VARICOSE VEINS

Literature overview AMBREEN AMNA

BMS02100005

DEFINATION

• VARICOSE VEINS are dilated , usually tortuous subcutaneous veins greater than or equal to 3mm in diameter measured in upright position with demonstrable reflux.

Varicose veins

ANATOMY OF VENOUS SYSTEM OF LEGS

• The venous system of lower limb consists of 1) Superficial veins :- They are GREAT & SMALL saphenous

veins.2) Deep veins:- They include tibial venae comitantes,

popliteal & femoral veins.3 ) Perforators:- May , Cockett , Boyd , Dodd

SUPERFICIAL VEINS

PERFORATORS

DEEP VEINS

PATHOPHYSIOLOGY

• The venous pressure in a foot vein on standing is equivalent to the height of a column of blood extending from the heart to the foot e.g. approx 100 mmHg.

• To enable blood to be returned against gravity CALF MUSCLE PUMP(soleus muscle i.e. peripheral heart) is essential.

• During calf muscle contraction e.g. walking deep veins are compressed & they force blood into popliteal & crural veins

PATHOPHYSIOLOGY (Contd..)

• The VALVES only allow blood to pass in the direction of heart.

• Now, pressure rises to 200-300 mmHg during muscle contraction.

• During muscle relaxation the pressure falls.• Blood from the superficial veins pass into deep

veins through saphenous junction and the perforating veins.

PATHOPHYSIOLOGY

Varicose veins may develop due to 1) PRIMARY VALVE INCOMPETENCE :- congenital absence of venous valves congenital defect in venous valve due to dysfunctional smooth muscle cell proliferation,

collagen deposition, decreased elastin content & increased matrix metalloproteinase's.

2) SECONDARY VALVULAR INCOMPETENCE :- due to post thrombotic limb, and congenital anomalies

such as Klippel-Trenaunay syndrome, multiple AV fistulae

EPIDEMIOLOGY

The adult prevalence of visible varicose vein is 25-30 % in women & 15% in men.

RISK FACTORS :- 1) geographical : more common in

western population, may be diet related. 2) Gender :- Women > Men 3) Age :- Increase with age

EPIDEMIOLOGY (CONTD..)

4) Body mass & height :- Increase body mass index & height

increases prevalence of varicose veins. 5) Pregnancy :- Increase risk[ hormonal effect } 6 )Family history :- Positive family history

increases the risk 7) Occupation & Lifestyle factors :- Increase risk

in smokers, patients who suffer constipation & prolonged standing

CEAP CLASSIFICATION

CLINICAL FEAUTURES

• EARLY SYMPTOMS :- Aching & heaviness Ankle swelling Itching • LATE SYMPTOMS:- skin changes lipodermatosclerosis venous ulceration bleeding marjulin ulcer{ignored prolonged ven ulcer transforming

malignant changes ,,,,,SCC }

SIGNS • Tortuous dilated subcutaneous veins• Telengectasia • Reticular veins • Saphena-varix• Atrophic blanche• Corona phlebectasia • Pigmentation ; ulceration • Eczema ; Lipodermatosclerosis• Dependent pitting edema

CLINICAL EXAMINATION

• The patient should be standing , exposed from umbilicus to foot.

• Look for the extent and distribution of varicose vein.

• Long saphenous varicose veins• Antero-lateral tributary of Long saphenous vein• Short saphenous varicose vein• Communicating vein varicosity

LOOK FOR :-

• Swelling (localized or general? ) • Color changes• Pigmentation • Eczema • Scar marks • Ulceration• Hair distribution• Toe nails• Cough impulse for saphena-varix

PALPATION

• Temperature• Tenderness• Palpate along the distribution of long & short

saphenous veins• Morrissey's Cough impulse test• Brodie Trendelenburg test• Multiple Tourniquet test• Perth's test • Fagan's test

PALPATION (Contd..)

