varicose veins core surgical trainees vascular teaching day kent and canterbury hospital 1st...

Varicose VeinsVaricose Veins

Core Surgical TraineesCore Surgical TraineesVascular Teaching DayVascular Teaching Day

Kent and Canterbury HospitalKent and Canterbury Hospital1st December 20091st December 2009

Hasantha Thambawita

SpR Vascular Surgery

EpidemiologyEpidemiology

½ of the population suffer from some form ½ of the population suffer from some form of lower limb varicose vein problemsof lower limb varicose vein problems

Female 50-55%Female 50-55%Male 40-45%Male 40-45%

But only ½ of them have visible varicose But only ½ of them have visible varicose veinsveins

Lower limb ulcersLower limb ulcersVenousVenous -- 75%75%ArterialArterialtraumatictraumatic

Varicose VeinsVaricose Veins

DefinitionDefinitionDilated, elongated and tortuous veinsDilated, elongated and tortuous veins

DilatationDilatationElongationElongationTortuousTortuous

Anatomy of leg veinsAnatomy of leg veins

3 Systems3 Systems

Deep SystemDeep System Superficial systemSuperficial system

Long saphenous veinLong saphenous vein Short saphenous veinShort saphenous vein

PerforatorsPerforators

Physiology of Venous functionPhysiology of Venous function

Vis a tergo of circulationVis a tergo of circulationCompetent valves in the systemCompetent valves in the systemMuscle pumpMuscle pumpNegative intra thoracic pressureNegative intra thoracic pressure

Surgical PathologySurgical Pathology

Incompetence of valvesIncompetence of valves

PerforatorsPerforatorsLSV & SSVLSV & SSVSFJ & SPJSFJ & SPJDeep veinsDeep veins

AetiologyAetiology

CongenitalCongenital

Primary (Idiopathic) Primary (Idiopathic) 95%95%

Congenital incompetence of valves &/or weakness Congenital incompetence of valves &/or weakness of muscular coatof muscular coat

SecondarySecondary 5%5%

PrimaryPrimary

Prolonged standingProlonged standingViolent muscular effectsViolent muscular effectsObesityObesityAgeingAgeingOCPOCPHRTHRTFHxFHx

SecondarySecondary

PregnancyPregnancyAbdominal or Pelvic tumoursAbdominal or Pelvic tumoursChronic constipationChronic constipationLocal damage to valvesLocal damage to valves

ThromboplebitisThromboplebitisPhebothrombosisPhebothrombosis

Arterio Venous fistulasArterio Venous fistulasCavernous haemangiomaCavernous haemangioma

Symptoms/SignsSymptoms/Signs

Tiredness & Dull acheTiredness & Dull acheNight crampsNight cramps

With complicationsWith complications

ComplicationsComplications Itching Itching DisfigurementDisfigurement EczemaEczema Swelling around ankleSwelling around ankle PigmentationPigmentation UlcerationUlceration PeriostitisPeriostitis Calcification of vein wallCalcification of vein wall HaemorrhageHaemorrhage ThromboplebitisThromboplebitis

Types of VeinsTypes of Veins

Thread veinsThread veinsSpider veinsSpider veinsReticular veinsReticular veinsSmall varicose veinsSmall varicose veinsElongated tortuous veinsElongated tortuous veinsSaphina varixSaphina varix

Clinical testsClinical tests

1.1. Identify systemIdentify systemI.I. ObservationObservation

II.II. Tap test ( Schwartz test)Tap test ( Schwartz test)

2.2. Incompetent perforator/valvesIncompetent perforator/valvesI.I. Cough impulse – SFICough impulse – SFI

II.II. Trendelenberg test – SFI,SPI,PerforatorsTrendelenberg test – SFI,SPI,Perforators

3.3. Patency of deep veinsPatency of deep veinsI.I. Perthes’ test Perthes’ test

““Historical” --- replaced with DopplerHistorical” --- replaced with Doppler

Don’t forget…….Don’t forget…….

