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![Page 1: Varicose Veins Core Surgical Trainees Vascular Teaching Day Kent and Canterbury Hospital 1st December 2009 Hasantha Thambawita SpR Vascular Surgery.](https://reader035.fdocuments.in/reader035/viewer/2022062320/56649d985503460f94a82249/html5/thumbnails/1.jpg)
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
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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
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Varicose VeinsVaricose Veins
DefinitionDefinitionDilated, elongated and tortuous veinsDilated, elongated and tortuous veins
DilatationDilatationElongationElongationTortuousTortuous
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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
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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
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Surgical PathologySurgical Pathology
Incompetence of valvesIncompetence of valves
PerforatorsPerforatorsLSV & SSVLSV & SSVSFJ & SPJSFJ & SPJDeep veinsDeep veins
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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%
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PrimaryPrimary
Prolonged standingProlonged standingViolent muscular effectsViolent muscular effectsObesityObesityAgeingAgeingOCPOCPHRTHRTFHxFHx
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SecondarySecondary
PregnancyPregnancyAbdominal or Pelvic tumoursAbdominal or Pelvic tumoursChronic constipationChronic constipationLocal damage to valvesLocal damage to valves
ThromboplebitisThromboplebitisPhebothrombosisPhebothrombosis
Arterio Venous fistulasArterio Venous fistulasCavernous haemangiomaCavernous haemangioma
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Symptoms/SignsSymptoms/Signs
Tiredness & Dull acheTiredness & Dull acheNight crampsNight cramps
With complicationsWith complications
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ComplicationsComplications Itching Itching DisfigurementDisfigurement EczemaEczema Swelling around ankleSwelling around ankle PigmentationPigmentation UlcerationUlceration PeriostitisPeriostitis Calcification of vein wallCalcification of vein wall HaemorrhageHaemorrhage ThromboplebitisThromboplebitis
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Types of VeinsTypes of Veins
Thread veinsThread veinsSpider veinsSpider veinsReticular veinsReticular veinsSmall varicose veinsSmall varicose veinsElongated tortuous veinsElongated tortuous veinsSaphina varixSaphina varix
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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
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Don’t forget…….Don’t forget…….
Distal pulsesDistal pulsesAnkle mobilityAnkle mobilityAbdominal examination (DER)Abdominal examination (DER)
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InvestigationsInvestigations
Duplex scanDuplex scan
(Venography) --- MRV(Venography) --- MRV
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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
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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
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TreatmentTreatment
OptionsOptions
o SymptomaticSymptomatico Obliteration of venous lumenObliteration of venous lumeno Removal of vein Removal of vein
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IndicationsIndications
CosmeticCosmetic
NHS guidelinesNHS guidelines
1.1. SymptomsSymptoms
2.2. Complications/prevention of Complications/prevention of complicationscomplications
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Symptomatic TreatmentSymptomatic Treatment
IndicationsIndications• AgedAged• Pregnancy/PeuperiumPregnancy/Peuperium• Unfit/refuse/waiting for surgeryUnfit/refuse/waiting for surgery• Pelvic tumoursPelvic tumours• DVTDVT
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Symptomatic treatment - MethodsSymptomatic treatment - Methods
1.1. Postural drainagePostural drainage
2.2. ExerciseExercise
3.3. SupportSupport
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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
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Obliteration of venous lumen - Obliteration of venous lumen - MethodsMethods
1.1. SclerotherapySclerotherapy
2.2. Form injectionsForm injections
3.3. LaserLaser
4.4. RadiofrequencyRadiofrequency
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SurgerySurgery
IndicationsIndications• As a primary modalityAs a primary modality• Remove unsightly veinsRemove unsightly veins• Failed other optionsFailed other options
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Surgical OptionsSurgical Options
1.1. LigationLigation
2.2. Ligation & strippingLigation & stripping
3.3. Ligation, stripping & BK multiple Ligation, stripping & BK multiple avulsionsavulsions
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Complications of SurgeryComplications of Surgery
PainPainBruisingBruisingRecurrenceRecurrence Groin complicationsGroin complications InfectionInfectionParaesthesiaeParaesthesiaeScar Scar
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ContraindicationsContraindications
DVTDVTPregnancyPregnancyThrombophlebitisThrombophlebitisOCPOCP
Peripheral vascular diseasePeripheral vascular disease
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