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MANAGEMENT OF VARICOSE VEINS MANAGEMENT OF VARICOSE VEINS
WHEN & HOWWHEN & HOW
BYDR.G.THULASIKUMAR
M.S.(Gen.Surg) M.Ch. (Vascular Surgery)Department of Vascular Surgery
Govt. Kilpauk Medical College HospitalChennai-10
Votive offerings such Votive offerings such as these were given to as these were given to physicians by grateful physicians by grateful
patients after patients after successful treatmentsuccessful treatment
Chronic venous diseaseChronic venous disease
Most common vascular disorder3 Billion US dollars spent a year for
treatment3 % of the total Heath care Budget2 million USA work days lost per year
DEFINITIONDEFINITION
A VEIN THAT BECOMES ELONGATED,
DILATED, TORTUOUS, POUCHES AND
THICKENED DUE TO DYSFUNCTIONING
VALVES CAUSING CONTINOUS
DILATATION UNDER PRESSURE .
DefinitionDefinition
Telangiectasias - are a confluence of dilated intradermal venules less than one millimeter in diameter.
Reticular veins - are dilated bluish subdermal veins, one to three millimeters in diameter. Usually tortuous.
Varicose veins - are subcutaneous dilated veins three millimeters or greater in size. They may involve the saphenous veins, saphenous tributaries, or nonsaphenous superficial leg veins.
Subcutaneous VeinsSubcutaneous Veins
When abnormal: - Telangiectasia
(spider – 1mm) - Reticular (1- 3
mm)
Varicose (>3mm)
Abnormal VeinsAbnormal Veins
Telangiectasias
Reticular veins
Varicose vein
INCIDENCEINCIDENCE
MEN : 10-15%WOMEN : 20-25%
WHEN NON SAPHENOUS VARICOSITIES ARE INCLUDED
MEN : 45% WOMEN : 50%
RISK FACTORS
FEMALE GENDER
ADVANCED AGE
CAUCASIAN RACE
FAMILY HISTORY
ACCELERATORS
PREGNANCY
OBESITY
VENOUS SYSTEM OF LOWER LIMBSVENOUS SYSTEM OF LOWER LIMBS
SUPERFICIAL VEINSDEEP VEINSPERFORATORS
SUPERFICIAL VEINSSUPERFICIAL VEINS
LONG SAPHENOUS SYSTEMSHORT SAPHENOUS SYSTEM
LONG SAPHENOUS SYSTEMLONG SAPHENOUS SYSTEM
FROM MEDIAL LIMB THE DORSAL ARCH TO SAPHENOUS OPENING – SAPHENO FEMORAL JUNCTION
SFJ TRIBUTARIES
SUPERFICIAL EPIGASTRIC VEINSUPERFICIAL EXTERNAL PUDENDAL VEINSUPERFICIAL LATERAL CIRCUMFLEXILIAC VEIN.
THIGH TRIBUTARIES
ANTEROLATERAL VEINPOSTEROMEDIAL VEIN
CALF TRIBUTARIES
ANTERIOR ARCH VEINPOSTERIOR ARCH VEIN
SHORT SAPHENOUS SYSTEM
SAPHENO POPLITEAL JUNCTION
BRANCHES
LATERL CALF VEIN
MEDIAL CALF VEIN
VEINS CONNECTING LSV & SSVLATERAL THIGH VEIN
INTER SAPHENOUS VEIN
ACCOMPANYING NERVESLSV – SAPENOUS NERVE
SSV – SURAL NERVE
PerforatorsPerforators
Connect deep and superficial systems
Flow normally from superficial to deep
PERFORATORSPERFORATORS
LSV PERFORATORSTHIGH –
DODD’S GROUPHUNTER’S PERFORATORDODD’S PERFORATING
VEINHACH PERFORATING VEIN
•USUALLY DOUBLE•1-2mm IN DIAMETER•UPWARD DIRECTION FROM THEIR SUP.VEIN
