EVALUATION AND TREATMENT OF VARICOSE VEINS/VENOUS...

Anatomy There are three basic components to the venous system

1. Deep veinsIliac, femoral, popliteal, tibial, giocamini

2. Superficial veinsgreater and small saphenous, anterior branch of saphenous

3. Communicating or perforators (3 primary, but there are more)Hunterian in proximal thigh, Dodds in inferior 1/3 of thighBoyd’s at the knee, Cockett in posterior arch vein (mid calf)

Valves in the superficial and deep veins open in response to the calf pump to allow blood flow toward the heart.

When the pumping stops, blood is prevented from refluxing back down the legs by the closure of the valves within the deep and superficial veins.

Arterial flow fills the venous system at rest.

As the venous system fills, the valves in the foot, distal leg and perforating system open to allow blood into the deep system.

Venous obstruction DVT, iliac venous obstructive lesions

Valvular insufficiency Abnormal closure of a valve

Calf muscle pump malfunction <10% of population have this Calf muscle problems generally begin within the

delicate veins in the deep system (which run deep within the calf muscle that is sheathed within the fascia).

Hx of DVTFamily hx of

Varicose VeinsObesitySmokingFemale

Pregnancy InactivityProlonged periods

of sitting or standing

Over age 50

Signs- Talengiectasias Edema Hyper pigmentation Lipodermatosclerosis Venous ulcers Appearance of large, ropey varicose veins Veins that are dark purple or blue in color Bleeding varicosity

Symptoms Complaints of swelling, heaviness Leg cramps or aches Painful veins Swelling Enlarging Veins Pain with standing Nocturnal muscle cramps Leg tiredness Itching and/or burning Venous claudication usually with chronic ilio-femoral venous obstruction in which they

develop severe thigh pain and a sensation of tightness with vigorous exercise and usually takes 15 – 20 min to subside.

Limping and/or pain due to inadequate venous drainage

Poor return of blood by the veins from the legs

Usually chronic ileofemoral venous obstruction.

Pts develop severe thigh pain and a sensation of tightness with vigorous exercise and takes 15 – 20 minutes to subside

Venous Pain is often

improved by walking or elevating legs

Warmth tends to aggravate the symptoms and cold tends to relieve them

Compression stockings tend to decrease the pain

Arterial Pain is usually worse

with walking or elevating legs

Cold tends to aggravate the symptoms while warmth tends to relieve them

Compression stockings usually aggravate the pain

Thorough history and physicalWarm roomWell illuminated Pt standing at least 5 minutes Inspection PalpationMeasurement PhotographyDocumentation

Non-invasive vascular testing

DermatitisHyperpigmentation Lipodermatosclerosis CellulitisHealed ulcerOpen ulcer

Full leg exposure View the leg from all sides

Major vein anatomy Document

- size- extent- discoloration or skin changes

What types of veins are present? Telangiectasia Reticular veins Varicose veins No veins noted (symptomatic)

Multiple vein types GSV phlebitits Varicose veins telangiectasia

Explain the vein types to the patient Set expectations for therapy

The most common indications for treatment of varicose veins are intractable symptoms which interfere with the patient’s daily activities of life in spite of conservative treatments

Whole limb swellingAbdominal wall varicositiesProximal extremity varicosities Medial or lateral across inguinal ligament Vulvar varicosities Gluteal varicosities

Thin, athletic patients (maybe not)LymphedemaCharcot footKnee issuesBack issuesSoft tissuesLipemia (presence in the blood of an

abnormally high concentration of emulsified fat)

The primary therapy remains essentially the same

Treat symptoms

Restore normal physiologic function to the diseased limbs

Common complications Bruising Hematoma Bleeding Pain Paresthesia

*Recurrence rate that is nearly 30% at 5 years

Can be done either by laser or radiofrequency energy

Done by gaining percutaneous vein access Catheter is passed through sheath and

advanced to SFJ Areas to be ablated are filled with tumescent

Bruising EdemaDVT < 5% Paresthesia Skin burns Thermal injury to adjacent tissues Inadvertent injury to deep veins

Ablation Assess treated vein Varicose veins: assess regression or

decompression, thrombosis Phlebectomy Incisions closed No fluid collections, inflammation, cellulitis Completeness of the phlebectomy

Telangiectasia Pt satisfaction

-missing diagnosis of DVT -missing diagnosis of superficial venous thrombosis -mis-diagnosis of stasis dermatitis as contact

dermatitis -misdiagnosis venous vs. arterial disease

Subjective symptoms worsen Non-healing ulcers develop Increased lifetime risk of DVT and/or PE Tissue atrophy & staining not reversible Venous insufficiency syndromes can lead to death from

thromboembolis or hemorrhage Ankle joint stiffness from progressive subcutaneous

scarring occasionally extends into the subcutaneous tissue around the ankle join, restricting ankle movement, reducing calf pump efficiency, and exacerbating the venous hypertension. Fibrous ankylosis may, eventually, fix the ankle joint with scar tissue.

Fixed plantar flexion: chronic pain of acute lipodermatosclerosis or ulcer may result in abnormal weight bearing and eventually ankle stiffening and shortening of the Achilles tendon.

Periostitis: long standing inflammation in soft tissues may induce hyperemia in the underlying periosteum, which can then produce new subperiosteal bone (usually happens underneath an area of recurrent ulceration).

History guides the exam Thorough physical is key Recognize the abnormal findingsMeasure and document a baseline Predict the anatomic findings of subsequent

testing Know the difference between venous and

arterial signs/symptoms

THE END… THANK YOU