Management of varicose veins

MANAGEMENT OF VARICOSE VEINS

1. MODERATOR: Dr.MohanlalNaikMS [PROFESSOR]
Dr.MadhavaKrishna MS[ASST.PROF]
Dr.MalleswariMS [ASST. PROF]

2. Investigations:
Main aim of the investigations in varicose veins is to
Localise the anatomical location of the disease
Nature of the lesion
Rule out DVT

3. Investigations:
Non –Invasive tests
Invasive tests

4. Non invasive tests:
❖Venous Doppler:
With the patient standing, the dopplerprobe is placed
at saphenofemoraljunction; by hearing the changes in
sound, venous flow, venous patency, venous reflux can
be very well identified.
Doppler test: When a hand held Doppler (continuous
wave 8 MHz flow detector) is kept at SFJ, typical audible,
‘whoosh signal’ > 0.5 sec while performing Valsalva
manoeuvre is the sign of reflux at SFJ. It is also used at
SPJ and at perforators.

5. ❖Duplex scan:
✓It is a highly reliable Ultrasound Doppler imaging technique;
here high resolution B mode ultrasound imaging and Doppler
ultrasound is used.
✓In this, direct visualisation of veins, the functional and
anatomical information, and colour mapping can be made out.
✓Hand-held Doppler probe is placed over the site and visualised
for any block and reversal of flow.
✓DVT is very well-identified by this method.
✓Venous haemodynamic mapping or Cartography is
essential prior to surgery.
✓Uniphasicsignals signify flow in one direction—normal.
✓Biphasic flow signifies reversal flow with incompetence.

6. Doppler ultrasound examination of a competent
proximal great saphenous vein. Spectral waveform shows
antegradeblood flow with no evidence of venous reflux.

7. Doppler ultrasound showing
biphasic flow which signifies
reversal flow with incompetence

8. ❖Plethysmography:
It is a noninvasivemethod which measures volume changes in
the leg.
It gives functional information on venous volume changes and calf
muscle pump insufficiency.
✓Photoplethysmography: Using probe transmission of light
through the skin, venous filling of the surface venuleswhich
reflects the superficial venous pressure is measured.
In normal people, it occurs through arterial inflow in 20-30
seconds.
In venous incompetence filling also occurs by venous reflux and
so refilling time is faster than normal.
Disadvantage: Site of reflux cannot be localised by this method.

9. ✓Air plethysmography:
Air filled plastic pressure bladder is placed on calf to detect
volume changes.
Patient is initially in supine position with veins emptied by
elevation of leg. Minimum volume is recorded.
Patient is turned to upright position and venous volume is
assessed.
Maximum venous volume divided by time required to
achieve maximum venous volume gives the venous filling
index (VFI).
VFI is a measure of reflux

10. Others:
U/S abdomen, peripheral smear, platelet count, other
relevant investigations are done depending on the
cause of the varicose veins.
If venous ulcer is present, then the discharge is
collected for culture and sensitivity, biopsy from ulcer
edge is taken to rule out Marjolin’sulcer.
Plain X-ray of the part is taken to look for periostitis

11. Invasive tests:
Now a days these are obsolete.
❑Venography/Phlebography:
Ascending venography--
A tourniquet is applied above the malleoli and vein of
dorsal venous arch of foot is cannulated. Water soluble dye
injected, flows into the deep veins (because of the applied
tourniquet). X-rays are taken below and above knee level.
Any block in deep veins, its extent, perforator status can be
made out by this.
It is a good reliable investigation for DVT.
Ascending phlebography defines obstruction.

12. Descending venogramis done when ascending
venogramis not possible and also to visualise
incompetent veins.
Contrast material is injected into the femoral vein
through a cannula in standing position. X-ray pictures
are taken to visualise deep veins and incompetent
veins.
Descending phlebography identifies valvular
incompetence.

