this presentation is to clarify anatomy and pathology of lower limb varicose veins and different lines for management

1. Recent Trends In
Management of Lower
Limb Varicose Veins

2. Under supervision of
Prof Dr
Ahmed Alaa El-Deen Abd El-Mageed Salman
Prof . Of general surgery Ain Shams Uni.
Dr /
Mohamed Ismail Mohamed
Lecturer Of vascular surgery Ain Shams Uni.

3. Objectives of this
presentation

4. Review of :
• Basic anatomy and histopathology related to
L.L. V.V.
• Diagnosis of V.V.
• Classical treatment of V.V.
• Recent trends in management .

5. Basic anatomy and histopathology
Definition: Dilated, tortuous, palpable veins more than 3 mm in
diameter
WhyV.V. : One of the most common disorders of vascular
diseases
Prevalence : Males : 2% to 56%
Females 1% to 73%

6. Anatomical Hints
Veins of L.L. organized into three systems:
• Superficial System : Great & Small S.V.
• Deep System : ant. , post tibial veins , popleteal veins , femoral
veins
• Perforating veins
These veins are located in two compartments:
• The superficial compartment
• The deep compartment

7. (Geza and peter, 2014).

8. The Great saphenous vein
• Saphenous means visible !
• Longest vein in the body
• originates from the confluence of the dorsal
foot veins
• Easily identified at the ankle, in close
proximity to saphenous nerve >>>>
susceptible to injury .
• ascends upward on the medial side
• Ends at the inner third of the groin by
merging into the femoral vein at the SFJ
.
(Daniel and Eric, 2014)

9. The Small saphenous vein
• Origine : dorsal venous arch
• Course : anterior to the lateral malleolus
ascends upward on the medial side
• enters the fascia between the heads of
the gastrocnemius muscle
• Mostly ends by draining into the
popliteal vein (deep system) 5 cm
cephalic to the knee crease
(Daniel and Eric, 2014)

10. HISTOPATHOLOGY

11. V.V. formation has a genetic component that is linked
to environmental stimuli
Normally blood flow back from the L.L. towards the
heart
In venous insuffeciency it leaks out of the deep veins
at some points >>>
enter the superficial veins >>>
overloads a segment >>> varicose veins

13. • The biophysics/mechanical forces may allow a primary vein wall
dilation to expand to the neighboring valves and cause direct valve
distortion ,dysfunction and leakage
• On the other hand, a primary valve dysfunction may need to reach a
threshold level that causes significant reflux, increased venous
hydrostatic pressure and chronic venous hypertension, which may
then cause secondary vein wall dilation

14. Three important causes for developing V.V. :
• 1) A primary anomaly of the matrix of the vein wall >>> changes of
its elasticity.
• 2) A primary anomaly of the cups of the valves >>>white cell
trapping, inflammation and destruction of the cups.
• 3) Post thrombotic

15. • History : General history
Vascular history : visible abnormal
vessels , edema, superficial or deep
thrombophlebitis….
• Clinical examination >> although occasionally
useful, are often unreliable and have been largely
replaced by diagnostic imaging
• Duplex examination >>> Most accurate

17. •Conservative modalities
•Surgical treatment
•Recent new lines

18. Conservative modalities :
Include :
• Compression
• leg elevation
• Exercise
• Diet and weight loss
• Analgesics and anti edema drugs

19. Compression bandage:
(Jeffrey 2011)
•compression at 20–30 mmHg
seems effective for symptomatic
varicosities.
•improves symptoms and
quality of life but it does not
reverse disease .
• Reduction of capillary
filtration

20. • Shift of fluid into non-compressed
parts of the body
• Increase of lymphatic re-absorption
and lymphatic transport
(Jeffrey 2011)

21. • A combination of Ligation, axial stripping, and stab phlebectomy
may be applied For GSV,SSV and local varicosities
• The GSV is most easily approached through an oblique incision 1
cm above and parallel to the groin crease
• There are six main tributaries joining the GSV near its termination
• Division of these hidden tributaries should be ensured
• High ligation without stripping is associated with a high rate of
recurrence
• The incidence of apparent saphenous nerve injury reaches 4.5%.

22. Complications:
Common complications :
* Scarring
* Thrombophlebitis
* Hyperpigmentation
* Telangiectatic matting
Rare and/or serious complications:
* DVT
* Pulmonary embolism
* Nerve injury
* Postoperative wound infection (Mark andThomas, 2014).

