varicoseveins.pptx dr syed obaid professor of surgery

varicoseveins.pptx dr syed obaid professor of surgery

1. CHRONIC VENOUS INSUFFICIENCY- Varicose veins

2. CVI-DEFINITION Medical condition where veins cannot pump enough deoxy blood back to the heart “impaired musculovenous pump” Mainly in a ) Legs b)CNS c)L i ver

3. CVI in legs Includes Telangectasias Reticular veins Varicose veins

4. Leg Vein Anatomy The venous system is comprised of: Deep veins Superficial veins Perforator veins VN20-03-B 10/04

5. Superficial veins Great saphenous vein Be g i n s f r o m media l margina l v ei n o n the dorsum of foot Ascends in front of tibial malleolus In the medial aspect of leg (related to???) behind medial condyles of tibia and femur posteromedial surface of the knee In anteromedial aspect of thigh Terminates into femoral vein at fossa ovalis 2.5cm below and lateral to pubic tubercle

6. TRIBUTARIES Ankle-medial marginal vein Leg-anastomose with SSV communication-ant.& post.tibial veins receives post. & ant.arch veins Thigh-communicate with femoral vein receives accessory saphenous vein and other cutaneous veins Fossa ovalis-superficial epigastric vein superficial iliac circumflex superficial external pudental vein

7. Short saphenous vein Begins from the lateral marginal vein behind lateral malleolous Lateral margin of tendocalcaneous Posterolateral aspect of calf Perforates the deep fascia of poppliteal fossa Empties into popliteal vein Tributaries Superficial circumflex vein,superficial inferior epigastric,ant.vein of leg,post.arch vein Long intersaphenous communicating vein( comm.vein of Giacomini Cruveilhier ) Ant.accesory great saphenous vein

8. Deep veins Veins of conduits Pumping veins/peripheral heart -soleal venous sinus gastronemial venous sinus of Gilot within the deep fascia Blood flow in greater pressure and volume Accounts for 80 -90% venous return

9. Perfora t o r s Perforating veins connect the d e e p system wit h th e s u p e rficial system They pass through the deep fascia Guarded by valves-unidirectional flow from superficial to deep veins VN20-03-B 10/04

10. Types of perforators Ankle perforators-may or kuster Lower leg perforators of cockett-I,II,III a)Posteroinferior to med malleolus b)10cm above med.malleolus c)15cm above med.malleolus Gastrocnemius perforators of Boyd Mid thigh perforators of Dodd Hunter’s perforator in thigh

11. Physiology of venous blood flow Venous return from leg is governed by Arterial pressure Calf musculovenous pump Gravity Thoracic pump Vis a tergo of adjoining muscles Valves in veins

12. Foot and calf muscles act to squeeze blood out of deep veins. One way valve allow only upward and inward flow. During muscle relaxation blood is drawn inward thru perforating veins.

13. Valve leaflets allow unidirectional flow upward or inward. “nonrefluxing of valves” Major valves- ostial valve preterminal valve Venous valvular function

14. Pathophysiology of CVI Primary muscle pump failure Venous obstruction Venous valvular incompetance perforator incompetence- hydrodynamic reflux 2.sup.vein incompetence- hydrostatic reflux 3.deep vein incompetence- isolated/2 °

15. ANY RISK FACTOR INCREASED VENOUS PRESSURE DILATION OF VEIN WALLS STRECHING OF VALVES-VALVULAR INCOMPETENCE REVERSAL OF BLOOD FLOW FAILURE OF MUSCLES TO PUMP BLOOD V E INS DISTEND,ELONGATE,TORTOUS,POUCHED,INELASTIC AND FRIABLE

16. Telangectasias Small(0.5-1mm) widened blood vessels in skin- small intradermal varicosities “SPIDER VEINS”/”venulectasias" In anywhere on the body esp-leg Usually no severe symptoms Rarely heamorhagic “corona phlebectatica”- blue spiderveins on medial aspect ankle below malleolus

17. Reticular veins Subcutaneous dilated veins -enter tributaries of main axial/trunk veins ( 1 - 3mm) Size >spider veins <varicose vein “feeder veins” - refluxing reticular veins spider veins Cause discomfort and is cosmetically undesirable

18. Varicose veins Dilated,tortuous and elongated veins with reversal of blood flow mainly due to valvular incompetence Only in humans Includes varicose veins in legs Hemorrhoids Varicocele Oesophageal varices

19. Risk factors Age Gender Height left>right Heredity Preg n an c y Obesity and overweight Posture

20. Aetiology More common in lower limb due to erect posture Primary varicosities Congenital incompetence/absence of valves Weakness or wasting of muscles Stretching of deep fascia Inheritance with FOXC2 gene Klippel-trenaunay syndrome

