Dr Shanavas CDNB Trainee In General Surgery

They are dilated, tortuous, elongated veins in the leg. There is reversal of blood flow through its faulty valves.It is permanently elongated, dilated vein/veins with tortuous path causing pathological circulation.

Risk factors being heredity; female sex; occupation that demands prolongedstanding; immobility; raised intra-abdominal pressure like in sports, tight clothing, pregnancy, raised progesterone level and altered estrogen-progesterone ratio, chronic constipation, highheels. Prevalence of varicose veins is 35%; severe varicoseveins is 10%; chronic venous insuffi ciency (CVI) is 8%; Ulcer is 2%.

Introduction The venous drainage system of the lower

extremity consists of three sets of veins:Deep veins,Superficial veinsPerforating veins. All veins contain delicate one-way valves that

normally open to allow blood to flow toward the heart and prevent blood from flowing in a retrograde fashion after the valves close .

Veins of lower limb 1: Superficial veins: Long saphenous vein Short saphenous vein 2: Deep veins : Anterior & Posterior Tibial veins Peroneal vein Popliteal vein Femoral vein 3: Perforator veins

Long saphenous vein (LSV)Largest and longest

superficial vein of the limb.

Begins on the dorsum of foot from medial end of dorsal venous arch.

Run 1 to 1.5 inch anterior to the medial malleolus ,along the medial side of the leg , and behind knee .

At the ankle the position of the LSV is constant , lying in the groove b/w the anterior border of the medial malleolus and tendon of tibialis anterior.

In the thigh it inclines forwards to reach the saphenous opening where it pierces the cribriform fascia and opens into the femoral vein 3-4 cm below and lateral to the pubic tubercle.

The long saphenous vein and deep fascia In the lower 2/3 of leg

and in upper 2/3 of the thigh vein lie on deep fascia .

Where the vein crosses the knee joint it become more superficial and often subcuticular .

The structures accompanying the LSV In the leg saphenous nerve lies in close

relation with the LSV.The nerve is very closely applied to the vein

in lower 2/3 of leg and often injured in exploring or stripping the saphenous vein .

In the thigh medial femoral cutaneous nerve run in close relation with vein .

Throughout its length the LSV is accompanied by lymphatic trunks draining the dorsum of foot and anterior and medial aspects of the legs and thigh .

This lymphatic drain in superficial inguinal lymph nodes.

Tributaries of LSV and communication Just below knee LSV receive posterior arch

vein (Leonardo's vein) which collect the blood from post-medial aspect of calf .

Anterior veins of leg(stocking vein) ascend across the shin and join either LSV or posterior arch vein .

There is a free anastomosis b/w tributaries of short saphenous vein and venous arch connecting medial ankle perforating vein and this medial ankle perforating veins are connected with LSV in lower third of leg .

In the thigh before entering in the saphenous opening it recieves

1. Anterolateral vein 2. Posteromedial vein of thigh 3. Superficial external pudendal vein 4. Superficial epigastric vein 5. Superficial circumflex iliac vein 6. Deep External Pudendal Vein

In the lower third of thigh long saphenous vein connect with femoral vein in hunter’s canal by long perforating vein

( hunterian perforator)

Short saphenous vein(SSV)It begins by the fusion

of number of small veins below and behind the lateral malleolus . Here vein runs with the large sural nerve up to lower third of leg.

SSV is runs upward up to the middle of the popliteal space, where it passes deep to fascia to enter into popliteal vein .

In the lower third of the calf it lies on the deep fascia and cover by skin and superficial fascia .

In the middle third of leg it enters in the intrafascia compartment in the aponeurotic investment of the gastrocnemius muscle .

Upper third of leg it penetrates the deep fascia and enter popliteal space and lie b/w head of two gastrocnemius muscle which lies 1.25cm below the transvers skin crease behind knee .

Here SSV join popliteal vein .

Structures accompanying the SSV

Sural nerve in lower third of leg

Lymphatic trunk which drains lateral aspect of foot and drain in the popliteal lymph nodes.

