Transcript Varicose GTK - Chennai City Branch Of ASI
MANAGEMENT OF VARICOSE VEINS WHEN & HOW BY DR.G.THULASIKUMAR M.S.(Gen.Surg) M.Ch. (Vascular Surgery) Department of Vascular Surgery Govt. Kilpauk Medical College Hospital Chennai-10
Votive offerings such as these were given to physicians by grateful patients after successful treatment
Chronic venous disease
Most common vascular disorder
3 Billion US dollars spent a year for treatment
3 % of the total Heath care Budget
2 million USA work days lost per year
DEFINITION
A VEIN THAT BECOMES ELONGATED, DILATED, TORTUOUS, POUCHES AND THICKENED DUE TO DYSFUNCTIONING VALVES CAUSING CONTINOUS DILATATION UNDER PRESSURE .
Definition
Telangiectasias - are a confluence of dilated intradermal venules less than one millimeter in diameter.
Reticular veins - are dilated bluish subdermal veins, one to three millimeters in diameter. Usually tortuous.
Varicose veins - are subcutaneous dilated veins three millimeters or greater in size. They may involve the saphenous veins, saphenous tributaries, or nonsaphenous superficial leg veins.
Subcutaneous Veins
When abnormal: - Telangiectasia (spider – 1mm)
- Reticular (1- 3 mm)
Varicose (>3mm)
Abnormal Veins
Telangiec tasias Reticular veins Varicose vein
INCIDENCE
MEN : 10-15% WOMEN : 20-25% WHEN NON SAPHENOUS VARICOSITIES ARE INCLUDED MEN : 45% WOMEN : 50%
RISK FACTORS FEMALE GENDER ADVANCED AGE CAUCASIAN RACE FAMILY HISTORY ACCELERATORS PREGNANCY OBESITY
VENOUS SYSTEM OF LOWER LIMBS
SUPERFICIAL VEINS
DEEP VEINS
PERFORATORS
SUPERFICIAL VEINS
LONG SAPHENOUS SYSTEM
SHORT SAPHENOUS SYSTEM
LONG SAPHENOUS SYSTEM
FROM MEDIAL LIMB THE DORSAL ARCH TO SAPHENOUS OPENING – SAPHENO FEMORAL JUNCTION SFJ TRIBUTARIES SUPERFICIAL EPIGASTRIC VEIN SUPERFICIAL EXTERNAL PUDENDAL VEIN SUPERFICIAL LATERAL CIRCUMFLEX ILIAC VEIN.
THIGH TRIBUTARIES ANTEROLATERAL VEIN POSTEROMEDIAL VEIN CALF TRIBUTARIES ANTERIOR ARCH VEIN POSTERIOR ARCH VEIN
SHORT SAPHENOUS SYSTEM SAPHENO POPLITEAL JUNCTION BRANCHES LATERL CALF VEIN MEDIAL CALF VEIN VEINS CONNECTING LSV & SSV LATERAL THIGH VEIN INTER SAPHENOUS VEIN ACCOMPANYING NERVES LSV – SAPENOUS NERVE SSV – SURAL NERVE
Connect deep and superficial systems
Flow normally from superficial to deep
Perforators
PERFORATORS
•
USUALLY DOUBLE
•
1-2mm IN DIAMETER
•
UPWARD DIRECTION FROM THEIR SUP.VEIN
LSV PERFORATORS THIGH – DODD’S GROUP HUNTER’S PERFORATOR DODD’S PERFORATING VEIN HACH PERFORATING VEIN
PERFORATORS
BELOW KNEE BOYD’S SHERMAN’S - 24cm COCKETT’S - III---18cm II---12cm I--- 6cm CALF PERFORATORS GASTROCNEMIUS (MAY’S) SOLEUS PERFORATORS BASSI’S VEIN- PERONEAL TO LSV FIBULAR FOOT PERFORATORS KUSTER-------MARGINAL BELOW MEDIAL + LATERAL MALLEOLI
VALVES
PHYSIOLOGY
VIS A TERGO—LV CONTRACTION
VIS A FONTE---R A CONTRACTION
FOOT MUSCLE PUMP
DEEP PLANTAR ARCH
SUPERFICIAL DORSAL ARCH
BOW STRING EFFECT - FLATTENS BOTH ARCHES EMPTYING
VEINS PRESSURE > 100mg OF Hg CONTRIBUTES > 50% BLOOD LEAVING CALF
Muscle Pump
CALF MUSCLE PUMP
–
200 – 300 mm OF Hg
–
>80 ml OF BLOOD Contractions propel blood towards heart Relaxation draws blood from - superficial veins - lower deep veins
Thoracoabdominal Pump
Inspiration decreases intrathoracic pressure promoting venous return Expiration reverses the process Findings easily seen in US
REFILLING THE PUMP
FROM ARTERIAL SYSTEM
FROM SUPERFICIAL VENOUS SYSTEM
PRESSURE IN ERECT POSTURE >100mg OF Hg
INTRAVENOUS PRESSURE IN SUPINE POSTURE SELDOM < 5mm OF Hg
REFILLING TIME 20-30 S
AMBULATORY VENOUS PRESSURE
RESIDUAL VENOUS PRESSURE
VIS –A-TERGO 0.3mm OF Hg
HYDROSTATIC PRESSURE 100mm OF Hg
AVP (MINIMUM PRESSURE. SHOWN DURING EXERCISE)
–
FALLS BY 60-80% IN FEW SECONDS.
