VARICOSE VEIN

Erny Ashyqien
Norul Ain
Visagan Diya Das
THE ANATOMY OF VENOUS
SYSTEM OF THE LOWER
LIMB
Superficial venous system
Deep venous system
SUPERFICIAL VEINS
• They lie in the superficial
fascia.
• They possess many valves
along their course.
• They communicate with
deep veins by perforating
veins
• They consist of
• Dorsal venous arch
• Great saphenous vein &
its tributaries
• Small saphenous vein &
its tributaries
Dorsal venous arch

• It lies in the superficial fascia of

dorsum of foot over the heads of
metatarsal bones
• Drains on the medial side into great
saphenous vein.
• Drains on the lateral side into small
saphenous vein.
• Recieves blood from the foot via
digital veins & communicating veins
from the sole.
Great saphenous vein
• Longest vein in the body
• Begins at medial end of dorsal
venous arch of foot.
• Passes up about 2.5 cm anterior
to medial malleolus.
• Ascend the leg accompanied by
saphenous nerve to the knee.
• Looping posteriorly at medial
condyle.
• Runs along the medial side of
thigh, passes through saphenous
opening.
• In groin, passes
through saphenous
opening after
piercing cribiform
fascia.
• Drains into femoral
vein at the
saphenofemoral
junction.
• Commonly harvest
for coronary artery
bypass.
GREAT SAPHENOUS VEIN
TRIBUTARIES
• In groin:
• Anterolateral vein
• Posteromedial vein
• Tight:
• Superficial & deep
external pudendal vein
• Superficial epigastric
vein
• Circumfrential iliac vein
• Below knee:
• Anterior vein of the leg
• posterior arch vein
Small (short) saphenous vein

• Commences at the ankle

behind lateral malleolus
• Drains the lateral side of
dorsal venous plexus of the
foot
• It courses, over the back of
the calf
• Perforates the deep fascia
over the popliteal fossa.
• Terminates in the popliteal
vein through
saphenopopliteal junction.
Perforating veins
• Veins other than short and long saphenous vein.
• Penetrate the deep fascia, passing blood from
superficial to deep.
• Between 50-100 indirect perforating veins.
• Not normally important to calf muscle pump function.
• May be dilated and become haemodynamically
significant for deep vein thrombosis.
• Perforating veins:
• The calf and ankle perforating veins
• The corona phlebectatica
• Foot perforating veins
• Tight perforating veins
Deep veins
• As a general rule, the
deep veins accompany
and share the name of
the major arteries in
the lower limb.
• Often, the artery and
vein are located within
the same vascular
sheath
• so that the arterial
pulsations aid the
venous return.
Varicose Vein
• Dilated, tortuous subcutaneous vein more or equal
to 3mm in diameter measured in upright position
with demonstrable reflux
Risk factors
• Female > affected than male
• High BMI
• Pregnancy
• Family history of vv
• Occupation (prolonged standing)
• Lifestyles ( smokers, constipation)
Pathophysiology
• Venous obstruction
• Valvular incompetence
• Muscular pump dysfunction

• Chronic ambulatory venous hypertension

• Chronic venous insufficiency

 How does venous ulcer develop?
Long standing venous hypertension causes malformation of capillaries
and leakage of fluid into extracapillaries space

Edema, inflammation and reduce blood flow to the skin

Results in tissue ischemia

Hypoxic tissue is prone to ulceration even there is minor trauma and

wound healing is slow due to poor tissue oxygenation

Venous ulcer develops!

 Clinical features
Symptoms
• Aching or heaviness ( increase throughout the day)
• Less common :
• Ankle swelling
• Itching
• Bleeding
• Superficial thrombophlebitis
• Eczema
• Lipodermatosclerosis
• Ulceration
Venous clinical severity score
 Clinical examination
• Inspection ( anterior, lateral and posterior)
• Tortuous and dilated vein, erythema, swollen and
hyperpigmentation
• Site
• Medial thigh and calf : long saphenous vein incompetence
• Posterolateral calf : short saphenous vein incompetence
• Anterolateral thigh and calf : isolated incompetence of the proximal
anterolateral long saphenous tributaries
• Palpation
• Hard vein : thrombosis
• Tenderness : thrombophlebitis
Special test
• Perthes walking test
• Tests for incompetency of the valves of the saphenous
vein and varicose veins.
• It is used to asses the patency of the deep femoral vein
before varicose vein surgery.

