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MANAGEMENT OF VARICOSE VEINS WHEN & HOW BY DR.G.THULASIKUMAR M.S.(Gen.Surg) M.Ch. (Vascular Surgery) Department of Vascular Surgery Govt. Kilpauk Medical.

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Presentation on theme: "MANAGEMENT OF VARICOSE VEINS WHEN & HOW BY DR.G.THULASIKUMAR M.S.(Gen.Surg) M.Ch. (Vascular Surgery) Department of Vascular Surgery Govt. Kilpauk Medical."— Presentation transcript:

1 MANAGEMENT OF VARICOSE VEINS WHEN & HOW BY 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 Telangiec tasias 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

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14 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 LSV PERFORATORS THIGH – DODDS GROUP HUNTERS PERFORATOR DODDS PERFORATING VEIN HACH PERFORATING VEIN USUALLY DOUBLE 1-2mm IN DIAMETER UPWARD DIRECTION FROM THEIR SUP.VEIN

17 PERFORATORS BELOW KNEE BOYDS SHERMANS - 24cm COCKETTS -III---18cm II---12cm I--- 6cm CALF PERFORATORS GASTROCNEMIUS (MAYS) SOLEUS PERFORATORS BASSIS VEIN- PERONEAL TO LSV FIBULAR FOOT PERFORATORS KUSTER MARGINAL BELOW MEDIAL + LATERAL MALLEOLI

18 VALVES

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20 PHYSIOLOGY VIS A TERGOLV 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 Muscle Pump 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 0.3mm 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 VEINSDEEP 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 WBC TRAPPING, ADHESION, ACTIVATION MACROMOLECULES ENTER CIRCULATION IMPAIRED TISSUE PERFUSION AND OXYGENATION VENOUS ULCERATION DECREASED LYMPHATIC DRAINAGE IMPEDANCE OF MICROCIRCULATORY FLOW PLUS RELEASE FREE RADICALS, PROTEOLYTIC ENZYMES, CYTOKINES AND CHEMOTACTIC AGENTS PERICAPILLARY FIBRIN CUFF

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

30 SYMPTOMS PAIN – THROBBING – ACHING – STINGING – BURNING – EXERCISE – VARIABLE EFFECT ON PAIN – NIGHT PAINCRAMPINESS 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. 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 NAEVITELENGIECTASIA RETICULAR VEINVENULECTASIS TRUNCAL VARICOSITIES

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

39 TRENDELENBURG TEST I & II

40 SCHWARTZ TEST (CRUVHEILLIERS SIGN)

41 MORISSEYS COUGH IMPULSE

42 FEGANS METHOD. (PHALENS TEST)

43 PRATTS TEST

44 THREE TOURNIQUET TEST (Mahorne-ochsner )

45 PERTHES TEST

46 PHYSICAL EXAMINATION ABDOMINAL PELVIC EXAMINATION. AUSCULTATION.

47 CEAP CLASSIFICATION CLINICAL ETIOLOGIC ANATOMIC PATHOPHYSIOLOGIC

48 CLINICAL CLASSIFICATION CO NO SIGN OF VENOUS DISEASE C1TELENGIECTASIA AND SPIDER VEINS C2VARICOSE VEINS C3EDEMA DUE TO VENOUS DISEASE C4SKIN CHANGES; LIPODERMATOSCLEROSIS C5HEALED ULCERS C6ACTIVE ULCERS

49 ETIOLOGIC CONGENITALEC PRIMARYEP SECONDARYES 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 REFLUXPr 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 MHz linear transducer - Exam sitting and standing - Superficial and deep systems evaluated - Physiologic reflux: < 0.5 sec - Pathologic reflux: > 0.5 sec

55 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. Lee W et al. AJR 2008;191: ©2008 by American Roentgen Ray Society

57 43-year-old woman with varicose veins. Lee W et al. AJR 2008;191: ©2008 by American Roentgen Ray Society

58 INVASIVE PROCEDURES 1. ASCENDING PHLEBOGRAPHY 2. DESCENDING PHLEBOGRAPHY 3. CAVOGRAPHY 4. 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) 4 + 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 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 ELASTOCREPE BANDAGE ELASTOCREPE BANDAGE GRADIENT COMPRESSION STOCKINGS GRADIENT COMPRESSION STOCKINGS Class I – 20–30(18-22) mmHg (Asymptomatic varicose) 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) IV - 50 – 60 mm Hg Lymph Edema) INTERMITTENT PNEUMATIC COMPRESSION INTERMITTENT PNEUMATIC COMPRESSION NEW LEGGING ORTHOSIS (CIRC – AID) NEW LEGGING ORTHOSIS (CIRC – AID) UNNA BOOT 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 – 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 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

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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

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80 PERFORATOR VEIN INCOMPETENCE LINTONS 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 LINTONS RADICAL OPERATION SUBFASCIAL LIGATION Sural N. Perforator V.

82 MODIFIED LINTONS PROCDURE TO AVULSE THE INCOMPETENT PERFORATORS UNDER DUPLEX GUIDANCE

83 SEPS

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

85 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 ENDOVENOUS LASER SURGERY

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 THURNERS SYNDROME) CORRECTION OF CONGENITAL WEBS

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