際際滷

際際滷Share a Scribd company logo

varicose veins-Investigations & Management

Download as PPT, PDF
Rankeen Raj
Rankeen Raj

1. Duplex ultrasound, plethysmography, and venography are common non-invasive and invasive tests used to investigate varicose veins. 2. Treatment options include conservative measures, injection sclerotherapy, and surgery. Surgery involves stripping the saphenous vein and removing tributaries and perforators. 3. Newer treatments include endovenous laser ablation which closes the vein using laser without removal and subfascial endoscopic perforator surgery to ligate perforators through a small incision.

1 of 29
Download to read offline
VARICOSE VEINS- INVESTIGATIONS AND MANAGEMENT
INVESTIGATIONS INVASIVE NON INVASIVE VENOGRAPHY 1.DOPPLER USG 2.PLETHYSMOGRAPHY 3.COLOUR DOPPLER
DOPPLER ULTRASOUND Procedure With patient in standing position,the hand held doppler probe is placed at the saphenofemoral junction(SFJ) With other hand,the examiner gently squeezes the calf to propel blood forward- this is heard as a whooshfrom the loudspeaker of the doppler machine
varicose veins-Investigations & Management
PLETHYSMOGRAPHY This is a graphical representation of the pressures in the superficial and deep veins at rest and during exercise various techniques include: 1. strain gauge plethysmography 2.photoplethysmography 3.impedance plethysmography 4.air plethysmography
VENOGRAPHY Both ascending and descending venography have to be done to give to give the same information as colour doppler Good alternative in places where there are no ultrasound facilities
ASCENDING VENOGRAPHY USES 1.To diagnose perforator incompetence 2.To map out the deep venous system 3.To diagnose deep vein thrombosis-seen as a filling defect
procedure Tourniquet is tied just above the medial maleoli to prevent blood flow into the superficial veins Non-ionic contrast is injected into the dorsal venous arch Normally,only the deep venous system can be seen
DESCENDING VENOGRAPHY Uses: To test for the competence of Saphenofemoral Junction Procedure
DUPLEX ULTRASOUND IMAGING(COLOUR DOPPLER) Involves use of higher resolution B-mode USG with Doppler USG to obtain images of arteries, veins and simultaneously measure flow in these vessels. The machine represents blood flow as a colour map that is superimposed on the greyscale image of the vessel. Forward flow which occurs when the calf is squeezed is seen as blue in the colour flow map. When incompetent veins are present reverse flow is seen as red when the calf is released.
Advantages 1)Is the most appropriate investigation to obtain the anatomy and physiology of the venous system. 2)All the lower limb vessels may be imaged. 3)The origin of varicose veins and venous ulceration can be identified. 4)If DVT is present the thrombus can be seen.
MANAGEMENT TREATMENT OPTIONS OPERATIVE NON-OPERATIVE CONSERVATIVE INJECTION-COMPRESSION RX
Conservative treatment: Indications- 1)Uncomplicated Varicose veins 2)Patient unwilling or unfit for surgery Bizzgards Regimen Avoid prolonged standing Foot end elevation at night Crepe bandage during the day Exercise to strengthen calf muscles
Injection-Compression treatment: Used to treat Varicose veins in the absence of Junctional incompetence. Aim: To inject a small volume of effective Sclerosant into veins lumen to destroy the intima. Solution: 3% Sodium Tetredecyl Sulphate Procedure: 0.5ml of Sclerosant is injected into the empty vein at points of control-Sites at which incompetent perforators join the superficial veins. After injection external compression has to be applied.
Disadvantages: 1)Local pain and Periphlebitis 2)Reccurence: Rates upto 30% have been reported Causes: 1)Presence of SFJ incompetence 2)Failure to apply external compression
