1. VARICOSE VEINS AND
MANAGEMENT
Dr PRASHANTH.S
GENERAL SURGERY RESIDENT
CAIMS

2.  Superficial veins : located above the muscular
fascia. The saphenous vein rests over the
muscular fascia and appears like a “Egyptian
eye” on duplex scan.
 Deep veins : located in the muscular
compartment, follows the same course as
arteries.
 Perforator veins :these are rich network of
perforating veins that traverse the muscular
fascia between the deep and superficial veins.
They direct the flow from superficial to deep
veins.

3. Venous valves
 They prevent retrograde flow of blood in a
proximal to distal direction.
 They are found throughout the body, but
highest concentration is located in the lower
extremities.
 They are bicuspid and can form sinusoidal
dilatations due to locally reversed flow.
 Close with velocity-30 cm/sec.
 The inferior vena cava (IVC), common iliac
veins, portal venous system, and cranial
sinuses are valveless

4. Venous wall structure and
composition
 Composed of 3 layers
 INTIMA: it is a single layer of cells resting on a
thin layer of connective tissue.Valves are lined
on both sides with a layer of intima over thin
connective tissue skeleton.
 MEDIA: consists of smooth muscles and
connective tissue such as collagen. It conveys
protection from dilatation and varicosity
formation.
 ADVENTITIA: its not well differentiated from
media contains of loose connective tissue, vasa
vasorum.

5. Anatomy of great saphenous
vein
 The great saphenous vein drains the medial end
of the dorsal venous arch of the foot and passes
upwards directly in front of the medial malleolus.
 It then ascends in company with the saphenous
nerve in the superficial fascia over the medial
side of the leg.
 The vein passes behind the knee and curves
forward around the medial side of the thigh.
 It passes through the lower part of the
saphenous opening in the deep fascia and joins
the femoral vein about 1.5 inches below and
lateral to the pubic tubercle.

6.  The great saphenous vein possesses numerous
valves and is connected to the small saphenous
vein by one or two branches that pass behind the
knee.
 Several perforating veins connect the great
saphanous to the deep veins along the medial
side of the calf.
 At the saphenous opening in the deep fascia, the
great saphenous vein usually receives three
tributaries that are variable in size and
arrangement– superficial circumflex iliac,
superficial epigastric and superficial external
pudendal

7. Main perforators of the great saphenous vein
 May perforators- at the level of ankle
 Cockett – at 5, 10 and 15 cm
from medial malleolus
 Boyd - below knee
 Dodd - above knee
 Mid thigh perforator
 SFJ

8. Short saphenous vein
 It arises from the lateral part of the dorsal venous
arch of the foot.
 It ascends behind the lateral malleolus in company
with sural nerve
 It follows the lateral border of the tendo calcaneus
and then runs up the middle of the back of the leg.
 The vein pierces the deep fascia and passes between
the two heads of the gastrocnemius muscle in the
lower part of the popliteal fossa.
 The mode of termination of the small saphenous
vein is subject to variation- may join the popliteal
vein, may join the great saphenous, may split into
two one joins popliteal and one joins great
saphenous.

9. Pathogenesis
Two theories
 Fibrin cuff theory
 White cell trapping theory

10. Incompetence of venous valves
Stasis of blood
Chronic ambulatory venous hypertension
Defective microcirculation
RBC’s diffuses into tissue planes
Lysis of RBC’s
Release of haemosiderin
Pigmentation
Dermatitis
Capillary endothelial damage
Prevention of diffusion and exchange of nutrients
Severe anoxia
Chronic venous ulceration
Fibrin cuff theory

11. White cell trapping theory
Inappropriate activation of trapped leucocytes
release proteolytic enzymes which cause cell
destruction and ulceration.
Fibrin deposition, tissue death, scarring occurs
together called as lipodermatosclerosis

13. Classification of lower
extremity venous disease
(CEAP)
 C - clinical signs
 E – etiological classification
 A – anatomic distribution
 P – pathological dysfunction

14. Grading of clinical signs
0-- no visible or palpable signs of venous
disease
1– telangiectases, reticular veins or malleolar
flare
2– varicose veins
3– oedema without skin changes
4– skin changes ascribed to venous diseases
5– skin changes with healed ulcer
6– skin changes with active ulcer

15. Aetiology
A. Primary varicosities due to:
 Congenital incompetence or absence of
valves.
 Weakness or wasting of muscles- defective
connective tissue and smooth muscle in the
venous wall.
 Stretching of deep fascia
 Inheritance with FOXC2 gene
 Klippel-Trenaunay syndrome

