LBM 5 Swollen leg accompanied with redness and painSTEP 1a) Varicose : is delated venose with tortuous hardened channel of blood vessel on the lower leg.

STEP 21. Explain the anatomy and fisiology of vein and the rule of vein valves!2. What are the etiology of varicose vein?3. What are the classification of varicose vein?4. What is the patofisiology of varicose vein?5. Why the predilection of varicose vein almost in the leg?6. Why the varicose showed after the second pregnancy?7. Why the patient had a profuse bleeding on the affected limb?8. Why the skin was brownish in color and hard when palpated?9. Why the people complain swelling redness and pain in the right leg?10. What is the relationship between obese and varicose vein?11. What is the relationship between the physical examination in this scenario with varicose vein?12. What are the risk factor of varicose vein?13. How to prevent the varicose vein?14. What is the treatment of the varicose vein?15. What are the complication of varicose vein?

STEP 31. Explain the anatomy and fisiology of vein and the rule of vein valves! Characteristic: Thin, collaps, have valve and not elastic Function: Membantu dalam pemompaan darah ke atas, tidak kembali lagi ke bawah Superficial: terlihat dari luar, dekat permukaan kulit (Contoh: v.saphena magna, v. Saphen parva) punya katupProfundal: cenderung tidak terlihat Ketika bernafas, tekanannya negatifVCS, VCI, Yang mempengaruhi aliran balik vena: Gravitasi, tekanan, sedotan jantung, saraf, pompa thoracal abdominal, inspirasi.2. What are the etiology of varicose vein?Endogen: hormone (in the woman pragnancy, example: estrogen volume darah meningkat, angiotensinogen), genetic, insuficiensy of valve, thrombus (karena plak, emboli udara)Eksogen: Kurang aktivitas, sering berdiri (pompa vena tidak bekerja), penggunaan sepatu hak tinggi, work hard.3. What are the classification of varicose vein?Pembagian (menurut etiologi) Primer : karena kelemahan struktur vena ,akibatnyapelebaran pembuluh vena Sekunder: oleh gangguan patologis vena, bisa didapat kongenital, menyebabkan dilatasi, kerusakan vena dalam akan menyebabkan gangguan aliran darah menuju jantung.Derajat: C 0 : tidak ada kerusakan vena C 1 : Telangioektasis, diameter = 1- 2 mm (vena superfisial) C 2 : Varises vena , diameter > 2 mm C 3 : Edem tanpa kelainan kulit C 4 : Perubahan kulit (lipodermatosklerosis) C 5 : ulkus sembuh C 6 : ulkus aktifCO- C3 : KronisC4-C6: Insufiency of veinPelebaran arteri: aneurismaPelebaran AORTA:Berdasarkan Pf:1. Keluhan samar- samar (bengkak, nyeri)2. Pelebaran vena , Berdasarkan letak: Ven superfisial dan pofundal, diameter berapa?4. What is the patofisiology of varicose vein? Adanya tekanan: berkontraksi, tekanan naik Ada kerusakan katup: Primer (akibat katupnya, bukan karena pelebaran) Sekunder (ada dilatasi, mengakibatkan katupnya merengang, tidak rapat) Kelemahan otot (pengaruh obese, tekanan hidrostatis, volume darah, memperburuk penyangga vena; lemaknya numpuk di sekitar fasia, jd pembuluh darah sulit kembali)5. Why the predilection of varicose vein almost in the leg?

6. Why the varicose showed after the second pregnancy?7. Why the patient had a profuse bleeding on the affected limb?8. Why the skin was brownish in color and hard when palpated?9. Why the people complain swelling redness and pain in the right leg?10. What is the relationship between obese and varicose vein?11. What is the relationship between the physical examination in this scenario with varicose vein?12. What are the risk factor of varicose vein?13. How to prevent the varicose vein?14. What is the treatment of the varicose vein?15. What are the complication of varicose vein? 16. What are the DDs of varicose vein?17. What is the different between artery dilatation and aorta dilatation?18. Why the varicose vein can be happen in right leg?

STEP 4

STEP 7

1. Explain the anatomy and fisiology of vein and the rule of vein valves!

Venous AnatomyAnatomic Classifications of the Venous SystemThe venous system can be broken down into four major classes. Insufficiencies can present in any of these veins, and treatment can vary depending on the classification. It is important to also understand the nervous system of the lower extremities before performing any laser vein treatment.

