The collecting system of veins.

The conduits for blood to travel from superficial to the deep veins.

The channel through which blood is pumped out of the legs.

Contraction of leg muscles pumps blood through one-way valves up and out of the legs.

Superficial System arises from foot & ends at Sapheno- Superficial System arises from foot & ends at Sapheno- femoral junction or Sapheno- popliteal junction.femoral junction or Sapheno- popliteal junction.

Formed by union of dorsal digital vein of great toe & Formed by union of dorsal digital vein of great toe & dorsal venous archdorsal venous arch

Ascends ant: to medial malleolus, post: to medial condyle Ascends ant: to medial malleolus, post: to medial condyle of femur.of femur.

Prox: it traverses saphenous opening in fascia to enter Prox: it traverses saphenous opening in fascia to enter femoral vein.femoral vein.

Along its course, a variable number of named perforating Along its course, a variable number of named perforating veins may connect to deep system i.e. femoral, posterior veins may connect to deep system i.e. femoral, posterior tibial, gastrocnemius, & soleal veins.tibial, gastrocnemius, & soleal veins.

Formed by union of dorsal digital vein of 5th digit Formed by union of dorsal digital vein of 5th digit

& distal venous arch. & distal venous arch.

Runs post: to lateral malleolus, lateral to calcaneal Runs post: to lateral malleolus, lateral to calcaneal tendon.tendon.

Runs superiorly medial to fibula and penetrates Runs superiorly medial to fibula and penetrates deep fascia of popliteal fossa, ascends b/w heads deep fascia of popliteal fossa, ascends b/w heads of gastrocnemius muscle to join popliteal vein.of gastrocnemius muscle to join popliteal vein.

These veins transverse deep fascia of lower These veins transverse deep fascia of lower extremity.extremity.

Valves are located just distal to penetration of deep fascia.

A number of named perforators are found at thigh, A number of named perforators are found at thigh, knee & leg.knee & leg.

Cockett perforators b/w ankle & knee are special Cockett perforators b/w ankle & knee are special group of perforating veins. group of perforating veins.

Rather than directly connecting sup: to deep venous Rather than directly connecting sup: to deep venous systems they connect subfascial deep system with systems they connect subfascial deep system with post: arch vein which then empties into GSV.post: arch vein which then empties into GSV.

  

Named perforators along the greater Named perforators along the greater saphenous distributionsaphenous distribution

Deep veins accompany the arteries.Deep veins accompany the arteries. Usually paired and run with named arteries inside a Usually paired and run with named arteries inside a

vascular sheath, this allows arterial pulsation to vascular sheath, this allows arterial pulsation to force blood proximally. force blood proximally.

Popliteal vein joins femoral vein in popliteal fossa.Popliteal vein joins femoral vein in popliteal fossa. Femoral vein is joined by deep vein of thigh . Femoral vein is joined by deep vein of thigh . Femoral vein passes deep to inguinal ligament to Femoral vein passes deep to inguinal ligament to

become external iliac vein.become external iliac vein.

Foot and calf muscles act to squeeze blood out of deep veins.

One way valve allow only upward and inward flow.

During muscle relaxation blood is drawn inward thru perforating veins.

Valve leaflets allow unidirectional flow upward or inward.

Dilation of vein wall prevents apposition of valve leaflets,resulting in reflux.

Valvular fibrosis,destruction, or agenesis results in reflux.

Long Long tortuoustortuous & & dilateddilated veins of superficial varicose veins of superficial varicose system.system.

Varicose veins are bulging veins that are larger than Varicose veins are bulging veins that are larger than spider veins i.e. typically 3 mm or more in diameter.spider veins i.e. typically 3 mm or more in diameter.

Force of gravity,pressure of body weight & task of Force of gravity,pressure of body weight & task of carrying blood from bottom of body up to heart make carrying blood from bottom of body up to heart make legs primary location for varicose veins.legs primary location for varicose veins.

May also occur else where i.e. Abdominal May also occur else where i.e. Abdominal Wall,Anus,Vulva, Oesophagus.Wall,Anus,Vulva, Oesophagus.

Visible, palpable veins in Visible, palpable veins in the subcutaneous skin the subcutaneous skin greater than 3 mmgreater than 3 mm

Also called spider veins, Also called spider veins, hyphen webs, or thread veins.hyphen webs, or thread veins.

