varicose veins

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Varicose veins : 

Varicose veins DR.MRAVICHANDRA,M.S, ASST. PROFESSOR OF SURGERY RIMS, SRIKAKULAM

DEFINITION: 

DEFINITION VARICOSE VEINS ARE DILATED TORTUOUS AND ELONGATED VEINS

PHYSIOLOGICAL DEFINITION: 

PHYSIOLOGICAL DEFINITION A VARICOSE VEIN IS ONE WHICH PERMITS REVERSE FLOW THROUGH IT’S FAULTY VALVES

COMMON SITES OF VARICOSE VEINS: 

COMMON SITES OF VARICOSE VEINS SUPERFICIAL VENOUS SYSTEM OF LOWER LIMB SPERMATIC VEINS (VARICOCELE) SITES OF PORTO SYSTEMIC ANASTOMOSIS OESOPHAGEAL VARICES HAEMORRHOIDAL VARICES AROUND UMBILICUS(CAPUT MEDUSAE) BARE AREA OF LIVER RETROPERITONEAL REGION

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*Image via Bing VARICOSE VEINS OF SUPERFICIAL VENOUS SYSTEM OF LOWER LIMBS

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VARICOSE VEINS: 

VARICOSE VEINS A SYMPTOM NOT A DISEASE

VARICOSE VEINS ARE MANIFESTATION OF AN UNDERLYING DISEASE PROCESS NOT ITSELF A DISEASE: 

VARICOSE VEINS REPRESENT ENLARGED COLLATERALS OF SAPHENOUS VENOUS SYSTEM AFFECTED BY DISEASE CALLED SUPERFICIAL VENOUS INSUFFICIENCY OF LOWER EXTREMITIES VARICOSE VEINS ARE MANIFESTATION OF AN UNDERLYING DISEASE PROCESS NOT ITSELF A DISEASE

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ANATOMY

CLASSIFICATION OF LOWER LIMB VEINS: 

CLASSIFICATION OF LOWER LIMB VEINS SUPERFICIAL VEINS DEEP VEINS COMMUNICATING VEINS / PERFORATORS

SUPERFICIAL VENOUS SYSTEM: 

SUPERFICIAL VENOUS SYSTEM 2 MAJOR TRUNKS GREATER SAPHENOUS VEIN(GSV) LESSER SAPHENOUS VEIN(LSV) HAVE THICK MUSCULAR WALLS RUN IN A TUNNEL CREATED BY A CONDENSATION OF SUPERFICIAL FASCIA THIS EXPLAINS WHY GSV IS LESS FREQUENTLY VARICOSE THAN IT’S TRIBUTARIES

THE GREATER SAPHENOUS VEIN: 

THE GREATER SAPHENOUS VEIN LONGEST VEIN IN THE BODY IT COMMENENCES FROM THE INNER PART OF THE DORSAL VENOUS ARCH OF FOOT PASSES IN FRONT OF MEDIAL MALLEOLUS RUNS OVER THE ANTEROMEDIAL ASPECT OF LEG UPTO POSTEROMEDIAL ASPECT OF KNEE JOINT THEN RUNS IN THE ANTEROMEDIAL ASPECT OF THIGH UPTO FOSSA OVALIS OR SAPHENOUS OPENING TO ENTER FEMORAL VEIN

TRIBUTARIES OF GSV: 

TRIBUTARIES OF GSV MEDIAL MARGINAL VEIN OF SOLE DORSAL VENOUS ARCH ANTERIOR VEIN OF LEG POSTERIOR ARCH VEIN ANTEROLATERAL VEIN OF THIGH POSTEROMEDIAL VEIN OF THIGH (COMMUNICATES WITH LSV) VEIN OF GIACOMINI SUP CIRCUMFLEX ILIAC SUP EPIGASTRIC SUP & DEEP EXTERNAL PUDENDAL VEIN SAPHENOUS NERVE IS RELATED TO GSV

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LESSER SAPHENOUS VEIN: 

