Post on 23-Dec-2015
Varicose VeinsVaricose Veins
Core Surgical TraineesCore Surgical TraineesVascular Teaching DayVascular Teaching Day
Kent and Canterbury HospitalKent and Canterbury Hospital1st December 20091st December 2009
Hasantha Thambawita
SpR Vascular Surgery
EpidemiologyEpidemiology
½ of the population suffer from some form ½ of the population suffer from some form of lower limb varicose vein problemsof lower limb varicose vein problems
Female 50-55%Female 50-55%Male 40-45%Male 40-45%
But only ½ of them have visible varicose But only ½ of them have visible varicose veinsveins
Lower limb ulcersLower limb ulcersVenousVenous -- 75%75%ArterialArterialtraumatictraumatic
Varicose VeinsVaricose Veins
DefinitionDefinitionDilated, elongated and tortuous veinsDilated, elongated and tortuous veins
DilatationDilatationElongationElongationTortuousTortuous
Anatomy of leg veinsAnatomy of leg veins
3 Systems3 Systems
Deep SystemDeep System Superficial systemSuperficial system
Long saphenous veinLong saphenous vein Short saphenous veinShort saphenous vein
PerforatorsPerforators
Physiology of Venous functionPhysiology of Venous function
Vis a tergo of circulationVis a tergo of circulationCompetent valves in the systemCompetent valves in the systemMuscle pumpMuscle pumpNegative intra thoracic pressureNegative intra thoracic pressure
Surgical PathologySurgical Pathology
Incompetence of valvesIncompetence of valves
PerforatorsPerforatorsLSV & SSVLSV & SSVSFJ & SPJSFJ & SPJDeep veinsDeep veins
AetiologyAetiology
CongenitalCongenital
Primary (Idiopathic) Primary (Idiopathic) 95%95%
Congenital incompetence of valves &/or weakness Congenital incompetence of valves &/or weakness of muscular coatof muscular coat
SecondarySecondary 5%5%
PrimaryPrimary
Prolonged standingProlonged standingViolent muscular effectsViolent muscular effectsObesityObesityAgeingAgeingOCPOCPHRTHRTFHxFHx
SecondarySecondary
PregnancyPregnancyAbdominal or Pelvic tumoursAbdominal or Pelvic tumoursChronic constipationChronic constipationLocal damage to valvesLocal damage to valves
ThromboplebitisThromboplebitisPhebothrombosisPhebothrombosis
Arterio Venous fistulasArterio Venous fistulasCavernous haemangiomaCavernous haemangioma
Symptoms/SignsSymptoms/Signs
Tiredness & Dull acheTiredness & Dull acheNight crampsNight cramps
With complicationsWith complications
ComplicationsComplications Itching Itching DisfigurementDisfigurement EczemaEczema Swelling around ankleSwelling around ankle PigmentationPigmentation UlcerationUlceration PeriostitisPeriostitis Calcification of vein wallCalcification of vein wall HaemorrhageHaemorrhage ThromboplebitisThromboplebitis
Types of VeinsTypes of Veins
Thread veinsThread veinsSpider veinsSpider veinsReticular veinsReticular veinsSmall varicose veinsSmall varicose veinsElongated tortuous veinsElongated tortuous veinsSaphina varixSaphina varix
Clinical testsClinical tests
1.1. Identify systemIdentify systemI.I. ObservationObservation
II.II. Tap test ( Schwartz test)Tap test ( Schwartz test)
2.2. Incompetent perforator/valvesIncompetent perforator/valvesI.I. Cough impulse – SFICough impulse – SFI
II.II. Trendelenberg test – SFI,SPI,PerforatorsTrendelenberg test – SFI,SPI,Perforators
3.3. Patency of deep veinsPatency of deep veinsI.I. Perthes’ test Perthes’ test
““Historical” --- replaced with DopplerHistorical” --- replaced with Doppler
Don’t forget…….Don’t forget…….
