examination of varicose veins are shown as video separately , others are mentioned in these slides in easy manner ,

1. VARICOSE VEINS

2. DEFINITION
Varicose veins are defined as dilated, tortuous,
subcutaneous veins >3 mm in diameter
measured in the upright position
with demonstrable reflux.

3. • ANATOMY
• PHYSIOLOGY
• CAUSES
• PATHOGENESIS
• SYMPTOMS
• CLINICAL EXAMINIATION
• TREATMENT

4. ANATOMY
Lower limb has 3 types of veins
1. superficial veins
2. deep veins
3. perforating veins

6. Superficial veins

7. Perforators
• Hunterian’s perforator
• Dodd’s perforator
• Boyd’s perforator
• Cockett’s perforator - 3 groups

8. • ANATOMY
• PHYSIOLOGY
• CAUSES
• PATHOGENESIS
• SYMPTOMS
• CLINICAL EXAMINIATION
• TREATMENT

9. PHYSIOLOGY
• Arterial blood reaches the leg by pumping of heart
• Venous return to heart occurs with the help of
MAINLY by
1. calf muscles hence it is called peripheral heart
2. valves are present in the veins, it prevents the
back flow

10. Important
concept

11. • ANATOMY
• PHYSIOLOGY
• CAUSES
• PATHOGENESIS
• SYMPTOMS
• CLINICAL EXAMINIATION
• TREATMENT

12. PATHOGENESIS
• When there is failure of normal unidirectional flow
in the leg veins , there is decreased venous return ,
it is called CHRONIC VENOUS INSUFFICIENCY (CVI).
• CVI can lead to stasis of blood in leg veins leading to
AMBULATORY VENOUS HYPERTENSION .
• Due to venous hypertension , superficial veins may
get dilated and tortuous , hence called VARICOSE
VEIN.

13. • ANATOMY
• PHYSIOLOGY
• CAUSES
• PATHOGENESIS
• SYMPTOMS
• CLINICAL EXAMINIATION
• TREATMENT

14. CAUSES
• Congenital – absence of valves
• Primary varicose veins
• Secondary veins
1. Post thrombotic
2. Pregnancy
3. Abdominal mass
4. Iliac vein thrombosis
5. AV Fistula

15. • ANATOMY
• PHYSIOLOGY
• CAUSES
• PATHOGENESIS
• SYMPTOMS
• CLINICAL EXAMINIATION
• TREATMENT

16. SYMPTOMS
• Aching pain
increases on prolonged standing
relieves on limb elevation
• Ankle swelling
• Pigmentation
• Itching
• Eczema
• Ulceration - medial and lateral aspect of lower leg
“ GAITER AREA “
Hemoglobin
Hemosiderin biliverdin

17. 2 hypothesis regarding venous ulcer :
Fibrin Cuff Theory : due to raised capillary pressure
, there is leakage of plasma fibrinogen and form a
cuff around the capillary thus reducing perfusion
leading to venous ulcer .
White Blood Cell trapping theory : due to venous
stasis , WBC may get attached to the endothelial
cell of capillaries and may extravasate into
extracellular space , this is followed by release of
proteolytic enzymes and damage of the cells
leading to ulcer

18. • ANATOMY
• PHYSIOLOGY
• CAUSES
• PATHOGENESIS
• SYMPTOMS
• CLINICAL EXAMINIATION
• TREATMENT

19. CLINICAL EXAMINATION
INSPECTION
• TELANGECTASIA – DILATED INTRADERMAL VENULES < 1
mm DIAMETER
• RETICULAR VEINS – DILATED SUBDERMAL VEINS 1-3
mm DIAMETER
• PITTING ODEMA
• ATROPHIC BLANCHE – WHITE ATROPHIC SKIN
SURROUNDED BY DILATED CAPILLARIES
• CORONA PHLEBECTASIA ANKLE FLARE
• LIPODEMATOSCLEROSIS – INVERTED WINE BOTTLE
APPEARANCE

20. • PIGMENTATION – HEMOSIDERIN DEPOSITION
• ECZEMA
• MORRISEY TEST
• ULCERATION
Margin – thin and bluish
showing growth of epithelium
Edge – sloping
Floor – granulation tissue and
slough
Base – fixed to deeper
structures

