MANAGEMENT OF VARICOSE VEINS
WHEN & HOW
BY
DR.G.THULASIKUMAR
M.S.(Gen.Surg) M.Ch. (Vascular Surgery)
Department of Vascular Surgery
Govt. Kilpauk Medical College Hospital
Chennai-10
Votive offerings such
as these were given to
physicians by grateful
patients after
successful treatment
Chronic venous disease

Most common vascular disorder
 3 Billion US dollars spent a year for
treatment
 3 % of the total Heath care Budget
 2 million USA work days lost per year
DEFINITION

A VEIN THAT BECOMES ELONGATED,
DILATED, TORTUOUS, POUCHES AND
THICKENED DUE TO DYSFUNCTIONING
VALVES CAUSING CONTINOUS
DILATATION UNDER PRESSURE .
Definition

Telangiectasias - are a confluence of dilated
intradermal venules less than one millimeter in
diameter.

Reticular veins - are dilated bluish subdermal veins,
one to three millimeters in diameter. Usually tortuous.

Varicose veins - are subcutaneous dilated veins three
millimeters or greater in size. They may involve the
saphenous veins, saphenous tributaries, or
nonsaphenous superficial leg veins.
Subcutaneous Veins
When abnormal:
 - Telangiectasia
(spider – 1mm)


- Reticular (1- 3
mm)

Varicose (>3mm)
Abnormal Veins
Telangiec
tasias
Reticular
veins
Varicose vein
INCIDENCE
MEN : 10-15%
WOMEN : 20-25%
WHEN NON SAPHENOUS VARICOSITIES ARE
INCLUDED
MEN : 45%
WOMEN : 50%
RISK FACTORS
FEMALE GENDER
ADVANCED AGE
CAUCASIAN RACE
FAMILY HISTORY
ACCELERATORS
PREGNANCY
OBESITY
VENOUS SYSTEM OF LOWER LIMBS

SUPERFICIAL VEINS
 DEEP VEINS
 PERFORATORS
SUPERFICIAL VEINS

LONG SAPHENOUS SYSTEM
 SHORT SAPHENOUS SYSTEM
LONG SAPHENOUS SYSTEM
FROM MEDIAL LIMB THE DORSAL ARCH TO SAPHENOUS
OPENING – SAPHENO FEMORAL JUNCTION
SFJ TRIBUTARIES
SUPERFICIAL EPIGASTRIC VEIN
SUPERFICIAL EXTERNAL PUDENDAL VEIN
SUPERFICIAL LATERAL CIRCUMFLEX
ILIAC VEIN.
THIGH TRIBUTARIES
ANTEROLATERAL VEIN
POSTEROMEDIAL VEIN
CALF TRIBUTARIES
ANTERIOR ARCH VEIN
POSTERIOR ARCH VEIN
SHORT SAPHENOUS SYSTEM
SAPHENO POPLITEAL JUNCTION
BRANCHES
LATERL CALF VEIN
MEDIAL CALF VEIN
VEINS CONNECTING LSV & SSV
LATERAL THIGH VEIN
INTER SAPHENOUS VEIN
ACCOMPANYING NERVES
LSV – SAPENOUS NERVE
SSV – SURAL NERVE
Perforators

Connect deep and
superficial systems

Flow normally from
superficial to deep
PERFORATORS
•USUALLY DOUBLE
•1-2mm IN DIAMETER
•UPWARD DIRECTION
FROM THEIR SUP.VEIN
LSV PERFORATORS
THIGH –
DODD’S GROUP
HUNTER’S PERFORATOR
DODD’S PERFORATING VEIN
HACH PERFORATING VEIN
PERFORATORS
BELOW KNEE
BOYD’S
SHERMAN’S - 24cm
COCKETT’S - III---18cm
II---12cm
I--- 6cm
CALF PERFORATORS
GASTROCNEMIUS (MAY’S)
SOLEUS PERFORATORS
BASSI’S VEIN- PERONEAL TO
LSV
FIBULAR
FOOT PERFORATORS
KUSTER-------MARGINAL
BELOW MEDIAL + LATERAL
MALLEOLI
VALVES
PHYSIOLOGY

VIS A TERGO—LV CONTRACTION

VIS A FONTE---R A CONTRACTION
FOOT MUSCLE PUMP

DEEP PLANTAR ARCH

SUPERFICIAL DORSAL ARCH
 BOW STRING EFFECT - FLATTENS
BOTH ARCHES EMPTYING
 VEINS PRESSURE > 100mg OF Hg
 CONTRIBUTES > 50% BLOOD
LEAVING CALF
Muscle Pump