16. B. Secondary varicosities
 Recurrent thrombophlebitis
 Occupational – standing for long hours
 Obstruction to venous return like abdominal
tumour, retroperitoneal fibrosis,
lymphadenopathy.
 Pregnancy
 A-V malfunctions
 Iliac vein thrombosis

17. Symptoms in varicose veins
 Dragging pain
 Heaviness in the legs
 Night time cramps
 Oedema of feet
 Discolouration/ ulceration in the feet / painful
walk

18. Causes of pain / cramps in
varicose veins
 Chronic venous hypertension
 Hypoxia of tunica media due to altered function of
vasa vasorum
 Increased capillary pressure
 Hyper viscosity of red cells
 Platelet hyperaggregation
 Reduced in capillary permeability causing capillary
functional disorder
 Altered cutaneous microcirculation due to leukocyte
adhesion and accumulation into the venous wall,
release of free radicals cause micro vascular lesional
disease.

19. Venous disability scoring
system
0– asymptomatic
1– symptomatic but able to carry out activities
without any therapy
2– symptomatic can do activities only with
compression or limb elevation
3-- symptomatic – unable to do daily activities
even with compression or limb elevation

20. Complications of varicose
veins
 Haemorrhage
 Eczema and dermatitis
 Periostitis
 Venous ulcer
 Marjolin’s ulcer
 Lipodermatosclerosis
 Ankylosis of the ankle joint
 Talipes equino varus
 DVT
 Calcification
 thrombophlebitis

21.  Brodie-Trendelenburg test– vein is emptied by
elevating the limb and a tourniquet is tied just
below the sapheno-femoral junction. Patient
is asked to stand quickly. When tourniquet or
thumb is released, rapid filling from above
signifies sapheno-femoral incompetence.
This isTrendelenburg test 1.
 In Trendelenburg test 2, after standing
tourniquet is not released. Filling of blood
from below upwards rapidly can be observed
within 30-60 seconds. It signifies perforator
incompetence.

22.  PERTHE’S test: the effected lower limb is
wrapped with elastic bandage and the patient
is asked to walk around and exercise.
Development of severe cramp like pain in the
calf signifies DVT.
 MODIFIED PERTHE’S test: tourniquet is tied just
below the sapheno-femoral without
emptying the vein. Patient is allowed to have
a brisk walk which precipitates bursting pain
in the calf and also makes superficial veins
more prominent. It signifies DVT

23.  Three tourniquet test: to find out the site of
incompetent perforator, three tourniquet are
tied after emptying the vein.
1 at sapheno-femoral junction
2 above knee level
3 another below knee level
Patient is asked to stand and looked for filling of
veins and site of filling. Then tourniquets are
released from below upwards, again to see
for incompetent perforators.

24.  SCHWARTZ test: in standing position, when
lower part of the long saphenous vein in leg is
tapped, impulse is felt at the saphenous
junction or at the upper end of the visible part
of the vein. It signifies continuous column of
blood due to valvular incompetence.
 PRATT’S test: Esmarch bandage is applied to the
leg from below upwards followed by a
tourniquet at sapheno-femoral junction. After
that the bandage is released keeping the
tourniquet in the same position to see the
“blow outs” as perforators.

25.  MORRISEY’S COUGH IMPULSE test: the varicose
veins are emptied. The leg is elevated and
then patient is asked to cough. If there is
sapheno-femoral incompetence, expansile
impulse is felt at saphenous opening. It is a
venous thrill due to vibration caused by
turbulent back flow.
 FEGAN’S test: on standing, the site where the
perforators enter the deep fascia bulges and
this is marked. Then on lying down, button
like depressions in the deep fascia is felt at
the marked out points which confirms the
perforator sites.

26. Venous Doppler
 With patient standing, the Doppler probe is placed at
sapheno-femoral junction and later wherever required.
 Basically by hearing the changes in sound, venous flow,
venous patency, venous reflux can be very well identified.
1. To find out DVT- very important
2. To find out sapheno-femoral, sapheno-popliteal
incompetence
3. To find out perforator incompetence
4. Uniphasic signals signify flow in one direction-normal
5. Biphasic flow signifies reversal flow with incompetence

27. Duplex scan
 It is a highly reliable U/S Doppler imaging
technique (high resolution B mode ultrasound
imaging and Doppler ultrasound is used),
which along with direct visualisation of veins,
gives the functional and anatomical
information and also colour map.
 Examination is done in standing, lying down
position and also valsalva manoeuvre.
 DVT is very well identified by this method.

28. Venography
 Ascending venography was a very common
investigation done before Doppler period.
A tourniquet is applied above the malleoli and
vein of the dorsal venous arch of foot is
cannulated. Water soluble dye is injected,
flows into the deep veins.
X-rays are taken below and above knee level.
Any block in deep veins, its extent, perforator
status can be made out by this.
It is good reliable investigation for DVT.