13. ❑Ambulatory venous pressure (AVP):
It is an invasive method.
Needle inserted into dorsal vein of foot is connected to
transducer to get its pressure which is equivalent to
pressure in the deep veins of the calf. Ten tiptoe
manoeuvres are done by the patient. With initial rise in
pressure, pressure decreases and eventually stabilises with
a balance. Pressure now is called as ambulatory venous
pressure (AVP).
Raise in AVP signifies venous hypertension.
Patients with AVP more than 80 mmHg has got 80%
chances of venous ulcer formation

14. ❑Varicography:
Nonionic, iso-osmolar, nonthrombogenic contrast is
injected directly into the variceal vein to get a detailed
anatomical mapping of the varicose veins.
It is used in recurrent varicose veins.

15. Treatment:
❖Conservative treatment:
These methods aim at reducing the Ambulatory venous pressure,reduce
transcapillaryfluid leakage and improve cutaneous microcirculation.
Elastic crepe bandage application from below upwards or use of
pressure stockings to the limb—pressure gradient of 30-40 mmHg is
provided.
Diosmintherapy -increases the venous tone.
Elevation of the limb—elevation of foot with feet above the level of
heart relieves edema.
Unna boots—provide nonelasticcompression therapy. It comprises a
gauze compression dressings that contain zinc oxide, calamine, and
glycerine that helps to prevent further skin break down. It is changed
once a week.
Pneumatic compression method—provide dynamic sequential
compression.

16. Medical Management:
Drugs used for varicose veins:
Calcium dobesilate—500 mg BD. Calcium dobesilate
improves lymph flow; improves macrophage mediated
proteolysis; reduces oedema.
Diosmin—450 mg BD. Diosminis micronized purified
flavanoid.It protects venous wall and valve, and it is anti-
inflammatory, profibrinolytic, lymphotropic.
Diosmin450 mg + Hesperidin 50 mg (DAFLON 500 mg).
Mainly used in relieving night cramps.
Toxerutin500 mg BD, TID. Antierythrocyteaggregation
agent which improves capillary dynamics.

17. Different modalities of
management

18. Indications for Varicose vein
intervention
✓Cosmesis
✓Symptoms refractory to conservative therapy
✓Bleeding from a varix
✓Superficial thrombophlebitis
✓Lipodermatosclerosis
✓Venous stasis ulcer

19. INJECTION SCLEROTHERAPY:
Fegan’stechnique: Complete sclerosis of the venous
walls can be achieved by injecting sclerosantsinto the
vein.
Mechanisms of action:
✓Causes aseptic inflammation
✓Causes perivenousfibrosis leading to block
✓Causes approximation of intima leading to
obliteration by endothelial damage
✓Alters intravascular pH/osmolality
✓Changes surface tension of plasma membrane

20. Indications
–Uncomplicated
perforator
incompetence.
–In the management of
smaller varices—reticular
veins, telangiectasias.
–Recurrent varices.
–Isolated varicosities.
–Aged/unfit patients
Contraindications
--Saphenofemoral
incompetence
--Deep venous
thrombosis
--Huge varicosities—may
precipitate DVT
--Peripheral arterial
diseases.
--Venous ulcer—relative
contraindication

21. Sclerosantsused are :
Sodium tetra decylsulphate 3% (STDS)—commonly
used
Sodium morrhuate
Ethanolamine oleate
Polidocanol

22. Procedure:
Technique is called as macrosclerotherapy
--A 23 gauge needle is inserted into the vein and vein
is emptied.
0.5-1 ml of sclerosantis injected into the vein and
immediately compression is applied on the vein so as to
allow the development of sclerosis and to have proper
endothelial apposition.
Later pressure bandage is applied for six weeks.
Injections may have to be repeated at 2-4 week intervals
for 2-4 sessions.

23. Microsclerotherapy:
Very dilute solution of sclerosingagent like STDS,
(0.1% of 0.1 ml—dilute) , Polidocanolis injected into the
thread veins and reticular veins followed by application
of compression bandage (30 G needle). Dermal flare will
disappear well by this method.
Transilluminationmicrosclerotherapy:
It is better imaging of the veins using light generated
by halogen bulb with high quality fibre illumination over
the skin uniformly and passing 30 gauge needle for
microsclerotherapy.

