VENOUS DISEASES

Fahad H. Al-Hulaibi 208004222

Ahmed K. Al Khalifah 208028652

General Surgery Course2012

Kingdom of Saudi Arabia

Ministry of Higher Education

King Faisal University

College of Medicine

objectives

Anatomy of the lower limb veins. Physiology of venous flow and its

alterations. Varicose veins definitions and

classifications. Clinical presentation of varicose vein. Diagnosis of varicose vein. Complications/venous ulcer. management

Anatomy of the lower limb veins

Deep veins:

within the muscle tissue and usually are paired with an artery

Anterior & posterior tibial & peroneal

Polpiteal vains

Femoral vains

external iliac vain.

Superfacial vains:- Above muscle fascia of the limb.- Greater saphinous Join to femoral vain.- Lesser saphinous varible site on

popliteal fossa.

Perforating “communicating”:- - in the calf & thigh.

Physiology of venous flow and its alterations

The venous system must move blood against the force of gravity in the standing position .

The pressure at the venular end of capillary is 12mmHg.

Continue to fall till it reach Rt. Atrium. Calf muscle pump +/- foot & thigh pump.

During contraction :

The veins which has valves pump the blood to the heart.

During relaxation:

The pressure fall and the blood from superficial veins enter to

the deep veins.

The pump mechanism mainly results from a combination of different forces:

1. Calf muscle pump .2. anti-reflux valves and the

resistance of the vein walls.3. The beating of the heart

and the negative pressure . 

VARICOSE VEINS

DEFINITION

Tortuous dilated veins.

Defective connective tissue and smooth muscle in the vain wall.

Valve not working. Gathering of blood

within veins.

CLASSIFICATION

(CEAP) classification from the American Venous Forum, last revised 2004.

Clinical• C0 - No visible or palpable signs of venous disease

• C1 - Telangiectases or reticular veins

• C2 - Varicose veins

• C3 - Edema• C4a - Pigmentation or eczema

• C4b - Lipodermatosclerosis or atrophie blanche

• C5 - Healed venous ulcer

• C6 - Active venous ulcer

Etiologic

• Ec – Congenital

• Ep – Primary

• Es - Secondary (post-thrombotic)

• En - No venous cause identified

Anatomic• As - Superficial veins

• Ap - Perforator veins

• Ad - Deep veins

• An - No venous location identified

Pathophysiologic 

• Pr – Reflux

• Po – Obstruction

• Pr,o – Reflux and obstruction

• Pn - No venous pathophysiology identifiable

EXAMPLE : C6, Ep, As,p,d, Pr

CAUSES

Primary:- Familial (weakness of vain wall).- Congenital absence of valve (rare). Secondary:- Obstruction of venous flow. Obesity, pelvic cancer,

ascites.

- Valve destruction. DVT

- Increase flow & pressure by arteno-venous fistula.- Occupational and prolong standing.- Lower leg fracture calf vain thrombosis

CLINICAL FEATURES

Many patient are asymptomatic.

Most common complain is :

Aching in the veins after prolong standing.

Other symptoms:

Ankle swelling, itching, bleeding, superfacial thrombophlebitis, eczema lipodermatosclerosis and ulceration.

Common site:

- In greater and lesser saphenous veins.

DIAGNOSIS

History. Clinical examination.

Tourniquet test. Doppler flow detector test. biphasic signal

Duplex US.

TOURNIQUET TEST

Varicography.

Venography

With tourniquet to direct contrast injection

In present of post-thrombotic changes

COMPLICATIONS

BleedingVaricose veins near the surface of your skin

can sometimes bleed if you cut or bump your leg.

Varicose veins bleed more than healthy veins because of abnormally high pressure within the damaged veins.

Thrombophlebitis

Chronic venous insufficiency- Varicose eczema “stasis dermatitis”- Lipodermatosclerosis- Venous ulcers

VENOUS ULCER

The edema is insidious, often beginning in the foot and ankle, worsening with activity and resolving with or elevation bedrest.

Patients often describe the pain as an aching heaviness.

Clinical features

Ischemic ulcer Venous ulcer

Gender Men > women Women > men

Age Usually presents > 60 years Typically develops 40-60 years

Risk factors

Smoking, diabetes, hyperlipidemia and

hypertension

Previous DVT, thrombophilia, varicose vein

Symptoms

Severe pain unless there is diabetic neuropathy

Pain but not severe, relieved by elevation

Site Pressure area (heel, metatarsal head and base)

Medial and lateral malleoli

Edge Regular, punched out Irregular, with neo-epithelium

Base Deep, green (sloughy) or black (necrotic) with no granulation tissue, may involve tendon,

bone and joint

Pink and granulating

Surrounding skin

Shows signs of ischemia (cold, pale, atrophic….)

Varicose eczema, indurations, pigmentation, redness.

Veins Empty Full, usually varicosed

Swelling Usually absent Often present

TREATMENT

Patient without symptoms or signs of lipodermatsclerosis or ulceration, simply reassurance.

Elastic compression stockings

Work up:

1. Injection sclerotherapy.

2. US guided foam sclerotherapy

3. surgery.

Inject directly to the superfacial vein the 3% sodium tetradecyle sulphate. And

compression are applied. It destroy the lipid membrane of

endothelial cells causing them to shed, leading to thrombosis, fibrosis and obliteration ( sclerosis ).

It is not suitable for major saphinous incompetence.

1. Injection sclerotherapy.

2. US guided foam sclerotherapy

A. saphino-femoral junction ligation & greater saphenous stripping.

B. saphino-popliteal junction ligation & lesser saphenous stripping.

3. surgery.

A. saphino-femoral junction ligation & greater saphenous stripping.

B. saphino-popliteal junction ligation & lesser saphenous stripping.

risk of injury to the popliteal vein and peroneal nerve

New techniques:Radiofrequency ablationThermal energy is delivered

directly to the vessel wall Destroy the endothelial lining.

Endovenous laser ablasion

A laser fiber produces endoluminal heat that destroys the vascular endothelium Collapse.

At entire course of vessels.

COMPLICATIONS OF SURGERY Bruising. Sensory Nerve Injury Deep vain thrombosis (rare). If so, give

LMW Heparin Most common is Recurrence .

References

Varicose Vein Surgery Workup Medscape Link: http://emedicine.medscape.com/article/462579-workup#showall

http://www.urgo.co.uk.