IN CVI / CVH
VALVULAR INCOMPETENCE CONTINUED REFLUX INCREASED AVP DURING EXERCISE DUE TO INCOMPLETE EMPTYING DECREASED REFILLING TIME <10S INDEPENDENT(PRIVATE) CIRCULATION – BLOOD IN THE DEEP SYSTEM FLOWS UP IN THE DEEP SYSTEM FLOWS DOWN IN THE SAPHENOUS SYSTEM
PATHOPHYSIOLOGY OF MICROCIRCULATION CHANGES IN VENOUS HYPERTENSION PRIMARY VARICOSE VEINS DEEP VENOUS INSUFFICIENCY AMBULATORY VENOUS HYPERTENSION VENULAR AND CAPILLARY DILATATION DECREASED CAPILLARY PERFUSION PRESSURE INCREASED CAPILLARY PERMEABILITY CHRONIC LYMPHATIC DAMAGE DECREASED LYMPHATIC DRAINAGE
PATHOPHYSIOLOGY OF MICROCIRCULATION CHANGES IN VENOUS HYPERTENSION DECREASED LYMPHATIC DRAINAGE WBC TRAPPING, ADHESION, ACTIVATION IMPEDANCE OF MICROCIRCULATORY FLOW PLUS RELEASE FREE RADICALS, PROTEOLYTIC ENZYMES, CYTOKINES AND CHEMOTACTIC AGENTS MACROMOLECULES ENTER CIRCULATION PERICAPILLARY FIBRIN CUFF IMPAIRED TISSUE PERFUSION AND OXYGENATION VENOUS ULCERATION
CLINICAL EVALUATION
ASYMPTOMATIC
COSMETIC
SYMPTOMATIC
–
PAIN & SWELLING
–
COMPLICATION
SYMPTOMS
PAIN
– – – – – –
THROBBING ACHING STINGING BURNING EXERCISE – VARIABLE EFFECT ON PAIN NIGHT PAIN—CRAMPINESS
ITCHING SKIN CHANGES COMPLICATIONS EFFECTS OF PREVIOUS TREATMENTS.
Complications
EXTREMELY PAINFUL ULCERS - NEAR VARICOSE VEINS, PARTICULARLY NEAR THE ANKLES.
BROWNISH PIGMENTATION USUALLY PRECEDES THE DEVELOPMENT OF AN ULCER.
OCCASIONALLY, VEINS DEEP BECOME ENLARGED.
BLEEDING SUPERFICIAL THROMBOPHLEBITIS
PERSONAL HISTORY
PREGNANCY MENSTURAL CYCLE PELVIC CONGESTION SYNDROMES
–
(VULVOPUDENDAL VARICES ASSOCIATED WITH PELVIC & OVARIAN VARICES
PAST MEDICAL HISTORY
CONGESTIVE FAILURE
RENAL & CIRCULATORY FAILURE
AUTOIMMUNE DISEASES
ALLERGIC HISTORY
HOSPITALISATION AND IMMOBILISATION
STRONG FAMILIAL COMPONENT
Not well studied
Twin studies 75% identical, 52% non identical
If both parents VVS - 90% of children VVs
If one parent was affected 25 percent for men and 62 percent for women
Cornu-Thenard, A, Boivin, P, Baud, JM, et al. Importance of the familial factor in varicose disease. Clinical study of 134 families. J Dermatol Surg Oncol 1994; 20:318.
