Varicose Veins

VARICOSE VEINS


VARICOSE VEINS

  • Dilated, torturous and elongated superficial veins caused by incompetent valve closure results in venous congestion and vein alignment.
  • Usually affects saphenous veins.

Venous system of Lower Limb-

1. Superficial veins-

  1. Long saphenous (most commonly affected by varicose veins)
  2. Short saphenous

2. Deep veins

3. Perforating veins

  1. Direct veins
  2. Indirect veins

Types of Perforators-

Primary Varicose Veins-

  • Primary varicose veins arise due to congenital weakness in the vein wall or congenital absence of valves.
  • Valve at the saphenofemoral junction is absent.

Klippel Trenaunary Syndrome-

  • It is congenital venous abnormality with no valves (valveless syndrome)
  • It has pulsating veins.
  • Cutaneous birthmark (portwine stains)
  • Soft tissue hypertrophy of the affected limb.
  • Have large arteriovenous malformations.

Secondary Varicose Veins-

  • Pregnancy & pelvic tumour, pills
  • Congenital arteriovenous (AV) fistula
  • Recurrent thrombophelitis
  • Deep venous thrombosis (DVT)

 Clinical features-

  • Aching, heaviness, throbbing, burning over limbs
  • Swelling of the ankle, oedema, itching.
  • Telangiectasia & reticular veins
  • Lipodermatosclerosis (brawny induration)

 Recurrence Varicose Veins-

  • It occurs in 10% of patients.

Complications-

  • Thrombophelibitis
  • Hemorrhage
  • Ulceration
  • DVT

Investigations-

1. Brodie- Tredenburg test (flush ligation + stripping of varicose veins)-

  • Saphenofemoral incompetence, perforator incompetence, greater saphenous vein (GSV)
  • Preferred treatment for GSV of very large veins

2. Perthe’s test

  • Deep venous thrombosis

3. Tourniquet’s test

  • Perforator incompetence

4. Schwartz test

  • Valvular incompetence

5. Fegan test

  • Perforator site localisation

6. Pratt’s test

  • Perforations

7. Venography

8. Duplex ultrasound imaging- investigation of choice

Treatment-

  • Elastic stockings
  • Trendelenburg’s operation- for saphenofemoral incompetence
  • Subfacial ligation of Cockett & Dodd perforator incompetence with saphenofemoral competency
  • Stab avulsion phlebectomy- for secondary branch varicosities
  • Endoscopic laser ablation- closure of GSV & small saphenous veins
  • Rupture of varicose veins at ankle can be treated with direct pressure & elevation.
  • Sclerotherapy- sclerolasants used are telangiectasia & varicose veins
  1. Ethanolamine oleate
  2. Sodium tetradecyl sulphate (commonly veins)
  3. Sodium morrhuate
  4. Polidocanol
  5. Hypertrophic saline
  6. Phenol in almond oil

Exam Important

Primary Varicose Veins-

  • Primary varicose veins arise due to congenital weakness in the vein wall or congenital absence of valves.
  • Valve at the saphenofemoral junction is absent.

Klippel Trenaunary Syndrome-

  • It is congenital venous abnormality with no valves (valveless syndrome)
  • It has pulsating veins.
  • Cutaneous birthmark (portwine stains)
  • Soft tissue hypertrophy of the affected limb.
  • Have large arteriovenous malformations.

Secondary Varicose Veins-

  • Pregnancy & pelvic tumour, pills
  • Congenital arteriovenous (AV) fistula
  • Recurrent thrombophelitis
  • Deep venous thrombosis (DVT)

 Recurrence Varicose Veins-

  • It occurs in 10% of patients.

Complications-

  • Thrombophelibitis
  • Hemorrhage
  • Ulceration
  • DVT

Investigations-

1. Brodie- Tredenburg test (flush ligation + stripping of varicose veins)-

  • Saphenofemoral incompetence, perforator incompetence, greater saphenous vein (GSV)
  • Preferred treatment for GSV of very large veins

2. Perthe’s test

  • Deep venous thrombosis

3. Tourniquet’s test

  • Perforator incompetence

4. Schwartz test

  • Valvular incompetence

5. Fegan test

  • Perforator site localisation

6. Pratt’s test

  • Perforations

7. Venography

8. Duplex ultrasound imaging- investigation of choice

Treatment-

  • Elastic stockings
  • Trendelenburg’s operation- for saphenofemoral incompetence
  • Subfacial ligation of Cockett & Dodd perforator incompetence with saphenofemoral competency
  • Stab avulsion phlebectomy- for secondary branch varicosities
  • Endoscopic laser ablation- closure of GSV & small saphenous veins
  • Rupture of varicose veins at ankle can be treated with direct pressure & elevation.
  • Sclerotherapy- sclerolasants used are telangiectasia & varicose veins
  1. Ethanolamine oleate
  2. Sodium tetradecyl sulphate (commonly veins)
  3. Sodium morrhuate
  4. Polidocanol
  5. Hypertrophic saline
  6. Phenol in almond oil
  • Direct Pressure and Elevation  is the first treatment of choice in a case of rupture of varicose veins at the ankle
  • Varicose veins  is associated with migratory thrombophlebitis 
  • Sclerotherapy for varicose vein is contraindicated in  Deep vein Thrombosis
  • Pulsatile varicose veins in lower limbs is seen in Klippel trenaunay syndrome
  • After the division of testicular vein for treatment of varicose vein, venous drainage of testes is by Cremasteric veins
  • Varicose veins are seen in  DVT & AV fistula
  • Most commonly varicose veins are seen with  Long saphenous vein
  • 5% oily phenol is an appropriate sclerosant for venous sclerotherapy.
  • Surgery in varicose veins is NOT attempted in presence ofDeep vein thrombosis
  • A pt presented with pulsating varicose veins of the lower limb. Most probable diagnosis is Klippel Trenaunay syndrome
  • Injection sclerotherapy for varicose veins is by using phenol
  • Commonest complication of varicose vein stripping is Ecchymosis
  • Pulsating varicose vein in a young adult is due to Arteriovenous fistula
  • An operated case of varicose veins has a recurrence rate of About 10%
  • Operations for varicose veins are best accomplished by Stripping
  • Gold standard diagnostic test in varicose veins is Duplex imaging
  • Trendelenburg’s operation is done for Varicose veins
  • Investigation of choice for varicose veins Duplex ultrasound imaging
  • Arteriovenous fistula, Deep venous thrombosis & Pregnancy may cause varicose veins
  • Drug used for sclerotherapy of varicose veins are Polidocanol, Sodium tetradecyl sulfate, Ethanolamine Oleate, 
  • Perthe’s test, Tourniquet test & Trendelenberg test are done for varicose veins
  • Patient presents with varicose vein with sapheno-femoral incompetence and normal perforator can be managed with Endovascular stripping, Sapheno-femoral flush ligation & Saphenofemoral flush ligation with striping
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