Varicose veins and treatment

Jeannouel van Leeuwen , surgeon Chirurgen Maatschap Emma Care Courtesy of Servier 25 january 2012

What well cover

Some Definitions Anatomy What are you looking for? Examination techniques Treatment options

Incidence
annual incidence of varicose veins is about 2% life-time prevalence of varicose veins approaches 40% Varicosities are more common in women (about 2-3 times as prevalent in women than in men) 10-20% actually are symptomatic enough to complain about their lower leg varicose veins and seek treatment.

What is a varicose vein?

Long, tortuous and dilated vein of the superficial varicose system Commonly legs but where else? Abdominal Wall Anus Vulva Oesophagus Scrotum

Why do they happen?

increased pressure in the superficial venous system normally blood flows from superficial system to deep if the valves protecting the superficial veins become incompetent there is higher pressure in the superficial veins and they become varicose

Normal venous flow in the Leg

Normal Flow Superficial veins drain into the deep veins From the foot up to the heart

Superficial vein disease always starts with abnormal valves and interruption to normal flow called venous reflux

Abnormal flow = Venous Reflux

Damaged Valves 1. Blood flows to the skin 2. Blood is pushed distally and proximally 3. Close loop recirculation 4. Blood is retained in the leg Increased volume of blood
(heaviness Fatigue)

Increased venous pressure Veins Dilate (varicose veins)

Taking the history

Presenting Complaint: Varicosities, abdominal/groin lump saphena varix Symptoms
Localized discomfort in the leg, Pain, Swelling, Venous claudication, Itching

Risk factors
Female, age, ethnicity, occupation, pregnancy, obesity, smoking ASK about history of abdominal complaints/cancer, DVT, previous & other venous complaints

So the examination
Inspection Auscultation Palpation
cough test tap test

Tourniquet Tests
Trendelenberg Tourniquet test Perthes

Doppler
Sapheno-femoral junction Sapheno-popliteal junction

Diagnosis of venous disease

Physical exam Appearance Trendelenburg test Palpation Hand Doppler Duplex Examination R/O DVT Size of veins Map out superficial veins Locate the site of reflux Reflux 0.5 sec in GSV and 1 sec in deep system Find refluxing perforators

Clinical picture - symptoms

Cosmetic disfigurement Pain and discomfort Night cramps Mild swelling at night Pigmentation Itching Ulceration

Anatomy
Superficial System arises from foot and ends at Sapheno- femoral junction (spiderhead) Long saphenous vein- medial leg up to SFJ Short saphenous vein- lateral malleolus , up calf to meet popliteal vein behind knee Sapheno- femoral junction- 4 cm lateral and 4cm below the pubic tubercle Communication veins: connecting deep and superficial system through piercing deep fascia, with valves to direct blood from superficial to deep viens. Perforator veins: there are 3 perforators on the medial side and 1 on the lateral side of the leg

Inspection- other features

1. Spider Veins- blueish vessels that distend above
the skin surface

2. Thrombophlebitis- superficial red painfull lump 3. Brown pigmentation- haemosiderin deposition 4. Venous Eczema 5. Venous Ulcers- over medial ankle 6. Lipodermatosclerosis-progressive sclerosis
of cutaneous fat- ankle becomes thin and hard- area above becomes oedematous

7. Scars from previous surgery

 Atrophy blanche

Inspection
Venous ulcers/eczema

Ulceration: active and healed Leaves a white patch

Pitting oedema
Spider veins

Inspection

Lipodermatosclerosis
Literally "scarring of the skin and fat A slow process that occurs over a number of years and has 2 phases:

1.

Acute
Venous pooling chronic venous hypertension RBC forced into surrounding tissue Haemoglobin broken down into brown haemosiderin Chronic haemosiderin formation leads to fibrin deposition Skin becomes thickened and shiny Skin around ankle constricts and the inverted champagne-bottle shape is seen

2.

Chronic

Stages of chronic venous insufficiency

(Expert meeting in Moscow, 2000.)

0 - no symptoms; 1 - heavy feet syndrome; 2 - intermittent edema; 3 - persistent edema, hyper- or hypopigmentation, lipodermatosclerosis, eczema; 4 - venous ulcer.

Causes Primary
Theories of Aetiology:
Weak wall theory Congenital valvular incompetence

Aggravating factors:
Female sex High parity Occupation requiring prolonged standing Marked obesity Constricting clothes Estrogen intake Deep venous thrombosis

Secondary Anything that raises intra-abdominal pressure or raises pressure in superficial/deep venous system so:

Pregnancy Abdominal/pelvic mass Ascites obesity constipation thrombosis of leg veins (DVT) AV fistula Vena cava thrombose Large liver cysts

Auscultation
Auscultate over any varicosities for bruits due to A-V malformation

Palpation
Palpate the veins to confirm they are infact veinswill refill if if gently pressed and released Next- find the sapheno-femoral junction (SFJ)
Find Pubic Tubercle just lateral to pubic symphisis 4 cm lateral then 4cm below Palpate for a sapheno varix- localised distension of the long saphenous vein in the groin