Where the vein passes through fascia Posterior cuteneous nerve emerges out from deep to superficial.

In the upper part of vein it communicates with LSV via the posteromedial vein of Leg.

SSV may run above the popliteal space and end in deep veins in lower thigh or may end in LSV in upper thigh.

Deep veins This veins lie in deep fascial plane and are

supported by powerful muscles of leg.These are 1: Anterior and posterior Tibial veins 2: Peroneal vein 3: Popliteal vein 4: Femoral vein These veins accompany with Arteries.

Perforating veins These are communicating veins b/w

superficial and deep veins .

Two type: 1 Indirect veins 2 Direct veins

1. 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.

Direct perforating veins :

These directly connect superficial veins with deep veins

Direct perforator 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. May/Kuster

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

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 .

Classification I

♦ Long/great saphenous vein varicosity.♦ Short/small saphenous vein varicosity.

♦ Varicose veins due to perforator incompetence.

Classification II♦ Thread veins (or dermal fl ares/telangiectasis/spider veins/Hypen veins are 0.5-1 mm in size): Are small varices in theskin usually around ankle which look like dilated, red orpurple network of veins (Venulectasia). Spider naevi/venousfl ares are common in females.♦ Reticular varices (1-4 mm in size): Are slightly larger varicesthan thread veins located in subcutaneous/subdermal region.♦ Varicose veins. Dilated palpable subcutaneous veins morethan 4 mm in diameter (specifi cally located in saphenouscompartment).♦ Combination of any of the above.

CEAP classifi cationC— Clinical signs (grade 0-6); (A) for asymptomatic or (S)

forsymptomatic presentationE— Etiological classification: Congenital (Ec), Primary (Ep),Secondary (Es), No venous etiology (En)A— Anatomic distribution: Superfi cial (As), Deep (Ad) or

Perfo-rator (Ap), No venous location identifi ed (An)P— Pathophysiologic dysfunction: Refl ux (Pr), Obstructive

(Po),Both, or No pathophysiology identifi ed (Pn)

Grading of clinical signs (C)0—No visible or palpable signs of venous diseases1—Telangiectases, reticular veins or malleolar fl are2—Varicose veins3—Oedema without skin changes4—Skin changes due to venous diseases like

pigmentation,eczema or lipodermatosclerosis 4a—pigmentation; 4b—

lipo-dermatosis, atrophia blanche5—Skin changes as above with healed ulceration6—Skin changes as above with active ulceration

As—superfi cial system:1–Telangiectases, reticular veins2– Great saphenous vein above the knee—ostial and preter-minal3–Great saphenous vein below the knee4–Small saphnous vein5–Nonsaphenous—43%Ad—deep system:From 6 to 15Ap—perforator system:17–Perforator vein (PV) of the thigh18–Perforator (PV) of the calf and legAn—no anatomical lesion identifi ed

Pathogenesis

Fibrin cuff theoryWhite cell trapping theory

CVIChronic venous insuffi ciency (CVI) is a syndrome resultingfrom continuous chronic venous hypertension/ambulatoryvenous hypertension [AVP] (> 80 mmHg venous pressureat ankle) in the erect posture either on standing or

exercise(in normal people venous pressure in superfi cial system

fallsduring calf contraction). CVI consists of postural

discomfort,varicose veins, oedema, pigmentation, induration, derma-titis, lipodermatosclerosis and ulceration.

CVI patients maybe having superficial vein incompetence

(30%) with orwithout perforator incompetence or deep

vein incompetence(30%) or having previous DVT with complete

obliterationor partial recanalisation with incompetence

called as post-thrombotic syndrome (30%)

Surgical modalities for Varicose vein

o Ligation & Stripping of vein o Ligation of Incompetent Perforators 1.Open subfascial ligation of perforators 2.Subfascial Endoscopic ligation of

perforators 3,Extra fascial ligation of perforatorso Sclerotherapyo Endovenous Laser Ablationo Radiofrequency ablation

Etiology of varicose veins

Primary varicosities due to:Congenital incompetence or absence of valves.