Deep Venous System

These are primary veins that drain venous blood from the lower extremity. They include: Common Femoral Deep femoral External Iliac Femoral Popliteal Tibial (Anterior and Posterior) PeronealDeep veins are located within the muscle fascia which allows a high volume and pressure of blood to pass through the veins. They account for approximately 90-95% of venous blood return to the heart. Deep veins can form deep vein thrombosis, or DVT, which is a dangerous clot in the deep system.Superficial Veins

Superficial veins serve to drain blood from the skin. Blood travels from the superficial veins through the perforator veins to the deep veins. Superficial veins are located near the surface of the skin, outside of the muscle fascia, and they account for approximately 5-10% of venous blood return to the heart. There are two primary superficial veins: Small Saphenous Vein (SSV) Great Saphenous Vein (GSV)The great saphenous vein is the longest vein in the body, running medially from the dorsal vein in the foot up to the common femoral vein in the groin, where it empties. The point where the GSV empties into the common femoral vein is called the Saphenofemoral Junction (SFJ). A typical GSV contains an average of 7 valves throughout its entire length, and it is the most common superficial vein to develop venous reflux.The small saphenous vein originates at the back of the ankle near the outer malleous bone, and usually runs up the back of the lower leg to the popliteal vein behind the knee.

Perforator Veins

Perforator veins connect superficial veins to deep veins. They contain one-way valves to direct the blood from the superficial system to the deep system. Perforators include: Cockett Perforators Boyd's Perforators Dodd's Perforators Hunterian PerforatorBoyd's perforators are common sites for primary varicose veins. These veins connect the GSV to the posterior tibial vein. Hunterian perforators connect the GSV to the superficial femoral vein, and these are common causes of medial thigh varicosities.Reticular Veins Connect branch veins to any of the deep, superficial, or perforating veins

PhysiologyVeins return blood to the heart. Over the course of a minute this volume is called the venous return (VR). By the time blood has reached the veins its pressure has been reduced to practically nothing. Because blood flows along its pressure gradient there are several mechanisms that assist the flow.ComplianceVeins are compliant (COM), that is, they stretch when filling with blood but, unlike elastic arteries, recoil is minimal.Compliance(COM) is shown as thedashed outline around the vein. The stretch is caused by thehydrostatic pressure(HP block arrow) resulting fromblood pressure(BP) entering veins.Compliant vessels (COM) have large diameters which means they have lowperipheral resistance(PR). Thisinverse relationshipis shown by the dashed arrow between these two factors. Also, lowperipheral resistanceisinversely relatedtoflowas indicated by the dashed arrow.High compliancefavors flowby providing little loss of pressure due to friction; the peripheral resistance is small. However, compliance simultaneouslydoes not favor flowbecause thepressure gradient--flow arrow between the two BP acronyms--is kept small. In other words, since less energy is lost to friction, the pressure at the downstream end of the vessel will not have dropped much.Mechanisms That Assist Flow in VeinsValvesMany veins have one way valves that prevent the backflow of blood; a handy mechanism especially in light of the low pressure gradient in veins. These are not shown on the model.Contractions of Skeletal MusclesDeep veins pass between skeletal muscles in the extremities. Contraction of these muscles (Csm) presses on the veins causing forward movement of blood through the one way valves. This is shown by the solid arrow (direct relationship) between Csm (i.e.,contraction of skeletal muscles) andvenous return(VR).Pleural PressureDuring inhalation, the pressure in the pleural cavities decreases causing the lungs to expand. The veins entering the heart are affected by this pressure drop in the same manner as the lungs; they expand. This pressure drop, due to decreasedpleural pressure(Pp) at the end of the great veins, decreasesblood pressure(BP) at this location. Thisdirect relationshipis shown by the solid arrow between these two factors. The term 'thoracic pump' is often applied to this phenomenon.

(http://venacure-evlt.com/endovenous-laser-vein-treatment/procedure/venous-anatomy/)

Physiology of the venous system in the lower limbs

The main purpose of the venous system within the general circulation, is to carry oxygen-depleted blood rich in cell metabolism waste back to the heart.It is within the legs that the stresses are the greatest and the specific characteristics of the venous system are the most important, sincethe venous system must move blood against the force of gravity in the standing position.A combination of two main actions ensures venous return in the lower limbs: Firstly,the presence of mobile anti-reflux valves and the resistance of the vein walls allowing the blood to move in one direction only: from the superficial to towards the deep venous system and from the feet to the heart. Secondly,a pump mechanism which activates and maintains the blood flow through the veins.The anti-reflux valves allow fluid to circulate in one direction only, making it possible to maintain the normal direction of venous blood flow, even in the absence of pressure or in the event of negative pressure and thereby prevent backflow of the blood.Normal blood flow is directed from the superficial towards the deep system and from the most distal part of the body towards the heart.

