This document discusses varicose veins, including definitions, anatomy, causes, symptoms, examination techniques, and treatment options. Some key points:
- Varicose veins are dilated, tortuous veins, usually in the legs, caused by incompetent valves that allow blood to flow in the wrong direction.
- Annual incidence is about 2% and lifetime prevalence is around 40%, being more common in women.
- Symptoms can include pain, swelling, heaviness, and skin changes like pigmentation.
- Examination involves inspection, palpation, auscultation, and Doppler ultrasound to map veins and locate sites of reflux.
- Treatment options include conservative compression therapy, sclerotherapy
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Varicose Veins
1. Varicose veins and treatment
โข Jeannouel van Leeuwen ,
surgeon
โข Chirurgen Maatschap
Emma Care
โข Courtesy of Servier
โข 25 january 2012
2. What weโll cover
โข Some Definitions
โข Anatomy
โข What are you looking for?
โข Examination techniques
โข Treatment options
3. Incidence
โข annual incidence of varicose veins is
about 2%
โข life-time prevalence of varicose veins
approaches 40%
โข Varicosities are more common in women
(about 2-3 times as prevalent in women
than in men)
โข 10-20% actually are symptomatic enough
to complain about their lower leg varicose
veins and seek treatment.
4. What is a varicose vein?
โข Long, tortuous and dilated vein of the
superficial varicose system
โข Commonly legs but where else?
โข Abdominal Wall
โข Anus
โข Vulva
โข Oesophagus
โข Scrotum
5. Why do they happen?
โข increased pressure in the
superficial venous
system
โข normally blood flows from
superficial system to deep
โข if the valves protecting the
superficial veins become
incompetent there is
higher pressure in the
superficial veins and they
become varicose
6. Normal venous flow in the Leg
Normal Flow
โข Superficial veins drain into the deep veins
โขFrom the foot up to the heart
Superficial vein disease always starts with abnormal
valves and interruption to normal flow called venous
reflux
7.
8. Abnormal flow = Venous Reflux
Damaged Valves
1. Blood flows to the skin
2. Blood is pushed distally and
proximally
3. Close loop recirculation
4. Blood is retained in the leg
โข Increased volume of blood
(heaviness Fatigue)
โข Increased venous pressure
โข Veins Dilate (varicose veins)
9. Taking the history
๏ฎ Presenting Complaint: Varicosities, abdominal/groin
lump โ saphena varix
๏ฎ Symptoms
๏ฎ Localized discomfort in the leg, Pain, Swelling, Venous
claudication, Itching
๏ฎ โRiskโ factors
๏ฎ Female, age, ethnicity, occupation, pregnancy, obesity, sm
oking
๏ฎ ASK about history of abdominal
complaints/cancer, DVT, previous & other venous
complaints
10. So the examination
โข Inspection
โข Auscultation
โข Palpation
โข cough test
โข tap test
โข Tourniquet Tests
โข Trendelenberg
โข Tourniquet test
โข Perthes
โข Doppler
โข Sapheno-femoral junction
โข Sapheno-popliteal junction
11. Diagnosis of venous disease
โข Physical exam
โข Appearance
โข Trendelenburg test
โข Palpation
โข Hand Doppler
โข Duplex Examination
โข R/O DVT
โข Size of veins
โข Map out superficial veins
โข Locate the site of reflux
โข Reflux 0.5 sec in GSV and 1 sec in
deep system
โข Find refluxing perforators
12. Clinical picture - symptoms
โข Cosmetic disfigurement
โข Pain and discomfort
โข Night cramps
โข Mild swelling at night
โข Pigmentation
โข Itching
โข Ulceration
13. Anatomy
โข Superficial System arises from foot and ends at Sapheno- femoral
junction (spiderhead)
โข Long saphenous vein- medial leg up to SFJ
โข Short saphenous vein- lateral malleolus , up calf to meet popliteal
vein behind knee
โข Sapheno- femoral junction- 4 cm lateral and 4cm below the pubic
tubercle
โข Communication veins: connecting deep and superficial system
through piercing deep fascia, with valves to direct blood from
superficial to deep viens.