21. Secondary varicosities recurrent thrombophlebitis Occupational Obstruction to venous return Pregnancy Iatrogenic-in AV fistula Deep vein thrombosis

22. Dilated tortuous veins Dragging pain worsening on prolonged standing/sitting Bursting pain on walking Swelling of the ankle Ithcing,oedema,thickening.eczema of feet Night cramps Appearance of spider veins in affected leg. Discoloration/ulceration Skin above ankle may shrink (lipodermatosclerosis) b/c fat underneath skin becomes hard. Bleeding blow outs Local gigantism Symptoms

23. Sig n s Special tests-positive Superficial thrombophlebitis Ankle flare Spider veins Reticular veins Saphena varix Talipes equino varus Champagne bottle sign Atrophic blanche

24. Ankle flare

25. Saphena varix A saphena varix is a dilatation at the top of the long saphenous vein due to valvular incompetence. It may reach the size of a golf ball or larger. The varix is: soft and compressible disappears immediately on lying down exhibits an expansile cough impulse demonstrates a fluid thrill

26. Champagne bottle sign Inverted beer bottle look Contraction of ankle skin and s/c tissue with prominent edematous calf

27. Talipes equinovarus

28. Special Tests The Trendelenburg test Used to assess the competence of SFJ Patient lies flat Elevate the leg and gently empty the veins Palpate the SFJ and ask the patient to stand whilst maintaining pressure Findings: Rapid filling after thumb released → SFJ is incompetent Filling from below upwards without releasing thumb → presence of distal incompetent perforators

29. 2. Tourniquet test Uses a tourniquet to control the junction rather than fingers Advantage of moving the tourniquet lower (mid-thigh region) Test is unreliable below the knee Perthes Test Empty the vein as above, place a tourniquet around the thigh, stand the patient up. Ask them to rapidly stand up and down on their toes – filling of the veins indicated deep venous incompetence. This is a painful and rarely used test. Schwartz test In standing position,tap the lower part of vein Impulse felt on saphenofemoral junction

30. 5.Pratt’s test- Esmarch bandage applied on the leg from below upward with tourniquet on saphenofemoral junction Release of bandages Perforators seen as blow outs 6.Morrissey’s cough impulse test limb elevated and veins emptied Patient is asked to cough Expansile impulse in saphenofemoral junction 7.Fegan’s test Line of varicosities marked Site where perforators pierce deep fascia- bulges on standing circular depressions on lying

31. Hemorrhage Ulcerations phlebitis Pigmentations Eczema lipodermatosclerosis Periostitis Calcification of vein Equinus deformity Acute fat necrosis can occur, esp: at ankle Deep vein thrombosis

32. 1. Fibrin cuff theory valvular incompetence venous stasis c/c ambulatory venous hypertension Defecti v e m i cr o c i rculation E x c es s i ve RB C l y s i s eczema Excessive release of hemosiderin and fibrin Pigmentation,dermatitis and lipodermatosclerosis capillary endothelial damage lack of exchange of nutrients An o x i a ULCER Reasons for complications

33. 2.WBC TRAPPING THEORY Raised venous pressure reduced capillary perfusion trapping of WBC Venous hypertension expression of leucocyte adhesion molecules adhesion of WBC to capillary endothelial cells release of proteolytic enzymes and free radicals Endothelial damage, tissue destruction, local ischemia

34. Varicose ulcer During recanalization of varicose veins or DVT Most common in medial malleolus Gaiter’s zone -handbreadth area around ankle where varicose ulcerations occur Ulcer-shallow,flat edge-sloping,pale blue slope-filled with pink granulation tissue c/c ulcer-edge-ragged floor-fibrous seropurulent discharge with trace of blood surrounding skin-induration,tenderness,pigmentation Rarely proceed to scarring,ankylosis,malignancy- Marjolin’s ulcer

35. VARICOSE ULCER MARJOLIN’S ULCER

36. T hrombophlebitis Thrombosis with infammation of superfiacial veins Occur spontaneously/due to minor trauma Can occur durin injection of sclerosing fluid for treatment

37. Eczema in varicose vein lipodermatosclerosis

38. C. (Clinical class): Class : No visible or palpable signs of venous disease. Class I : Telangiectasis or reticular veins. Class 2 : Varicose veins . Class 3 : Edema. Class 4 : Skin changes e.g. venous eczema, pigmentation and lipodermatosclerosis . Class 5 : Skin changes with healed ulceration Class 6 : Skin changes with active ulceration Classiffication- CEAP

39. E. (Etiology): Congenital. Primary (undetermined cause). Secondary:- Post-thrombotic - Post-traumatic A. (Anatomic distribution of veins): Su p erficial. Perforator. Deep. P. (Pathophysiologicmechanism): Reflux. Obs t ruct i o n . Reflux and obstruction.

