Varicose Veins - C/F, Investigations & Treatment

This topic comes under the category - Venous Diseases. It is very important for a 3rd year MBBS Student to know about Varicose Veins, which is one of the commonest diseases encountered among out-patients.

1. Prof. U. Murali.
Varicose Veins

2. Learning Objectives
 Define & Classify varicose veins.
 Explain the etio-pathogenesis & theories of VV.
 Identify the clinical tests to diagnose VV.
 Enumerate the C/F, complications & investigations of VV.
 Mention the various treatment aspects of VV.

3. Venous Anatomy of Lower Limbs
Superficial venous
system
Perforator veins
Deep venous
system

4. Perforator veins
Connect superficial to deep veins at various
levels.
Travel from superficial fascia through an opening
in the deep fascia before entering the deep veins.
The direction of blood flow - from superficial to
deep veins.
Guarded by valves so that the flow is
unidirectional, i.e. towards deep veins.
Reversal of flow occurs due to incompetence of
perforators which will lead to varicose veins.

5. Perforators – Types
Ankle perforators – May (or)
Kuster
Lower leg – Cockett I / II / III
Gastrocnemius – Boyd’s
Mid-thigh – Dodd
Adductor canal – Hunterian

6. Venous valves
The venous valves are abundant in the
distal lower extremity and number of
valves decreases proximally, with no
valves in SVC / IVC & Iliac veins.
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.

8. Introduction
Varicose veins are elongated, tortuous
and dilated superficial veins usually of
lower limb that arise due to faulty valves.
VV affects 20% and 10% of adult women
& men, respectively.
Prevalence of varicose veins is 30-50%;
severe varicose veins is 10%; chronic
venous insufficiency (CVI) is 8%; ulcer is
2%.
In clinical practice, patients are normally
categorized as having ‘varicose veins’ or
‘venous ulcer’. Cases of varicose veins
may be uncomplicated (or)
complicated.

9. Definition
Varicose vein is defined as dilated, tortuous,
elongated subcutaneous veins > 3mm in diameter
measured in the upright position with demonstrable
reflux.
E.g.
 Vein in the lower limb.
 Spermatic vein. ( Varicocele )
 Oesophageal vein. ( Oeso. Varices )
 Haemorrhoidal veins.

11. Pathogenesis Of Varicose Veins
Venous
insufficiency
Valvular
competence
Calf muscle
pump
Venous
patency
Endothelial damage
Shearing stress
Increased MMP
Alteration in relaxation and
constriction
Recurrent inflammation

12. Valve
incompetence
/ Ch. Venous
hypertension
Defective
microcirculation
RBC diffusion/
lysis
Hemosiderin
deposition
Dermatitis /
capillary
damage
Chronic
Venous
ulceration
Fibrin cuff Theory
Inappropriate
activation
Trapped WBC’s
Proteolytic
enzymes
Cell destruction
& ulceration
White cell trapping Theory

13. •Chronic venous insufficiency (CVI) is a
syndrome resulting from continuous chronic
venous hypertension / ambulatory venous
hypertension [AVP] in the erect posture either
on standing (or) exercise.
•CVI consists of postural discomfort, varicose
veins, oedema, pigmentation, induration,
dermatitis, lipodermatosclerosis and
ulceration.
•CVI patients may be having SVI (30%) with or
without PI or deep vein incompetence (30%)
or having previous DVT with complete
obliteration or partial recanalization with
incompetence called as post-thrombotic
syndrome (30%).

14. Clinical Features – Symptoms
Aching (or) heaviness
Itching & Ankle swelling
Discoloration
Ulceration
F O – Complications - LDS

15. Clinical Tests
•Sapheno-femoral incompetenceBrodie-Trendelenburg’s test I
•Perforator incompetenceBrodie-Trendelenburg’s test II
•DVTPerthe’s test / Modified P T
•Perforator incompetenceTourniquet’s test
•Perforator site localisationFegan’s test
•Blow outs = perforators / S P I Pratt’s test / Ian – Aird test
•S P I / Valvular incompetence
Cough Impulse test /
Schwartz test
(BPT – F – PICS)

17. Complications
Haemorrhage
Eczema & Dermatitis
Lipodermatosclerosis
Periostitis
Marjolin’s ulcer
Equinavarus deformity
Calcification
Ulcer (Venous)
Thrombophlebitis (R)
(HELP – ME – CUT)

18. Investigations
Venous Doppler Study
Duplex Scan
Venography
Plethysmography
Amb. Venous pressure
Ultrasound Abdomen
Blood Tests - PS / PC
X ray of the part
Varicography
‘Mickey Mouse’ sign

19. Treatment – Conservative
Elastic crepe bandage
From below upwards
Elevation of limbs
Above the level of heart
Graded Compression
stockings
Improves deep venous return
Prevents reflux
Reduces edema - microcirculation

