Varicose veins and management 1

1. Varicose veins and management Dr PRASHANTH.S GENERAL SURGERY RESIDENT CAIMS

2. Superficial veins : located above the muscular fascia. The saphenous vein rests over the muscular fascia and appears like a “Egyptian eye” on duplex scan. Deep veins : located in the muscular compartment, follows the same course as arteries. Perforator veins :these are rich network of perforating veins that traverse the muscular fascia between the deep and superficial veins. They direct the flow from superficial to deep veins.

3. Venous valves They prevent retrograde flow of blood in a proximal to distal direction. They are found throughout the body, but highest concentration is located in the lower extremities. They are bicuspid and can form sinusoidal dilatations due to locally reversed flow . Close with velocity-30 cm/sec. The inferior vena cava (IVC), common iliac veins, portal venous system, and cranial sinuses are valveless

4. Venous wall structure and composition Composed of 3 layers INTIMA : it is a single layer of cells resting on a thin layer of connective tissue. Valves are lined on both sides with a layer of intima over thin connective tissue skeleton. MEDIA : consists of smooth muscles and connective tissue such as collagen. It conveys protection from dilatation and varicosity formation. ADVENTITIA : its not well differentiated from media contains of loose connective tissue, vasa vasorum.

5. Anatomy of great saphenous vein The great saphenous vein drains the medial end of the dorsal venous arch of the foot and passes upwards directly in front of the medial malleolus. It then ascends in company with the saphenous nerve in the superficial fascia over the medial side of the leg. The vein passes behind the knee and curves forward around the medial side of the thigh. It passes through the lower part of the saphenous opening in the deep fascia and joins the femoral vein about 1.5 inches below and lateral to the pubic tubercle.

6. The great saphenous vein possesses numerous valves and is connected to the small saphenous vein by one or two branches that pass behind the knee. Several perforating veins connect the great saphanous to the deep veins along the medial side of the calf. At the saphenous opening in the deep fascia, the great saphenous vein usually receives three tributaries that are variable in size and arrangement– superficial circumflex iliac, superficial epigastric and superficial external pudendal

7. Main perforators of the great saphenous vein May perforators- at the level of ankle Cockett – at 5, 10 and 15 cm from medial malleolus Boyd - below knee Dodd - above knee Mid thigh perforator SFJ

8. Short saphenous vein It arises from the lateral part of the dorsal venous arch of the foot. It ascends behind the lateral malleolus in company with sural nerve It follows the lateral border of the tendo calcaneus and then runs up the middle of the back of the leg. The vein pierces the deep fascia and passes between the two heads of the gastrocnemius muscle in the lower part of the popliteal fossa. The mode of termination of the small saphenous vein is subject to variation- may join the popliteal vein, may join the great saphenous, may split into two one joins popliteal and one joins great saphenous.

9. Pathogenesis Two theories Fibrin cuff theory White cell trapping theory

10. Incompetence of venous valves Stasis of blood Chronic ambulatory venous hypertension Defective microcirculation RBC’s diffuses into tissue planes Lysis of RBC’s Release of haemosiderin Pigmentation Dermatitis Capillary endothelial damage Prevention of diffusion and exchange of nutrients Severe anoxia Chronic venous ulceration Fibrin cuff theory

11. White cell trapping theory Inappropriate activation of trapped leucocytes release proteolytic enzymes which cause cell destruction and ulceration. Fibrin deposition, tissue death, scarring occurs together called as lipodermatosclerosis

12. Classification of lower extremity venous disease (CEAP) C - clinical signs E – etiological classification A – anatomic distribution P – pathological dysfunction

13. Grading of clinical signs 0-- no visible or palpable signs of venous disease 1– telangiectases , reticular veins or malleolar flare 2– varicose veins 3– oedema without skin changes 4– skin changes ascribed to venous diseases 5– skin changes with healed ulcer 6– skin changes with active ulcer

14. Aetiology Primary varicosities due to: Congenital incompetence or absence of valves. Weakness or wasting of muscles- defective connective tissue and smooth muscle in the venous wall. Stretching of deep fascia Inheritance with FOXC2 gene Klippel-Trenaunay syndrome