40. Investigations Venous doppler Duplex scan Venography/phlebography Plethysmography AVP-ambulatory venous pressure Varicography Arm foot venous pressure Routine investigations

41. Manageme n t Conservative treatment Elevation of limb Support hosiery-elastic crepe bandage / unna boots drugs-dioxmin,toxerutin N’S TECHNIQUE) sodium tetradecyl sulphate of endothelial cells I njection-s Inje dest shed thro cleroth e rapy ( FEGA cting sclerosants into vein – ruction of lipid membranes ding of endothelial cells mbosis,fibrosis,obliteration of veins

42. Surgical treatment- Trendelenburg procedure (High tie and strip) High saphenous ligation Long saphenous strip Avulsion of varicosities-multiple ligation

43. Images: Mr Neeraj Bhas

44. Obliteration of venous lumen - Methods Foam Sclerotherapy Laser Radiofrequency Ablation

45. Foa m S c l e ro t h e rapy  Pr i n c i p a l :  By injecting sclerosant into a varicose vein, destroy its endothelium in that area , and thus induce an aseptic thrombosis which organises and closes the vein .

46.  I n d ica t i o n :  Residual vein after surgery  Large venous t e l a n g i e c t a s e s.  Isolated small dilated veins  C o n t ra i n d ica t i o n :  Pregnancy  Pelvic tumor  Sup thromboplebitis at the time of procedure  DVT  Previous h/o reaction to sclerosant

47.  S O LU T I O N S :  SODIUM TETRADECYL SULPHATE  SOD.MORRHUATE  HYPERTONIC SALINE SOL.  POLYDOCANOL,SOTRADECOL  ETHANOLAMINE OLEATE  GLUCOSE COMBINATIONS

48. `  PROCEDURE :  Depending upon the size of vein to be occluded, sclerosant is taken in 20 ml syringe and connected to another syringe with 4 times the amount of air.  By repeated to and fro motion of the solution and air into syringes , dense white foam is prepared .

49.  After giving position under USG guidance needle is inserted into the vein .  And sclerosant is injected into the vein .  Not more than 20 ml foam should be injected at one sitting ,  Multiple sitting may be required for successful obliteration of vein  The foam being dense , does not “run-away” up the vein, it require massaging the skin over varicose vein.

50.  Immediately after foam injection compression stocking is applied and patient is mobilized .  Patient can go home on the same day of procedure.  After 48 hr of procedure USG is done to R/o DVT

51.  Advantage  Cheap  Easy to learn  Truly an OPD procedure  Can be repeated many times  No anesthesia required  D isadvantage  Not suitable for SFJ/SPJ obliteration  Thrombophebitis  Pigmentation over skin  More than 3 wks compression is required

52. Endovenous Laser Treatment (EVLT)  Principal :  EVLT initiate a nonthrombotic occlusion by direct thermal injury to vein wall, causing endothelial denudation , collagen contraction and later fibrosis.

53.  Indication :  Long saphenous vein varicosity  Short saphenous vein varicosity  C o n t ra i n d ica t i o n :  Superficial vein t h r o m b o p h l e b i t i s  DVT

54. Proce d ure  EVLT is done under local anesthesia under USG guidance.  Varicose vein is marked preoperatively  Supine position is given  Vein is canulated with 0.035” J guide-wire via 19G needle.  The Laser fiber is then introduce over it under USG guidance upto 2-3 cm distal to SF junction.

55.  Fiber is withdrawn at the rate 1-3mm / sec under USG guidance .  This laser fiber causes thermal damage to the venous endothelium(1000 c) and o c c l u s i o n o f l u m e n b y f i b r o s i s.  Immediately after procedure compression stockings are given.  Patient can be discharge on same day with good analgesics and with compression stockings.

56.  A D V ANT A G E  M i n i m a l i n v a s i v e procedure  No post op scar  Done with local anesthesia  Minimal post-op pain  Recurrence rate ( at 2 year f/u only 3%  DISADVANTAGE  C ostly procedure  High technical skills req  Color Doppler and Radiologist is req  Skin burns  Thrombophebitis  Paresthesia

57. Radiofrequency Ablation  This technique based on same principal of EVLT  Here instead of laser fiber , special heater probe is inserted which work at 85 -120 c  Probe directly comes in contact with vein wall & causes tissue damage .  A 45 cm of vein segment takes only 3-5 min  Patient can directly go to home after procedure.

58. Endovascular occlusion of Saphenous veins using VNUS ClosureTM Catheter