24. Echosclerotherapy:
Sclerotherapy is done under duplex ultrasound image
guidance.

25. Foam sclerotherapy by Tessari:
Polidocanol/STDs is used for foam
sclerotherapy
Sclerosanttaken in a syringe is passed
rapidly into another syringe which
contains air to result in formation of
foam.
1 ml of STDS is mixed with 4 ml of air to
make 5 ml of foam which is injected to
vein.
Total 6 ml maximum of STDS with 30
ml foam can be used.
Foam is injected into the superficial
vein.
Air get absorbed between foam and
endothelial lining is destroyed.
Foam minimises thrombosis by pushing
the blood out of the site of the vessel
where action is needed.

26. Catheter directed sclerotherapy
This technique is under trial.
A specific catheter is used for the technique of sclerotherapy.
This catheter has got side holes all around the specific length for
uniform contact of venous wall with the foam.
It also has got a balloon at the tip which after inflation blocks the
SFJ thus preventing embolization of foam.
It has got three external ports one for balloon inflation; one for
bladder valve port; one for Injection.

27. Sclerotherapy
Advantages Disadvantages
✓Can be done as an outpatient
procedure.
✓Does not require
anaesthesia.
✓Inadvertent subcutaneous
injection can cause skin necrosis
or abscess formation.
✓Anaphylaxis, vasovagal shock,
allergy.
✓Hyperpigmentation.
✓Thrombophlebitis.
✓Deep venous thrombosis can
occur.
✓Inadvertent intra-arterial
injection—serious complication.
✓Intravenous haematoma

28. Ablative methods
Trendelenburg operation
✓It is juxta femoral flush ligation of long saphenous
vein
✓Ligation of named tributaries and Unnamed
tributaries
-Superficial circumflex iliac vein
-Superficial external pudendal
-Superficial epigastric vein
-Deep external pudendal vein

29. • AL-ANTEROLATERAL
• PM-POSTEROMEDIAL
• SEP-SUPERFICIAL EXTERNAL
PUDENDAL
• SE-SUPERFICIAL EPIGASTRIC
• SCI-SUPERFICIAL
CIRCUMFLEX ILIAC

30. Extraluminalcollision technique using Myer’s
stripper ;it damages the adjacent tissue, causes
infection, postoperative pain and discomfort and
haematoma along the stripped tract with possibility of
revascularization of the tract haematoma.
--Stripping from below upwards is technically easier. --
Immediate application of crepe bandage reduces the
chance of bleeding and haematoma formation.
--Stripping avulses the vein as well as obliterates the
tributaries.

31. Rigid metal pin stripper (Oesh)
passed down the inside of the
saphenous vein and recovered
through a small incision in the
upper part of calf.
A strong suture attached to the
end of the stripper and firmly
ligated to the proximal end of
the vein.
During pulling of stripper, LSV
will invert and can be delivered
through 2mm incision in midcalf
Region.
No olive used
INVERSION STRIPPING

32. Ligation of short saphenous vein at
saphenopoplitealjunction. It is done in prone position
with horizontal incision. Variations in SP junction are
common.
Stripping of short saphenous vein is more beneficial
than just ligation at saphenopoplitealjunction.
It is done from above downwards using a rigid stripper
to avoid injury to sural nerve.

33. Complications of stripping:
✓Saphenous neuralgia due to saphenous nerve
injury/avulsion
✓Numbness and tingling along femoral nerve distribution
✓Haematoma
✓Infection;
✓Ulceration;
✓Recurrence of the disease is common (30%) which is due to
progression of disease itself by neo-angiogenesis and re-
vascularisation

34. Sub-Fascial Ligation
It is ligation of perforator where it enters the deep
fascia i.edeeper to deep fascia.
It is done for perforator incompetence.
Perforators are marked prior to procedure using
duplex scan.
❑subfascialligation of cockettand Dodd
❑subfascialligation of all perforators by Linton’s
Vertical approach

35. Subfascialligation of
Cockettand Dodd
Perforators are clearly marked prior to surgery
by using duplex Doppler scan. Multiple small
transverse incisions are made on the sites of
perforators. Perforators are ligated deep to
deep fascia

36. Vertical incision is made on the medial
side of the calf at the anterior margin of
the soleus little away from tibia.
Incision over the ankle is divided like in
an inverted ‘Y’ or a posterior ‘stocking
seam’ incision.
Skin, subcutaneous tissue and deep fascia
are incised without raising any flaps under
the skin.
Perforators passing across gastrocnemius
and deep fascia will be clearly seen.
All perforators are identified are ligated
Linton’s Vertical
approach

