VARICOSE VEINSVARICOSE VEINS

Bhavesh BangBhavesh Bang

Under guidance ofUnder guidance of

Dr Shalu Gupta Dr Shalu Gupta

INTRODUCTIONINTRODUCTION

DEFINITIONSDEFINITIONS Chronic Venous Insufficiency ( CVI ) – Venous Chronic Venous Insufficiency ( CVI ) – Venous

Hypertension in Lower limb Causing Symptoms Hypertension in Lower limb Causing Symptoms like pain, swelling, edema & Skin Changeslike pain, swelling, edema & Skin Changes

Varicose Veins -Any Dilated, tortuous, elongated Varicose Veins -Any Dilated, tortuous, elongated vein of any calibervein of any caliber

Telengiectasias - Intradermal Varicosities also Telengiectasias - Intradermal Varicosities also c/as Spider veins/Thread veins c/as Spider veins/Thread veins or Dermal Flaresor Dermal Flares Reticular veins –Subcutaneous dilated veinsReticular veins –Subcutaneous dilated veins

VENOUS ANATOMY VENOUS ANATOMY

GREAT SAPHENOUS VEINGREAT SAPHENOUS VEIN Originates on dorsum from Originates on dorsum from

DVADVA

Relatively Constant Relatively Constant anatomyanatomy

Lies between the Lies between the superficial & deep fasciasuperficial & deep fascia

LESSER SAPHENOUS VEINLESSER SAPHENOUS VEIN

From Lat. Side of DVAFrom Lat. Side of DVA

Ascends in Midline of calfAscends in Midline of calf

Sapheno – popliteal Sapheno – popliteal junction is inconstant junction is inconstant

Duplicated saphenous Duplicated saphenous system present in 8 % system present in 8 % populationpopulation

PERFORATOR SYSTEMPERFORATOR SYSTEMClinically Important PerforatorsClinically Important Perforators Cockett PerforatorCockett Perforator Medial Lower LegMedial Lower Leg Constant Perforators Constant Perforators Post. Arch vein to Post. Post. Arch vein to Post. Tibial VeinTibial Vein Boyd’s PerforatorsBoyd’s Perforators GSV to Deep veinsGSV to Deep veins Approx. 10 cm below Knee Approx. 10 cm below Knee Usually first to become Usually first to become incompetent incompetent

Dodd PerforatorsDodd Perforators May be found anywhere May be found anywhere

along the saphenous along the saphenous pathway in the distal 3pathway in the distal 3rdrd of thighof thigh

Hunter PerforatorsHunter Perforators Mid thigh Mid thigh InconstantInconstant Absent in 10 – 15 % Absent in 10 – 15 %

PARATIBIAL PERFORATORSPARATIBIAL PERFORATORSConnect GSV directly to post tibial veinsConnect GSV directly to post tibial veinsThree groups are present at 24, 27 & 30 cmThree groups are present at 24, 27 & 30 cm

from Sole of footfrom Sole of foot

ANTERIOR & LATERAL PERFORATORSANTERIOR & LATERAL PERFORATORS Imp in Pt. with Lateral UlcerationImp in Pt. with Lateral UlcerationAnt Perforators Connect GSV or LSV to Ant Perforators Connect GSV or LSV to

ant Tibial Veinant Tibial VeinBassi’s PerforatorsBassi’s Perforators in Distal calf connect LSV in Distal calf connect LSV

to Peroneal Veinsto Peroneal Veins

PATHOGENESISPATHOGENESIS

CALF PUMPCALF PUMP

Calf Muscle Pump Calf Muscle Pump

facilitates Venous returnfacilitates Venous return

Max. Press In Muscles Max. Press In Muscles

During Exercise 150 –During Exercise 150 –

200 mm Hg200 mm Hg

In Perforator Incompetence Pressure transmitted to In Perforator Incompetence Pressure transmitted to Superficial veinsSuperficial veins