PERFORATORSPERFORATORS
BELOW KNEEBOYD’SSHERMAN’S - 24cmCOCKETT’S - III---18cm
II---12cm I--- 6cm
CALF PERFORATORSGASTROCNEMIUS (MAY’S)SOLEUS PERFORATORSBASSI’S VEIN- PERONEAL TO LSVFIBULAR
FOOT PERFORATORSKUSTER-------MARGINALBELOW MEDIAL + LATERALMALLEOLI
VALVESVALVES
PHYSIOLOGYPHYSIOLOGY
VIS A TERGO—LV CONTRACTION
VIS A FONTE---R A CONTRACTION
FOOT MUSCLE PUMPFOOT MUSCLE PUMP
DEEP PLANTAR ARCH
SUPERFICIAL DORSAL ARCH
BOW STRING EFFECT - FLATTENS BOTH ARCHES EMPTYING
VEINS PRESSURE > 100mg OF Hg CONTRIBUTES > 50% BLOOD LEAVING
CALF
Muscle Pump Muscle Pump CALF MUSCLE PUMP
– 200 – 300 mm OF Hg– >80 ml OF BLOOD
Contractions propel blood towards heart
Relaxation draws blood from
- superficial veins
- lower deep veins
Thoracoabdominal PumpThoracoabdominal Pump
Inspiration decreases intrathoracic pressure promoting venous return
Expiration reverses the process
Findings easily seen in US
REFILLING THE PUMPREFILLING THE PUMP
FROM ARTERIAL SYSTEM FROM SUPERFICIAL VENOUS SYSTEM
PRESSURE IN ERECT POSTURE >100mg OF Hg
INTRAVENOUS PRESSURE IN SUPINE POSTURE SELDOM < 5mm OF Hg
REFILLING TIME 20-30 S
AMBULATORY VENOUS PRESSUREAMBULATORY VENOUS PRESSURE
RESIDUAL VENOUS PRESSUREVIS –A-TERGO 0.3mm OF HgHYDROSTATIC PRESSURE 100mm
OF HgAVP (MINIMUM PRESSURE. SHOWN
DURING EXERCISE) – FALLS BY 60-80% IN FEW SECONDS.
IN CVI / CVHIN CVI / CVH
VALVULAR INCOMPETENCE
CONTINUED REFLUX
INCREASED AVP DURING EXERCISE DUE TO INCOMPLETE EMPTYING
DECREASED REFILLING TIME <10S
INDEPENDENT(PRIVATE) CIRCULATION – BLOOD IN THE DEEP SYSTEM
FLOWS UP IN THE DEEP SYSTEM
FLOWS DOWN IN THE SAPHENOUS SYSTEM
PATHOPHYSIOLOGY OF MICROCIRCULATION CHANGES IN PATHOPHYSIOLOGY OF MICROCIRCULATION CHANGES IN VENOUS HYPERTENSIONVENOUS HYPERTENSION
PRIMARY VARICOSE VEINS DEEP VENOUS INSUFFICIENCY
AMBULATORY VENOUS HYPERTENSION
VENULAR AND CAPILLARY DILATATIONDECREASED CAPILLARY PERFUSION PRESSUREINCREASED CAPILLARY PERMEABILITY
CHRONIC LYMPHATIC DAMAGE
DECREASED LYMPHATIC DRAINAGE
PATHOPHYSIOLOGY OF MICROCIRCULATION CHANGES IN PATHOPHYSIOLOGY OF MICROCIRCULATION CHANGES IN VENOUS HYPERTENSIONVENOUS HYPERTENSION
WBC TRAPPING, ADHESION, ACTIVATION
MACROMOLECULES ENTER CIRCULATION
IMPAIRED TISSUE PERFUSION AND OXYGENATION
VENOUS ULCERATION
DECREASED LYMPHATIC DRAINAGE
IMPEDANCE OF MICROCIRCULATORY FLOW PLUS RELEASE FREE RADICALS, PROTEOLYTIC ENZYMES, CYTOKINES AND CHEMOTACTIC AGENTS
PERICAPILLARY FIBRIN CUFF
CLINICAL EVALUATIONCLINICAL EVALUATION
ASYMPTOMATIC COSMETIC
SYMPTOMATIC– PAIN & SWELLING– COMPLICATION
SYMPTOMSSYMPTOMS PAIN
– THROBBING– ACHING– STINGING– BURNING– EXERCISE – VARIABLE EFFECT ON PAIN– NIGHT PAIN—CRAMPINESS
ITCHING SKIN CHANGES COMPLICATIONS EFFECTS OF PREVIOUS TREATMENTS.
