 dr M.

Arman Nasution SpPD

 Ranjith.R.Thampi
Intern
Department of General Surgery
 “Varicosity is the penalty for verticality against
gravity”
In man, owing to his upright posture, blood has to
flow from lower limbs to heart against gravity.

Defined as Dilated, Tortuous and Elongated

superficial veins of the lower limb.
1. Superficial System
-Long saphenous
vein
-Short saphenous
vein
plus their tributaries
2. Perforators
3. Deep System of veins
There are about 5 constant
perforators in the lower limb on
medial side which include:

-Ankle Perforators(Cockett) 3 in
number (all related to medial
malleolus)
-Knee Perforator(Boyd)
-Thigh Perforator(Dodd)
Blood flows in the leg because it is pumped by the
heart along the arteries. By the time it emerges from
the capillaries, it is at a low pressure, but it is
enough to return blood to the heart.

Factors helping blood return to heart include:

-Calf muscle pump
-Competent valves
-Vis-a-tergo
-Negative intrathoracic pressure
-Venae comitantes
 Clinical- 0-6 grades

 Etiologic-
congenital, primary,
secondary

 Anatomic- superficial, perforator,

deep

 Pathophysiologic- reflux,
obstruction, both
 CONGENITAL

 PRIMARY

 SECONDARY
 Abnormality present since birth
 Also due to muscular weakness or
congenital absence of valves
 SYNDROME-
Klippel Trenuanay Syndrome
(Valveless syndrome)- Complete absence
of valves in superficial and deep veins
 GENETIC- Abnormalities in the FOXC2
gene
 Venous dysfunction due to undetermined
cause

 May be result of congenital weakness in the

vein wall due to defective connective tissue
and smooth muscle.

 Concomitant factors prolonged standing

(occupational)
 Seen in people with an associated known cause
- Post Thrombotic, Post Traumatic, etc.

 In
women, Pregnancy, Pelvic tumours, OC Pills,
Progesterone intake

 Congenital AV fistula

 DVT secondary to RTAs or Post-op can result in

destruction of valves resulting in varicose veins
 Blood from the leg muscles returns through deep
veins.

 Blood from skin and superficial tissues, external

to deep fascia, drains via the long and short
saphenous veins and communicating veins into
deep veins.

*Valves prevent flow of blood from the deep to the superficial

system
 On standing, blood continues to circulate even
in the absence of muscle activity.

 Onwalking and on exercising, foot pump and

muscle pump come into play and maintain
venous return
 The first source is hydrostatic pressure due to
gravity, a result of venous blood coursing in a
distal direction.
It is the weight of the blood column from the right
atrium
 The second source of venous hypertension is
dynamic. It is the force of muscular contraction,
usually contained within the compartments of the
leg
 If a perforating vein fails, high pressures of 150-
200 mm Hg developed within the muscular
compartments during exercise are transmitted
directly to the superficial venous system
Symptoms:
 Patient with symptomatic varicose veins
commonly has heaviness, discomfort, and
extremity fatigue
 Associated with Dragging pain, Night cramps,
Eczema, Dermatitis, Pruritis, Ulceration,
Bleeding
 Pain is characteristically dull, and is
exacerbated in the afternoon, especially after
periods of prolonged standing
 The symptoms are relieved by leg elevation
or elastic support
 Females complain of symptom exacerbation
during the early days of the menstrual cycle
1. Visible dilated veins in the leg with/ without
blow outs

2. Ankle flare, Pedal edema, pigmentation,

dermatitis, ulceration, tenderness, restricted
ankle joint movement.

