Dr.

Karim Bhurgri

Senior Registrar
Surgical Unit-III
LUM&HS-Jamshoro
Varicose vein
 Characterized as varicose veins or varicose ulcers
 Varicose veins
o Uncomplicated
 Asymptomatic
 Symptomatic
o Complicated
 Thrombophlebitis
 Bleeding
 Skin changes
Epidemiology
 Adult prevalence of varicose veins between 30% & 50%
 Factors affecting prevalence includes
o Gender
 Higher prevalence in women than men
o Age
 Prevalence increase with age
 18-24 years 11.5%
 25-34 years 14.6%
 35-44 years 28.8%
 45-57 years 41.9%
 55-64 years 55.7%
o Ethnicity
o Body mass & height
 Increasing body mass index & height associated with a higher prevalence of varicose vein
o Pregnancy increases the risk of varicose vein
o Family history evidence support familial
o Occupation & life style factors
 Symptoms/Signs
 Patient describes
o Aching, heaviness, throbbing, burning or bursting over affected area or whole limb
o Symptoms increase throughout day or with prolonged standing & relieved by elevation or compression
hosiery
o Itch & swelling at ankle in presence of complications
•Signs
 Presence of tortuous dilated subcutaneous veins is usually clinically obvious
 Confine to
o GSV 60%
o SSV 20%
 Distribution of varicosities indicate which superficial axis is defective;
o Medial thigh & calf varicosities suggests GSV incompetence
o Posteriolateral calf varicosities are suggestive of SSV incompetence
o Anteriolateral thigh & calf varicosities indicate isolated incompetence of the SSV
 Large dilated veins around the SFJ present as painless lump emergent when standing &
disappearing when recumbent (saphena varix) & thrill palpated over varix on cough impulse
Investigation

 Tourniquet tests & hand-held Doppler have now abandoned

 Duplex ultrasound scan
o For all patients with varicose veins prior to any investigation
o High frequency linear array transducer of 7.5-13 MHz used
o The aim of duplex scan
 Presence of reflux in the deep & superficial venous system
 Exact distribution & extent of reflux in the superficial venous system including affected
junctions & perforators
 Presence of obstruction in the deep venous system
 The suitability of the incompetent superficial veins for the different treatments available
(based upon diameter extent, tortuosity, saphena varix)
 Presence of thrombus within superficial veins
 An indication of a pelvic source of reflux or obstruction
Management
 Aim is to improve the significant quality life by treatment
• Compression
o Compression hosiery relies on graduated external pressure to improve deep venous return &
reduce venous pressure
o Compression may be knee length (preferred) or hip length
o Compression classified according to the pressure they exert:
 The British classification
 Class 1 stocking exert pressure of 14-17 mmHg
 Class 2 stocking exert pressure of 18-24 mmHg
 Class 3 stocking exert pressure of 25-35 mmHg
o Advantage: significantly improve the varicose vein symptoms
o Disadvantage:
 Compliance rate & long term tolerance being poor
 Pressure necrosis
 Tourniquet effects
• Endo-thermal ablation
o Endo-thermal ablation replaced surgical ligation & stripping as the gold
standard treatment because safer, with rapid recovery & improvement in
quality of life in the long term under local anaesthesia
o Basic concept is that a treatment device is inserted into the incompetent
axial vein percutaneous. The vein is surrounded by tumescent local
anaesthetic solution. This compresses the vein onto the treatment device,
emptying it of blood. It also hydro-dissects tissues such as nerves away from
the zone of injury. Finally, it act as a heat sink, mopping up excess thermal
energy to prevent remote damage. Treatment devices produces thermal
energy that destroy the structure of the vein, resulting in permanent
occlusion.
o Two broad categories
 Laser ablation
 Radiofrequency ablation
Non-endothermal, non-tumescent ablation

•ULTRASOUND-GUIDED FOAM SCLEROTHERAPY

•CATHETER-DIRECTED SCLEROTHERAPY & MECHANICOCHEMICAL
ABLATION
•ENDOVENOUS GLUE
 Endoluminal application of cyanoacrylate adhesive by a catheter placed
within the vein lumen. A handle is used to infiltrate the adhesive in 0.1
ml application via catheter. Vein is compressed, sealing the lumen
• Longterm results are similar to mechanicochemical ablation
OPEN SURGERY

