varicose veins 2.pptx hashish Irish Irish

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1. Varicose veins case presentation DR TARAK

2. HISTORY Name Age Sex : More common in women 10:1 ratio Occupation : More common in jobs having prolonged standing, e.g. policeman, petrol bunk workers, tram drivers, etc.

3. Chief complaints: Asymptomatic Aching pain Bursting type of pain while walking (Deep vein thrombosis) Appearance of varicosity. Ulcers

4. History of Suggestive Secondary Causes History of pregnancy History of prolonged immobilization History of oral contraceptive pill consumption History of constipation.

5. Past History history of diabetes, hypertension, ischemic heart disease, bronchial asthma, tuberculosis.

6. Personal History History of smoking and alcoholism History of diet. Family History Similar history in the family.

7. General Examination Anemia Cyanosis Jaundice Clubbing Lymph adenopathy

8. INSPECTION

9. Examine which system is involved: Short saphenous system: Lateral side Great saphenous system: Medial side

10. Swelling of the leg: Localized : Superficial venous system is affected Generalized : May be due to deep vein thrombosis

11. Skin changes in the leg: Color : Local redness—Superficial thrombophlebitis Texture : Stretched skin Eczema/pigmentation Ulceration Scars Loss of hair Impending gangrene Brittleness of nail

12. Palpation

13. Thickening of skin Pitting edema Tenderness Temperature Redness Lipodermatosclerosis Varicose venous ulcer

14. Brodie Trendelenburg test: Test 1. For saphenofemoral incompetence Test 2. For perforator incompetence Procedure: Step 1 : Patient in recumbent position legs raised to empty the vein, may be hastened by milking the veins. Step 2 : Tourniquet is applied below saphenofemoral (SF) junction (Thumb may be used to occlude the SF junction).

15. Test 1 : • Pressure released at the SF junction. Varices fill very quickly from above Test 1 is positive, i.e. saphenofemoral incompetence is present.

16. Test 2 : • Do not release the pressure for one minute Gradual filling of veins occur in the lower limb. Test 2 is positive, i.e. perforator incompetence is present.

17. II. Three tourniquets test (or) multiple tourniquets test : Step 1 : Patient in recumbent position Milk all the veins Step 2 : Three tourniquets are applied: 1. Just below saphenofemoral junction 2. Just below mid-thigh 3. Just below knee

18. Appearance of veins between tourniquet 1 and 2 is seen in adductor canal perforator incompetence Appearance of veins between tourniquet 2 and 3 is seen in below knee perforator incompetence Appearance of veins below the 3rd tourniquet is seen in lower leg perforators incompetent

19. III . Perthes test : Steps: Wrap the whole lower limb with elastic bandage Ask the patient to walk or exercise. results in severe cramps.

20. IV. Modified Perthes test: To find deep vein thrombosis Important preliminary to do this test is that there should not be any perforator incompetence to do this test.

21. V. Pratt’s test: To mark the position of weak perforators (blow outs). Steps: Apply Esmarch elastic bandage from toes to groin to empty the superficial veins. Apply tourniquet at groin (below SF junction). With tourniquet in position remove bandage gradually from above below

22. VI. Fegan’s test: After marking the blow outs make the patient lie down to empty the veins. You can palpate the defect in deep fascia at these spots

23. VII . Schwartz test: Ask the patient to stand and keep thumb of one hand at the saphenous opening Tap with other hand along the course of long saphenous vein in the lower part of leg. Inference: Impulse is felt in the thumb at saphenous opening. This test implies the valves along the GSV are incompetent .

24. VIII . Morrissey’s cough impulse: Limb is elevated to empty the veins and the limb is then put to bed and the patient is asked to cough forcible An expansile impulse is felt at the saphenofemoral junction in cases of saphenofemoral incompetence.

25. IX . Tests for deep vein thrombosis: Homan’s sign : Forcible dorsiflexion of foot with knee extension causes pain in the calf . Moses sign: Squeezing the calf muscles from side-to-side results in severe pain at the calf.

26. Percussion: ‘Schwartz test’ Auscultation: ‘ Morrisey’s cough impulse test’.

27. • Regional nodes • Other limb • Measure both limbs circumference above or below a fixed bony point and mention any swelling of affected limb. • Arterial pulsations.

28. Diagnosis Primary (or) secondary varicose vein Involving great saphenous (or) short saphenous (or) both venous system With or without saphenofemoral incompetence (or) saphenopopliteal incompetence With or without perforator incompetence With clinical class With or without complications

29. What are varicose veins?

30. tortuous, dilated, and lengthened veins with incompetence of the contained valves. Physiologically varicose vein is one that permits reversal of flow through its faulty valves.

31. The fibrin-cuff theory of Browse Persistently raised venous pressure ↓ Capillary proliferation and inflammation ↓ increased capillary leakage ↓ Perivascular cuff of fibrin, collagen type IV and fibronectin around the capillaries ↓ Fibrotic process affecting the skin and subcutaneous fat ( lipodermatosclerosis ) ↓ Barrier to diffusion preventing nutrient exchange ↓ Ulcer

32. White cell trapping theory ( Dormandy ) Venous hypertension ↓ Blood slows down in capillaries ↓ White cells marginate and are trapped ↓ Leukocyte sequestration ↓ Activation of trapped leukocyte ↓ Release of proteolytic enzymes ↓ Damage to capillary endothelium ↓ Leg ulcer

33. What are the agents used for injection sclerotherapy ?

34. STDS—Sodium Tetradecyl Sulphate (3%) Polidocanol Ethanolamine oleate .

35. What are the complications of varicose veins?

36. Complications of varicose veins Hemorrhage Superficial thrombophlebitis Eczema Pigmentation Lipodermatosclerosis Deep vein thrombosis (rarely) Venous ulcer Marjolin’s ulcer Calcification Periostitis Talipes equinus

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