The pump mechanism mainly results from a combination of different forces: The stimulation of the venous system of thefoot Themuscle pump, more specifically, the muscles of the calf (leading to alternate opening and closing of the valves): which is the main driving force behind the pump mechanism, The beating of the heart and the negative pressure due to the phenomenon of aspiration from the abdominal cavity that occurs during deep breathing.

(http://www.urgo.co.uk/262-physiology-of-the-venous-system-in-the-lower-limbs)

2. What are the etiology of varicose vein?

Varicose veins are usually caused by weak vein walls and valves.Weakened valvesInside your veins are tiny one-way valves that open to let the blood through and then close to prevent it flowing backwards.Sometimes, the walls of the veins can become stretched and lose their elasticity, causing the valves to weaken. If the valves do not function properly,this can cause the blood to leak and flow backwards. If this happens, the blood will collect in your veins, which will become swollen and enlarged.The reasons why the walls of the veins stretch and valves in your veins weaken are not fully understood. Some people develop the condition for no obvious or apparent reason.

(http://www.nhs.uk/Conditions/Varicose-veins/Pages/Causes.aspx)

3. What are the classification of varicose vein?

In order to standardize the reporting and treatment of the diverse manifestations of chronic venous disorders, a comprehensive classification system (CEAP) has been developed to allow uniform diagnosis and comparison of patient populations. Created by an international ad hoc committee of the American Venous Forum in 1994, it has been endorsed throughout the world and is now accepted standard for classifying chronic venous disorders.The fundamentals of the CEAP classification include a description of the clinical class (C) based upon objective signs, the etiology (E), the anatomical (A) distribution of reflux and obstruction in the superficial, deep and perforating veins, and the underlying pathophysiology (P), whether due to reflux or obstruction. (1)Seven clinical categories are recognizedas shown on the table below:CEAP classification of chronic venous diseaseClinical classificationC0: no visible or palpable signs of venous diseaseC1: telangiectasies or reticular veinsC2: varicose veinsC3: edemaC4a: pigmentation or eczemaC4b: lipodermatosclerosis or athrophie blancheC5: healed venous ulcerC6: active venous ulcerS: symptomatic, including ache, pain, tightness, skin irritation, heaviness, and muscle cramps, and other complaints attributable to venous dysfunctionA: asymptomatic

Etiological classificationEc: congenitalEp: primaryEs: secondaryEn: no venous cause identified

Anatomical classificationAs: superficial veinsAp: perforating veinsAd: deep veinsAn: no venous location identifiedPathophysiologyPr: refluxPo: obstructionPr,o: reflux and obstructionPn: no venous pathophysiology identifiable

(http://www.sigvaris.com/en/scientific-corner/ceap-classification)

There are several types of varicose veins, such as: Trunk varicose veinsare near to the surface of the skin and are thick and knobbly. They are usually visible, often quite long and can look unpleasant. Reticular varicose veinsare red and are sometimes grouped close together in a network. Telangiectasia varicose veins, also known as thread veins or spider veins, are small clusters of blue or red veins that sometimes appear on your face or legs. They are harmless and, unlike trunk varicose veins, do not bulge underneath the surface of the skin.(http://www.nhs.uk/Conditions/Varicose-veins/Pages/Whatarevaricoseveins.aspx)