LESSER SAPHENOUS VEIN BEGINS BY FUSION OF SMALL VEINS BELOW AND BEHIND LAT. MALLEOLUS RUNS ALONG OUTER EDGE OF ACHILLES TENDON & PASSES TO MIDLINE RUNS OVER THE POST. ASPECT OF LEG UP TO MIDLLE OF POPLITEAL FOSSA THERE IT DIPS SHARPLY TO ENTER THE POPLITEAL VEIN RELATED TO SURAL NERVE WHERE IT PIERCES FASCIA IT IS IN RELATION WITH POST. CUT. N. OF THIGH

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PERFORATORS: 

PERFORATORS COMMUNICATING VESSELS BETWEEN SUP. & DEEP VEINS 2 TYPES 1. INDIRECT SMALL SUP. VEINS PENETRATE DEEP FASCIA AND CONNECT WITH A VESSEL IN MUSCLE WHICH IN TURN IS CONNECTED TO ONE OF THE DEEP VEINS AS THERE IS LITTLE MUSCLE AT ANKLE VENOUS RETURN IS DEPENDENT ON INDIRECT PERFORATORS – SIGNIFICANT FACTOR IN ANKLE ULCERATION

PERFORATORS (CONTD)…: 

PERFORATORS (CONTD)… 2.DIRECT PERFORATORS A)GSV &LSV COMMUNICATE BETWEEN SUP.& DEEP SYSTEM THEY ARE VALVED B)SMALLER PERFORATORS FAIRLY CONSTANT INTIMATELY RELATED TO POST. BORDER OF TIBIA & FIBULA CONNECT TRIBUTARIES OF GSV&LSV TO DEEP VEINS AFTER PERFORATING DEEP FASCIA VALVED AT EACH END AS A RULE ACCOMPANIED BY A NAMED ART.

CLASSIFICATION OF PERFORATORS: 

CLASSIFICATION OF PERFORATORS ANKLE PERFORATORS ( MAY/KUSTER) LOWER LEG ( COCKETT) BELOW KNEE (BOYD) ABOVE KNEE/DISTAL THIGH( DODD) MID THIGH/SARTORIAL CANAL( HUNTERIAN

PERFORATORS: 

PERFORATORS

VALVES: 

VALVES PRESENT IN ALL THE VEINS ,MORE IN LOWER LIMB THEY ARE BICUSPID GSV HAS 10-20 VALVES MORE IN LEG PRESENT AT SFJ & SPJ ALSO MAINTAIN BLOOD FLOW FROM SUP. TO DEEP & BELOW UPWORDS TOWARDS WHEN NORMAL

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NAMES ACCORDING TO DIAMETER: 

NAMES ACCORDING TO DIAMETER When abnormal: - VARICOSE (> 3MM) - RETICULAR (1- 3 MM) - TELANGIECTASIA (SPIDER VEINS, THREAD VEINS DERMAL FLARE)

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Epifascial Subcutaneous veins Intrafascial Superficial veins Subfascial Deep veins Three Anatomical Areas: Three fully interacting systems: superficial, deep, perforators

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PHYSIOLOGY

NORMAL BLOOD CIRCULATION: 

NORMAL BLOOD CIRCULATION

FACTORS MAINTAINING FLOW TOWARDS HEART: 

FACTORS MAINTAINING FLOW TOWARDS HEART 1.MUSCLE PUMPS 2.RESPIRATION 3.VALVES

1.MUSCLE PUMP: 

1.MUSCLE PUMP SECOND HEART/PERIPHERAL HEART ON EXERCISE CALF & THIGH MUSCLES CONTRACT COMPRESSING THE VEINS & EJECTING BLOOD TOWARDS HEART FOOT PUMP EJECTS BLOOD FROM PLANTAR VEINS AS PRESSURE IS PLACED ON FOOT DURING WALKING

Muscle Pump : 

Muscle Pump Contractions propel blood toward heart Relaxation draws blood from - superficial veins - lower deep veins

2.RESPIRATIONS : 

2.RESPIRATIONS THORACOABDOMINAL PUMP NEGATIVE INTRA THORACIC PRESSURE DURING INSPIRATION DRAWS BLOOD TOWARDS THE HEART REVERSE HAPPENS IN EXPIRATION EASILY SEEN ON DUPLEX SCAN

