Varicose Veins Of Lower Limb

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 Venous System of Lower Leg
Superficial Veins Deep Veins
 Great saphenous vein Femoral vein
 Superficial inguinal veins Profunda femoris vein
Medial circumflex femoral
 External pudendal vein
Lateral circumflex femoral
 Superficial circumflex vein Perforating veins
 Superficial epigastric vein Sciatic vein
 Accessory saphenous vein Popliteal vein

 Small saphenous vein Sural veins

 Dorsal venous arch
 Plantar venous arch
 Lateral marginal vein
 Medial marginal vein
Soleal veins
Gastrocnemius veins
Genicular venous plexus
Tibial veins
Fibular or peroneal veins
 Superficial Veins Of Leg
Superficial Epigastric
External Iliac Vein
Superficial External
Pudendal
Femoral Great Saphenous
vein Hunter’s Perforator

Boyd’s
Dodd’s Perforator
Perforator

“24 cm” Perforator Cockett’s Perforator

May & Kuster
Perforator
Medial marginal
Greater Saphenous Vein
The greater
saphenous vein,
in close
proximity to the
saphenous
nerve, ascends
anterior to the
medial malleolus.
 Great Saphenous Vein

In the leg & thigh

region, it crosses,
and then ascends
medial to the knee.
 Great Saphenous Vein
Ascends in the
superficial
compartment
and empties into
the common
femoral vein
after entering
the fossa ovalis.
 Varicose Veins - Definition
Dilated, tortuous and
elongated veins.
Veins of lower limbs,
spermatic, esophageal
& haemorrhoidal
show tendency for
varicosity.
 Etiology
Risk Factors:
1. Age > 50 years
2. Female sex hormones
3. Heredity
4. Gravitational hydro stasis
5. Muscular hydrodynamics
 Etiology
Primary: Secondary:
Cause not known. 1. Obstruction to venous
outflow.
• Valves may be
Pregnancy
incompetent.
Fibroid
• Very rarely Ovarian cyst
valves may be Lymphadenopathy
congenitally Ascites
absent. Retroperitoneal
fibrosis
 Etiology
2. Destruction of valves. 3. High pressure flow.

Usually follows Arteriovenous

Deep Vein fistula ( Parks-
Thrombosis Weber Syndrome)
Venous
malformation
(Klippel-Trenaunay
Syndrome )
 Clinical Features
Morphologically:
1. Large vein varicosity
•Affecting Saphenous
veins or their tributaries
•Large in diameter (5 to
15 mm)
•Usually symptomatic
 Clinical Features
2. Tiny veins varicosity
a) Reticular Veins:
Lying immediately beneath
the skin (1-3 mm diameter)

b) Thread veins :
Dilated skin vessels (0.5 mm)
Also called Dermal flares
 Normal Venous Dynamics
Resting upright During muscle
With muscle relaxation
position contraction

Deep veins squeezed pushing blood Blood in deep veins can’t reflux
Blood flowing slowly
upwards, without reflux due to due to valve closure & blood is
from below upwards competent valves sucked from superficial veins
 Venous Flow Dynamics in
Varicose Veins
Upright position Muscle contraction Muscle relaxation

Sluggish flow in normal

Venous reflux into Superficial
direction but valves are Deep veins empty upwards veins due to incompetent valves
incompetent
 Pathogenesis
 Varicose veins permit reverse flow through
it’s incompetent valves.
 This reflux adds extra work on veno-
muscular pump.
 As long as veno-muscular pump copes with
this extra work, patient remains
asymptomatic.
 Symptoms start only when pump fails to
cope extra work.
 Clinical Features
Common features:
1.Cosmetic disfigurement
2.Heaviness
3.Limb fatigue
4.Pain
 Clinical Features
Pain
 Dull aching, continuous
 More towards end of the day
 Relieved by leg elevation
 Bursting calf pain during walking,
called, venous claudication
 Clinical Features
Rare features:
1. Pigmentation

