Treatment of varicose veins
Exercise
There is an exponential rise in the prevalence of venous disease as the amount of daily movement is reduced, therefore exercises that emphasize ankle flexion are encouraged. Activation of the musculo-venous pump provides periods of lowered venous pressure and improves function of the calf muscle pump.
Elevation
Raising the feet above the level of the heart for 15-30 minutes per day reduces symptoms and oedema.
Compression hosiery
Compression reduces the diameter of the veins, increases the blood flow velocity and lymphatic flow and reduces oedema. It is the first-line therapy in patients who are unwilling or unfit for surgery, or if there is a possibility that the symptoms are not from venous disease. Response to compression stockings usually indicates that surgery will be beneficial.
Elastic compression comes in four classes based on the pressure exerted at the ankle. The pressure is reduced further up the leg to create a gradient to encourage venous flow. Elastic therapy may reduce the severity of symptoms and halt progression of disease but poorly fitting stockings can lead to a 'tourniquet effect', creating an opposite gradient and worsening the reflux.
Inelastic compression is more effective in augmenting venous pumping, as the semi-rigid compression ensures that the muscular pump directs blood towards the heart, rather than a circle of pumping blood in and around muscles which can occur with elastic hosiery; however, compliance is more difficult.
Laser therapy
Laser therapy is increasingly used for the treatment of telangiectasia and venous flaring. Laser and light therapy produce foci of high-intensity heat which potentially cause less inflammation and chemical irritation as the target tissue absorbs different wavelengths of light compared to surrounding structures. To date these methods are unsuitable for coloured skin.
Surgical management
High tie strip and avulsions
Surgery is indicated in patients with skin changes, venous ulceration and intractable pain. The decision for surgical treatment is less straightforward for patients with symptomatic trunk varices with no skin changes as it is impossible to determine which of these patients go on to develop ulceration.
High tie strip and avulsions is the preferred operation for long saphenous reflux. A short oblique incision 2 cm below and lateral to the pubic tubercle is made along the groin crease. The five specific tributaries are identified and ligated. A stripper is placed down the distal part of the disconnected saphenous vein to as far down as 5 cm below the knee and a ligature placed proximally. An oblique 1.5 cm incision is made at the tip of the stripper and the distal vein ligated and divided. The stripper is then pulled down, stripping the saphenous vein from groin to knee. Stab avulsion incisions are made for the remaining varicosities and pulled out using a hook and artery forceps. At the completion of the operation a crepe bandage is applied firmly from ankle to mid thigh in order to aid haemostasis and minimize postoperative bruising.
For short saphenous reflux a 3-5 cm incision is made in the popliteal fossa targetted to the sapheno-popliteal junction using a hand-held Doppler. The vein is disconnected at the junction using a similar technique to that above, with or without avulsions. The deep fascial layer is closed with care to avoid the potential of popliteal hernia developing. Extreme attention is paid not to damage the nearby sural nerve.
Complication of varicose vein surgery:
Complications of surgery are saphenous or sural nerve neuralgia (10%), postoperative bruising (90%), wound infection (2%), and transient lymphocele (2%). Recurrence is 20-30% at 10 years from surgical therapy. The most common cause is failure to identify and ligate all the saphenous vein tributaries. In the past many surgeons would tie and ligate the saphenous vein in isolation without stripping. This method has a high rate of recurrence secondary to venous recanalization.
Sclerotherapy
Intravenous injection of sclerosants (such as sodium tetradecyl sulphate) causes venous fibrosis and obliteration. This method of treatment is usually reserved for residual varicosities after surgery. Its use as first-line treatment lost favour due to high recurrence rates, skin staining and the risk of ulceration and deep venous thrombosis. An important principle in successful sclerotherapy is the prevention of exposure of the sclerosant to normal vessels.
Latest developments in varicose vein’s treatment:
Radiofrequency endovenous occlusion is a technique that uses radiofrequency energy delivered through an endovenous electrode). Heat dissipates within the lumen of the vessel leading to vein shrinkage and occlusion by contraction of venous collagen. Vein occlusion rates are reported as high as 97% at 1 week, 95% at 6 weeks, and 92% at 1 year. The major complication of this technique is the creation of venous thrombus (1%). Other side effects include phlebitis (6%), skin burn (3%) and temporary paraesthesia (18%).
Endovenous laser therapy (EVLT) is a laser version that works in a very similar manner.
Prognosis of Varicose Veins:
The natural history of patients with varicose veins is very variable. In patients who undergo surgery, the recurrence rates are low.
