varicose veins

VARICOSE VEINS

VIDULA SHEVADE

GROUP 603

VARICOSE VEINS

Definition:

Varicose veins are veins that have become distended over time. Long, tortuous and dilated veins of the superficial varicose system due to the pooling of blood in the lower extremities.

LEG VEIN ANATOMY Legs are made of network of

veins that carry blood to heart. The venous system is comprised

of – 1 Superficial veins long saphenous vein short saphenous vein

LEG VEIN ANATOMY2 Deep veins femoral vein Popliteal vein Peroneal vein Anterior tibial vein Posterior tibial vein3 perforating veins 90% of blood is returned by deep

veins and not by superficial veins.

PERFORATING VEINS Direct perforating veins :

These directly connect superficial veins with deep veins

PERFORATING VEINS In thigh : Adductor canal perforator

connects long saphenous with femoral vein in lower part of adductor canal. (hunterian’s perforator)

In the lower thigh on medial aspect Long SV connect femoral vein via DODD’s Perforator

Below knee : Perforator connects long SV or

post-Arch vein with posterior tibial vein knows as BOYD’S Perforator.

PERFORATING VEINS In leg : 1.Lateral perforator is presented at the junction of mid & lower third of leg .It connect SSV with peroneal vein. 2. Medially there are three perforator

which connect posterior arch vein with posterior tibial vein , know as COCKETT’S Perforator

PERFORATING VEINS Upper medial perforator lies

at the junction of middle and lower third of leg.

Middle medial perforator lies 4Inch above the medial malleolus .

Lower medial perforator lies posterio-inferior to the medial malleolus .

PERFORATING VEINS Indirect perforating veins: These consist of small

superficial veins which penetrate the deep fascia to connect with vessel in muscle and in turn end in Deep vein.

LEG VEIN ANATOMY Blood is drained from superficial

to deep veins of legs through perforating veins .

And through deep veins it is carried to heart.

Back flow of blood is impossible. But due to defect in valve of

blood flows in opposite direction .

LEG VEIN ANATOMY

VENOUS VALVES The venous valves are abundant in the

distal lower extremity and number of valves decreases proximally, with no valves in superior and inferior vena cava

Delicate structures Prevent reverse flow in the veins Ensure that the blood is pumped from

the superficial to the deep system and back towards the heart when the patient is walking

ETIOLOGY PRIMARY VARICOSE VEINS Defect in saphanofemoral valve Defect in saphanopoplitial valve Defect in valve of perforators

SECONDARY

Anything that increases intra-abdominal pressure

Or raises pressure in superfical or deep veins

Pregnancy Obesity Abdominal or pelvic mass Old age Long standing Thrombosis of leg veins

CONGENITAL CAUSES Arteriovenous fistulas

CLINICAL FEATURES Heaviness in the legs Night time cramps Dragging pain, postural discomfort Oedema, itching Discolouration Ulceration

CAUSES OF PAIN Anoxia Hyperviscosity or red cells Chronic venous hypertension Platelet aggregation Capillary functional disorder Altered cuteneous microcirculation

COMPLICATION Hemorrhage Pigmentation/ eczema Periostitis Venous ulcer Lipodermatosclerosis DVT Tromboplebitis

ECZEMA

VENOUS ULCER

STAGES C0 no visible or palpable signs of venous

disease C1 telangectacia or reticular veins C2 varicose veins (without symptoms) C3 edema C4a skin changes due to venous disorders:

pigmentation, eczema C4b skin changes due to venous

disorders: lipodermatosclerosis C5 as C4 but with healed ulcers C6 skin changes with active ulcers (venous

insufficiency ulceration)

INVESTIGATION Venography Venous doppler Trendelenburg test Tourniquet test Cough impulse test Perthe test

TRENDELENBURG TEST

TOURNIQUET TEST 3 tourniquets are tied. 1st at thigh 2nd at below knee 3rd above knee Now patient is asked to stand and

appearance of varicosity is looked for,within 30 sec in each segment

If the veins above the tourniquet fill up ,it indicates incompetence of communicating veins above tourniquet.

TOURNIQUET TEST If veins below tourniquet fill up

rapidly ,it indicates communicating veins below tourniquet are incompetent.

COUGH IMPULSE TEST Patient is asked to elevate the

limb . Then patient is asked to cough

forcibly. The impulse is felt on long

saphenous vein. This indicates the incompetent

of sapheno-femoral valve.

PERTHE TEST A tourniquet is tied around the

upper thigh. Then patient is asked to walk. If veins get dilated ,it indicates

the presence of incompetence.

CONSERVATIVE MANAGEMENT Elastic crepe bandage – stockings

Elevation of limbs

Graded compression

Excercise

Avoidance of prolonged standing

CONSERVATIVE MANAGEMENT Compression methods

Reduce ambulatory venous pressure

Improve cutaneous micro circulation

SCLEROTHERAPY Injection of sclerosant (ethanolamine

oleate) into an varicose vein causes sclerosis.

Leading to complete obliteration of vein.

SURGICAL MANAGEMENTINDICATION LSV /SSV incompetency . Perforating vein incompetency.

CONTRAINDICATION DVT Pregnancy Thrombophlebitis Peripheral vascular disease

STEPS OF SURGERY After anesthesia proper position

is given. The whole table is tilted head

down to an angle of about 10 degree. (trendelenberg position)

STEPS OF SURGERY Incisions :1. Hockey stick incision2. Oblique incision Incision is kept at groin at Saphenous opening 3-4 cm below and lateral to pubic tubercle.

STEPS OF SURGERY

STEPS OF SURGERY Then stripper is passed down the

saphenous vein and directed downward by finger .

Vein is tied with stripper and then stripper is slowly and steadily pulled out through lower wound

STEPS OF SURGERY

NEW SURGICAL TECHNIQUES Vein valve tranplantation