37. Subfascialendoscopic perforator ligation
surgery (SEPS)
–A special telescope is introduced deep to
deep fascia through a single small vertical
incision at proximal leg selecting healthy
skin.
-Potential space between muscle and deep
fascia with loose areolar tissue is easy to
dissect using endoscope.
-Technique is done under300 mmHg
pressure usingtorniquet.
-Endoscope is advanced down along the
medial border of the tibia. Perforators
travelling in subfascialplane are
identified and fulgurated using bipolar
cautery or clips can be applied into the
perforators.
-It is recommended in chronic venous
insufficiency(CVI).
Limitation is difficulty in getting ‘lift off’
skin in cases with severe
lipodermatosclerosisto identify the
perforators.

38. Phlebectomy
It is the technique of management of residual
varicosities after vein stripping.
There are two techniques to treat secondary branch
varicosities.
❖Ambulatory Phlebectomy
❖TransilluminatedPowered Phlebectomy

39. Ambulatory Phlebectomy
Ambulatory phlebectomyis performed by the STAB
AVULSION technique .
The patient’s varicosities are marked after standing to allow
optimal dilation and visualization .
The technique can be done under local anesthesiawith
tumescence and IV sedation.
First, 1-mm incisions are made along Langer skin lines,
and the vein is retrieved with a hook.
Continuous retraction of the vein segment affords
maximal removal of the vein, and direct pressure is applied
over the site.
Incisions are made at approximately 2-cm intervals.

40. Technique of ambulatory phlebectomy
(otherwise known as stab avulsions of
varicosities).

41. The extremity is wrapped with a layered compression
dressing, and patients are instructed to ambulate on
the day of surgery.
Nonsteroidal antiinflammatorydrugs for discomfort.
Compression stockings are worn for 2 weeks after the
procedure.
Complications are unusual and include bleeding,
infection, temporary or permanent paresthesias, and
phlebitis from retained segments.

42. TransilluminatedPowered Phlebectomy
While the patient was under general or spinal anesthesia, TIPP was
performed using the endoscopic TriVexSystem (InaVein, Lexington,
MA).
Incisions followed natural Langer skin lines to obtain the most
cosmetically appealing result and were placed strategically to maximize
vein cluster removal within the instrumentation arc. Endoscopic
instrumentation was alternated through stab incisions to further
minimize the number of incisions.
The irrigation-illumination device was inserted into the first stab
incision and tumescent anesthesia(3L of 0.9% normal saline solution
with 150 mL of 1% lidocaine and 6 mL of 1:1,000 epinephrine) was
instilled at 450 mL/min. The device then was used to transilluminate
the varicose veins, including those that may not have been seen or
palpated during preoperative marking.

43. Under this direct visualization, additional 2-to 3-mm stab
incisions were created that were used for insertion of the
resection device in the diameter appropriate to vein size.
Varicose veins were resected by suction and morcellation
using higher oscillation frequency initially and lower
oscillation frequency thereafter.
During resection, the skin was held taut to aid resection
and prevent skin penetration.
Stab incisions were closed with benzoin and adhesive
strips. Layered compression dressing was applied from the
base of the toes to high on the thigh.

44. Saphenous Sparing Surgeries:
It is based on newer haemodynamic concept –
antegradehaemodynamic evolution of saphenous vein
incompetence from suprafascialcompartment to great
saphenous vein.
Evolution of disease starts in collateral veins and their
reflux leads into varicose reservoir. If varicose reservoir
is abolished saphenous reflux will stop.
Procedure is done under local anaesthesia i.e
Ambulatory Selective Varices Ablation under Local
anaesthesia.

45. CHIVA(Conservatriceet Heodynamique
de I’Insuffisanceveineuseen
Ambulatoire)
•It is one of the methods used to
achieve ASVA.
•Pittalugatechnique is used.
•Here attention has focused on
surgical treatment of tributaries
retaining the main trunk –ambulatory
conservative haemodynamic
management of varicose veins.
•Saphenofemoraland
saphenopoplitealjunctions are
identified and marked under US
guidance.
•Individual gastrocnemius,
intersaphenous, popliteal area veins
are identified and marked;
•Longitudinal 3 mm stabs are made
using No. 11 blade; phlebectomies
achieved.
•Selective targeted diseased veins
only are removed with preservation
of healthy veins.

