This document discusses varicose veins, including definitions, anatomy, causes, symptoms, examination techniques, and treatment options. Some key points: - Varicose veins are dilated, tortuous veins, usually in the legs, caused by incompetent valves that allow blood to flow in the wrong direction. - Annual incidence is about 2% and lifetime prevalence is around 40%, being more common in women. - Symptoms can include pain, swelling, heaviness, and skin changes like pigmentation. - Examination involves inspection, palpation, auscultation, and Doppler ultrasound to map veins and locate sites of reflux. - Treatment options include conservative compression therapy, sclerotherapy

1. Varicose veins and treatment
• Jeannouel van Leeuwen ,
surgeon
• Chirurgen Maatschap
Emma Care
• Courtesy of Servier
• 25 january 2012

2. What we‟ll cover
• Some Definitions
• Anatomy
• What are you looking for?
• Examination techniques
• Treatment options

3. Incidence
• annual incidence of varicose veins is
about 2%
• life-time prevalence of varicose veins
approaches 40%
• Varicosities are more common in women
(about 2-3 times as prevalent in women
than in men)
• 10-20% actually are symptomatic enough
to complain about their lower leg varicose
veins and seek treatment.

4. What is a varicose vein?
• Long, tortuous and dilated vein of the
superficial varicose system
• Commonly legs but where else?
• Abdominal Wall
• Anus
• Vulva
• Oesophagus
• Scrotum

5. Why do they happen?
• increased pressure in the
superficial venous
system
• normally blood flows from
superficial system to deep
• if the valves protecting the
superficial veins become
incompetent there is
higher pressure in the
superficial veins and they
become varicose

6. Normal venous flow in the Leg
Normal Flow
• Superficial veins drain into the deep veins
•From the foot up to the heart
Superficial vein disease always starts with abnormal
valves and interruption to normal flow called venous
reflux

8. Abnormal flow = Venous Reflux
Damaged Valves
1. Blood flows to the skin
2. Blood is pushed distally and
proximally
3. Close loop recirculation
4. Blood is retained in the leg
• Increased volume of blood
(heaviness Fatigue)
• Increased venous pressure
• Veins Dilate (varicose veins)

9. Taking the history
 Presenting Complaint: Varicosities, abdominal/groin
lump – saphena varix
 Symptoms
 Localized discomfort in the leg, Pain, Swelling, Venous
claudication, Itching
 “Risk” factors
 Female, age, ethnicity, occupation, pregnancy, obesity, sm
oking
 ASK about history of abdominal
complaints/cancer, DVT, previous & other venous
complaints

10. So the examination
• Inspection
• Auscultation
• Palpation
• cough test
• tap test
• Tourniquet Tests
• Trendelenberg
• Tourniquet test
• Perthes
• Doppler
• Sapheno-femoral junction
• Sapheno-popliteal junction

11. Diagnosis of venous disease
• Physical exam
• Appearance
• Trendelenburg test
• Palpation
• Hand Doppler
• Duplex Examination
• R/O DVT
• Size of veins
• Map out superficial veins
• Locate the site of reflux
• Reflux 0.5 sec in GSV and 1 sec in
deep system
• Find refluxing perforators

12. Clinical picture - symptoms
• Cosmetic disfigurement
• Pain and discomfort
• Night cramps
• Mild swelling at night
• Pigmentation
• Itching
• Ulceration

13. Anatomy
• Superficial System arises from foot and ends at Sapheno- femoral
junction (spiderhead)
• Long saphenous vein- medial leg up to SFJ
• Short saphenous vein- lateral malleolus , up calf to meet popliteal
vein behind knee
• Sapheno- femoral junction- 4 cm lateral and 4cm below the pubic
tubercle
• Communication veins: connecting deep and superficial system
through piercing deep fascia, with valves to direct blood from
superficial to deep viens.
• Perforator veins: there are 3 perforators on the medial side and 1
on the lateral side of the leg

