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

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

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

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

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

11. Aetiology Congenital Congenital Primary (Idiopathic) 95% Primary (Idiopathic) 95% Congenital incompetence of valves &/or weakness of muscular coat Secondary5% Secondary5%

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

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

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

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

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

21. Clinical tests 1. Identify system I. Observation II. Tap test ( Schwartz test) 2. Incompetent perforator/valves I. Cough impulse – SFI II. Trendelenberg test – SFI,SPI,Perforators 3. Patency of deep veins I. Perthes’ test  “Historical” --- replaced with Doppler

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

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

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

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

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

27. Indications Cosmetic Cosmetic NHS guidelines NHS guidelines 1. Symptoms 2. Complications/prevention of complications

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

29. Symptomatic treatment - Methods 1. Postural drainage 2. Exercise 3. Support

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

32. Obliteration of venous lumen - Methods 1. Sclerotherapy 2. Form injections 3. Laser 4. Radiofrequency

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

36. Surgical Options 1. Ligation 2. Ligation & stripping 3. Ligation, stripping & BK multiple avulsions

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

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