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Management of varicose vein presentation
- 1. Management of VaricoseVein Dr Navdeep Kaur Lubana Junior Resident Department of Surgery Dr RPGMC, Tanda Dr Rajesh Sharma Assistant Professor Department of Surgery Dr RPGMC, Tanda
- 2. Introduction •Varicose veins aredefined as dilated, elongated, tortuous and palpable superficial vein as a result of Venous Hypertension
- 3. Anatomy • Venous systemof lower limb consists of • Deep system of veins, which lies below the deep fascia • Superficial system of veins, which lies outside the deep fascia • Perforating veins, which passes through the deep fascia, joining the superficial to deep system of veins
- 4. Etiology • Long hoursof standing • Family history. • Pregnancy • Ageing. • DVT • Obesity • Oral contraceptives.
- 5. • The perforatorveins have an important function, • Their valve system aids in preventing reflux from the deep to the superficial system, particularly during periods of standing and ambulation
- 6. • Crockett perforators,which connect the posterior arch and posterior tibial veins; • Boyd perforators, which connect the great saphenous and gastrocnemius veins; and • Hunterian and Dodd perforators, which connect the great saphenous and superficial femoral veins
- 7. CEAP Classification • CClinical signs (grade0-6), supplemented by A for asymptomatic and S for symptomatic presentation • E Classification by cause (etiology)—congenital, primary, secondary • A Anatomic distribution—superficial, deep, or perforator, alone or in combination • P Pathophysiologic dysfunction—reflux or obstruction, alone or in combination
- 8. • Clinical Classificationof Chronic Lower Extremity Venous Disease* • 0 - No visible or palpable signs of venous disease • 1 - Telangiectasia, reticular veins, malleolar flare • 2 - Varicose veins • 3 - Edema without skin changes • 4 - Skin changes ascribed to venous disease (e.g., pigmentation, venous eczema, lipodermatosclerosis) • 5 - Skin changes as defined above with healed ulceration • 6 - Skin changes as defined above with active ulceration
- 9. • Classification byCause of Chronic Lower Extremity Venous Disease • Congenital (Ec) Cause of the chronic venous disease present since birth • Primary (Ep) Chronic venous disease of undetermined cause • Secondary (Es) Chronic venous disease with an associated known cause (e.g., postthrombotic, posttraumatic, other)
- 10. • Anatomic Classification(As, Ad, or Ap) • The anatomic site(s) of the venous disease should be described as superficial (As), deep (Ad), or perforating (Ap) vein(s). One, two, or three systems may be involved in any combination
- 11. • Pathophysiologic Classificationof Chronic Lower Extremity Venous Disease • Reflux (Pr) • Obstruction (Po) • Reflux and obstruction (Pr,o)
- 12. Management • Investigation • Mainaim of the investigation is to • Localise the anatomical location of the disease • Nature of the lesion • Rule out DVT
- 13. Investigation • Venous Doppler– With the patient in standing position, the probe is placed at saphenofemoral junction, midthigh and saphenopopliteal junction • Inference – • Normal - no sound • Abnormal – • Obstruction – Continous sound • Venous reflux – When calf is compressed a ‘woosh’ sound is heard
- 14. Investigation • Duplex scan– high resolution B – Mode ultrasound imaging and doppler ultrasound • It allows direct visualization of the deep veins. It provides anatomical and physiological variations
- 15. Investigation • Ultrasound andCT Scan — should be performed when secondary varicose vein is suspected due to abdominal tumours
- 16. Management Modalities Bandaging SclerotherapySurgery Pneumatic/crepe/stockings Liquid/foam Stripping/EVLT/RFA
- 17. Treatment • Lifestyle modification- Initial recommendations for lifestyle changes are avoidance of vigorous exercise and leg elevation in order to improve symptoms caused by venous hypertension
- 18. • Compression therapy-The rationale of compression therapy is to oppose the reflux induced venous hypertension • Gradient elastic stockings are considered the most initial intervention • 15 to 20 mm Hg (class 1; over-the-counter); for prevention • 20 to 30 mm Hg (class 2; prescription); for varicose veins • 30 to 40 mm Hg (class 3; prescription); for venous ulcers • >40 mm Hg (class 4 high compression; prescription);for refractory venous ulcers
- 19. • Patients whoexhibit venous stasis ulceration will require local wound care A four-layer compression dressing with a zinc oxide paste gauze wrap in contact with the skin .
