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varicose veins a case presentation dr ayesha.pptx
- 1. CASE PRESENTATION DR AYESHA QASEEM PGR - S1
- 2. PATIENT PROFILE NAME: M. ILYAS AGE: 34YRS RESIDANT OF LAHORE MILKMAN BY PROFESSION
- 3. Presented in OPD with complain of: Prominent veins on both legs for 3 years Swelling and pain in the lower limbs for 1 year Ulcer on the right lower limb for 1 month
- 4. HOPI According to the patient , he started noticing prominent veins in his lower limbs 3-4 years back, more on the right side.The veins gradually became more dilated , especially after prolonged standing. He also complained of pain and swelling in both limbs for 1 year.The pain was gradual in onset, and progressive in nature.The patient described a dragging feeling which worsens when the patient stands for a long time and relieves after rest.The pain is non-radiating and not relieved with pain killers. He also presented with an ulcer on the right lower limb for 1 month. It occurred spontaneously and initially was small in size.The size increased with time.There was no history of trauma. There is also complain of itching over the lower limb
- 5. There is no history of constipation, chronic cough, pain abdomen or fever. His bowel and bladder habits are regular. No history suggestive of DVT in the past. No history of smoking. Newly diagnosed hypertention ( not taking any medication)
- 6. Past surgical history: not significant No family history of varicose veins.
- 7. GENERAL PHYSICAL EXAMINATION The patient was a morbidly obese male, conscious and oriented to time ,place and person. No pallor, icterus, cyanosis, clubbing, lymphedema noted. VITALS: BP: 160/90 Pulse : 98 bpm Weight: 181 kg
- 8. INSPECTION: Patient was examined in standing position Long, tortuous and dilated veins seen extending from above the medial malleolus to above the knee. Skin of the right lower leg was hyperpigmented and thickened. There is eczema over the medial malleolus. An ulcer was noticed over the medial aspect of the right lower limb.Approx. 4*3 cm in size with irregular sloping margins, floor covered with scab. Seropurulent discharge noted from the ulcer, scanty in amount and non foul smelling. Redness noted over the right foot extending to the ankle.
- 9. Palpation: No tenderness noted, Sloping edge is felt with irregular margins. Depth approx.2mm The ulcer does not bleed on touch. Temperature of the right foot was raised as compared to the left. Peripheral pulses were palpable. Abdominal exam: unremarkable
- 10. DIAGNOSIS BilateralVaricose veins with active venous ulcer along with cellulitis. CEAP classification: Right leg: C6 Left leg: C2
- 11. INVESTIGATION Colour Doppler: showed incompetent sapheno-femoral and sapheno-popliteal junction. Incompetant perforators also noted below the knee joint and above the ankle region. Gross subcutaneous edema in lower part of the leg. No evidence of DVT The accompanying arteries showed normal triphasic blood flow.
- 12. MANAGEMENT: Multilayer compressive dressing done to decrease the venous hypertention. Antibiotic treatment started for treatment of cellulitis Plan of EVLA / Foam Sclerotherapy after the infection settles down .
- 13. VARICOSE VEINS Varicose veins are enlarged, swollen, and tortous veins, usually occurring in the legs. They result from weakened or damaged valves in the veins, leading to poor blood circulation and the appearance of bulging, blue or purple veins.
- 14. ANATOMY Deep system of veins; Lie below the deep fascia Superficial system of veins; lie above the deep fascia eg great and short saphenous vein Perforating veins; connect superficial and deep venous system, they perforate deep fascia, Guarded by valves; unidirectional blood flow from superficial to deep venous system Locations Dodd: mid-thigh prforators Boyd; Gestrocnemius perforator Cocket (I-III) lower leg perforators May or Kuster;Ankle perforators
- 15. TYPES Primary; Congenital incompetence / Absence of valves Weakness or wasting of muscles Stretching of deep fascia Klippel-trenauny syndrome
- 16. TYPES Secondary; Previous DVT Recurrent thrombophelibitis Obstruction to venous return Occupational or pregnancy Iatrogenic in AV fistula
- 17. EPIDEMIOLOGY The adult prevalence of visible varicose veins is between 30% and 50%. Factors affecting prevalence include: Gender: the vast majority of studies report a higher prevalence in women than men Age: the prevalence of varicose veins increases with age Ethnicity Body mass and height: increasing body mass index and height associated with a higher prevalence of varicose veins. Pregnancy: increases the risk of varicose veins.
- 18. EPIDEMIOLOGY Family history: evidence supports familial susceptibility to varicose veins. Occupation and lifestyle factors: there is inconclusive evidence regarding increased prevalence of varicose veins in smokers, patients who suffer constipation and occupations that involve prolonged standing.