VENOUS HYPERTENSIONVENOUS HYPERTENSION

Responsible for valve failureResponsible for valve failureTwo Reasons For venous HypertensionTwo Reasons For venous Hypertension

Hydrostatic Pressure – Due To Column ofHydrostatic Pressure – Due To Column of

BloodBlood

Dynamic Pressure – Due to MuscularDynamic Pressure – Due to Muscular

ContractionsContractions

VENOUS VALVE REFLUXVENOUS VALVE REFLUXThree main Causes of RefluxThree main Causes of Reflux

CongenitalCongenital – Aplasia of valve – Aplasia of valve

Dysplasias Like Avalvular Dysplasias Like Avalvular

duplication Conduitduplication Conduit

Structural AbnormalityStructural Abnormality

Primary valve RefluxPrimary valve Reflux –Structurally normal –Structurally normal

Valves with redundant Valves with redundant

LeafletsLeaflets

Post Thrombotic RefluxPost Thrombotic Reflux – Most Common – Most Common

CauseCause

RISK FACTORSRISK FACTORSAgeAgeObesityObesityFemale SexFemale Sex Increased ParityIncreased ParityProlonged StandingProlonged StandingHRT/OCPHRT/OCPFamily HistoryFamily HistoryH/O DVTH/O DVTSmokingSmoking

CLASSIFICATIONCLASSIFICATION

Primary Varicose veinsPrimary Varicose veins Intrinsic vessel wall abnormalitiesIntrinsic vessel wall abnormalities Decreased Vein wall elasticityDecreased Vein wall elasticity

Secondary Varicose VeinsSecondary Varicose Veins Antecedent event Preceding reflux m/c Antecedent event Preceding reflux m/c DVTDVT

CLINICAL FEATURESCLINICAL FEATURESSymptomsSymptoms

Aching pain – m/c symptomAching pain – m/c symptom

Unsightly AppearanceUnsightly Appearance

HeavinessHeaviness

Early FatigueEarly Fatigue

ItchingItching

EdemaEdema

Skin ChangesSkin ChangesWorse at the End of dayWorse at the End of day

Symptoms Result from irritation of superficial Symptoms Result from irritation of superficial nerve fibers by Local Pressure nerve fibers by Local Pressure

Marked Improvement After Overnight RestMarked Improvement After Overnight RestWorsening of Symptoms During Menstrual Worsening of Symptoms During Menstrual

cyclecycleDistribution Distribution

Long Saphenous Territory – 90 %Long Saphenous Territory – 90 %

Short Saphenous Territory – 15 %Short Saphenous Territory – 15 %

DIAGNOSTIC WORKUPDIAGNOSTIC WORKUP

CLINICAL EXAMINATIONCLINICAL EXAMINATION

Trendelenburg testTrendelenburg testTourniquet testTourniquet testPratt’s testPratt’s testPerthe’s testPerthe’s testSchwartz testSchwartz testCough Impulse testCough Impulse testFegans testFegans test

INVESTIGATIONSINVESTIGATIONS DOPPLER ULTRASOUNDDOPPLER ULTRASOUND Minimum Level InvestigationMinimum Level Investigation

Required for T/tRequired for T/t UsesUses

To Exclude Arterial DiseasesTo Exclude Arterial Diseases

Determine vein PatencyDetermine vein Patency

Detect venous RefluxDetect venous Reflux

Done with Patient StandingDone with Patient Standing

DUPLEX ULTRASOUNDDUPLEX ULTRASOUND

Standard Imaging Modality Standard Imaging Modality

for Diagnosis & Treatmentfor Diagnosis & Treatment

PlanningPlanning

To Evaluate Reflux In To Evaluate Reflux In

Individual Venous Individual Venous

segments of leg segments of leg

Transducer Placed Over the segment & Cuff Transducer Placed Over the segment & Cuff

inflated & rapidly deflatedinflated & rapidly deflated

If Valve Closure takes > 0.5 sec, it is abnormal If Valve Closure takes > 0.5 sec, it is abnormal