3.VALVES: 

3.VALVES WHEN NORMAL THEY ALLOW BLOOD FLOW ONLY IN ONE DIRECTION ,TOWARDS HEART ALL VEINS HAVE VALVES EVERY FEW CENTIMETRES

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NORMALLY: 

NORMALLY MUSCLES

PRESSURE CHANGES DURING WALKING: 

PRESSURE CHANGES DURING WALKING CONTRACTION OF CALF MUSCLE --200TO 300MMHG WHICH PROPELS BLOOD TOWARDS HEART RELAXATION PRESSUREFALLS - BLOOD FROM SUP. VEINS ENTER DEEP VEINS THROUGH PERFORATORS DECREASES PRESSURE IN SUPERFICIAL VEINS

(CONTD…): 

( CONTD…) Pressure in sup. Veins falls during walking Resting pressure in sup. Veins of foot & ankle is 80 to 100 mmHg During walking decreases to 20mmHg CRUCIAL TO THE HEALTH OF LOWER LIMB

PATHOPHYSIOLOGY : 

PATHOPHYSIOLOGY A. Normal Incompetent Valve Progression B. Leaky Valve Syndrome - Valves become stretched -Allow back flow of Blood C. Superficial Valvular Reflux -Vein becomes engorged -Increasing pressure -Thinning walls -Weaken muscle support -Can enlarge vessel diameters greater than 10mm

1.VEIN WALL WEAKNESS : 

1.VEIN WALL WEAKNESS 2.VALVE FAILURE 3.OUT FLOW OBSTRUCTION 3 MAIN FACTORS

ETIOLOGY: 

ETIOLOGY Pregnancy Pelvic obstruction Chronic straining Prolonged standing Prolonged sitting

ETIOLOGY: 

ETIOLOGY Wearing constricting clothing Obesity Hormones Heredity risk? Both parents = 80% 50/50 chance if one parent 20% chance if neither parent DVT TRAUMA CONGENITAL KLIPPEL TRANAUNAY SYN, CONG. AVALVIA

SYMPTOMS OF VARICOSE VEINS: 

SYMPTOMS OF VARICOSE VEINS Pain: aching, throbbing, tingling, sharp Cramps, heaviness, tiredness of legs “Restless” legs at night Itching, dermatitis, hyperpigmentation, skin ulceration, bleeding, blood clots All increase with dependency, resolve with leg elevation or compression

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PAIN CAUSED BY VENOUS INSUFFICIENCY IS IMPROVED BY WALKING & ELEVATION OF LEGS IN CONTRAST TO ART. INSUFFICIENCY. WORSENS WITH MENSTRUAL CYCLES , PREGNANCY & O.C PILLS ALSO WORSENS AFTER SEXUAL INTERCOURSE

Superficial Venous Insufficiency: 

Superficial Venous Insufficiency Abnormal veins - telangiectasia (spider) - reticular - Non-saphenous VV - Saphenous VV Abnormal skin

Superficial Venous Insufficiency: 

Superficial Venous Insufficiency Abnormal veins - telangiectasia (spider) - reticular - Non-saphenous VV - Saphenous VV Abnormal skin

Superficial Venous Insufficiency: 

Superficial Venous Insufficiency Abnormal veins - telangiectasia (spider) - reticular - Non-saphenous VV - Saphenous VV Abnormal skin

Superficial Venous Insufficiency: 

Superficial Venous Insufficiency Abnormal veins - telangiectasia (spider) - reticular - Non-saphenous VV - Saphenous VV Abnormal skin

Superficial Venous Insufficiency: 

Superficial Venous Insufficiency Abnormal veins Abnormal skin - eczema - edema - corona phlebectatica ankle flare - lipodermatosclerosis - ulceration - atrophe blanche

Classification Of CVD CEAP: 

Classification Of CVD CEAP C - clinical signs 0: No visible venous disease 1: Telangiectasias or reticular veins 2: Varicose veins 3: Edema 4: Skin changes 5: Healed ulceration 6: Active ulceration J Vasc Surg 1995; 21:635-645.

