Varicose VeinsDr. Sudhir Kumar Jain, MS, FRCSProfessor of Surgery,Maulana Azad Medical College,New Delhi

Varicose Veins:

Presented By:Dr. Sudhir. K. Jain, M.S, MBA(HCA), FRCS, FICS, FIAS.

Professor of Surgery, Maulana Azad Medical College and Associated LokNayak Hospital, New Delhi.

With Credits to:Dr. Vishnuraja, PG2, Dept of Surgery, MAMC.Dr. Ronal Kori, PG2, Dept of Surgery, MAMC.

First in History

• ‘Siragranthi’- Varicose Veins

• Sushrutha- Indian surgeon of antiquity is the first in history to document ‘Siragranthi=Varicose veins’ as aneurysmal dilation of Veins in ‘Samhit’

-History of Vascular surgery, Chapter 13, Page 147

First Surgery

• 2nd Century AD• Galen describes the first surgery for Varicose

veins:

In varicose veins of the legs, we mark out the whole extent of them by scratches on the outside, then put them on their backs, take hold of the skin surface, and divide that first, then lift up the varicosity with a hook and tie it off, and do the same thing at all the incisions. Or we pull them out with a varicocele hook and cut off the ends, or we pass thread through the coil of the veins with a probe and pull them up and take them out.

Definition

• Varicose veins are defined as dilated, elongated, tortuous and palpable superficial veins as a result of venous hypertension.

• It usually occurs due to permanent loss of valvular mechanism and resultant venous hypertension.

Venous System of lower limb

Consists of:• Deep system of veins which

lies below the deep fascia.• Superficial system of veins

which lies outside the deep fascia (carry 10% blood)

• Perforating veins which pass through the deep fascia joining the superficial to the deep system of veins.

Deep veins

Three Pairs of venae commitantes accompanying

• anterior tibial ,

• posterior tibial and

• Peroneal arteries

Valves in the veins• Valves present in superficial veins.

• Prevent flow of blood from proximal to distal and from deep to superficial

• Absent from above groin level

• Valves can resist pressure up to 300 mm of Hg.

Long saphenous vein• Originates at the medial border of the foot.

• It passes 1-1.5 inches anterior to the medial malleolus over the distal 1/3rd of the tibia.

• It is accompanied by the saphenous nerve below the knee joint

• Travels close to the deep fascia except at the knee joint, where it may become subcuticular

• In the thigh it passes antero-superiorly to reach the saphenous opening which is 3.75 cm below and lateral to the pubic tubercle.

• The vein of Giacomini joins LSV to SSV in thigh , responsible for recurrences.

Location of perforatorsSix Perforators joining the superficial to deep venous system are located at constant positions which are:

• 2, 4 and 6 inches above the medial malleolus (Cockett’sperforator)

• Just below the Tibialtubercle(Boyd’s)

• In the adductor(Hunter’s) canal of the thigh(Dodd’s perforator)

• Level of Mid-thigh

• Around 200 perforators are described most of them unnamed

Short Saphenous vein• Arises on the lateral border of the foot by joining of

lateral marginal vein and lateral deep venous arch.

• Passes behind the lateral malleolus

• Runs up in the midline posteriorly in the intra fascial compartment.

• Pierces the deep fascia in the upper part of the calf, and terminates in the popliteal vein in the midline 4cm below the popliteal skin crease.

• It is accompanied by the Sural nerve, lymphatics and popliteal nerve along its course.

• Derived from posterior axial vein of lower limb

Location of short saphenous perforators

• Bassi’s perforator- 5 cm above calcaneous

• Soleus point perforator

• Gastroenemius point perforator

• Negative pressure in thorax during inspiration to -6 mm.

• Calf muscle pump: Normal venous pressure in relaxed state 20mm of Hg.Rises to 80-100 mm of Hg during muscle contraction.

• Vis a tergo : arterial pressure transmitted to venous side through capillary bed

• Competent valves

• Venae commitants: lie by the side of artery, helped by arterial pulsation to propel blood.