CALF MUSCLE PUMP
– 200 – 300 mm OF Hg
– >80 ml OF BLOOD
 Contractions propel
blood towards heart
 Relaxation draws
blood from
- superficial veins
- lower deep veins
Thoracoabdominal Pump
Inspiration
decreases
intrathoracic
pressure
promoting venous
return
 Expiration
reverses the
process
 Findings easily
seen in US

REFILLING THE PUMP

FROM ARTERIAL SYSTEM
 FROM SUPERFICIAL VENOUS SYSTEM

PRESSURE IN ERECT POSTURE >100mg OF
Hg
 INTRAVENOUS PRESSURE IN SUPINE
POSTURE SELDOM < 5mm OF Hg
 REFILLING TIME 20-30 S
AMBULATORY VENOUS PRESSURE

RESIDUAL VENOUS PRESSURE
 VIS –A-TERGO
0.3mm OF Hg
 HYDROSTATIC PRESSURE 100mm
OF Hg
 AVP (MINIMUM PRESSURE. SHOWN
DURING EXERCISE)
– FALLS BY 60-80% IN FEW SECONDS.
IN CVI / CVH
VALVULAR INCOMPETENCE
CONTINUED REFLUX
INCREASED AVP DURING EXERCISE
DUE TO INCOMPLETE EMPTYING
DECREASED REFILLING TIME <10S
INDEPENDENT(PRIVATE) CIRCULATION –
BLOOD IN THE DEEP SYSTEM
FLOWS UP IN THE
DEEP SYSTEM
FLOWS DOWN IN THE
SAPHENOUS SYSTEM
PATHOPHYSIOLOGY OF MICROCIRCULATION CHANGES IN
VENOUS HYPERTENSION
PRIMARY VARICOSE VEINS
DEEP VENOUS INSUFFICIENCY
AMBULATORY VENOUS HYPERTENSION
VENULAR AND CAPILLARY DILATATION
DECREASED CAPILLARY PERFUSION PRESSURE
INCREASED CAPILLARY PERMEABILITY
CHRONIC LYMPHATIC DAMAGE
DECREASED LYMPHATIC DRAINAGE
PATHOPHYSIOLOGY OF MICROCIRCULATION CHANGES IN
VENOUS HYPERTENSION
DECREASED LYMPHATIC DRAINAGE
WBC TRAPPING, ADHESION,
ACTIVATION
IMPEDANCE OF
MICROCIRCULATORY FLOW
PLUS RELEASE FREE
RADICALS, PROTEOLYTIC
ENZYMES, CYTOKINES AND
CHEMOTACTIC AGENTS
MACROMOLECULES ENTER
CIRCULATION
PERICAPILLARY FIBRIN CUFF
IMPAIRED TISSUE PERFUSION AND OXYGENATION
VENOUS ULCERATION
CLINICAL EVALUATION

ASYMPTOMATIC


COSMETIC
SYMPTOMATIC
– PAIN & SWELLING
– COMPLICATION
SYMPTOMS

PAIN
–
–
–
–
–
–




THROBBING
ACHING
STINGING
BURNING
EXERCISE – VARIABLE EFFECT ON PAIN
NIGHT PAIN—CRAMPINESS
ITCHING
SKIN CHANGES
COMPLICATIONS
EFFECTS OF PREVIOUS TREATMENTS.
Complications

EXTREMELY PAINFUL
ULCERS - NEAR VARICOSE
VEINS, PARTICULARLY NEAR
THE ANKLES.

BROWNISH PIGMENTATION
USUALLY PRECEDES THE
DEVELOPMENT OF AN ULCER.

OCCASIONALLY, VEINS DEEP
BECOME ENLARGED.
BLEEDING
SUPERFICIAL
THROMBOPHLEBITIS



PERSONAL HISTORY

PREGNANCY
MENSTURAL CYCLE
PELVIC CONGESTION SYNDROMES
– (VULVOPUDENDAL VARICES ASSOCIATED
WITH PELVIC & OVARIAN VARICES


PAST MEDICAL HISTORY





CONGESTIVE FAILURE
RENAL & CIRCULATORY FAILURE
AUTOIMMUNE DISEASES
ALLERGIC HISTORY
HOSPITALISATION AND IMMOBILISATION
STRONG FAMILIAL COMPONENT

Not well studied
 Twin studies 75% identical, 52% non
identical
 If both parents VVS - 90% of children
VVs
 If one parent was affected 25 percent for
men and 62 percent for women

