varicose vein dr victor jesron nababan spbtkv 160116

Victor Jesron Nababan, MD, Cardiothoracic & Vascular Surgeon @ Awal Bros Hospital Batam

PENGENALAN CAKUPAN BEDAH

TORAK, KARDIAK DAN VASKULER

TORAK TRAUMA

NON TRAUMA

NEOPLASMA DINDING DADA ORGAN INTRA TORAK

INFEKSI SPESIFIK/NON SPESIFIK

DEGENERASI PARENKIM PARU BLD

KELAINAN DINDING DADA

DIAFRAGMA

LAIN2 PALMAR HIPERHIDROSIS (TORAKAL SIMPATEKTOMI), RAYNAUD, TOS


KARDIAK JANTUNG PEDIATRI

KELAIANAN JANTUNG BAWAAN PDA, ASD, VSD, TOF, DORV, TA, DLL

KELAINAN JANTUNG DIDAPAT RHD, IE, DLL

JANTUNG DEWASA KORONER ON PUMP, OFF PUMP KATUB ARYTMIA SURGERY MAZE PACE MAKER PERMANENT ASSIST DEVICE IABP, ECMO, LVAD, RVAD, BIVAD AORTA TORAKAL DHCA NEOPLASMA MYXOMA EMBOLI PARU PENYAKIT PERICARD TRAUMA


VASKULER TRAUMA

NON TRAUMA VENA CVD (VARICES, CVI), DVT, MAY

TURNER, DLL

ARTERI ANEURISMA, PSEUDOANEURISMA, PAPO, DIABETIC FOOT ULCER

AORTA TAA, AAA

MALFORMASI ARTERIO VENOUS

AKSES VAKULER CENTRAL, PERIFER, HD AKSES (AV SHUNT, HD CATHETER), CHEMOPORT


VICTOR JESRON NABABAN,MDCARDIOTHORACIC AND VASCULAR SURGEON

Background Chronic venous disorders include a spectrum of

clinical manifestations extending from telangiectasias & varicose veins to lipodermatosclerosis & ulceration.

Varicose veins are the most common manifestation of primary chronic venous disease.

varicose veins are usually differentiated from reticular veins and telangiectasias


Terminology & New definition CVD, chronic venous disorders: embraces C1–C6.

CVI, chronic venous insufficiency: limited to C3–C6.

Telangiectasias:a confluence of dilated intradermal venules of less than 1 mm in caliber. Synonyms include spider veins, hyphen webs, and thread vein

Reticular veins: dilated bluish subdermal veins usually from 1 mm in diameter to less than 3 mm in diameter. They are usually tortuous.


Definition


Epidemiology Varicose veins are present in 25% - 33% & chronic venous

insufficiency, with skin changes and ulceration, in 2% -5% of Western populations.

The prevalence of VV increases markedly with age and they are an almost universal finding in individuals over the age of 60 years.


Valvular Function in V V’sHealthy Diseased


2 venous drainage systems: deep and superficial

Superficial: long and short saphenous veins

Superficial connects to deep system via perforators

Saphenofemoral junction 2-4cm inferolateral to pubic tubercle


The CEAP Classification C linical Classification

E tiological Classification

A natomical segmental localization

P athophysiological classification


Revisi CEAP tahun 2004

Class-0

...kalau periksa jangan lama lama.....


CEAP Class 1

Hanya nampak

varises kapilaris

atau retikularis saja

Class-1


CEAP Class 2

Varise trunkal

sederhana (Grade-

II-III)

Class-2


CEAP Class 3Edema ankle/ malelolus

kearah proksimal .

Kongesti venous

karena inkompetensi

vena safena dapat

menyebabkan edema

ortostatik.

Class-3


CEAP Class 4

Pigmentasi kulit

tungkai bawah medial

(lipodermatosklerosis).

Deposit hemosiderin

menentukan warna

perubahan kulit dan

bisa menjadi tanda

keradangan kronis

yang menyebabkan

proses fibrosis

Class-4


CEAP Class 5Ulkus venous yang

MENYEMBUH .

Kenaikan tekanan vena

menyebabkan hipoksia

jaringan yang

menyebabkan

kerapuhan kulit dan

terjadi ulserasi.

Class-5


CEAP Class 6Ulkus venous

terbuka/ aktif. ulcer.

Hipertensi venous

menyebabkan

periubahan gradien

tekanan yang

menyebabkan

ulkus.

Class-6


Beware : CEAP-6 in a diabetic

patientTreated (personally) with

diabetic wound dressing....

(more than 2 months)

Then treated with Pasta-Unna

wound dressing.... (2 weeks)


Risk Factors


Symptoms Great majority of individuals with VV are

asymptomatic

A wide variety of lower limb symptoms have been attributed to VV. These include: 1. aching

2. heaviness and tension

3. a feeling of swelling

4. tiredness

5. restless legs

6. nocturnal cramps

7. itching.


Physical Examination

Position

The patient should be examined standing in a good light in a warm room.

Inspection

dilated, elongated, tortuous, and sacculated vein

signs of CVI include

corona phlebectatica,

lipodermatosclerosis, and

open ulceration


Physical Examination (1)

Palpation

Percussion over a varix while palpating with the other hand at a higher or lower level will help trace out the pattern (the “tap” test of Chevrier).

Particularly helpful in the obese.

There may be a cough impulse, even a thrill over a large varix, particularly a saphena varix in the groin.



Tredelenburg Test

Purpose: to identify the level and location of deep to superficial reflux.

Value in circumstances in which duplex scanning is not readily available.



Tredelenburg Test The test comprises two parts : Part 1:

The patient lying down the leg is elevated to 45° and

A tourniquet or the examiner’s hand compresses the GSV in the high thigh.

With compression in place, the patient stands in a well-lit room.