4. What is the patofisiology of varicose vein?

Varicose veins and spider veins are normal veins that have dilated under the influence of increased venous pressure.In healthy veins, one-way valves direct the flow of venous blood upward and inward. Blood is collected in superficial venous capillaries, flows into larger superficial veins, and eventually passes through valves into the deep veins and then centrally to the heart and lungs. Superficial veins are suprafascial, while deep veins are within the muscle fascia. Perforating veins allow blood to pass from the superficial veins into the deep system.Within muscle compartments, muscular contraction compresses deep veins and causes a pumping action that can produce transient deep venous pressures as high as 5 atmospheres. Deep veins can withstand this pressure because of their construction and because their confining fascia prevents them from becoming excessively distended. In contrast to deep veins, the venous pressure in superficial veins normally is very low. Exposure to high pressures causes superficial veins of any size to become dilated and tortuous.Perfectly normal veins dilate and become tortuous in response to continued high pressure, as is observed in patients with dialysis shunts or with spontaneous arteriovenous malformations. In a subset of patients with hereditary vein wall weakness, even normal venous pressures produce varicose changes and venous insufficiency.Elevated venous pressure most often is the result of venous insufficiency due to valve incompetence in the deep or superficial veins. Varicose veins are the undesirable pathways by which venous blood refluxes back into the congested extremity. Ablation of the varicose pathways invariably improves overall venous circulation.Chronically increased venous pressure can also be caused by outflow obstruction, either from intravascular thrombosis or from extrinsic compression. In patients with outflow obstruction, varicosities must not be ablated because they are an important bypass pathway allowing blood to flow around the obstruction. Specific diagnostic tests can distinguish between patients who will benefit from ablation of dilated superficial veins and those who will be harmed by the same procedure.Deep vein thrombosis initially produces an obstruction to outflow, but in most cases the thrombosed vessel eventually recanalizes and becomes a valveless channel delivering high pressures from above downward.Most commonly, superficial venous valve failure results from excessive dilatation of a vein from high pressure of reverse flow within the superficial venous system. Valve failure can also result from direct trauma or from thrombotic valve injury. When exposed to high pressure for a long enough period, superficial veins dilate so much that their delicate valve leaflets no longer meet.In the most common scenario, a single venous valve fails and creates a high-pressure leak between the deep and superficial systems. High pressure within the superficial system causes local dilatation, which leads to sequential failure (through over-stretching) of other nearby valves in the superficial veins. After a series of valves have failed, the involved veins are no longer capable of directing blood upward and inward. Without functioning valves, venous blood flows in the direction of the pressure gradient: outward and downward into an already congested leg.As increasing numbers of valves fail under the strain, high pressure is communicated into a widening network of dilated superficial veins in a recruitment phenomenon. Over time, large numbers of incompetent superficial veins acquire the typical dilated and tortuous appearance of varicosities.Varicose veins of pregnancy most often are caused by hormonal changes that render the vein wall and the valves themselves more pliable. The sudden appearance of new dilated varicosities during pregnancy still warrants a full evaluation because of the possibility that these may be new bypass pathways related to acute deep vein thrombosis.The sequelae of venous insufficiency are related to the venous pressure and to the volume of venous blood that is carried in a retrograde direction through incompetent veins. Unfortunately, the presence and size of visible varicosities are not reliable indicators of the volume or pressure of venous reflux. A vein that is confined within fascial planes or is buried beneath subcutaneous tissue can carry massive amounts of high-pressure reflux without being visible at all. Conversely, even a small increase in pressure can eventually produce massive dilatation of an otherwise normal superficial vein that carries very little flow.(http://emedicine.medscape.com/article/1085530-overview#a0104)

5. Why the predilection of varicose vein almost in the leg?

Most varicose and spider veins appear in the legs due to the pressure of body weight, force of gravity, and task of carrying blood from the bottom of the body up to the heart.Compared with other veins in the body, leg veins have the toughest job of carrying blood back to the heart. They endure the most pressure. This pressure can be stronger than the one-way valves in the veins.(http://www.womenshealth.gov/publications/our-publications/fact-sheet/varicose-spider-veins.cfm#E)

6. Why the varicose showed after the second pregnancy?women are much more likely to develop varicose veins during their pregnancy than at any other time in their lives. A pregnant woman has much more blood in her body, compared to when she is not pregnant - this places extra pressure on the circulatory system. A change in hormone levels and hormone balance can also lead to a relaxation of the blood vessel walls. Both these factors raise the risk of having varicose veins.

