Varicose veins

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VARICOSE VEINS

• WANDWI- HKMU MD3 LECTURES 2021/22/23

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VARICOSE VEINS OUTLINE

• DEFINITION
• ANATOMY
• AETIOLOGY/RISK FACTORS
• PATHOPHYSIOLOGY
• COMPLICATIONS
• PRESENTATION
• DIAGNOSIS
• MANAGEMENT

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VARICOSE VEINS DEFINITION

• Dilated
• Tortuous saccular superficial veins
• D/T VENOUS HYPERTENSION
• Occur in 2 of the population (increasing
  incidence with age)

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VARICOSE VEINS - PHYSIOLOGY
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VARICOSE VEINS - PHYSIOLOGY

• Flow
• Distal to proximal and from superficial to deep
  VALVES prevent retrograde flow.
• Calf muscle pump - musculo-venous pumps
• Negative intrathoracic pressure
• Arterial pressure across the capillary increases
  the pumping action of vein

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VARICOSE VEINS - PHYSIOLOGY
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VARICOSE VEINS - ANATOMY

• Veins of the lower limbs are divided into 3
  groups-
• Superficial veins LSV SSV
• Communicating/ perforating veins
• Deep veins
• tibial/peroneal/popliteal/femoral/ iliac

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VARICOSE VEINS - ANATOMY
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VARICOSE VEINS - ANATOMY

• Superficial veins take blood from the surface
  to deep veins via perforating veins.
• LSV - Origin medial border of the foot
• - Tributaries of the dorsal venous arch

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VARICOSE VEINS - ANATOMY

• Superficial veins
• LSV - Ascends in front of the medial
  malleolus along the medial side of the leg.
• 1 to 1.5 inches anterior to the medial
• cf venous cut down

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VARICOSE VEINS - ANATOMY

• NOTE
• Below knee - saphenous nerve to LSV.
• Thigh medial femoral cutaneous nerve

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VARICOSE VEINS - ANATOMY

• Superficial veins
• LSV below knee
• joined by 2 branches anterior - (Stocking vein)
  and posterior arch branches- (Leonardo's vein)
• lies superficially in a posterior position. Just
  below knee

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VARICOSE VEINS - ANATOMY

• Superficial veins
• LSV.
• In the thigh LSV passes antero superiorly up the
  medial side of the thigh to reach the saphenous
  opening in deep fascia to join the femoral vein.

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VARICOSE VEINS - ANATOMY

• SFJ

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VARICOSE VEINS - ANATOMY
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VARICOSE VEINS - ANATOMY

• SSV
• -arises at the lateral border of the foot
• -passes upward behind the lateral malleolus
• -lies over the lat. the post of the leg
• - enters deep fascia in popliteal fossa joins
  the popliteal vein.

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VARICOSE VEINS - ANATOMY

• SSV
• -arises at the lateral border of the foot
• -passes upward behind the lateral malleolus
• -lies over the lat. the post of the leg
• - enters deep fascia in popliteal fossa joins
  the popliteal vein.

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VARICOSE VEINS - ANATOMY
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VARICOSE VEINS - ANATOMY

• PERFORATING VEINS-
• Connect sup. to deep veins
• - Valves
• - ankle perforators(may or Kuster)
• - lower leg perforators(1,2,3) Cockett
• - below knee perforator(Boyd)
• - mid-thigh perforators (Dodd)

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VARICOSE VEINS - ANATOMY

• PERFORATING VEINS-

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VARICOSE VEINS - ANATOMY
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VARICOSE VEINS - RISK FACTORS

• SEX FgtM
• GEOGRAPHY RACE--less common outside Western
  World
• AGE gt 40YRS
• HEREDITY-run in the family

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VARICOSE VEINS - RISK FACTORS

• PREGNANCY
• - More pregnancies are more likely to develop
  VV.
• -VV d/t pressure of the womb on the veins /vein
  walls relaxation by hormones
• OCCUPATION AND POSTURE- stand up at work
  particularly who stand still for long periods.