โข Perforator veins: there are 3 perforators on the medial side and 1
on the lateral side of the leg
14.
15. Inspection- other features
1. Spider Veins- blueish vessels that distend above
the skin surface
2. Thrombophlebitis- superficial red painfull lump
3. Brown pigmentation- haemosiderin
deposition
4. Venous Eczema
5. Venous Ulcers- over medial ankle
6. Lipodermatosclerosis-progressive sclerosis
of cutaneous fat- ankle becomes thin and hard- area
above becomes oedematous
7. Scars from previous surgery
16.
17. ๏ฎ Atrophy blanche
๏ฎ Ulceration: active and healed
Inspection ๏ฎ Leaves a white patch
๏ฎ Venous ulcers/eczema
๏ฎ Pitting oedema
๏ฎ Spider veins
18. Inspection
๏ฎ Lipodermatosclerosis
๏ฎ Literally "scarring of the skin and fatโ
๏ฎ A slow process that occurs over a number of years
and has 2 phases:
1. Acute
๏ฎ Venous pooling โchronic venous hypertension
๏ฎ RBC forced into surrounding tissue
๏ฎ Haemoglobin broken down into brown
haemosiderin
2. Chronic
๏ฎ Chronic haemosiderin formation leads to fibrin
deposition
๏ฎ Skin becomes thickened and shiny
๏ฎ Skin around ankle constricts and the inverted
champagne-bottle shape is seen
19. Stages of chronic venous
insufficiency
(Expert meeting in Moscow, 2000.)
โข 0 - no symptoms;
โข 1 - heavy feet syndrome;
โข 2 - intermittent edema;
โข 3 - persistent edema, hyper- or
hypopigmentation, lipodermatosc
lerosis, eczema;
โข 4 - venous ulcer.
20.
21. Causes
Primary
โข Theories of Aetiology:
โข Weak wall theory
โข Congenital valvular incompetence
โข Aggravating factors:
โข Female sex
โข High parity
โข Occupation requiring prolonged standing
โข Marked obesity
โข Constricting clothes
โข Estrogen intake
โข Deep venous thrombosis
22. Secondary
Anything that raises intra-abdominal pressure or
raises pressure in superficial/deep venous system
soโฆ:
โขPregnancy
โขAbdominal/pelvic mass
โขAscites
โขobesity
โขconstipation
โขthrombosis of leg veins (DVT)
โขAV fistula
โขVena cava thrombose
โขLarge liver cysts
24. Palpation
โข Palpate the veins to confirm they are infact veins-
will refill if if gently pressed and released
โข Next- find the sapheno-femoral junction (SFJ)
โข Find Pubic Tubercle just lateral to pubic symphisis
โข 4 cm lateral then 4cm below
โข Palpate for a sapheno varix- localised distension of the
long saphenous vein in the groin
โข Cough Test- Fingers over SFJ, ask patient to cough
can you feel a thrill, if yes suggest incompetence
โข Tap Test- tap over the SFJ and feel further down
long saphenous vein for any transmitted sounds, if
yes suggest incompetence
25. Trendelenberg/Tourniquet tests
Aim- to localise the valve/s that are
incompetent
Trendelenberg
โข Lie patient down and raise leg attempting
to drain varicosities of blood.
โข Using either a tourniquet or fingers put
pressure over SFJ to occlude it
โข Ask patient to stand
If varicosities DO NOT refill indicates SFJ
incompetence
If DO refill the leaky valve is lower down
โI will now try and locate the incompetent
perforator using the tourniquet testโ
26. Tourniquet test continued
โข Same as before- lie down, raise and drain
leg
โข Place tourniquet approximately over area
of each perforator( mid thigh, sapheno
popliteal, calf perforators)
โข If varicosities DO NOT refill that perforator
is incompetent
โข If varicosities DO refill continue down leg
27. To complete my examination I
would like toโฆ
โข Perform a full Abdominal Examination
โข Scrotal examination ( on males!)
