evaluation and treatment of varicose veins/venous...
TRANSCRIPT
Anatomy There are three basic components to the venous system
1. Deep veinsIliac, femoral, popliteal, tibial, giocamini
2. Superficial veinsgreater and small saphenous, anterior branch of saphenous
3. Communicating or perforators (3 primary, but there are more)Hunterian in proximal thigh, Dodds in inferior 1/3 of thighBoyd’s at the knee, Cockett in posterior arch vein (mid calf)
Valves in the superficial and deep veins open in response to the calf pump to allow blood flow toward the heart.
When the pumping stops, blood is prevented from refluxing back down the legs by the closure of the valves within the deep and superficial veins.
Arterial flow fills the venous system at rest.
As the venous system fills, the valves in the foot, distal leg and perforating system open to allow blood into the deep system.
Venous obstruction DVT, iliac venous obstructive lesions
Valvular insufficiency Abnormal closure of a valve
Calf muscle pump malfunction <10% of population have this Calf muscle problems generally begin within the
delicate veins in the deep system (which run deep within the calf muscle that is sheathed within the fascia).
Hx of DVTFamily hx of
Varicose VeinsObesitySmokingFemale
Pregnancy InactivityProlonged periods
of sitting or standing
Over age 50
Signs- Talengiectasias Edema Hyper pigmentation Lipodermatosclerosis Venous ulcers Appearance of large, ropey varicose veins Veins that are dark purple or blue in color Bleeding varicosity
Symptoms Complaints of swelling, heaviness Leg cramps or aches Painful veins Swelling Enlarging Veins Pain with standing Nocturnal muscle cramps Leg tiredness Itching and/or burning Venous claudication usually with chronic ilio-femoral venous obstruction in which they
develop severe thigh pain and a sensation of tightness with vigorous exercise and usually takes 15 – 20 min to subside.
Limping and/or pain due to inadequate venous drainage
Poor return of blood by the veins from the legs
Usually chronic ileofemoral venous obstruction.
Pts develop severe thigh pain and a sensation of tightness with vigorous exercise and takes 15 – 20 minutes to subside
Venous Pain is often
improved by walking or elevating legs
Warmth tends to aggravate the symptoms and cold tends to relieve them
Compression stockings tend to decrease the pain
Arterial Pain is usually worse
with walking or elevating legs
Cold tends to aggravate the symptoms while warmth tends to relieve them
Compression stockings usually aggravate the pain
Thorough history and physicalWarm roomWell illuminated Pt standing at least 5 minutes Inspection PalpationMeasurement PhotographyDocumentation
Non-invasive vascular testing
DermatitisHyperpigmentation Lipodermatosclerosis CellulitisHealed ulcerOpen ulcer
Full leg exposure View the leg from all sides
Major vein anatomy Document
- size- extent- discoloration or skin changes
What types of veins are present? Telangiectasia Reticular veins Varicose veins No veins noted (symptomatic)
Multiple vein types GSV phlebitits Varicose veins telangiectasia
Explain the vein types to the patient Set expectations for therapy
The most common indications for treatment of varicose veins are intractable symptoms which interfere with the patient’s daily activities of life in spite of conservative treatments
Whole limb swellingAbdominal wall varicositiesProximal extremity varicosities Medial or lateral across inguinal ligament Vulvar varicosities Gluteal varicosities
Thin, athletic patients (maybe not)LymphedemaCharcot footKnee issuesBack issuesSoft tissuesLipemia (presence in the blood of an
abnormally high concentration of emulsified fat)
The primary therapy remains essentially the same
Treat symptoms
Restore normal physiologic function to the diseased limbs
Common complications Bruising Hematoma Bleeding Pain Paresthesia
*Recurrence rate that is nearly 30% at 5 years
Can be done either by laser or radiofrequency energy
Done by gaining percutaneous vein access Catheter is passed through sheath and
advanced to SFJ Areas to be ablated are filled with tumescent
Bruising EdemaDVT < 5% Paresthesia Skin burns Thermal injury to adjacent tissues Inadvertent injury to deep veins
Ablation Assess treated vein Varicose veins: assess regression or
decompression, thrombosis Phlebectomy Incisions closed No fluid collections, inflammation, cellulitis Completeness of the phlebectomy
Telangiectasia Pt satisfaction
-missing diagnosis of DVT -missing diagnosis of superficial venous thrombosis -mis-diagnosis of stasis dermatitis as contact
dermatitis -misdiagnosis venous vs. arterial disease
Subjective symptoms worsen Non-healing ulcers develop Increased lifetime risk of DVT and/or PE Tissue atrophy & staining not reversible Venous insufficiency syndromes can lead to death from
thromboembolis or hemorrhage Ankle joint stiffness from progressive subcutaneous
scarring occasionally extends into the subcutaneous tissue around the ankle join, restricting ankle movement, reducing calf pump efficiency, and exacerbating the venous hypertension. Fibrous ankylosis may, eventually, fix the ankle joint with scar tissue.
Fixed plantar flexion: chronic pain of acute lipodermatosclerosis or ulcer may result in abnormal weight bearing and eventually ankle stiffening and shortening of the Achilles tendon.
Periostitis: long standing inflammation in soft tissues may induce hyperemia in the underlying periosteum, which can then produce new subperiosteal bone (usually happens underneath an area of recurrent ulceration).
History guides the exam Thorough physical is key Recognize the abnormal findingsMeasure and document a baseline Predict the anatomic findings of subsequent
testing Know the difference between venous and
arterial signs/symptoms
THE END… THANK YOU