Can evaluate Deep Veins also Can evaluate Deep Veins also

Following Indices can be calculatedFollowing Indices can be calculated

Valve Closure TimeValve Closure Time

Venous DiametersVenous Diameters

Peak Reflux velocitiesPeak Reflux velocities

Volume Flow at Peak reflux ( VFPR )Volume Flow at Peak reflux ( VFPR )

VFPR value > 10 ml/sec correlates with VFPR value > 10 ml/sec correlates with increased incidence of Lipodermatosclerosisincreased incidence of Lipodermatosclerosis

PLETHYSMOGRAPHYPLETHYSMOGRAPHYBased on Measurement of changes in Blood Based on Measurement of changes in Blood

FlowFlowTwo types of Venous Plethysmography are Two types of Venous Plethysmography are

usedused

Photo PlethysmographyPhoto Plethysmography – – Evaluates VenousEvaluates Venous

function through function through

Infrared LightInfrared Light

Measures Overall Venous function Measures Overall Venous function

AVPAVP – Pressure in the Deep Veins of Leg Measured – Pressure in the Deep Veins of Leg Measured

after Light Excersiseafter Light Excersise

VRTVRT – Time req. for Venous Pressure to – Time req. for Venous Pressure to

Return to 90 % baseline From AVPReturn to 90 % baseline From AVP

Air Plethysmography - Air Plethysmography - Calf Pump FunctionCalf Pump Function Venous Reflux Venous Reflux Overall Venous FunctionOverall Venous Function Following Indices are CalculatedFollowing Indices are Calculated

VFIVFI – Max Venous Volume / Time. Measure – Max Venous Volume / Time. Measure

of Refluxof Reflux

EF EF – Change In recorded Blood volume In a – Change In recorded Blood volume In a

Tip Toe Maneuver. Measure of Calf Tip Toe Maneuver. Measure of Calf

FunctionFunction

RVFRVF - Change in Blood Volume after 10 - Change in Blood Volume after 10

Maneuver. Measure of Overall Function Maneuver. Measure of Overall Function

CONTRAST STUDIESCONTRAST STUDIES

MR Venography MR Venography ( MRV )( MRV )Most Sensitive & Specific Investigation for Most Sensitive & Specific Investigation for

Venous diseases of lower limbVenous diseases of lower limbRule out other nonvascular causes of Leg pain Rule out other nonvascular causes of Leg pain

& edema& edema

DIRECT CONTRAST VENOGRAPHYDIRECT CONTRAST VENOGRAPHYUsed in Inconclusive casesUsed in Inconclusive cases

Ascending Phlebography – Deep Vein StatusAscending Phlebography – Deep Vein Status

Descending Phlebography – Identifies SpecificDescending Phlebography – Identifies Specific

Valvular Valvular

IncompetenceIncompetence

COMPLICATIONSCOMPLICATIONS

ThrombophlebitisThrombophlebitisHyperpigmentationHyperpigmentationLipodermatosclerosisLipodermatosclerosisVaricose UlcersVaricose UlcersBleedingBleedingEczemaEczemaPeriostitisPeriostitisEquinus DeformityEquinus Deformity

MANAGEMENTMANAGEMENT

INDICATIONS FOR INTERVENTIONINDICATIONS FOR INTERVENTIONUnsightly AppearanceUnsightly AppearanceAching painAching painEasy FatigueEasy FatigueSuperficial ThrombophlebitisSuperficial ThrombophlebitisExternal BleedingExternal BleedingAnkle Hyper pigmentationAnkle Hyper pigmentationLipodermatosclerosisLipodermatosclerosisVenous UlcerVenous Ulcer

C/I FOR INVASIVE INTERVENTIONC/I FOR INVASIVE INTERVENTION

Acute Inflammatory Thrombophlebitis – At Acute Inflammatory Thrombophlebitis – At least 3 mo time should be allowed to passleast 3 mo time should be allowed to pass