3. Thickening of tibia due to periostitis

4. Positive cough impulse at the sapheno-femoral

junction
5. Brodie-Trendelenburg test: Vein is emptied by
elevating the limb and a tourniquet is tied just
below the sapheno-femoral junction (or using
thumb, sapheno-femoral junction is occuluded).
Patient is asked to stand quickly. When tourniquet or
thumb is released, rapid filling from above signifies
sapheno- femoral incompetence. This is
Trendelenburg test I
In Trendelenburg test II, after standing tourniquet
is not released. Filling of blood from below upwards
rapidly can be observed within 30-60 seconds. It
signifies perforator incompetence.
6. Perthe’s test: The affected lower limb is wrapped with
elastic bandage and the patient is asked to walk around
and exercise. Development of severe cramp like pain in
the calf signifies DVT.
7. Modified Perth’s test: Tourniquet is tied just
below the sapheno – femoral junction without
emptying the vein. Patients is allowed to have a
brisk walk which precipitates bursting pain in
the calf and also makes superficial veins more
prominent. It signifies DVT. DVT is
contraindicated for any surgical intervention of
superficial varicose veins. It is also
contraindicated for sclerosant therapy.
8. Three tourniquet test: To find out the site of
incompetent perforator, three tourniquets are
tied after emptying the vein.
1. at sapheno- femoarl junction
2. above knee level
3. another below knee level.
Patient is asked to stand and looked for filling
of veins and site of filling. Then tourniquets are
released from below upwards, again to see for
incompetent perforators
9. Schwartz test: In standing position, when
lower part of the long saphenous vein in leg
is tapped, impulse is felt at the saphenous
junction or at the upper end of the visible
part of the vein. It signifies continuous
column of blood due to valvular
incompetence.

10. Pratt’s test: Esmarch bandage is applied to

the leg from below upwards followed by a
tourniquet at sapheno – femoral junction.
After that the bandage is released keeping
the tourniquet in the same position to see
the “blow outs” as perforators.
11. Morrissey’s cough impulse test: The varicose veins
are emptied. The leg is elevated and then the
patient is asked to cough. If there is sapheno-
femoral incompetence, expansile impulse is felt at
saphenous opening.

12. Fegan’s test: On standing, the site where the

perforators enter the deep fascia bulges and this is
marked. Then on lying down, button like
depression in the deep fascia is felt at the marked
out points which confirms the perforator site.

13. Ian- Aird test: On standing, proximal segment of

long saphenous vein is emptied with two fingers.
Pressure from proximal finger is released to see the
rapid filling from above which confirms sapheno –
femoral incompetence.
 System involved- LSV/SSV
 SFJ incompetent? Yes- T1 +/ No- T1 –
 Perforator incompetence? Yes- T2 +/ No- T2
–
 Group of perforators incompetent?-MTT
 Is there DVT? Yes- Perthes’ +/ No- Perthes’ –
 Any abdominal mass? Pelvic pathology/
tumors
 Any complications? – Eczema/ Dermatitis/
Ulcer
 Unilateral or Bilateral?
 THOROUGH HISTORY
 BRODIE TRENDELENBERG TEST
 TOURNIQUET TEST
 ASSESS SKIN CHANGES
 PERIPHERAL PULSES
 ABDOMINAL EXAMINATION
 DOPPLER ULTRASOUND
 DUPLEX ULTRASOUND
 VENOGRAPHY
Duplex Scan
1. Conservative
2. Injection line of treatment
3. Foam Sclerotherapy
4. Surgery
 Limb Elevation + Elastic compression
bandage
 Elastic compression stockings
 Unna Boot
Unna Boot- Gauze impregnated with a thick,
creamy mixture of zinc oxide and calamine
to promote healing. It may also contain
acacia, glycerin, castor oil and white
petrolatum
Indicated in Below knee varicosity and
recurrent varicosity after surgery
Complications:
Allergy, pigmentation, DVT,
Thrombophlebitis, Skin
necrosis
Sodium tetradecyl sulfate 1.5–
3.0%
Polidocanol 3–5%
Polyiodinated iodine 2–12%
Sodium morrhuate 5%
Hypertonic saline 11.7 – 23.4%
Chromated glycerin 50%
 Foam sclerosant C
(Polidocanol) used in few
centres in the UK
Air mixed with sclerosant
and injected into veins by
US image
Complications:
-Extravasation: Skin
ulceration
-Escape into deep veins:
DVT
-Entering brain: Stroke,
Headache
I. Trendelenburg’s Operation

