1. VARICOSITY A. VAYDA department of surgery with urology and anesthesiology

2. The varicose veins is the disease which is characterized by nonreversible progressing changes in superficial, perforating and deep veins, and clinically manifests by the dilation of superficial veins of the inferior extremities VARICOSITY

3. Epidemiology Varicosity is the most widespread disease among the vascular pathology. Aproximately 20 % of male and 40 % of female population suffer from different forms of varicosity. 50 % of patients are the people before aged from 20 to 60, furthermore, 10-15 % of this pathology occurs in school children. The cost of treatment of varicosity in UK is 2000-4000 € consisting annually of 2 % of national budget of the country.

4. Etiology Hereditary factors (60 %) Congenital weakness of the vascular connective tissue, anatomical insufficiency of venous valves Endocrine factors Pubertal and climacteric age, pregnancy, labor Obesity Excess weight on 20 kg increases the risk of varicosity in 5 times. Mode of life Prolonged standing, hot environment, increased intraabdominal pressure, weightlifting varicosity is the consequence of the human vertical standing position

6. Factors of normal venous hemodynamic Venous vascular tonus Venous valves Muscular contractions Arterial pressure, arterio-venous fistulae Negative diaphragmatic pressure, breathing movements Arterial pulsation Intraabdominal pressure

7. Pathogenesis

8. Increased venous pressure Dilatation of superficial veins Valvular incompetence Intravascular stagnation of venous blood Sclerosis of venous wall and valves Dilatation of perforating veins Edema, extravasal exudation Dilatation of deep veins, venous microcirculatory congestion Lipodermatosclerosis, dermatitis, eczema, hyperpigmentation Trophic ulcer

9. CLINIC 60-80 % of varicosity represents only cosmetic disturbances “Heavy leg” sensation Edema Hyperpigmentation Lipodermatosclerosis (indurative cellulitis) Eczema Trophic ulcer

11. І stage – heavy sensation; ІI stage – transitory or persistent edema, lipodermatosclerosis, hyperpigmentation; ІII stage – trophic ulcer (open or healed). Classification

14. Anamnesis Objective examination General blood and urine analyses Coagulogram Functional tests for definition of the state of a valvular system of superficial, deep and perforating veins Dopplerography Colour-flow duplex imaging Phlebography Diagnostic

15. The cause of varicosity (the state of deep veins) The presence of saphenofemoral and saphenopopliteal reflux Localization of saphenopopliteal junction The valvular state of great and small saphenous veins The presence of perforating reflux and its localization AIM OF THE DIAGNOSTICS

18. Differential diagnosis Postthrombotic disease Arterio-venous fistulas Venous angiodysplasia

19. Treatment Conservative treatment Sclerosing therapy Surgery

20. MEDICAMENTAL TREATMENT Aim: Exclusion of the risk factors ( correction of job overload, diet ) Improving of the venous wall nutrition and venous outflow Correction of microcirculation, rheology and lymph outflow Arrest of inflammatory reaction Trophic changes sanation

21. Conservative treatment Elastic bandage Phlebotonics (detralex, phlebodia, venoplant, hincor-forte) Antiinflammatory therapy (diclofenac Na, mesulid, naclofen) Physiotherapy (darsonvalization, ultraviolet insolation in suberythematous doses, laser therapy) Local therapy (antiseptics, curiosin, treatment of dermatitis and eczema)

22. І – 18,4-21,2 mm Hg ІІ – 25,1-32,1 mm Hg ІІІ – 36,4-46,5 mm Hg ІV – more than 59 mm Hg Elastic bandage

23. THE TREATMENT OF TROPHIC ULCERS Exclusion of the risk factors ( correction of job overload, diet ) Elastic bandage Correction of microcirculation, rheology and lymph outflow (phlebodia, detralex – double doses, enzymes) Antiinflammatory therapy (diclofenac Na, mesulid, naclofen) Physiotherapy (darsonvalization, ultraviolet insolation in suberythematous doses, laser therapy) Local therapy (antiseptics, curiosin) Surgical treatment (subfascial ligation of perforative veins by Linton, endoscopic subfascial clipping of perforative veins )

24. SCLEROSING TREATMENT Reticular varicosity Teleangiectases Varicosity relapse (diameter of vein less 4 mm) Complications Early (urticaria, allergic reactions, pain syndrome) Late (thrombophlebites, skin necrosis) Fibrovein 0.5 %, varicocid

26. SURGERY Saphenectomy

27. SURGERY

28. THE CAUSES OF VARICOSITY RELAPCE Diagnosis mistakes Secondary varicosity, arterio-venous fistulae, proxymal compression by tumour, scars. Technical errors Unligated and unremoved the trunk of v. Saphena magna Missed double or triple trunk of v. Saphena Long stump of v. Saphena magna Missed varicose trunk of v. Saphena parva Unligated incompetent perforative veins The mistakes in postoperative period Early refuse of elastic compression Obesity Prolonged standing job Job overload Repeated pregnancies