SURGERY FOR VARICOSE VEINS Indications 1)Symptoms of aching heaviness and cramps 2)Complications of venous stasis i.e. Pigmentation, dermatitis, ulceration, thrombosis 3)Large Varicosities subjected to trauma 4)Cosmetic concern
Objectives: 1)Releive symptoms 2)Alleviate stasis complications 3)Restore normal venous physiology 4)Improve cosmetic appearance
Principles of Surgery All incompetent superficial veins and perforators to be thoroughly removed to prevent recurrence Veins having a potential to develop varicosities should also be removed Special care to be taken not to damage or destroy normal competent Greater or Lesser Saphenous veins as they may be needed for future Bypass procedures Superficial varices that follow DVT may be the only route for the venous drainage of the lower limbs hence should not be removed until the patency of the deep veins are established
PROCEDURE OF STRIPPING OF VEIN Pre Op All veins have to be carefully and accurately marked with an indelible pencil Anesthesia - General/Regional Position Supine with legs elevated to 15 to 20属 to minimize bleeding Incision: 1st - Groin incision just below the inguinal crease medial to femoral artery pulsation 2nd Small transverse incision placed anterior and proximal to medial malleolus and transverse incision on the distal Saphenous vein
Steps: 1. Ligation or removal of tributaries near the SFJ Medial femoral cutaneous Lateral femoral cutaneous Superficial external pudendal Superficial circumflex iliac 2. Flush ligation of SFJ Modified Trendelenburg operation 3. Insertion of a flexible intraluminal metallic stripper into the Greater or Lesser Saphenous veins 4. Resection of incompetent perforator veins 5. Stripping of Saphenous vein and closure
varicose veins-Investigations & Management
varicose veins-Investigations & Management
Precautions during stripping surgery 1.Tributaries of saphenous vein at the SFJ have to be removed first 2.Stripper may encounter obstruction due to tortuosities at the site of perforators 3.Stripper may enter the deep venous system through one of the perforators 4.Care is taken to avoid damage to the Saphenous nerve which lies adjacent to the vein from the ankle to knee Nerve damage causes sensory loss or traumatic neuritis of medial aspect of ankle
MULTIPLE STAB AVULSION TECHNIQUE (Ambulatory phlebectomy) This is done as an alternative to stripping of greater saphenous vein after flush ligation of SFJ At the points of greatest tortuosity, tiny incisions are made and the vein is picked up with a special hook and clamped on both sides, then avulsed This is done at multiple points till the whole vein is removed Advantages: Complication of injury to the saphenous nerve is prevented Extremely useful for residual clusters after Saphenectomy
Post Op: 1.Patient to ambulate on first post op day 2.Bandages are remove on second post op day for inspection of wound 3.Aambulation is permitted only with elastic external support for the first two weeks
PERFORATOR INCOMPETENCE PROCEDURES 1. Cockett and Dodds subfascial ligation 2. Robs procedure 3. Felder-Robs procedure 4. Modified Felder-Robs procedure (by Dr. Ananthakrishnan)
NEWER TREATMENTS Endovenous Laser treatment (EVLT) Done under strict LA Permanently closes the vein while leaving it in place Laser is delivered into the vein via fine Fibreoptic probe through a fine skin nick and the probe is guided via USG Successful treatment depends on heating of veins Lasers used are Diode, Nd-YAG, Alexandrite Precaution-The laser device is used with the cooling of the skin with cool gel or chilled air to decrease risk of injury to skin
varicose veins-Investigations & Management
Subfascial endoscopic perforator surgery (SEPS) Entails placing of endoscope beneath fascia of calf through a single small skin incision Perforating veins traversing subfacial space are ligated under direct vision