Dilated intradermal venules Dilated intradermal venules

greater than 1 mm in diameter.greater than 1 mm in diameter.

Also called blue veins, Also called blue veins, subdermal varices or subdermal varices or venulectasias.venulectasias.

Visible, dilated bluish Visible, dilated bluish subdermal, nonpalpable veins subdermal, nonpalpable veins

1-3 mm1-3 mm. .

Valvular insufficiency of the superficial veins, most Valvular insufficiency of the superficial veins, most commonly at the saphenofemoral junction.commonly at the saphenofemoral junction.

Mainly caused by deep vein thrombosis (DVT) that leads Mainly caused by deep vein thrombosis (DVT) that leads to chronic deep venous obstruction or valvular to chronic deep venous obstruction or valvular insufficiency. insufficiency.

Catheter-associated DVTs are also included.Catheter-associated DVTs are also included. Pregnancy-induced and progesterone-induced venous Pregnancy-induced and progesterone-induced venous

valve weaknessvalve weakness Trauma.Trauma.

This includes any venous malformations.i.eKlippel-This includes any venous malformations.i.eKlippel-Trenaunay variants,avalvulia etc.Trenaunay variants,avalvulia etc.

Pathways leading to varicose veins and other clinical manifestations of venous hypertension.

Aging causes wear and tear on valves in veins that Aging causes wear and tear on valves in veins that help regulate blood flow, that wear can cause valves help regulate blood flow, that wear can cause valves to malfunction.to malfunction.

Women are more likely than men to develop Women are more likely than men to develop condition.condition.

Hormonal changes during pregnancy or menopause Hormonal changes during pregnancy or menopause may be factor.may be factor.

Female hormones tend to relax vein walls.Female hormones tend to relax vein walls. Taking hormone replacement therapy or birth control Taking hormone replacement therapy or birth control

pills may increase risk. pills may increase risk.

If other family members had varicose If other family members had varicose veins,there's greater chance you will too. veins,there's greater chance you will too.

Being overweight puts added pressure in veins.Being overweight puts added pressure in veins.

Prolonged immobile standing impairs venous Prolonged immobile standing impairs venous return.return.

Pregnancy,Abdominal/pelvic Pregnancy,Abdominal/pelvic mass,Ascites,constipation etc inc: risk.mass,Ascites,constipation etc inc: risk.

Achy or heavy feeling in legs. Achy or heavy feeling in legs. Burning, throbbing & muscle cramping in lower legs.Burning, throbbing & muscle cramping in lower legs. Prolonged sitting or standing tends to make legs feel Prolonged sitting or standing tends to make legs feel

worse.worse. Restless” legs at night.Restless” legs at night. Appearance of spider veins in affected leg. Appearance of spider veins in affected leg. Skin ulcers near ankle, which represent severe form of Skin ulcers near ankle, which represent severe form of

vascular disease & require immediate attention.vascular disease & require immediate attention. Redness, dryness & itchiness of areas of skin - termed Redness, dryness & itchiness of areas of skin - termed

stasis dermatitis or venous eczema b/c of waste stasis dermatitis or venous eczema b/c of waste products building up in leg.products building up in leg.

Skin above ankle may shrink (lipodermatosclerosis) b/c Skin above ankle may shrink (lipodermatosclerosis) b/c fat underneath skin becomes hard.fat underneath skin becomes hard.

A careful inspection & documentation of the A careful inspection & documentation of the site of varicosities is extremely important.site of varicosities is extremely important.

Look along distribution of Long saphenous vein Look along distribution of Long saphenous vein i.e. Medial side along length of leg.i.e. Medial side along length of leg.

Next look along distribution of Short Next look along distribution of Short Saphenous vein i.e. Below knee, posterior & Saphenous vein i.e. Below knee, posterior & lateral aspects of leg.lateral aspects of leg.

Varicosities can lead to major complications due to poor Varicosities can lead to major complications due to poor circulation thru affected limb.circulation thru affected limb.

Extremely painful ulcers may form on skin particularly near Extremely painful ulcers may form on skin particularly near ankles.ankles.

Pigmentations & skin changes ie.brownish darkening of skin Pigmentations & skin changes ie.brownish darkening of skin resulting from extravasated blood that causes resulting from extravasated blood that causes lipodermatosclerosis.lipodermatosclerosis.

