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بسم الله الرحمن الرحيم. دكتر مرتض ی خوانين زاده گروه جراح ی دانشگاه علوم پزشکی ایران. ب ي مار ی ها ی وريد ی.
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دكتر مرتضی خوانين زاده گروه جراحی دانشگاه علوم پزشکی ایران بيماری های وريدی
A 35-year-old female presented with complaints of achingdiscomfort and a sense of fatigue in her right leg, whichdeveloped after a vein in her right leg started to enlarge.She believed that one vein in her left leg had also becomemore apparent and unsightly. Her symptoms had lastedfor a few months and seemed to worsen with her menstrualperiods and at the end of the day. They improved bylying down with the legs elevated. She stated that hermother had a leg ulcer and her sister had had a vein stripping.On physical examination, she appeared to be healthywithout abdominal or pelvic masses. No inguinal lymphadenopathy was present.
The right greater saphenous vein was elongated and dilated in its entire length. Severalcollaterals originating from the greater saphenous veinwere also dilated in both the medial aspect of the thighand calf where some weak spots were palpated in the superficial fascia. No bruits or thrills were felt over the mainvaricosities, and no areas of dermatitis or signs of previousulceration were found over the medial malleolus. The leftleg appeared normal with a minimally dilated greater saphenous vein. With the patient standing, a Valsalva maneuver was performed, and an obvious transmitted impulsewas felt below the fossa ovalis bilaterally. Similarly, aTrendelenburg’s test was positive and a Perthe’s test wasnegative in both extremities. No further testing was done
SYMPTOMATIC VARICOSE VEINS she was advised to have a vein stripping on the rightleg and to wear an elastic stocking on the left leg.
آناتومی وريدهای اندام تحتانی • وريدهای سطحی • وريدهای عمقی • وريدهای سوراخ كننده • دريچه های وريدی
Anatomy • Deep veins • Superficial veins • Perforating veins • Reticular veins • Epidermal veins (spider veins)
آناتومی وريدهای اندامفوقانی • وريدهای سطحی • وريدهای عمقی • وريدهای سوراخ كننده • دريچه های وريدی
فيزيولوژی • فشارهای وريدی
History • Varicose vein plague over 2000 years • Votive tablet found near the Acropolis in the sanctuary of Dr. Amynos in the 4th century • Multiple treatment modalities
Etiology • 10%-20% of Western & European adults: 15% of male over 18 30% of female over 18 • Females are effected twice as frequently Progesterone and estrogens cause dilation of varicosities increase symptoms prior to menstruation. • Genetic play a role in up to 70% of cases • Risk factors: Prolonged standing, prior blood clots, pregnancy.
Pathophysiology • Failing venous pump mechanism • Perforation veins • Dilation of superficial veins
تشخيص داپلر ونوگرافي درمان طبی جراحی اسكلروتراپی اتيولوژی اوليه ثانويه تظاهرات بالينی معاينه فيزيكی وريدهای واريسی
Elevate the patients limb & empty the L.L. veins Apply the tourniquet below the saphenous opening 2 3 The site of incompetent perforator is suspected by a palpable fascial defect, multiple tourniquet & confirmed by Duplex As the patient stands, the V.V. fill rapidly from above. This means that the incompetent connection between the deep & superficial system is NOT the sap-fem junction (which is controlled by the tourniquet), but it is below it. 5 4 Example of “Trendelenburg” Test Localize the site of saphenous opening: 4cm below & lateral to the pubic tubercle
Treatment of varicose veins • Part One • Get rid of the reflux • Part Two • Get rid of the varicose veins
Treatment Varicose Veins • Compression stockings • Surgical, vein stripping • Endoluminal • Laser • Radiofrequency ablation • Subfascial Endoscopic Perforator vein Surgery (SEPS) • Sclerotherapy • Ultrasound guided • Catheter delivered
Vein Stripping • Typically requires general anesthesia • Two incisions are need • Can be painful post-operatively • Requires 4-7 days off work
EndoVenous treatment • Laser ablation 810 nm 940 nm 980nm • Radio-Frequency ablation
