Recurrent varicose veins and its management
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Transcript of Recurrent varicose veins and its management
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RECURRENT VARICOSE VEINS AND ITS MANAGEMENT
DR JOEL ARUDCHELVAMCONSULTANT VASCULAR AND TRANSPLANT
SURGEON
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Varicose veins Dilated tortuous superficial veins (derived
from the Greek word "varix," - “grapelike”)
Old disease Hippocrates and Galen described the
disease
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Recurrent varicose veins Prevalence of varicose veins - 2% to over 60%
in population studies Recurrence rate of 20%-60% after 5 years
Epidemiology of chronic venous disease.Robertson L, Evans C, Fowkes FG Phlebology. 2008; 23(3):103-11
Allaf N, Welch M. Recurrent varicose veins: Inadequate surgery remains a problem. Phlebology. 2005;20:138–40.
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Venous anatomy
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Venous anatomy
Named perforators along Greater saphenous distribution
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New perforator vein terminology
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Causes of recurrence Inadequate initial procedure
Not stripping
Neo vascularisation -new veins appearing in the granulation tissue connecting the end of the ligated sapheno-femoral junction (SFJ)
Recanalisation – after thermal, chemical ablation
New source of reflux Accessory Long Saphenous Vein (LSV) Accessory Short Saphenous Vein (SSV)
Deep venous disease
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Recurrence after stripping and non stripping
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Causes of recurrence Inadequate initial procedure
Not stripping
Neo vascularisation -new veins appearing in the granulation tissue connecting the end of the SFJ
Recanalisation – after thermal, chemical ablation
New source of reflux Accessory Long Saphenous Vein (LSV) Accessory Short Saphenous Vein (SSV)
Deep venous disease
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Neo vascularisation
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Causes of recurrence Inadequate initial procedure
Not stripping
Neo vascularisation -new veins appearing in the granulation tissue connecting the end of the SFJ
Recanalisation – after thermal, chemical ablation
New source of reflux Accessory Long Saphenous Vein (LSV) Accessory Short Saphenous Vein (SSV)
Deep venous disease
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CEAP Classification
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CLINICAL CLASSIFICATION
C0: No Varicose Veins C1: Telangiectasia ( reticular veins , spider
veins) C2: Varicose veins C3: Edema C4: Skin changes
C4a: pigmentation and eczema C4b: lipodermatosclerosis and atrophie blanche
C5: Healed venous ulcer C6: Active venous ulcer
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Reticular veins and spider veins
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CLINICAL CLASSIFICATION
C0: No Varicose Veins C1: Telangiectasia ( reticular veins , spider
veins) C2: Varicose veins C3: Edema C4: Skin changes
C4a: pigmentation and eczema C4b: lipodermatosclerosis and atrophie blanche
C5: Healed venous ulcer C6: Active venous ulcer
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Skin Changes
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CLINICAL CLASSIFICATION
C0: No Varicose Veins C1: Telangiectasia ( reticular veins , spider
veins) C2: Varicose veins C3: Edema C4: Skin changes
C4a: pigmentation and eczema C4b: lipodermatosclerosis and atrophie blanche
C5: Healed venous ulcer C6: Active venous ulcer
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Skin changes
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Duplex ultrasound
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Duplex ultrasound To identify the cause of recurrence
SFJ incompetence (SFI), Sapheno poplieal junction incompetence (SPI)
Acc LSV, Acc SSV DVT Perforators / site Neo vascularisation
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INDICATIONS FOR TREATMENT
COSMETIC SYMPTOMATIC COMPLICATED
Oedema C4 – skin changes
C4a: pigmentation and eczema. C4b: lipodermatosclerosis and atrophie blanche.
C5: healed venous ulcer. C6: active venous ulcer
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Treatment Options Surgery
Thermal Ablation ( Radio frequncy ablation /LASER )
Sclerotherapy
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Surgery for recurrent SFJ Dangers
Risk of injury to femoral vein Lymphatic leak
Expose artery first and approach vein from lateral side
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LASER - Light Amplification by Stimulated Emission of Radiation
• Energy source• Gain medium• Resonant cavity
• LASER• Monochromatic – same
wave length• Coherent – unidirectional• Collimated - parallel
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LASER
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LASER
Laser energy is
absorbed by vein wall
and hemoglobin
producing heat and vein
wall destruction
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Sclerotherapy Scleroscents used
SODIUM TETRADECYL SULPHATE(STD) HYPERTONIC SALINE SOL POLYDOCANOL SOTRADECOL ETHANOLAMINE OLEATE GLUCOSE COMBINATIONS
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Sclerotherapy
• sclerosant is taken in 20 ml syringe ,another syringe with 4 times the amount of air
• By repeated to and fro motion ,dense white foam prepared
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Sclerotherapy Mechanism of action
Endothelial damage Inflammation obliteration
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Recurrent Varicose veins Recurrent SFJ /SFI
Surgical,Laser neovascularisation
Sclerotherapy, surgery LSV
Thermal ablation (LASER, RFA), Stripping Varicosities
Sclerotherapy, Avulsion, thermal ablation (LASER, RFA)
Pelvic DVT - Venous Angioplasty
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How to prevent recurrence Duplex scanning and identifying the right
source - accessory LSV, (Giacomini vein), correct site of reflux of SSV. Ect
Stripping of Long Saphenous Vein
Duplex scanning and Avoiding varicose vein intervention in patients with past DVT
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Recurrence after stripping and non stripping
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How to prevent recurrence Duplex scanning and identifying the right
source - acc LSV, (Giacomini vein), correct site of reflux of SSV. Ect
Stripping of Long Saphenous Vein , Ligation of tributaries
Duplex scanning and Avoiding varicose vein intervention in patients with past DVT
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Thank You