As the uterus (womb) grows there is more pressure on the veins in the mother's pelvic area. In the majority of cases, the varicose veins go away after the pregnancy is over (not always and/or sometimes not all of them)(http://www.medicalnewstoday.com/articles/240129.php)

Varises terjadi karena ada kelemahan pada dinding otot pembuluh darah atau ada gangguan pada klep vena, sehingga peredaran darah jadi tak lancar. Namun pada wanita hamil, kemunculan varises biasanya dikaitkan dengan perubahan hormonal.Seperti diketahui, saat hamil terjadi peningkatan hormon progesteron yang mengakibatkan perubahan fisik dan psikis. Payudara ibu akan membesar, tubuh terasa lemas, pusing, mual, muntah, dan lainnya. Berbarengan dengan itu, elastisitas pembuluh darah, arteri maupun vena, semakin bertambah lentur. Akibatnya, pembuluh darah, terutama vena, jadi tambah besar dan melebar.Sebenarnya, pelebaran pembuluh darah ini sangat bermanfaat untuk menyuplai bahan makanan ke janin. Dengan pembuluh darah yang semakin lebar, transportasi makanan ke janin akan semakin lancar, sehingga pertumbuhan janin pun lebih optimal.Hanya, terkadang aliran darah dari anggota gerak bawah, yaitu kaki, juga panggul seperti anus dan vagina, tidak dapat berbalik dengan lancar ke atas (jantung).Hal ini disebabkan oleh tekanan yang lebih kuat akibat pembesaran rahim, disebut efek mekanik yang membuat bendungan, sehingga menghambat jalannya darah dan terjadilah pelebaran vena, disebut dengan varises.Dikatakan bahwa, risiko varises semakin besar terjadi pada wanita yang pernah hamil dan melahirkan anak lebih dari 2 kali, juga pada wanita hamil usia di atas 40 tahun. Sebabnya, arteriosclerosis (penebalan dinding pembuluh darah) yang dialami mereka, berdampak pada dinding pembuluh darah yang kehilangan daya lentur/elastisitasnya. Kekakuan ini akan menghambat aliran vena sehingga memudahkan varises muncul.Risiko varises yang parah akan semakin besar pada ibu hamil yang terlalu lama berdiri atau duduk. Misalnya, ibu hamil yang bekerja sebagai sales promotion girl (SPG), harus berdiri sepanjang hari. Juga, ibu hamil yang bekerja sebagai sekretaris dimana harus duduk terus-menerus.Bila varisesnya berat, dikhawatirkan ibu akan mengalami perdarahan hebat saat bersalin. Bila tertekan tubuh janin yang akan lahir, maka gesekannya dapat membuat varises pecah dan mengeluarkan darah. Tak hanya tertekan tubuh janin, saat mengejan pun bisa saja pembuluh darah pecah karena otot-otot di seputar vagina menegang dan keras. Perdarahan hebat ini bisa berdampak, ibu kehilangan banyak darah, lemas, sulit bekerja sama sehingga persalinan menjadi lebih lama. Persalinan lama dikhawatirkan akan membahayakan keselamatan ibu juga janin.Dr Masdulhag SpOG, http://www.hariansumutpos.com/arsip/?p=23984

7. Why the patient had a profuse bleeding on the affected limb?The skin over the veins becomes thin and easily injured. When an injury occurs, there can be significant blood loss.(http://www.womenshealth.gov/publications/our-publications/fact-sheet/varicose-spider-veins.cfm#E)

8. Why the skin was brownish in color and hard when palpated?

Perubahankulitdi kaki juga dapat dilihat karena kapiler proliferasi, nekrosis lemak, dan fibrosis darijaringankulit dan subkutan. Kulit tampak kemerahan atau cokelat karena deposisi (proses pengkristalan karena mengalami pengerasan) hemosiderin. COKLAT: Insuffisiensi katup vena superficial atau profunda Regurgitasi aliran darah (kemabali ke bawah) akumulasi tekanan tinggi kapiler dan vv. Kecil rusak eritrosit ikut bocor ke jaringan timbulkan warna coklat.

PERABAAN KERAS:Varises yang terus progress dinding vena semakin rapuh endotel rentan cedera trauma minor bisa akibatkan cedera endotel peningkatan permeabilitasnya;gangguan ekskresi vasodilator yang diproduksinya molekul trombosit yangselalu ada dekaat dinding pembuluh mudah mengendap sebabkan thrombus hasilkan sumbatan reaksi peradangan.

9. Why the people complain swelling redness and pain in the right leg?

Hubungan peradangan:Insuffisiensi vena kronik Akumulasi darah di ekstremitas bawah P nya tinggi cairan plasma bocor ke jaringan interstisial protein fibrinogen buat barrier antara jaringan dengan dinding vaskuler peradangan ; halangi pertukaran nutrisi, oksigen dengan zat2 sisa pembakaran sel nutrisi terhambat;zat sampah akumulasi kerusakan sel peradanganbisa jadi dermatitis stasis, lipodermatosclerosis atau bahkan ulcer hiperpigmentasi menetap.LDS literally means "scarring of the skin and fat" and is a slow process that occurs over a number of years. (http://www.simondodds.com/Venous/LDS.htm)

10. What is the relationship between obese and varicose vein?Being overweight or obese can put extra pressure on your veins. This can lead to varicose veins. Excessive weight increases the pressure on the veins of the legs and aggravates the condition.