15. Inspection- other features
1. Spider Veins- blueish vessels that distend above
the skin surface
2. Thrombophlebitis- superficial red painfull lump
3. Brown pigmentation- haemosiderin
deposition
4. Venous Eczema
5. Venous Ulcers- over medial ankle
6. Lipodermatosclerosis-progressive sclerosis
of cutaneous fat- ankle becomes thin and hard- area
above becomes oedematous
7. Scars from previous surgery

17.  Atrophy blanche
 Ulceration: active and healed
Inspection  Leaves a white patch
 Venous ulcers/eczema
 Pitting oedema
 Spider veins

18. Inspection
 Lipodermatosclerosis
 Literally "scarring of the skin and fat“
 A slow process that occurs over a number of years
and has 2 phases:
1. Acute
 Venous pooling →chronic venous hypertension
 RBC forced into surrounding tissue
 Haemoglobin broken down into brown
haemosiderin
2. Chronic
 Chronic haemosiderin formation leads to fibrin
deposition
 Skin becomes thickened and shiny
 Skin around ankle constricts and the inverted
champagne-bottle shape is seen

19. Stages of chronic venous
insufficiency
(Expert meeting in Moscow, 2000.)
• 0 - no symptoms;
• 1 - heavy feet syndrome;
• 2 - intermittent edema;
• 3 - persistent edema, hyper- or
hypopigmentation, lipodermatosc
lerosis, eczema;
• 4 - venous ulcer.

21. Causes
Primary
• Theories of Aetiology:
• Weak wall theory
• Congenital valvular incompetence
• Aggravating factors:
• Female sex
• High parity
• Occupation requiring prolonged standing
• Marked obesity
• Constricting clothes
• Estrogen intake
• Deep venous thrombosis

22. Secondary
Anything that raises intra-abdominal pressure or
raises pressure in superficial/deep venous system
so…:
•Pregnancy
•Abdominal/pelvic mass
•Ascites
•obesity
•constipation
•thrombosis of leg veins (DVT)
•AV fistula
•Vena cava thrombose
•Large liver cysts

23. Auscultation
• Auscultate over any varicosities for bruits
• due to A-V malformation

24. Palpation
• Palpate the veins to confirm they are infact veins-
will refill if if gently pressed and released
• Next- find the sapheno-femoral junction (SFJ)
• Find Pubic Tubercle just lateral to pubic symphisis
• 4 cm lateral then 4cm below
• Palpate for a sapheno varix- localised distension of the
long saphenous vein in the groin
• Cough Test- Fingers over SFJ, ask patient to cough
can you feel a thrill, if yes suggest incompetence
• Tap Test- tap over the SFJ and feel further down
long saphenous vein for any transmitted sounds, if
yes suggest incompetence

25. Trendelenberg/Tourniquet tests
Aim- to localise the valve/s that are
incompetent
Trendelenberg
• Lie patient down and raise leg attempting
to drain varicosities of blood.
• Using either a tourniquet or fingers put
pressure over SFJ to occlude it
• Ask patient to stand
If varicosities DO NOT refill indicates SFJ
incompetence
If DO refill the leaky valve is lower down
„I will now try and locate the incompetent
perforator using the tourniquet test‟

26. Tourniquet test continued
• Same as before- lie down, raise and drain
leg
• Place tourniquet approximately over area
of each perforator( mid thigh, sapheno
popliteal, calf perforators)
• If varicosities DO NOT refill that perforator
is incompetent
• If varicosities DO refill continue down leg

27. To complete my examination I
would like to…
• Perform a full Abdominal Examination
• Scrotal examination ( on males!)
• Arterial Examination
Investigations
• Duplex Ultrasonography- maps valve
incompetence
• Phlebography not done anymore

28. Spider Veins
The proper term is Telangiectasia
•These are non raised dilated veins located in the
Dermis (deep layer of the skin)
•Single layer endothelium, minimal muscle
•Can be Red or Blue in color depending on the origin
•Do not cause major medical complications
•Appears earlier than varicose veins (4% of teenagers ,
and 13 % in 18 to 20 year olds
•More common in females
•Reticular Veins are lager feeding veins