Weakness or wasting of muscles—defective connective tissue and smooth muscle in the

venous wall.Stretching of deep fascia.Inheritance (family history) with FOXC2 gene.

Klippel-Trenaunay syndrome, avalvulia, Parkes-Webersyndrome. Here varices are of atypical

distribution.

Secondary varicosities:Recurrent thrombophlebitis.Occupational—standing for long hours (traffi c police,guards, sportsman).Obstruction to venous return like abdominal tumour,retroperitoneal fi brosis, lymphadeno pathy, ascites.Pregnancy (due to progesterone hormone), obesity,chronic constipation.AV malformations—congenital or acquired.Iliac vein thrombosis.Tricuspid valve incompetence.

Sites where varicosities can occurLower limbPampiniform plexus of veinsVulva, perineumSites of portosystemic anastomosis

Clinical featuresVisible dilated veins in the leg with pain, distress,

nocturnalcramps, feeling of heaviness, pruritus.♦ Pedal oedema, pigmentation, dermatitis, ulceration,

tender-ness, restricted ankle joint movement.♦ Bleeding, thickening of tibia occurs due to perio

stitis.♦ Positive cough impulse at the saphenofemoral

junction.♦ Saphena varix—a large varicosity in the groin, whichbecomes visible and prominent on coughing

Venous disability scoring systemScore 0 AsymptomaticScore 1 Symptomatic but able to carry outactivities without any therapyScore 2 Symptomatic—can do activities onlywith compression/limb elevationScore 3 Symptomatic—unable to do daily

activities even withcompression or limb elevation

Complications of Varicose Veins Haemorrhage:Pigmentation, eczema and dermatitisVenous ulcer. Marjolin`s ulcerLipodermatosclerosis. Deep venous thrombosis Calcifi cation of the wall of varicose veins or

of sclerosed soft tissue Recurrent thrombophlebitis.

Investigations-

Venous dopplerDuplex scanningVenographyPlethysmography:Photoplethysmography:Air plethysmography

Ambulatory venous pressure (AVP):Arm-foot venous pressure:U/S abdomen, peripheral smear, platelet count,

otherrelevant investigations are done depending on

the cause ofthe varicose veinIf venous ulcer is present, then the discharge is

collected for culture and sensitivity, biopsy from ulcer edge is taken to rule out Marjolin’s ulcer.

TreatmentConservative treatment:Elastic crepe bandage application from below

upwardsor use of pressure stockings to the limb—

pressuregradiant of 30-40 mmHg is provided.

Drugs used for varicose veins:Calcium dobesilate—500 mg BD. Calcium dobesilateimproves lymph fl ow; improves macrophage mediatedproteolysis; and reduces oedema.Diosmin—450 mg BD.Diosmin 450 mg + Hesperidin 50 mg (DAFLON 500mg). Mainly used in relieving night cramps but not toimprove healing of ulcers.Toxerutin 500 mg BD, TID. Antierythrocyte aggregationagent which improves capillary dynamics.Diosmin is micronized purifi ed fl avanoid fraction. Itprotects venous wall and valve, and it is anti-infl amma-tory, profi brinolytic, anti-oedema, lymphotropic

Surgical modalities for Varicose vein

o Ligation & Stripping of vein o Ligation of Incompetent Perforators 1.Open subfascial ligation of perforators 2.Subfascial Endoscopic ligation of

perforators 3,Extra fascial ligation of perforatorso Sclerotherapyo Endovenous Laser Ablationo Radiofrequency ablation

SurgeryLigation and stripping of varicose vein :Indication :

LSV /SSV incompetency .Perforating vein incompetency.

ContraindicationsDVTPregnancyThrombophlebitisPeripheral vascular disease

Pre-op marking of varicose vein As the varicose

vein disappear when pt lies down on operating table so its essential to mark the course of the major superficial tortuous vein to be removed.

