VARICOSE VEIN

 VARICOSE VEIN

INTRODUCTION:

Varicose vein word derive from the latin word varix means " TWISTED".

We can define the varicose vein as a dilated and tortuous vein which seems like a snake under skin.

ETIOPATHOGENESIS:

ETIOLOGICAL FACTOR:

•  Congenital weakness of venous wall
•  Leakage of valves
•  Obstruction

           a) Internal : Deep venous thrombosis
           b) External: Trauma, Trauma, Compresion

PREDISPOSING FACTOR:

•  Pregnancy
•  Obescity
•  Prolong standing

SYMPTOMS:

• Dullache at calf
• Itching around ankle
• Discomfort
• Pigmentation at ankle
• Eczema
• Odema
• Ulceration 
• Dilated and toutuous veins

INVESTIGATION:

USG Doppler gold standard for diagnosis.

STAGING

           

                                                                                                                                                                       

CEAP CATEGORY	DESCRIPTION
CEAP 1	1.       Reticular and spider veins
CEAP 2	2.       Varicose veins
CEAP 3	3.       Varicose veins and leg swelling
CEAP 4	4.       Varicose veins and evidence of venous stasis skin changes
CEAP 5	5.       Varicose veins and a healed venous stasis ulceration
CEAP 6	6.       Varicose veins and an open venous ulceration

Recommendations for new patients with venous disease based on CEAP Category:

GROUP	RECOMMENDATION
CEAP 1	No need to refer to NHS clinic, cosmetic problem only
CEAP 2	Refer routinely to "Fast Track Varicose Vein Clinic" for photoplethysmography assessment
CEAP 3 CEAP 4 CEAP 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

MANAGEMENT:

A) PRIMARY 

B) SURGICAL

A) PRIMARY MANAGEMENT:

1) Weight loss

2) Avoid prolong standing

3) Limit the excercise

4) Compresion stokings

Gradient elastic stockings pioneered by engineer and patient, Conrad Jobst®, in the early 1950s remain the standard in the management of chronic venous disease. Gradient compression delivers a squeezing to the leg that is tightest at the ankle. The amount of squeezing or compression gradually decreases up the leg. While the exact mechanism of action of compression remains elusive, compression is believed to provide two primary benefits to individuals suffering from chronic venous insufficiency.

MECHENISM OF COMPRESION STOCKING

CLASSES OF COMPRESION STOKINGS :

GRADING	PRESSURE	INDICATION
CLASS 1	15-20 mm Hg	Great for travel, standing or sitting for long periods of time. Relief from minor swelling and varicose veins, often recommended during pregnancy.
CLASS 2	20-30 mmHg	These are also good for venous thrombosis prevention during extended travel. Relief from moderate to severe varicose veins and swelling, edema, lymphedema, venous insufficiency, superficial thrombophlebitis. Often prescribed post-sclerotherapy and to prevent venous stasis ulcers.
CLASS 3	30-40 mm Hg	Relief from severe varicose veins and swelling, edema, lymphedema, or following an episode of deep venous thrombosis. For severe chronic venous insufficiency or post-thrombotic syndrome (PTS) which may result in: edema and skin changes such as: hyperpigmentation, stasis dermatitis, lipodermatosclerosis, or venous stasis ulcers. These should be worn under doctors’ supervision.
CLASS 4	40-50 mm Hg	Extra firm compression and therefore should only be worn when recommended by your treating physician or other health care provider. For severe chronic venous insufficiency or post-thrombotic syndrome (PTS) which may result in: edema and skin changes such as: hyperpigmentation, stasis dermatitis, lipodermatosclerosis, or venous stasis ulcers. These should be worn under a doctor's supervision.

CONTRAINDICATION FOR STOCKINGS:

• Peripheral Arterial disease
• Active skin infection

NICE GUIDELINES FOR SURGICAL INTRVENTION

2) SURGICAL MANAGEMENT :

LIGATION

1) LIGATION:

Incompetant saphenofemoral junction , saphenopopleteal junction and perforators are simply ligated.