46. Thermal Ablation techniques:
There are two different options of energy for thermal
ablation of incompetent veins.
❖EndovenousLaser Ablation
❖Radio frequency Ablation

47. EndovenousLaser Ablation-MOA:
Various concept based theories have been explained.
The Steam Bubble Theory focuses on the hyperechoic bubbles
seen with UltraSoundat the fibertip during energy application
and suggests that these represent boiling blood that has an
indirect effect, heating the vein wall.
The Heat Pipe Theory maintains that blood in immediate
contact with the fiberbecomes coagulated, forming a clot
around the tip that acts as an insulating layer, trapping and then
conducting heat to the vein wall.
The Direct Contact Theory suggests that maximal heat transfer
to the vein wall occurs when the laser fibercontacts the vein
wall. This happens frequently over the course of treatment, as
the vein is typically relatively tortuous.Segmentsbetween these
sites receive energy by conduction.

48. Pre operative Planning
On the day of the procedure, the patient should be well
hydrated to achieve maximal distention of the leg veins.
Venodilationcan be further enhanced by warming of the
ultrasound gel and keeping the patient warm in the
procedure room.
Duplex ultrasonography is performed prior to the
procedure to mark the skin overlying the target treatment
vein.
Informed consent should be obtained, including a
discussion of risks and benefits and other treatment
alternatives.

49. Tumescent anesthesia
Tumescent anaesthesia is given under US guidance.
Tumescent anaesthesia (500 ml of cold saline, 30-50 ml of
1% xylocaine with adrenaline, 30 ml of 8.4% sodium
bicarbonate) is prepared and injected along the entire
length of the GSV to be fired.
Injection is done manually using 50 cc syringe or
tumescence pump or using as drip set.
It should form a cushion surrounding the vein along its
entire length to provide local anaesthesia, to give
protection like a ‘heat sink’ preventing thermal damage of
skin and soft tissues, to provide adequate venous
compression to create complete apposition of the venous
wall and so effective venous obliteration.

50. Procedure
After consent is obtained, the patient is placed supine
(for GSV treatment) or prone (for SSV treatment), and
the region to be treated is sterilely prepared and
isolated with sterile barriers.
Local anestheticis delivered to the skin at the
percutaneous access site.
Under real-time US guidance, the needle is advanced
percutaneously into the vein lumen and a 0.18-inch
guidewire is advanced through the needle once
intravascular position is confirmed

51. Percutaneous access under
ultrasound guidance. (a) The left great
saphenous vein was punctured at the
level of the knee.
(b) Transverse ultrasound
image demonstrating the intravascular
position of the needle tip.
A small skin incision is performed at
the puncture site and the needle is
exchanged for the micropuncturesheath
over the guidewire. The guidewire and the
inner stiffener of the micropuncturesheath
are then removed and a 0.35-inch guidewire
is advanced through the sheath.

52. The micropuncturesheath is then exchanged over the wire
for the long vascular sheath through which the laser fiber
will be inserted. The wire and inner stiffener of the vascular
sheath are removed and the position of the sheath is
assessed by US.
Under direct US guidance, the tip of the vascular sheath is
positioned in the superficial venous system, typically 2 cm
distal to the saphenofemoralor saphenopoplitealjunction.
The laser fiberis advanced through the vascular sheath and
the position of the laser tip is confirmed by US.
Confirmation of laser tip position in the superficial venous
system distal to the saphenofemoralor saphenopopliteal
junction before laser activation is crucial to avoid damage
to the deep venous system.

