Date post: | 10-Feb-2017 |
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Health & Medicine |
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DEFINITION
Varicose veins are defined as dilated, tortuous, subcutaneous veins >3 mm in diameter
measured in the upright position with demonstrable reflux.
Perforators
• Hunterian’s perforator • Dodd’s perforator • Boyd’s perforator• Cockett’s perforator - 3 groups
PHYSIOLOGY• Arterial blood reaches the leg by pumping of heart • Venous return to heart occurs with the help of MAINLY by 1. calf muscles hence it is called peripheral heart 2. valves are present in the veins, it prevents the
back flow
PATHOGENESIS• When there is failure of normal unidirectional flow
in the leg veins , there is decreased venous return , it is called CHRONIC VENOUS INSUFFICIENCY (CVI).
• CVI can lead to stasis of blood in leg veins leading to AMBULATORY VENOUS HYPERTENSION .
• Due to venous hypertension , superficial veins may get dilated and tortuous , hence called VARICOSE VEIN.
CAUSES
• Congenital – absence of valves• Primary varicose veins • Secondary veins 1. Post thrombotic2. Pregnancy 3. Abdominal mass 4. Iliac vein thrombosis5. AV Fistula
SYMPTOMS
• Aching pain increases on prolonged standing
relieves on limb elevation• Ankle swelling • Pigmentation • Itching • Eczema • Ulceration - medial and lateral aspect of lower leg
“ GAITER AREA “
Hemoglobin
Hemosiderin biliverdin
2 hypothesis regarding venous ulcer : Fibrin Cuff Theory : due to raised capillary
pressure , there is leakage of plasma fibrinogen and form a cuff around the capillary thus reducing perfusion leading to venous ulcer .
White Blood Cell trapping theory : due to venous
stasis , WBC may get attached to the endothelial cell of capillaries and may extravasate into extracellular space , this is followed by release of proteolytic enzymes and damage of the cells leading to ulcer
CLINICAL EXAMINATION INSPECTION• TELANGECTASIA – DILATED INTRADERMAL VENULES < 1
mm DIAMETER• RETICULAR VEINS – DILATED SUBDERMAL VEINS 1-3
mm DIAMETER• PITTING ODEMA• ATROPHIC BLANCHE – WHITE ATROPHIC SKIN
SURROUNDED BY DILATED CAPILLARIES • CORONA PHLEBECTASIA \ ANKLE FLARE• LIPODEMATOSCLEROSIS – INVERTED WINE BOTTLE
APPEARANCE
• PIGMENTATION – HEMOSIDERIN DEPOSITION • ECZEMA• MORRISEY TEST • ULCERATION
Margin – thin and bluish showing growth of epithelium
Edge – sloping Floor – granulation tissue and
slough Base – fixed to deeper
structures
PALPATION
• TEMPERATURE • FEGAN METHOD• CRUVEILHIER’S SIGN• SCHWARTZ TEST • BRODIE TRENDLENBURG TEST – 2 METHODS 1ST – SAPHENO FEMORAL INCOMEPETENCE
2ND – PERFORATING VEIN INCOMPETENCE
• ANATOMY • PHYSIOLOGY• CAUSES• PATHOGENESIS• SYMPTOMS • CLINICAL EXAMINIATION• INVESTIGATION • TREATMENT
• ANATOMY • PHYSIOLOGY• CAUSES• PATHOGENESIS• SYMPTOMS • CLINICAL EXAMINIATION• INVESTIGATION • TREATMENT
COMPRESSION HOISERY
class 1 – 14 – 17 mmHg class 2 – 18 – 24 mmHg {varicose vein} class 3 – 25 – 35 mmHg
ULTRASOUND GUIDED FOAM SCLEROTHERAPHY
• SODIUM TETRADECYL SULPHATE IS INJECTED INTO THE VEIN.
• IT DESTROYS THE ENDOTHELIAL CELL , HEALING OCCURS BY FIBROSIS AND BLOOD VESSEL GETS OBLITRATED.
RADIOFREQUENCY ABLATION
• Similar like endovenous laser ablation • But bipolar catheter is used to heat
SURGERY
TRENDLENBURG OPERATION :FOR SAPHENOFEMORAL INCOMPETENCY
PERFORATOR LIGATION AND SEPS(SUBFASCIAL ENDOSCOPIC PERFORATOR LIGATION SURGERY) :FOR PERFORATOR INCOMPETENCY
STEP 4
• INCISION OBLIQUE INCISION
INCISION IS MADE 4 CM BELOW AND LATERAL TO PUBIC TUBERCLE OVER THE SAPHENOFEMORAL JUNCTION
STEP 6
• TRIBUTARIES ARE IDENTIFIED AND LIGATED AND CUT.
• FLUSH LIGATION IS DONE • IT IS LIGATION OF LONG SAPHENOUS VEIN
NEAR ITS TERMINATION .• AND IT IS CUT
INDICATIONS OF PERFORATOR INCOMPETENCY
• PERFORATOR LIGATION -USING FEGANS METHOD .
THE PITS ARE FOUND IN THE DEEP FASCIA INCISION IS MADE OVER IT PERFORATOR IS IDENTIFIED AND LIGATED• SUBFASCIAL ENDOSCOPIC PERFORATOR
LIGATION SURGERY IN THIS METHOD AIR IS INFLATED DEEP TO DEEP
FASCIA
• ANATOMY • PHYSIOLOGY• CAUSES• PATHOGENESIS• SYMPTOMS • CLINICAL EXAMINIATION• INVESTIGATION • TREATMENT