PHYSICAL EXAMINATIONS
STANDING POSITION
SKIN SHOULD BE INSPECTED,TAPPED, TOUCHED, PRESSED & SQUEEZED
EVALUATION FOR:
– –
COLOR TEMPERATURE
– –
TEXTURE TURGOR
– –
MOISTURE HAIR QUALITY
SKIN CHANGES
CORONAPHLEBECTATICA VENOUS ECZEMA BROWN HAEMOSIDERIN DEPOSITION ACUTE/CHRONIC LIPODERMATO SCLEROSIS INDURATION ATROPHIC BLANCHE OEDEMA VENOUS ULCERATION CONTRACTURES MARJOLINS ULCER
VARICOSITIES
SPIDER NAEVI—TELENGIECTASIA RETICULAR VEIN—VENULECTASIS TRUNCAL VARICOSITIES
CLINICAL TESTS
TO KNOW WHICH SYSTEM WHICH PERFORATOR PATENCY OF DEEP VEIN
TRENDELENBURG TEST I & II
SCHWARTZ TEST (CRUVHEILLIER’S SIGN)
MORISSEY’S COUGH IMPULSE
FEGAN’S METHOD. (PHALEN’S TEST)
PRATT’S TEST
THREE TOURNIQUET TEST ( Mahorne-ochsner )
PERTHE’S TEST
PHYSICAL EXAMINATION
ABDOMINAL PELVIC EXAMINATION.
AUSCULTATION.
CEAP CLASSIFICATION
CLINICAL
ETIOLOGIC
ANATOMIC
PATHOPHYSIOLOGIC
CLINICAL CLASSIFICATION
CO NO SIGN OF VENOUS DISEASE
C1 TELENGIECTASIA AND SPIDER VEINS
C2 VARICOSE VEINS
C3 EDEMA DUE TO VENOUS DISEASE
C4 SKIN CHANGES; LIPODERMATOSCLEROSIS
C5 HEALED ULCERS
C6 ACTIVE ULCERS
ETIOLOGIC
CONGENITAL
PRIMARY
SECONDARY
POST THROMBOTIC
POST TRAUMATIC
OTHERS EC EP ES
ANATOMIC SEGMENTS 18
SUP VEINS As
1. LSV
2. ABOVE KNEE
3. BELOW KNEE
4. SSV
5. NON SAPHENOUS DEEPVEIN Ad 6. IVC 16. MUSCULAR PERFORATING VEIN Ap 17. THIGH 18. CALF
PATHOPHYSIOLOGIC CLASSIFICATION
REFLUX
OBSTRUCTION Pr Po
REFLUX & OBSTRUCTION Pro
INVESTIGATIONS CONTINUOUS WAVE DOPPLER
TO ASSES FLOW DIRECTION
QUALITATIVE ASSESSMENT OF VENOUS REFLUX
DOES NOT GIVE ANY ANATOMIC INFORMATION.
USEFUL FOR EVALUATION OF REFLUX IN SFJ & SPJ
DUPLEX SCANNING
84% SENSITIVITY 88% SPECIVICITY DIRECT DETECTION OF VALVULAR REFLUX.
VISUALIZATION OF VALVE LEAFLET MOTION QUANTIFY DEGREE OF INCOMPETENCE
Duplex Ultrasonography
Replaced plethysmography and venography 7-10MHz linear transducer Exam sitting and standing Superficial and deep systems evaluated Physiologic reflux: < 0.5 sec Pathologic reflux: > 0.5 sec
PLETHYSMOGRAPHY
–
VOLUME CHANGE OF LIMB
–
SECONDARY TO CHANGES IN VENOUS BLOOD FLOW
PRESSURE MEASUREMENTS
–
TRANSMURAL PRESSURE
–
AMBULATORY VENOUS PRESSURE
—43-year-old woman with varicose veins.
©2008 by American Roentgen Ray Society
Lee W et al. AJR 2008;191:1186-1191
—43-year-old woman with varicose veins.
©2008 by American Roentgen Ray Society
Lee W et al. AJR 2008;191:1186-1191
INVASIVE PROCEDURES
1.
2.
3.
4.