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CLINICAL EVALUATION

INSPECTION: 

INSPECTION

1.INSPECTION OF VEIN 2.INSPECTION OF ANKLE & FOOT: 

1.INSPECTION OF VEIN 2.INSPECTION OF ANKLE & FOOT

INSPECTION OF VEIN: 

INSPECTION OF VEIN POSITION- STANDING 1.SITE &EXTENT TO KNOW WHETHER IT BELONGS TO GREAT SAPHENOUS SYSTEM OR SHORT SAPHENOUS SYSTEM STRAY VARICOSITIES OR NON SAPHENOUS VARICOSITIES EXAMINE FROM ALL SIDES

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2.BLOW OUT: 

2.BLOW OUT LOCALISED BULGE PRESENCE OF INCOMPETENT OR DILATED PERFORATORS

3.INSPECTION OF SAPHENOUS OPENING: 

3.INSPECTION OF SAPHENOUS OPENING FOR SAPHENA VARIX SAPHENA VARIX IS A BLOW OUT OVER THE SFJ DUE TO SF VALVE INCOMPETENCE VISIBLE COUGH IMPULSE

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4.INSPECTION OF LOWER ANT.ABDOMINAL WALL: 

4.INSPECTION OF LOWER ANT.ABDOMINAL WALL SUP. INFERIOR EPIGASTRIC V. SUP. CIRCUMFLEX ILIAC V. SUP. EXTERNAL PUDENDAL V.

5.COLLAPSABILITY: 

5.COLLAPSABILITY AT 60 DEGREES UNCOMLICATED VARICOSE VEINS USUALLY COLLAPSE. IN PELVIC VEIN THROMBOSIS AND AV FISTULA VARICOSE VEIN DOES NOT COLLAPSE

6.MORISSEY’S TEST: 

6.MORISSEY’S TEST AT 30 DEGREES PT. IS ASKED TO COUGH SAPHENA VARIX IF PRESENT WILL BULGE OUT ALONG WITH IT A RETROGRADE PRESSURE WAVE WILL BE SEEN IN THE VEIN WHICH SLOWLY RAISES AND FALLS POSITIVE TEST INDICATES INCOMPETENCY OF SAPHENOPHEMORAL VALVE

INSPECTION OF ANKLE & FOOT: 

INSPECTION OF ANKLE & FOOT ANKLE FLARE/CORONA PHLEBECTATICA DIFFUSE SOFTTISSUE SWELLING OF ANKLE WITH DILATATION OF SMALL SUB CUTANEOUS VENULES HOLLOW BETWEEN THE MEDIAL MALLEOLUS AND HEEL IS OBLITERATED IN ASSOCIATION WITH ANKLE PERFORATORS

SKIN: 

SKIN SKIN OVER MEDIAL ASPECT OF LOWER ONE THIRD OF LEG & ANKLE SHOULD BE INSPECTED FOR OEDEMA DERMATITIS PIGMENTATION OOZING ATROPHE BLANCHE LIPODERMATOSCLEROSIS

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*Image via Bing ATROPHE BLANCHE

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VENOUS HYPERTENSION HAEMOGLOBIN HEMOSIDERIN PIGMENTATION BILIVERDIN ITCHING & DERMATITIS

VARICOSE ULCER: 

VARICOSE ULCER MOST COMMON SITE– MEDIAL ASPECT OF ANKLE & LOWER ONE THIRD OF LEG CHARACTERISTIC FEATURES SUPERFICIAL VERTICALLY OVAL IN SHAPE PAINLESS IRREGULAR,RAGGED ,SLOPING EDGES PALE,UNHEALTHY GRANULATIONS NEVER PENETRATE DEEP FASCIA MORE COMMONLY SEEN WITH D.V.T

WHY COMMON OVER LOWER ONE THIRD & ANKLE ?: 

WHY COMMON OVER LOWER ONE THIRD & ANKLE ? MORE NUMBER OF PERFORATORS PERFORARORS AT THIS SITE ARE DIRECT PERFORATORS

CAUSE FOR LEG ULCERATION: 