โข Arterial Examination
Investigations
โข Duplex Ultrasonography- maps valve
incompetence
โข Phlebography not done anymore
28. Spider Veins
The proper term is Telangiectasia
โขThese are non raised dilated veins located in the
Dermis (deep layer of the skin)
โขSingle layer endothelium, minimal muscle
โขCan be Red or Blue in color depending on the origin
โขDo not cause major medical complications
โขAppears earlier than varicose veins (4% of teenagers ,
and 13 % in 18 to 20 year olds
โขMore common in females
โขReticular Veins are lager feeding veins
30. Venous Stasis Ulcers
โข Differential Diagnosis
1. Venous ulcerations 50% on non healing ulcers
2. Arterial ulcers in about 10%
3. Malignancy : basal and squamous cell, lymphoma
4. Infections: HIV, fungal
5. Collagen vascular disorders: Lupus ec.
6. Lymphatic obstruction
โข Affects over 1 million people in the US
โข 100,000 are disabled from this
โข More common in elderly population
33. Management
๏ฎ Surgical
๏ฎ Conservative/Medical
โข Ankle-to-groin saphenous vein
๏ฎ Graded compression stripping (with stab avulsion)
bandaging, Compression โข Segmental saphenous vein stripping
hosiery (with stab avulsion)
โข Saphenous vein ligation:
๏ฎ Paste Gauze (Unna) Boots
high, low, or both
๏ฎ Diuretics? Zinc? โข Saphenous vein ligation and
Phlebotrophic/Hemorheologi sclerotherapy
c agents? Aspirin/NSAIDs etc โข Saphenous vein ligation (with stab
avulsion)
โข Stab avulsion of varices without
saphenous vein stripping
(phlebectomy)
โข Endoluminal occlusion of the
saphenous vein by radiofrequency
(RF) or laser energy
34. Surgical ligation and Stripping
โข Standard treatment
for a century
โข General anesthesia
โข Pain
โข Long recovery
โข Some complications
โข Good cosmetic
results
35. Surgical treatment
โข Crossectomy or/and
vein stripping till
below knee better
than compressive
therapy alone
โข Other techniques :
Endovas.burning or
foam injection
36. Vein Ablation
โข Laser Ablation (EVLA )
โข Uses light to heat the vein
โข Radio Frequency (VNUS Procedure)
โข Uses radio frequency to heat the vein
โข Office based procedure
โข Done under local anesthesia
โข One needle puncture at the level of the
knee
โข Takes about 1 hour
โข Patient resumes normal activity same
day
37. EVLA Results
Images from
http://venacure-evlt.com/
38. Sclerotherapy
โข Cumulate vein with needle
โข Inject Sclerosing Solution
โข Ethoxysclerol
โข Hyper tonic Saline
โข Foam (Mix STS with air and make
bubbles)
โข Intravenous injection causes intima
inflammation and thrombus
formation
39. Sclerotherapy Use
โข Neovascularization
โข Perforators
โข Clean up after Phlebectomies
โข Spider veins
โข Reticular veins
โข GSV: can closure the, but has
high recurrence rate
41. UNNA boot
result
โข Weekly change with
UNNA boot bandage
gives nice result
42. โข Compressive
bandages first choice
with simple small vein
ulcer
43. โข Skin grafting can be
put on a non infected
granulating skin
defect of a venous
ulcer
44. Treatment complications
โข Major complications following VV surgery are relatively rare
โข Up to 20% morbidity
โข Infection
โข Hematoma
โข Pain
โข Nerve damage
โข Saphenous nerve (LSV surgery)
โข Sural, peroneal nerve (SSV surgery)
โข Lymphatic leak - Venous thrombosis - Vascular injury
โข Recurrence
45. Oral medication
โข Effect on edema , hematocrit , augmentation
capillary permeability , inflammation , less fibrinolysis
, leukocyte function en erythrocytes
โข No evidence for monotherapy only in addition effect
on ulcer healing
โข ๏ Daflon , Trental , Aspirine