Varicose Veins - Causes, Symptoms and Complications
Diagnosis of Varicose Veins
Varicose Vein - Treatment and Prognosis
Showing posts with label Peripheral vascular disease. Show all posts
Showing posts with label Peripheral vascular disease. Show all posts
Wednesday, April 29, 2009
Diagnosis of Varicose Vein
Diagnosis of varicose veins:
Clinical techniques to determine reflux such as the tourniquet and Perthes test have been superseded by the use of hand-held Doppler. For completeness, the two traditional examination techniques, I am mentioning here.
The tourniquet test is performed by laying the patient flat and emptying the superficial veins in the leg. A tourniquet is applied and the patient is instructed to stand . Absence of varicosities implies control of the site of reflux proximal to the tourniquet and implies a positive test.
Perthes test is performed by repeating the tourniquet test but allowing some blood into the leg. The patient stands up and down on tiptoes and emptying of the veins implies that the muscle pump is functioning.
Investigations done in varicose veins:
Hand-held Doppler evaluation
The tip of the Doppler probe is applied to the saphenofemoral junction and the calf is squeezed or varicosities are tapped with the fingertips. A single swoosh implies a competent valve and a double swoosh indicates an incompetent valve. The procedure is repeated at the saphenopopliteal junction.
Duplex Doppler evaluation
Duplex evaluation provides real time images with physiological data on blood flow which can be amalgamated to determine luminal and parietal diameter, compressibility, echogenicity, flow direction, and valve leaflet function of the vessel.
Colour duplex should be performed in all patients who have recurrent disease, skin changes, or a history of deep venous thrombosis (DVT) or thrombophlebitis. Patients presenting with venous flaring or telangiectasia should also have colour duplex as up to a third will have superficial venous insufficiency
Photoplethysmography
Patients noted to have both superficial and deep venous reflux should undergo functional testing to determine the relative contribution of each system to reflux. Photoplethysmography works on the premise that infrared light is absorbed in varying degrees based on the volume of haemoglobin present within the limbs, and measures venous refilling time as well as the efficiency of the calf muscle pump.
Varicose Veins - Causes, Symptoms and Complications
Diagnosis of Varicose Veins
Varicose Vein - Treatment and Prognosis
Clinical techniques to determine reflux such as the tourniquet and Perthes test have been superseded by the use of hand-held Doppler. For completeness, the two traditional examination techniques, I am mentioning here.
The tourniquet test is performed by laying the patient flat and emptying the superficial veins in the leg. A tourniquet is applied and the patient is instructed to stand . Absence of varicosities implies control of the site of reflux proximal to the tourniquet and implies a positive test.
Perthes test is performed by repeating the tourniquet test but allowing some blood into the leg. The patient stands up and down on tiptoes and emptying of the veins implies that the muscle pump is functioning.
Investigations done in varicose veins:
Hand-held Doppler evaluation
The tip of the Doppler probe is applied to the saphenofemoral junction and the calf is squeezed or varicosities are tapped with the fingertips. A single swoosh implies a competent valve and a double swoosh indicates an incompetent valve. The procedure is repeated at the saphenopopliteal junction.
Duplex Doppler evaluation
Duplex evaluation provides real time images with physiological data on blood flow which can be amalgamated to determine luminal and parietal diameter, compressibility, echogenicity, flow direction, and valve leaflet function of the vessel.
Colour duplex should be performed in all patients who have recurrent disease, skin changes, or a history of deep venous thrombosis (DVT) or thrombophlebitis. Patients presenting with venous flaring or telangiectasia should also have colour duplex as up to a third will have superficial venous insufficiency
Photoplethysmography
Patients noted to have both superficial and deep venous reflux should undergo functional testing to determine the relative contribution of each system to reflux. Photoplethysmography works on the premise that infrared light is absorbed in varying degrees based on the volume of haemoglobin present within the limbs, and measures venous refilling time as well as the efficiency of the calf muscle pump.
Varicose Veins - Causes, Symptoms and Complications
Diagnosis of Varicose Veins
Varicose Vein - Treatment and Prognosis
Varicose Veins - Causes, Symptoms and Complicatons
What are Varicose Veins
The WHO defines varicose veins as saccular dilatations of veins, often being tortuous. Varicose veins can be classified as trunk varicosities, reticular varicosities or telangiectasia (thread veins). Although the majority of varicose veins are primary (due to inherent weakness of the wall of the veins), there are secondary causes also, need to be recognized, as they are managed differently.
Varicose veins occur in approximately 17% of males and 31% of females between the ages of 35 and 70 years. The prevalence increases with age. Varicose veins are more common in women and in developed countries.