CAUSE FOR LEG ULCERATION WHITE CELL TRAPPING OR LEUCOCYTE TRAPPING HYPOTHESIS

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VENOUS HYPERTENSION LEUCOCYTE SEQUESTRATION IN MICROCIRCULATION ACTIVATED LEUCOCYTES RELEASE PROTEOLYTIC ENZYMES CAUSES LEG ULCERATION

FOOT: 

FOOT TALIPES EQUINUS DEFORMITY LIMPING ON TOES THIS DEVELOPS WHEN ULCERATION & SEVERE PIGMENTATION ARE FOUND AT ANKLE DUE TO CONTRACTION OF SOFT TISSUE OVER MEDIAL ASPECT OF ANKLE BECAUSE OF ULCER

PALPATION 1.TEMP.&TENDERNESS : 

PALPATION 1.TEMP.&TENDERNESS WARM & TENDER IN SUPERFICIAL THROMBOPHLEBITIS

2.FEGAN’S METHOD OF PALPATION : 

2.FEGAN’S METHOD OF PALPATION TO KNOW THE SITE OF INCOMPETENT PERFORATORS DEEP FASCIA IS PALPATED FOR THE PRESENCE OF PITS

3.COUGH IMPULSE : 

3.COUGH IMPULSE AT SAPHENOUS OPENING SAPHENA VARIX IF POSITIVE INDICATES INCOMPETENT SAPHENO FEMORAL VALVE THRILL- CRUVEILHIER’S SIGN

4.SCHWARTZ TEST: 

4.SCHWARTZ TEST TAP TEST POSITIVE TEST INDICATES VENOUS VALVE INCOMPETENCY

5.BRODIE TRENDELENBERG TEST: 

5.BRODIE TRENDELENBERG TEST TO KNOW SAPHENO FEMORAL VALVE INCOMPETENCY AND WHETHER THERE IS ANY INCOMPETENCY OF PERFORATORS

POSSIBLE RESULTS: 

POSSIBLE RESULTS WITH PRESSURE MAINTAINED WITH PRESSURE RELEASED INFERENCE NEGATIVE POSITIVE PURE SFJ INCOMPETENCY POSITIVE NEGATIVE PURE PERFORATOR INCOMPETENCY POSITIVE POSITIVE BOTH SFJ & PRFORATOR INCOMPETENCY

6.MULTIPLE TOURNIQUET TEST: 

6.MULTIPLE TOURNIQUET TEST TO KNOW THE POSITION OF INCOMPETENT PERFORATORS 3 TOURNIQUETS ARE TIED AT 1.JUST BELOW SAPHENOUS OPENING 2.JUST ABOVE KNEE 3.JUST BELOW KNEE

7.PRATT’S TEST: 

7.PRATT’S TEST TO LOCATE INCOMPETENT PERFORATORS MORE ACCURATELY ELASTO CREEP BANDAGE & TOURNIQUET ARE USED

TESTS FOR PATENCY OF DEEP VEINS: 

TESTS FOR PATENCY OF DEEP VEINS 1.MODIFIED PERTHE’S TEST A TOURNIQUET IS USED 2.ORIGINAL PERTHE’S TEST SAME TEST PERFORMED WITH ELASTOCREPE BANDAGE APPLIED FROM TOES TO MID THIGH

TESTS FOR ACTIVE DVT: 

TESTS FOR ACTIVE DVT 1.TENDER CALF SWELLING 2.TENDERNESS ALONG COURSE OF THE VEINS(FEMORAL,POPLITEAL,POSTERIOR TIBIAL) 3.HOMAN’S SIGN 4.MOSE’S SIGN

FOCAL & GENERAL EXAMINATION: 

FOCAL & GENERAL EXAMINATION 1.INGUINAL LYMPH NODES 2.OPPOSITE LEG 3.ABDOMEN FOR LUMPS PRESSING ON PELVIC VEINS 4.SCROTUM FOR VARICOCELE OR TEST. TUMOUR 5.P/R FOR CO EXISTING HAEMORRHOIDS