Cough Test- Fingers over SFJ, ask patient to cough can you feel a thrill, if yes suggest incompetence Tap Test- tap over the SFJ and feel further down long saphenous vein for any transmitted sounds, if yes suggest incompetence

Trendelenberg/Tourniquet tests
Aim- to localise the valve/s that are incompetent Trendelenberg Lie patient down and raise leg attempting to drain varicosities of blood. Using either a tourniquet or fingers put pressure over SFJ to occlude it Ask patient to stand If varicosities DO NOT refill indicates SFJ incompetence If DO refill the leaky valve is lower down I will now try and locate the incompetent perforator using the tourniquet test

Tourniquet test continued

Same as before- lie down, raise and drain leg Place tourniquet approximately over area of each perforator( mid thigh, sapheno popliteal, calf perforators) If varicosities DO NOT refill that perforator is incompetent If varicosities DO refill continue down leg

To complete my examination I would like to

Perform a full Abdominal Examination Scrotal examination ( on males!) Arterial Examination Investigations Duplex Ultrasonography- maps valve incompetence Phlebography not done anymore

Spider Veins

The proper term is Telangiectasia These are non raised dilated veins located in the Dermis (deep layer of the skin) Single layer endothelium, minimal muscle Can be Red or Blue in color depending on the origin Do not cause major medical complications

Appears earlier than varicose veins (4% of teenagers ,

and 13 % in 18 to 20 year olds

More common in females Reticular Veins are lager feeding veins

Spider Veins
Etiology: Multifactorial
Venous Hypertension associated with varicose veins Congenital: vascular nevi, neonatal hemangiomatosis, others.. Collage Vascular Disease: lupus, Hormonal factors: pregnancy, estrogen therapy, topical steroids

Trauma: contusion, incisions

Infections

Venous Stasis Ulcers

Differential Diagnosis
1. 2. 3. 4. 5. 6. Venous ulcerations 50% on non healing ulcers Arterial ulcers in about 10% Malignancy : basal and squamous cell, lymphoma Infections: HIV, fungal Collagen vascular disorders: Lupus ec. Lymphatic obstruction

Affects over 1 million people in the US 100,000 are disabled from this More common in elderly population

Ulcus cruris venosum

Venous Stasis Ulcers

Etiology 1. Venous Hypertension
Venous reflux DVT Varicose veins

2. Edema 3. Biological factors Leakage of proteins impedes diffusion O2 Aggregation of white cells
Block capillary flow Release on inflammatory proteins

Management
Conservative/Medical
Graded compression bandaging, Compression hosiery Paste Gauze (Unna) Boots Diuretics? Zinc? Phlebotrophic/Hemorheologi c agents? Aspirin/NSAIDs etc

Surgical
Ankle-to-groin saphenous vein stripping (with stab avulsion) Segmental saphenous vein stripping (with stab avulsion) Saphenous vein ligation: high, low, or both Saphenous vein ligation and sclerotherapy Saphenous vein ligation (with stab avulsion) Stab avulsion of varices without saphenous vein stripping (phlebectomy) Endoluminal occlusion of the saphenous vein by radiofrequency (RF) or laser energy

Surgical ligation and Stripping

Standard treatment for a century General anesthesia Pain Long recovery Some complications Good cosmetic results

Surgical treatment
Crossectomy or/and vein stripping till below knee better than compressive therapy alone Other techniques : Endovas.burning or foam injection

Vein Ablation
Laser Ablation (EVLA ) Uses light to heat the vein Radio Frequency (VNUS Procedure) Uses radio frequency to heat the vein

Office based procedure Done under local anesthesia One needle puncture at the level of the

knee Takes about 1 hour Patient resumes normal activity same day

EVLA Results

Images from http://venacure-evlt.com/

Sclerotherapy
Cumulate vein with needle Inject Sclerosing Solution
Ethoxysclerol Hyper tonic Saline Foam (Mix STS with air and make bubbles)

Intravenous injection causes intima inflammation and thrombus formation

Sclerotherapy Use
Neovascularization Perforators Clean up after Phlebectomies Spider veins Reticular veins GSV: can closure the, but has high recurrence rate

Sclerotherapy results

UNNA boot result

Weekly change with UNNA boot bandage gives nice result

 Compressive bandages first choice with simple small vein ulcer

 Skin grafting can be put on a non infected granulating skin defect of a venous ulcer

Treatment complications
Major complications following VV surgery are relatively rare Up to 20% morbidity
Infection Hematoma Pain Nerve damage
Saphenous nerve (LSV surgery) Sural, peroneal nerve (SSV surgery)

Lymphatic leak - Venous thrombosis - Vascular injury Recurrence

Oral medication
Effect on edema , hematocrit , augmentation capillary permeability , inflammation , less fibrinolysis , leukocyte function en erythrocytes No evidence for monotherapy only in addition effect on ulcer healing Daflon , Trental , Aspirine

hlebotropic drugs
Daflon Venal Venoruton Doxium

Rheologic hemocorrectors
acetylcalicylic acid, dipiridamol pentoxyphylline low-molecular dextranes

Thank you for your attention

www.surgerycuracao.com www.curacaoveininstitute.com

Chirurgen Maatschap Curacao

www.cmc.an