ComplicationsComplications EXTREMELY PAINFUL
ULCERS - NEAR VARICOSE VEINS, PARTICULARLY NEAR THE ANKLES.
BROWNISH PIGMENTATION USUALLY PRECEDES THE DEVELOPMENT OF AN ULCER.
OCCASIONALLY, VEINS DEEP BECOME ENLARGED.
BLEEDING SUPERFICIAL
THROMBOPHLEBITIS
PERSONAL HISTORY
PREGNANCY MENSTURAL CYCLE PELVIC CONGESTION SYNDROMES
– (VULVOPUDENDAL VARICES ASSOCIATED WITH PELVIC & OVARIAN VARICES
PAST MEDICAL HISTORY
CONGESTIVE FAILURE RENAL & CIRCULATORY FAILURE AUTOIMMUNE DISEASES ALLERGIC HISTORY HOSPITALISATION AND IMMOBILISATION
STRONG FAMILIAL COMPONENT STRONG FAMILIAL COMPONENT
Not well studiedTwin studies 75% identical, 52% non
identicalIf both parents VVS - 90% of children VVsIf one parent was affected 25 percent for
men and 62 percent for women
Cornu-Thenard, A, Boivin, P, Baud, JM, et al. Importance of the familial factor in varicose disease. Clinical study of 134 families. J Dermatol Surg Oncol 1994; 20:318.
PHYSICAL EXAMINATIONSPHYSICAL EXAMINATIONS STANDING POSITION SKIN SHOULD BE INSPECTED,TAPPED,
TOUCHED, PRESSED & SQUEEZED
EVALUATION FOR:– COLOR– TEMPERATURE– TEXTURE– TURGOR– MOISTURE– HAIR QUALITY
SKIN CHANGESSKIN CHANGES
CORONAPHLEBECTATICA
VENOUS ECZEMA
BROWN HAEMOSIDERIN DEPOSITION
ACUTE/CHRONIC LIPODERMATO SCLEROSIS
INDURATION
ATROPHIC BLANCHE
OEDEMA
VENOUS ULCERATION
CONTRACTURES
MARJOLINS ULCER
VARICOSITIESVARICOSITIES
SPIDER NAEVI—TELENGIECTASIA
RETICULAR VEIN—VENULECTASIS
TRUNCAL VARICOSITIES
CLINICAL TESTSCLINICAL TESTS
TO KNOW
WHICH SYSTEM
WHICH PERFORATOR
PATENCY OF DEEP VEIN
TRENDELENBURG TEST I & IITRENDELENBURG TEST I & II
SCHWARTZ TEST (CRUVHEILLIER’S SIGN)SCHWARTZ TEST (CRUVHEILLIER’S SIGN)
MORISSEY’S COUGH IMPULSEMORISSEY’S COUGH IMPULSE
FEGAN’S METHOD. (PHALEN’S TEST)FEGAN’S METHOD. (PHALEN’S TEST)
PRATT’S TESTPRATT’S TEST
THREE TOURNIQUET TEST THREE TOURNIQUET TEST ((Mahorne-ochsner Mahorne-ochsner ))
PERTHE’S TESTPERTHE’S TEST
PHYSICAL EXAMINATIONPHYSICAL EXAMINATION
ABDOMINAL PELVIC EXAMINATION. AUSCULTATION.
CEAP CLASSIFICATIONCEAP CLASSIFICATION
CLINICALETIOLOGICANATOMICPATHOPHYSIOLOGIC
CLINICAL CLASSIFICATIONCLINICAL CLASSIFICATION
CO NO SIGN OF VENOUS DISEASE
C1 TELENGIECTASIA AND SPIDER VEINS
C2 VARICOSE VEINS
C3 EDEMA DUE TO VENOUS DISEASE
C4 SKIN CHANGES; LIPODERMATOSCLEROSIS
C5 HEALED ULCERS
C6 ACTIVE ULCERS
ETIOLOGICETIOLOGIC
CONGENITAL ECPRIMARY EPSECONDARY ES
POST THROMBOTIC POST TRAUMATIC OTHERS
ANATOMIC SEGMENTS 18ANATOMIC SEGMENTS 18
SUP VEINS As1. LSV2. ABOVE KNEE3. BELOW KNEE4. SSV5. NON
SAPHENOUS
DEEPVEIN Ad
6. IVC16. MUSCULAR
PERFORATING VEIN Ap17. THIGH18. CALF
PATHOPHYSIOLOGIC CLASSIFICATIONPATHOPHYSIOLOGIC CLASSIFICATION
REFLUX PrOBSTRUCTION PoREFLUX & OBSTRUCTION Pro
INVESTIGATIONSINVESTIGATIONSCONTINUOUS WAVE DOPPLERCONTINUOUS WAVE DOPPLER
TO ASSES FLOW DIRECTION
QUALITATIVE ASSESSMENT OF VENOUS
REFLUX
DOES NOT GIVE ANY ANATOMIC
INFORMATION.