 Principles of ligation & stripping are to fully dissect the point of

junctional incompetence & to remove the refluxing axial vein &
dilated tributaries
 Anaesthesia
o General anaesthesia usually but loco regional anaesthesia can be used
o Tumescent local anaesthesia around the axial vein (not widely used)
• SAPHENOFEMRAL LIGATION & GREAT SAPHENOUS STRIPPING
 Six GSV tributaries may be encountered close to the SFJ:
o Laterally
 Superficial inferior epigastric vein
 Superficial circumflex iliac vein
o Medially
 Superficial external pudendal vein
 Deep external pudendal vein
o Distally
 Anterior accessory saphenous vein
 Posteriomedial thigh vein
 Classically, these are ligated distal to their divisions. A flush SFJ ligation is then
performed & the GSV retrogradely stripped to around the knee. Phlebectomy
performed
Deep Venous Thrombosis

 It is semisolid clot in the vein which has got tendency to develop

pulmonary embolism & sudden death.
 Common site of the beginning of thrombus is soleal veins which later
propagate proximally & detached to cause acute massive pulmonary
embolism or moderate sized emboli can cause pyramidal/wedge
shaped pulmonary infarcts.
 Aetiology
o Virchow’s triad
 Stasis
 Hypercoagulability
 Vein wall injury
o Causes
 Following the childbirth
 Trauma – to leg, ankle, thigh, pelvis
 Muscular violence
 Immobility – bed ridden or bus travel (travelers thrombus)
 Debilitating illness like
 Obesity
 Immobility
 Bed rest
 Pregnancy
 Puerperium
 Oral contraceptive (estrogen)
 Postoperative thrombosis (most common)
 Malignancy (spontaneous thrombosis)
 Features of DVT
o Asymptomatic (60%)
o Fever – most common
o Tense, tender, warm, pale/bluish, shiny swelling calf
o Positive homan’s, mose’s or neuhof’s signs
o Inverted champagne bottle sign
o Features of pulmonary embolism
 Differential diagnosis
o Ruptured baker’s cyst
o Ruptured planter’s tendon
o Calf muscle Haematoma
o Cellulitis of leg
o Superficial thrombophlebitis
 Investigations
o Venous Doppler
o Duplex scan: shows noncompressible vein, which is wider than normal
o Venogram: occlusive & non-occlusive thrombus can be differentiated by this
o Radioactive I125 fibrinogen study
 Treatment
o Rest, elevation of limb, bandageing of the entire limb with crepe bandage
o Anticoagulant
 Heparin / low molecular weight heparin, warfarin, phenindione
o For fixed thrombus
 Initially high dose of heparin of 25,000 units/day for 7 days
 Latter
 To continue warfarin for 3-6 months
 Dose is controlled by assessing APTT
 Oral anticoagulants being teratogenic cannot be used during pregnancy
o Foe free thrombus
 Fibrinolysis
 Thrombectomy using Fogarty’s catheter
 I/V filter
Superficial vein thrombosis or thrombophlebitis

 Common causes includes

o External trauma
o Venepunctures
o Infusions of hyperosmolar solutions
o Drugs
o Presence of an intravenous cannula for longer than 24-48 hours leads to local thrombosis
o Systemic disease like
 Thromboangiitis/Buerger’s disease
 Malignancy
o Coagulation disorders
 Polycythemia
 Thrombocytosis
 Sickle cell disease
 Features
o Surface vein feels solid & tender on palpation
o Overlying skin attached to the vein & in the early stages may be erythematous before gradually turning brown
 Investigations
o CBC
o Coagulation screen
o Duplex scan for deep veins
o Investigations for any malignancy
 Treatment
o NSAIDs
o Topical heparinoid preparations & condition resolves spontaneously
o Rarely infected thrombi require incision or excision
o Ligation to prevent propagation into the deep veins is almost never required
o Associated DVT or thrombophilia is treated with anticoagulation
Types of Hemorrhage