53. The patient is then repositioned to a flat position to
facilitate vein emptying, and tumescent anesthesiais
delivered under real-time US guidance in the perivenous
sheath and surrounding subcutaneous tissue of the entire
length of the anatomic region to be ablated.
The thermal energy is delivered according to protocols
inherent to the device utilized.
Power delivered can be varied from 5 to 20W.
Energy per centimeterranges from 20 to 100 J/cm, and
energy may be delivered in a continuous or pulsed manner.
Typically, the pullback of the laser fiberduring venous
ablation is performed at a 10 to 12 cm/minute rate and
common protocols are continuous delivery of 80 J/cm at
12W for 810-nm fibersand 70J/cm at 14W for 980-nm
fibers.

54. EndovenousRadio frequency
ablation
Preoperative evaluation and preparation is same as for
EVLA.
RFA includes the use of a generator with an especially
devised disposable electrode catheter to deliver bipolar RF
energy to the vein with temperatures not exceeding 120°C.
The most commonly used device is the VNUS Ablation
system which uses a generator and bipolar catheter. This
system is also called TheClosureprocedure.
This system uses the ClosureFastcatheter, which heats the
vein in 7-cm segments with 20-second treatment cycles
resulting in venous occlusion.

55. The temperature and power are continuously
monitored duringtheprocedure, heating the vein
wall in a controlled fashion between 85 and 95°C.
The ClosureFastcatheter is also available with a 3-
cm heating element, which is ideal for the
treatment of shorter vein segments.
The ClosureRFSStylet is another available catheter
option, which was specifically designed for the
treatment of incompetent perforator and tributary
veins

57. Technique
The same technique as for EVLT is utilized for RFA,
with US-guided access of the GSV or SSV, followed by
US-guided positioning of an RF catheter similar to
positioning of the laser fiber.
Tumescent anesthesiais delivered as described for
EVLT.
The vein is treated with segmental 3-or 7-cm
ablations, depending on the selected catheter
A 45-cm venous segment is usually ablated in 3 to 5
minutes with a 7-cm catheter.

58. Post procedure care and follow up
At the completion of the procedure, US evaluation of the
SFJ or SPJ is performed to rule out deep vein thrombosis,
followed by the placement of compression stocking (class
2) on the treated extremity.
The patients are sent home after a brief recovery
period.Patientsare instructed to wear compression
stockings for 1 to 2 weeks. Ambulation is initiated
immediately and should be encouraged during post-
procedure use of compression stockings.
Patients are routinely screened 1 to 2 weeks after
endovenoustreatment. Efficacy of endovenousablation is
assessed by US.

59. Endothermal heat-induced
thrombosis
Endothermal heat-induced thrombosis (EHIT) is an
expected finding in the treated GSV and this type of
thrombosis is typicallhyperechoic, in contrast to de
novo DVT, which is typically acutely hypoechoic.
Classification of EHIT is based on relation to SFJ

60. Class 1 EHIT describes thrombosis to the level of the SFJ.
Class 2 describes non-occlusive thrombus extending into
less than 50% the common femoral vein (CFV).
Class 3 refers to non-occlusive thrombus extending more
than 50% of the CFV lumen..
Class 4 refers to thrombus occluding the CFV lumen.
Class 1 EHIT may be managed conservatively, with
monitoring by US.
Class 2 and above are treated with anticoagulation,
typically low-molecular weight heparin, to prevent further
propagation.

61. Management of Varicose Ulcer
✓Investigations:
Discharge from the ulcer for culture and sensitivity.
X-ray of the area to look for periostitis.
Biopsy from the ulcer edge to rule out Marjolin’sulcer.
Investigations to rule out other causes of leg ulcers
like arterial; neurological; diabetes; sickle cell disease
and other haemolytic diseases.
Erythrocyte sedimentation rate; C-reactive protein,
peripheral smear; red cell counts.
ArterioVenous Doppler.

62. ✓Treatment:
1) Compression Therapy
2)Regular dressings
3)Skin Grafting
Bisgaardmethod of treating venous ulcer:
--Mainly to reduce oedema, increase venous drainage, so
as to promote ulcer healing.
–Elevation.
–Massage of the indurated area and whole calf.
–Passive and active exercise.
Care of ulcer by regular cleaning with povidone
iodine,H2O2 and Dressing with EUSOL.