USEFUL FOR EVALUATION OF REFLUX IN
SFJ & SPJ
DUPLEX SCANNINGDUPLEX SCANNING
84% SENSITIVITY
88% SPECIVICITY
DIRECT DETECTION OF VALVULAR REFLUX.
VISUALIZATION OF VALVE LEAFLET MOTION
QUANTIFY DEGREE OF INCOMPETENCE
Duplex UltrasonographyDuplex Ultrasonography Replaced
plethysmography and venography
- 7-10MHz linear transducer
- Exam sitting and standing
- Superficial and deep systems evaluated
- Physiologic reflux: < 0.5 sec
- Pathologic reflux: > 0.5 sec
PLETHYSMOGRAPHY
– VOLUME CHANGE OF LIMB
– SECONDARY TO CHANGES IN VENOUS
BLOOD FLOW
PRESSURE MEASUREMENTS
– TRANSMURAL PRESSURE
– AMBULATORY VENOUS PRESSURE
—43-year-old woman with varicose veins.
Lee W et al. AJR 2008;191:1186-1191
©2008 by American Roentgen Ray Society
—43-year-old woman with varicose veins.
Lee W et al. AJR 2008;191:1186-1191
©2008 by American Roentgen Ray Society
INVASIVE PROCEDURESINVASIVE PROCEDURES
1. ASCENDING PHLEBOGRAPHY
2. DESCENDING PHLEBOGRAPHY
3. CAVOGRAPHY
4. VARICOGRAPHY
ASCENDING PHLEBOGRAPHYASCENDING PHLEBOGRAPHY
GOLD STANDARD
ANATOMIC FEATURES OF THE VEINS
AND THEIR VALVES ARE OUTLINED
POST THROMBOTIC CHANGES
PERFORATORS – INCOMPLETLY
IDENTIFIED
DESCENDING PHLEBOGRAPHYDESCENDING PHLEBOGRAPHY
GRADE 0 NO EVIDENCE OF REFLUX
GRADE 1 MINIMAL REFLUX THRO 1 OR MORE
VALVE
GRADE 2 CONSIDERABLE REFLUX IN THE
THIGH
GRADE 3 GRADE 2 + LEAKAGE IN TO
POPLITEAL VEIN
GRADE 4 GRADE 3 + LEAKAGE IN TO CALF
VEIN.
VARICOSE VEINS MAYBE DUE TOVARICOSE VEINS MAYBE DUE TO
1) PRIMARY DISEASE OF LSV
2) 1 + PERFORATOR INCOMPETENCE
3) 2 + DEEP VEIN REFLUX DUE TO VALVULAR INCOMPETENCE
4) 2 + POSTTHROMBOTIC REFLUX OR OBSTRUCTION.
