MANAGEMENT OF VARICOSE VEINS

-- recent concepts

-- Dr. Deepak Aravind

MS Gen Surg PG
16 th june, 2006
VARICOSE VEINS

refers to any dilated, tortuous, elongated vein of

any caliber

‘telengiectasias’– intradermal varicosities,0.5-1mm

diameter
-- cosmetically unappealing
-- thread veins or dermal flare

‘Reticular veins’– 1-3mm, S/C dilated veins

-- enter tributr. of trunk /axial veins
TELENGIECTASIA
SPIDER VEINS , RETICULAR VEINS
CEAP Classification of Lower Extremity Venous Disease

C linical signs (GR 0-6), A/B for asymt /symtm.

Class 0 – no visible/palpable signs of ven. Dis.
Class 1 – telengiect.,retic. veins,malleolar flare
Class 2– varicose veins
Class 3 – oedema without skin changes
Class 4 – skin changes (pigmn,ven. Eczema,lipodermatoscl. )
Class 5 – skin changes + healed ulceration
Class 6 – skin changes + active ulceration
E tiologic classification( Ec , Ep ,Es )
Ec --- cause present since birth(congenital )
Ep --- of undetermined cause(primary)
Es --- with an assoc known cause(secondary)
A natomic classification (As , Ad , Ap )
As -- superficial
Ad -- deep
Ap -- perforators
P athophysiologic classification ( Pr /Po/Pr,o )
Pr -- s/s result from reflux
Po -- obstruction
Pr,o -- both
PATHOPHYSIOLOGY

Ambulatory venous pressure >>>> Ambulatory venous HYPERTENSION

--- calf pump > one way valves >high pressures in calf compartment during
exercise
>> muscle relaxation phase > blood flow thru perforators into deep v >>
dramatic drop in superficial venous pressure(from 80-100mm Hg to 20mm Hg)

VALVULAR INCOMPETENCE >> failure of superfc ven pressure from

falling during exercise >> amb. Ven. HTN >> the main cause of varicose
eczema,
skin damage & LEG ULCERATION

2 sources of ven. Hypertension (1) Gravitational (hydrostatic pressure )

(2) Dynamic (force of muscle contraction )

Characteristics of the vein wall

--- increased collagen & decreased elastin ( Gandhi et al, J Vasc Surg 1993)
Anatomical differnce in location of superfic. Veins of LL

--Main saphn. Trunk not always involvd> has well developed medial fibromuscular layer
& supported by fibrous connective tissue
-- tributaries less supported in S/C fat & are superfc. To membrn ly, also less muscle mass in
their walls

Hormonal Influence
-- undoubted influence
-- progesterone > smooth muscle relaxation>passive venous dilatation >
valvular dysfunction
-- Oestrogen also relaxtn of smooth muscle & softening of collagen
fibres
-- influence by oestrgn/progestr ratio>predomin sympts on 1 st day of perods

Changes at cellular levels

-- capill prolifer > extensive capill permiability> trans capill leakage of fibrinogen etc
>extravasc fibrin prevents normal exchange of oxygen & nutrients
DIAGNOSTIC EVALUATION

 MI : thorough full history & physical examination

 h/o any injury to leg or swelling ?DVT
h/o tiredness,aching,tingling,itching,restless legs & ankle swelling worse by end of
day
h/o any skin changes
 O/E: with pt standing> reveal extend, LSV or SSV

 further inform. to determine source :BRODIE TRENDLENBERG TEST

* 4 Possible results of this test & their significance

 Examin : for skin changes/ulceration;

: peripheral pulses
: of abdomen

 Other tests for DVT and Perforators largely replaced by

Handheld DOPPLER USS study
HAND HELD DOPPLER US
DOPPLER STUDY ( Christian Johann Doppler,1803-1853 )
-- now the minimum level of investigation required before treating a patient

-- doppler flow probe (5-7.5MHz) to determine the patency of veins

to exclude arterial disease
-- bidirectional probe to detect venous reflux

-- carried out with patient standing > 1 st placed over SFJ > Assess venous flow thru
common femoral vein > squeezes the calf gently > heard as ‘Whoosh’
>calf compression released and any reverse flow in veins sought

-- when the source of recurrent varices or a leg ulcer is sought

DUPLEX USG is more reliable

-- DUPLEX US involves use of High Resolution B-mode US imaging

& Doppler US
-- To obtain images of veins & simultaneously measure flow in these vessels