Development of carcinoma or sarcoma in longstanding venous Development of carcinoma or sarcoma in longstanding venous ulcers. ulcers.

Blood clotting within affected veins termed Blood clotting within affected veins termed sup:thrombophlebitis that can extend into deep veins sup:thrombophlebitis that can extend into deep veins becoming more serious problem. becoming more serious problem.

Acute fat necrosis can occur, esp: at ankle of overweight pats Acute fat necrosis can occur, esp: at ankle of overweight pats with varicose veins.with varicose veins.

This is physical exam: techniqueThis is physical exam: technique to localise valves that to localise valves that are incompetentare incompetent

Lie patient down & raise leg attempting to drain Lie patient down & raise leg attempting to drain varicosities varicosities

Using either tourniquet or fingers put pressure over SFJ Using either tourniquet or fingers put pressure over SFJ to occlude it & ask patient to standto occlude it & ask patient to stand

If varicosities don’t refill indicates SFJ incompetence & if If varicosities don’t refill indicates SFJ incompetence & if do refill then leaky valve is lower downdo refill then leaky valve is lower down

Now try and locate incompetent perforatorsNow try and locate incompetent perforators Place tourniquet aprox: over area of each perforator Place tourniquet aprox: over area of each perforator

i.e.mid thigh,sapheno popliteal,calf perforatorsi.e.mid thigh,sapheno popliteal,calf perforators If varicosities don’t refill that perforator is incompetent & If varicosities don’t refill that perforator is incompetent &

if varicosities do refill continue down legif varicosities do refill continue down leg

This is also physical exam: technique in which tourniquet is This is also physical exam: technique in which tourniquet is placed over prox: part of leg to compress any sup: varicose placed over prox: part of leg to compress any sup: varicose veins while leaving deep veins unaffected.veins while leaving deep veins unaffected.

Pat walks to activate calf-muscle pump which normally Pat walks to activate calf-muscle pump which normally causes varicose veins to be emptied.causes varicose veins to be emptied.

If obstruction of deep system exists then activation of calf-If obstruction of deep system exists then activation of calf-muscle pump causes paradoxical congestion of sup:venous muscle pump causes paradoxical congestion of sup:venous system and engorgement of varicose veins resulting in system and engorgement of varicose veins resulting in positive test.positive test.

To verify pat is then placed supine & leg is then elevated To verify pat is then placed supine & leg is then elevated (Linton test). (Linton test).

If varices distal to tourniquet fail to drain after a few seconds If varices distal to tourniquet fail to drain after a few seconds again deep venous obstruction must be considered. again deep venous obstruction must be considered.

Doppler transducer is positioned along axis of vein Doppler transducer is positioned along axis of vein with probe at angle of 45° to skin.with probe at angle of 45° to skin.

When distal vein is compressed audible forward flow When distal vein is compressed audible forward flow exists .exists .

If valves are competent no audible backward flow is If valves are competent no audible backward flow is heard with release of compression.heard with release of compression.

If valves are incompetent an audible backflow exists.If valves are incompetent an audible backflow exists.

These compression-decompression maneuvers are These compression-decompression maneuvers are repeated while gradually ascending limb to level at repeated while gradually ascending limb to level at which reflux can no longer be appreciated .which reflux can no longer be appreciated .

Duplex US with color-flow imaging sometimes called Duplex US with color-flow imaging sometimes called triplex ultrasound.triplex ultrasound.

This is special type of 2-dimensional ultrasound that uses This is special type of 2-dimensional ultrasound that uses Doppler-flow information to add color for blood flow in Doppler-flow information to add color for blood flow in image.image.

Vessels in blood are colored red for flow in one direction Vessels in blood are colored red for flow in one direction and blue for flow in other with graduated color scale to and blue for flow in other with graduated color scale to reflect speed of flow. reflect speed of flow.

Venous valvular reflux is defined as regurgitant flow with Venous valvular reflux is defined as regurgitant flow with Valsalva that lasts great than 2 seconds.Valsalva that lasts great than 2 seconds.

This is a physiologic test,using plethysmography. This is a physiologic test,using plethysmography.

VRT is time necessary for lower leg to become infused VRT is time necessary for lower leg to become infused with blood after calf-muscle pump has emptied lower with blood after calf-muscle pump has emptied lower leg. leg.

