSMENT OF VENOUS REFLUX
DOES NOT GIVE ANY ANATOMIC INFORMATION.
USEFUL FOR EVALUATION OF REFLUX IN SFJ & SPJ

53. DUPLEX SCANNING 84% SENSITIVITY 88% SPECIVICITY
DIRECT DETECTION OF VALVULAR REFLUX.
VISUALIZATION OF VALVE LEAFLET MOTION
QUANTIFY DEGREE OF INCOMPETENCE

54. Duplex Ultrasonography
Replaced plethysmography and venography
7-10MHz linear transducer
Exam sitting and standing
Superficial and deep systems evaluated
Physiologic reflux: < 0.5 sec
Pathologic reflux: > 0.5 sec

55. PRESSURE MEASUREMENTS
PLETHYSMOGRAPHY
VOLUME CHANGE OF LIMB
SECONDARY TO CHANGES IN VENOUS BLOOD FLOW
PRESSURE MEASUREMENTS
TRANSMURAL PRESSURE
AMBULATORY VENOUS PRESSURE

56. —43-year-old woman with varicose veins.
—43-year-old woman with varicose veins. Three-dimensional volume-rendered image produced at opacity–transparency function setting for superficial visualization shows enlarged right great saphenous vein (arrow) and tortuous varicose vein in medial aspect of thigh and calf. Varicose vein pathway is situated along superficial duplication of right great saphenous vein.
Lee W et al. AJR 2008;191:
©2008 by American Roentgen Ray Society

57. —43-year-old woman with varicose veins.
—43-year-old woman with varicose veins. Volume-rendered image shows enlarged superficial duplication (arrow) and unenlarged midsegment of main great saphenous vein in its original location (arrowhead).
Lee W et al. AJR 2008;191:
©2008 by American Roentgen Ray Society

58. INVASIVE PROCEDURES ASCENDING PHLEBOGRAPHY DESCENDING PHLEBOGRAPHY
CAVOGRAPHY
VARICOGRAPHY

59. ASCENDING PHLEBOGRAPHY
GOLD STANDARD
ANATOMIC FEATURES OF THE VEINS AND THEIR VALVES ARE OUTLINED
POST THROMBOTIC CHANGES
PERFORATORS – INCOMPLETLY IDENTIFIED

60. DESCENDING PHLEBOGRAPHY
GRADE 0 NO EVIDENCE OF REFLUX
GRADE 1 MINIMAL REFLUX THRO 1 OR MORE VALVE
GRADE 2 CONSIDERABLE REFLUX IN THE THIGH
GRADE 3 GRADE 2 + LEAKAGE IN TO POPLITEAL VEIN
GRADE 4 GRADE 3 + LEAKAGE IN TO CALF VEIN.

61. VARICOSE VEINS MAYBE DUE TO
1) PRIMARY DISEASE OF LSV
2) 1 + PERFORATOR INCOMPETENCE
3) 2 + DEEP VEIN REFLUX DUE TO VALVULAR INCOMPETENCE
4) 2 + POSTTHROMBOTIC REFLUX OR OBSTRUCTION.
5) THROMBOTIC OCCLUSION OF ILIAC VEINS

62. TREATMENT OPTIONS COMPRESSION THERAPY PHARMACOTHERAPY SCLEROTHERAPY
SURGICAL TREATMENT
SEPS (Subfascial Endoscopic Perforator Surgery)
LASER ABLATION
RADIOFREQUENCY ABLATION

63. COMPRESSION THERAPY ELASTIC COMPRESSION - Bandage
- Stockings – Class II
PASTE GAUZE (UNNA) BOOT
CIRC AID ORTHOSIS
INTERMITTENT PNEUMATIC COMPRESSION

64. COMPRESSION THERAPY Action Increase venous blood flow
1. HEMODYNAMIC EFFECT
Increase venous blood flow
Decrease venous blood volume
Reduce reflux in diseased superficial and/or deep veins
Reduce a pathologically elevated venous pressure
 2. EFFECT ON TISSUE
Reduce an elevated water content of the tissue
Increase the drainage of nocious substances
Reduce inflammation
Sustain reparative processes
Improve movement of tendons and joints

65. GRADIENT COMPRESSION STOCKINGS
ELASTOCREPE BANDAGE
GRADIENT COMPRESSION STOCKINGS
Class I – 20–30(18-22) mmHg (Asymptomatic varicose)
II – 30-40(23-32) mm Hg (Symptomatic varicose)
III - 40–50(34-40) mm Hg ( For
IV - 50 – 60 mm Hg Lymph Edema)
INTERMITTENT PNEUMATIC COMPRESSION
NEW LEGGING ORTHOSIS (CIRC – AID)
UNNA BOOT

66. PHARMACOLOGIC THERAPY
DIURETICS – limited use
ZINC
FIBRINOLYTIC AGENTS
STANOZOLOL – Androgenic steroid
OXYPENTIPHYLLINE – Cytokine Antagonist
PHLEBOTROPHIC AGENTS
HYDROXY-RUTOSIDES
CALCIUM DOBESILATE
TROXERUTIN

67. PHARMACOLOGIC THERAPY
HAEMORRHEOLOGIC AGENTS
PENTOXIPHYLLINE
ASPIRIN
FREE RADICAL SCAVENGERS
TOPICAL ALLOPURINOL
DIMETHYL SULFOXIDE
PROSTAGLANDINS
PROSTAGLANDIN E
PROSTAGLANDIN F

68. PHARMACOTHERAPY TOPICAL THERAPIES GROWTH FACTORS AND CYTOKINES
ANTIBIOTICS
Application counter-productive
IODOSORB
KETANSERINE
AMNION
OCCLUSIVE DRESSINGS
GROWTH FACTORS AND CYTOKINES
SKIN SUBSTITUTES
APLIGRAFT