II. Subfascial ligation of Cockett and Dodd

III. Subfascial endoscopic perforator

surgery(SEPS)
a. Trendelenburg operation: It is a juxta
femoral flush ligation of long saphenous vein
(i.e. flush with femoral vein), after ligating
named (superficial circumflex, superficial
external pudendal, superficial epigastric vein)
and unnamed tributaries. All tributaries should
be ligated, otherwise recurrence will occur.
b. Stripping of vein: Using Myer’s stripper vein
is stripped off. Stripping from below upwards
is technically easier. Immediate application of
crepe bandage reduces the chance of
bleeding and haematoma formation.
Complication is injury to saphenous
nerve causing saphenous neuralgia.
Stripping is not usually done for the veins in the
lower part of the leg.
Stripping of the vein is more effective.
‘Inverting or invaginating stripping’ using rigid
Oesch pin stripper is better as postoperative
pain and haematoma is less common and also
there is tissue damage. Vein should be very
firmly fixed to the end of the stripper and pulled
out to cause the inverting of the vein.
Stripping of short saphenous vein is more
beneficial than just ligation at sapheno popliteal
junction. It is done from above downwards using
a rigid stripper to avoid injury to sural nerve.
Perforators are marked out by Fegan’s
method. Perforators are ligated deep to
the deep fascia through incisions in
antero medial side of the leg.
 Video techniques that allow direct visualization
through small-diameter scopes have made
endoscopic subfascial exploration and perforator
vein interruption possible
 Minimal morbidity and wound complications
 The connective tissue between the fascia cruris and
the underlying flexor muscles is so loose that this
potential space can be opened up easily and
dissected with the endoscope
 This operation, done with a vertical proximal
incision, accomplishes the objective of perforator
vein interruption on an outpatient basis
 VNUS closure- Ablation catheter
Complications: DVT, recurrence, damage to
overlying skin
 TriVex
Complications: Induration, Bruising,
Subcutaneous grooves
 Radiofrequency ablation- Metal prongs
 Endovenous laser ablation- Laser probe
 Also known as endovenous
radiofrequency ablation, it is a minimally-
invasive procedure used to treat the great
saphenous vein (GSV), small saphenous
vein (SSV) and other superficial veins. It
uses a patented radiofrequency catheter
inserted into the vein, which applies RF
energy to heat the vein. This causes the
vein to collapse and seal shut.
VNUS closure
Involves a novel technique called transilluminated powered
phlebectomy. While most varicose vein surgery is done
without directly visualizing the varicose veins, the TRIVEX
system transilluminates the veins requiring removal via
advanced fiberoptic technology (much like a flashlight can
shine through your skin).
Once the surgeon has visually confirmed the location of the
diseased varicose vein(s), a local anesthetic is delivered
under pressure into the area. A powered vein resector is
then guided next to the vein and suction is used to draw up
and remove the vein (much like ‘liposuction’). This
varicose vein treatment allows accurate removal of large
clusters of varicose veins with a minimal number of
incisions.
 Disadvantages:
It may cause bruising,
grooves, skin
induration.
i. Eczema & Dermatitis
ii. Lipodermatosclerosis
iii. Haemorrhage
iv. Thrombophlebitis
v. Venous Ulcer- Fibrin cuff hypothesis &
White cell trapping hypothesis
vi. Calcification
vii. Periostitis
viii. Equinovarus deformity
ix. Marjolin’s ulcer
Marjolin’s Ulcer
 Doctors at the China Rehabilitation Research Centre in
Beijing have developed an egg cup-like casing for a miracle
survivor who was cut in half in a freak accident back in 1995.
It took 20 doctors to save his life and nobody thought he'd be
able to do anything again, but when doctors at the CRRC
heard about his case, they created these robotic legs for him.
thrombophlebitis
 Nursing assumed the role of intravenous
therapy in the 1940’s
 Application of the nursing process is
critical in the prevention of complications
 90% of hospitalized patients receive IV
fluids and medications
 Classified according to their location
• Local complication: at or near the insertions site
or as a result of mechanical failure
• Systemic complications: occur within the vascular
system, remote from the IV site. Can be serious
and life threatening
 Occur as adverse reactions or trauma to the
surrounding venipuncture site
 Assessing and monitoring are the key
components to early intervention
 Good venipuncture technique is the main factor
related to the prevention of most local
complications associated with IV Therapy.
 Local complications include: hematoma,
thrombosis, phlebitis, postinfusion phlebitis,
thrombophlebitis, infiltration, extravasation,
local infection, and veno spasm.
 Hematoma and ecchymosis demote
formations resulting from the infiltration
of blood into the tissues at the
venipuncture site
• Related to venipuncture technique
• Use of large bore cannula: Trauma to the vein
during insertion
• Patients receiving anticoagulant therapy and
long term steroids
 Subcutaneous hematoma is the most common
complication
 Can be a starting point for other complications:
thrombophlebitis and infection
 Related to:
• Nicking the vein
• Discontinuing the IV without apply adequate
pressure
• Applying the tourniquet to tightly above a priviously
attempted venipuncture site.
 Signs and symptoms:
• Discoloration of the skin
• Site swelling and discomfort
• Inability to advance the cannula all the way into
the vein during insertion
• Resistance to positive pressure during the lock
flushing procedure
 Use of an indirect method
 Apply tourniquet just before
venipuncture
 Use a small need in the elderly and
patients on steriods, or patients with thin
skin.
 Use blood pressure cuff to apply pressure
 Be gentle
 Apply direct, light pressure for 2-3
minutes after needle removed
 Have patient elevate extremity
 Apply Ice