- 20. • Pharmacological -large chronic venous ulcers may benefit from venoactive medications, in particular, pentoxifylline and micronized purified flavonoid fractions,calcium dobyslate.
- 21. Interventional Treatment • Definitivemanagement • For saphenofemoral incompetence: Trendelenberg operation. • For perforator incompetence: Subfascial/suprafascial ligation. • For saphenopopliteal incompetence: Flush ligation • Small varicosities/flares: Sclerotherapy • Dilated small veins: Hook phlebectomy • Endovenous laser ablation (EVLA) • SEPS
- 22. • Indications forinterventional treatment are • Symptoms refractory to conservative therapy, • recurrent superficial thrombophlebitis, • variceal bleeding, and • venous stasis ulceration.
- 23. Injection sclerotherapy • FEGANSTECHNIQUE :Injection sclerotherapy is a technique that involves direct injection of a sclerosant agent into the feeding vein (reticular vein) or spider vein • Sclerosants act to disrupt the venous endothelium, causing a periphlebitic reaction, which obliterate vein segment • Hypertonic saline used before was painful and exhibit hyperpigmentation after treatment. • Sodium tetradecyl sulfate (3 %),polidocanol,ethanol amine oleate
- 24. Disadvantages • Subcutaneous injectioncause skin necrosis and abscess formation • Anaphylaxis ,allergy,hyperpigmentation • Inadverent intraarterial injection
- 25. TECHNIQUE • 0.5 to1 ml of sclerosant is injected into feeding vein {reticular} and immediately compression is applied so as to allow sclerosis. • Pressure bandage is applied over 6 weeks ,injections may have to be repeated at 2-4 week interval. • Foam sclerotherapy by TESSARI METHOD -1 ml of STDS is mixed with 4ml of air to make 1ml of foam which is injected in vein .Air get absorbed and endothelial lining is destroyed .
- 26. Trendelenburg operation • Trendelenburgoperation is juxta femoral flush ligation of great saphenous vein and Ligation of named tributaries and Unnamed tributaries – • Superficial circumflex iliac vein • Superficial external pudendal • Superficial epigastric vein • Deep external pudendal vein
- 28. Vein Stripping • Thesedays high ligation as well as stripping of the great saphenous vein from the knee to the groin recommended • Stripping at the ankle has been largely abandoned because of a high incidence of saphenous nerve injury
- 29. • High ligationand vein stripping usually require general or spinal anesthesia. • A transverse or oblique groin incision is made just medial to the femoral artery pulse and inferior to the inguinal crease • Sharp dissection allows identification of the proximal great saphenous vein and other venous tributaries that can be ligated and divided • The great saphenous vein can then be brought up into the surgical field with gentle traction on the saphenofemoral junction.
- 30. • A smalltransverse incision on the proximal, medial calf. • The great saphenous vein is identified, ligated distally, and transected. • The Codman stripper is then advanced proximally through the great saphenous vein to exit the transected vein in the groin incision.
- 31. Sub-Fascial Ligation • Itis ligation of perforator where it enters the deep fascia i.e deeper to deep fascia. It is done for perforator incompetence. • Perforators are marked prior to procedure using duplex scan.
- 32. Thermal Ablation techniques: •Thermal Ablation techniques: • There are two different options of energy for thermal ablation of incompetent veins. • Endo venous Laser Ablation • Radio frequency Ablation
- 33. Endo venous LaserAblation- MOA • Various concept based theories have been explained. • The Steam Bubble Theory these represent boiling blood that has an indirect effect, heating the vein wall. • The Heat Pipe Theory maintains that blood in immediate contact with the fiber becomes coagulated, forming a clot around the tip • Direct Contact Theory maximal heat transfer to the vein wall occurs when the laser fiber contacts the vein wall
- 34. Endovenous Radio frequencyablation • Endovenous Radio frequency ablation • RFA includes the use of a generator with an especially devised disposable electrode catheter to deliver bipolar RF energy to the vein with temperatures not exceeding 120°C.
- 35.