How Varicose veins develop?
Venous return is dependent on venous valve integrity. Varicose veins are the manifestation of venous reflux and vein dilatation that develop due to imbalance between hydrostatic (gravitational) and hydrodynamic (muscle pump) forces within the limbs. The risk factors for the development of venous insufficiency can be primary or secondary.
In primary disease, there is an inherent weakness within the walls of the vein, causing dilatation and widening of the space between valve cusps. As the valve becomes incompetent, hydrostatic forces increase and lead to peripheral pooling, standing columns of blood within the veins and the development of varicosities. A genetic predisposition in the development and severity of varicosities can be identified in up to 70% of patients.
Secondary causes are damage to the venous walls (deep venous thrombosis), outflow obstruction (pelvic tumours) and, rarely, congenital absence of venous valves.
The sizes of the veins, though are unrelated to the extent or severity of complications.
Risk factors for the development of venous insufficiency
Primary
#Age
#Female sex
#Contraceptive pill use
#Prolonged standing
#Obesity
#Positive family history
Secondary
#Deep venous valvular insufficiency
#Incompetent perforating veins
#Venous outflow obstruction (pelvic tumours)
#Congenital abnormalities
#Arteriovenous malformation
Symptoms of varicose veins:
The majority of patients with varicose veins are asymptomatic. Of symptomatic patients, men often attend complaining of itch whilst females usually present with heaviness, tension and aching. Up to a third of patients' symptoms can be attributed to other problems. It is vital to ascertain whether the patient has had varicose vein surgery in the past and/or suffered a deep venous thrombosis or thrombophlebitis. These conditions make varicose vein surgery more difficult and increase the likelihood of deep venous insufficiency for which treatment is markedly different.
The distribution of disease, particularly whether the long, short or both saphenous veins are involved is determined by the clinician.
Complications of varicose veins
#Bleeding
#Ulceration
#Thrombophlebitis
#Complications of venous hypertension
#Pigmentation
#Lipodermatosclerosis
#Oedema
#Eczema
Varicose Veins - Causes, Symptoms and Complications
Diagnosis of Varicose Veins
Varicose Vein - Treatment and Prognosis
The WHO defines varicose veins as saccular dilatations of veins, often being tortuous. Varicose veins can be classified as trunk varicosities, reticular varicosities or telangiectasia (thread veins). Although the majority of varicose veins are primary (due to inherent weakness of the wall of the veins), there are secondary causes also, need to be recognized, as they are managed differently.
Varicose veins occur in approximately 17% of males and 31% of females between the ages of 35 and 70 years. The prevalence increases with age. Varicose veins are more common in women and in developed countries.
How Varicose veins develop?
Venous return is dependent on venous valve integrity. Varicose veins are the manifestation of venous reflux and vein dilatation that develop due to imbalance between hydrostatic (gravitational) and hydrodynamic (muscle pump) forces within the limbs. The risk factors for the development of venous insufficiency can be primary or secondary.
In primary disease, there is an inherent weakness within the walls of the vein, causing dilatation and widening of the space between valve cusps. As the valve becomes incompetent, hydrostatic forces increase and lead to peripheral pooling, standing columns of blood within the veins and the development of varicosities. A genetic predisposition in the development and severity of varicosities can be identified in up to 70% of patients.
Secondary causes are damage to the venous walls (deep venous thrombosis), outflow obstruction (pelvic tumours) and, rarely, congenital absence of venous valves.
The sizes of the veins, though are unrelated to the extent or severity of complications.
Risk factors for the development of venous insufficiency
Primary
#Age
#Female sex
#Contraceptive pill use
#Prolonged standing
#Obesity
#Positive family history
Secondary
#Deep venous valvular insufficiency
#Incompetent perforating veins
#Venous outflow obstruction (pelvic tumours)
#Congenital abnormalities
#Arteriovenous malformation
Symptoms of varicose veins:
The majority of patients with varicose veins are asymptomatic. Of symptomatic patients, men often attend complaining of itch whilst females usually present with heaviness, tension and aching. Up to a third of patients' symptoms can be attributed to other problems. It is vital to ascertain whether the patient has had varicose vein surgery in the past and/or suffered a deep venous thrombosis or thrombophlebitis. These conditions make varicose vein surgery more difficult and increase the likelihood of deep venous insufficiency for which treatment is markedly different.
The distribution of disease, particularly whether the long, short or both saphenous veins are involved is determined by the clinician.
