RECURRENT VARICOSE VEINS AND ITS MANAGEMENT

DR JOEL ARUDCHELVAMCONSULTANT VASCULAR AND TRANSPLANT

SURGEON

Varicose veins Dilated tortuous superficial veins (derived

from the Greek word "varix," - “grapelike”)

Old disease Hippocrates and Galen described the

disease

Recurrent varicose veins Prevalence of varicose veins - 2% to over 60%

in population studies Recurrence rate of 20%-60% after 5 years

Epidemiology of chronic venous disease.Robertson L, Evans C, Fowkes FG Phlebology. 2008; 23(3):103-11

Allaf N, Welch M. Recurrent varicose veins: Inadequate surgery remains a problem. Phlebology. 2005;20:138–40.

Venous anatomy

Venous anatomy

Named perforators along Greater saphenous distribution

New perforator vein terminology

Causes of recurrence Inadequate initial procedure

Not stripping

Neo vascularisation -new veins appearing in the granulation tissue connecting the end of the ligated sapheno-femoral junction (SFJ)

Recanalisation – after thermal, chemical ablation

New source of reflux Accessory Long Saphenous Vein (LSV) Accessory Short Saphenous Vein (SSV)

Deep venous disease

Recurrence after stripping and non stripping

Causes of recurrence Inadequate initial procedure

Not stripping

Neo vascularisation -new veins appearing in the granulation tissue connecting the end of the SFJ

Recanalisation – after thermal, chemical ablation

New source of reflux Accessory Long Saphenous Vein (LSV) Accessory Short Saphenous Vein (SSV)

Deep venous disease

Neo vascularisation

Causes of recurrence Inadequate initial procedure

Not stripping

Neo vascularisation -new veins appearing in the granulation tissue connecting the end of the SFJ

Recanalisation – after thermal, chemical ablation

New source of reflux Accessory Long Saphenous Vein (LSV) Accessory Short Saphenous Vein (SSV)

Deep venous disease

CEAP Classification

CLINICAL CLASSIFICATION

C0: No Varicose Veins C1: Telangiectasia ( reticular veins , spider

veins) C2: Varicose veins C3: Edema C4: Skin changes

C4a: pigmentation and eczema C4b: lipodermatosclerosis and atrophie blanche

C5: Healed venous ulcer C6: Active venous ulcer

Reticular veins and spider veins

CLINICAL CLASSIFICATION

C0: No Varicose Veins C1: Telangiectasia ( reticular veins , spider

veins) C2: Varicose veins C3: Edema C4: Skin changes

C4a: pigmentation and eczema C4b: lipodermatosclerosis and atrophie blanche

C5: Healed venous ulcer C6: Active venous ulcer

Skin Changes

CLINICAL CLASSIFICATION

C0: No Varicose Veins C1: Telangiectasia ( reticular veins , spider

veins) C2: Varicose veins C3: Edema C4: Skin changes

C4a: pigmentation and eczema C4b: lipodermatosclerosis and atrophie blanche

C5: Healed venous ulcer C6: Active venous ulcer

Skin changes

Duplex ultrasound

Duplex ultrasound To identify the cause of recurrence

SFJ incompetence (SFI), Sapheno poplieal junction incompetence (SPI)

Acc LSV, Acc SSV DVT Perforators / site Neo vascularisation

INDICATIONS FOR TREATMENT

COSMETIC SYMPTOMATIC COMPLICATED

Oedema C4 – skin changes

C4a: pigmentation and eczema. C4b: lipodermatosclerosis and atrophie blanche.

C5: healed venous ulcer. C6: active venous ulcer

Treatment Options Surgery

Thermal Ablation ( Radio frequncy ablation /LASER )

Sclerotherapy

Surgery for recurrent SFJ Dangers

Risk of injury to femoral vein Lymphatic leak

Expose artery first and approach vein from lateral side

LASER - Light Amplification by Stimulated Emission of Radiation

• Energy source• Gain medium• Resonant cavity

• LASER• Monochromatic – same

wave length• Coherent – unidirectional• Collimated - parallel

LASER

LASER

Laser energy is

absorbed by vein wall

and hemoglobin

producing heat and vein

wall destruction

Sclerotherapy Scleroscents used

SODIUM TETRADECYL SULPHATE(STD) HYPERTONIC SALINE SOL POLYDOCANOL SOTRADECOL ETHANOLAMINE OLEATE GLUCOSE COMBINATIONS

Sclerotherapy

• sclerosant is taken in 20 ml syringe ,another syringe with 4 times the amount of air

• By repeated to and fro motion ,dense white foam prepared

Sclerotherapy Mechanism of action

Endothelial damage Inflammation obliteration

Recurrent Varicose veins Recurrent SFJ /SFI

Surgical,Laser neovascularisation

Sclerotherapy, surgery LSV

Thermal ablation (LASER, RFA), Stripping Varicosities

Sclerotherapy, Avulsion, thermal ablation (LASER, RFA)

Pelvic DVT - Venous Angioplasty

How to prevent recurrence Duplex scanning and identifying the right

source - accessory LSV,  (Giacomini vein), correct site of reflux of SSV. Ect

Stripping of Long Saphenous Vein

Duplex scanning and Avoiding varicose vein intervention in patients with past DVT

Recurrence after stripping and non stripping

How to prevent recurrence Duplex scanning and identifying the right

source - acc LSV,  (Giacomini vein), correct site of reflux of SSV. Ect

Stripping of Long Saphenous Vein , Ligation of tributaries

Duplex scanning and Avoiding varicose vein intervention in patients with past DVT

Thank You