15. B. Secondary varicosities Recurrent thrombophlebitis Occupational – standing for long hours Obstruction to venous return like abdominal tumour, retroperitoneal fibrosis, lymphadenopathy. Pregnancy A-V malfunctions Iliac vein thrombosis

16. Symptoms in varicose veins Dragging pain Heaviness in the legs Night time cramps Oedema of feet Discolouration/ ulceration in the feet / painful walk

17. Causes of pain / cramps in varicose veins Chronic venous hypertension Hypoxia of tunica media due to altered function of vasa vasorum Increased capillary pressure Hyper viscosity of red cells Platelet hyperaggregation Reduced in capillary permeability causing capillary functional disorder Altered cutaneous microcirculation due to leukocyte adhesion and accumulation into the venous wall, release of free radicals cause micro vascular lesional disease.

18. Venous disability scoring system 0– asymptomatic 1– symptomatic but able to carry out activities without any therapy 2– symptomatic can do activities only with compression or limb elevation 3-- symptomatic – unable to do daily activities even with compression or limb elevation

19. Complications of varicose veins Haemorrhage Eczema and dermatitis Periostitis Venous ulcer Marjolin’s ulcer Lipodermatosclerosis Ankylosis of the ankle joint Talipes equino varus DVT Calcification thrombophlebitis

20. Brodie-Trendelenburg test – vein is emptied by elevating the limb and a tourniquet is tied just below the sapheno-femoral junction. Patient is asked to stand quickly. When tourniquet or thumb is released, rapid filling from above signifies sapheno-femoral incompetence. This is Trendelenburg test 1. In Trendelenburg test 2, after standing tourniquet is not released. Filling of blood from below upwards rapidly can be observed within 30-60 seconds. It signifies perforator incompetence.

21. PERTHE’S test : the effected lower limb is wrapped with elastic bandage and the patient is asked to walk around and exercise. Development of severe cramp like pain in the calf signifies DVT. MODIFIED PERTHE’S test : tourniquet is tied just below the sapheno-femoral without emptying the vein. Patient is allowed to have a brisk walk which precipitates bursting pain in the calf and also makes superficial veins more prominent. It signifies DVT

22. Three tourniquet test : to find out the site of incompetent perforator, three tourniquet are tied after emptying the vein. 1 at sapheno-femoral junction 2 above knee level 3 another below knee level Patient is asked to stand and looked for filling of veins and site of filling. Then tourniquets are released from below upwards, again to see for incompetent perforators.

23. SCHWARTZ test : in standing position, when lower part of the long saphenous vein in leg is tapped, impulse is felt at the saphenous junction or at the upper end of the visible part of the vein. It signifies continuous column of blood due to valvular incompetence. PRATT’S test : Esmarch bandage is applied to the leg from below upwards followed by a tourniquet at sapheno-femoral junction. After that the bandage is released keeping the tourniquet in the same position to see the “blow outs” as perforators.

24. MORRISEY’S COUGH IMPULSE test : the varicose veins are emptied. The leg is elevated and then patient is asked to cough. If there is sapheno-femoral incompetence, expansile impulse is felt at saphenous opening. It is a venous thrill due to vibration caused by turbulent back flow. FEGAN’S test : on standing, the site where the perforators enter the deep fascia bulges and this is marked. Then on lying down, button like depressions in the deep fascia is felt at the marked out points which confirms the perforator sites.

25. Venous Doppler With patient standing, the Doppler probe is placed at sapheno-femoral junction and later wherever required. Basically by hearing the changes in sound, venous flow, venous patency, venous reflux can be very well identified. To find out DVT- very important To find out sapheno-femoral, sapheno-popliteal incompetence To find out perforator incompetence Uniphasic signals signify flow in one direction-normal Biphasic flow signifies reversal flow with incompetence

26. Duplex scan It is a highly reliable U/S Doppler imaging technique (high resolution B mode ultrasound imaging and Doppler ultrasound is used), which along with direct visualisation of veins, gives the functional and anatomical information and also colour map. Examination is done in standing, lying down position and also valsalva manoeuvre. DVT is very well identified by this method.

