varicose veins INVESTIGATIONS &MANAGEMENT

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varicose veins:

varicose veins INVESTIGATIONS AND MANAGEMENT OF

INVESTIGATIONS:

INVESTIGATIONS 1.DOPPLER ULTRASOUND 2.DUPLEX ULTRA SOUND IMAGING 3.VENOGRAPHY 4.MR VENOGRAPHY(MRV) 5.PLETHISMOGRAPHY(VRT) 6.MAXM. VENOUS OUT FLOW(MVO) 7.MUSCLE PUMP EJECTION FRACTION (MPEP)

DOPPLER ULTRASOUND:

DOPPLER ULTRASOUND MINIMAL LEVEL OF INVESTIGATION REQUIRED USED TO 1.EXCLUDE ART. DISEASE2. DETERMINE PATENCY OF AVEIN3. DETECT VENOUS REFLUX CARRIED IN STANDING POSITION TO SHOW FLOW IS RETROGRADE , ANTEGRADE OR TO&FRO

(DOPPLER U/S CONTD…):

(DOPPLER U/S CONTD…) PROCEDURE DOPPLER TRONSDUCER IS POSITIONED ALONG THE AXIS OF AVEIN AT 45 DEGREES TO THE SKIN CALF IS COMPRESSED TO PRODUCE AN ACCELERATION OF BLOOD FLOW THIS IS HEARD AS A WOOSH WHEN CALF COMPRESSION IS RELEASED IF VALVES ARE COMPETENT ,NO RETROGRADE FLOW AND NO WOOSH BUT IF INCOMPETENT RETROGRADE FLOW AND SECOND WOOSH IS HEARD

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DUPLEX ULTRASOUND IMAGING:

DUPLEX ULTRASOUND IMAGING STANDARD IMAGING MODALITY USED 1.TO DIAGNOSE VENOUS INSUFFICIENCY2.PLAN TREATMENT 3.PREOPERATIVE MAPPING COMBINES HIGH RESOLUTION B-MODE ULTRASONOGRAPHY & DOPPLER ULTRASOUND OBTAINS IMAGES OF VESSELS & MEASURES FLOW SIMULTANEOUSLY PROVIDES ANATOMICAL & FUCTIONAL INFORMATION

(DUPLEX U/S CONTD…):

(DUPLEX U/S CONTD…) PROCEDURE PERFORMED IN STANDING POSITION TWO DIMENSIONAL U/S STRUCTURES THAT ABSORB,TRANSMIT OR SCATTER U/S WAVES APPEAR DARK, STRUCTURES THAT REFLECT APPEAR WHITE VESSEL WALL S REFLECT SO APPEAR WHITE,BLOOD ABSORBS & SCATTERS SO APPEAR DARK NORMAL BLOOD VESSELS APPEAR AS DARK FILLED WHITE WALLED STRUCTURE

(DUPLEX U/S CONTD…):

(DUPLEX U/S CONTD…) DOPPLER U/S AFTER IMAGING THE VESSEL , THE CALF IS COMPRESSED TO PRODUCE FORWARD FLOW THE FLOW TOWARDS HEART IN A NORMAL VEIN IS SHOWN AS BLUE IN THE COLOUR FLOW MAP CALF IS RELEASED IF THE VALVES ARE COMPETENT NO RETROGRADE FLOW BUT INCOMPETENT PRODUCES RETROGRADE FLOW REPRESENTEED AS RED IN THE COLOUR FLOW MAP

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*Image via Bing DUPLEX SCAN OF FEMORAL VEIN SHOWING THROMBUS & REVERSE FLOW

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VENOGRAPHY (DIRECT CONTRAST VENOGRAPHY):

VENOGRAPHY (DIRECT CONTRAST VENOGRAPHY) X- RAY EQUIVALENT OF DUPLEX U/S MOST COMBURSOME ,INVASIVE IMAGING TECHNIQUE ASCENDING VENOGRAM A VEIN IN DORSUM OF FOOT IS CANNULATED TOURNIQUET IS APPLIED OVER MALLEOLI TO DIRECT BLOOD INTO DEEP VEINS NON IONIC CONTRAST IS GIVEN GIVES EXCELLENT ANATOMIC INFORMATION LESS INFORMATION WHEN VALVES HAVE FAILED