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VARICOSE VEINS - RISK FACTORS

• Standing for long time
• Positive family history.
• Pregnancy.
• Abdominal tumors.
• Use of OCP.
• Physical inactivity.
• Obesity.
• Increased age

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VARICOSE VEINS - RISK FACTORS
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VARICOSE VEINS - types

• Primary varicosity
• Congenital incompetence/absence of valves
• Weakness or wasting of muscles
• Stretching of deep fascia
• Klippel Trennuaney syndrome, familial

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VARICOSE VEINS - types

• Secondary varicosity
• Recurrent thromboplebitis
• Pregnancy
• Pelvic tumors
• OCPs

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VARICOSE VEINS - types

• Secondary varicosity
• Occupational
• Obstruction to VR eg abdominal tumors
• Retroperitoneal fibrosis
• AV malformation
• Iliac vein thrombosis

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VARICOSE VEINS - COMPLICATION

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VARICOSE VEINS -VENOUS ULCER Pathogenesis

• Two theories
• Fibrin cuff theory
• White cell trapping theory

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VARICOSE VEINS -Pathogenesis

• Inappropriate activation of trapped leucocytes
  release proteolytic enzymes which cause cell
  destruction and ulceration- white cell theory
• Fibrin deposition. Tissue death, and scaring
  occur together called as lipodermatosclerosis

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VARICOSE VEINS -Pathogenesis
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VARICOSE VEINS -PRESENTATION

• Symptoms
• Asymptomatic early disease
• Cosmetic
• Dull aching discomfort in lower extremities
• Exacerbated by standing and hot weather
• Itching and tingling
• Dry and hard skin
• Ulcers

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VARICOSE VEINS -DIAGNOSIS

• HISTORY
• PE
• INVESTIGATIONS
• DUPLEX U/S
• ARM-FOOT VENOUS PRESSURE
• VENOGRAPHY

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Diagnosis

• HISTORY risk factors/ onset progression
• P/E Determine whether likely to be primary or
  secondary (include full exam for potential
  secondary causes)
• Determine site of incompetence
• Skin changes
• Ulceration
• INV.
• Dupplex

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Diagnosis

• HISTORY
• Age
• Sex F.M 101
• Occupation
• common in standing long hours -bus conductors,
  nurses, doctors, surgeons, manual labourers,
  watchmen, athletes, traffic policemen,
• Occupation - may exacerbate the condition.

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VARICOSE VEINS -PRESENTATION

• Signs
• Dilation and tortuosity of superficial veins
• Pigmented skin at site of varicosity
• Ulceration
• Edema can be present

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VARICOSE VEINS -TESTS

• Brodie-Trendelenburg test-reveal site of
  incompetent valves
• -elevate leg to ensure venous emptying.
• -tourniquet placed on the thigh below the
  saphenofemoral junction to block the superficial
  veins.

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VARICOSE VEINS -TESTS

• Brodie-Trendelenburg test-reveal site of
  incompetent valves
• -elevate leg to ensure venous emptying.
• -tourniquet placed on the thigh below the
  saphenofemoral junction to block the superficial
  veins.

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• The patient stands and venous filling pattern is
  noted.
• Normal veins do not fill within 30s, and there
  is not rapid refilling with removal of
  tourniquet.
• If rapid refilling with removal of tourniquet
  occurs, suspect incompetent saphenous-vein
  valves.
• If veins rapidly refill prior to removal of
  tourniquet, suspect incompetent valves in
  perforator veins

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VARICOSE VEINS -TESTS
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TREATMENt

• Part One
• Get rid of the reflux
• Part Two
• Get rid of the varicose veins

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VARICOSE VEINS -TESTS
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TREATMENT

• Compression stockings
• Surgical, vein stripping
• Endoluminal
• Laser
• Radiofrequency ablation
• Sclerotherapy
• Ultrasound guided
• Catheter delivered

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Management -CONSERVATIVE

• Crepe bandage
• Unna boots
• Limb elevation
• Pneumatic compression method
• Medical
• Calcium dobesilate 500mg BD
• Diosmin 450mg BD

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Compression
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Management -INJECTION

• Indication of Sclerotherapy
• -Uncomplicated perforator incompetence
• -Smaller varices
• - Recurrent varices
• - Isolated varicosities

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Management -INJECTION

• Advantages
• - OPD procedure
• - No requirement of anesthesia
• Disadvantage
• Anaphylaxis,
• hyperpigmentation

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Management -INJECTION

• Contraindications of sclerotherapy
•  - SF incompetence
• DVT
• - Huge varicosities

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Management

• Conservative measures
• Compression stockings/ Sclerotherapy
• Endovenous laser therapy (EVLT)
• Edoluminal radiofrequency ablation (RFA)
• Foam injection
• Surgery

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Vein Stripping

• Typically requires general anesthesia
• Two incisions are need
• Can be painful post-operatively
• Requires 4-7 days off work

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SURGERY
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