29.  Descending venogram
It is done when ascending venogram is not
possible and also to visualise incompetent
veins.
Here contrast material is injected into femoral
vein through a cannula in standing position.
X rays pictures are taken to visualise deep veins
and incompetent veins.

30. Plethysmography
It is a non invasive method which measures
volume changes in the leg.
 Photo plethysmography
 Air plethysmography

31. Photo plethysmography
 Using probe transmission of light through the
skin, venous filling of the surface venules which
reflects the superficial venous pressure is
measured.
 Initially patient performs dorsiflexion at ankle for
10 times to empty the venules and pressure
tracing falls in photo plethysmography.
 Patient takes rest and refilling occurs. In normal
people, it occurs through arterial inflow in 20-30
seconds.
 In venous incompetence filling also occurs by
venous reflux and refilling time is faster than
normal
 Site of reflux cannot be localised by this method.

32. Air plethysmography
 Patient is initially in supine position with veins emptied by
elevation of leg. Air filled plastic pressure bladder is placed on calf
to detect volume changes.
 Minimum volume is recorded. Patient is turned to upright
position and venous volume is assessed.
 Maximum venous volume divided by time required to achieve
maximum venous volume gives the venous filling index.
 VFI is a measure of reflux
 Ejection fraction is volume change measured prior and after
single tiptoe manoeuvre which is a measure of calf pump action.
 Residual venous fraction is an index of overall venous function
which is venous volume in the leg after ten tiptoe manoeuvres
divided by venous volume prior to manoeuvre.
 Increased VFT and diminished ejection fraction in patient will
benefit from surgery

33. Treatment
1. Conservative treatment
 Elastic crepe bandage application from below
upwards or use of pressure stockings to the limb
pressure gradient of 30-40 mmHg is provided.
 Diosmin therapy which increases the venous tone.
 Elevation of the limb- relieves oedema.
 Unna boots- provide non elastic compression
therapy. It comprises a guaze compression
dressings that contain zinc oxide, calamine and
glycerine that helps to prevent further skin break
down. It is changed once a week.
 Pneumatic compression method– provide dynamic
sequential compression.

34. 2. Drugs used for varicose veins
 Calcium dobesilate—500 mg BD. Calcium
dobesilate improves lymph flow; improves
macrophage mediated proteolysis and
reduces edema.
 Diosmin 450 mg + Hesperidin 50 mg
(DAFLON 500 mg). Mainly used in relieving
night cramps but not to improve healing of
ulcers.

35. 3. Injection– sclerotherapy: By injecting
sclerotic agent into the vein, complete
sclerosis of the venous walls can be achieved.
Indication
 Uncomplicated perforator incompetence
 In the management of smaller varices-
reticular
 Recurrent varices
 Isolated varices
 aged / unfit patients

36. Sclerosants used are—
 Sodium tetradecylsulphate 3%(STDS) –
commonly used
 Sodium morrhuate
 Ethanolamine oleate
 Polidocanol
Mechanism of action
 Causes aseptic inflammation
 Causes perivenous fibrosis leading to block
 Causes approximation of intima leading to
obliteration by endothelial damage
 Alters intravascular pH / osmolality
 Changes surface tension of plasma membrane.

37.  A 23 gauge needle is inserted into the vein (3-8
mm sized) and vein is emptied. 0.5-1 ml of
sclerosant is injected into the vein and
immediately compression is applied on the vein.
 So as to allow the development of sclerosis and
to have proper endothelial apposition.
 Usually injection is started at the ankle region
and then proceeded upwards along the length of
veins at different points.
 Later pressure bandage is applied for six weeks.
Often injections may have to be repeated at 2-
4weeks intervals for 2-4 sessions. Technique is
called as macrosclerotherapy

38. Microsclerotherapy
 Very dilute solutions of sclerosing agent like
STDS(0.1% of 0.1 ml dilute) polidoconol is
injected into the thread veins and reticular
veins followed by application of compression
bandage
 Dermal flare will disappear well by this
method

39. Contraindiactions for sclerotherapy
 Sapheno femoral incompetence
 Deep venous thrombosis
 Huge varicosities– may precipitate DVT
 Peripheral arterial diseases
 Hypersentivity / immobilty
 Venous ulcer– relative contrainidication
Advantages
 It can be done as an outpatient procedure
 It does not require aneasthesia

40. Disadvantage
 Inadvertent subcutaneous injection can cause
skin necrosis or abscess formation
 Anaphylaxis
 Hyperpigmentation
 Thrombophlebitis
 Deep vein thrombosis can occur

41. Surgery
A. Trendelenburg operation:
It is juxta-femoral flush ligation of long saphenous
vein (flush with femoral vein), after ligation
superficial circumflex, superficial external
pudendal, superficial epigastric vein, deep
external pudendal vein and unnamed
tributaries.
All tributaries should be ligated, otherwise
recurrence will occur
Double saphenous vein is the commonest anomaly
occuring near sapheno-venous junction.