29. Spider Veins
Etiology: Multifactorial
• Venous Hypertension associated with varicose
veins
• Congenital: vascular nevi, neonatal
hemangiomatosis, others..
• Collage Vascular Disease: lupus,
• Hormonal factors: pregnancy, estrogen
therapy, topical steroids
• Trauma: contusion, incisions
• Infections

30. Venous Stasis Ulcers
• Differential Diagnosis
1. Venous ulcerations 50% on non healing ulcers
2. Arterial ulcers in about 10%
3. Malignancy : basal and squamous cell, lymphoma
4. Infections: HIV, fungal
5. Collagen vascular disorders: Lupus ec.
6. Lymphatic obstruction
• Affects over 1 million people in the US
• 100,000 are disabled from this
• More common in elderly population

31. Ulcus cruris venosum

32. Venous Stasis Ulcers
• Etiology
1. Venous Hypertension
• Venous reflux
• DVT
• Varicose veins
2. Edema
3. Biological factors
• Leakage of proteins impedes
diffusion O2
• Aggregation of white cells
• Block capillary flow
• Release on inflammatory proteins

33. Management
 Surgical
 Conservative/Medical
• Ankle-to-groin saphenous vein
 Graded compression stripping (with stab avulsion)
bandaging, Compression • Segmental saphenous vein stripping
hosiery (with stab avulsion)
• Saphenous vein ligation:
 Paste Gauze (Unna) Boots
high, low, or both
 Diuretics? Zinc? • Saphenous vein ligation and
Phlebotrophic/Hemorheologi sclerotherapy
c agents? Aspirin/NSAIDs etc • 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

34. Surgical ligation and Stripping
• Standard treatment
for a century
• General anesthesia
• Pain
• Long recovery
• Some complications
• Good cosmetic
results

35. Surgical treatment
• Crossectomy or/and
vein stripping till
below knee better
than compressive
therapy alone
• Other techniques :
Endovas.burning or
foam injection

36. Vein Ablation
• Laser Ablation (EVLA )
• Uses light to heat the vein
• Radio Frequency (VNUS Procedure)
• Uses radio frequency to heat the vein
• Office based procedure
• Done under local anesthesia
• One needle puncture at the level of the
knee
• Takes about 1 hour
• Patient resumes normal activity same
day

37. EVLA Results
Images from
http://venacure-evlt.com/

38. Sclerotherapy
• Cumulate vein with needle
• Inject Sclerosing Solution
• Ethoxysclerol
• Hyper tonic Saline
• Foam (Mix STS with air and make
bubbles)
• Intravenous injection causes intima
inflammation and thrombus
formation

39. Sclerotherapy Use
• Neovascularization
• Perforators
• Clean up after Phlebectomies
• Spider veins
• Reticular veins
• GSV: can closure the, but has
high recurrence rate

40. Sclerotherapy results

41. UNNA boot
result
• Weekly change with
UNNA boot bandage
gives nice result

42. • Compressive
bandages first choice
with simple small vein
ulcer

43. • Skin grafting can be
put on a non infected
granulating skin
defect of a venous
ulcer

44. Treatment complications
• Major complications following VV surgery are relatively rare
• Up to 20% morbidity
• Infection
• Hematoma
• Pain
• Nerve damage
• Saphenous nerve (LSV surgery)
• Sural, peroneal nerve (SSV surgery)
• Lymphatic leak - Venous thrombosis - Vascular injury
• Recurrence

45. Oral medication
• Effect on edema , hematocrit , augmentation
capillary permeability , inflammation , less fibrinolysis
, leukocyte function en erythrocytes
• No evidence for monotherapy only in addition effect
on ulcer healing
• Daflon , Trental , Aspirine

46. Рhlebotropic drugs
• Daflon
• Venal
• Venoruton
• Doxium

47. Rheologic
hemocorrectors
• acetylcalicylic acid,
• dipiridamol
• pentoxyphylline
• low-molecular dextranes

48. Thank you for
your attention
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