24. •Foam sclerotherapy
•Radiofrequency ablation (RFA)
•Endovenous laser ablation (EVLA)
•Cryo-surgery

25. • Introduction of a chemical into the lumen of a vein
U/S guided
• Induce endothelial damage that results in
thrombosis and eventually fibrosis
• activation of coagulation cascade. Subsequent
endofibrosis of the vein
• Can be used to treat almost any abnormal vein
• Most effective for veins less than 6-7 mm
• After injection >> avoid anti-inflammatory
medications ,whirlpools, saunas, and hot baths for
at least 48 hours
• Complications hyper-pigmentation , telangiectatic
matting, pain with injection, and urtication after
injection. (Lowell S. ,2014)

26. • compression stockings(30–40 mmHg) is applied and worn for 1–2
weeks

27. • Electro thermal energy is used to
heat and obliterate the vein
• A radiofrequency catheter is inserted
into the abnormal vein and the vessel
treated with radio-energy under
ultrasound guidance
• Used to treat GSV, SSV, and the
perforator veins.
(Manju and Peter, 2009).

28. • Branch varicose veins are then usually treated with other minimally
invasive procedures
• Non-steroidal anti-inflammatory drugs may be taken on an as-needed
basis for discomfort
• Studies >> high success rate with low rates of complications
• Complications : skin burns, phlebitis, perforation, thrombosis ,pulmonary
embolism hematoma, infection, and paresthesias
• follow-up DUS at 24–72hours after the procedure as surveillance of
junctional thrombus extension from the treated vein into the deep vein
• compression stockings(30–40 mmHg) is applied and worn for 1–2 weeks
• Duplex US at about 12 months after the procedure will ultimately
determine the anatomical success of the ablation

29. • Ideal for linear primary truncal varicosities with a diameter of 5mm or more
e.g. GSVs and SSVs because of the rigidity and size of the disposables
• Under direction of duplex guidance .
• Insufficient GSV is entered at knee level because of ease of access
• Special caution : too tortuous, small diameter(due to spasm) and large side
branches, or contains thrombotic or sclerotic fragments >>>advancing the
wire can be difficult
• Risk of perforation and embolic events
• Prescription of a non-steroidal anti-inflammatory is allowed

30. 34-year-old white female
with very symptomatic
varicose veins of the left
leg. (A) An EVLT was done
to treat an incompetent
left GSV.
The GSV was closed on
ultrasound at follow-up 6
weeks later.The patient
stated that her leg feels
much better.The mild
residual varices were
subsequently treated with
sclerotherapy (Neil and
Steven 2011)
Above 34-year-old white female with very symptomatic varicose veins of the left leg. (A) An EVLT was done to treat an incompetent left GSV.
Below The GSV was closed on ultrasound at follow-up 6 weeks later. The patient stated that her leg feels much better. The mild residual varices were subsequently treated with sclerotherapy (Neil an

31. Complications
•The commonest complication following Evla is
thrombophlebitis
•The high temperatures of laser energy induce multiple
micro-perforations of the venous wall that often result in
pain and ecchymosis
•DVT and skin burns

32. • A modification of the classical surgical stripping
• Uses a freezing probe to remove the entire saphenous vein via the
inguinal incision alone (cryo-stripping)
• widely used because it is a less traumatic procedure and has lower
rates of postoperative morbidity
• complication rates are similar to those of traditional stripping
• a cryoprobe is intruduced in the vein after ligation of the GSV at the
SFJ.The cryoprobe is brought up just proximally to the knee, after
which the tip of the probe is cooled with NO2 or CO2 to a
temperature of)85_C.This causes the vein to freeze which is then
retrogradely removed

33. • main disadvantages is cost
• Complications >> extremely low: pain, hematoma, skin
pigmentation, and paresthesia

35. • All treatments had similar clinical efficacy, but there were fewer
complications after laser treatment and ablation rates were lower
after treatment with foam
• Open vascular surgery traditionally offered the “gold standard” with
respect to durability and efficacy
• lastly and recentlyWith the goal of decreasing the morbidity of
vascular interventions, the shift toward endovascular procedures is
well justified. When an endovascular intervention is not anatomically
possible, open vascular surgery can be used in a hybrid fashion to
modify the anatomy so that endovascular intervention is possible