VENOGRAPHY CONTD…:

VENOGRAPHY CONTD… DESCENDING VENOGRAPHY INCOMPETENT VEINS CAN BE SHOWN CANNULA INSERTED INTO FEMORAL VEIN CONTRAST INJECTED WITH PATIENT STANDING CONTRAST IS HEAVIER THAN BLOOD & FLOWS DOWN THROUGH INCOMPETENT VEINS VARICOGRAM TO DETECT SOURCE OF RECURRENT VARICOSE VEINS CONTRAST IS GIVEN INTO ONE OF THE VARICOSE VEINS& FOLLOWED TO IDENTIFY SOURCE

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MAGNETIC RESONANCE VENOGRAPHY:

MAGNETIC RESONANCE VENOGRAPHY MOST SENSITIVE & MOST SPECIFIC FOR BOTH SUP.& DEEP VEINS OF L.L & PELVIS WHERE OTHER MODALITIES CANNOT REACH UNSUSPECTED NONVASCULAR CAUSES FOR LEG PAIN & EDEMA MAY BE OBSERVED ON MRV SCAN WHEN CLINICAL PRESENTATION ERRONEOUSLY SUGGESTS VENOUS INSUFFICIENCY/OBSTRUCTION

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PLETHISMOGRAPHY:

PLETHISMOGRAPHY MEASURES VENOUS REFILLING TIME(VRT) PROBE ATTACHED TO SKIN MEASURES VENOUS REFILLING TIME BY ASSESING LIGHT TRANSMISSION OF SKIN 1 ST PATIENT SITS QUITELY UNTIL THE TRACE STABILISES THEN PERFORMS 10 TO 20 TIP TOES /ANKLE DORSIFLEXIONS PRESSURE IN SUP.VEINS FALLS & CUTANEOUS VENULES EMPTY THE PT. THEN SITS & VEINS REFILL

PLETHISMOGRAPHY CONTD…:

PLETHISMOGRAPHY CONTD… VRT IS THE TIME NECESSARY FOR THE LOWER LIMB VEINS TO BECOME FULLY SUFFUSED WITH BLOOD AFTER CALF MUSCLE PUMP HAS COMLETELY EMPTIED LOWER LEG AS THOUROUGHLY AS POISSIBLE IN PERFECT HEALTHY LIMB IT OCCURS ONLY THROUGH ARTERIAL INFLOW & REQUIRES 2 MINUTES

PLETHISMOGRAPHY CONTD…:

PLETHISMOGRAPHY CONTD… VRT 40-120 SEC INDICATES MILD / ASYMPTOMATIC VENOUS INSUFFICIENCY ,FILLING OCCURS THROUGH LEAKY VALVES VRT 20TO 40 SEC SIGNIFICANT HIGH VOLUME REFLUX THROUGH RETROGRADE FLOW IN FAILED VALVES, ASSOCIATED WITH SYMPTOMS VRT<20SEC INDICATES HIGH VOLUME OF RETROGRADE FLOW ,ALWAYS SYMPTOMATIC VRT<10SEC ASSOCIATED WITH LEG ULCERS

MAXM. VENOUS OUTFLOW(M.V.O):

MAXM. VENOUS OUTFLOW(M.V.O) USED TO DETECT OUT FLOW OBSTRUCTION IT IS A MEASURE OF THE SPEED WITH WHICH BLOOD CAN FLOW OUT OF A MAXIMALLY CONGESTED LOWER LIMB WHEN AN OCCLUDING THIGH TOURNIQUET IS REMOVED SUDDENLY FUCTIONAL TEST SENSITIVE TO SIGNIFICANT INTRINSIC/EXTRINSIC OBSTRUCTION DUE TO ANY CAUSE

MVO CONTD…:

MVO CONTD… MVO CAN DETECT OBSTRUCTION DUE TO 1.THROMBUS(CALF VEINS.ILIAC VEINS&I.VC) 2.HEMATOMAS 3.TUMOURS 4.OTHER EXTRINSIC DISEASE PROSESSES