-- provides FUNCTIONAL as well as ANATOMICAL information

-- in pts with suspected DVT the presence of thrombus can be seen

DUPLEX IMAGE SHOWING REFLUX(RED)
 PLETHYSMOGRAPHIC STUDIES

-- used to evaluate venous system physiology

-- used to quantify the impairment of venous function caused

by obstructed or incompetent valves

-- air displacement plethysmograph re-introduced to assess

physiologic function of muscle pump & venous valves using
computer technology

-- photoplethysmography,photorheograph etc no longer in

common use
VENOGRAPHY ( PHLEBOGRAPHY )

-- The radiography equivalent of DUPLEX USG

-- provides excellent anatomical information but gives much less information about the
veins when the valves have failed

-- useful in a suspected DVT when USG not available

-- Ascending Phlebography defines obstruction

--Descending Phlebography identifies specific valvular incompetence

suspected on B-mode US & clinical examn.

-- unnecessary in primary varicose veins

-- specific utility in complex problems of severe CVI

TREATMENT OF VARICOSE VEINS

REASSURANCE

ELASTIC COMPRESSION STOCKINGS

INJECTION SCLEROTHERAPY

SURGICAL TREATMENT

INDICATIONS FOR TREATMENT ARE

pain
easy fatigueability
heaviness
recurrent superfic thrombophlebitis
external bleeding
cosmetic indications
NON OPERATIVE TREATMENT

Cornerstone of therapy is external compression

Exact mechanism still not known but certain observed alterations are
>> reduction in ambulatory pressure
>> improvement in skin microcirculation
>> increase in subcutaneous pressure which counters transcapillary fluid leakage

Graduated compression is the AIM

TO BE EFFECTIVE requires a PRESSURE of 30-40mm Hg at the ankle

becoming less at more proximal levels

TRIPLE LAYER COMPRESSION DRESSING Zinc oxide paste gauze wrap in

contact with the skin showed more rapid healing of ulcers than alone

Compliance is a problem

R/O any signs of arterial insufficiency before prescribing

COMPRESSION STOCKINGS CLASS 2

30 – 40 mm Hg pressure at
Ankle & proximal gradient
 SCLEROTHERAPY

OBJECTIVE is : to ABLATE THE SUPERFICIAL VEINS

Inj of a small amount of sclerosant solution( STD or POLYDOCANOL) into an empty

Vein > produce an endothelial reaction >chemical phlebitis very rapidly > walls get
approximated.

If inadeq compression applied >local thrombus formation> thrombophlebitis with

Recanalisation and recurrence

1st exclude SFJ & SPJ incompetence, else high incidence of recurrence
Duration of post sclero compression ?? (2-6 WEEKS)

USE STD 0.1or 0.5% max upto 0.5 ml ; allergic pts can use hypertonic saline
sclerosant FOAM recently tried, larger volume can be injected

Evacuation of entraped blood ,I&D at 2-3 weeks to check recanalisation

WHATS NEW --- USG GUIDED SCLEROTHERAPY

--- TRANSILLUMINATED SCLEROTHERAPY
---- MICRO SCLEROTHERAPY
COMPLICATIONS OF
SCLEROTHERAPY

--- anaphylaxis to sclerosant

--- accidental intra arterial inj

--- neurological damage

--- haematoma at inj site

REASONS FOR RECURRENCE

--- Inaccurate clinical asseessment

--- inadequate primary surgery

-- recanalisation

-- injudicious use of sclerotherapy

 SURGICAL TREATMENT

PRINCIPLES
to ligate the source of reflux ( SFJ or SPJ ) &
to remove the incompetent saphenous trunks & assoc. varices

TRENDLENBERG OPERATION > Saphenofemoral FLUSH Ligation

Still some debate whether STRIPPING of LSV is necessary

Does indeed reduce the risk of recurrence Vs Opponents

?nerve injury ?hematoma ?pain

STRIPPING BEST done from ABOVE DOWNWARDS to avoid lymphatic and

cutaneous nerve damage
RADHA , 46YRS

B/L VARICOSE VEINS

TRENDLENBERG OPERATION
Incision
 Rigid metal pin-stripper
rigid metal pin-stripper used