In healthy subjects VRT is greater than 120 secondsIn healthy subjects VRT is greater than 120 seconds In pats with significant venous insufficiency VRT is In pats with significant venous insufficiency VRT is

abnormally fast at 20-40 seconds.abnormally fast at 20-40 seconds.

VRT of less than 20 seconds is markedly abnormal & is VRT of less than 20 seconds is markedly abnormal & is nearly always symptomatic.nearly always symptomatic.

If VRT is less than 10 seconds venous ulcerations are If VRT is less than 10 seconds venous ulcerations are likely.likely.

Most sensitive & most specific test to find causes of Most sensitive & most specific test to find causes of anatomic obstruction. anatomic obstruction.

MRV is particularly useful b/c unsuspected MRV is particularly useful b/c unsuspected nonvascular causes for leg pain and edema may nonvascular causes for leg pain and edema may often be seen on scan image when clinical often be seen on scan image when clinical presentation erroneously suggests venous presentation erroneously suggests venous insufficiency or venous obstruction.insufficiency or venous obstruction.

This is expensive test used only as adjuvant when This is expensive test used only as adjuvant when

doubt still exists.doubt still exists.

Elevating legs often provides temporary symptomatic Elevating legs often provides temporary symptomatic relief.relief.

Wearing of graduated compression stockings with Wearing of graduated compression stockings with pressure of 30–40 mmHg has been shown to correct pressure of 30–40 mmHg has been shown to correct swelling, nutritional exchange & improve swelling, nutritional exchange & improve microcirculation in affected legs.microcirculation in affected legs.

Caution should be exercised in patients with Caution should be exercised in patients with concurrent arterial disease.concurrent arterial disease.

They are offered in different levels of compression.They are offered in different levels of compression.

They are constructed using elastic fibers or rubber They are constructed using elastic fibers or rubber which help compress limb, aiding in circulation.which help compress limb, aiding in circulation.

It is commonly performed non-surgical treatment.It is commonly performed non-surgical treatment.

Often used for spider veins & varicose veins that persist Often used for spider veins & varicose veins that persist or recur after vein stripping.or recur after vein stripping.

Sodium tetradecyl sulphate etc is inj: in veins to make Sodium tetradecyl sulphate etc is inj: in veins to make them shrink.them shrink.

Sclerotherapy can also be performed using foamed Sclerotherapy can also be performed using foamed sclerosants under ultrasound guidance to treat larger sclerosants under ultrasound guidance to treat larger varicose veins including GSV & SSV.varicose veins including GSV & SSV.

In U/S guided sclerotherapy u/s is used to visualize In U/S guided sclerotherapy u/s is used to visualize underlying vein so surgeon can deliver and monitor underlying vein so surgeon can deliver and monitor injection.injection.

Microsclerotherapy is used to treat spider veins & other Microsclerotherapy is used to treat spider veins & other very small varicose veins. very small varicose veins.

GSV SaphenectomyGSV Saphenectomy

Surgical removal of GSV have evolved from large open Surgical removal of GSV have evolved from large open incisions to less invasive stripping.incisions to less invasive stripping.

Stripping consists of removal of all or part of saphenous Stripping consists of removal of all or part of saphenous vein main trunkvein main trunk

Different devices are used in stripping i.e Mayo stripper, Different devices are used in stripping i.e Mayo stripper, Babcock device, Keller device etc.Babcock device, Keller device etc.

Perforation-invagination (PIN) stripper is mainly used now a Perforation-invagination (PIN) stripper is mainly used now a days.days.

Technique of PIN stripping begins with 2-3cm incision Technique of PIN stripping begins with 2-3cm incision made at groin.made at groin.

Femoral vein and SFJ are exposed with dissection & all Femoral vein and SFJ are exposed with dissection & all tributaries of SFJ must be identified and flush-ligated tributaries of SFJ must be identified and flush-ligated to minimize incidence of reflux recurrence.to minimize incidence of reflux recurrence.

Vessel is then inverted into itself tearing away from Vessel is then inverted into itself tearing away from each tributary & perforator as stripper is pulled each tributary & perforator as stripper is pulled downward thru leg & out thru incision in upper calf.downward thru leg & out thru incision in upper calf.

Long epinephrine-soaked gauze or ligature may be Long epinephrine-soaked gauze or ligature may be secured to stripper before invagination allowing secured to stripper before invagination allowing hemostatic packing to be pulled into place after hemostatic packing to be pulled into place after stripping is complete.stripping is complete.