Factors Helping in Venous return

Pathology

Primary

• Long hours of standing, which increase the hydrostatic pressure of gravity,

• Family history

• Pregnancy

• Ageing

Secondary

• Deep vein thrombosis

• Arterio venous malformation- ParkesWeber syndrome

• Hemangiomatousmalformation- KlippelTrenaunay syndrome

• Pelvic mass

• Retro peritoneal fibrosis

Parkes-weber syndrome

Klippel Trenaunay syndrome

• Varicose veins• Limb hypertrophy• Port wine Stains

Factors in Primary Varicose veins

• Valvular incompetence

• Perforator incompetence

• Venous obstruction in superficial veins

• Muscle dysfunction

Complications

• Bleeding• Thrombophlebitis• Venous Hypertension leading to

venous ulcer• Calcification• Talipes Equinovarus deformity of

foot• Eczematoid dermatitis and

pigmentation• Periostitis of subcutaneous

surface of tibia• Carcinoma in long standing

venous ulcer-Marjolins ulcer

Varicose presentation

• More common in males in India

• Left lower limb more commonly involved

• Long saphenous system affected in 2/3 rd of cases

Examination

Aims:

• Finding the system involved

• Extent of involvement

• Skin changes/ulcer around malleolus

• Trendelenberg test for patency of Sapheno-femoral junction

• Perthe’s test for patency of deep veins

Investigations

• Ambulatory venous pressure studies

• Venous Doppler study

• Air plethysmography

Ambulatory venous pressure study

Ambulatory venous pressure more than 80 mm of Hg is associated with venous ulceration.

Air Plethysmography

• Indicated for diagnosis of calf muscle dysfunction

• Measures changes in leg volume in response to exercise and posture.

• Leg placed in 40 cm tubular Vinyl air chamber Leg volume measured in supine, elevated , standing on opposite leg and after 10 tip toe jumps.

• Venous volume(VV), venous filling time90(VFT 90) and venous filling index(VFI) and ejection fraction (EF)calculted

Air Plethysmography

Air Plethysmography

Interpretation API

• If venous volume > 350 ml (normal 100-150 ml) Indicates chronic venous insufficiency(CVI)

• If VFI is 7 ml per second(normal < 2ml per second) indicates CVI

• If ejection fraction venous blood of calf muscle is less than 60 percent after one tip toe indicates Calf Muscle dysfunction

• If remaining venous fraction(RVF) after 10 tip toes is more than 40 percent indicates calf muscle dysfunction

• If RVF more than 40 percent and Venous filling index (VFI) > 2 ml per second then it indicates reflux

Color Doppler Study

• To find patency of deep veins.

• To define the site of incompetent perforators & to mark them preoperatively.

• To find out the competence of Saphenofemoral junction & Sapheno popliteal junction.

• If Sapheno-popliteal junction is incompetent it should be marked preoperatively because of its highly variable & inconstant position.

• Ankle brachial index should be measured to rule out any concomitant arterial disease.

Color doppler

Venous disease-Classification

Class Description

0 No visible or palpable signs of venous disease

1 Telangiectasia (intra dermal vein upto 1 mm) or reticular veins (Subdermal upto 4 mm non palpable)

2 Varicose veins-Palpable more than 4 mm

3 Edema

4 Skin changes-Pigmentation, eczema, lipodermatosclerosis

5 Skin changes with healed ulceration

6 Skin changes with active ulceration

• CEAP-Clinical, etiological, anatomical and pathological signs

Conservative management:

• Avoiding prolonged standing

• Crepe bandaging and elastic stockings from toe to thigh, which causes decreased edema, venous volume and reflux and increases venous return.

• Limb elevation above the level of heart while lying down

Conservative Management

Indications

• Refusal for surgery

• Capillary veins, Venous

Stars (C1)

• Pregnant patients

• Waiting for surgery

• Early cases

Contraindications

• Arterial Insufficiency

Ultrasound guided foam sclerotherapy

• Under Ultrasound guidance.

• Polidocanol is used

• Polidocanol converted in foam by mixing air using three way tap.

• Spread of foam monitored under USG guidance as it spreads.

• Apex of saphenous opening compressed by probe to prevent foam entering deep veins.

