Varicose veins By:Mahmoud Zaghloul Raslan, MD Consultant Surgeon, MGH Madina,KSA

1. By
Mahmoud Zaghloul Raslan, MD
Consultant Surgeon, MGH
Madina

2. Definition
 Dilated tortuous superficial veins in
the lower limbs

3. Anatomy
 Venous drainage from LL is through 3 systems:
- Superficial veins:
- Long saphenous vein and tributaries
- Short saphenous vein and tributaries
- Deep veins: Ant. Tibial, post. Tibial,
peroneal, popliteal, deepF., superficial F.
and common F.
- Perforating veins: perforating deep fascia
to connect superficial with deep veins

9. Pathophysiology
Physiology:
_ Blood conductor:
- Muscular compression
- Negative ITP
- Calf Muscle pump
- Presence of valves

10. _ Blood reservoir:
- Dilatable
- Capacious

11. Etiology and Types
 Primary VV
_ High IVP: prolonged standing,
prolonged sitting with crossed
legs, chronic straining,
_ Weakness of vein walls:
- Obesity
- Pregnancy
- Hormonal

12.  Secondary VV:
- After previous DVT
- With pelvic tumours

13. Clinical Picture

14.  Thorough history taking:
- Occupation and prolonged standing
- Throbophlebitis or DVT
- Coaguation disorders
- Diabetes
- Results of previous treatment
- Pregnancy and contraceptive pills

15.  Symptoms:
- Pain: aching, throbbing, tingling
- Cramps, heaviness, tiredness of
legs, restless legs at night
- Of complications: Itching,
hyperpigmentation, skin ulceration
and bleeding
- Leg disfigurement

19. Trendlenberg test

20. Investigations

21.  General:
- Assess the general condition of the patient:
e.g. CBC,liver and kidney function tests
 Specific:
- Hand-held Doppler
- Duplex ultrasound: The best; gives both anatomical
and functional diagnosis
- Others: e.g. CT venography and MRI rarely needed

27. Treatment

28. Initial conservative
treatment
(I) General measures:
 Leg elevation
 Excerise
(II) Compression therapy:

29. (III) Pharmacologic therapy:
 Venoactive drugs
- Micronized purified flavonoid
MPFF e.g.Daflon
- Hydroxyethylrutoside

30.  Rheologic agents:
- Aspirin
- Stanozolol
- pentoxifylline
- prostacyclin analogues

31. (IV) Skin care:
 Skin cleansing e.g. Dove, Olay
 Emollients e.g. vaseline, cetaphil
 Barrier preparations e.g. zinc oxide
cream, Vaseline
 Topical corticosteroids

32. (V) Ulcer care
 Ulcer debridement
 Role of systemic antibiotics
 Topical agents:
- e.g. Silver sulfadiazine
- Other antiseptic agents

33.  Ulcer dressings
- Low-adherent gauze
- Hydrogels and alginate dressing
- Silver containing dressings
 Compressing dressing
 Skin grafting
 Others:
- Hyperbaric oxygen
- Electromagnetic therapy
- Therapeutic ultrasound

34. Vein ablative therapy
 Indications:
- Venous hemorrhage
- Superficial thrombophlebitis
- Venous reflux associated with
symptoms

35.  Contraindications:
- Pregnancy
- Acute superficial or deep venous
thrombosis
- Moderate to severe PAD
- Advanced generalized systemic
disease

36. Types of vein ablative
therapy
 Chemical:
- Sclerotherpy
 Mechanical:
- Surgical excision
 Thermal:
- Radiofrequency ablation RFA
- Endovenous laser therapy EVLA

37. Sclerotherapy
 Sclerosants:
_ Sodium tetradecyl sulphate
_ Sodium marrhuate
_ Polydocanol
_ Ethanolamine oleate
_ Hypertonic saline

40. Surgical stripping

42. Endoscopic subfascial
ligation of incompetent
perforators

44. Radiofrequency ablation
therapy
 By directing radiofrequency energy through a
vein, a narrow rim of tissue less than 1mm is
heated by an electrode.
 The amount of heating is modulated using a
microprocessor resulting in controlled
collagen contraction, thermocoagulation and
absorption of the vein.

49.  Endovenous laser ablation:
Initiates nonthrombotic occlusion by direct
thermal injury to vein wall causing
endothelial destruction, collagen
contraction and later fibrosis

54. Management by clinical category
 No visible or palpable signs of
venous dis. (CEAP category 0):
- If C/O venous symptoms:
Treated conservatively

55.  Telangiectasias and reticular veins
(CEAP category 1):
_ Asymptomatic patients with no
reflux: Treated by
- Sclerotherapy
- Laser light therapy
_ Symptomatic patients with reflux:
- Treat reflux first by surgical or
thermal ablation

56.  Varicose veins (CEAP category 2):
_ Isolated varicosities without trunkal
reflux are treated by:
- Sclerotherapy
- Surgical excision
Depending on size, location and
number of affected veins
_ With reflux: Treated by vein ablation

57.  Comparison of ablative therapies:
_ Recent studies reveal that minimally
invasive therapies are as effective as
surgical ablation with fewer
complications and rapid regain of daily
activities

58.  Advanced venous disease:
_ Patients with edema, skin changes or
ulceration (CEAP categories C3, C4,
C5, C6: Treated by initial conservative
measures
_ Refractory patients to conservative
measures: Treated by ablative therapy

59. Summary and conclusion

60.  Visibly dilated LL veins may indicate
underlying venous reflux, especially if
symptomatic, However, they can occur
in absence of symptoms or reflux
 Duplex US is essential to identify
superficial, deep or perforator vein reflux
and R/O DVT

61.  Patients with venous reflux and those
with complications should be referred to
venous or at least vascular specialist for
further evaluation and management
 Goals of treatment are improved
symptoms and appearance

62.  Most patients are treated by initial
conservative measures
 Patients refractory to conservative
measures for 3 months with documented
reflux (>0.5 second duration) are
candidates for vein ablative therapy

63.  Patients with telangiectasias, reticular
vein and VV with reflux should undergo
vein ablation before treating these
lesions
 Telangiectasias, reticular veins and
small VV large enough to admit 27 or 30
gauge needle are treated best by
sclerotherapy with good results

64.  Laser therapy is the only option for
telangiectasias too small to access,
allergy to sclerosants, patients afraid of
needles and after failed sclerotherapy
 Endovenous ablation techniques are
preferred for saphenous and other
trunkal veins over surgical ablation

65.  Persistent or recurrent perforators (by
duplex scan) after vein ablation are
treated by US-guided sclerotherapy or
endovenous methods
 Occasionally, surgical methods may be
required for recurrent or refractory
venous ulceration