5) 4 + THROMBOTIC OCCLUSION OF ILIAC VEINS
TREATMENT OPTIONSTREATMENT OPTIONS
COMPRESSION THERAPY
PHARMACOTHERAPY
SCLEROTHERAPY
SURGICAL TREATMENT
SEPS (Subfascial Endoscopic Perforator Surgery)
LASER ABLATION
RADIOFREQUENCY ABLATION
COMPRESSION THERAPYCOMPRESSION THERAPY
ELASTIC COMPRESSION
- Bandage
- Stockings – Class II PASTE GAUZE (UNNA) BOOT CIRC AID ORTHOSIS INTERMITTENT PNEUMATIC
COMPRESSION
COMPRESSION THERAPYCOMPRESSION THERAPY Action
1. HEMODYNAMIC EFFECT
Increase venous blood flow Decrease venous blood volume Reduce reflux in diseased superficial and/or deep veins Reduce a pathologically elevated venous pressure
2. EFFECT ON TISSUE
Reduce an elevated water content of the tissue Increase the drainage of nocious substances Reduce inflammation Sustain reparative processes Improve movement of tendons and joints
ELASTOCREPE BANDAGEELASTOCREPE BANDAGE
GRADIENT COMPRESSION STOCKINGSGRADIENT COMPRESSION STOCKINGS Class I – 20–30(18-22) mmHg (Asymptomatic varicose)Class I – 20–30(18-22) mmHg (Asymptomatic varicose)
II – 30-40(23-32) mm Hg (Symptomatic varicose)II – 30-40(23-32) mm Hg (Symptomatic varicose)
III - 40–50(34-40) mm Hg ( For III - 40–50(34-40) mm Hg ( For
IV - 50 – 60 mm Hg Lymph Edema)IV - 50 – 60 mm Hg Lymph Edema)
INTERMITTENT PNEUMATIC COMPRESSIONINTERMITTENT PNEUMATIC COMPRESSION
NEW LEGGING ORTHOSIS (CIRC – AID)NEW LEGGING ORTHOSIS (CIRC – AID)
UNNA BOOTUNNA BOOT
PHARMACOLOGIC THERAPYPHARMACOLOGIC THERAPY
DIURETICS – limited use ZINC FIBRINOLYTIC AGENTS
STANOZOLOL – Androgenic steroid OXYPENTIPHYLLINE – Cytokine Antagonist
PHLEBOTROPHIC AGENTS– HYDROXY-RUTOSIDES
CALCIUM DOBESILATE TROXERUTIN
PHARMACOLOGIC THERAPYPHARMACOLOGIC THERAPY
HAEMORRHEOLOGIC AGENTS PENTOXIPHYLLINE ASPIRIN
FREE RADICAL SCAVENGERS TOPICAL ALLOPURINOL DIMETHYL SULFOXIDE
PROSTAGLANDINS PROSTAGLANDIN E PROSTAGLANDIN F
PHARMACOTHERAPYPHARMACOTHERAPY
TOPICAL THERAPIES– ANTIBIOTICS
Application counter-productive– IODOSORB– KETANSERINE– AMNION– OCCLUSIVE DRESSINGS
GROWTH FACTORS AND CYTOKINES SKIN SUBSTITUTES
– APLIGRAFT
SCLEROTHERAPYSCLEROTHERAPY
THE LOWEST APPROPRIATE CONCENTRATION AND VOLUME OF SOLUTION AT THE SLOWEST RATE AND LOWEST PRESSURE CAN MINIMISE COMPLICATIONS
SCLEROSANTSSCLEROSANTS
DETERGENT SOLUTIONS SODIUM TETRADECYL SULFATE POLIDACANOL SODIUM MORRHUATE ETHANOLAMINE OLEATE
OSMOTIC SOLUTIONS HYPERTONIC SALINE HYPERTONIC SALINE AND DEXTROSE SODIUM SALICYLATE
CHEMICAL IRRITANTS POLYIODINATED IODINE CHROMATED GYLCERINE
MicrosclerotherapyMicrosclerotherapy
30 g butterfly needle0.2% STSSeveral courses required
benefit compression
FOAM SCLEROTHERAPYFOAM SCLEROTHERAPY
TESSARI TECHNIQUE
1 PART (2ml) DETERRGENT & 4 PARTS AIR (8ml) AIR AGITTATED USING TWO 10 ml SYRIGES, CONNECTED BY A 2/3 WAY CONNECTOR
