MBBS IV WCS 001 – Varicose Veins
Varicose veins
Anatomy
o Superficial venous system
o Deep venous system
o Separated by deep fascia, perforating venous system (communicating vein)
o Blood flows from 1. superficial to deep veins; and 2. bottom to the top
o Veins have thin walls – not supposed to stand high pressure
Long saphenous system
o Medial side empties into deep veins (femoral vein) in saphenous opening
(2cm lateral below pubic tubercle)
o Superficial veins: often examine long saphenous system
o Anterior to medial malleolus (if need emergency access)
Short saphenous system
o Lateral side behind calve popliteal vein in knee joint area (less constant
junction; rarely examined on pathology in short saphenous vein)
Sapheno-femoral junction
o Many branches of superficial vein (from near sapheno-femoral junction)
need to ablade deep vein as close as possible cannot regurgitate as easy
Perforating and communicating veins
o Traverse the deep fascia
o Converge at locations in the lower limb
Lower, middle, upper calf, knee, mid thigh perforators
o Connected to a branch axial vein (instead of axial vein itself) should ablade
the axial vein when surgery
MBBS IV WCS 001 – Varicose Veins
2 main pathologies
1. Incompetence: valves not functioning well (chronic venous insufficiency)
2. Obstruction: clots inflammation blockage of flow (thrombosis)
1. Chronic venous insufficiency (valvular malfunction – incompetence)
Mildest: varicose veins severe: reflux, ulceration
2 common presentations of chronic venous insufficiency (in wards, exams)
o 1. Varicose veins (clinical description of chronic venous insufficiency)
Dilated veins
Reflux
Thin walls cannot withstand pressure dilated, expanded veins
o 2. Leg swelling, chronic non-healing leg ulcers
Pathophysiology – subjected to higher venous pressure
o Competent valves
Stand erect, free the upper limbs
Venous blood under low pressure – column of blood (weight of blood)
exerted to the lowest part of the leg
Return to the heart rely on muscles in the lower limb using the
calf muscles to pump the blood back to the heart
Relax muscle blood drawn from superficial to knee veins
Valves in all 3 systems
o Incompetent valves
Causes: damaged, relaxed (pregnancy: hormones), congenital
Leaky valves
When muscles contract blood pumped upwards and downwards
(valves cannot prevent backward flow of blood)
Pumped back into superficial system as well (higher pressure)
MBBS IV WCS 001 – Varicose Veins
o Pressure chart: normal
Blood pull to catheter stop at level to the heart (weight of the blood)
compared to weight of manometer
Venous pressure in lowest part of leg (when static)
When walking blood is pumped back towards the heart venous
pressure at the lowest part will be reduced thus, have a lower
pressure during exercise rest (blood pressure come back)
o Pressure chart: superficial reflux - valve incompetence
Pressure will drop, but some blood reflux back into the distal limbs
not drop as low ambulatory venous hypertension (in the “varicose
veins” line) (elevated venous pressure when walking)
Elevation of pressure symptoms (aching, pain)
High venous reflux overloads lymphatic system (cannot absorb the
insterstitial fluid)
Results in a spectrum of clinical disease
1. Swelling
2. RBC come out stay in tissue die (hemoglobin stays in
tissues) = hemosiderin brownish pigmentation in lowest
part of the leg
3. Proteins in blood diffuse out (do not return) white cells
activated chronic inflammation thickened skin (itchy)
protein form a layer of cuff around the capillaries
4. Ulcers (due to protein layer covering the capillaries)
Clinical symptoms
o 1. Disfigurement
o 2. Swelling and ache (venous pressure)
o 3. Complications: bleeding, thrombosis (if close to the surface)
Etiology (insufficiency/incompetence of valves)
o Primary (unknown cause)
Congenital
Posture (e.g. surgeons, teachers)
o Secondary (previous episode of DVT valves damaged removal of clots
attacking the clot AND valves)
