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VENOUS DISORDERS VARICOSE VEINS DVT 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 • 1. 2. 3. 4. PERFORATORS V MID THIGH DODD’S GASTROCNEMIUS BOYD’S LOWER LEG COCKETT’S I, II, III ANKLE MAY AND KUSTER PATHO PHYSIOLOGY 9 SUPERFICIAL VENOUS SYSTEM – LOW PRESSURE 20 mm Hg 9 DEEP V. HIGH PRESSURE – SUPPORTED BY MUSCLES 9 VENOUS PUMPS: CALF MUSCLE, THIGH MUSCLES FOOT PUMP – WALKING 9 VALVES : BICUSPED VALVES – DIRECTS BLOOD TOWARDS HEART 9 FROM SUPERFICIAL TO DEEP VEINS VARICOSE VEINS – CAUSE • • • • • • • FAILURE OF VALVES IN LSV & SSV 10 – 20 % OF ADULTS DIET, INHERITANCE – WOMEN VALVES - COMMISSURE -GAP – DEGENERATION VEIN BELOW VALVE DILATES PROLONGED STANDING PREGNANCY - HORMONAL - SMOOTH MUSCLE RELAXATION 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 • SYMPTOMS - NOT RELATED TO SEVERITY OF VARICES COMPLICATION OF VARICOSE VEINS • • • • THROMBOSIS - THROMBOPHLEBITIS HAEMORRHAGE ULCERATION ECZEMA AND PIGMENTATION DEEP VEIN INCOMPETENCE 9 9 9 9 FOLLOWING DVT - RECANALISATION VALVES DESTROYED VENOUS RETURN – SUPERFICIAL VEINS CALF MUSCLE INCREASE IN SIZE – “CHAMPAGNE BOTTLE LEG” 9 ANKLE OEDEMA 9 ULCERATION, ECZEMA, PIGMENTATION HAEMOSIDERIN 9 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 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 – REFLUXSFJ – INCOMPETENCE SPJ – LESS RELIABLE PRIMARY VARICOSE VEINS – EASY 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 VENOGRAPHY • ASCENDING VENOGRAME DVT • DESCENDING VENOGRAPHY CANNULA FEMORAL V. PATIENT STANDING • RECURRENT VARICOSE VEIN MANAGEMENT 9 PRIMARY OR SECONDARY A. CONSERVATIVE 1. ELASTIC GRADED PRESSURE STOCKING 2. ELEVATION OF LIMB B. SCLEROTHERAPY • NO MAJOR PERFORATING VEINS • NO SFJ INCOMPETENCE Indications for Sclerotherapy Optimal indications Telangiectasias Reticular varicosities and reticular veins Isolated varicosities * Below-knee varicosities * Recurrent varicosities ■ Anaphylaxis ■ Allergic reactions ■ Thrombophlebitis ■ Cutaneous necrosis ■ Pigmentation ■ Neoangiogenesis • 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 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 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 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 THANK YOU