Procedure :
• Place a torniquet just below the SFJ
• Ask the patient to stand and walk for 60 seconds.
• Check for varicosities
Tredelenburg test
Procedure
• Patient lie in supine position
• Elevate the leg above the level of heart ( to empty the
vein)
• Occlude saphenofemoral junction by using thumb
• Ask the patient to stand
Interpretation
• Slow filling of long saphenous vein : perforator defect
• After releasing the thumb, rapid gush of blood from
above downward : SFJ incompetence
How to diagnose ?
• History and PE
• Investigation
• Non invasive
• US & Plethysmography
• CT scan
• Invasive
• Venography
Standard doppler ultrasound
• When the blood flow, it emits signal
• In SF incompetence, the forward and backward
flow can be detected
• Uniphasic signal on squeezing with no sound on
relaxation indicate competent valve with forward
flow
• Biphasic signal with prolonged retrograde flow on
releasing the compression indicate reflux and
valvular incomptence
Duplex ultrasound
• Gold standard
• Compression and relaxation demonstrate the
presence of reflux
• Examine deep vein, superficial vein and look for
incompetence and patency
Photoplethysmography
• It shines infrared light into the skin. Some of the
light is reflected back from blood in the capillaries.
• Research has shown that the amount of light
reflected back is proportional to the pressure in the
veins.
• Although photoplethysmography (PPG) cannot
measure direct pressure, it is able to map the
changes in pressure after movement and rest.
• Therefore, photoplethysmography (PPG) can be
used to measure the severity of the venous reflux
disease
 How is it performed ?
• A small plastic probe is attached to the skin above the ankle
joint on the inner aspect of the leg
• The patient sits in a chair.
• The leg being examined is stretched out in front of the patient
with a heel on the floor.
• The machine is started and the patient is asked to start flexing
and extending their foot whilst keeping their heal on the
ground.
• This is performed 10 times, one beat per second.
• At the end of 10 motions, movement is stopped and the
patient is asked to keep very still.
• A photophletysmographic (PPG) trace is then obtained from
the machine and can be examined.
•
Venography
• Inject contrast superficial vein of foot
• Useful if duplex scan indicates but cannot confirm
the presence of post thrombotic changes.
Management of Varicose
Veins

Presented by: Visagan Diya Das

 At a glance…
• Treatment modalities

• Conservative

• Sclerotherapy

• Surgical

• Other therapies
 Conservative Management
• Indicated for :-
• Uncomplicated cases with mild varicosity

• Asymptomatic cases

• Patients w/o symptoms or signs of

lipodermatosclerosis or ulceration

• In absence SFJ incompetence

• Secondary varicosities  treat the causal factor

 Conservative Management
• Elastic crepe bandage  30-40 mmHg

• Limb elevation  Above the heart level

• Graded compression stoking

• Unna boot
Conservative Management
 Conservative Management
• Medications

• Calcium debosilate  improves lymph flow,

reduction in edema

• Diosmin  protects venous valve / anti-

inflammatory
 Sclerotherapy
• Indication
• Small to medium sized varicose veins
• Recurrent varicosities
• Below knee varicose and by incompetent
perforaters

• Contraindication
• DVT
• Sapheno-femoral incompetence
 Sclerotherapy
• Sclerosants:-
• Hypertonic saline (23.4%)
• Sodium tetradecylsulfate (0.1%)
• Polidoconol (0.5%)
• Ethoxy scleral
• Ethanolamine oleate

Goal  obliterate the abnormal vein by

inducing localized endothelial destruction and
fibrosis
 Sclerotherapy
• Post- treatment
• Encourage walking and mobilization

• Disadvantages
• Thrombophlebitis
• Recanalization
• Skin tanning
• > maximum dose  thrombosis
Sclerotherapy
 Surgical Procedure
• Indication
• Cosmetic
• Varicose ulcers
• Symptomatic cases
• Sapheno-femoral incompetence

• Types of surgery
• Sapheno-Femoral Incompetence
• Sapheno-Popliteal Incompetence
• Stripping of veins
 Surgical Procedure
• Sapheno-Femoral Incompetence Surgery

• Trendelenburg Procedure  Sapheno-

femoral flush ligation / high ligation

• GSV is ligated near the femoral vein 

3mm length are left with its tributaries 
reduction in recurrence
 Surgical Procedure
• Sapheno-Popliteal Incompetence
Surgery

• Termination of SSV either at 2 cm below or

15 cm above the knee  confirmed by
Duplex

• Sapheno-popliteal flush ligation is

performed  similar to SFFL
 Surgical Procedure
• Stripping of Veins
• Babcock stripper or Oesch pin stripper

• Care:
• GSV: No striping beyond mid calf level. Why?

• SSV: No stripping at mid calf level. Why?

Surgical Procedure
 Other Therapies
• Endovenous ablation

• Ambulatory phlebectomy
 Endovenous Ablation
• Ablation of diseased saphenous vein trunks,
large incompetent tributaries or perforating
veins

• Achieved by:-
• Radiofrequency energy
• Laser energy
 Endovenous Ablation
• It is accomplished by thermal injury in situ

• It can be performed in an office setting using

local anaesthesia

• Patient can return to normal daily activity

immediately
 Endovenous Ablation
• Advantages of EVLA over RFA

• Can ablate any vein that can take guidewire

• Standard EVLA may be used to ablate

perforators

• Inexpensive
 Endovenous Ablation
• Advantages of RFA over EVLA

• Standardised treatment protocol

• Does not require continuous pullback

• Does not require laser precaution

• It is associated in marginal pain and bruises

reduction
Endovenous Ablation
Endovenous Ablation
 Ambulatory Phlebectomy
• Procedure which large varicose vein branches
are removed

• Can be safely performed under local

anaesthesia in office setting

• Excellent cosmetic results and relief of symptoms

• Performed in conjunction with endovenous

ablation
Ambulatory Phlebectomy
 References
• Williams, N., O'Connell, P. and McCaskie, A.
(2018). Bailey & Love's short practice of surgery.
27th ed. CRC Press, pp.974-982.