Cornu-Thenard, A, Boivin, P, Baud, JM, et al. Importance of the familial factor in varicose
disease. Clinical study of 134 families. J Dermatol Surg Oncol 1994; 20:318.
PHYSICAL EXAMINATIONS

STANDING POSITION
 SKIN SHOULD BE INSPECTED,TAPPED,
TOUCHED, PRESSED & SQUEEZED

EVALUATION FOR:
–
–
–
–
–
–
COLOR
TEMPERATURE
TEXTURE
TURGOR
MOISTURE
HAIR QUALITY
SKIN CHANGES

CORONAPHLEBECTATICA

VENOUS ECZEMA

BROWN HAEMOSIDERIN
DEPOSITION

ACUTE/CHRONIC
LIPODERMATO SCLEROSIS

INDURATION

ATROPHIC BLANCHE

OEDEMA

VENOUS ULCERATION

CONTRACTURES

MARJOLINS ULCER
VARICOSITIES
SPIDER NAEVI—TELENGIECTASIA
RETICULAR VEIN—VENULECTASIS
TRUNCAL VARICOSITIES
CLINICAL TESTS

TO KNOW
WHICH SYSTEM
WHICH PERFORATOR
PATENCY OF DEEP VEIN
TRENDELENBURG TEST
I & II
SCHWARTZ TEST (CRUVHEILLIER’S SIGN)
MORISSEY’S COUGH IMPULSE
FEGAN’S METHOD. (PHALEN’S TEST)
PRATT’S TEST
THREE TOURNIQUET TEST
(Mahorne-ochsner )
PERTHE’S TEST
PHYSICAL EXAMINATION

ABDOMINAL PELVIC EXAMINATION.
 AUSCULTATION.
CEAP CLASSIFICATION

CLINICAL
 ETIOLOGIC
 ANATOMIC
 PATHOPHYSIOLOGIC
CLINICAL CLASSIFICATION

CO NO SIGN OF VENOUS DISEASE

C1 TELENGIECTASIA AND SPIDER VEINS

C2 VARICOSE VEINS

C3 EDEMA DUE TO VENOUS DISEASE

C4 SKIN CHANGES; LIPODERMATOSCLEROSIS

C5 HEALED ULCERS

C6 ACTIVE ULCERS
ETIOLOGIC

CONGENITAL
 PRIMARY
 SECONDARY



POST THROMBOTIC
POST TRAUMATIC
OTHERS
EC
EP
ES
ANATOMIC SEGMENTS 18
SUP VEINS As
 1. LSV
 2. ABOVE KNEE
 3. BELOW KNEE
 4. SSV
 5. NON
SAPHENOUS
DEEPVEIN Ad
6. IVC
16. MUSCULAR
PERFORATING VEIN
Ap
17. THIGH
18. CALF
PATHOPHYSIOLOGIC CLASSIFICATION

REFLUX
Pr
 OBSTRUCTION
Po
 REFLUX & OBSTRUCTION Pro
INVESTIGATIONS
CONTINUOUS WAVE DOPPLER

TO ASSES FLOW DIRECTION

QUALITATIVE ASSESSMENT OF VENOUS
REFLUX

DOES NOT GIVE ANY ANATOMIC
INFORMATION.

USEFUL FOR EVALUATION OF REFLUX IN
SFJ & SPJ
DUPLEX SCANNING
84% SENSITIVITY
88% SPECIVICITY
DIRECT DETECTION OF VALVULAR
REFLUX.
VISUALIZATION OF VALVE LEAFLET
MOTION
QUANTIFY DEGREE OF INCOMPETENCE
Duplex Ultrasonography

-
-
-
Replaced
plethysmography and
venography
7-10MHz linear
transducer
Exam sitting and
standing
Superficial and deep
systems evaluated
Physiologic reflux: < 0.5
sec
Pathologic reflux: > 0.5
sec

PLETHYSMOGRAPHY
– VOLUME CHANGE OF LIMB
– SECONDARY TO CHANGES IN
VENOUS BLOOD FLOW

PRESSURE MEASUREMENTS
– TRANSMURAL PRESSURE
– AMBULATORY VENOUS PRESSURE
—43-year-old woman with varicose veins.
Lee W et al. AJR 2008;191:1186-1191
©2008 by American Roentgen Ray Society
—43-year-old woman with varicose veins.
Lee W et al. AJR 2008;191:1186-1191
©2008 by American Roentgen Ray Society
INVASIVE PROCEDURES
1. ASCENDING PHLEBOGRAPHY
2. DESCENDING PHLEBOGRAPHY
3. CAVOGRAPHY
4. VARICOGRAPHY
ASCENDING PHLEBOGRAPHY