Distal pulsesDistal pulsesAnkle mobilityAnkle mobilityAbdominal examination (DER)Abdominal examination (DER)

InvestigationsInvestigations

Duplex scanDuplex scan

(Venography) --- MRV(Venography) --- MRV

CEAP ClassificationCEAP Classification

CClinicallinical C1 = Thread veinsC1 = Thread veins C2 = Std VVsC2 = Std VVs C3 = OedemaC3 = Oedema C4 = PigmentationC4 = Pigmentation C5 = Healed ulcerC5 = Healed ulcer C6 = Active ulcerC6 = Active ulcer

(A)(A)EEtiologytiology CongenitalCongenital PrimaryPrimary SecondarySecondary

AAnatomynatomy DeepDeep LSVLSV SSVSSV PerforatorsPerforators Combination(s)Combination(s)

PPathophysiologyathophysiology RefluxReflux ObstructionObstruction CombinationCombination

Group & ActionGroup & Action

CEAP – 1 No need to refer to NHS clinic, cosmetic problem onlyCEAP – 1 No need to refer to NHS clinic, cosmetic problem only

CEAP – 2 Refer routinely to Varicose Vein ClinicCEAP – 2 Refer routinely to Varicose Vein Clinic

CEAP 3 – 5 Refer soon to "Fast Track Varicose Vein Clinic" for CEAP 3 – 5 Refer soon to "Fast Track Varicose Vein Clinic" for venous duplex ultrasound assessmentvenous duplex ultrasound assessment

CEAP 6 - Refer urgently to "One Stop Leg Ulcer Clinic" for full leg CEAP 6 - Refer urgently to "One Stop Leg Ulcer Clinic" for full leg ulcer assessmentulcer assessment

TreatmentTreatment

OptionsOptions

o SymptomaticSymptomatico Obliteration of venous lumenObliteration of venous lumeno Removal of vein Removal of vein

IndicationsIndications

CosmeticCosmetic

NHS guidelinesNHS guidelines

1.1. SymptomsSymptoms

2.2. Complications/prevention of Complications/prevention of complicationscomplications

Symptomatic TreatmentSymptomatic Treatment

IndicationsIndications• AgedAged• Pregnancy/PeuperiumPregnancy/Peuperium• Unfit/refuse/waiting for surgeryUnfit/refuse/waiting for surgery• Pelvic tumoursPelvic tumours• DVTDVT

Symptomatic treatment - MethodsSymptomatic treatment - Methods

1.1. Postural drainagePostural drainage

2.2. ExerciseExercise

3.3. SupportSupport

Obliteration of venous lumenObliteration of venous lumen

IndicationsIndications• Below kneeBelow knee• < 5mm< 5mm• Following surgery (adjunct)Following surgery (adjunct)• Existing causesExisting causes• Alternative to surgeryAlternative to surgery

Obliteration of venous lumen - Obliteration of venous lumen - MethodsMethods

1.1. SclerotherapySclerotherapy

2.2. Form injectionsForm injections

3.3. LaserLaser

4.4. RadiofrequencyRadiofrequency

SurgerySurgery

IndicationsIndications• As a primary modalityAs a primary modality• Remove unsightly veinsRemove unsightly veins• Failed other optionsFailed other options

Surgical OptionsSurgical Options

1.1. LigationLigation

2.2. Ligation & strippingLigation & stripping

3.3. Ligation, stripping & BK multiple Ligation, stripping & BK multiple avulsionsavulsions

Complications of SurgeryComplications of Surgery

PainPainBruisingBruisingRecurrenceRecurrence Groin complicationsGroin complications InfectionInfectionParaesthesiaeParaesthesiaeScar Scar

ContraindicationsContraindications

DVTDVTPregnancyPregnancyThrombophlebitisThrombophlebitisOCPOCP

Peripheral vascular diseasePeripheral vascular disease