63. Four layer bandage (45 mmHg pressure) technique to
achieve high compression pressure.
It is changed once a week.
Antibiotics depending on culture and sensitivity of the
discharge.
Once ulcer bed granulates well, split skin graft is
placed.
Specific treatment for varicose veins should be
undertaken—Trendelenburg operation, stripping of
veins, perforator ligation.

64. Compression Therapy
It is always better.
Reduces the venous wall tension –prevents reflux –
controls the venous over distension –ambulatory venous
hypertension decreases –improves microcirculation
Compression diverts the blood towards deep veins through
perforating veins, prevents the outward flow of blood in
perforator incompetence, improves the efficacy of calf
muscle pump.
Compression improves venous and lymphatic drainage –
reduces edema, improves venous elasticity, improves micro
circulation, it prevents further damage of the venous wall.

65. Depending on amount of pressure in compression stockings;
Class I: 14-17 mmHg
Class II: 17-24 mmHg
Class III: 24-35 mmHg
Three types of compression materials are known.
1) Inelastic type –used for continoususe in severe chronic
venous device.
2)Elastic type –Compression stockings are made of variety
of materials including Nylon, Cotton, spandex and natural
rubber.
MC used is Spandex with different proportions of added
cotton / other materials.
These type are self applied at day time.

66. 3) Combination of elastic and inelastic materials ex: Unna Boot
Unna Boot: Three layered paste guagecompression dressing
containing calamine, zinc oxide, glycerine, sorbitol, Gelatinand
Aluminium Silicate which has mainly inelastic inner component
with partly elastic outer layer wrap.
Recommended pressure in mild varicose veins, pregnancy and
postoperative period is 20 mmHg; in symptomatic varicose veins
and after sclerotherapy is 30 mmHg; in venous ulcer and post-
phlebiticleg it is 40-45 mmHg.
Skin maceration, excoriation, dryness, infection, ulceration and
failure are the complications of compression therapy.
Ankle-arm pressure index less than 0.6 is contraindication for
compression therapy as it may precipitate ischaemic ulcer
formation.

67. RECENT ADVANCES IN THE
MANAGENT OF VARICOSE VEINS:
❖Mechanicochemical Ablation
❖CyanoAcrylate Embolization

68. MechanicoChemical ablation
A hybrid method of endovenousablation utilizing both
mechanical abrasion via a rotating wire tip and simultaneous
chemical ablation via injection of liquid sclerosant, either
sodium tetradecylsulfate(STS) or POL.
The ClariVein® device is composed of two components,an
infusion catheter and a battery motorized handle. A syringe
containing the liquid sclerosant(STS or POL) attaches to the
handle.
The catheter which is 45 or 65cm in length with an outer
diameter of 0.035 inches contains a rotating wire that is activated
and controlled by the handle.
A small metal ball is attached to the angled tip of the wire.
The diameter of rotation of the wire tip is 6.5mm, but the
effective diameter is larger due to wire oscillation during
rotation.

69. -Method combines mechanical damage
to the endothelium caused by the rotating
wire with the chemical damage caused by the
infused sclerosantagent.
-The mechanical damage promotes
coagulation activation by damaging the
endothelium; induces local vasospasm and
decreases the diameter of the treated vein;
promotes better distribution of the sclerosant
within the vascular lumen; and increases the
action of the sclerosantagent by mechanical
damage to the endothelium.
-The liquid sclerosantfurther damages the
lipid cell membrane of the endothelium,
ultimately resulting in occlusion and
fibrosis of the treated vein.

70. The ClariVeindevice and wire tip.

71. --At the beginning of the procedure, a micropunctureor equivalent
intravascular access is obtained distally into the vessel to be treated under
ultrasound guidance and after administration of local
anesthesia.
--The ClariVeincatheter, detached to the handle, is then advanced through
the vascular access to the desired proximal ablation edge under direct
ultrasound guidance.
-For ablation of the GSV, the tip of the wire should be positioned 2 cm distal
to the SFJ.
--For small saphenous vein (SSV) ablation, the wire tip should be positioned
within the initial portion of the superficial straight segment of the SSV distal
to the saphenopoplitealjunction.
--No tumescent anesthesiaor patient sedation is required.
--After appropriate positioning under ultrasound guidance, the catheter is
attached to the device handle. Once the catheter and handle are attached,
they cannot be disassembled.

