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Thread: Varicose Vein

  1. #1
    Join Date
    Mar 2007
    Leeds, United Kingdom
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    Smile Varicose Vein

     What is the definition of varicose veins ?
     Dilated elongated tortous veins

     Cause of v.v. ?
     Venous hypertension

     Is it a disease of which veins ?
     It affects the veins which are visible

     Sites of v.v. ?
     Saphenous vein
     oesophageal varices (by endoscopy)
     piles (proctoscopy)
     varicocele

     What is the venous drainage of lower limb ?
     Superficial & deep veins separated by deep fascia

     What are the deep veins ?
     The deep veins accompany the arteries
     Arteries: external iliac artery → femoral artery → popliteal artery → anterior & posterior tibial arteries
     Veins: vena commitants of anterior & posterior tibial arteries → popliteal vein → femoral vein → external iliac vein

     What are the superficial veins ?
     Long & short saphenous veins
     Course: both start on the dorsum of foot on medial & lateral side respectively.
     long saphenous vein: start on medial side of dorsum of foot & pass along the medial aspect of leg & thigh & passes through saphenous opening to form saphenofemoral junction 4 cm down 7 lateral to pubic tubercle
     short saphenous vein: starts along the lateral side of foot & pass along the back of leg to join the popliteal vein forming the saphenopopliteal junction

     what is the mechanism of venous return in lower limb ?
     peripheral heart :
    1) muscles contraction squeeze the veins especially calf muscles causing inc. in pressure inside veins & inc. venous return to heart from lower limbs
    2) the action of muscles requires rigid fascia & closed compartment to allow for inc. in pressure of veins
    3) the presence of valves inside the veins which prevent return of venous blood
    4) after compression of deep veins the pressure inside the vein becomes –ve so it takes blood from superficial veins
     so the direction of flow of blood in deep veins is → up & the direction of flow of blood in superficial veins is → up or inwards
     The veins which communicate the superficial veins with deep veins are called communicators & they also penetrate the deep fascia so they also called perforators
     These communicators contain valves .If incompetent, blood will pass from deep to superficial veins

     What are the sites of these communicators ?
     It differs from one person to another but 3 of them are stable :
    1) saphenofemoral junction
    2) middle of thigh
    3) just above the knee
    4) just below the knee

     What is the cause of v.v.?
     1ry due to problem in superficial veins
     2ry due to problem in deep veins
     what are the causes of venous hypertension ?
    1. decreased drainage due to :
     pressure outside vein : tumor , L.N , pregnant uterus
     pressure inside vein : thrombosis (triad of thrombosis in stasis , inc. viscosity , rough endothelium)
    2. also the arteriovenous fistula → inc. blood passing to vein beyond ability of drainage

    • pregnancy can cause D.V.T due to inc. pressure on vein & inc. viscosity
    • D.V.T cause swelling & severe bursting pain
    • a case of D.V.T should be hospitalized & placed in bed with leg elevated upwards & no movement & should give heparin to prevent increase
    • in size of thrombosis or its detatchement which may cause pulmonary embolism.
    • The patient should be hospitalized until :
     organization of thrombus (1 week)
     pain & swelling disappears أيهما أبعد

     Why no gargrene in case of D.V.T. ?

     3 tributaries to saphenous vein come from abdomen so they become dilated
     N.B : if they are enlarged → 2ry v.v
     Do the deep veins remain close ?
     No, due to recanalization but the valves are destroyed causing chronic venous insufficiency or post phlebitic limb

     How to know type whether 1ry or 2ry V.V. ?

