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

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

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

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

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.

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

Abnormal Veins Telangiectasias Reticular veins Varicose vein

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

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

VENOUS SYSTEM OF LOWER LIMBS SUPERFICIAL VEINS DEEP VEINS PERFORATORS

SUPERFICIAL VEINS LONG SAPHENOUS SYSTEM SHORT SAPHENOUS SYSTEM

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

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

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

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

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

VALVES

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

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

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

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

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 20-30 S

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.

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

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

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

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

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.

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

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

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

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.

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

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

VARICOSITIES SPIDER NAEVI—TELENGIECTASIA RETICULAR VEIN—VENULECTASIS TRUNCAL VARICOSITIES

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

TRENDELENBURG TEST I & II

SCHWARTZ TEST (CRUVHEILLIER’S SIGN)

MORISSEY’S COUGH IMPULSE

FEGAN’S METHOD. (PHALEN’S TEST)

PRATT’S TEST

THREE TOURNIQUET TEST (Mahorne-ochsner )

PERTHE’S TEST

PHYSICAL EXAMINATION ABDOMINAL PELVIC EXAMINATION. AUSCULTATION.

CEAP CLASSIFICATION CLINICAL ETIOLOGIC ANATOMIC PATHOPHYSIOLOGIC

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

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

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

PATHOPHYSIOLOGIC CLASSIFICATION REFLUX Pr OBSTRUCTION Po REFLUX & OBSTRUCTION Pro

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

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

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

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

—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;191:1186-1191 ©2008 by American Roentgen Ray Society

—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;191:1186-1191 ©2008 by American Roentgen Ray Society

INVASIVE PROCEDURES ASCENDING PHLEBOGRAPHY DESCENDING PHLEBOGRAPHY CAVOGRAPHY VARICOGRAPHY

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

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.

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

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

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

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  

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

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

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

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

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

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

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

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

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

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

SAPHENOUS VEIN LIGATION – GROIN INCISION

SAPHENOUS VEIN LIGATION LSV

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

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

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

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

SEPS

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

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

EVLT – Endovenous Laser Treatment

RADIOFREQUENCY ABLATION RADIOFREQUENCY INDUCED THERMO THRAPY (RFiTT)

RADIOFREQUENCY ABVLATION SEGMENTAL ABLATION

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

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

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

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