Diseases of the veins

Dr. Pisake Boontham M.D., Ph.D.

Department of surgeryPhramongkutklao hospital

Lecture Objectives

Anatomy of leg veinsVenous Insufficiency: varicose veinsDeep Vein Thrombosis

MAJOR VEINS

Anatomy principles

Superficial venous systemLong saphenous veinShort saphenous vein

Deep venous systemPerforating veins

Anatomy

Perforating Veins

Valves

More frequent distally Ensure one way flow

SUPERFICIAL TO DEEP DISTAL TO PROXIMAL

Essential to passive calf pump system of venous return

Varicose veins Varicose veins affect

20 - 25% of adult females 10 - 15% of adult males

75,000 operations are performed annually in United Kingdom

20% of operations are for recurrent disease

May develop anywhere in body, but most develop in lower extremities: Long Saphenous

Factors associated with varicose veins

InheritedFemale > Male: age > 35 yearsPregnancy – smooth muscle relaxationWestern lifestyle: Whites > BlacksProlonged standing

Varicose Veins

CausesSevere damage or trauma to saphenous

veinEffects of gravity produced by long periods

of standing

TypesPrimary: no deep veins involvedSecondary: caused by obstruction of deep

veins (Most Common)

The long saphenous vein (LSV) and its tributaries most often form varicose veins The short saphenous vein (SSV) and its tributaries can also become

varicose but less often

The veins in the leg are divided into two systems; the deep and the superficial veins The two systems are linked periodically by perforating veins. A superficial vein can

become varicose because a perforating vein is allowing blood to flow the wrong way (outwards)

Normal vs Abnormal

Varicose veins

Consequence of superficial vein valve failure (incompetent valves)

Pooling of blood distal to incompetent valve (blood flows backwards, from deep to superficial veins)

Vein wall distended

Pathophysiology

Thin-walled, unsupported veinsFew valvesAbnormalities in collagenPregnancyGravityUpright position

Pathophysiology Major cause: sustained stretching of

vascular wall die to long-standing increased intravenous pressure

Valves become incompetent because they cannot close properly due to stretching

Prolonged standing, the force of gravity, lack of lower limb exercise, & incompetent venous valves all weaken muscle-pumping mechanism, & return of venous blood to heart decreases

As client stands for long time, blood pools and vessel wall continues to stretch, and valves become increasingly incompetent

Varicose veins-pathophysiology

Congenital or acquired valvular incompetence of the deep and superficial veins along with weakness of the venous wall

Self-perpetuating cycle of venous reflux leading to further vein dilatation and valve failure.

Venous hypertension leads to fluid and protein extravasation into the subcutaneous tissue-edema

Edema & high venous pressure results in reduced local capillary flow and reactive hypoxia leading to further inflammation and tissue damage.

Clinical Manifestations No symptoms Leg fatigue &/or heaviness Itching over affected leg (stasis dermatitis) Feelings of heat in the leg Visibly dilated veins

Telangiectasia veins Reticular varices Varicose veins

Severe, aching pain in leg Thin, discolored skin above ankles Complications: insufficiency, stasis ulcers,

chronic stasis dermatitis, thrombophlebitis

Signs of venous hypertension

Perimalleolar oedema Pigmentation Lipodermatosclerosis Eczema Ulceration

Pathogenesis

Result of severe impairment of venous return causing venous hypertension; often with deep vein incompetence

Haemosiderin deposition – eczema – calf muscle hypertrophy – oedema – lipodermatosclerosis

+/- ulceration

Lipodermatosclerosis

Venous ulcer

Assessment of varicose veins

History

Examination; Identify distribution of

varicose veins - long saphenous (LSV) vs

short saphenous (SSV) No specific labsDiagnostic

Doppler ultrasound

Assessment: Labs & Diagnostics

No specific labsDiagnostics

Doppler ultrasound flow tests & angiographic studies or Duplex Doppler ultrasound

Trendelenburg tests assists w/diagnosis

Indications for duplex scanning

Suspected short saphenous incompetence

Recurrent varicose veins

Complicated varicose veins (e.g. ulceration, Lipodermatosclerosis)

History of deep venous thrombosis 

Treatments

Treat varicose veinsSymptom control with compression

therapySclerosant injection for Telangiectasia &

Reticular veinsSurgery to strip veins/disconnect

perforator veinsSuperficial vein ablation – laser/foam

Conservative Interventions

Conservative measures include antiembolism stockings and regular walking & leg elevation

