Varicose veins

By, Dr.Srinivasan Raman,Tbilisi state medical university,Georgia.

VARICOSE VEINS

VEINS ANTERIOR VIEW

VENOUS SYSTEM OF THE LOWER EXTREMITY

Superficial veins of lower extremity

PHYSIOLOGY

• Fluid Movements: Bulk Flow (Starlings Law of the Capillary)

• Hydrostatic pressure (HP) is the force of a fluid against a membrane.

• Colloid osmotic pressure (OP), the force opposing hydrostatic pressure, is created by the presence of large, nondiffusible molecules that are prevented from moving through the capillary membrane.

• Fluids will leave the capillaries if net HP exceeds net OP, but fluids will enter the capillaries if net OP exceeds net HP.

CAPILLARY DYNAMICS

EPIDEMIOLOGY

• Adult prevalence of visible varicose veins are 25-30 % in women and 15% in men factors affecting prevalence as per edinburgh vein study include,

• Gender: women > men• Age: increases with age• Body mass index and height: increased BMI and height

increases prevalence• Pregnancy: Increase risk• Family history: familial susceptibility present• Occupation and lifestyle factors: smoking, constipation

increases prevalence and occupations with prolonged standing also increases

CLASSIFICATION:• CEAP classification(clinical-etiology-anatomy-pathophysiology)

Clinical classification:Co: no signs of venous disease C1: telengiectasia or reticular veinsC2: varicose veinsC3: edemaC4: pigmentation of eczemaC4b: lipodermatosclerosis or atrophie blancheC5: healed venous ulcerC6: active venous ulcereach clinical class is further divided as symptomatic(S) and asymptomatic(A), e.g. C2S

Etiologic classification: Ec: congenitalEp: primaryEs: secondaryEn: no venous cause identified

Anatomical classification:As: superficial veinsAp: perforator veinsAd : deep veinsAn: no venous locations identified

Pathophysiological classification:Pr: refluxPo: obstructionPr,o: reflux and obstructionPn: no venous pathophysiology identifiable

Clinical feature:• Symptoms:• More commonly: aching and heaviness,

which typically increases throughout the day or with prolonged standing and is relieved by elevation or compression hosiery.

• Less commonly: ankle swelling and itching • Complications like bleeding, superficial

thrombophlebitis, eczema, lipodermatosclerosis and ulceration

SIGNS• Tortuous dilated superficial veins, mostly they are confined to long and

short saphenous systems in 20 to 60 % of cases• By distribution of varicosities we can determine which superficial system

is defective, medial thigh and calf varicosities suggest long saphenous incompetence posterolateral varicosities indicate short saphenous incompetence and anterolateral thigh and calf varicosities indicate isolated incompetenceof proximal anterolateral long saphenous tributory

• Other signs commonly found are,• Telengiectasia• Reticular veins are dilated • Atrophie blanche• Corona phlebectasia• Pigmentation• Eczema• Dependent pitting edema• Lipodermatosclerosis• Ulceration

INVESTIGATION• Doctors often diagnose varicose veins based on a physical exam alone. Sometimes tests or

procedures are used to find out the extent of the problem or to rule out other conditions.• Specialists Involved• If a patient have varicose veins, he/she may see a vascular medicine specialist or vascular

surgeon. These doctors specialize in blood vessel conditions. He/she also may see a dermatologist. This type of doctor specializes in skin conditions.

• Physical Exam• To check for varicose veins in your legs, the doctor will just look at patients legs while

he/she is standing or sitting with their legs dangling. He or she may ask you about your signs and symptoms, including any pain you're having.

• Diagnostic Tests and Procedures• Duplex Ultrasound• Your doctor may recommend duplex ultrasound to check blood flow in your veins and to

look for blood clots. Duplex ultrasound combines traditional with Doppler ultrasound.• Angiogram• Although it is not very common, your doctor may recommend an angiogram to get a more

detailed look at the blood flow through your veins.• For this procedure, dye is injected into your veins. The dye outlines your veins on x-ray

images.• An angiogram can help your doctor confirm whether you have varicose veins or another

condition.

Duplex Ultrasound- Normal valve

Incompetent valve

Duplex ultrasound: incompetent valves

MANAGEMENT

• Compression hosiery• Ultrasound guided foam sclerotherapy• Endovenous laser ablation• Radiofrequency ablation

SCLEROTHERAPY• Sclerosant used in u.k is sodium

tetradecyl sulphate

Endovenous laser ablation

MANAGEMENT

SURGERY

• Saphenofemoral ligation and long saphenous stripping

• Saphenopopliteal junction ligation and lesser saphenous stripping

• Perforator ligation• Phlebectomies

Ligation and stripping

• To treat varicose veins in the leg, the saphenous vein may be removed by ligation and stripping (A). First an incision is made in the upper thigh, and the saphenous vein is separated from its tributaries (B). Another incision is made above the foot (C). The lower portion of the vein is cut, and a stripper is inserted into the vein (D). The stripper is pulled through the vein and out the incision in the upper thigh (E)

Saphenofemoral ligation

Ligation and stripping

Saphenopopliteal junction ligation

Phlebectomies • Performed for

junctional competencies under local anaesthetic in patients with isolated tributary incompetencies

• During phlebectomies, small stab incisions using small mosquito forceps or phlebectomy hooks which is more superior in terms of bruising, pain and genetic quality of life than transilluminated powered phlebectomy

Surgical complications

• Vein stripping is a surgical procedure, and there are always risks associated with surgeries. They include:

• allergic reaction to anesthesia• breathing problems• bleeding• bruising• infection at cut site• scarring• nerve injury• reoccurrence of varicose veins• temporary severe pain

Surgical complications

• Serious complications are possible with any kind of procedure, although extremely rare with ambulatory phlebectomy.

• However, inconveniences such as blister formation, wound infection, visible scars, bruising or hematomas along the course of the removed varicose vein, and loss of sensation in small areas, may occur.

• Most of the time, these events run a limited course and resolve without any long-term problems.

Reference • http://www.medscape.com/viewarticle/778728_2• http://www.mayoclinic.org/diseases-conditions/

varicose-veins/basics/complications/con-20043474• http://www.surgeryencyclopedia.com/St-Wr/Vein-

Ligation-and-Stripping.html• http://www.healthline.com/health/varicose-vein-

stripping#Purpose2• http://www.emedicinehealth.com/varicose_veins-

health/page3_em.htm• http://www.medicalnewstoday.com/articles/

182793.php• Bailey and love short practice of medecine• http://www.sigvaris.com/global/en/ceap-classification