Nowadays only perforators are ligated if they are incompetant.

                                       
                                                    PERFORATOR LIGATION IN GSV TERITORY

2) LIGATION AND STRIPING:

When the saphenopopleteal and saphenofemoral junction are incompetant we can do ligation of junction and than striping of whole rmaining vein.

DISTAL END OF GSV WITH STRIPPER INSIDE

                                   

                                         PROXIMAL END OF GSV WITH STRIPER

                                      

                                           STRIPPED VEIN

                       
                                                   STRIPPED VEIN

3) ENDOVASCULAR:

A) RADIOFREQUENCY ABLATION

     

After canulation of vein with sheath RFA catheter passed through it and the vein is ablated.

Mechenism: 

Temerature is 120`C for 20 sec  and catheter removed for 7 cm at each cycle. The heat damage is just 2 mm of the surface to which catherte is in contact.

                                      

                                          RFA MACHINE

                  

                                          RFA MACHINE WITH RFA CATHETER IN VEIN

                                         RFA MACHINE AT 120*C AT 15 WTS

CANULATION OF GSV JUST ABOVE THE KNEE WITH RFA CATHETER INSIDE THE VEIN

B) LASER

Diode laser 810,940,980,1064 

After passing the catheter in vein 70-100 jule energy at 14 wts delivered and catheter withdrawn at the rate of 2 mm/sec.

MECHENISM :

                                 

COMLICATION OF ENDOVASCULAR PROCEDURE :

• Skin burn
• Local paresthesia
• Deep venous thrombosis

OUTCOME OF ENDOVASCULAR PROCEDURE :

Recanalisation rate:

4) FOAM SCLEROTHERAPHY

Most patients with small or moderate size varicose veins can be treated in this way. Those patients with very extensive large varicose veins are usually best treated  surgically to obtain a more   rapid result. It is    often far easier    to treat recurrent    varicose veins by foam     injections than by more surgery. These suggest that 80 – 90% of saphenous   veins (the main surface vein) are permanently occluded    by this   treatment when   examined five years later using  ultrasound imaging . This is     similar to the success rate claimed for other new techniques  such as VNUS Closure – Venefit  and Endovenous Laser Ablation .  Clinical trials which have   compared surgery,     foam sclerotherapy,   laser ablation    and RF   ablation have   found     that the   clinically assessed and   patient reported outcomes are identical

Either visually or with ultrasound guidance, a tiny needle is used to inject foamed sclerosant into the vein.  The lining of the vein then swells and eventually seals shut.  The vein will usually fade in a few weeks.

                           

WITH NEEDLE FOAM INJECTED  IN VEIN

ADVANTAGE AND DISADVANTAGE

ADVANTAGE	DISADVANTAGE
o    Stripping of the vein is avoided and there is little or no discomfort after treatment.	o    The treatment produces mild discomfort in the leg which may last for 2 – 4 weeks.
o    There is much less bruising than following surgery.	o    It also produces mild bruising and some lumps which may last for several weeks following treatment. However, both of these features are usually seen following surgical treatment for varicose veins.
o    There is no need for general anaesthetic, incisions in the leg, admission to hospital or an operating theatre.	o    The final outcome may take a number months to evolve following treatment, and this is longer than would be taken following surgery.
o    There are no scars.	o    The treatment produces mild discomfort in the leg which may last for 2 – 4 weeks.
o    Re-treatment for further varices is simple.	o    It also produces mild bruising and some lumps which may last for several weeks following treatment. However, both of these features are usually seen following surgical treatment for varicose veins.

DR TUSHAR SHARMA
CARDIOVASCULAR AND THORACIC SURGEON
WWW.GCCRS.IN
WWW.DRTUSHARCVTS.COM
9978966778