Mild analgesics may relieve pain

Sclerotherapy

Only suitable for below knee varicose veins Need to exclude SFJ or SPJ incompetence Main use is for persistent or recurrent

varicose veins after adequate saphenous surgery

Complications of sclerotherapyExtravasation causing pigmentation or

ulcerationDVT

Indications for varicose vein surgery

Most surgery is cosmetic or for minor symptoms

Absolute indications for surgery :

Lipodermatosclerosis leading to venous ulceration

Recurrent superficial thrombophlebitis Bleeding from ruptured varix

Treatment of venous ulcer

AFTER EXCLUDING ARTERIAL DISEASE:4 layer compression bandagingTreat varicose veinsLong term compression

Venous Stripping

ENDOVENOUS LAZER:an alternative choice for surgery of varicose veins

Indication

Varicose veins with:Saphenofemoral junction refluxPrimary insufficiency of GSVLasser saphenous vein reflux

Contraindication

Technical unable to accessRisk for DVT: hypercoagulationPostphebitic limbInfected venous ulcerMedically high-risk patient

Advantages

Minimally invasive procedureAmbulatory procedureQuick methodNo scaring

Outcome

Follow up (yr) Treated/ occluded

Continued occlusion (%)

<1 231/218 94

1-2 247/245 99

2-3 151/151 100

>3 72/72 100

Procedure

Recurrent varicose veins

15 - 25 % of varicose vein surgery is for recurrence

Outcome of recurrent varicose veins surgery is less successful

Can be avoided with adequate primary surgery

Reasons for recurrence Inaccurate clinical assessment Confusion as to whether varicosities are in

LSV or SSV distribution Can be avoided with use of hand held

Doppler Inadequate primary surgery 10% cases SFJ not correctly identified 20% cases tributaries mistaken for LSV Failure to strip LSV 70% of those with SF incompetence treated

with sclerotherapy alone will develop recurrence

Neovascularisation

Deep vein thrombosis

Very common especially in hospital patients

Incidence of about 50-150 DVTs per 100,000

population per year

Asymptomatic in 30% (calf veins only)

10% pulmonary embolism when popliteal

vein and above involved

Deep Vein Thrombosis (DVT)

Most likely to occur in deep veins of the calf (80%)

25% of thrombi that occur in calf will extend to the popliteal & femoral veins

PE may be the first sign of DVT

Risk Factors

Hypercoagulable state

Age Obesity Immobility Surgery Pregnancy

OCP Malignancy Heart Failure Infection Inflammatory bowel Nephrotic syndrome

Hypercoagulable state

Factor V Leiden mutationProthrombin gene mutationProtein C or S deficiencyAntithrombin III deficiencyHomocysteineAntiphospholipid syndrome

Pathophysiology: Virchow’s Triad

Stasis of blood Increased blood coagulability Injury to vessel wall

2 of 3 factors must be present for thrombi to form

DVT Manifestations

When clot is in formative stage, may notice no

symptoms

Usually profound tenderness; affected extremity

may be larger (unilateral edema)

Dull aching esp when walking: Most common

Severe pain, esp when walking

Cyanosis of extremity

Slightly elevated temp

General malaise

Diagnosis of DVT

HistoryExamination – swelling, tender,

redness, dilated superficial veins, low grade pyrexia

Duplex US + d-dimer. If still uncertain, (MRI) venography

Homan’s Sign

Was long considered classic manifestation—this is no longer true

Sign is not specific to DVT & can be elicited by any condition of the calf

As calf muscles contract, there is risk of detaching thrombus from the wall

DVT

Prevention of DVT

Mobilise ASAPLow compression stocking for

inpatientsProphylactic LMW Heparin

Treatment of DVT

Medical therapyHeparinise immediatelyWarfarinise over next 3 daysLong term warfarin

Conservative therapyExclude risk factors IVC filter! For PE preventionSurgery

Conservative Therapy: DVT

Anticoagulants may be prescribed for severe

cases

Strict bed rest until symptoms of tenderness

& edema resolve

Legs elevated, knees slightly flexed, above

heart level to promote venous return &

discourage venous pooling

TED’s or pneumatic compression devices

IVC filter Re-embolism despite

anticoagulation Anticoagulation contraindicated Extensive thrombus persists

SurgeryVenous thrombectomy; done when

thrombi are lodged in femoral vein & excision of clots is required to prevent PE or to prevent gangrene

Venous surgery is rarely indicated.Venous stenting combined with catheter-

directed thrombolytic therapy is being used in some centers to treat patients with iliofemoral venous thrombosis and severe obstruction.