Distal pulsesDistal pulsesAnkle mobilityAnkle mobilityAbdominal examination (DER)Abdominal examination (DER)
InvestigationsInvestigations
Duplex scanDuplex scan
(Venography) --- MRV(Venography) --- MRV
CEAP ClassificationCEAP Classification
CClinicallinical C1 = Thread veinsC1 = Thread veins C2 = Std VVsC2 = Std VVs C3 = OedemaC3 = Oedema C4 = PigmentationC4 = Pigmentation C5 = Healed ulcerC5 = Healed ulcer C6 = Active ulcerC6 = Active ulcer
(A)(A)EEtiologytiology CongenitalCongenital PrimaryPrimary SecondarySecondary
AAnatomynatomy DeepDeep LSVLSV SSVSSV PerforatorsPerforators Combination(s)Combination(s)
PPathophysiologyathophysiology RefluxReflux ObstructionObstruction CombinationCombination
Group & ActionGroup & Action
CEAP – 1 No need to refer to NHS clinic, cosmetic problem onlyCEAP – 1 No need to refer to NHS clinic, cosmetic problem only
CEAP – 2 Refer routinely to Varicose Vein ClinicCEAP – 2 Refer routinely to Varicose Vein Clinic
CEAP 3 – 5 Refer soon to "Fast Track Varicose Vein Clinic" for CEAP 3 – 5 Refer soon to "Fast Track Varicose Vein Clinic" for venous duplex ultrasound assessmentvenous duplex ultrasound assessment
CEAP 6 - Refer urgently to "One Stop Leg Ulcer Clinic" for full leg CEAP 6 - Refer urgently to "One Stop Leg Ulcer Clinic" for full leg ulcer assessmentulcer assessment
TreatmentTreatment
OptionsOptions
o SymptomaticSymptomatico Obliteration of venous lumenObliteration of venous lumeno Removal of vein Removal of vein
IndicationsIndications
CosmeticCosmetic
NHS guidelinesNHS guidelines
1.1. SymptomsSymptoms
2.2. Complications/prevention of Complications/prevention of complicationscomplications
Symptomatic TreatmentSymptomatic Treatment
IndicationsIndications• AgedAged• Pregnancy/PeuperiumPregnancy/Peuperium• Unfit/refuse/waiting for surgeryUnfit/refuse/waiting for surgery• Pelvic tumoursPelvic tumours• DVTDVT
Symptomatic treatment - MethodsSymptomatic treatment - Methods
1.1. Postural drainagePostural drainage
2.2. ExerciseExercise
3.3. SupportSupport
Obliteration of venous lumenObliteration of venous lumen
IndicationsIndications• Below kneeBelow knee• < 5mm< 5mm• Following surgery (adjunct)Following surgery (adjunct)• Existing causesExisting causes• Alternative to surgeryAlternative to surgery
Obliteration of venous lumen - Obliteration of venous lumen - MethodsMethods
1.1. SclerotherapySclerotherapy
2.2. Form injectionsForm injections
3.3. LaserLaser
4.4. RadiofrequencyRadiofrequency
SurgerySurgery
IndicationsIndications• As a primary modalityAs a primary modality• Remove unsightly veinsRemove unsightly veins• Failed other optionsFailed other options
Surgical OptionsSurgical Options
1.1. LigationLigation
2.2. Ligation & strippingLigation & stripping
3.3. Ligation, stripping & BK multiple Ligation, stripping & BK multiple avulsionsavulsions
Complications of SurgeryComplications of Surgery
PainPainBruisingBruisingRecurrenceRecurrence Groin complicationsGroin complications InfectionInfectionParaesthesiaeParaesthesiaeScar Scar
ContraindicationsContraindications
DVTDVTPregnancyPregnancyThrombophlebitisThrombophlebitisOCPOCP
Peripheral vascular diseasePeripheral vascular disease