2. Itching & Eczema

3. Venous ulcer

4. Lipodermatosclerosis
 Clinical Features
Past History:
I. Operation for Varicose veins
II. Injection treatment
III. Serious illness
IV. Complicated surgery
V. Deep vein thrombosis
 Clinical Features
On Examination:
• Phlegmasia alba dolens – White leg
• Phlegmasia cerulea dolens – Blue leg
• Eczema, pigmentation, scars, ulcers
• Saphena varix – Impulse on coughing
 Clinical Features
Trendelenberg’s test
Localize the Elevate the Apply the
site of patients tourniquet
saphenous limb & below the
opening: empty the saphenous
4cm below & L.L. veins opening
lateral to the
pubic tubercle
2 3
As the patient stands, the The site of
V.V. fill rapidly from above.
incompetent
This means that the perforator is
incompetent connection
between the deep & suspected by a
superficial system is NOT palpable fascial
the sap-fem junction (which defect, multiple
4 is controlled by the tourniquet),
tourniquet &
but it is below it.
confirmed by
5 Duplex
 Classification of Chronic Lower
Extremity Venous Disease

C Clinical signs (grade0-6)

E Etiologic classification

A Anatomic distribution
P Pathophysiologic dysfunction
 Classification of Chronic Lower
Extremity Venous Disease
C Clinical Classification
Grade 0 No visible or palpable signs of venous disease
Grade 1 Telangiectasia, reticular veins, malleolar flare
Grade 2 Varicose veins
Grade 3 Edema without skin changes
Grade 4 Skin changes ascribed to venous disease (e.g., pigmentation, venous
eczema, lipodermatosclerosis)
Grade 5 Skin changes as defined above with healed ulceration

Grade 6 Skin changes as defined above with active ulceration

 Classification of Chronic Lower
Extremity Venous Disease
E Etiologic
Classification
Present at birth but may not be
Congenital
recognized
Unknown cause, but not Congenital
Primary

Associated known cause ( post-

Secondary
thrombotic, post-traumatic )
Classification of Chronic Lower
Extremity Venous Disease

A Anatomic Classification

A(S) Superficial Veins

A(D) Deep Veins

A(P) Perforating Veins

 Classification of Chronic Lower
Extremity Venous Disease
P Pathophysiologic Classification

P(R) Reflux

P(O) Obstruction

P(R,O) Reflux & Obstruction

 Complications
1.Thrombosis or Superficial
Thrombophlebitis
2.Hemorrhages
3.Ulceration
4.Malignancy (Marjolin’s)
5.Calcification
6.Periostitis
 Investigations
 Clinical Tests
 Doppler Study
 Duplex study
 Plethysmography
 Venography
 Treatment
Indications
1. Pain
2. Easy fatigability
3. Heaviness
4. Recurrent Superficial Thrombophlebitis
5. Bleeding
6. Cosmetic
 Treatment
 Aim is to overcome venous
congestion
 Improving muscle pump by
regular exercise can
overcome venous
hypertension
 Compression Stockings
Compression stockings
supports varicose veins
abolishing the effect of venous
reflux
They are especially suitable
to control deep venous reflux
and secondary varicose
veins
Available in 3 Grades
 Injection Sclerotherapy
•Cosmetic for
reticular veins
•For residual varices
after surgery
Should be given in an empty vein
and compressed immediately
afterwards.
 Surgery
 Trendelenburg’s operation
 Sub-fascial ligation of Cockett’s & Dodd’s
 Sub-fascial Endoscopic Perforator Surgery (SEPS)
 VNUS Closure
 TriVex

 Radiofrequency ablation
 Endovenous laser ablation
 Trendelenburg’s Procedure
 High juxta-femoral flush ligation of the
saphenous vein with division of ALL the groin
tributaries, with or without saphenous vein
stripping in the thigh is classically done for
documented sapheno-femoral reflux

 Recurrence rates are higher with ligation

alone.
 Vein stripping below the knee is not needed
(it is not varicosed, not connected to perforators
and may cause saphenous nerve injury)
 SEPS
 Small port incisions are made

 Carbon dioxide insufflation done

 2-6 perforators identified & ligated

 Indication: Below knee perforators

 Newer Techniques
VNUS Closure
Ultrasound guided ablation catheter introduced
into Sapheno-femoral junction & slowly
withdrawn
Low incidence of Hematoma & Pain
TriVex
Veins identified by subcutaneous illumination
Injection of large volume of fluids
Superficial veins are sucked out
Thank You  
For your kind attention 