varicose veins

varicose veins

1. VARICOSE VEINS VIDULA SHEVADE GROUP 603

2. VARICOSE VEINS Definition: Varicose veins are veins that have become distended over time. Long, tortuous and dilated veins of the superficial varicose system due to the pooling of blood in the lower extremities.

3. LEG VEIN ANATOMY Legs are made of network of veins that carry blood to heart. The venous system is comprised of – 1 Superficial veins long saphenous vein short saphenous vein

4. LEG VEIN ANATOMY 2 Deep veins femoral vein Popliteal vein Peroneal vein Anterior tibial vein Posterior tibial vein 3 perforating veins 90% of blood is returned by deep veins and not by superficial veins.

5. PERFORATING VEINS Direct perforating veins : These directly connect superficial veins with deep veins

6. PERFORATING VEINS In thigh : Adductor canal perforator connects long saphenous with femoral vein in lower part of adductor canal. ( hunterian’s perforator) In the lower thigh on medial aspect Long SV connect femoral vein via DODD’s Perforator Below knee : Perforator connects long SV or post-Arch vein with posterior tibial vein knows as BOYD’S Perforator .

7. PERFORATING VEINS In leg : 1.Lateral perforator is presented at the junction of mid & lower third of leg .It connect SSV with peroneal vein. 2. Medially there are three perforator which connect posterior arch vein with posterior tibial vein , know as COCKETT’S Perforator

8. PERFORATING VEINS Upper medial perforator lies at the junction of middle and lower third of leg. Middle medial perforator lies 4Inch above the medial malleolus . Lower medial perforator lies posterio -inferior to the medial malleolus .

9. PERFORATING VEINS Indirect perforating veins : These consist of small superficial veins which penetrate the deep fascia to connect with vessel in muscle and in turn end in Deep vein .

10. LEG VEIN ANATOMY Blood is drained from superficial to deep veins of legs through perforating veins . And through deep veins it is carried to heart. Back flow of blood is impossible. But due to defect in valve of blood flows in opposite direction .

11. Leg vein anatomy

12. VENOUS VALVES The venous valves are abundant in the distal lower extremity and number of valves decreases proximally, with no valves in superior and inferior vena cava Delicate structures Prevent reverse flow in the veins Ensure that the blood is pumped from the superficial to the deep system and back towards the heart when the patient is walking

13. ETIOLOGY PRIMARY VARICOSE VEINS Defect in saphanofemoral valve Defect in saphanopoplitial valve Defect in valve of perforators

14. SECONDARY Anything that increases intra-abdominal pressure Or raises pressure in superfical or deep veins Pregnancy Obesity Abdominal or pelvic mass Old age Long standing Thrombosis of leg veins

15. Congenital causes Arteriovenous fistulas

16. CLINICAL FEATURES Heaviness in the legs Night time cramps Dragging pain, postural discomfort Oedema, itching Discolouration Ulceration

17. CAUSES OF PAIN Anoxia Hyperviscosity or red cells Chronic venous hypertension Platelet aggregation Capillary functional disorder Altered cuteneous microcirculation

18. COMPLICATION Hemorrhage Pigmentation/ eczema Periostitis Venous ulcer Lipodermatosclerosis DVT Tromboplebitis

19. ECZEMA

20. VENOUS ULCER

21. STAGES C0 no visible or palpable signs of venous disease C1 telangectacia or reticular veins C2 varicose veins (without symptoms) C3 edema C4a skin changes due to venous disorders: pigmentation, eczema C4b skin changes due to venous disorders: lipodermatosclerosis C5 as C4 but with healed ulcers C6 skin changes with active ulcers (venous insufficiency ulceration)

22. iNVESTIGATION Venography Venous doppler Trendelenburg test Tourniquet test Cough impulse test Perthe test

23. Trendelenburg test

24. Tourniquet test 3 tourniquets are tied. 1 st at thigh 2 nd at below knee 3 rd above knee Now patient is asked to stand and appearance of varicosity is looked for,within 30 sec in each segment If the veins above the tourniquet fill up ,it indicates incompetence of communicating veins above tourniquet.

25. Tourniquet test If veins below tourniquet fill up rapidly ,it indicates communicating veins below tourniquet are incompetent .

26. COUGH IMPULSE TEST Patient is asked to elevate the limb . Then patient is asked to cough forcibly. The impulse is felt on long saphenous vein. This indicates the incompetent of sapheno -femoral valve .

27. PERTHE TEST A tourniquet is tied around the upper thigh. Then patient is asked to walk. If veins get dilated ,it indicates the presence of incompetence .

28. Conservative management Elastic crepe bandage – stockings Elevation of limbs Graded compression Excercise Avoidance of prolonged standing

29. Conservative management Compression methods Reduce ambulatory venous pressure Improve cutaneous micro circulation

30. SCLEROTHERAPY Injection of sclerosant (ethanolamine oleate) into an varicose vein causes sclerosis. Leading to complete obliteration of vein .

31. Surgical management INDICATION LSV /SSV incompetency . Perforating vein incompetency . CONTRAINDICATION DVT Pregnancy Thrombophlebitis Peripheral vascular disease

32. STEPS OF SURGERY After anesthesia proper position is given. The whole table is tilted head down to an angle of about 10 degree. (trendelenberg position)

33. STEPS OF SURGERY Incisions : 1. Hockey stick incision 2. Oblique incision Incision is kept at groin at Saphenous opening 3-4 cm below and lateral to pubic tubercle.

34. STEPS OF SURGERY

35. STEPS OF SURGERY Then stripper is passed down the saphenous vein and directed downward by finger . Vein is tied with stripper and then stripper is slowly and steadily pulled out through lower wound

36. STEPS OF SURGERY

37. NEW SURGICAL TECHNIQUES Vein valve tranplantation