21. PALPATION
• TEMPERATURE
• FEGAN METHOD
• CRUVEILHIER’S SIGN
• SCHWARTZ TEST
• BRODIE TRENDLENBURG TEST – 2 METHODS
1ST – SAPHENO FEMORAL INCOMEPETENCE
2ND – PERFORATING VEIN INCOMPETENCE

22. • MULTIPLE TOURNIQUET TEST
• PRATT’S TEST
• PERTHES TEST
• MODIFIED PERTHES TEST

23. • ANATOMY
• PHYSIOLOGY
• CAUSES
• PATHOGENESIS
• SYMPTOMS
• CLINICAL EXAMINIATION
• INVESTIGATION
• TREATMENT

24. INVESTIGATION
DUPLEX ULTRASONOGRAPHY

26. Varicography
• Rarely done in case of complex anatomy

27. • ANATOMY
• PHYSIOLOGY
• CAUSES
• PATHOGENESIS
• SYMPTOMS
• CLINICAL EXAMINIATION
• INVESTIGATION
• TREATMENT

28. MANAGEMENT

29. COMPRESSION HOISERY
class 1 – 14 – 17 mmHg
class 2 – 18 – 24 mmHg {varicose vein}
class 3 – 25 – 35 mmHg

30. ULTRASOUND GUIDED FOAM
SCLEROTHERAPHY
• SODIUM TETRADECYL SULPHATE IS INJECTED
INTO THE VEIN.
• IT DESTROYS THE ENDOTHELIAL CELL ,
HEALING OCCURS BY FIBROSIS AND BLOOD
VESSEL GETS OBLITRATED.

31. ENDOVENOUS LASER ABLATION

32. RADIOFREQUENCY ABLATION
• Similar like endovenous laser ablation
• But bipolar catheter is used to heat

33. SURGERY
TRENDLENBURG OPERATION :FOR
SAPHENOFEMORAL INCOMPETENCY
PERFORATOR LIGATION AND SEPS(SUBFASCIAL
ENDOSCOPIC PERFORATOR LIGATION
SURGERY) :FOR PERFORATOR
INCOMPETENCY

34. TRENDLENBURG OPERATION
INDICATION – SAPHENOFEMORAL INCOMPETENCY

35. STEP 1
• MARK THE VARICOSE VEIN BECAUSE THE VEIN
MAY DISAPPEAR WHEN PT LIES DOWN

36. STEP 2
• SPINAL ANESTHESIA IS GIVEN

37. STEP 3
• BED IS TILTED IN HEAD DOWN POSITION OF
ABOUT 10*
TRENDLENBURG POSITION

38. STEP 4
• INCISION
OBLIQUE INCISION
INCISION IS MADE 4 CM BELOW AND LATERAL
TO PUBIC TUBERCLE OVER THE
SAPHENOFEMORAL JUNCTION

39. STEP 5
• SAPHENOFEMORAL JUNCTION IS EXPOSED

40. STEP 6
• TRIBUTARIES ARE IDENTIFIED AND LIGATED
AND CUT.
• FLUSH LIGATION IS DONE
• IT IS LIGATION OF LONG SAPHENOUS VEIN
NEAR ITS TERMINATION .
• AND IT IS CUT

41. STEP 7
• UPPER 10CM OF LONG SAPHENOUS VEIN IS
LIGATED AND EXCISED.

42. COMPLICATIONS
• Haematoma
• Wound sepsis
• Edema of leg
• DVT

43. INDICATIONS OF PERFORATOR
INCOMPETENCY
• PERFORATOR LIGATION -USING FEGANS
METHOD .
THE PITS ARE FOUND IN THE DEEP FASCIA
INCISION IS MADE OVER IT
PERFORATOR IS IDENTIFIED AND LIGATED
• SUBFASCIAL ENDOSCOPIC PERFORATOR
LIGATION SURGERY
IN THIS METHOD AIR IS INFLATED DEEP TO
DEEP FASCIA

44. • NOW ENDOSCOPE IS INSERTED DEEP TO DEEP
FASCIA
• PERFORATORS ARE IDENTIFIED AND THEY ARE
LIGATED

45. • ANATOMY
• PHYSIOLOGY
• CAUSES
• PATHOGENESIS
• SYMPTOMS
• CLINICAL EXAMINIATION
• INVESTIGATION
• TREATMENT

46. THANK U