•Hemorrhages occur anywhere in the body & affect all three blood vessel types:
 Arterial hemorrhage:
 When bleeding occurs due to a damaged artery, the blood is bright red and comes out in spurts,
matching the heart's rhythm. Arterial bleeding can be life-threatening due to rapid blood loss.
 Venous hemorrhage:
 When a vein is damaged, dark red blood flows steadily from the affected blood vessel. Venous
bleeding is less severe than arterial bleeding but can still be significant and requires prompt
treatment.
 Capillary hemorrhage:
 Capillary hemorrhage occurs when capillaries—the smallest blood vessels—are damaged.
Capillary bleeding is generally slow and oozes or trickles. Though it can be the most painful, it is
the least severe type of bleeding and often stops on its own.
Symptoms

•External Hemorrhage Symptoms

•External bleeding is visible, making it easier to pinpoint the cause and
source of the bleeding. With external bleeding, blood comes through an
opening in the skin, usually due to a cut or puncture wound. Symptoms
can include:1
 Pain
 Swelling
 Bruising
•Internal Hemorrhage Symptoms
•With internal bleeding, blood may pool inside the body or exit through the mouth (via vomit), nose, anus (with or without
stool), vagina, or urethra (in urine).1 Symptoms vary depending on where the bleeding is occurring, but may involve: 9
 Pain in the abdomen
 Chest tightness
 Abdominal swelling
 Skin color changes (pale or bruised skin)
 Fatigue
 Weakness
 Shortness of breath
 Blurry or double-vision
 Tingling in the hands and feet
 Nausea or vomiting
 Lightheadedness or dizziness
•Signs and symptoms of hypovolemic shock can include: 11
 Confusion
 Anxiety or agitation
 Extreme thirst
 Lethargy
 Cool, clammy, pale, or bluish-colored skin
 Excessive sweating
 Rapid heart rate
 Decreased urination
 Loss of consciousness
Causes

• Trauma:
• Medical conditions
 These include
 Liver disease,
 Cancer,
 Diabetes,
 Vitamin K deficiency,
 Alcohol use disorder,
 Peptic ulcer disease,
 High blood pressure, and
 Bleeding disorders such as hemophilia and von Willebrand disease.
 Medications: Aspirin and blood thinners, such as heparin and warfarin
Treatment

•First aid for minor external hemorrhages includes: 1

 Cleaning the affected area with mild soap and water and a sterile cloth
 Applying pressure to the wound
 Bandaging the wound to stop the bleeding
•Severe external bleeding requires immediate medical attention. If someone you know is
bleeding heavily, call 911 and: 22
 Cover the wound with a clean cloth
 Use a tourniquet (a band that you tie 2 to 3 inches above the bleeding site) if the wound is on
an arm or leg
 Pack the wound with gauze or a clean cloth if a tourniquet is unavailable
 Apply direct pressure to the wound until emergency medical technicians arrive
•In-Hospital Treatments
•Internal bleeding and severe external hemorrhaging require prompt emergency medical care. Healthcare
providers will assess the source and severity of bleeding to determine the most appropriate treatment,
which may involve:2324
 Stitches (sutures) or staples: Close an open wound to stop bleeding and prevent bacteria and other
harmful pathogens from entering the body
 Surgery: Surgical procedures may be necessary to stop bleeding from major blood vessels or to repair
damaged organs or body tissues
 Blood transfusion: Donated blood is provided through an intravenous (IV) line to replace any blood
you've lost and improve oxygen delivery throughout the body
 Medications: Medicines help stop and stabilize blood pressure, which may include tranexamic acid
(controls bleeding), vitamin K (promotes blood clotting), and desmopressin (increases blood clotting)
Complications

Possible hemorrhage-related complications include:

 Hypovolemic shock
 Organ failure:
 Damage to vital organs, such as the brain, lungs, and liver, can occur when
organs do not get sufficient blood and oxygen19
 Anemia
 Causes fatigue, weakness, and shortness of breath
 Death: Excessive blood loss can be fatal if not treated promptly
THANKS