Post-thrombotic (after recanalization no longer valves pressure
transmitted to superficial veins)
MBBS IV WCS 001 – Varicose Veins
Anatomical locations
o Sapheno-femoral incompetence (2cm lateral, below pubic tubercle)
Commonly for primary etiologies
First valve that goes
o System (can be a combination of all three)
Superficial system
Deep system
Perforators
Classification (CEAP):
o Clinical: 1-6 (C1: best prognosis; C6: worst prognosis)
o Etiology: congenital, primary, secondary
o Anatomy: superficial, perforator, deep
o Pathophysiology: due to reflux, obstruction (chronic venous obstruction can
produce exactly the same symptoms), both
Physical examination: Tourniquet examination
o Varicose veins greater saphenous veins reflux
o Lie patient down tie below sapheno-junction
o Stand up check if reflux is present (reflux +ve if can be controlled by
tourniquet can pinpoint the level of reflux)
Investigations
o Ultrasound
Reflux in axial system (greater saphenous vein) large incompetent
communication (causing reflux from deep to superficial)
Check the sapheno-femoral junction
Use of Duplex scan (to see the flow)
Incompetence: upward and downward flow (both directions of flow)
done any segment = directional reflux in system (axial vein) and
perforating vein
MBBS IV WCS 001 – Varicose Veins
Treatment
o Conservative treatment of varicose veins
*Principle: reduce venous pressure (if do not get up, do not get varicose viens)
1. Elevation (above heart level)
2. Postural adjustments
3. Graduated compression stockings (woven tighter; lower = tighter
at ankle; lesser and lesser creates a pressure gradient)
o Surgery: varicose treatment
*Ligate incompetent perforators (for cosmetics, symptoms, complications)
*Not absolutely indicated since not life threatening until complications
i. Interrupt the perforators (source of reflux) – main source is at the
sapheno-femoral junction ligate the incompetent junction (destroy)
Sapheno-femoral flush/high ligation (2cm incision in
saphenous opening; at 2cm below, lateral pubic tubercle: find
common femoral vein and saphenous vein find the junction
put arteries into it – flow cut saphenous vein NOT the
deep vein (as close to junction to destroy all the tributaries)
ii. Remove diseased veins (avoid blood getting in) recurrent
symptoms
Stripping of veins of incompetent LSV
o Removal of vein
o Smaller cuts below tie pull the vein up from under
the skin at the top (connect the two ends via stripper)
Stab avulsion of branches (remove tributaries that cannot be
stripped)
Interruption of perforating veins (identify via ultrasound)
o Minimally invasive surgery
i. Thermal: laser (EVLT endovenous laser treatment EVLT, cheaper)
or radiofrequency (Venefit)
More painful (need to reduce pain)
Put catheter in the great saphenous vein (2cm behind sapheno-
venous junction) inject saline to elevate the skin
Connect catheter to machine energy transmitted closure
ii. Non-thermal: mechanical chemical ablation or glue (inject
into veins glue the veins short)
Not painful (but there is higher risk of recurrence)
o Sclerotherapy agents (an adjunct) (for cosmetic treatment, primary – destroy
junction and remove axial vein)
MBBS IV WCS 001 – Varicose Veins
Indication: Reticular varicosis (network of veins in subcutaneous layer)
Detergent (for esophageal varices as well) destroy protein structure
using small needle fill vein using sclerotherapy (protein in
endothelium will denature)
o External laser (cosmetic purposes)
Telangiectasa (intra-dermal): capillaries difficult to inject
Severe chronic venous insufficiency (class 5 and 6)
o Other names
Post-thrombotic/post phlebitis syndrome (thought it is a result of DVT)
Chronic venous stasis
Chronic venous hypertension
o Clinical features of severe chronic venous insufficiency
1. Pigmentation
2. Edema
3. Eczema
4. Ulcers (usually inside of the leg; medial side of the foot; where the
perforators are skin are subjected to the highest level of pressure)
Not extremely painful (arterial ischemia to nerve = painful)