DVTDVTPregnancyPregnancyPelvic tumorsPelvic tumorsOral Contraceptive PillsOral Contraceptive PillsArterial Occlusive DiseaseArterial Occlusive Disease

Non OperativeNon OperativeCOMPRESSION THERAPYCOMPRESSION THERAPY

First line therapy in the T/t of varicose veinsFirst line therapy in the T/t of varicose veins

Highly effective in controlling Symptoms & Highly effective in controlling Symptoms & promoting Healing of Venous Ulcerspromoting Healing of Venous Ulcers

Acts by increasing the interstitial pressure & Acts by increasing the interstitial pressure & thereby promoting fluid resorptionthereby promoting fluid resorption

Elastic Compression StockingElastic Compression Stocking 20 – 30 mm Hg pressure Stockings are used 20 – 30 mm Hg pressure Stockings are used initially f/b High Pressure stockings if these initially f/b High Pressure stockings if these

are not effectiveare not effective Worn throughout day & taken off at nightWorn throughout day & taken off at night Primary therapy in cases of venous ulcers Primary therapy in cases of venous ulcers

along with wound carealong with wound care Problems ofProblems of Poor Patient Compliance Poor Patient Compliance HypersensitivityHypersensitivity Exacerbating concomitant Arterial Exacerbating concomitant Arterial InsufficiencyInsufficiency

UNNA BOOTS UNNA BOOTS ( Paste Gauze Boots )( Paste Gauze Boots ) Used in cases of Varicose UlcersUsed in cases of Varicose Ulcers It provides both Compression as wellIt provides both Compression as well

as topical therapy for the ulcersas topical therapy for the ulcers Consists of three layer dressingConsists of three layer dressing

11stst Layer – Dome Paste Containing Calamine, Layer – Dome Paste Containing Calamine,

Zinc Oxide, Glycerin, Sorbitol,Zinc Oxide, Glycerin, Sorbitol,

Gelatin & Magnesium Aluminum Gelatin & Magnesium Aluminum

SilicateSilicate

22ndnd Layer – 4‘’ wide Continuous Gauze Dressing Layer – 4‘’ wide Continuous Gauze Dressing

33rdrd Layer – Elastic Compression bandage Layer – Elastic Compression bandage Changed WeeklyChanged Weekly

AdvantagesAdvantages

Improved Patient ComplianceImproved Patient Compliance

Better Wound healingBetter Wound healing

DisadvantagesDisadvantages

Need for trained personnel to applyNeed for trained personnel to apply

DiscomfortDiscomfort

Inability to monitor Ulcer between DressingInability to monitor Ulcer between Dressing

Contact dermatitisContact dermatitis

ADJUNCTIVE COMPRESSION DEVICESADJUNCTIVE COMPRESSION DEVICES

Circ-Aid OrthosisCirc-Aid Orthosis – Multiple rigid compression – Multiple rigid compression

bands held with Velcro tapebands held with Velcro tape

Pneumatic Compression DevicesPneumatic Compression Devices – Useful in Patients – Useful in Patients

with massive with massive edema & Morbid obesity who have Varicose ulcersedema & Morbid obesity who have Varicose ulcers

SclerotherapySclerotherapy For varicosites < 3 mmFor varicosites < 3 mm Optimal IndicationsOptimal Indications

TelengiectasiasTelengiectasias

Reticular VeinsReticular Veins

Below knee VaricositiesBelow knee Varicosities

Recurrent VaricositiesRecurrent Varicosities

Non Surgical candidatesNon Surgical candidates Contraindication – Allergy to sclerosantContraindication – Allergy to sclerosant SF Reflux & Venous HTN must be corrected firstSF Reflux & Venous HTN must be corrected first Destroys Vascular EndotheliumDestroys Vascular Endothelium

