Detailed Notes on Venous Disease and Varicose Veins

• Lecturer: Dr. C. Borz

• Topic: Chronic Venous Disease - Overview of problems, diagnosis, and management.

Chronic Venous Disease

• Prevalence: Affects 40% of adults.

• Components: - Varicose veins

  • Postthrombotic syndrome

  • Venous ulcers

  • Spider veins (telangiectasias)

Anatomy

• Central Venous System: Includes IVC, SVC, iliac, and subclavian veins.

• Peripheral Venous System: Includes extremity and head/neck veins. - Divided into superficial and deep veins with interconnections.

• Lower Extremity Veins: - Greater (long) and lesser (short) saphenous veins, including tributaries (superficial veins).

  • Deep veins responsible for 90% of blood flow and patency.

• Valves: - Bicuspid valves prevent retrograde flow in saphenous veins.

• Perforating Veins: - Interconnections between superficial and deep veins.

• Incompetency: Leads to retrograde flow and varicose veins.

Physiology and Pathology

• Muscle Contraction: Aids in blood return to the heart.

• Risk Factors for DVT: - Virchow’s triad: stasis, endothelial injury, hypercoagulable states (e.g. pregnancy, contraceptives, surgery, sepsis, obesity, trauma).

• Consequences: - Superficial and deep venous thrombosis

  • Pulmonary embolism

  • Varicose veins and edema

  • Chronic venous insufficiency

  • Secondary varicose veins (due to tumor compression or DVT)

CEAP Classification

• C - Clinic: - C1 to C6 (includes spider veins, edema, skin lesions, etc.)

• E - Etiology: - Hereditary, primary, secondary

• A - Anatomy: - Superficial, deep, perforating

• P - Pathophysiology: - Reflux, obstruction, or both mechanisms

CEAP Classification Details

• C (Clinic): - C0: No clinical signs

  • C1: Spider veins

  • C2: Varicose veins (>3 mm)

  • C3: Edema

  • C4a: Hyperpigmentation or eczema

  • C4b: Lipodermatosclerosis or white atrophy

  • C5: Healed venous ulcer

  • C6: Active venous ulcer

• E (Etiology): - Ec: Congenital, Ep: Primary, Es: Secondary (postthrombotic)

• A (Anatomy): - As: Superficial veins, Ap: Perforator veins, Ad: Deep veins, An: Unspecified veins

• P (Pathophysiology): - Pr: Reflux, Po: Obstruction, Pn: Unspecified

Clinical Presentation

• Symptoms: - Heaviness, fatigue, night cramps, superficial thrombophlebitis, hemorrhage

• Clinical Findings: - Varicose veins and skin changes examined in a standing position.

  • Can investigate distribution to identify saphenofemoral incompetence.

Pathophysiology of Varicose Veins

• Mid-thigh Perforating Veins: Can initiate anatomical abnormalities even if the sapheno-femoral junction is intact.

• Importance of Valves: - Failure at the junction causes progressive incompetency of valves downstream.

• Hydrostatic Pressure: - Causes dilation/tortuosity of tributaries exposed to increased pressure.

Anatomy

• Detailed anatomy of veins involved in varicose conditions including the femoral vein and superficial veins.

Examination of Varicose Veins

• Initial Examination: - Assess the severity and extent while the patient stands.

• Skin Examination: - Look for swelling, ulcers, and varicose eczema.

• Varicosities: - Documenting presence above the knee can suggest sapheno-femoral incompetence.

Diagnosis

• Diagnostic Tools: - Tourniquet Test

  • Doppler Ultrasound: For assessing venous incompetency and patency.

  • Other Techniques: Venography and plethysmography.

Differential Diagnosis & Complications

• Differential Diagnosis: Includes hernias, lymph node diseases, arterial diseases, and cancers.

• Complications: - Chronic venous insufficiency, thrombosis, rupture.

  • Obesity may be an aggravating factor.

Treatment

• Surgical Options: - High Saphenous Ligation: Ligation of the saphenous vein at the sapheno-femoral junction.

• Process: - Incision and exposure of the vein, ligation of tributaries, closure to prevent reconnection.

Saphenous Vein Stripping

• Stripping Mechanism: The stripper is introduced into the saphenous vein aiding removal by pulling it out through small incisions and tearing off tributaries.

• Post-operative Care: Important to minimize subcutaneous bleeding and manage bruising post-surgery.

Conclusion

• Chronic Venous Disease: Recognized as a progressive inflammatory disorder leading to potential complications.- Requires a multidisciplinary team approach for effective management: Includes GP, surgeons, and dermatologists.