27. Venography Ascending venography was a very common investigation done before Doppler period. A tourniquet is applied above the malleoli and vein of the dorsal venous arch of foot is cannulated. Water soluble dye is injected, flows into the deep veins. 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 good reliable investigation for DVT.

28. Descending venogram It is done when ascending venogram is not possible and also to visualise incompetent veins. Here contrast material is injected into femoral vein through a cannula in standing position. X rays pictures are taken to visualise deep veins and incompetent veins.

29. Plethysmography It is a non invasive method which measures volume changes in the leg. Photo plethysmography Air plethysmography

30. Photo plethysmography Using probe transmission of light through the skin, venous filling of the surface venules which reflects the superficial venous pressure is measured. Initially patient performs dorsiflexion at ankle for 10 times to empty the venules and pressure tracing falls in photo plethysmography. Patient takes rest and refilling occurs. In normal people, it occurs through arterial inflow in 20-30 seconds. In venous incompetence filling also occurs by venous reflux and refilling time is faster than normal Site of reflux cannot be localised by this method.

31. Air plethysmography Patient is initially in supine position with veins emptied by elevation of leg. Air filled plastic pressure bladder is placed on calf to detect volume changes. 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 is a measure of reflux Ejection fraction is volume change measured prior and after single tiptoe manoeuvre which is a measure of calf pump action. Residual venous fraction is an index of overall venous function which is venous volume in the leg after ten tiptoe manoeuvres divided by venous volume prior to manoeuvre. Increased VFT and diminished ejection fraction in patient will benefit from surgery

32. Treatment Conservative treatment Elastic crepe bandage application from below upwards or use of pressure stockings to the limb pressure gradient of 30-40 mmHg is provided. Diosmin therapy which increases the venous tone. Elevation of the limb- relieves oedema. Unna boots- provide non elastic compression therapy. It comprises a guaze 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.

33. 2. Drugs used for varicose veins Calcium dobesilate—500 mg BD. Calcium dobesilate improves lymph flow; improves macrophage mediated proteolysis and reduces edema. Diosmin 450 mg + Hesperidin 50 mg (DAFLON 500 mg). Mainly used in relieving night cramps but not to improve healing of ulcers.

34. 3. Injection– sclerotherapy : By injecting sclerotic agent into the vein, complete sclerosis of the venous walls can be achieved. Indication Uncomplicated perforator incompetence In the management of smaller varices- reticular Recurrent varices Isolated varices aged / unfit patients

35. Sclerosants used are— Sodium tetradecylsulphate 3%(STDS) – commonly used Sodium morrhuate Ethanolamine oleate Polidocanol Mechanism of action Causes aseptic inflammation Causes perivenous fibrosis leading to block Causes approximation of intima leading to obliteration by endothelial damage Alters intravascular pH / osmolality Changes surface tension of plasma membrane.

36. A 23 gauge needle is inserted into the vein (3-8 mm sized) and vein is emptied. 0.5-1 ml of sclerosant is 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. Usually injection is started at the ankle region and then proceeded upwards along the length of veins at different points. Later pressure bandage is applied for six weeks. Often injections may have to be repeated at 2-4weeks intervals for 2-4 sessions. Technique is called as macrosclerotherapy

37. Microsclerotherapy Very dilute solutions of sclerosing agent like STDS(0.1% of 0.1 ml dilute) polidoconol is injected into the thread veins and reticular veins followed by application of compression bandage Dermal flare will disappear well by this method

38. Contraindiactions for sclerotherapy Sapheno femoral incompetence Deep venous thrombosis Huge varicosities– may precipitate DVT Peripheral arterial diseases Hypersentivity / immobilty Venous ulcer– relative contrainidication Advantages It can be done as an outpatient procedure It does not require aneasthesia

39. Disadvantage Inadvertent subcutaneous injection can cause skin necrosis or abscess formation Anaphylaxis Hyperpigmentation Thrombophlebitis Deep vein thrombosis can occur

40. Surgery Trendelenburg operation : It is juxta-femoral flush ligation of long saphenous vein (flush with femoral vein), after ligation superficial circumflex, superficial external pudendal, superficial epigastric vein, deep external pudendal vein and unnamed tributaries. All tributaries should be ligated, otherwise recurrence will occur Double saphenous vein is the commonest anomaly occuring near sapheno-venous junction.

