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Varicose veins
Raymond G Buick FRCS
Approx 12 minutes
Varicose veins
• Varicose veins are swollen and enlarged veins • usually blue or dark purple• Lumpy• Bulging • torturous• twisted
Varicose-veins.jpg Original uploader was Jackerhack at en.wikipediaCC-BY-SA-2.5.
Varicose veins
• Legs• Testicular veins• Portal vein• Ano-rectal• Oesophageal• umbilicus
Varicose veins
• common – may be present in up to 30% of the UK adult
population– 40,000 operations/year in England & Wales– F>M
Varicose veins
• Long (great) saphenous vein in 50% • Short (small) saphenous vein in 30% • both saphenous veins in 20%.
Aetiology / Pathogenesis
• Aetiology unknown.
• Limb veins – valves
Aetiology / Pathogenesis
• Limb veins – valves– Muscle pump
Venous drainage of the lower limb
• Limb veins – valves• Superficial veins– Great (long) saphenous vein – Small (Short) saphenous vein
• Deep Veins • Perforating veins
Aetiology / Pathogenesis
• Limb veins – valves– Muscle pump
• Incompetent valves
Aetiology / Pathogenesis
• Limb veins – valves– Muscle pump
• Incompetent valves
Aetiology / Pathogenesis
• Limb veins – valves– Muscle pump
• Incompetent valves
Diagnosis
• The best diagnostic tool is the duplex ultrasound. – Sensitivity 90 to 95% – specificity 95 to 100%.
Risk Factors• a positive family, • increasing age, • pregnancy.
Risk Factors• a positive family, • increasing age, • pregnancy.
• Other controversial risk factors• obesity, • menopause• standing for long periods of time, • decreased mobility• Injury / post phlebitis• Abdominal straining• Venous / arteriovenous malformations
Risk Factors• a positive family, • increasing age, • pregnancy.
• Other controversial risk factors• obesity, • menopause• standing for long periods of time, • decreased mobility• Injury / post phlebitis• Abdominal straining• Venous / arteriovenous malformations
Symptoms• aching; heavy legs• itching; • leg cramps; (making a sudden move or standing up)
• restless legs (relieved by walking, symptoms worse during the evening and night)
• Skin discolouration (brownish blue shinny skin)
• eczema-like skin changes • swelling; ankles• small reticular veins and varicosities
complications• Injury• Bleeding• superficial thrombophlebitis (Blood clotting within affected
veins. - can extend into deep veins)
• Acute fat necrosis (ankle of overweight patients – lipodermatosclerosis)
• ulceration• carcinoma or sarcoma (longstanding venous ulcers -malignant
transformation - rate 0.4% to 1%.)
complications• Injury• Bleeding• superficial thrombophlebitis (Blood clotting within affected veins. - can
extend into deep veins)
• Acute fat necrosis • (ankle of overweight patients – lipodermatosclerosis)
• ulceration• carcinoma or sarcoma (longstanding venous
ulcers -malignant transformation - rate 0.4% to 1%.)
complications• Injury• Bleeding• superficial thrombophlebitis (Blood clotting within affected
veins. - can extend into deep veins)
• Acute fat necrosis (ankle of overweight patients – lipodermatosclerosis)
• ulceration• carcinoma or sarcoma (longstanding venous ulcers -malignant
transformation - rate 0.4% to 1%.)
complications• Injury• Bleeding• superficial thrombophlebitis (Blood clotting within affected
veins. - can extend into deep veins)
• Acute fat necrosis (ankle of overweight patients – lipodermatosclerosis)
• ulceration• carcinoma or sarcoma (longstanding venous ulcers -malignant
transformation - rate 0.4% to 1%.)
complications• Injury• Bleeding• superficial thrombophlebitis (Blood clotting within affected
veins. - can extend into deep veins)
• Acute fat necrosis (ankle of overweight patients – lipodermatosclerosis)
• ulceration• carcinoma or sarcoma (longstanding venous ulcers -malignant
transformation - rate 0.4% to 1%.)
Treatment
• asymptomatic - no treatment required. Prophylactic treatment does not reduce the progression of venous disease.
• Symptomatic patients – to reduce symptoms– cosmetic reasons (may be valid)
Treatment
• aim of treatment
– to reduce symptoms – improve appearance
Treatment
• Conservative treatment
• Invasive Treatment
Treatment
• Conservative treatment – compression – Elevate leg– Address risk factors
Treatment
• Invasive Treatment
• Surgery
• Endovenous Ablation Techniques
Treatment
• Invasive Treatment• Surgery– Surgical ligation – Surgical stripping– Cryostripping
– Subfascial Endoscopic Perforator vein Surgery – SEPS– Transilluminated Powered Phlebectomy - TIPP
Treatment
• Invasive Treatment• Endovenous Ablation Techniques– Radiofrequency Ablation– Endovenous Laser Treatment
– Sclerotherapy• Liquid• foam
Surgery
– Surgical ligation – Surgical stripping• Great Saphenous Vein
– Saphenofemoral disconnection + stripping» Groin to ankle - unnecessary: increased risk of
Saphenous Nerve Injury» Groin to knee – good initial results - reduced recurrence rate
• Small Saphenous Vein– Saphenopopliteal disconnection
» Stripping – damage to Sural Nerve
Risks of Treatment
• Problems arising from superficial venous surgery are the most common reason for litigation in the UK.
Risks of Treatment
• Problems arising from superficial venous surgery are the most common reason for litigation in the UK.
Risks of Treatment
• Most settled claims result from a failure to warn patients about nerve damage.
Risks of Treatment
•Most settled claims result from a failure to warn patients about nerve damage.
Risks of Treatment
• Conservative treatment - Very few
• Invasive Treatment
Risks of Treatment
• Invasive Treatment– Long saphenous vein - saphenous nerve damage
– 8% to 40%
Risks of Treatment
• Invasive Treatment– Long saphenous vein - saphenous nerve damage
– LONG STRIP(groin to ankle Level)
– SHORT STRIP (groin to knee level
Risks of Treatment
• Invasive Treatment– Long saphenous vein - saphenous nerve damage
– LONG STRIP(groin to ankle Level) - saphenous nerve damage 40%
– SHORT STRIP (groin to knee level)- saphenous nerve damage 8%
Risks of Treatment
• Invasive Treatment– Long saphenous vein - saphenous nerve damage
SHORT STRIP
more safe than
LONG STRIP
Risks of Treatment
• Invasive Treatment– Short saphenous vein - Sural nerve damage • 2.1%
• Problems arising from superficial venous surgery are the most common reason for litigation in the UK.• Most settled claims result from a
failure to warn patients about nerve damage
Varicose veins
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