VENOUS DISORDERS VARICOSE VEINS DVT

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1 VENOUS DISORDERS VARICOSE VEINS DVT

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4 ANATOMY OF VENOUS SYSTEM SUPERFICIAL VENIS AND DEEP VEINS LONG AND SHORT SAPHENOUS VEINS (LSV & SSV) CARRY ONLY 10 % OF VENOUS RETURN VENOUS DISORDER COMMON IN LOWER LIMBS LSV FROM DORSAL VENOUS ARCH MEDIALLY ASCENDS MEDIAL SIDE OF LEG- SUB CUTANEOUS PLANE JOINS IN FEMORAL TRIANGLE WITH FEMORAL V.SAPHENO FEMORAL JUNCTION ( SFJ) SSV : FROM LATERAL DORSAL VENOUS ARCH ASCENDS LATERAL SIDE OF LEG JOINS POPLITEAL VEIN AT POPLITEAL FOSSA

5 PERFORATORS V 1. MID THIGH DODD S 2. GASTROCNEMIUS BOYD S 3. LOWER LEG COCKETT S I, II, III 4. ANKLE MAY AND KUSTER PATHO PHYSIOLOGY SUPERFICIAL VENOUS SYSTEM LOW PRESSURE 20 mm Hg DEEP V. HIGH PRESSURE SUPPORTED BY MUSCLES VENOUS PUMPS: CALF MUSCLE, THIGH MUSCLES FOOT PUMP WALKING VALVES : BICUSPED VALVES DIRECTS BLOOD TOWARDS HEART FROM SUPERFICIAL TO DEEP VEINS

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7 VARICOSE VEINS CAUSE FAILURE OF VALVES IN LSV & SSV % OF ADULTS DIET, INHERITANCE WOMEN VALVES - COMMISSURE -GAP DEGENERATION VEIN BELOW VALVE DILATES PROLONGED STANDING PREGNANCY - HORMONAL - SMOOTH MUSCLE RELAXATION

8 Clinical features COSMETIC DISCOMFORT AND ACHING BLEEDING PHLEBITLS EZEMA, LIPO DERMATIC SCLEROSIS ULCERATION DEFINITION DILATED TORTUOUS VEINS IN LEG LSV, SSV WITH DEFECTIVE VALVES 5-15 mm DIAMETER 0.5 mm VEINS IN SKIN - FLARE 1-3 mm VEINS IN SUB-DERMAL RETICULAR

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12 SYMPTOMS - NOT RELATED TO SEVERITY OF VARICES COMPLICATION OF VARICOSE VEINS THROMBOSIS - THROMBOPHLEBITIS HAEMORRHAGE ULCERATION ECZEMA AND PIGMENTATION DEEP VEIN INCOMPETENCE FOLLOWING DVT - RECANALISATION - VALVES DESTROYED VENOUS RETURN SUPERFICIAL VEINS CALF MUSCLE INCREASE IN SIZE CHAMPAGNE BOTTLE LEG ANKLE OEDEMA

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15 ULCERATION, ECZEMA, PIGMENTATION HAEMOSIDERIN LIPODERMATOSCLEROSIS AMBULATORY VENOUS HYPERTENSION REVERSAL FLOW DEEP TO SUPERFICIAL VAVULAR INCOMPETENCE DVT SEVERE SYMPTOMS CAUSE OF VENOUS ULCERATION FIBRIN CUFF HYPOTHESIS FIBRIN, COLLAGEN IV, FIBRONECTIN PREVENT DIFFUSION OF NUTRIENTS TO CELLS WHITE CELL TRAPPING HYPOTHESIS LEUCOCYTE SEQUESTRATION - PROTEOLYTIC - ENZYMES INJURY TO CAPPILARY ENDOTHELIUM