ASCENDING PHLEBOGRAPHY DESCENDING PHLEBOGRAPHY CAVOGRAPHY VARICOGRAPHY
ASCENDING PHLEBOGRAPHY
GOLD STANDARD
ANATOMIC FEATURES OF THE VEINS AND THEIR VALVES ARE OUTLINED
POST THROMBOTIC CHANGES
PERFORATORS – INCOMPLETLY IDENTIFIED
DESCENDING PHLEBOGRAPHY
GRADE 0 NO EVIDENCE OF REFLUX
GRADE 1 MINIMAL REFLUX THRO 1 OR MORE VALVE
GRADE 2 CONSIDERABLE REFLUX IN THE THIGH
GRADE 3 GRADE 2 + LEAKAGE IN TO POPLITEAL VEIN
GRADE 4 GRADE 3 + LEAKAGE IN TO CALF VEIN.
VARICOSE VEINS MAYBE DUE TO
1) PRIMARY DISEASE OF LSV 2) 1 + PERFORATOR INCOMPETENCE 3) 2 + DEEP VEIN REFLUX DUE TO VALVULAR INCOMPETENCE 4) 2 + POSTTHROMBOTIC REFLUX OR OBSTRUCTION.
5) 4 + THROMBOTIC OCCLUSION OF ILIAC VEINS
TREATMENT OPTIONS
COMPRESSION THERAPY
PHARMACOTHERAPY
SCLEROTHERAPY
SURGICAL TREATMENT
SEPS (Subfascial Endoscopic Perforator Surgery)
LASER ABLATION
RADIOFREQUENCY ABLATION
COMPRESSION THERAPY
ELASTIC COMPRESSION - Bandage - Stockings – Class II
PASTE GAUZE (UNNA) BOOT
CIRC AID ORTHOSIS
INTERMITTENT PNEUMATIC COMPRESSION
COMPRESSION THERAPY
Action
1. HEMODYNAMIC EFFECT
Increase venous blood flow Decrease venous blood volume Reduce reflux in diseased superficial and/or deep veins Reduce a pathologically elevated venous pressure
2. EFFECT ON TISSUE
Reduce an elevated water content of the tissue Increase the drainage of nocious substances Reduce inflammation Sustain reparative processes Improve movement of tendons and joints
ELASTOCREPE BANDAGE GRADIENT COMPRESSION STOCKINGS Class I – 20–30(18-22) mmHg (Asymptomatic varicose) II – 30-40(23-32) mm Hg (Symptomatic varicose) III - 40–50(34-40) mm Hg ( For IV - 50 – 60 mm Hg Lymph Edema) INTERMITTENT PNEUMATIC COMPRESSION NEW LEGGING ORTHOSIS (CIRC – AID) UNNA BOOT
PHARMACOLOGIC THERAPY
DIURETICS – limited use
ZINC
FIBRINOLYTIC AGENTS
STANOZOLOL – Androgenic steroid
OXYPENTIPHYLLINE – Cytokine Antagonist
PHLEBOTROPHIC AGENTS
–
HYDROXY-RUTOSIDES
CALCIUM DOBESILATE
TROXERUTIN
PHARMACOLOGIC THERAPY
HAEMORRHEOLOGIC AGENTS
PENTOXIPHYLLINE
ASPIRIN
FREE RADICAL SCAVENGERS
TOPICAL ALLOPURINOL
DIMETHYL SULFOXIDE
PROSTAGLANDINS
PROSTAGLANDIN E
PROSTAGLANDIN F
PHARMACOTHERAPY
TOPICAL THERAPIES
–
ANTIBIOTICS
Application counter-productive
– – – –
IODOSORB KETANSERINE AMNION OCCLUSIVE DRESSINGS GROWTH FACTORS AND CYTOKINES SKIN SUBSTITUTES
–
APLIGRAFT
SCLEROTHERAPY
THE LOWEST APPROPRIATE CONCENTRATION AND VOLUME OF SOLUTION AT THE SLOWEST RATE AND LOWEST PRESSURE CAN MINIMISE COMPLICATIONS
SCLEROSANTS
DETERGENT SOLUTIONS
SODIUM TETRADECYL SULFATE POLIDACANOL SODIUM MORRHUATE ETHANOLAMINE OLEATE OSMOTIC SOLUTIONS
HYPERTONIC SALINE HYPERTONIC SALINE AND DEXTROSE SODIUM SALICYLATE CHEMICAL IRRITANTS