    1ry V.V. 2ry V.V.
    history Absent history of operation history of operation & prolonged rest in bed or
    history of severe bursting pain & swelling of limb
    examination Move commonly bilateral Move commonly unilateral
    distribution takes the normal distribution of veins haphazard distributed
    shape sacular , tubular serpentine
    groin -------- dilated veins
    swelling mild ankle edema diffuse swelling

     What are the complications of V.V. ?
     Edema.
     Pigementaion.
     Eczema.
     Superficial thrombophlebitis.
     Haemorrage: due to veins crossing over chin of tibia (communication between long and short saphenous veins).
     varicose ulcers:
    • mechanism : leakage of blood from superficial veins → Hb → haemosederin leading to pigementation and dermatitis and eczema.
    Also leakage of fibrin→ fibrosis and tissue anoxia causing ulceration.
    • site: lower medial aspect of leg
    • cause : veins passing from skin & subcutaneous tissue into the deep veins it is called direct perforators
    • site of direct perforators (also named ankle perforators) :
    2, 4,6 inches above medial mallelus .

     site of problem :
     saphenofemoral junction or one of the perforators
    • in saphenofemoral junction incompetence :
    swelling called saphenavarix which is rounded , blue & compressible
    • if there is no swelling & you want to detect the incompetence, place your hands tightly on the sphenofemoral junction & ask the patient to cough you will notice palpable thrill if there is incompetence

     tests to detect the sites of incompetent perforators :
    1. Trendleberg test
     aim of the test:
     to determine the site of incompetence
    whether in saphenophemoral junction or the perforators or both of them.
     Technique:
     while the pt is lying in bed elevate his leg and
     empty the veins gently no need for violence and then
     tie a tourniquet below the saphenofemoral junction and then
     ask the pt to stand and inspect
     results:
     If the veins become engorged
     This means the presence of incompetent perforators
     If the veins are not engorged and when we remove the tourniquet
     This means that the saphenofemoral junction is incompetent but the other perforators are normal
     If the veins become engorged and after removal of the tourniquet the veins becomes more engorged
     This means that both of them are incompetent
    2. multiple tourniquet test followed by manual localization test:

     percussion test to detect the valves of superficial veins :
     Technique:
     percuss the upper part of vein & receive the impulse down
     results:
     if felt → all valves are lost
     if not felt → at least one valve is competent

     tests done to detect patency of deep system(not to diff. between1ry or 2ry) ?
     these tests are done to be sure that the deep veins are intact before removing of superficial veins :
    1. Perth’s test :
     Technique:
     tie a tourniquet around the whole limb to close the superficial veins &
     ask the patient to run for 5 mins.
     Results:
     If bursting pain occur → the deep veins are closed
     Disadvantages:
     this test is subjective
    (based on patients word not determined by doctor)
    2. modified Purth’s test :
     technique: the same but we tie a tourniquet at saphenofemoral junction & then he runs for 5 mins & we observe the superficial veins
     results:
     if deep vein occluded → engorged superficial veins + severe pain
     if deep vein intact → superficial veins become empty

     ttt of Varicose veins ?
    1. conservative ttt :
     indication: mild cases ,cases with no canalized D.V.T. ,cases not fit for surgery.
     Instructions: avoid prolonged standing , raising legs while sleeping , daflon to support vein wall , below knee or above knee stockings

    2. injection sclerotherapy :
     substance: ethanolamine oleate 5% injection .
     indicayion : cosmetic for small varicosities , for residual varicosities postoperative.
     Risks: but there may be a risk that this substance reaches the deep system causing thrombosis so we ask the patient immediately after the injection to move for about 20 minutes so that any leakage becomes washed away into the circulation, if it reach subcutaneous tissue it causes necrosis and sloughing.

    3. surgery:
     indication: large varicosities , incompetent saphenofemoral junction or other perforators.
     Types of operation depends on vein affection:
    • Great saphenous vein affection:
    o Large varicosities: vein stripping
    o Small varicosities and incompetent saphenofemoral junction : trendelberg's
    o Mild varicosities and incompetent perforators : subfascial ligation.

    • Short saphenous affection:
    o Large varicosities: stripping of vein.
    o Mild varicosities and incompetent perforators :subfascial ligation.
    • Other vein varicosities :
    o If large : subcutaneous stripping or punch excision.

    4. ttt of ulcers : by ligation of the direct perforators by an operation called subfascial ligation .
    Never Let Student Die In Your Heart When It Dies You Want Remain A Doctor But You Will Be A Technician

  2. #2
    Join Date
    Nov 2006
    Gujarat, India
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    improve presentation of your posts.
    Enjoy posting.!!

  3. #3
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    Oct 2008
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    long case good for last min revision......

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