Varicose Vein

VARICOSE VEINS Primary:
  • Congenital absence or incompetence of valves
  • Inheritance with FOXC2 gene
  • Klippel-Trenuanay syndrome
  • Congenital AV fistula
  • Cutaneous hemangiomas
  • Hypertrophy of involved limb
  • Absence of deep venous system
Secondary:
  • Recurrent thrombophlebitis
  • Occupational – prolonged standing
  • Obstruction to venous return – abdominal tumors, retroperitoneal fibrosis
  • Pregnancy
  • Iliac vein thrombosis
Clinical features
  • Lipodermatosclerosis(brawny induration) pigmentation, thickening, chronic inflammation and induration of skin in calf muscle and around ankle.
Brodie-Trendelenburg test
  • To assess the competence of SFJ
  • Patient lies flat, elevate the leg and gently empty the veins, palpate the SFJ and ask the patient to stand whilst maintaining pressure
  • If the veins do not refill SFJ is incompetent
  • If the veins do refill SFJ may or may not be incompetent, presence of distal incompetent perforators.
Cough impulse (Morrisey's test)
  • Locate the saphenofemoral junction(2-4cm inferolateral to pubic tubercle) and ask the pt to cough
  • Impulse or fluid thrill felt indicates saphenofemoral incompetence.
Modified Perthes Test:
  • Ask the pt to stand and tourniquet is applied at SF junction and ask to walk
  • Superficial veins become prominent – indicate deep vein thrombosis.
  • Three tourniquet test 
  • To find the site of incompeter“: perforator
  • Tourniquets at SFJ, above knee level, below knee level Fegan's test:
  • Detect the perforators
Investigations:
  • Duplex Ultrasound imaging – gold standard
  • Doppler examination – only when duplex is not available
  • Phlebography – not needed in primary venous insufficiency. Only performed as preoperative adjuncts when deep venous reconstruction is being planned
  • Ascending phlebography – differentiates primary from secondary insufficiency
  • Descending phlebography - identifies specific valvular incompetence suspected on B mode scanning.
Medical treatment
  • Calcium dobesilate
  • Diosmin
  • Hesperidin
  • Toxerutin
Surgical management:
  • Trendelenburg's operation (juxta femoral flush ligation + stripping the varicose vein) for SFJ incompetency
  • Subfacial ligation of Cockett and Dodd :perforator incompetence with SF competency
  • VNUS closure(ablation catheter introduced into the SF junction and slowly with drawn )
  • TRIVEX – veins identified by subcutaneous illumination; injection of fluid & superficial veins are sucked
  • Endo venous laser ablation(EVLA)
  • Sclerotherapy
Exam Question
  • Direct Pressure and Elevation is the first treatment of choice in a case of rupture of varicose veins at the ankle
  • Varicose veins is associated with migratory thrombophlebitis 
  • Sclerotherapy for varicose vein is contraindicated in Deep vein Thrombosis
  • Pulsatile varicose veins in lower limbs is seen in Klippel trenaunay syndrome
  • After the division of testicular vein for treatment of varicose vein, venous drainage of testes is by Cremasteric veins
  • Varicose veins are seen in DVT & AV fistula
  • Most commonly varicose veins are seen with Long saphenous vein
  • 5% oily phenol is an appropriate sclerosant for venous sclerotherapy.
  • Surgery in varicose veins is NOT attempted in presence ofDeep vein thrombosis
  • A pt presented with pulsating varicose veins of the lower limb. Most probable diagnosis is Klippel Trenaunay syndrome
  • Injection sclerotherapy for varicose veins is by using phenol
  • Commonest complication of varicose vein stripping is Ecchymosis
  • Pulsating varicose vein in a young adult is due to Arteriovenous fistula
  • An operated case of varicose veins has a recurrence rate of About 10%
  • Operations for varicose veins are best accomplished by Stripping
  • Gold standard diagnostic test in varicose veins is Duplex imaging
  • Trendelenburg's operation is done for Varicose veins
  • Investigation of choice for varicose veins Duplex ultrasound imaging
  • Arteriovenous fistula, Deep venous thrombosis & Pregnancy may cause varicose veins
  • Drug used for sclerotherapy of varicose veins are Polidocanol, Sodium tetradecyl sulfate, Ethanolamine Oleate, 
  • Perthe's test, Tourniquet test & Trendelenberg test are done for varicose veins
  • Patient presents with varicose vein with sapheno-femoral incompetence and normal perforator can be managed with Endovascular stripping, Sapheno-femoral flush ligation & Saphenofemoral flush ligation with striping
Don't Forget to Solve all the previous Year Question asked on Varicose Vein