Sclerosing Agents IncludeSclerosing Agents Include Sodium Tetradecyl sulfate – 0.125 to 0.75 %Sodium Tetradecyl sulfate – 0.125 to 0.75 % Polidocanol – 0.5 to 1 %Polidocanol – 0.5 to 1 % Hypertonic saline – 11.7 to 23 %Hypertonic saline – 11.7 to 23 %Post therapy Pressure dressing for 24 – 72 hrsPost therapy Pressure dressing for 24 – 72 hrsPost therapy Drainage of entrapped blood at Post therapy Drainage of entrapped blood at

14 – 21 days14 – 21 daysComplicationsComplications Allergic ReactionAllergic Reaction PigmentationPigmentation ThrombophlebitisThrombophlebitis Skin necrosisSkin necrosis

OPERATIVEOPERATIVE Goals Of SurgeryGoals Of Surgery

Permanent removal of varicositiesPermanent removal of varicosities

with the source of venous HTNwith the source of venous HTN

Cosmetic acceptabilityCosmetic acceptability

Minimum ComplicationsMinimum Complications Appropriate forAppropriate for

Large varicose clustersLarge varicose clusters

Axial Veins with gross refluxAxial Veins with gross reflux

Varicosities above kneeVaricosities above knee Presence of DVT is an absolute C/I for SurgeryPresence of DVT is an absolute C/I for Surgery

OPTIONS FOR SURGICAL TREATMENTOPTIONS FOR SURGICAL TREATMENT

Groin to Ankle Saphenous Vein StrippingGroin to Ankle Saphenous Vein StrippingSegmental Saphenous Vein StrippingSegmental Saphenous Vein StrippingSaphenous vein LigationSaphenous vein LigationSaphenous Vein Ligation With SclerotherapySaphenous Vein Ligation With SclerotherapySaphenous Vein Ligation with stab avulsion of Saphenous Vein Ligation with stab avulsion of

varicesvaricesStab Avulsion of Varices without vein StrippingStab Avulsion of Varices without vein Stripping

SFJ LIGATIONSFJ LIGATIONAlso c/as Trendelenburg ProcedureAlso c/as Trendelenburg ProcedureProcedure removes gravitational reflux Procedure removes gravitational reflux

across SFJacross SFJAdvantagesAdvantages

Simple ProcedureSimple Procedure

Decreased Bleeding & PainDecreased Bleeding & Pain

Lower Incidence of Wound infectionLower Incidence of Wound infection

Preserves GSVPreserves GSVDisadvantagesDisadvantages

Very High Recurrence rate Very High Recurrence rate

SAPHENOUS VEIN STRIPPINGSAPHENOUS VEIN STRIPPINGRemoves Gravitational reflux & therefore Removes Gravitational reflux & therefore

hydrostatic element of venous hypertensionhydrostatic element of venous hypertensionBelow knee Stripping not advocated b/seBelow knee Stripping not advocated b/se

Below knee Perforators are part ofBelow knee Perforators are part of

Post Arch circulationPost Arch circulation

Associated Saphenous Nerve InjuryAssociated Saphenous Nerve Injury

All Inguinal Tributaries Should be tied & Cut All Inguinal Tributaries Should be tied & Cut Incisions at groin, thigh & ankle are TransverseIncisions at groin, thigh & ankle are TransverseOther Incisions Should be LongitudinalOther Incisions Should be Longitudinal

Stripper is Introduced Stripper is Introduced

from Groinfrom Groin

Stripping Should be Stripping Should be

done from above done from above

DownwardsDownwards

ComplicationsComplications

Saphenous Nerve InjurySaphenous Nerve Injury

Injury to Vessels & Nerve Of FemoralInjury to Vessels & Nerve Of Femoral

Seroma FormationSeroma Formation

STAB AVULSIONSTAB AVULSIONAlso c/as Ambulatory Phlebectomy / Micro Also c/as Ambulatory Phlebectomy / Micro

Extraction PhlebectomyExtraction Phlebectomy

Saphenous vein reflux Should be absentSaphenous vein reflux Should be absent

Detaches Perforating Veins from Varicose Detaches Perforating Veins from Varicose ClustersClusters