But ulcer is not painful, blood supply is good (unless infected)
But very chronic ulcers pigmentation and skin changes
o Pressure chart: post-phlebitic (whether walk or stand venous pressure is still
high) consistently high venous pressure (top line)
o Differential diagnosis of leg ulcers
Arterial
Signs (loss of pulse, skin changes, gangrene)
Painful (affecting the nerves)
Pressure areas
Venous
Signs of CVI (varicose veins), pigmentation, skin changes,
healing evidence (if remove pressure)
Good pulse
Less painful
Site (medial side of leg)
Neurogenic (leprosy, diabetes)
Painless
Neuropathy
MBBS IV WCS 001 – Varicose Veins
Malignant
Squamous cancer (malignancy in skin)
o Irregular
o Raised edges
o Biopsy at the edge of the ulcer (not in the centre – dead tissue)
o Groin LNs (enlarged)
o Evidence of spread from the lymphatics
Marjoin’s ulcer (chronic irritation grow into malignant ulcer)
o Due to previous chronic venous ulcer
Infection
Chronic osteomyelitis (tuberculosis)
Syphilis
Trauma
o Treatment of severe venous ulcers
1. Reduce venous pressure
Bed rest: elevation of the leg
2. Treat ulcer
Compression therapy (wound nurse)
Reduce infection
3. Topical ulcer treatment
Skin graft (for healing)
4. Venous surgery
Adjunct: identify superficial vein (can treat superficial vein)
Superficial reflux can overload the deep veins dilated deep
veins secondary reflux of the deep veins (to help with the
deep vein reflux)
5. Venous reconstruction
Treat deep reflux (rarely done)
2. Deep vein thrombosis (obstruction)
Virchow’s triad (remember)
o 1. Stasis (blood is not moving)
o 2. Trauma (injury to vein)
o 3. Coagulability (clotting causes)
o Inflammation pain, swelling, signs of inflammation (redness, warmth)
Clinical features (suspect when having leg swelling, acute, pain, warmth)
o Silent (phlebothrombosis)
o Thrombophlebitis
1. Swelling
2. Tender
3. Warmth
4. Redness
Homan’s sign (dorsiflex ankle joint, pain in the calf stretch vein)
o Venous gangrene (poor blockage)
Venous congestion, pressure cut off the capillary supply
o Note: Left common iliac vein crossed over by common iliac artery thus left
side is more common
Investigations
o Ultrasound (venous Duplex) (gold standard)
MBBS IV WCS 001 – Varicose Veins
Filling defect without blood flow (no phasic flow after taking deep
breathe since flow is sluggish)
Squeeze the leg (press down with ultrasound probe, can compress the
vein and not the artery) = artery is on the medial side
Deep vein with clots filling defect in deep veins
o Venogram (not done commonly – injection in the vein, cutoff in the vein)
Complications
o 1. Pulmonary embolism
Occurs when there is major deep vein thrombosis (ileo-femoral DVT)
Not everyone with DVT has PE, and not always die from PE either
o 2. Chronic venous insufficiency
Varicose veins, ulcers
o 3. Chronic venous obstruction
Veins are not re-canalized (not resolved) block flow)
o 4. Venous hypertension (due to chronic venous insufficiency and obstruction)
Treatment of DVT
o 1. Prevent pulmonary embolism (propagation of clot)
o 2. Relieve acute symptoms
Conservative
i. Bed rest
ii. Elevation
iii. Anti-coagulation (blood does not clot)
o Heparin 5 days followed by oral anticoagulants, or
o SC heparin/LMWH x 3 months
o reduce risk of fatal PE to 0.3-0.4%
Aggressive therapy
Catheter directed thrombolysis (early): protect valve
reduce the chance of chronic venous sequelae/venous gangrene
Venous thrombectomy (using stent): squeeze out clot
o 3. Prevent recurrent DVT (prophylaxis)
Indications: can be high risk
Stasis: physical means/physical movement
Posture
Stocking
Intermittent compression (keep pressure going)
Trauma:
Avoid (and better surgery)
Coagulability: chemical agents
Low dose heparin BEFORE operation (subcutaneous)
o 4. Prevent post-thrombotic sequelae
IVC Filter
Indications
o Recurrent pulmonary embolism despite adequate
anticoagulation
o Cannot give anticoagulation
Trap the clots prevent going to the heart