 Document
 Catheter-related obsturctions can be
mechanical or non-thrombotic
 Trauma to the endothelial cells of the
venous wall causes red blood cells to
adhere to the vein wall, forms a clot or
Thrombosis
 Drip rate slows, line does not flush easily,
resistance is felt
 Never forcible flush a catheter
 Persistent withdrawal occlusion
 Partial occlusion
 Complete occlusion
 Fibrin tail
 Fibrin sheath
 Mural thrombosis
 Intaluminal thrombus Fibrin Flap

“Reopen the Pipeline”, Hadaway C, Nursing. 2005, 35(8)

Total Occlusion
Probable cause: Intraluminal thrombus Symptom:
Unable to infuse or aspirate

Partial Occlusion
Probable cause: Fibrin flap
“Reopen the Pipeline”, Hadaway C, Nursing. 2005,
Symptom: Unable to aspirate
35(8)
 Thrombosis related to:
• Hypertensive pt; blood backing up
• Low flow rate
• Location of the IV cannula
• Compression of the IV line for an extended
period of time
• Trauma to the wall of the vein
 Signs and Symptoms
• Fever and Malaise
• Slowed or stopped infusion rate
• Inability to flush
 Prevention
• Use pumps and controllers to manage flow rate
• Microdrip tubing for rate below50mL/hr
• Avoid areas of flexion
• Use filters
• Avoid lower extremeties
 Treatment
• Never flush a cannula to remove an occlusion
• Discontunue the cannula
• Notify the physician and assess the site for
circulatory impairment

