Diseases of the veins

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

Department of surgery
Phramongkutklao hospital
 Lecture Objectives
 Anatomy of leg veins
 Venous Insufficiency: varicose veins
 Deep Vein Thrombosis
MAJOR VEINS
 Anatomy principles
 Superficial venous system
 Long saphenous vein
 Short saphenous vein

 Deep venous system

 Perforating 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
 Inherited
 Female > Male: age > 35 years
 Pregnancy – smooth muscle relaxation
 Western lifestyle: Whites > Blacks
 Prolonged standing
 Varicose Veins
 Causes
 Severe damage or trauma to saphenous
vein
 Effects of gravity produced by long periods
of standing
 Types
 Primary: no deep veins involved
 Secondary: 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 veins

 Few valves
 Abnormalities in collagen
 Pregnancy
 Gravity
 Upright 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 labs
 Diagnostic
 Doppler ultrasound
Assessment: Labs & Diagnostics
 No specific labs
 Diagnostics
 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 veins
 Symptom control with compression
therapy
 Sclerosant injection for Telangiectasia &
Reticular veins
 Surgery to strip veins/disconnect
perforator veins
 Superficial 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 sclerotherapy
 Extravasation causing pigmentation or
ulceration
 DVT
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 bandaging
 Treat varicose veins
 Long term compression
Venous Stripping
ENDOVENOUS LAZER:
an alternative choice for surgery of varicose
veins
 Indication
 Varicose veins with:
 Saphenofemoral junction reflux
 Primary insufficiency of GSV
 Lasser saphenous vein reflux
 Contraindication
 Technical unable to access
 Risk for DVT: hypercoagulation
 Postphebitic limb
 Infected venous ulcer
 Medically high-risk patient
 Advantages
 Minimally invasive procedure
 Ambulatory procedure
 Quick method
 No scaring
 Outcome
Follow up (yr) Treated/ Continued
occluded 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  OCP
state  Malignancy
 Age  Heart Failure
 Obesity  Infection
 Immobility  Inflammatory bowel
 Surgery  Nephrotic syndrome
 Pregnancy
 Hypercoagulable state
 Factor V Leiden mutation
 Prothrombin gene mutation
 Protein C or S deficiency
 Antithrombin III deficiency
 Homocysteine
 Antiphospholipid 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
 History
 Examination – 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 ASAP
 Low compression stocking for
inpatients
 Prophylactic LMW Heparin
 Treatment of DVT
 Medical therapy
 Heparinise immediately
 Warfarinise over next 3 days
 Long term warfarin

 Conservative therapy
 Exclude risk factors
 IVC filter! For PE prevention
 Surgery
 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
 Surgery
 Venous 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.