42. B. Stripping of vein: using Myer’s stripper vein is
stripped off. Stripped from below upwards is
technically easier.
Immediate application of crepe bandage reduces the
chance of bleeding and hemotoma formation.
Stripping avulses the vein as well as obliterates the
tributaries.
Babcock’s stripper and rigid metal pin stripper can also
be used.
Stripping of the short saphenous vein is done from
ankle below upward after passing stripper from
above downwards.
Complication is injury to saphenous or sural nerve
causing neuralgia.
Inverting or invaginating stripping using rigid Oesch pin
stripper is better as postoperative pain and
hematoma is less common and also there is tissue
damage.

43. C. Subfascial ligation of Cockett and Dodd
Perforators are marked out by fegan’s method.
Perforators are ligated deep to deep fascia
through incisions in antero medial side of
the leg.

44. Radiofrequency ablation
(RFA)
 This is done under general or regional
anaesthesia.
 RFA catheter is passed into long / short
saphenous vein near SFJ or SPJ under guidence.
85 Celsius temperature is used for long period of
time to cause endothelial damage, collagen
denaturation and venous constriction.
 Phlebectomy is done while withdrawing the
catheter. Wall of vein is destroyed through its full
thickness.
 Vein forms a cord, which gets dissolved by
macrophages and immune cells.

45. Endo venous laser ablation
 It is done as a OP procedure.
 Patient lies in supine with diseased leg flexed, hip
externally rotated and knee flexed.
 With aseptic precaution, under U/S guidance GSV is
cannulated above the knee and a guide wire is
passed beyond SJF and 5- French catheter is passed
over guide wire and tip is placed 1cm distal to the
junction.
 200 ml of 0.1% lignocaine is infilterated along the
length of the GSV.
 Laser fibre is inserted up to the tip of the catheter
and catheter is withdrawn for 2 cm and laser fibre
protrudes for 2 cm.
 Laser fibre is fired step by step using diode laser, one
mm withdrawal in 2 seconds.

46.  Once procedure is over catheter is removed
and pressure bandage is applied for 2 weeks.
 Heat produced (729 – 1000 Celsius) by the
laser produces steam bubbles with thermal
damage of endothelium leading into
occlusion of the vein.
 Laser therapy has inability to create flush
occlusion allowing tributaries to open up and
cause recurrence.

47. SUBFASCIAL ENDOSCOPIC
PERFORATOR SURGERY (SEPS)
 First described by Heuer in 1980, it became the most
accepted surgical treatment of advanced stages of chronic
venous insufficiency because it is minimally invasive nature
and safety profile
 Can be performed with one or two endoscopic ports, the
two port technique uses one 10 mm video port for camera
and 5 mm port for instrumentation.
 The limb is elevated and the field is made bloodless by
using a Esmarch bandage, and a thigh tourniquet is inflated
to 300 mmHg.
 10 mm port is placed in the healthy medial aspect of calf, 10
cms distal to tibial tuberosity.
 Avoid large opening because gas may leak and cause poor
visibility.

48.  The camera is inserted into the 10mm port and then second
5 mm port is inserted under direct vision about 10-20 cm
distal and posterior to the first port.
 CO2 is insufflated to enlarge and optimally visualise the
subfascial space, with pressure maintained at around 30
mmHg.
 All the visible perforators after dissection are interrupted by
using harmonic scalpel, electrocautery or division with
scissors between metallic clips.
 More proximal paratibial perforators are visualised better
by exposing the medial insertion of the soleus on the tibia,
remain close to tibia to avoid damage to posterior tibial
vessels and nerve.
 On completion, the ports are removed, tourniquet is
deflated and CO2 is manually expressed from subfascial
space.
 Local anaesthetic solution is instilled into the subfascial
space to help with postoperative analgesia and
compressive bandage is applied.

50. Transilluminated phlebectomy
 It is done by passing transilluminating light
under the skin and passing a rotating blade
through another small incision.
 Veins are grasped and removed by rotating
movements.

51. AMBULATORY PHLEBECTOMY
Done through small incisions using special
phlebectomy instruments.
ELECTRODESSICATION
Using weak electric current through a fine
needle directly into the spider veins.

52. THANK YOU