If Combined Stab Avulsion & Stripping is to be If Combined Stab Avulsion & Stripping is to be done, Stab Avulsion Should be done 1done, Stab Avulsion Should be done 1stst

Done LADone LA

1- 2 mm Vertical Incisions 1- 2 mm Vertical Incisions

are madeare made

Retained Vein ends Retained Vein ends

need not be Ligated or Clipped as leg elevation, need not be Ligated or Clipped as leg elevation,

Venospasm & Direct Pressure will ensure Hemostasis Venospasm & Direct Pressure will ensure Hemostasis

Incisions Do Not require stitch closureIncisions Do Not require stitch closure

Compression Stocking worn for 1 moCompression Stocking worn for 1 mo

PERFORATOR MANAGEMENTPERFORATOR MANAGEMENTPerforator incompetence is present in approx. Perforator incompetence is present in approx.

2/32/3rdrd patients with Venous Ulceration patients with Venous UlcerationGaiter area of leg is the most common site of Gaiter area of leg is the most common site of

Venous Ulceration & Skin changesVenous Ulceration & Skin changesPerforator Surgery is indicated when there arePerforator Surgery is indicated when there are

Incompetent perforators in presence of skin Incompetent perforators in presence of skin changeschanges

Three Approaches Linton’s ProcedureThree Approaches Linton’s Procedure

Laparoscopic ProcedureLaparoscopic Procedure

Single Scope ProcedureSingle Scope Procedure

CONTRAINDICATIONS CONTRAINDICATIONS

Chronic Arterial Occlusive DiseaseChronic Arterial Occlusive DiseaseUlcer in Diabetics, RF patients, CTD PatientsUlcer in Diabetics, RF patients, CTD PatientsMorbid obesityMorbid obesityNonambulatory PatientNonambulatory PatientLateral UlcerationsLateral UlcerationsPrevious Perforator SurgeryPrevious Perforator SurgeryExtensive skin ChangesExtensive skin Changes Infected ulcerInfected ulcer

OPEN PERFORATOR SURGERY OPEN PERFORATOR SURGERY

Also c/as Linton’s procedureAlso c/as Linton’s procedure

Associated with Wound Complications d/t Associated with Wound Complications d/t incisions in the lipodermatosclerotic skinincisions in the lipodermatosclerotic skin

Edward’s Procedure involves use of an Edward’s Procedure involves use of an instrument c/as instrument c/as “Phlebotome” “Phlebotome” introduced introduced proximally from kneeproximally from knee

RECONSTRUCTIVE VEIN SURGERYRECONSTRUCTIVE VEIN SURGERY

Used for Cases where valve Structure is Used for Cases where valve Structure is abnormal m/c in Cases of Post Phlebitic Reflux abnormal m/c in Cases of Post Phlebitic Reflux & Some cases of primary reflux& Some cases of primary reflux

Uppermost Superficial femoral valve is m/c Uppermost Superficial femoral valve is m/c repaired valverepaired valve

In Cases Of Primary Reflux, Single valve repair In Cases Of Primary Reflux, Single valve repair is sufficient in most cases is sufficient in most cases

In Post Phlebitic cases Multiple Valve Repair is In Post Phlebitic cases Multiple Valve Repair is neededneeded

VENOUS OBSTRUCTIONVENOUS OBSTRUCTION

PALMA OPERATIONPALMA OPERATION – – Inserting The Long Inserting The Long Saphenous Vein Of Diseased leg into Saphenous Vein Of Diseased leg into Opposite Femoral VeinOpposite Femoral Vein

MAY–HUSNI PROCEDUREMAY–HUSNI PROCEDURE – In case of Sup. – In case of Sup. Femoral vein Obstruction, GSV is Connected Femoral vein Obstruction, GSV is Connected to Popliteal Veinto Popliteal Vein

