By

Mahmoud Zaghloul Raslan, MD

Consultant Surgeon, MGH

Madina

Definition

Dilated tortuous superficial veins in

the lower limbs

Anatomy

Venous drainage from LL is through 3 systems:

- Superficial veins:

- Long saphenous vein and tributaries

- Short saphenous vein and tributaries

- Deep veins: Ant. Tibial, post. Tibial,

peroneal, popliteal, deepF., superficial F.

and common F.

- Perforating veins: perforating deep fascia

to connect superficial with deep veins

Pathophysiology

Physiology:

_ Blood conductor:

- Muscular compression

- Negative ITP

- Calf Muscle pump

- Presence of valves

_ Blood reservoir:

- Dilatable

- Capacious

Etiology and Types

Primary VV

_ High IVP: prolonged standing,

prolonged sitting with crossed

legs, chronic straining,

_ Weakness of vein walls:

- Obesity

- Pregnancy

- Hormonal

Secondary VV:

- After previous DVT

- With pelvic tumours

Clinical Picture

Thorough history taking:

- Occupation and prolonged standing

- Throbophlebitis or DVT

- Coaguation disorders

- Diabetes

- Results of previous treatment

- Pregnancy and contraceptive pills

Symptoms:

- Pain: aching, throbbing, tingling

- Cramps, heaviness, tiredness of

legs, restless legs at night

- Of complications: Itching,

hyperpigmentation, skin ulceration

and bleeding

- Leg disfigurement

Trendlenberg test

Investigations

General:- Assess the general condition of the patient:

e.g. CBC,liver and kidney function tests

Specific: - Hand-held Doppler

- Duplex ultrasound: The best; gives both anatomical and functional diagnosis

- Others: e.g. CT venography and MRI rarely needed

Treatment

Initial conservative

treatment

(I) General measures:

Leg elevation

Excerise

(II) Compression therapy:

(III) Pharmacologic therapy:

Venoactive drugs

- Micronized purified flavonoid

MPFF e.g.Daflon

- Hydroxyethylrutoside

Rheologic agents:

- Aspirin

- Stanozolol

- pentoxifylline

- prostacyclin analogues

(IV) Skin care: Skin cleansing e.g. Dove, Olay

Emollients e.g. vaseline, cetaphil

Barrier preparations e.g. zinc oxide

cream, Vaseline

Topical corticosteroids

(V) Ulcer care Ulcer debridement

Role of systemic antibiotics

Topical agents:

- e.g. Silver sulfadiazine

- Other antiseptic agents

Ulcer dressings

- Low-adherent gauze

- Hydrogels and alginate dressing

- Silver containing dressings

Compressing dressing

Skin grafting

Others:

- Hyperbaric oxygen

- Electromagnetic therapy

- Therapeutic ultrasound

Vein ablative therapy

Indications:

- Venous hemorrhage

- Superficial thrombophlebitis

- Venous reflux associated with

symptoms

Contraindications:

- Pregnancy

- Acute superficial or deep venous

thrombosis

- Moderate to severe PAD

- Advanced generalized systemic

disease

Types of vein ablative

therapy

Chemical:

- Sclerotherpy

Mechanical:

- Surgical excision

Thermal:

- Radiofrequency ablation RFA

- Endovenous laser therapy EVLA

Sclerotherapy

Sclerosants:

_ Sodium tetradecyl sulphate

_ Sodium marrhuate

_ Polydocanol

_ Ethanolamine oleate

_ Hypertonic saline

Surgical stripping

Endoscopic subfascial

ligation of incompetent

perforators

Radiofrequency ablation

therapy

By directing radiofrequency energy through a

vein, a narrow rim of tissue less than 1mm is

heated by an electrode.

The amount of heating is modulated using a

microprocessor resulting in controlled

collagen contraction, thermocoagulation and

absorption of the vein.

Endovenous laser ablation:

Initiates nonthrombotic occlusion by direct

thermal injury to vein wall causing

endothelial destruction, collagen

contraction and later fibrosis

Management by clinical category

No visible or palpable signs of

venous dis. (CEAP category 0):

- If C/O venous symptoms:

Treated conservatively

Telangiectasias and reticular veins

(CEAP category 1):

_ Asymptomatic patients with no

reflux: Treated by

- Sclerotherapy

- Laser light therapy

_ Symptomatic patients with reflux:

- Treat reflux first by surgical or

thermal ablation

Varicose veins (CEAP category 2):

_ Isolated varicosities without trunkal

reflux are treated by:

- Sclerotherapy

- Surgical excision

Depending on size, location and

number of affected veins

_ With reflux: Treated by vein ablation

Comparison of ablative therapies:

_ Recent studies reveal that minimally

invasive therapies are as effective as

surgical ablation with fewer

complications and rapid regain of daily

activities

Advanced venous disease:

_ Patients with edema, skin changes or

ulceration (CEAP categories C3, C4,

C5, C6: Treated by initial conservative

measures

_ Refractory patients to conservative

measures: Treated by ablative therapy

Summary and conclusion

Visibly dilated LL veins may indicate

underlying venous reflux, especially if

symptomatic, However, they can occur

in absence of symptoms or reflux

Duplex US is essential to identify

superficial, deep or perforator vein reflux

and R/O DVT

Patients with venous reflux and those

with complications should be referred to

venous or at least vascular specialist for

further evaluation and management

Goals of treatment are improved

symptoms and appearance

Most patients are treated by initial

conservative measures

Patients refractory to conservative

measures for 3 months with documented

reflux (>0.5 second duration) are

candidates for vein ablative therapy

Patients with telangiectasias, reticular

vein and VV with reflux should undergo

vein ablation before treating these

lesions

Telangiectasias, reticular veins and

small VV large enough to admit 27 or 30

gauge needle are treated best by

sclerotherapy with good results

Laser therapy is the only option for

telangiectasias too small to access,

allergy to sclerosants, patients afraid of

needles and after failed sclerotherapy

Endovenous ablation techniques are

preferred for saphenous and other

trunkal veins over surgical ablation

Persistent or recurrent perforators (by

duplex scan) after vein ablation are

treated by US-guided sclerotherapy or

endovenous methods

Occasionally, surgical methods may be

required for recurrent or refractory

venous ulceration