- 19. PATHOPHYSIOLOGY
- 20. SYMPTOMS Varicose veins frequently cause symptoms. Patients describe aching, heaviness, throbbing, burning or bursting over affected areas and sometimes the whole limb. Such symptoms typically increase throughout the day or with prolonged standing, and are relieved by elevation or compression hosiery. There may be pruritus, pedal edema, pigmentation, dermatitis, ulceration, tenderness, Compagne-bottle deformity, lipodermatosclerosis
- 21. SIGNS The presence of tortuous dilated subcutaneous veins is usually clinically obvious. These are confined to the GSV and SSV systems in approximately 60% and 20% of cases, respectively. medial thigh and calf varicosities suggest GSV incompetence and posterolateral calf varicosities are suggestive of SSV incompetence SAPHENAVARIX; a large, usually painless lump in the groin which becomesVisible and prominent on standing and coughing and disappear in recumbent position
- 22. CLINICAL CLASSIFICATIONS OFVARICOSEVEINS C0; no visible or palpable signs of venous disease C1; Telangiectasia, reticular veins or malleolar flare C2; varicose veins C3; Edema without skin changes C4; Skin changes due to venous disease like C4a; Pigmentation C4b; lipodermatosclerosis C5; skin changes as above with healed ulceration C6; skin changes as above with active ulceration
- 24. CEAP CLASSIFICATION Clinical signs (Grade 1 to 6) supplemented by A for asymptomatic and S for symptomatic Etiologic classification; Congenital, primary, secondary (post-thrombotic) Anatomic distribution (Superficial, deep or perforators alone or in combination) pathophysiologic classification (reflux or obstruction alone or in combination)
- 25. REGIONAL CLASSIFICATION Great saphenous vein (60%) Medial thigh and calf Small saphenous vein (20%) Posterolateral calf Anterior (accessory) saphenous vein; isolated anterolateral thigh and calf Saphena varix; Large dilated painless lump at saphenofemoral junction which is emergent on standing and coughing and disappear in recumbent position
- 26. INVESTIGATIONS Done to Localize the anatomical lesion of disease Nature of lesion Rule out DVT
- 27. INVESTIGATIONS Duplex ultrasound scanning; Investigation of choice The aim is to establish: the presence of refux in the deep and superfcial venous system; the exact distribution and extent of refux in the superfcial venous system the presence of obstruction in the deep venous system; the presence of thrombus within the superfcial veins; an indication of a pelvic source of reflux or obstruction
- 29. TREATMENT Conservative therapy (compression) Avoidance of long standing 1. Elastic crepe bandage from below upwards or use of pressure stockings 2. Elevation of limbs 3. Pneumatic compression
- 30. TREATMENT 2. Endothermal ablation; (gold standard) A Catheter is inserted into the incompetent axial vein percutaneously.The vein is surrounded by tumescent local anaesthetic solution.This compresses the vein onto the treatment device, emptying it of blood. The catheter then produces thermal energy that destroys the structure of the vein, resulting in permanent occlusion. Two broad technologies exist: 1. Endovenous laser ablation (EVLA) 2. Radiofrequency Ablation (RFA)
- 31. TREATMENT 1. Endovenous laser ablation (EVLA) It utilises a small flexible glass fibre that is inserted into the vein. Laser energy (typically at a wavelength of 1470nm) is transmitted down the fibre 2. Radio-frequency ablation (RFA) It uses the same treatment principles, but an electromagnetic current is used to create the thermal energy There have been a range of studies comparing EVLA and RFA.The evidence is generally equivocal, with both treatments having relative advantages and disadvantages; choice often comes down to personal preference. Both are excellent treatment options and can be applied successfully to the majority of patients.
- 32. TREATMENT 1. Ultrasound guided foam sclerotheraphy It involves the injection of a sclerosing agent directly into the superficial veins. The most commonly used is sodium tetradecyl sulphate. The direct contact with detergent causes cellular death and initiates an inflammatory response, aiming to result in thrombosis, fibrosis and obliteration (sclerosis). 2. Catheter directed sclerotheraphy 3. Catheter directed mechanicochemical ablation The catheter is placed within the vein lumen as for endothermal ablation, spinning wire causes physical damage to the endothelium and allows a deeper penetration of the sclerosant into the vein wall.
- 33. TREATMENT Endovenous glue (cyanoacrelate gel) Catheter based, A handle is used to infiltrate the adhesive in 0.1mL applications via the catheter. The vein is then compressed, sealing the lumen closed.
- 35. TREATMENT Open surgeries The principles of traditional ligation and stripping are to fully dissect the point of junctional incompetence and to remove the refluxing axial vein and dilated tributaries. 1. Saphenofemoral junction ligation and great saphenous stripping 2. Saphenopopliteal junction ligation and small saphenous stripping
- 36. TREATMENT Adjunctive procedures Phlebotomy; Small Superficial veins of leg do not disappear following GSV stripping, they are separately removed Perforator ligation; for prforator incompetence
- 37. TREATMENT Complications of surgery Complications (minor and major) are reported in up to 20% of patients who undergo traditional varicose vein surgery. 1.Wound infections, are the most common complication 2.Nerve injury is the most common serious complication . saphenous nerve neuralgia is up to 7% following GSV stripping to the knee The incidence of sural nerve neuropraxia and common peroneal nerve injury may be as high as 20% and 4%, respectively, following SSV surgery. 3.The incidence of venous thromboembolic complications is approximately 0.5% following varicose vein surgery
- 38. COMPLICATIONS Bleeding Thrombophlebitis Venous hypertension leading to venous ulcer Calcification Eczematous dermatitis and pigmentation
- 39. VENOUS ULCER Venous disease is responsible for around 85% of all chronic lower limb ulcers. Community-based prevalence is 0.10.3% in adults (24% in the elderly).
- 40. MANAGEMENT The keystone of management is to decrease venous hypertension using venous ablation and compression therapy. The most clinical and cost-efective compression regimes are two-layer compression hosiery or four-layer compression bandaging.
- 41. The latter includes: Orthopaedic wool: distributes the pressure and reduces undue pressure on sensitive areas susceptible to pressure damage.Also helps to absorb excess exudate that escapes the primary dressing. Cotton crepe: smooths the wool and holds it in place. Elastic bandage: frst compressive layer, contributes about one-third of the interface pressure. Cohesive bandage: second compressive layer, increases stifness and adds approximately two- thirds of the interface pressure