Steps of surgery for LSV After anesthesia

proper position is given.

The whole table is tilted head down to an angle of about 10 degree. (trendlenberg position)

Incisions :1. Hockey stick

incision2. Oblique incision Incision is kept at

groin at Saphenous

opening 3-4 cm below and lateral to pubic tubercle.

After division of deep layer of fascia , saphenofemoral junction is exposed.

Then flush saphenofemoral ligation (& tranfixation) done with ligation of all tributaries of long SV .

Then stripper is passed down the saphenous vein and directed downward by finger .

.

Stripper delivered through small incision over ankle on medial aspect

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

The ‘vein bolus’ is withdrawn slowly from the lower wound.

The residual veins are then ‘wormed out ‘ using multiple stab avulsions using vein hooks ,from the preoperative marked sites.

Post operatively limb elevation and compression stockings are given .

STEPS OF SURGERY FOR SSVAfter anesthesia proper position is given.The patient must be face down and the knee

is flexed a little, by placing sandbag under the ankle .

Some prefer lateral leg position.The foot of the table is tilted up a little, so

that legs are above the heart.

Incision is kept atleast 5 cm long, transversely across the popliteal fossa, in one of the transverse line of skin about the level with knee joint.

The incision is deepened until the deep fascia and short saphenous vein lies deep to this.

The fascia is divided transversely in the line of incision.

The short saphenous vein is then seen or sought for betweeen the two heads of gastrocnemius.

As soon as the SSV is identified, it is lifted up in a pair of artery forceps and the knee is flexed still further.

Then flush saphenopopliteal ligation (& transfixation) done with ligation of all the side branches of SSV, right upto its junction with the popliteal vein.

Then stripper is passed down distally, directed by finger.

And delivered to point below external malleous through a small transverse incision.

INTRA- OPERATIVE COMPLICATIONS OF THE SURGERYBLEEDING FROM A TORN SAPHENA VARIX INJURY TO COMMON FEMORAL VEIN INJURY TOCOMMON FEMORAL ARTERYINJURY TO SAPHANEOUS NERVEINJURY TO SURAL NERVE

IMMEDIATE POST-OP CAREThree factors to be kept in mind in the first

week :

1 Maintenance of firm elastic pressure over whole limb.

2 Regular movement and exercise of the legs3 Elevation of the foot of the bed 6 to 9

inches so that the legs are just above the heart level when the patient is in bed.

POSITION :

The foot of the bed is raised 6 to 9 inches

Patient is not allowed more than 2 pillows.

BANDAGING :

The original firm crepe bandage put on at the operation should remain untouched for seven days

GETTING UP :Started 24 hrs after the operation.When the foot is placed on the ground for the

first time, extra firm webbing elastic bandage are placed over knee and ankle.

At 7 days the stitches are removed.A firm webbing elastic bandage from ankle to

knee is worn through-out the day for a whole fortnight.

Post operative complicationsHaematoma and buising- normally bruise absorbed within 3-4 wks- small haematos get reabsorbed large

haematomas more than 4 cm evacuated with sterile precaution under LA with sterile precautions

Lymphatoma-Generally occurs on 5-6 post op day-Get absorbed within 1-2 wks -Should not be interveined as may lead to

lymphatic fistula formation

Wound sepsisPost operative saphenous neuritisLymphoedema of legInduration of stripper tractDVT and embolism

Extra fascial ligation of perforators(Cocketts procedure)Not commonly employedAim is to clear all the extrafascial veinsMore traumatic due to adherence of

subcutaneous fat and connective tissue to the fascia

Subfascial Endoscopic Perforator Surgery

People who suffer with leg ulcers due to incompetent venous perforators

Indication :Incompetent perforating veins in calf with no

superficial venous reflux or no evidence of DVT on Doppler .

Patient with LSV / SSV varicosity with ulcer

Procedure Using spinal or general anesthesia a ¾

inch incision is made on the inside of the calf.