41. B. Stripping of vein : using Myer’s stripper vein is stripped off. Stripped from below upwards is technically easier. Immediate application of crepe bandage reduces the chance of bleeding and hemotoma formation. Stripping avulses the vein as well as obliterates the tributaries. Babcock’s stripper and rigid metal pin stripper can also be used. Stripping of the short saphenous vein is done from ankle below upward after passing stripper from above downwards. Complication is injury to saphenous or sural nerve causing neuralgia. Inverting or invaginating stripping using rigid Oesch pin stripper is better as postoperative pain and hematoma is less common and also there is tissue damage.

42. Subfascial ligation of Cockett and Dodd Perforators are marked out by fegan’s method. Perforators are ligated deep to deep fascia through incisions in antero medial side of the leg.

43. Radiofrequency ablation (RFA) This is done under general or regional anaesthesia. RFA catheter is passed into long / short saphenous vein near SFJ or SPJ under guidence. 85 Celsius temperature is used for long period of time to cause endothelial damage, collagen denaturation and venous constriction. Phlebectomy is done while withdrawing the catheter. Wall of vein is destroyed through its full thickness. Vein forms a cord, which gets dissolved by macrophages and immune cells.

44. Endo venous laser ablation It is done as a OP procedure. Patient lies in supine with diseased leg flexed, hip externally rotated and knee flexed. With aseptic precaution, under U/S guidance GSV is cannulated above the knee and a guide wire is passed beyond SJF and 5- French catheter is passed over guide wire and tip is placed 1cm distal to the junction. 200 ml of 0.1% lignocaine is infilterated along the length of the GSV. Laser fibre is inserted up to the tip of the catheter and catheter is withdrawn for 2 cm and laser fibre protrudes for 2 cm. Laser fibre is fired step by step using diode laser, one mm withdrawal in 2 seconds.

45. Once procedure is over catheter is removed and pressure bandage is applied for 2 weeks. Heat produced (729 – 1000 Celsius) by the laser produces steam bubbles with thermal damage of endothelium leading into occlusion of the vein. Laser therapy has inability to create flush occlusion allowing tributaries to open up and cause recurrence.

46. SUBFASCIAL ENDOSCOPIC PERFORATOR SURGERY (SEPS) First described by Heuer in 1980, it became the most accepted surgical treatment of advanced stages of chronic venous insufficiency because it is minimally invasive nature and safety profile Can be performed with one or two endoscopic ports, the two port technique uses one 10 mm video port for camera and 5 mm port for instrumentation. The limb is elevated and the field is made bloodless by using a Esmarch bandage, and a thigh tourniquet is inflated to 300 mmHg. 10 mm port is placed in the healthy medial aspect of calf, 10 cms distal to tibial tuberosity. Avoid large opening because gas may leak and cause poor visibility.

47. The camera is inserted into the 10mm port and then second 5 mm port is inserted under direct vision about 10-20 cm distal and posterior to the first port. CO2 is insufflated to enlarge and optimally visualise the subfascial space, with pressure maintained at around 30 mmHg. All the visible perforators after dissection are interrupted by using harmonic scalpel, electrocautery or division with scissors between metallic clips. More proximal paratibial perforators are visualised better by exposing the medial insertion of the soleus on the tibia, remain close to tibia to avoid damage to posterior tibial vessels and nerve. On completion, the ports are removed, tourniquet is deflated and CO2 is manually expressed from subfascial space. Local anaesthetic solution is instilled into the subfascial space to help with postoperative analgesia and compressive bandage is applied.

48. Transilluminated phlebectomy It is done by passing transilluminating light under the skin and passing a rotating blade through another small incision. Veins are grasped and removed by rotating movements.

49. AMBULATORY PHLEBECTOMY Done through small incisions using special phlebectomy instruments. ELECTRODESSICATION Using weak electric current through a fine needle directly into the spider veins.

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