72. --The sclerosantsyringe is attached to the handle, and then the tip
of the wire is unsheathed under ultrasound guidance, ensuring no
proximal migration.
--When the handle is gripped with one hand, the index finger can
activate the trigger for the motor and the thumb is used to depress
the sclerosantsyringe plunger.
--The maximum motor rotation speed is 3,500 rpm, is the default
speed and is the most often used.
--Wire rotation without administration of sclerosantagent is
recommended initially for 3 seconds to induce venospasmat the
proximal segment of the treated vessel, followed by continued
spinning and pullback with infusion of sclerosant.
--The recommended pullback speed is between 1 an 2 mm/second.
--The total volume of sclerosantis usually 6 to 10mL for GSV and 2
to 4mL for SSV treatment.
--Compression stockings are recommended for 2 weeks.

73. No major complications
Minor complications have been reported which
include ecchymosis, superficial thrombophlebitis and
hematomas at the puncture site.

74. Cyanoacrylate
Embolization/VenaSeal
SapheonClosure System
The VenaSealdelivery system
components include a 5-Fr catheter
with an effective length of 91 cm, a 7-Fr
introducer with an effective length of80
cm, a 5-Fr dilator with an effective
length of 87 cm, an adhesive dispenser
gun, dispenser tips with a length of
3.8cm and an inner diameter of 1.5 mm,
3-mL syringes, and a 0.035-inch 180-cm
Jtipguidewire.

75. Cyanoacrylates are liquid adhesives that have
been safely used in numerous medical
applications.
The VenaSealSapheonClosure System utilizes
a proprietary cyanoacrylate formulation that is
delivered endovenouslyto treat varicose
veins.
Contraindications for Vena-Seal include
hypersensitivity to cyanoacrylates, acute
superficial thrombophlebitis, thrombophlebitis
migrans, and acute sepsis.

76. Mechanism of Action
The proprietary VenaSealadhesive is n-butyl-2
cyanoacrylate based product.
Cyanoacrylate polymerizes in a cascade reaction upon
contact with blood, creating an adhesive bond.
The formed adhesive halts blood flow through the
vein and the adhesive is eventually encapsulated in a
fibrosis reaction to establish chronic occlusion

77. --The vein to be treated is accessed distally with a
micropuncturekit or equivalent under ultrasound
guidance after administration of local anesthesia.
--For treatment of the incompetent GSV, the
introducer/ dilator system is advanced to the level
of the SFJ over a guidewire under ultrasound
guidance.
--The introducer tip is then positioned 5cm distal
to the SFJ. Using a dispenser tip attached to one of
the provided 3-mL syringes, the cyanoacrylate
adhesive is drawn up from its vial.
The syringe containing cyanoacrylate is then
connected to the VenaSealcatheter and its plunger
end locked into the dispenser gun.
The catheter is then primed by pulling the trigger
of the dispenser gun. Each depression of the trigger
delivers a controlled 0.10-mL amount of adhesive.

78. --The primed catheter is inserted into the introducer
and advanced under ultrasound guidance until its tip is
positioned 5 cm distal to the SFJ.
--The ultrasound probe is then turned transverse,
placed just cephalad to the catheter tip, and pressure is
applied to compress the GSV near the SFJ, sealing off
venous outflow. While applying compression to the
GSV, two injections of 0.10-mL adhesive are delivered
at 5 and 6 cm distal to the SFJ.
--The introducer and catheter are then withdrawn by 3
cm while holding transverse compression for at least 3
minutes. Following this, 0.10mL of adhesive is
delivered every 3cm along the vein to be treated while
holding ultrasound compression just caudal to the
previousinjectionfor 30 seconds after each
administration.
--Treatment is stopped 5 cm cephalad from the
access site.

79. Non thermal Ablation techniques
. Laser-assisted foam sclerotherapy (LAFOS) utilizes a
low-energy laser immediately preceding foam
injection. The laser energy was sufficiency low that no
tumescent anaesthesia was necessary.
The V-Block procedure consists of placement of a
conic basket distal to the SFJ with or without
endovenousinfusion of liquid sclerotherapy. This
procedure has only been performed in animal trials
with promising results