 Document
 Inflammation of the vein in which the
endothelial cells of the venous wall
become irritated and cells roughen,
allowing platelets to adhere and
predispose the vein to inflamation-
induced phlebitis
• Tender to touch and can be very painful
 Mechanical:
• To large a catheter for the size of the vein
• Manipulation of the catheter: improper stabilization
 Chemical: vein becomes inflamed by irritating
or vessicant solutions or medication
• Irritation medication or solution
• Improperly mixed or diluted
• Too-rapid infusion
• Presence of particulate matter
 Chemical (cont):
• The more acidic the IV solution the greater the
risk
• Additives: Potassium
• Type of material
• Length of dwell:
 30% by day 2, 39-40% by day 3 (Macki and Ringer)
• The slower the rate of infusion the less irritation
 Also called Septic phlebitis: least common
 Inflammation of the intima of the vein
 Contributing factors
• Poor aseptic technique
• Failure to detect breaks in the integrity of the
equipment
• Poor insertion technique
• Inadequate stabilization
• Failure to perform site assessment
• Aseptic preparation of solutions
• Hand washing and preparing the skin
 Inflamation of the vein 48-96 hr after
discontinued
 Factors that contribute:
• Insertion technique
• Condition of the vein used
• Type, compatibility, pH of solution used
• Gauge, size, length, and material
• Dwell time
• Infrequent dressing change
• Host factors: age, gender, age and presence of
disease
 Immune system causes leukocytes to
gather at the inflamed site
 Pyrogens stimulate the hypothalamus to
raise body temperature
 Pyrogens stimulate bone marrow to
release more leukocytes
 Redness and tenderness increase
 Signs and Symptoms
• Redness at the site
• Site warm to touch
• Local swelling
• Palpable cord along the vein
• Sluggish infusion rate
• Increase in basal temperature of 1degree C or more
 Prevention
• Use larger veins for hypertonic solutions
• Central lines for Infusions lasting longer than 5 days
0 – No clinical symptoms
 1- Erythema at access site with or without pain
 2- Pain at access site, with erythema and / or
edema
 3- Pain at access site with erythema and / or
edema, streak formation, and palpable venous
cord
 4- Pain at access site with erythema and / or
edema, streak formation, palpable venous cord
> 1 inch, purulent drainage
 Thrombophlebitis denotes a twofold
injury: thrombosis and inflammation
 Related to:
• Use of veins in the lower extremity
• Use of hypertonic or highly acidic infusion
solutions
• Causes similar to those leading to phlebitis
 Signs and Symptoms
• Sluggish flow rate
• Edema in the limbs
• Tender and cord like vein
• Site warm to the touch
• Visible red line above venipuncture site
• Diminished arterial pulses
• Mottling and cyanosis of the extremities
 Prevention
• Use veins in the forearm rather than the hands
• Do not use veins in a joint
• Assess site q 4 hr in adults, q 2 hr in children
• Catheter securment
• Infuse at rate prescribed
• Use the smallest size catheter to do the job
• Proper dilution
 Septic
thrombophlebits can be
prevented:
• Appropriate skin preparation
• Aseptic technique in the maintance of infusion
• Proper hand hygiene
 60% from patients skin
 35% from the line itself
 5% from hands
 The inadvertent administration of a non-
vesicant solution into surrounding tissue
 Dislodgment of the catheter from the vein
 Second to phlebitis as a cuase of IV
therapy morbidity
 Related to:
• Puncture of the distal vein wall during access
• Puncture of the vein wall by mechanical friction
• Dislodgement of the catheter from the intima of
the vien
• Poor securment
• High delivery rate
• Overmanipulation
 Signs and Symptoms
• Coolness of the skin around site
• Taut skin
• Dependent edema
• Absence of blood return
• “Pinkish” blood return
• Infusion rate slows
 Complications fall into 3 catagories
• Ulceration and possible tissue necrosis
• Compartment syndrome
• Reflex sympathetic dystrophy syndrome
 Inadvertent administration of a vesicant
solution into surrounding tissue
• Vesicant is a fluid or medication that causes the
formation of blisters, with subsequent sloughing
of tissues occurring from the tissue necrosis
 Extravasations related to:
• Puncture of the distal wall
• Mechanical friction
• Dislodgement of the catheter
 Phenergan pH is 4 to 5.5
 Dilantin pH is 12 (Drano has a pH of 14)
 High concentration KCL pH is 5 to 7.8
 Calcium gluconate pH is 6.2
 Amphotericin B pH is 5.7 to 8
 Dopamine pH is 2.5 to 5
 Nipride pH is 3.5 to 6
 10%, 20% or 50% dextrose pH is 3.5 to 6.5
 Sodium bicarbonate pH is 7 to 8.5
 Signs and Symptoms
• Complaints of pain or burning
• Swelling proximal to or distal to the IV site
• Puffiness of the dependent part of the limb
• Skin tightness at the veinpuncture site
• Blanching and coolness of the skin
• Slow or stopped infusion
• Damp or wet dressing
 Prevention:
• Use of skilled practitioners
• Knowledge of vesicants
• Condition of the patients veins
• Drug administration technique
 If continuous give in CVAD
 Only with brisk blood return of 3-5 cc
 Use of a free flow IV
 Do not use a pump on vesicants given peripherally
 Assess for blood return frequently
 Prevention (cont)
• Site of venous access
• Condition of the patient
 Vomiting, coughing, retchin
 Sedated
 Unable to communicate

• Treatment
 Local infection:
• Microbial contamination of the cannula or the
infusate
• Thrombus becomes infected
 Venous Spasm: a sudden involuntary
contraction of a vein or an artery
resulting in temporary cessation of blood
flow through a vessel
 Central Venous Access Devices
 Ass wr wb