INVERSION STRIPPING

LESS BLEEDING & POST OP

PAIN
SAPHENO POPLITEAL LIGATION

>> Correct identification of SPJ , Confusing anatomy

>> care about common peroneal nerve in popliteal fossa

>> in most cases there is a continuation of SSV in superior direction joining LSV,
profunda vein or even accompanying sciatic nerve up the leg

PERFORATOR SURGERY
>> Significance of incompetent calf perforators remains unclear

>> DUPLEX scanning– found to have clinically occult proximal saphn incompetence

>> it is reasonable to ligate separately any LARGE perforators which are found to be
GROSSLY incompetent despite proximal control of saphn system

>> widespread ligation does not seem justifiable for simple V V

>> advent of SEPS with greater safety rate

>> BUT evidence regarding benefit from widespread interruption of perforators remains
scanty
REMOVING SUPERFICIAL VARICES

-- Unsightly varices do not disappear following stripping & should be removed

through small incisions

-- limited avulsions/ ligations can be done thru multiple small incisions

-- latest is HOOK PHLEBECTOMY >> uses small hooks & 1-2mm incisions
AIM is to remove all varicosities thru small incisions that require no suture
skin closure with adhesive tapes

POST OP COMPRESSION BANDAGING

-- Applied to prevent excessive bruising

-- after 24-48 hrs can be replaced by thigh length high (class 2 appropriate)
compression stockings
STAB AVULSION HOOK PHLEBECTOMY
COMPLICATIONS OF V V SURGERY

-- Bruising & discomfort common after removal of varices

pain usually responds to mild analgesics

-- sensory N injury seen occassionally, 1% cases

* Saphn N & branches accompany LSV in calf

* Sural N accompanies the SSV

-- small areas of anaesthesia more frequent( upto 10% )

-- DVT occurs in 1 per 1000 V V surgery

* past h/o DVT should get prophylactic S/C heparin+ compressn stockings

* those pts on oestrogen also need prophylaxis

LATEST SURGICAL TECHNIQUES………….

VNUS Closure

-- intraluminal destruction of the LSV & SSV using an ablation catheter

using RADIOFREQUENCY HEAT energy

-- minimally invasive, 45 min OP procedure under LA/RA

-- C/I >> pacemakers, internal defibrillators, aneurysms in sections of V V

-- complic >> numbness ,bruising, DVT, phlebitis etc..

-- reduced incidence of thigh haematoma & pain

VNUS CLOSURE
TRIVEX ( TRans Illuminated Vein EXtraction )

-- using POWERED vein extracting device

& TRANSCUTANEOUS ILLUMINATION

-- percutaneous removal of superficial veins by suction

following injecion of large quantities of fluid

-- assoc. with induration, bruising, S/C grooves

TRans Illuminated Vein EXtraction (TRIVEX)
E V L T ( Endo Venous Laser Therapy )

-- new minimally invasive LASER procedure

-- works by means of THERMAL DESTRUCTION of the venous tissues

-- repeated firing of laser to vein wall causes permanent

ablation of the vein

-- compression stockings are worn for 1 week after >>> normal activity

-- is of use in treatm. of truncal varicose veins in pts

with SFJ incompetence
EVLT
ENDOVENOUS LASER THERAPY
S E P S (Subfascial Endoscopic Perforator Surgery )

-- 1985,G.Hauer demonstrated a new surg technique

-- under GA, a keyhole telescope inserted under skin & fascia cruris

but above the flexor muscles ( loose connective tissue b/w

-- incompetent perforator can be seen running from muscle out thru

the fascia

-- veins dissected free of surrounding tissue & clipped with steel clips

-- improved ulcer healing rates( avg time 6 wks )

-- wound complication morbidity low, day care surgery

SEPS
Subfascial Endoscopic Perforator vein Surgery (SEPS)
VENOUS ULCER -- Management
 MANAGEMENT OF VENOUS ULCER
-- in pts with venous ulcer due to superficial venous incompetence
alone,V V surgery is effective in producing ulcer healing

-- its not necessary to delay surgery until ulcer has healed

-- such ulcers heal rapidly after surgery(within 4 weeks)

In those with Deep Venous Insufficiency or unfit/unwilling pts

-- mainstay is LOCAL ULCER MANAGEMENT + COMPRESSION

-- NO TOPICAL ANTIBIOTICS

-- Use of high levels of compression(30-45mm Hg) to the ulcer region

hence Below Knee stockings is adequate

-- Four Layer Bandaging Technique

Which

do

you

Prefer
?
or

these …..
Thank you all