69. SCLEROTHERAPY
THE LOWEST APPROPRIATE CONCENTRATION AND VOLUME OF SOLUTION AT THE SLOWEST RATE AND LOWEST PRESSURE CAN MINIMISE COMPLICATIONS

70. SCLEROSANTS DETERGENT SOLUTIONS OSMOTIC SOLUTIONS CHEMICAL IRRITANTS
SODIUM TETRADECYL SULFATE
POLIDACANOL
SODIUM MORRHUATE
ETHANOLAMINE OLEATE
OSMOTIC SOLUTIONS
HYPERTONIC SALINE
HYPERTONIC SALINE AND DEXTROSE
SODIUM SALICYLATE
CHEMICAL IRRITANTS
POLYIODINATED IODINE
CHROMATED GYLCERINE

71. Microsclerotherapy 30 g butterfly needle 0.2% STS
Several courses required
benefit compression

72. FOAM SCLEROTHERAPY TESSARI TECHNIQUE
1 PART (2ml) DETERRGENT & 4 PARTS AIR (8ml) AIR AGITTATED USING TWO 10 ml SYRIGES, CONNECTED BY A 2/3 WAY CONNECTOR

73. SURGICAL TREATMNET GOAL:
PERMANENT REMOVAL OF VARICOSITIES WITH THE SOURCE OF VENOUS HYPERTENSION
AS COSMETIC A RESULT AS POSSIBLE
MINIMUM NUMBER OF COMPLICATIONS

74. SAPHENOUS VEIN LIGATION
INCISION 1 CM ABOVE VISIBLE SKIN CREASE
TO DRAW EACH OF THE TRIBUTARIES INTO THE INCISION INORDER NOT TO LEAVE INTER ANASTOMOSING INGUINAL TRIBUTARIES BEHIND
TO AVOID EXTRAVASATION OF BLOOD SUBCUTANEOUSLY
TO INTRODUCE STRIPPER FROM ABOVE
DAMAGED VALVES ALLOW PASSAGE
STAB AVULSION TO BE DONE BEFORE STRIPPING

75. SAPHENOUS VEIN LIGATION – GROIN INCISION

76. SAPHENOUS VEIN LIGATION
LSV

78. SHORT SAPHENOUS VEIN TO MARK TERMINATION IMMEDIATE PREOPERATIVELY
PRONE POSITION
POPLITEAL SPACE RELAXED BY KNEE FLEXION
SURAL N. IDENTIFIED AND PRESERVED
STRIPPING LIMITED TO PROXIMAL LESSER SAPHENOUS VEIN ABOVE MID-CALF

80. PERFORATOR VEIN INCOMPETENCE
LINTON’S RADICAL OPERATION SUBFASCIAL LIGATION
INCISION
LONG MEDIAL
ANTEROLATERAL
POSTEROLATERAL CALF INCISIONS
COCKETT SUPRAFASCIAL LIGATION
DEPALMA
MULTIPLE PARALLEL BIPEDICLED FLAPS
LIGATION OF VEINS ABOVE OR BELOW THE FASCIA
SEPS
SINGLE PORT TO VIEW AND WORK
TWO PORTS – ONE TO VIEW; ANOTHER TO WORK

81. LINTON’S RADICAL OPERATION SUBFASCIAL LIGATION
Sural N.
Perforator V.

82. MODIFIED LINTON’S PROCDURE
TO AVULSE THE INCOMPETENT PERFORATORS UNDER DUPLEX GUIDANCE

83. SEPS

84. ABLATIVE PROCEDURES ENDO VENOUS THERMO ABLATION - LASER
- RADIO - FREQUENCY

85. ENDOVENOUS LASER SURGERY
ENDOLUMINAL OBLITERATION BY HEAT
- INDUCED COLLAGEN CONTRACTION & DENUDATION OF ENDOTHELIUM
- FIBROSIS
810 nm DIODE LASER ENERGY
TUMUSCENT ANAESTHESIA
ADVANTAGE
NO GROIN DISSECTION
NO NEOVASCULARISATION
1470 nm DIODE LASER

86. EVLT – Endovenous Laser Treatment

87. RADIOFREQUENCY ABLATION
RADIOFREQUENCY INDUCED THERMO THRAPY (RFiTT)

88. RADIOFREQUENCY ABVLATION
SEGMENTAL ABLATION

89. SURGERY FOR DEEP VEIN VALVE INCOMPETENCE
VALVE RECONSTRUCTION
INTERNAL VALVULOPLASTY
EXTERNAL AND TRANSCOMMISURAL VALVULOPLASTY
ANGIOSCOPIC VALVULOPLASTY
PROSTHETIC SLEEVE IN SITU
AXILLARY VEIN TRANSFER

90. SURGERY FOR CHRONIC VENOUS HYPERTENSION
SAPHENO POPLITEAL BYPASS
MAY HUSNI OPERATION
CROSS PUBIC VENOUS BYPASS
PALMA DALE PROCEDURE
CONTRALATERAL SAPHENOUS VEIN IS USED
PROSTHETIC FEMOROCAVAL, ILIOCAVAL OR IVC BYPASS
ILIAC VEIN DECOMPRESSION
CAVOATRIAL BYPASS

91. ENDOVENOUS
ANGIOPLASTY AND STENTING OF STENOSED / OCCLUDED THROMBOSED ILIAC VEIN (MEY THURNER’S SYNDROME)
CORRECTION OF CONGENITAL WEBS

92. THANK YOU