• Arterial pulsations of both legs• Nerves ( Dermatomal distribution ) of both

legs• Ankle jerks of both legs• Palpate the regional lymph nodes

PERCUSSION

• Schwarts test :- In long standing case if a tap is made on

the long saphenous varicose vein on the lower part of leg ,an impulse can be felt at the saphenous opening with the other hand

AUSCULTATION

• For AV fistulae where a continuous machinery murmur may be heard.

• Always examine both limbs.

GENERAL EXAMINATION

• Examination of abdomen is most important. • Sometime a pregnant uterus or intrapelvic

tumor, fibroid, ovarian cyst, cancer of cervix or rectum or abdominal lymph adenopathy may cause pressure on the external iliac vein and become responsible for secondary varicosities.

• Scrotal examination must be carried out to rule out varicocele.

INVESTIGATION

Gold standard investigation is DUPLEX ULTRASOUND IMAGING

INVESTIGATIONS ( CONTD…)

If duplex ultrasound scan1) is not available OR2) Is non diagnostic Then go for Doppler ultrasonography.

INVESTIGATION (Contd..)

3) VARICOGRAPHY :- It involves injection of contrast directly into

superficial varices which allows detailed mapping of the varices to their termination. This is helpful in patients with recurrent varicose veins or with complex anatomy

VARICOGRAPHY

INVESTIGATION (Contd..)

4 ) Venography :- Descending IV venography where contrast is

injected via the deep veins or magnetic resonance venography is useful when lower limb varicosities appear to arise from pelvic vein incompetence.

VENOGRAPHY

Management

• Reassurance for asymptomatic patients • Indication for referral to vascular surgeon

includes :-C2 disease associate with bleeding

superficial thrombophlebitis symptoms which are impairing quality of life C3 to C6 disease.

Conservative:

1)Change life style(diet) 2)change standing occupation if

possible 3)Decrease long standing hours. 4)Compression hosieries.5) Avoid smoking

COMPRESSION STOCKINGS

SURGICAL OPTIONS AVAILABLE

1 )MINIMAL INVASIVE SURGERY• Ultrasound guided foam sclerotherapy• Endovenous laser ablation• Radiofrequency ablation

ULTRASOUND GUIDED FOAM SCLEROTHERAPY

ULTRASOUNDED GUIDED FOAM SCLEROTHERAPY

Ultrasound guided foam sclerotherapynvolves the injection of detergent directly into superficial veins , most commonly used is SODIUM TETRA DECYL SULPHATE.

It destroy the lipid membrane of endothelial cells causing them to shed leading to thrombosis , fibrosis, and obliteration.

COMPLICATIONS OF UGFS

• Phlebitis• Pigmentation• Headache• Visual disturbance• Cough

ENDOVENOUS LASER ABLATION

RADIOFREQUENCY ABLATION

CONVENTIONAL SURGICAL PROCEDURES

• Saphenofemoral flush ligation and long saphenous stripping

• Saphenopopliteal junction ligation and lesser saphenous stripping

• Perforator ligation• phlebectomies

SAPHENOFEMORAL FLUSH LIGATION AND LONG SAPHENOUS STIPPING

SAPHENOPOPLETEAL JUNCTION LIGATION AND LESSER SAPHENOUS STIPPING

PERFORATOR LIGATION

PHLABECTOMIES

Complication of standard vericose surgery

• Recurrence• Wound infections• Nerve injury• Venous thromboembolic complications

RECUURENT VARICOSE VEINS

• Approximately 10-20% of patients who present to hospital with varicose veins have had previous interventions.

• Significant clinical recurrence 5-10 years following varicose veins surgery occurs in 10-35 % of patients but duplex detected recurrence is much more common being in the order of 70%

Recurrent varicose veins

Conventional surgery> minimal invasive surgeryShort sap v surgery > long saphenous vein surgeryIncreased BMIWHAT ARE THE CAUSES OF RECURRUNCENeorevascularizationReflux in residual axial veinNew reflux Inadequate initial surgeryThus endovenous intervention would seem to offer an

interactive alternative where feasible.