16 INVESTIGATIONS a) CLINICAL TESTS 1. TOURNIQUET TEST (BRODE 1846) THREE LEVELS : SAPHENO FEMORAL ABOVE KNEE 2. TRENDELENBURG TEST - BELOW KNEE 3. PERTHE S TEST DOPPLER ULTRASOUND BI DIRECTIONAL PROBE REFLUX- SFJ INCOMPETENCE SPJ LESS RELIABLE PRIMARY VARICOSE VEINS EASY

17 PHOTOPLETHYSMOGRAPHY PROBE TO ASSESS THE VENOUS FILLING OF SUPERFICIAL VEINS PATIENT LIES DORSIFLEX ANKLE JOINT 10 TIMES SUPERFICIAL VEIN EMPTY PPG READING FALLS PATIENT SITS UP : - SLOW FILLING 30 SECONDS NORMAL - RAPID FILLING - VEIN INCOMPETANT DUPLEX IMAGING B - MODE ULTRASOUND WITH DOPPLER ANATOMICA AND FLOW PATTERN WITH COLOUR CODING DVT, PERFORATORS, REFLUX INCOMPETENCE OF VALVES

18 VENOGRAPHY ASCENDING VENOGRAME DVT DESCENDING VENOGRAPHY CANNULA FEMORAL V. PATIENT STANDING RECURRENT VARICOSE VEIN MANAGEMENT PRIMARY OR SECONDARY A. CONSERVATIVE 1. ELASTIC GRADED PRESSURE STOCKING 2. ELEVATION OF LIMB B. SCLEROTHERAPY NO MAJOR PERFORATING VEINS NO SFJ INCOMPETENCE

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20 Indications for Sclerotherapy Optimal indications Telangiectasias Reticular varicosities and reticular veins Isolated varicosities * Below-knee varicosities * Recurrent varicosities

21 Anaphylaxis Allergic reactions Thrombophlebitis Cutaneous necrosis Pigmentation Neoangiogenesis

22 STD SODIUM TETRADECYL - EMPTY THE VEIN INJECTION COMPRESSION ENDOTHELIUM DESTROYED - HIGH RECURRENCE STD WITH FOAM ECHO SCLEROTHERAPY MULTIPLE SITTINGS REQUIRED - SKIN PIGMENTATION - ULCERATION MICRO SCLEROTHERAPY SURGICAL TREATMENT DVT TO BE RULLED OUT A. TRENDELENBERG PROCEDURE SFJ: LIGATION ALONE WITH ITS THREE TRIBUTARIES 1. SCI 2. SE 3. SP

23 Options available for surgical treatment of varicose veins are as follows: Ankle-to-groin saphenous vein stripping (with stab avulsion) Segmental saphenous vein stripping (with stab avulsion) Saphenous vein ligation: high, low, or both Saphenous vein ligation and sclerotherapy Saphenous vein ligation (with stab avulsion) Stab avulsion of varices without saphenous vein stripping (phlebectomy) Endoluminal occlusion of the saphenous vein by radiofrequency (RF) or laser energy

24 B. WITH STRIPING LSV TERMINATION SSV AT POPLITEAL FOSSA VARIABLE IDEALLY ALL PERFORATORS MAPED WITH DUPLEX SCAN POOT OPERATIVE COMPRESSION BANDAGE 3 DAYS FOLLOWED BY GRADED STOCIKNGS MANAGING PERFORATORS HOOK PHLEBECTOMY LINTON S PROCEDURE ENDOSCOPIC SUB FACIAL LIGATION NEW TECHNIQUES LASER RF COMPLICATIONS BRUISING LONG SAPHENOUS NERVE

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27 SURAL NERVE INJURY DVT RARE VENOUS RECONSTRUCTIVE SURGERY DEEP VEIN SPIRAL GRAFT OF SAPHENOUS VEIN PALMA S PROCEDURE : LSV FROM OPPOSITE LEG REVERSED FROM ANASTAMOSED WITH FEMORAL REPAIR OF VALVES VALVELOPLASTY AXILLARY VEIN TRANSPLANT

28 THANK YOU