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Approach to the patient with varicose veins
J.Rowen MD,CCFP(EM)
Varicose Veins
1)SCOPE OF THE PROBLEM2)ANATOMY3)PATHOPHYSIOLOGY4)CLINICAL5)TREATMENT OPTIONS– SCLEROTHERAPY– ENDOVASCULAR ABLATION(EVLT)– COMPRESSION– SURGERY
OBJECTIVES
Scope of the problem
• About 50 % by age 50 (women);men somewhat less 25 % by age 40
• Incidence increases with age for all types of v.v.(spider veins,truncal varicosities).
• Heredity impacts largely on the incidence;eg:if you are female and BOTH parents have v.v.,then the chance is 90%.
ANATOMY• Understand that there are 2 parallel systems:• -A)DEEP SYSTEM:responsible for >90% of
venous circulation.Surrounded by muscle pump.
• -B)SUPERFICIAL SYSTEM:Truncal veins are subfascial;the majority in loose subcutaneous tissue.
• -C)PERFORATING VEINS:connect surface to deep.
Pathophysiology
• No one specific ‘cause’.• Primary and secondary causes• Definite genetic component• Primary changes to the integrity of the vein
wall(poorly organized smooth muscle,reduced amounts of elastin,increased amounts of collagen)-all lead to lack of compliance and diminished coaptation of valves.
Pathophysiology
• All changes to the wall and valvular insufficiency lead to venous hypertension and resultant inflammation.
• Many other secondary causes:obstruction(dvt,abdominal,pelvic),mus-cle pump ineffeciency,environmental(hormones,clothing,trauma).
Spider veins
CLINICAL
.Asymptomatic VS Symptomatic
.Asymptomatic have esthetic concerns which may have an impact on their lives
Definite symptoms associated with V.V.
SYMPTOMS
• Discomfort described as heaviness, throbbing,and aching especially when standing
• Night cramps(restless legs)• Swelling-edema• Pruritus-rash• Even spider veins may be symptomatic.Relief
with compression.
Spectrum
• Surface varicosities:• -A)Telangiectasia:spider veins.Smallest veins 1
mm in caliber.May or may not be associated with deeper varicosities.
• -B)Reticular veins:usually 3 mm or less in caliber.Often found on lateral surface of legs.More common in women.
Spectrum
• Truncal varicosities:• -leads to dilated,tortuous and bulging veins• -A)GSV:medial aspect proximal to distal with
different patterns.May also be anterior or posterior if tributaries are involved
• -B)SSV:present in posterior calf• -C)Tributaries:more superficial because they
are not subfascial.Anterior/posterior.
Spectrum
• Other;• -Corona phlebectatica:flare of veins on
medial/lateral ankle.Often represents advanced disease.
• -Lipodermatosclerosis:Fibrosis of the skin and subcutaneous tissue.Advanced disease.
• -Venous ulcer:usually found medial ankle.Painful.Advanced CVD.