An instrument is inserted deep to the fascia of the leg and a large balloon is inflated with water to create a working space.

The balloon is then emptied and the space is insufflated with air.

The camera is inserted and the perforator veins can be seen in the space passing from superficial to deep layers.

Another small incision is made in the calf for passage of another instrument.

The perforator veins are carefully dissected, Clips are applied and the veins are divided

if necessary. All trocars are then removed and the wounds

are closed. The patient is generally sent home the same

day of surgery with elastic stocking.

Obliteration of venous lumen - Methods

1. Foam Sclerotherapy2. Laser3. Radiofrequency Ablation

Foam SclerotherapyPrincipal : By injecting

sclerosant into a varicose vein, destroy its endothelium in that area , and thus induce an aseptic thrombosis which organises and closes the vein.

Indication :

Residual vein after surgery

Large venous telangiectases.

Isolated small dilated veins

Contraindication :

PregnancyPelvic tumor Sup thromboplebitis

at the time of procedure

DVTPrevious h/o

reaction to sclerosant

SOLUTIONS :

SODIUM TETRADECYL SULPHATESOD.MORRHUATEHYPERTONIC SALINE SOL.POLYDOCANOL,SOTRADECOLETHANOLAMINE OLEATEGLUCOSE COMBINATIONS

`PROCEDURE :Depending upon the size

of vein to be occluded, sclerosant is taken in 20 ml syringe and connected to another syringe with 4 times the amount of air.

By repeated to and fro motion of the solution and air into syringes , dense white foam is prepared .

After giving position under USG guidance needle is inserted into the vein .

And sclerosant is injected into the vein .

Not more than 20 ml foam should be injected at one sitting ,

Multiple sitting may be required for successful obliteration of vein

The foam being dense , does not “run-away” up the vein, it require massaging the skin over varicose vein.

Immediately after foam injection compression stocking is applied and patient is mobilized .

Patient can go home on the same day of procedure.

After 48 hr of procedure USG is done to R/o DVT

AdvantageCheapEasy to learn Truly an OPD

procedure Can be repeated

many timesNo anesthesia

required

Disadvantage Not suitable for

SFJ/SPJ obliterationThrombophebitisPigmentation over

skin More than 3 wks

compression is required

Endovenous Laser Treatment (EVLT)Principal :

EVLT initiate a nonthrombotic occlusion by direct thermal injury to vein wall, causing endothelial denudation , collagen contraction and later fibrosis.

Indication :Long saphenous vein

varicosityShort saphenous

vein varicosity

Contraindication :Superficial vein

thrombophlebitisDVT

Procedure EVLT is done under local

anesthesia under USG guidance.

Varicose vein is marked preoperatively

Supine position is givenVein is canulated with

0.035” J guide-wire via 19G needle.

The Laser fiber is then introduce over it under USG guidance upto 2-3 cm distal to SF junction.

Fiber is withdrawn at the rate 1-3mm / sec under USG guidance .

This laser fiber causes thermal damage to the venous endothelium(1000 c) and occlusion of lumen by fibrosis.

Immediately after procedure compression stockings are given.

Patient can be discharge on same day with good analgesics and with compression stockings.

ADVANTAGEMinimal invasive

procedure No post op scarDone with local

anesthesiaMinimal post-op

pain Recurrence rate ( at

2 year f/u only 3%

DISADVANTAGECostly procedureHigh technical skills

reqColor Doppler and

Radiologist is req Skin burnsThrombophebitis Paresthesia

Radiofrequency AblationThis technique based on

same principal of EVLT Here instead of laser

fiber , special heater probe is inserted which work at 85 -120 c

Probe directly comes in contact with vein wall & causes tissue damage .

A 45 cm of vein segment takes only 3-5 min

Patient can directly go to home after procedure.

TRIVEXAlternative to avulsion phlebectomy for

superficial vein excision.

In this technique with the help of transcutaneous light, veins are seen and extracted with the help of suction dissector.

Thank You