varicose veins management and diagnosis and treatment

varicose veins management and diagnosis and treatment plan recent guidelines and clinical methods

1. Varicose veins Dr Sayyed HAMZA SHAHID House officer Surgery unit 1

2. Introduction Varicose veins are enlarged, swollen, and tortous veins, usually occurring in the legs. They result from weakened or damaged valves in the veins, leading to poor blood circulation and the appearance of bulging, blue or purple veins.

3. Anatomy Deep system of veins; Lie below the deep fascia Superficial system of veins; lie above the deep fascia eg great and short saphenous vein Perforating veins; connect superficial and deep venous system, they perforate deep fascia, Guarded by valves; unidirectional blood flow from superficial to deep venous system Locations Dodd: mid-thigh prforators Boyd; Gestrocnemius perforator Cocket (I-III) lower leg perforators
May or Kuster ; Ankle perforators

4. Types Primary; Congenital incompetence / Absence of valves Weakness or wasting of muscles Stretching of deep fascia Klippel-trenauny syndrome Secondary Previous DVT Recurrent thrombophelibitis Obstruction to venous return Occupational or pregnancy Iatrogenic in AV fistula

5. Epidemiology The adult prevalence of visible varicose veins is between 30% and 50%. Factors affecting prevalence include: Gender: the vast majority of studies report a higher prevalence in women than men
Age: the prevalence of varicose veins increases with age
Ethnicity Body mass and height: increasing body mass index and height associated with a higher prevalence of varicose veins.
Pregnancy: increases the risk of varicose veins.

6. Epidemiology Family history: evidence supports familial susceptibility to varicose veins.
Occupation and lifestyle factors: there is inconclusive evidence regarding increased prevalence of varicose veins in smokers, patients who suffer constipation and occupations that involve prolonged standing.

7. Pathophysiology

8. Symptoms Varicose veins frequently cause symptoms. Patients describe aching, heaviness, throbbing, burning or bursting over affected areas and sometimes the whole limb. Such symptoms typically increase throughout the day or with prolonged standing,
and are relieved by elevation or compression hosiery. There may be pruritus, pedal edema , pigmentation, dermatitis, ulceration, tenderness, Compagne -bottle deformity, lipodermatosclerosis

9. Signs The presence of tortuous dilated subcutaneous veins is usually clinically obvious. These are confined to the GSV and SSV systems in approximately 60% and 20% of cases, respectively.
The distribution of varicosities may indicate which superficial axis is defective; medial thigh and calf varicosities suggest GSV incompetence and posterolateral calf varicosities are suggestive of SSV incompetence whereas anterolateral thigh and calf varicosities may indicate isolated incompetence of the ASV SAPHENA VARIX; a large varicose in the groin which becomes Visible and prominent on standing and coughing and disappear in recumbent position

10. Clinical tests Brodie Trendeleburg Test 1; for competency of Sphanofemoral junction Test II; for Competency of perforators Perthe’s test; for competency of deep venous system Fegans’s test; for locating incompetent perforators Schwartz test Pratts test Morrisey cough impulse test Torniquet test

11. Clinical classifications of varicose veins C0; no visible or palpable signs of venous disease C1; Telangiectasia, reticular veins or malleolar flare C2; varicose veins C3; Edema without skin changes C4; Skin changes due to venous disease like C4a; Pigmentation C4b; lipodermatosis and atrophic blanche C5; skin changes as above with healed ulceration C6; skin changes as above with active ulceration

12. CEAP Classification Clinical signs (Grade 1 to 6) supplemented by A for asymptomatic and S for symptomatic Etiologic classification; Congenital, primary, secondary (post-thrombotic) Anatomic distribution (Superficial, deep or perforators alone or in combination) pathophysiologic classification (reflux or obstruction alone or in combination)

13. ReGional classification Great saphenous vein (60%) Medial thigh and calf Small saphenous vein (20%) Posterolateral calf Anterior (accessory) saphenous vein; isolated anterolateral thigh and calf Saphena varix; Large dilated painless lump at saphenofemoral junction which is emergent on standing and coughing and disappear in recumbent position

14. Complications Bleeding Thrombophlebitis Venous hypertension leading to venous ulcer Calcification Eczematous dermatitis and pigmentation

15. Investigations Done to Localize the anatomical lesion of disease Nature of lesion Rule out DVT

16. Investigations Non-invasive Duplex ultrasound scanning; Investigation of choice
platyhysmography
CT venography
MR venography Invasive Phlebography / venography
Varicography
Ambulatory venous pressure
intravenous ultrasound

17. Treatment Conservative therapy (compression) Avoidance of long sranding Elastic crepe bandage from below upwards or use of pressure stockings Elevation of limbs Unna boots Pneumatic compression Elastic compression stockings

18. Treatment 2. Endothermal ablation; (gold standard) A Catheter is inserted into the incompetent axial vein percutaneously . The vein is surrounded by tumescent local anaesthetic solution. This compresses the vein onto the treatment device, emptying it of blood. The catheter then produces thermal energy that destroys the structure of the vein, resulting in permanent occlusion. Two broad technologies exist: Endovenous laser ablation (EVLA) Radiofrequency Ablation (RFA)

19. Treatment Endovenous laser ablation (EVLA) It utilises a small flexible glass fibre that is inserted into the vein. Laser energy (typically at a wavelength of 1470nm) is transmitted down the fibre Radio-frequency ablation (RFA) It uses the same treatment principles, but an electromagnetic current is used to create the thermal energy Non- endothermal , non-tumescent ablation Ultrasound guided foam sclerotheraphy Catheter disrected sclerotherapy and mechanicochemical ablation Endovenous glue ( cyanoacrelate gel)

20. Treatment Ultrasound guided foam sclerotheraphy It involves the injection of a sclerosing agent directly into the superficial veins. The most commonly used is sodium tetradecyl sulphate. The direct contact with detergent causes cellular death and initiates an inflammatory response, aiming to result in thrombosis, fibrosis and obliteration (sclerosis). 2. Catheter directed sclerotheraphy 3. Catheter directed mechanicochemical ablation The catheter is placed within the vein lumen as for endothermal ablation, spinning wire causes physical damage to the endothelium and allows a deeper penetration of the sclerosant into the vein wall.

21. Treatment Endovenous glue ( cyanoacrelate gel) Catheter based, A handle is used to infiltrate the adhesive in 0.1mL applications via the catheter . The vein is then compressed, sealing the lumen closed.

22. Treatment Open surgeries The principles of traditional ligation and stripping are to fully dissect the point of junctional incompetence and to remove the refluxing axial vein and dilated tributaries. Absolute contraindication; DVT Saphenofemoral junction ligation and great saphenous stripping Saphenopopliteal junction ligation and small saphenous stripping

23. Treatment Adjunctive procedures
Phlebotomy; Small Superficial veins of leg do not disappear following GSV stripping, they are separately removed
Perforator ligation; for prforator incompetence

24. Treatment Complications of surgery Complications (minor and major) are reported in up to 20% of patients who undergo traditional varicose vein surgery.
Wound infections, are the most common complication
Nerve injury is the most common serious complication. The incidence of saphenous nerve neuralgia is up to 7% following GSV stripping to the knee (the incidence is higher with stripping to the ankle). The incidence of sural nerve neuropraxia and common peroneal nerve injury may be as high as 20% and 4%, respectively, following SSV surgery. The incidence of venous thromboembolic complications is approximately 0.5% following varicose vein surgery