VENOUS INCOMPETENCEVENOUS INCOMPETENCE

INTERNAL VALVULOPLASTYINTERNAL VALVULOPLASTY

PROSTHETIC SLEEVE IN SITUPROSTHETIC SLEEVE IN SITU

AXILLARY VEIN TRANSFER AXILLARY VEIN TRANSFER

NEWER APPROACHESNEWER APPROACHES

SAPHENOUS REFLUXSAPHENOUS REFLUXRadiofrequency Ablation of SFJRadiofrequency Ablation of SFJBipolar endothermal energy is used which Bipolar endothermal energy is used which

causes heat contracture of collagen in the vein causes heat contracture of collagen in the vein wallwall

Vessel occludes d/t formation of thrombus plug Vessel occludes d/t formation of thrombus plug within the reduced vein lumenwithin the reduced vein lumen

System used is System used is VNUS VNUS systemsystemTreatment time – 12 to 16 min approxTreatment time – 12 to 16 min approxAccess to veins is via Percutaneous routeAccess to veins is via Percutaneous route

or Cut down or Cut down

Short GA is usedShort GA is usedVein Characteristics Vein Characteristics

StraightStraight Free of ThrombusFree of Thrombus Without AneurysmsWithout Aneurysms

C/IC/I Postphlebitic veinPostphlebitic vein Mega saphenous veinMega saphenous vein ( > 12 mm )( > 12 mm ) Aneurysmal SFJAneurysmal SFJ

ENDOVENOUS LASER THERAPYENDOVENOUS LASER THERAPY ( EVLT ) ( EVLT )

Laser energy @ 810 nm is delivered via a fiberLaser energy @ 810 nm is delivered via a fiberLaser causes boiling of blood & steam bubblesLaser causes boiling of blood & steam bubblesThere is thickening of vessel wall with Collagen There is thickening of vessel wall with Collagen

contraction & thrombosis of lumencontraction & thrombosis of lumenDiode Laser is usedDiode Laser is usedLocal AnesthesiaLocal AnesthesiaCompression Stockings used for 1 weekCompression Stockings used for 1 week

VARICOSITIESVARICOSITIESTransilluminated Power Phlebectomy ( TIPP )Transilluminated Power Phlebectomy ( TIPP )Trivex SystemA light source beneath the skin is used for

varicose vein visualization & Suction resector to perform Phlebectomy

Resector aspirates varicosities, morcillates them & then removes by suction

Complications include

Ecchymosis – Most common

DVT

FOAM SCLEROTHERAPYFOAM SCLEROTHERAPY Standard Sclerotherapy is effective only for Standard Sclerotherapy is effective only for

smaller veinssmaller veins In foam Sclerotherapy, a mix of standard In foam Sclerotherapy, a mix of standard

sclerosant with air is usedsclerosant with air is used Surface area of the sclerosant is increasedSurface area of the sclerosant is increased LA is usedLA is used External compression at SFJ prevents entry of External compression at SFJ prevents entry of

Sclerosant in Deep Venous SystemSclerosant in Deep Venous System Minor Complications – Pigmentation & Minor Complications – Pigmentation &

Superficial thrombophlebitisSuperficial thrombophlebitis Major Complications – Anaphylaxis & IA InjectionMajor Complications – Anaphylaxis & IA Injection

PERFORATOR SURGERYPERFORATOR SURGERY SUBFACIAL ENDOSCOPIC PERFORATOR SURGERYSUBFACIAL ENDOSCOPIC PERFORATOR SURGERY

( SEPS )( SEPS )

Two techniques Two techniques

Single Scope Single Scope

Laparoscopic Laparoscopic

TechniqueTechnique

Two 10 mm Ports are placed 6 – 10 cm apart in Two 10 mm Ports are placed 6 – 10 cm apart in

proximal Calfproximal Calf

COCO2 2 at 30 mm Hg pressure is insufflated

Perforators are divided between Clips ( > 2mm ) or

Harmonic Scalpel ( < 2mm )