Previously noted superficial veins are then carefully observed for filling with blood

Part 2:

The compression is then released.

The superficial veins are then carefully observed for increased filling with blood.



Interpretation of Tredelenburg Test


Physical Examination (3) Ulcer Examination

This should include

1. a description of the ulcer, concentrating on the

2. pulse status and ankle–brachial index

3. gait and, in particular, ankle mobility

4. general physical examination


Diagnostic Tools

Diagnostic Vascular Laboratory Non invasive test

Indirect : Plethysmography is used in the assessment of the amount of reflux, the efficiency of the calf muscle

pump, and obstruction.

Direct: Duplex scan can determine the presence of anatomic obstruction with a sensitivity and specificity

of over 90%

Radiologic Imaging Computed tomography or (MRI)

Invasive Phlebography

IVUS


RULE # 1


RULE # 2


Sign of the egyptian EYE


Management

Medical Ablation

Compression

Sclerotherapy

Drugs

Surgery

Percutaneous Laser

RF ablation

Stripping

Babcock excision


Medical Management Compression tx standard first-line treatment for CVI and venous ulcer

Goal: to facilitate ulcer healing, provide rapid ulcer healing, and prevent recurrence

Including: elastic compression stockings,

paste gauze boots (Unna’s boot),

and multilayer wraps,dressings, and bandages.

Pneumatic compression devices


Medical Management Drugs treatment No drug will cure varicose veins, although some drugs benefit

venous edema & ulceration.

Some phlebotonic drugs improve the symptoms and edema associated with venous disease. These could be used in association with compression for the management of troublesome symptoms.

Drugs for venous ulcer: Fibrinolytic tx

Drugs that modify Leukocyte metabolism

Platelet inhibitors


Medical Management Sclerotheraphy Indication: Superficial venules, “venous spiders” (veins < 1 mm of internal

diameter), venous lakes, and other venous blemishes.

Varicosities 1–3 mm in diameter in the absence of detectable valvularreflux as evidenced by duplex examination.

Postoperative residual veins are those < 3 mm in Ø that the surgeon chose not to excise in order to limit the number of incisions.

Incompetent perforating veins (< 4 mm)

Bleeding varicosities (varicorrhage)


Medical Management Sclerotheraphy

Contraindication:

Pregnancy

Elderly and sedentary patients

Generalized, severe systemic disease

Advanced rheumatic disease, osteoarthritis or any disease of the musculoskeletal system that interferes with the patient’s mobility.

Arterial insufficiency of the lower extremities

Patients with history of severe allergic disease or bronchial asthma


Medical Management Sclerotheraphy

Contraindication:

Febrile illnesses

Acute superficial thrombophlebitis or deep vein thrombosis

Obesity.

Varicose veins in communication with a source of venous reflux, demonstrated by duplex ultrasound,

Patients on anticoagulants


Medical Compression Stockings

CLINICAL

SITUATIONS

COMPRESSION in mmHg

10-20 20-30 30-40

C0s, C1s

C1 Post-Injections

C2s Pregnancy

C3 Prevention

C4b

C5

C6

The efficacy of MCS have been proved in a lot of

clinical situations, even leg ulcers


Surgical Management 3 principle goals The varicosities must be permanently removed and the

underlying cause of venous hypertension treated the repair must be done in as cosmetic a fashion as possible complications must be minimized.

Indication: Truncal varicose vein gr III-IV

Contraindication Pts with VTE Pts with anesthetic complication


Surgical Management Early Complication:

discomfort

bruising

bleeding

wound infections

deep venous thrombosis

nerve injury

Technique: Stripping GSV or SSV

Phlebectomy


PHLEBECTOMY


Main RULES Phlebectomy

1. Small incisions (1-2 mm)2. Longitudinal3. Hooks4. Steristrips5. compression

Phlebectomy can replace all the component parts of

the operation except flush ligation

Good practical experience is necessaryCan rescue the operation

Spare wheel


• Simplifies Surgery (recurrences)

• Makes it less traumatic

• Goes where surgeon cannot go:

• lympho-nodal networks of the groin

• Deep and long, dystrophic perforators

• Recurrent VV inside the saph. compartment

* Creton D. et Uhl JF EJVES 1998;15:412-5


70 incisions

Mean number : 30 incisions per operation


Endoluminal radiofrequency/laser ablation of the great saphenous vein: methods

Photograph courtesy of VNUS medical Technologies, San Jose, CA.

Percutaneous access to the greater saphenous vein most commonly at the level of the knee under duplex ultrasound guidance

Bola Pratt P&S MS 4


Endoluminal radiofrequency ablation of the great saphenous vein: methods

Photographs courtesy of VNUS medical Technologies, San Jose, CA.

1) A guidewire is then advanced to the saphenofemoral junction over which the closure catheter is passed

2) catheter prongs are extruded tocontact the intimal lining of the vessel wall

3) radiofrequency generator allows the tip of the catheterand the prongs to attain a temperature of 85 degrees C.

CFA = common femoral arteryCFV = common femoral veinSEV= superficial epigastric veinSFJ = saphenofemoral junction

Bola Pratt P&S MS 4


FEMORAL BLOCK

EPIDURAL - SPINAL

GENERAL anesthesia


TUMESCENT

anesthesia

The best technique +++++

Only one technique

For varicose veins surgery


- a solution of iso Bicar (500 ml) Klein pump

+

+ 20 ml 1% lidocain + 2% adrenalin


Take home message

Anesthesia by Blocks possible but

Tumescent Anesthesia is the best ++

Avoid general or peridural anesthesia For GSV surgery

risk, bleeding , early walk

quick return to normal activity +++

complication nerve injury


Thank you!Any Questions?


varicose vein dr victor jesron nababan spbtkv 160116

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