SURGICAL TREATMNETSURGICAL TREATMNET
GOAL: PERMANENT REMOVAL OF VARICOSITIES
WITH THE SOURCE OF VENOUS HYPERTENSION
AS COSMETIC A RESULT AS POSSIBLE MINIMUM NUMBER OF COMPLICATIONS
SAPHENOUS VEIN LIGATIONSAPHENOUS VEIN LIGATION
INCISION 1 CM ABOVE VISIBLE SKIN CREASE
TO DRAW EACH OF THE TRIBUTARIES INTO THE INCISION INORDER NOT TO LEAVE INTER ANASTOMOSING INGUINAL TRIBUTARIES BEHIND
TO AVOID EXTRAVASATION OF BLOOD SUBCUTANEOUSLY
TO INTRODUCE STRIPPER FROM ABOVE DAMAGED VALVES ALLOW PASSAGE
STAB AVULSION TO BE DONE BEFORE STRIPPING
SAPHENOUS VEIN LIGATION SAPHENOUS VEIN LIGATION – GROIN INCISION– GROIN INCISION
SAPHENOUS VEIN LIGATIONSAPHENOUS VEIN LIGATION
LSV
SHORT SAPHENOUS VEINSHORT SAPHENOUS VEIN
TO MARK TERMINATION IMMEDIATE PREOPERATIVELY
PRONE POSITION
POPLITEAL SPACE RELAXED BY KNEE FLEXION
SURAL N. IDENTIFIED AND PRESERVED
STRIPPING LIMITED TO PROXIMAL LESSER SAPHENOUS VEIN ABOVE MID-CALF
PERFORATOR VEIN INCOMPETENCEPERFORATOR VEIN INCOMPETENCE
LINTON’S RADICAL OPERATION SUBFASCIAL LIGATION– INCISION
– LONG MEDIAL
– ANTEROLATERAL
– POSTEROLATERAL CALF INCISIONS
COCKETT SUPRAFASCIAL LIGATION
DEPALMA– MULTIPLE PARALLEL BIPEDICLED FLAPS
– LIGATION OF VEINS ABOVE OR BELOW THE FASCIA
SEPS– SINGLE PORT TO VIEW AND WORK
– TWO PORTS – ONE TO VIEW; ANOTHER TO WORK
LINTON’S RADICAL OPERATION LINTON’S RADICAL OPERATION SUBFASCIAL LIGATIONSUBFASCIAL LIGATION
Sural N. Perforator V.
MODIFIED LINTON’S PROCDUREMODIFIED LINTON’S PROCDURE
TO AVULSE THE INCOMPETENT PERFORATORS UNDER DUPLEX GUIDANCE
SEPSSEPS
ABLATIVE PROCEDURESABLATIVE PROCEDURES
ENDO VENOUS THERMO ABLATION
- LASER
- RADIO - FREQUENCY
ENDOLUMINAL OBLITERATION BY HEAT - INDUCED COLLAGEN CONTRACTION & DENUDATION OF
ENDOTHELIUM - FIBROSIS
810 nm DIODE LASER ENERGYTUMUSCENT ANAESTHESIA
ADVANTAGENO GROIN DISSECTIONNO NEOVASCULARISATION
1470 nm DIODE LASER
ENDOVENOUS LASER SURGERY
EVLT – EEVLT – Endondovvenous enous LLaser aser TTreatmentreatment
RADIOFREQUENCY ABLATIONRADIOFREQUENCY ABLATION RADIOFREQUENCY INDUCED
THERMO THRAPY (RFiTT)
RADIOFREQUENCY ABVLATIONRADIOFREQUENCY ABVLATION
SEGMENTAL ABLATION
SURGERY FOR DEEP VEIN VALVE SURGERY FOR DEEP VEIN VALVE INCOMPETENCEINCOMPETENCE
VALVE RECONSTRUCTION INTERNAL VALVULOPLASTY EXTERNAL AND TRANSCOMMISURAL
VALVULOPLASTY ANGIOSCOPIC VALVULOPLASTY PROSTHETIC SLEEVE IN SITU
AXILLARY VEIN TRANSFER
SURGERY FOR CHRONIC VENOUS SURGERY FOR CHRONIC VENOUS HYPERTENSIONHYPERTENSION
SAPHENO POPLITEAL BYPASS MAY HUSNI OPERATION
CROSS PUBIC VENOUS BYPASS PALMA DALE PROCEDURE CONTRALATERAL SAPHENOUS VEIN IS USED
PROSTHETIC FEMOROCAVAL, ILIOCAVAL OR IVC BYPASS
ILIAC VEIN DECOMPRESSION
CAVOATRIAL BYPASS
ENDOVENOUSENDOVENOUS
ANGIOPLASTY AND STENTING OF STENOSED / OCCLUDED THROMBOSED ILIAC VEIN (MEY THURNER’S SYNDROME)
CORRECTION OF CONGENITAL WEBS