(http://www.womenshealth.gov/publications/our-publications/fact-sheet/varicose-spider-veins.cfm#E)

11. What is the relationship between the physical examination in this scenario with varicose vein?

12. What are the risk factor of varicose vein?

Anumber ofthings can increase your likelihood of developing varicose veins, including: gender genetics age being overweight occupation being pregnant other conditionsGenderWomen are more likely to be affected by varicose veins than men. Research suggests this may be because female hormones tend to relax the walls of veins, making the valves more prone to leaking. Hormones are chemicals produced by the body.GeneticsYour risk of developing varicose veins is increased if a close family member has the condition. This suggests varicose veins may be partly caused by your genes (the units of genetic materialyou inherit from your parents).

AgeAs you get older, your veins start to lose their elasticity and the valves inside them stop working as well.Being overweightBeing overweight puts extra pressure on your veins, which means they have to work harder to send the blood back to your heart. This can put increased pressure on the valves, making them more prone to leaking. The impact of body weight on the development of varicose veins appears to be more significant in women.

OccupationSome research suggests jobs that require long periods of standing may increase your risk of getting varicose veins. This is because your blood does not flow as easily when you are standing for long periods of time.

PregnancyDuring pregnancy, the amount of blood increases to help support the developing baby. This puts extra strain on your veins.Increased hormone levels during pregnancy also cause the muscular walls of the blood vessels to relax, which also increases your risk.Varicose veins may also develop as the womb (uterus) begins to grow. As the womb expands it puts pressure on veins in your pelvic area, which can sometimes cause them to become varicose.Although being pregnant can increase your risk of developing varicose veins, most women findtheir veins significant improve after the baby is born.Other conditionsIn rare cases, varicose veins are caused by other conditions. These include a previous blood clot a swelling or tumour in the pelvis abnormal blood vessels(http://www.nhs.uk/Conditions/Varicose-veins/Pages/Causes.aspx)

13. How to prevent the varicose vein?

Exercise:Walking is a great way to increase blood flow in the legs. Lose weight:Shedding excess pounds takes unnecessary pressure off veins in the legs. Wear compression stockings. Avoid high heels:Stick with low-heeled shoes that give the calf muscles a better workout, which can help give you healthier veins. Elevate legs:Take 3 or 4 daily breaks (10 to 15 minutes) to elevate the legs above the level of the heart (e.g., lie down with legs resting on 3 or 4 pillows). Avoid long periods of sitting or standing:Make a point to change position frequently to encourage blood flow.

(http://bodyandhealth.canada.com/condition_info_details.asp?channel_id=0&relation_id=0&disease_id=216&page_no=2)14. What is the treatment of the varicose vein?

Your doctor may suggest that you take the following self-care steps to help manage varicose veins: Wear compression stockings to decrease swelling. They gently squeeze your legs to move blood up your legs. Do not sitor stand for long periods. Even moving your legs slightly helps keep the blood flowing. Raise your legs above your heart three or four times a day for 15 minutes at a time. Care for wounds in you have any open sores or infections. Your health care provider can show you how. Lose weight if you are overweight. Get more exercise. This canhelp you keep off weight and help move blood up your legs. Walking or swimming are good options. If you have dry or cracked skin on your legs, moisturizing may help. However, some skin care treatments can make the problem worse. Talk to your health care provider before using any lotions, creams or antibiotic ointments. Your provider can recommend lotions that can help.If your condition is severe, your doctor may recommend the following treatments: Laser therapy:Strong bursts of light are projected on smaller varicose veins, making them disappear. Sclerotherapy:Saltwateror a chemical solution is injected into the vein. The vein hardens and disappears. Ablation:Heat is used to close off and destroy the vein. The vein disappears over time. Vein stripping:Small surgical cuts are made in the leg near the damaged vein. The vein is removed through one of the cuts. Valve repair:A small incision is made in the leg and the damaged valve is repaired. Bypass:This is surgery to reroute blood flow around the blocked vein. A tube or blood vessel taken from your body is used to make a detour around, or bypass, the damaged vein. Angioplastyand stenting:This is a procedure to open a narrowed or blocked vein. Angioplasty uses a tiny medical balloon to widen the blocked vein. The balloon presses against the inside wall of the vein to open it and improve blood flow. A tiny metal mesh tube called a stent is then placed inside the vein to prevent it from narrowing again.