More Related Content

varicose veins-Investigations & Management

  • 2. INVESTIGATIONS INVASIVE NON INVASIVE VENOGRAPHY 1.DOPPLER USG 2.PLETHYSMOGRAPHY 3.COLOUR DOPPLER
  • 3. DOPPLER ULTRASOUND Procedure With patient in standing position,the hand held doppler probe is placed at the saphenofemoral junction(SFJ) With other hand,the examiner gently squeezes the calf to propel blood forward- this is heard as a whooshfrom the loudspeaker of the doppler machine
  • 5. PLETHYSMOGRAPHY This is a graphical representation of the pressures in the superficial and deep veins at rest and during exercise various techniques include: 1. strain gauge plethysmography 2.photoplethysmography 3.impedance plethysmography 4.air plethysmography
  • 6. VENOGRAPHY Both ascending and descending venography have to be done to give to give the same information as colour doppler Good alternative in places where there are no ultrasound facilities
  • 7. ASCENDING VENOGRAPHY USES 1.To diagnose perforator incompetence 2.To map out the deep venous system 3.To diagnose deep vein thrombosis-seen as a filling defect
  • 8. procedure Tourniquet is tied just above the medial maleoli to prevent blood flow into the superficial veins Non-ionic contrast is injected into the dorsal venous arch Normally,only the deep venous system can be seen
  • 9. DESCENDING VENOGRAPHY Uses: To test for the competence of Saphenofemoral Junction Procedure
  • 10. DUPLEX ULTRASOUND IMAGING(COLOUR DOPPLER) Involves use of higher resolution B-mode USG with Doppler USG to obtain images of arteries, veins and simultaneously measure flow in these vessels. The machine represents blood flow as a colour map that is superimposed on the greyscale image of the vessel. Forward flow which occurs when the calf is squeezed is seen as blue in the colour flow map. When incompetent veins are present reverse flow is seen as red when the calf is released.
  • 11. Advantages 1)Is the most appropriate investigation to obtain the anatomy and physiology of the venous system. 2)All the lower limb vessels may be imaged. 3)The origin of varicose veins and venous ulceration can be identified. 4)If DVT is present the thrombus can be seen.
  • 13. Conservative treatment: Indications- 1)Uncomplicated Varicose veins 2)Patient unwilling or unfit for surgery Bizzgards Regimen Avoid prolonged standing Foot end elevation at night Crepe bandage during the day Exercise to strengthen calf muscles
  • 14. Injection-Compression treatment: Used to treat Varicose veins in the absence of Junctional incompetence. Aim: To inject a small volume of effective Sclerosant into veins lumen to destroy the intima. Solution: 3% Sodium Tetredecyl Sulphate Procedure: 0.5ml of Sclerosant is injected into the empty vein at points of control-Sites at which incompetent perforators join the superficial veins. After injection external compression has to be applied.
  • 15. Disadvantages: 1)Local pain and Periphlebitis 2)Reccurence: Rates upto 30% have been reported Causes: 1)Presence of SFJ incompetence 2)Failure to apply external compression
  • 16. SURGERY FOR VARICOSE VEINS Indications 1)Symptoms of aching heaviness and cramps 2)Complications of venous stasis i.e. Pigmentation, dermatitis, ulceration, thrombosis 3)Large Varicosities subjected to trauma 4)Cosmetic concern
  • 17. Objectives: 1)Releive symptoms 2)Alleviate stasis complications 3)Restore normal venous physiology 4)Improve cosmetic appearance
  • 18. Principles of Surgery All incompetent superficial veins and perforators to be thoroughly removed to prevent recurrence Veins having a potential to develop varicosities should also be removed Special care to be taken not to damage or destroy normal competent Greater or Lesser Saphenous veins as they may be needed for future Bypass procedures Superficial varices that follow DVT may be the only route for the venous drainage of the lower limbs hence should not be removed until the patency of the deep veins are established
  • 19. PROCEDURE OF STRIPPING OF VEIN Pre Op All veins have to be carefully and accurately marked with an indelible pencil Anesthesia - General/Regional Position Supine with legs elevated to 15 to 20属 to minimize bleeding Incision: 1st - Groin incision just below the inguinal crease medial to femoral artery pulsation 2nd Small transverse incision placed anterior and proximal to medial malleolus and transverse incision on the distal Saphenous vein
  • 20. Steps: 1. Ligation or removal of tributaries near the SFJ Medial femoral cutaneous Lateral femoral cutaneous Superficial external pudendal Superficial circumflex iliac 2. Flush ligation of SFJ Modified Trendelenburg operation 3. Insertion of a flexible intraluminal metallic stripper into the Greater or Lesser Saphenous veins 4. Resection of incompetent perforator veins 5. Stripping of Saphenous vein and closure
  • 23. Precautions during stripping surgery 1.Tributaries of saphenous vein at the SFJ have to be removed first 2.Stripper may encounter obstruction due to tortuosities at the site of perforators 3.Stripper may enter the deep venous system through one of the perforators 4.Care is taken to avoid damage to the Saphenous nerve which lies adjacent to the vein from the ankle to knee Nerve damage causes sensory loss or traumatic neuritis of medial aspect of ankle
  • 24. MULTIPLE STAB AVULSION TECHNIQUE (Ambulatory phlebectomy) This is done as an alternative to stripping of greater saphenous vein after flush ligation of SFJ At the points of greatest tortuosity, tiny incisions are made and the vein is picked up with a special hook and clamped on both sides, then avulsed This is done at multiple points till the whole vein is removed Advantages: Complication of injury to the saphenous nerve is prevented Extremely useful for residual clusters after Saphenectomy
  • 25. Post Op: 1.Patient to ambulate on first post op day 2.Bandages are remove on second post op day for inspection of wound 3.Aambulation is permitted only with elastic external support for the first two weeks
  • 26. PERFORATOR INCOMPETENCE PROCEDURES 1. Cockett and Dodds subfascial ligation 2. Robs procedure 3. Felder-Robs procedure 4. Modified Felder-Robs procedure (by Dr. Ananthakrishnan)
  • 27. NEWER TREATMENTS Endovenous Laser treatment (EVLT) Done under strict LA Permanently closes the vein while leaving it in place Laser is delivered into the vein via fine Fibreoptic probe through a fine skin nick and the probe is guided via USG Successful treatment depends on heating of veins Lasers used are Diode, Nd-YAG, Alexandrite Precaution-The laser device is used with the cooling of the skin with cool gel or chilled air to decrease risk of injury to skin
  • 29. Subfascial endoscopic perforator surgery (SEPS) Entails placing of endoscope beneath fascia of calf through a single small skin incision Perforating veins traversing subfacial space are ligated under direct vision