POLYIODINATED IODINE CHROMATED GYLCERINE
Microsclerotherapy
30 g butterfly needle
0.2% STS
Several courses required benefit compression
FOAM SCLEROTHERAPY
TESSARI TECHNIQUE 1 PART (2ml) DETERRGENT & 4 PARTS AIR (8ml) AIR AGITTATED USING TWO 10 ml SYRIGES, CONNECTED BY A 2/3 WAY CONNECTOR
SURGICAL TREATMNET
GOAL:
PERMANENT REMOVAL OF VARICOSITIES WITH THE SOURCE OF VENOUS HYPERTENSION
AS COSMETIC A RESULT AS POSSIBLE
MINIMUM NUMBER OF COMPLICATIONS
SAPHENOUS VEIN LIGATION
INCISION 1 CM ABOVE VISIBLE SKIN CREASE
TO DRAW EACH OF THE TRIBUTARIES INTO THE INCISION INORDER NOT TO LEAVE INTER ANASTOMOSING INGUINAL TRIBUTARIES BEHIND TO AVOID EXTRAVASATION OF BLOOD SUBCUTANEOUSLY TO INTRODUCE STRIPPER FROM ABOVE
DAMAGED VALVES ALLOW PASSAGE STAB AVULSION TO BE DONE BEFORE STRIPPING
SAPHENOUS VEIN LIGATION – GROIN INCISION
SAPHENOUS VEIN LIGATION
LSV
SHORT SAPHENOUS VEIN
TO MARK TERMINATION IMMEDIATE PREOPERATIVELY
PRONE POSITION
POPLITEAL SPACE RELAXED BY KNEE FLEXION
SURAL N. IDENTIFIED AND PRESERVED
STRIPPING LIMITED TO PROXIMAL LESSER SAPHENOUS VEIN ABOVE MID-CALF
PERFORATOR VEIN INCOMPETENCE
LINTON’S RADICAL OPERATION SUBFASCIAL LIGATION
–
INCISION
– – –
LONG MEDIAL ANTEROLATERAL POSTEROLATERAL CALF INCISIONS
COCKETT SUPRAFASCIAL LIGATION
DEPALMA
– –
MULTIPLE PARALLEL BIPEDICLED FLAPS LIGATION OF VEINS ABOVE OR BELOW THE FASCIA
SEPS
– –
SINGLE PORT TO VIEW AND WORK TWO PORTS – ONE TO VIEW; ANOTHER TO WORK
LINTON’S RADICAL OPERATION SUBFASCIAL LIGATION
Sural N.
Perforator V.
MODIFIED LINTON’S PROCDURE
TO AVULSE THE INCOMPETENT PERFORATORS UNDER DUPLEX GUIDANCE
SEPS
ABLATIVE PROCEDURES
ENDO VENOUS THERMO ABLATION - LASER - RADIO - FREQUENCY
ENDOVENOUS LASER SURGERY
ENDOLUMINAL OBLITERATION BY HEAT - INDUCED COLLAGEN CONTRACTION & DENUDATION OF ENDOTHELIUM - FIBROSIS 810 nm DIODE LASER ENERGY TUMUSCENT ANAESTHESIA ADVANTAGE NO GROIN DISSECTION NO NEOVASCULARISATION 1470 nm DIODE LASER
EVLT – E ndo v enous L aser T reatment
RADIOFREQUENCY ABLATION
RADIOFREQUENCY INDUCED THERMO THRAPY (RFiTT)
RADIOFREQUENCY ABVLATION
SEGMENTAL ABLATION
SURGERY FOR DEEP VEIN VALVE INCOMPETENCE
VALVE RECONSTRUCTION
INTERNAL VALVULOPLASTY
EXTERNAL AND TRANSCOMMISURAL VALVULOPLASTY
ANGIOSCOPIC VALVULOPLASTY
PROSTHETIC SLEEVE IN SITU
AXILLARY VEIN TRANSFER
SURGERY FOR CHRONIC VENOUS HYPERTENSION
SAPHENO POPLITEAL BYPASS
MAY HUSNI OPERATION
CROSS PUBIC VENOUS BYPASS
PALMA DALE PROCEDURE
CONTRALATERAL SAPHENOUS VEIN IS USED
PROSTHETIC FEMOROCAVAL, ILIOCAVAL OR IVC BYPASS
ILIAC VEIN DECOMPRESSION
CAVOATRIAL BYPASS
ENDOVENOUS
ANGIOPLASTY AND STENTING OF STENOSED / OCCLUDED THROMBOSED ILIAC VEIN (MEY THURNER’S SYNDROME)
CORRECTION OF CONGENITAL WEBS