SSV SaphenectomySSV Saphenectomy

Removal of SSV is complicated by variable local Removal of SSV is complicated by variable local anatomy and risk of injury to popliteal vein & peroneal anatomy and risk of injury to popliteal vein & peroneal nervenerve

Saphenopopliteal junction must be located by duplex Saphenopopliteal junction must be located by duplex exam: before beginning dissection.exam: before beginning dissection.

After ligation and division of junction stripping After ligation and division of junction stripping instrument is passed downward into distal calf where it instrument is passed downward into distal calf where it is brought out thru a small incision (2-4 mm). is brought out thru a small incision (2-4 mm).

Stripper is secured to proximal end of vein which is Stripper is secured to proximal end of vein which is invaginated into itself as it is pulled downward from invaginated into itself as it is pulled downward from knee to ankle and withdrawn from below.knee to ankle and withdrawn from below.

It is extremely useful for treatment of residual vein clusters It is extremely useful for treatment of residual vein clusters after saphenectomy & for removal of nontruncal tributaries after saphenectomy & for removal of nontruncal tributaries when saphenous vein is competent.when saphenous vein is competent.

Microincision is made over vessel phlebectomy hook is Microincision is made over vessel phlebectomy hook is introduced & vein is delivered thru incision.introduced & vein is delivered thru incision.

With traction, as long a segment as possible is pulled out of With traction, as long a segment as possible is pulled out of

body until vein breaks or cannot be pulled any further.body until vein breaks or cannot be pulled any further.

Another microincision is made and process is begun again and Another microincision is made and process is begun again and repeated along entire length of vein to be extracted.repeated along entire length of vein to be extracted.

Pat can go home same day after procedure is done.Pat can go home same day after procedure is done.

Laser fiber produces endoluminal heat that destroys Laser fiber produces endoluminal heat that destroys vascular endothelium.vascular endothelium.

Seldinger technique is used to advance long catheter Seldinger technique is used to advance long catheter along entire length of truncal varicosity to be ablated.along entire length of truncal varicosity to be ablated.

Under U/S guidance tumescent solution with local Under U/S guidance tumescent solution with local anesthetic is inj: around entire length of vessel.anesthetic is inj: around entire length of vessel.

Firm pressure is applied to collapse vein around laser Firm pressure is applied to collapse vein around laser fiber & laser is fired generating heat leading to fiber & laser is fired generating heat leading to intraluminal steam bubbles,irreversible endothelial intraluminal steam bubbles,irreversible endothelial damage & thrombosis.damage & thrombosis.

This process is repeated along entire course of vesselThis process is repeated along entire course of vessel

RF thermal energy is delivered directly to vessel wall RF thermal energy is delivered directly to vessel wall causing protein denaturation, collagenous contraction & causing protein denaturation, collagenous contraction & immediate closure of vessel.immediate closure of vessel.

Metal fingers at tip of RF catheter are deployed until they Metal fingers at tip of RF catheter are deployed until they make contact with vessel endothelium.make contact with vessel endothelium.

RF energy is delivered both in and around vessel to be RF energy is delivered both in and around vessel to be treated.treated.

Thermal sensors record temp: within vessel & deliver just Thermal sensors record temp: within vessel & deliver just enough energy to ensure endothelial ablation.enough energy to ensure endothelial ablation.

RF catheter is withdrawn a short distance & process is RF catheter is withdrawn a short distance & process is

repeated all along length of vein to be treatedrepeated all along length of vein to be treated

Endovascular occlusion of Saphenous Endovascular occlusion of Saphenous veins using VNUS ClosureTM Catheterveins using VNUS ClosureTM Catheter

Subcutaneous hematoma is a common Subcutaneous hematoma is a common complication.complication.

Dysesthesias can occur from injury to sural or Dysesthesias can occur from injury to sural or saphenous nerve.saphenous nerve.

At SFJ accidental treatment of femoral vein by At SFJ accidental treatment of femoral vein by inappropriate RF or laser catheter inappropriate RF or laser catheter placement,spread of sclerosant or inappropriate placement,spread of sclerosant or inappropriate surgical ligation can all lead to endothelium surgical ligation can all lead to endothelium damage. damage.

Hard tender lumps can sometimes form along the line of removed vein which usually disappears after few weeks.

Keloid scars can occur.