Venous Disease

Varicose Vein

Introduction: Dilated tortuous veins 5% of adult population Equal gender prevalence Family history

Pathology: Incompetence of the venous valves Primary venous incompetence Secondary venous incompetence

Clinical manifestations: Unsightly appearance Discomfort and aching at the end of the day Ankle swelling towards the end of the day Complications: Itching and eczema Lipodermatosclerosis Venous ulceration

Venous Eczema (stasis dermatitis):

Lipodermatosclerosis:

Venous Ulcer:

On examination: Great or small saphenous vein Incompetent saphenofemoral junction or incompetent perforators Exclude DVT or deep vein incompetence

Investigations: Usually diagnosed clinically Investigations done to confirm and exclude Duplex ultrasound Venography Abdominal and/or pelvic imaging

I- Conservative Treatment: Reassurance Elastic compression stockings Avoid prolong standing and change of occupation may be required Periodic elevation of the feet

II- Injection sclerotherapy: Sodium tetradecyl sulfate (STD)

III- Surgical Treatment: Indications for surgery: Symptomatic varicose veins Complicated or bleeding varicose veins Large varicose veins Cosmetic purposes Surgical options include: Ligation and stripping of the saphenous vein Multiple subfacial perforator ligation Combination of both. Complications of varicose vein surgery: Nerve injury (saphenous nerve and sural nerve) Recurrence

Varicose vein stripping:

IV- New Techniques: Radiofrequency Ablation Endovascular laser ablation.

Deep Vein Incompetence

Pathology:

Clinical presentation Leg swelling, Discomfort on walking, Edema, Varicose veins (which may not be present), Ankle flare (small varices), Lipodermatosclerosis Ulceration

Post Phlebetic syndrome:

Investigations: Duplex ultrasound Venography.

I- Conservative Treatment: Elastic compression stockings Avoid prolong standing and change of occupation may be required Periodic elevation of the feet Exercise of the calf muscles

II- Surgical Treatment: Venous bypass procedures (e.g. Palma procedure) Venous valve reconstruction Venous valve transposition

Venous Ulceration

Differential diagnosis of leg ulcers: Venous disease: deep vein incompetence Arterial ischemia Rheumatoid ulcer Traumatic ulcer Neuropathic ulcer (diabetic) Neoplastic ulcer (squamous cell carcinoma and basal cell carcinoma).

Etiolgy: Not fully understood Ambulatory venous hypertension Due to valve incompetence: Incompetent superficial veins Incompetent perforator veins Incompetent or obstructed deep veins

Clinical examination Site: gaiter region (between calf and ankle) Size: usually large Depth: usually superficial Edges: gently sloping edges Base: granulation tissue + slough and exudates Discharge: pus occasionally blood Surrounding tissue: features of chronic venous disease Local lymph nodes: enlarged (superadded infection) Movement of ankle joint: restricted due to pain

Venous Ulcer:

Investigations: Swab and culture from the ulcer Duplex ultrasound Venography

I- conservative Treatment: multilayered elastic compression bandaging system, avoid prolong standing, periodic leg elevation

Multilayer elastic compression

II- Surgical Treatment: Surgery for the cause of the venous ulcer (varicose vein, DVT or chronic venous insufficiency) Perforator vein subfacial ligation Skin graft to the ulcer after dealing with the underlying cause

Superficial Thrombophlebitis

Etiology: External trauma, Venepunctures and infusions of hyperosmolar solutions and drugs. Intravenous cannula Some systemic diseases: buerger’s disease, and malignancy, Coagulation disorders: polycythaemia, thrombocytosis and sickle cell disease

Examination: Treatment:: Overlying skin erythematous Palpable and tender superficial vein Treatment:: Reassurance NSAIDs Warm massage

Superficial thrombophlebitis

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