GOLD STANDARD

ANATOMIC FEATURES OF THE VEINS
AND THEIR VALVES ARE OUTLINED

POST THROMBOTIC CHANGES

PERFORATORS – INCOMPLETLY
IDENTIFIED
DESCENDING PHLEBOGRAPHY

GRADE 0 NO EVIDENCE OF REFLUX

GRADE 1 MINIMAL REFLUX THRO 1 OR MORE
VALVE

GRADE 2 CONSIDERABLE REFLUX IN THE
THIGH

GRADE 3 GRADE 2 + LEAKAGE IN TO
POPLITEAL VEIN

GRADE 4 GRADE 3 + LEAKAGE IN TO CALF
VEIN.
VARICOSE VEINS MAYBE DUE TO
1) PRIMARY DISEASE OF LSV
2) 1 + PERFORATOR INCOMPETENCE
3) 2 + DEEP VEIN REFLUX DUE TO VALVULAR INCOMPETENCE
4) 2 + POSTTHROMBOTIC REFLUX OR OBSTRUCTION.
5) 4 + THROMBOTIC OCCLUSION OF ILIAC VEINS
TREATMENT OPTIONS

COMPRESSION THERAPY

PHARMACOTHERAPY

SCLEROTHERAPY

SURGICAL TREATMENT

SEPS (Subfascial Endoscopic Perforator Surgery)

LASER ABLATION

RADIOFREQUENCY ABLATION
COMPRESSION THERAPY

ELASTIC COMPRESSION
- Bandage
- Stockings – Class II
 PASTE GAUZE (UNNA) BOOT
 CIRC AID ORTHOSIS
 INTERMITTENT PNEUMATIC
COMPRESSION
COMPRESSION THERAPY

Action

1. HEMODYNAMIC EFFECT

Increase venous blood flow
Decrease venous blood volume
Reduce reflux in diseased superficial and/or deep veins
Reduce a pathologically elevated venous pressure









2. EFFECT ON TISSUE
Reduce an elevated water content of the tissue
Increase the drainage of nocious substances
Reduce inflammation
Sustain reparative processes
Improve movement of tendons and joints
ELASTOCREPE BANDAGE
GRADIENT COMPRESSION STOCKINGS
Class I – 20–30(18-22) mmHg (Asymptomatic varicose)
II – 30-40(23-32) mm Hg (Symptomatic varicose)
III - 40–50(34-40) mm Hg ( For
IV - 50 – 60 mm Hg Lymph Edema)
INTERMITTENT PNEUMATIC COMPRESSION
NEW LEGGING ORTHOSIS (CIRC – AID)
UNNA BOOT
PHARMACOLOGIC THERAPY
DIURETICS – limited use
 ZINC
 FIBRINOLYTIC AGENTS




STANOZOLOL – Androgenic steroid
OXYPENTIPHYLLINE – Cytokine Antagonist
PHLEBOTROPHIC AGENTS
– HYDROXY-RUTOSIDES


CALCIUM DOBESILATE
TROXERUTIN
PHARMACOLOGIC THERAPY

HAEMORRHEOLOGIC AGENTS



FREE RADICAL SCAVENGERS



PENTOXIPHYLLINE
ASPIRIN
TOPICAL ALLOPURINOL
DIMETHYL SULFOXIDE
PROSTAGLANDINS


PROSTAGLANDIN E
PROSTAGLANDIN F
PHARMACOTHERAPY

TOPICAL THERAPIES
– ANTIBIOTICS

–
–
–
–


Application counter-productive
IODOSORB
KETANSERINE
AMNION
OCCLUSIVE DRESSINGS
GROWTH FACTORS AND CYTOKINES
SKIN SUBSTITUTES
– APLIGRAFT
SCLEROTHERAPY
THE LOWEST APPROPRIATE
CONCENTRATION AND VOLUME OF
SOLUTION AT THE SLOWEST RATE
AND LOWEST PRESSURE CAN
MINIMISE COMPLICATIONS
SCLEROSANTS

DETERGENT SOLUTIONS





OSMOTIC SOLUTIONS




SODIUM TETRADECYL SULFATE
POLIDACANOL
SODIUM MORRHUATE
ETHANOLAMINE OLEATE
HYPERTONIC SALINE
HYPERTONIC SALINE AND DEXTROSE
SODIUM SALICYLATE
CHEMICAL IRRITANTS


POLYIODINATED IODINE
CHROMATED GYLCERINE
Microsclerotherapy

30 g butterfly needle
 0.2% STS
 Several courses required
benefit compression
FOAM SCLEROTHERAPY