VENOUS ULCERVENOUS ULCER In association withIn association with

Varicose Veins – 40 %Varicose Veins – 40 %

DVT – 20 %DVT – 20 %

Venous Stasis Favors Local anoxiaVenous Stasis Favors Local anoxia

& Edema& Edema

Varicose Ulcers Respond toVaricose Ulcers Respond to

ambulatory T/t & Ligation ambulatory T/t & Ligation

Thrombotic ulcers are refractory & require rest Thrombotic ulcers are refractory & require rest

curettage & skin Graftingcurettage & skin Grafting

Ascending Venogram helps in identifying patency & Ascending Venogram helps in identifying patency &

lumen of deep veins & also presence of Incompetentlumen of deep veins & also presence of Incompetent

valvesvalves

MANAGEMENT OF VENOUS ULCERSMANAGEMENT OF VENOUS ULCERSBISGAARD METHOD BISGAARD METHOD – Massage in elevation– Massage in elevation Passive MovementPassive Movement Active MovementActive Movement Bandage ApplicationBandage ApplicationBandaging & Limb elevation are used when Pt. Bandaging & Limb elevation are used when Pt. compliance is not propercompliance is not properSubfascial Ligation Subfascial Ligation ( Cockett & Dodd Op )( Cockett & Dodd Op ) After Ulcer healing Perforators are identified After Ulcer healing Perforators are identified

& Divided by Lower Leg incision& Divided by Lower Leg incisionPHARMACOTHERAPY – PHARMACOTHERAPY – Zinc Zinc Fibrinolytic AgentsFibrinolytic Agents StanazolStanazol

Phlebotrophic Agents – Hydroxyrutosides Phlebotrophic Agents – Hydroxyrutosides

Calcium DobesilateCalcium Dobesilate

Rheological Agents – PentoxifyllineRheological Agents – Pentoxifylline

AspirinAspirin

Free Radical Scavengers – Dimethyl SulfoxideFree Radical Scavengers – Dimethyl Sulfoxide

Prostaglandins – PGEProstaglandins – PGE1 1 , PGF, PGF

Topical Agents – IodosorbTopical Agents – Iodosorb

KetanserinKetanserin

Growth Factors & CytokinesGrowth Factors & Cytokines

RECURRENT VARICOSE VEINSRECURRENT VARICOSE VEINS Incidence 15 – 20 % in 3 – 5 Yrs Incidence 15 – 20 % in 3 – 5 Yrs

SITE OF RECURRENCESITE OF RECURRENCESaphenous junction SFJ or SPJ – Major CauseSaphenous junction SFJ or SPJ – Major CausePerforating Veins in the thigh & CalfPerforating Veins in the thigh & CalfPreviously Unoperated Saphenous systemPreviously Unoperated Saphenous system

RECURRENT SFJ REFLUXRECURRENT SFJ REFLUXNeovascularisationNeovascularisationTechnical ErrorTechnical Error

CLINICAL EVALUATIONCLINICAL EVALUATIONEarly age at onset of original Varicose Vein Early age at onset of original Varicose Vein Family HistoryFamily HistoryRapid Recurrence Rapid Recurrence

All Suggest Strong Tendency for All Suggest Strong Tendency for recurrencerecurrence

Aching & Discomfort are less commonAching & Discomfort are less commonSkin Changes & ulceration respond poorly to Skin Changes & ulceration respond poorly to

SurgerySurgeryVaricography or Venography is required to Varicography or Venography is required to

clear venous anatomyclear venous anatomy

OPERATIVE STRATERGYOPERATIVE STRATERGYAim is to find common femoral vein above Aim is to find common femoral vein above

reconstituted junctionreconstituted junctionCommon femoral vein should be free of any Common femoral vein should be free of any

tributary including residual Saphenous Systemtributary including residual Saphenous SystemMeasures to prevent further recurrenceMeasures to prevent further recurrence

Pectineus Muscle Fascia FlapPectineus Muscle Fascia Flap

Prosthetic ( PTFE ) PatchProsthetic ( PTFE ) Patch

can be applied over Denuded CFVcan be applied over Denuded CFV

THANK YOUTHANK YOU