(http://www.drugs.com/enc/varicose-veins-and-venous-insufficiency.html)

15. What are the complication of varicose vein?

Varicose veins can lead to dermatitis (der-ma-TI-tis), an itchy rash. If you have varicose veins in your legs, dermatitis may affect your lower leg or ankle. Dermatitis can cause bleeding or skin ulcers (sores) if the skin is scratched or irritated.Varicose veins also can lead to a condition called superficial thrombophlebitis (THROM-bo-fleh-BI-tis). Thrombophlebitis is a blood clot in a vein. Superficial thrombophlebitis means that the blood clot occurs in a vein close to the surface of the skin. This type of blood clot may cause pain and other problems in the affected area.(http://www.nhlbi.nih.gov/health/health-topics/topics/vv/signs.html)

Varicose veins can cause complications because they stop your blood from flowing properly. Most people who have varicose veins will not developcomplications, but if you do, it will usually be several years after your varicose veins first appear.Some possible complications of varicose veins are explained below.BleedingVaricose veins near the surface of your skin can sometimes bleed if you cut or bump your leg. The bleeding may be difficult to stop. You should lie down, raise your leg and apply direct pressure to the wound. Seek immediate medical advice if this does not stop the bleeding.ThrombophlebitisThrombophlebitis is inflammation (swelling) of the veins in your leg caused by blood clots forming in the vein. This can occur within your varicose veins and it can: be painful look red feel warmWhen thrombophlebitis occurs in one of the superficial veins in your leg it is known as superficial thrombophlebitis. A superficial vein is a vein located just under the surface of your skin.Like varicose veins, thrombophlebitis can be treated with compression stockings.In some cases,non-steroidal anti-inflammatories (NSAIDs), such asibuprofen, may be prescribed.Chronic venous insufficiencyIf the blood in your veins does not flow properly, it can interfere with the way your skin exchanges oxygen, nutrients and waste products with your blood. If the exchange is disrupted over a long period of time it is known as chronic venous insufficiency.Chronic venous insufficiency can sometimes cause other conditions to develop, including those described below.Varicose eczemaVaricose eczemais a condition that causes your skin to become red, scaly and flaky. You may also develop blisters and crusting of your skin.This condition is often permanent.LipodermatosclerosisLipodermatosclerosis causes your skin to become hardened and tight, and you may find that it turns a red or brown colour. The condition usually affects the calf area.Venous ulcersA venous ulcer develops when there is increased pressure in the veins of your lower leg. This causes fluid to seep from your vein and collect under the skin. The fluid can cause the skin to thicken, swell andeventually break down to form an ulcer. Venous ulcers most commonly form in the ankle area.You should see your GP immediately if you notice any unusual changes in your skin, such as those mentioned above. These conditions can usually be easily treated, but it is importantyou receive treatment as soon as possible.

(http://www.nhs.uk/Conditions/Varicose-veins/Pages/Complications.aspx)

Bleeding- varicose veins near the skin may bleed if the patient's skin is cut or he/she bumps their leg. The bleeding may go on for much longer than normal. If this occurs, the patient should lie down, raise their leg and apply pressure directly onto the bleeding area. If the bleeding continues, get medical help. Thrombophlebitis- blood clots form in the vein of the leg, causinginflammationof the vein. The affected area can feel warm, may look red, and might also be painful. Treatment usually involves wearing compression stockings. For pain, the doctor may prescribe a suitable painkiller. Chronic venous insufficiency- this is when the skin does not exchange oxygen, nutrients and waste products with the blood properly, because the blood flow is weak. If this occurs over the long-term, it is called chronic venous insufficiency.

People with chronic venous insufficiency may develop varicose eczema, lipodermatosclerosis (hard and tight skin), and venous ulcers.(http://www.medicalnewstoday.com/articles/240129.php)16. What are the DDs of varicose vein?

Cellulitis Osler-Weber-Rendu Syndrome Stasis Dermatitis(http://emedicine.medscape.com/article/1085530-differential)17. What is the different between artery dilatation and aorta dilatation?18. Why the varicose vein can be happen in right leg?