• Leg also elevated

USG guided Sclerotherapy

SclerotherapyIndications Contraindications• Varicosity confined below

knee and caused by

incompetent perforators

• Recurrent/ residual

varicosities post-surgery

• Large Venous telangiectasia

• Dilated branch veins around

the knee following early long

saphenous incompetence

• Refusal for surgery

• Deep Venous thrombosis

• Sapheno Femoral

Incompetence

• Veins in lower 1/3rd of leg

• Veins on the foot

• Veins in elderly

• Veins in fat legs

• Immobile patient

• Post thrombotic syndrome

• Dirty ulcer or extensive

eczema

Complications

• Complications:

• Extravenous Injection

• Deep vein thrombosis

• Hypersensitivity

• Skin pigmentation

• Gangrene of distal limb

Agents used for sclerotherapy

• 5% monoethanolaminewith 2% benzyl alcohol

• 3% sodium tetradecylsulphate in 2% benzyl alcohol

• 25% glycerine with 2% phenol

Surgical Management

Types of surgeries done:

• Flush ligation of Sapheno femoral junction with ligation of all tributaries ending at SFJ.

• Stripping of long saphenous upto the knee joint.

• Flush Ligation of Short Saphenous vein.

• Subfascial ligation of perforators

Flush Ligation Of Saphenous Vein

• Curved or Hockey stick incision.• Alternatively a 7-8 cm long Oblique incision .• Femoral Vein is exposed 1 cm above and below the

Sapheno femoral junction.• The all tributaries joining the termination of saphenous

vein are defined and ligated• The end of the long saphenous vein is flush ligated at

Saphenofemoral junction with silk and a second ligature is transfixed to avoid haemorrhage.

• Femoral vein is inspected above and below the junction and long saphenous divided.

SFJ Ligation

Stripping of veins

• An Oliers stripper is passed from the groin Incision into the long saphenous vein.

• A vertical incision is made just below knee and vein exposed

• The stripper is extruded from the vein and the acorn firmly tied in the vein.

• The stripper is firmly withdrawn with the vein telescoped over it.

• The track is compressed with a large sterile pad for 3 to 5 minutes.

Varicose vein Stripping

Introduction of Stripper from Groin Incision

Stripper is extruded from the vein below

Knee

Complications of Surgery

• Haemorrhage from torn varix• Division or injury to the common Femoral Vein• Sural Nerve or Saphenous nerve injury• Postoperative Complications:• Haematoma and bruising• Wound infection• Neuritis• Lymphoedema• Induration of stripper track• Lymphatoma• Deep Venous Thrombosis

Post Operative Care

• Maintain firm pressure over the limb

• Regular movement of the operated limb

• Limb elevation above heart level to reduce venous pressure

• Removal of primary dressing after 7 to 10 days

SEPS

Indications Contraindications

Chronic Venous

Insufficiency (C4-6)

Secondary varicose

veins

Arterial Insufficiency

Deep Vein Thrombosis

Subfascial Endoscopic Perforator Surgery is a minimally invasive procedure where in Incompetent perforators are ligated below the deep fascia by creating space with CO2.

Insertion Of Ports for SEPS

A single 10 mm port for camera is inserted below the deep fascia at the medial end of upper part of tibia. Another 5mm port inserted at junction of upper 1/3rd and lower 2/3rd of the calf.

View of the Subfascial Space

All perforators traversing the subfascial space are identified and ligated using ultrasonic dissecting shears.

Radiofrequency Ablation

• The intima of smaller veins can be destroyed by heat generation and denaturation of collagen using a probe consisting of a bipolar heat generator.

• Performed under ultrasound guidance and position of the probe is confirmed near the Saphenofemoral junction.

• Probe is heated to 85 degrees and gradually retracted down at a constant rate of 2-3cm/minute.

• must be avoided in presence of dilated veins, veins with aneurysms and thrombosed veins.

Endovenous Laser Therapy

• Employs diode laser for the destruction of endothelial lining of the target vein.

• The ultrasound guides the location of probe, which is placed 2 cm distal to the Saphenofemoral junction.

• The probe is gradually withdrawn and ablates the lumen as it regresses down the vein by boiling the blood present within the lumen.

• Veins of all sizes can be treated with this procedure.

RFA and Endovenous Laser

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