20. Contd..
Unna boot
Non-elastic compression
Zinc oxide, calamine & glycerine
Dressing changed once in a week
Medications - Drugs
Calcium dobesilate – 500mg bd
Diosmin – 450 mg bd
Toxerutin – 500mg bd

21. Injection Sclerotherapy
It is done under Ultrasound
image guidance.
Mechanism of action
Aseptic inflammation
Peri-venous fibrosis
Alters intravascular pH
Approximation of intima

22. Contd…
Sclerosants - used are
S T D S – commonly used
Sodium morrhuate
Ethanolamine oleate
Polidocanol – 1% (or) 3%
Indications
Uncomplicated perforator incompetence
Smaller varices
Recurrent varices
Isolated varicosities
Aged / unfit patients

23. Sclerotherapy – Types
Fegan’s technique – By injecting
sclerosants into the vein, complete
sclerosis of the venous walls can be
achieved.
Foam sclerotherapy – STDS taken 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.
Micro-sclerotherapy – is injected into
the thread veins and reticular veins
followed by application of compression
bandage.

24. Transillumination microsclerotherapy
– It is better imaging of the veins using
light generated by halogen bulb with
high quality fibre illumination over the
skin uniformly.
Endosclerotherapy - Sclerotherapy
is done under duplex ultrasound image
guidance.
Catheter directed sclerotherapy
– It is devised at Miami vein clinic with
specific catheter for sclerotherapy. This
catheter has got side holes all around
the specific length for uniform contact of
venous wall with the foam.
Sclerotherapy – Types

25. Contd…
•Sapheno-femoral incompetence
•DVT
•Peripheral arterial disease
•Hypersensitivity
Contraindications
•OPD procedure
•No anaesthesia
Advantages
•Anaphylaxis / shock
•Abscess
•Thrombophlebitis
•Intravenous hematoma
•Skin necrosis
Disadvantages

26. Surgical management
Trendelenburg’s procedure
Juxta-femoral flush ligation
of LSV with ligating tributaries.
Tributaries
Superficial circumflex
Superficial external pudendal
Superficial epigastric
Deep external pudendal
Unnamed tributaries

27. Contd…
Stripping of LSV
Myer’s stripper is used
From below upwards
Avulses the vein &
Obliterates – tributaries
Saphenous nerve injury

28. Contd…
Perforator incompetence
Sub-fascial ligation of
perforators – Cockett & Dodd
Linton’s method
Stab avulsion method

29. Minimal Invasive methods
S E P S – Perforators are
identified and fulgurated using
bipolar cautery (or) clips can be
applied into the perforators.
R F A - uses a bipolar catheter
to generate thermal energy to
ablate the vein.
E V L A - involves the insertion of
a laser fibre into the lumen of
an incompetent truncal vein, with
subsequent thermal ablation of
the vein.

30. Complications – VVS
Infection – most common
Haematoma / Oedema
Nerve injury
Saphenous – LSV
Sural – SSV
Common peroneal – SSV
Recurrence – 20 - 30%
DVT – Rare - < 0.5%

31. References

32. Thank you

33. To Summarize
 Surgical Anatomy of varicose veins.
 Classification & Etiopathogenesis of VV.
 Various clinical tests to diagnose VV.
 Clinical features of VV.
 Investigative methods & Complications of VV.
 Various Treatment modalities to treat VV.
 Complications following VV surgery.

34. Question Time
 Define and Classify varicose veins.
 Explain the pathogenesis of VV.
 Mention the aetiology & C/F of VV.
 List 5 clinical tests to diagnose VV.
 Enumerate 5 complications of VV.
 Name the non-surgical methods to treat VV.
 Identify the 3 MIM & 3 surgical methods to treat VV.
 List the complications following VV surgery.

35. Drug used for sclerotherapy of varicose veins
are all the following, except –
a) Ethanolamine oleate.
b) Ethanol.
c) Polidocanol.
d) Sodium tetradecyl sulfate.

36. Brodie-Trendelenburg test – I is
positive in –
a) Perforator incompetence below knee.
b) Deep vein incompetence.
c) Sapheno-femoral incompetence.
d) Both SFI & PI.

37. The pathophysiological classification of
venous disorders is based on –
a) Edema.
b) Venous ulcer.
c) Pigmentation.
d) Obstruction.

38. Which of the following is the least likely
complication of varicose veins ? –
a) Spontaneous bleeding through intact skin.
b) Skin pigmentation.
c) Deep vein thrombosis.
d) Leg ulcer.

39. A patient has undergone Trendelenburg procedure for his
varicose vein of left lower limb. Later the patient
developed sudden onset of pain along the medial border
of the corresponding foot. Which nerve has been
accidentally ligated? –
a) Sural nerve.
b) Deep peroneal nerve.
c) Saphenous nerve.
d) Popliteal nerve.

41. 41
Pathogenesis – Varicose Veins

42. 42
Pathogenesis – Venous Ulcer

43. 43

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