TESSARI
TECHNIQUE
1 PART (2ml)
DETERRGENT & 4
PARTS AIR (8ml)
AIR AGITTATED
USING TWO 10 ml
SYRIGES,
CONNECTED BY A
2/3 WAY
CONNECTOR
SURGICAL TREATMNET

GOAL:

PERMANENT REMOVAL OF VARICOSITIES
WITH THE SOURCE OF VENOUS
HYPERTENSION

AS COSMETIC A RESULT AS POSSIBLE

MINIMUM NUMBER OF COMPLICATIONS
SAPHENOUS VEIN LIGATION

INCISION 1 CM ABOVE VISIBLE SKIN CREASE

TO DRAW EACH OF THE TRIBUTARIES INTO THE
INCISION INORDER NOT TO LEAVE INTER
ANASTOMOSING INGUINAL TRIBUTARIES BEHIND

TO AVOID EXTRAVASATION OF BLOOD
SUBCUTANEOUSLY

TO INTRODUCE STRIPPER FROM ABOVE


DAMAGED VALVES ALLOW PASSAGE
STAB AVULSION TO BE DONE BEFORE STRIPPING
SAPHENOUS VEIN LIGATION
– GROIN INCISION
SAPHENOUS VEIN LIGATION
LSV
SHORT SAPHENOUS VEIN

TO MARK TERMINATION IMMEDIATE
PREOPERATIVELY

PRONE POSITION

POPLITEAL SPACE RELAXED BY KNEE
FLEXION

SURAL N. IDENTIFIED AND PRESERVED

STRIPPING LIMITED TO PROXIMAL LESSER
SAPHENOUS VEIN ABOVE MID-CALF
PERFORATOR VEIN INCOMPETENCE

LINTON’S RADICAL OPERATION SUBFASCIAL
LIGATION
– INCISION
– LONG MEDIAL
– ANTEROLATERAL
– POSTEROLATERAL CALF INCISIONS

COCKETT SUPRAFASCIAL LIGATION

DEPALMA
– MULTIPLE PARALLEL BIPEDICLED FLAPS
– LIGATION OF VEINS ABOVE OR BELOW THE FASCIA

SEPS
– SINGLE PORT TO VIEW AND WORK
– TWO PORTS – ONE TO VIEW; ANOTHER TO WORK
LINTON’S RADICAL OPERATION
SUBFASCIAL LIGATION
Sural N.
Perforator V.
MODIFIED LINTON’S PROCDURE

TO AVULSE THE INCOMPETENT
PERFORATORS UNDER DUPLEX
GUIDANCE
SEPS
ABLATIVE PROCEDURES

ENDO VENOUS THERMO
ABLATION
- LASER
- RADIO - FREQUENCY
ENDOVENOUS LASER SURGERY
ENDOLUMINAL OBLITERATION BY HEAT
- INDUCED COLLAGEN CONTRACTION & DENUDATION OF
ENDOTHELIUM
- FIBROSIS
810 nm DIODE LASER ENERGY
TUMUSCENT ANAESTHESIA
ADVANTAGE
NO GROIN DISSECTION
NO NEOVASCULARISATION
1470 nm DIODE LASER
EVLT – Endovenous Laser Treatment
RADIOFREQUENCY ABLATION

RADIOFREQUENCY INDUCED
THERMO THRAPY (RFiTT)
RADIOFREQUENCY ABVLATION
SEGMENTAL ABLATION
SURGERY FOR DEEP VEIN VALVE
INCOMPETENCE


VALVE RECONSTRUCTION

INTERNAL VALVULOPLASTY

EXTERNAL AND TRANSCOMMISURAL
VALVULOPLASTY

ANGIOSCOPIC VALVULOPLASTY

PROSTHETIC SLEEVE IN SITU
AXILLARY VEIN TRANSFER
SURGERY FOR CHRONIC VENOUS
HYPERTENSION

SAPHENO POPLITEAL BYPASS


MAY HUSNI OPERATION
CROSS PUBIC VENOUS BYPASS

PALMA DALE PROCEDURE

CONTRALATERAL SAPHENOUS VEIN IS USED

PROSTHETIC FEMOROCAVAL, ILIOCAVAL OR
IVC BYPASS

ILIAC VEIN DECOMPRESSION

CAVOATRIAL BYPASS
ENDOVENOUS

ANGIOPLASTY AND STENTING OF
STENOSED / OCCLUDED
THROMBOSED ILIAC VEIN (MEY
THURNER’S SYNDROME)
 CORRECTION OF CONGENITAL
WEBS