Complications of varicose veins
#Bleeding
#Ulceration
#Thrombophlebitis
#Complications of venous hypertension
#Pigmentation
#Lipodermatosclerosis
#Oedema
#Eczema
Varicose Veins - Causes, Symptoms and Complications
Diagnosis of Varicose Veins
Varicose Vein - Treatment and Prognosis
Tuesday, April 7, 2009
Symptoms of peripheral vascular diseases
Symptoms of Peripheral Arterial disease
Blood flow through the arterial system may be reduced gradually or suddenly, in either large or small vessels. This leads to a range of potential presenting symptoms.
Claudication
Claudication is muscle pain that occurs with exercise. It is often cramping in nature and relieved by rest. Once recovered, the patient is able to exercise again for a similar duration before the cramp recurs. It is caused by chronic stenosis or occlusion in the artery feeding the muscle group: for example, calf pain on walking due to superficial femoral artery occlusion.
Rest pain
Pain occurring at rest reflects more severe ischaemia, either chronic or acute. The distal parts of the limb and foot are most affected, unlike claudication which involves the muscle groups in the calf and thigh. Typically rest pain is aggravated by elevation of the limb. Foot pain is therefore worse at night. The patient may wake to hang the foot out of the bed, or get up and walk around until the foot recovers. The pain is severe and often requires strong analgesics to control it.
Color changes of the limb
Acute arterial occlusion leads to a pale 'white' leg because the vessels in the skin contain little blood. These vessels then dilate and fill slowly with de-oxygenated blood producing a 'mottled blue' discoloration. If the occlusion is acute on chronic there will be some collateral supply: the color change may not be so dramatic and may recover to normal.
In chronic ischaemia the foot will become pale when elevated but is often red when dependent due to reactive hyperaemia. These color changes form the basis of Buerger's test for chronic severe ischaemia.
Sensory motor symptoms
With severe ischaemia patients may describe numbness of the foot or toes. Loss of motor function with weakness or paralysis is seen in severe acute ischaemia.
Change in temperature
The ischaemic limb fails to maintain a normal temperature and becomes cold. Patients may take to wearing thick socks and wrapping the feet in blankets. This does help to warm the limb to some extent and can occasionally be misleading.
Symptoms of Venous disease
Pain
The pain associated with venous insufficiency is often an ache on standing that gets worse as the day progresses. Distended varicose veins may be a focus of pain and tenderness. Inflamed thrombosed veins (thrombophlebitis) are acutely painful, red and tender.
Swelling
Oedema from the ankle extending up the leg is a common symptom in patients with worsening venous insufficiency.
Blood flow through the arterial system may be reduced gradually or suddenly, in either large or small vessels. This leads to a range of potential presenting symptoms.
Claudication
Claudication is muscle pain that occurs with exercise. It is often cramping in nature and relieved by rest. Once recovered, the patient is able to exercise again for a similar duration before the cramp recurs. It is caused by chronic stenosis or occlusion in the artery feeding the muscle group: for example, calf pain on walking due to superficial femoral artery occlusion.
Rest pain
Pain occurring at rest reflects more severe ischaemia, either chronic or acute. The distal parts of the limb and foot are most affected, unlike claudication which involves the muscle groups in the calf and thigh. Typically rest pain is aggravated by elevation of the limb. Foot pain is therefore worse at night. The patient may wake to hang the foot out of the bed, or get up and walk around until the foot recovers. The pain is severe and often requires strong analgesics to control it.
Color changes of the limb
Acute arterial occlusion leads to a pale 'white' leg because the vessels in the skin contain little blood. These vessels then dilate and fill slowly with de-oxygenated blood producing a 'mottled blue' discoloration. If the occlusion is acute on chronic there will be some collateral supply: the color change may not be so dramatic and may recover to normal.
In chronic ischaemia the foot will become pale when elevated but is often red when dependent due to reactive hyperaemia. These color changes form the basis of Buerger's test for chronic severe ischaemia.
Sensory motor symptoms
With severe ischaemia patients may describe numbness of the foot or toes. Loss of motor function with weakness or paralysis is seen in severe acute ischaemia.
Change in temperature
The ischaemic limb fails to maintain a normal temperature and becomes cold. Patients may take to wearing thick socks and wrapping the feet in blankets. This does help to warm the limb to some extent and can occasionally be misleading.
Symptoms of Venous disease
Pain
The pain associated with venous insufficiency is often an ache on standing that gets worse as the day progresses. Distended varicose veins may be a focus of pain and tenderness. Inflamed thrombosed veins (thrombophlebitis) are acutely painful, red and tender.
Swelling
Oedema from the ankle extending up the leg is a common symptom in patients with worsening venous insufficiency.
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