Varicose Veins

1. Varicose Veins Core Surgical Trainees Vascular Teaching Day Kent and Canterbury Hospital 1st December 2009 Hasantha Thambawita SpR Vascular Surgery

2. Epidemiology • ½ of the population suffer from some form of lower limb varicose vein problems • Female 50-55% • Male 40-45% • But only ½ of them have visible varicose veins • Lower limb ulcers • Venous - 75% • Arterial • traumatic

3. Varicose Veins • Definition • Dilated, elongated and tortuous veins • Dilatation • Elongation • Tortuous

5. Anatomy of leg veins • 3 Systems • Deep System • Superficial system • Long saphenous vein • Short saphenous vein • Perforators

7. Physiology of Venous function • Vis a tergo of circulation • Competent valves in the system • Muscle pump • Negative intra thoracic pressure

8. Surgical Pathology • Incompetence of valves • Perforators • LSV & SSV • SFJ & SPJ • Deep veins

11. Aetiology • Congenital • Primary (Idiopathic) 95% Congenital incompetence of valves &/or weakness of muscular coat • Secondary 5%

12. Primary • Prolonged standing • Violent muscular effects • Obesity • Ageing • OCP • HRT • FHx

13. Secondary • Pregnancy • Abdominal or Pelvic tumours • Chronic constipation • Local damage to valves • Thromboplebitis • Phebothrombosis • Arterio Venous fistulas • Cavernous haemangioma

14. Symptoms/Signs • Tiredness & Dull ache • Night cramps • With complications

16. Complications • Itching • Disfigurement • Eczema • Swelling around ankle • Pigmentation • Ulceration • Periostitis • Calcification of vein wall • Haemorrhage • Thromboplebitis

17. Types of Veins • Thread veins • Spider veins • Reticular veins • Small varicose veins • Elongated tortuous veins • Saphina varix

21. Clinical tests • Identify system • Observation • Tap test ( Schwartz test) • Incompetent perforator/valves • Cough impulse – SFI • Trendelenberg test – SFI,SPI,Perforators • Patency of deep veins • Perthes’ test • “Historical” --- replaced with Doppler

22. Don’t forget……. • Distal pulses • Ankle mobility • Abdominal examination (DER)

23. Investigations • Duplex scan • (Venography) --- MRV

24. Clinical C1 = Thread veins C2 = Std VVs C3 = Oedema C4 = Pigmentation C5 = Healed ulcer C6 = Active ulcer (A)Etiology Congenital Primary Secondary Anatomy Deep LSV SSV Perforators Combination(s) Pathophysiology Reflux Obstruction Combination CEAP Classification

25. Group & Action • CEAP – 1 No need to refer to NHS clinic, cosmetic problem only • CEAP – 2 Refer routinely to Varicose Vein Clinic • CEAP 3 – 5 Refer soon to "Fast Track Varicose Vein Clinic" for venous duplex ultrasound assessment • CEAP 6 - Refer urgently to "One Stop Leg Ulcer Clinic" for full leg ulcer assessment

26. Treatment Options • Symptomatic • Obliteration of venous lumen • Removal of vein

27. Indications • Cosmetic • NHS guidelines • Symptoms • Complications/prevention of complications

28. Symptomatic Treatment • Indications • Aged • Pregnancy/Peuperium • Unfit/refuse/waiting for surgery • Pelvic tumours • DVT

29. Symptomatic treatment - Methods • Postural drainage • Exercise • Support

31. Obliteration of venous lumen • Indications • Below knee • < 5mm • Following surgery (adjunct) • Existing causes • Alternative to surgery

32. Obliteration of venous lumen - Methods • Sclerotherapy • Form injections • Laser • Radiofrequency

35. Surgery • Indications • As a primary modality • Remove unsightly veins • Failed other options

36. Surgical Options • Ligation • Ligation & stripping • Ligation, stripping & BK multiple avulsions

38. Complications of Surgery • Pain • Bruising • Recurrence • Groin complications • Infection • Paraesthesiae • Scar

39. Contraindications • DVT • Pregnancy • Thrombophlebitis • OCP • Peripheral vascular disease