MUSCLE PUMP EJECTION FRACTION:

MUSCLE PUMP EJECTION FRACTION HIGHLY REPEATABLE PT. IS ASKED TO PERFORM 10-20 TIP TOES/DORSIFLEXIONS CHANGE SOME PARAMETER WHICH REFLECTS CALF BLOOD VOLUME IS RECORDED NORMALLY 10-20 TIP TOES CAUSE THE CAPACITANCE CIRCUIT OF THE CALF TOCOLLAPSE

MANAGEMENT:

MANAGEMENT 1.CONSERVATIVE 2.SCLEROTHERAPY 3.SURGICAL STRIPPING 4.CRYO STRIPPING 5.FLUSH LIGATION/TRENDELENBERG’S 6.AMBULATORY PHLEBECTOMY 7.HOOK PHLEBECTOMY 8.TRANSILLUMINATED PHLEBECTOMY (TIPP) 9.SUBFASCIAL ENDOSCOPIC PERFORATOR LIGATION(SEPS)

CONSERVATIVE:

CONSERVATIVE INITIAL ,MILD CASES CAN BE TREATED CONSERVATIVELY LEG ELEVATION REGULAR EXERCISES GRADUATED COMPRESSION STOCKINGS WITH VARIABLE PRESSURE (CLASS2/3) DECREASE SWELLING INCREASE NUTRIENT EXCHANGE IMPROVES MICROCIRCULATION SHOULD NOT BE USED IN CONCOMITANT ART.DIS.

CONSERVATIVE CONTD…:

CONSERVATIVE CONTD… FLAVANOIDS - DIOSMIN & HESPERIDIN BECAUSE OF THEIR EFFECT ON VASCULAR ENDOTHELIAL PERMEABILITY NSAIDS IN SUP. THROMBOPHLEBITIS

SCLEROTHERAPY:

SCLEROTHERAPY WHO GETS SCLEROTHERAPY? SMALL NON SAPHENOUS VARICES<5mm TELANGIECTASIA RETICULAR VEINS PERFORATOR VEINS RESIDUAL/RECURRENT FRAIL WITH RESISTANT/HEALED ULCERS

SCLEROTHERAPY CONTD…:

SCLEROTHERAPY CONTD… SCLEROSING AGENTS SODIUM TETRADECYL SULPHATE SOD.MORRHUATE HYPERTONIC SALINE SOL. POLYDOCANOL,SOTRADECOL ETHANOLAMINE OLEATE GLUCOSE COMBINATIONS

SCLEROTHERAPY CONTD…:

SCLEROTHERAPY CONTD… PRINCIPLE DAMAGES ENDOTHELIUM LEADING TO FORMATION OF FIBROUS CORD REABSORPTION OF ALL VASCULAR TISSUE LAYERS SCLEROSANT IS GIVEN INTO AN EMPTY VEIN & COMPRESSED IMMEDIATELY TO AVOID THROMBUS FORMATION TECHNIQUE

COMPLICATIONS:

COMPLICATIONS PHLEBITIS SKIN STAINING FAILURE RESIDUAL LUMPS MATTING EMBOLUS (CVA) DVT,PULMONARY EMBOLISM ULCERATION(RARE) ANAPHYLAXIS(VERY RARE) SKIN SLOUGHING DUE TO EXTRAVASATION

MICROSCLEROTHERAPY:

MICROSCLEROTHERAPY 30 G BUTTERFLY NEEDLE 0.2%STS& POLIDOCANOL SEVERAL COURSESARE REQUIRED FOR THREAD/RETICULAR VEINS COMPRESSION BANDAGE FOR 1-5 DAYS

FOAM SCLEROTHERAPY:

FOAM SCLEROTHERAPY SCLEROSANT & AIR ARE IN 4:1 RATIO 1%/3% SCLEROSANT IS USED INDUCES SPASM DISPERSES WELL ENHANCED SCLEROSIS

SAPHENOFEMORAL FLUSH LIGATION:

SAPHENOFEMORAL FLUSH LIGATION TRENDELENBERG’S OPERATION GSV IS LIGATED FLUSH WITH FEMORAL VEIN TRIBUTARIES OF GSV & FV 1CM ABOVE &BELOW SFJ ARE LIGATED & DEVIDED TO PREVENT RECURRENCE

STRIPPING:

STRIPPING CONVENTIONAL BABCOCK STRIPPER – FLEXIBLE WIRE PASSED DOWN GSV STRIPPER IS RETRIEVED IN THE UPPER END OF CALF THROUGH A 2mmINCISION OLIVE OF ABOUT 8mm DIAMETER IS ATACHED TO UPPER END GSV IS REMOVED BY FIRM PRESSURE ON THE STRIPPER INVERTING/INVAGINATING STRIPPING RIGID METAL PIN STRIPPER/OESCH PIN STRIPPER/MYER’S STRIPPER ,NO OLIVE

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CRYOSTRIPPING:

CRYOSTRIPPING VARIATION OF TRADITIONAL STRIPPING LIMITED TO GSV VEIN FREEZES &ADHERS TO THE DEVICE WHICH IS STRIPPED LESS P.O .BRUISING REQUIRES SPECIAL INSTRUMENTATION

SEPS:

SEPS SUB FASCIAL ENDOSCOPIC PERFORATOR LIGATION PTS. WITH REFRACTORY SYMPTOMS,ULCERATIONFAILED CATHETER TREATEMENT 2 PORTS ARE USED PERFORATORS DEVIDED WITH ELECTROCAUTERY,HARMONIC SCALPEL OR CLIPPED

PHLEBECTOMIES:

PHLEBECTOMIES AMBULATORY PHLEBECTOMY STAB / AVULSION PHLEBECTOMY HOOK PHLEBECTOMY

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CATHETER BASED TREATMENTS:

CATHETER BASED TREATMENTS ENDOVENOUS LASER ABLATION RADIO FREQUENCY ABLATION PRIMARILY TO TREAT GSV/LSV VARICOSE VEINS EQUALLY EFFICACIOUS AND HAVE SIMILAR RECANALISATION RATES

RADIO FREQUENCY ABLATION:

RADIO FREQUENCY ABLATION GENERATE A HIGH FREQUENCY ALTERNATING CURRENT IN THE RADIO RANGE OF FREQUENCY HEATS THE TISSUES SURRONDING THE CATHETER ELECTRODE TO A SPECIFIC TEMP. WORKS WELL ON TISSUES COMPOSED OF COLLAGEN SPECIAL PROBES TO MANAGE NON SAPHENOUS &PERFORTATORS

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ENDOVENOUS LASER ABLATION:

ENDOVENOUS LASER ABLATION USES BARE TIPPED OPTICAL FIBRE WHICH APPLIES LASER LIGHT ENERGY TO THE VEIN THERAPY BASED ON PHOTOTHERMOLYSIS (LIGHT INDUCED THERMAL CHANGE) LASER LIGHT HEATS TARGET TISSUE INDUCING THERMAL INJURY

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COMPLICATIONS OF EVLA:

COMPLICATIONS OF EVLA PAIN,BRUISING&HEMATOMA SKIN CHANGES BURNS INDURATION PIGMENTATION MATTING DYSESTHESIA,SUP.THROMBOPHLEBITIS NERVE INJURY DVT WOUND INFECTION

VENOUS RECONTRUCTIVE SURGERY:

VENOUS RECONTRUCTIVE SURGERY FOR VENOUS OBSTRUCTION PALMA PROCEDURE —FEMORO FEMORAL VEIN GRAFT,FOR FEMORAL VEIN OBSTRUCTION,GSV IS CONNECTED TO FEMORAL VEIN BELOW OBSTRUCTION ONCONTRALATERAL SIDE MAY – HUSNI PROCEDURE ---- FOR OBSTRUCTION OF SUP.FEMORAL VEIN ,THE GSV IS CONNECTED TO POPLITEAL VEIN ALLOWING BLOOD TO FLOW THROUGH SUP.SYSTEM MORE EASILY VENOUSINCOMPETENCY KISTNER TYPE VALVE REPAIR

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