Surgery Marrow Pg 477-486 (Vascular Surgery)

Varicose Veins

• Varicose veins are dilated and tortuous veins with defective valves.
• Primary varicose veins are caused by congenital defects in the vein walls or valves.
• Secondary varicose veins are more common, often caused by deep vein thrombosis (DVT) or tumors.
• Other risk factors include prolonged standing, female gender, family history, and pregnancy.

Pathophysiology

• Normal blood return against gravity is maintained by:
  • Increased intra-thoracic pressure during inspiration.
  • Compression of surrounding muscles.
  • Decreased pressure in superficial veins during exercise.
• Increased pressure in superficial veins during exercise, especially in the presence of valve dysfunction, can lead to ambulatory venous hypertension.

Clinical Features

• Common presentations include:
  • Dilated veins: Varicose veins (>3mm), reticular veins (1-3mm), and thread veins (≤1mm).
  • Dull, aching pain.
  • Pigmentation due to hemosiderin deposition.

Surgical Management

• The document focuses on surgical management of incompetent great saphenous vein (GSV) and small saphenous vein (SFJ).
• Endovenous Laser Ablation Therapy (EVLT) or Radiofrequency Ablation (RFA) are the preferred treatments for incompetent GSV + SFJ.
• Incompetent perforators can be addressed through Dodd & Cockett procedure or SEPS (Sub-fascial endoscopic) perforator surgery.

Complications

• Complications of Varicose Vein Surgery:
  • Wound infection (less common due to antibiotics).
  • Bruising.
  • Recurrence (more common in SSV).
  • Bleeding.
  • Injury to vessels.
  • Injury to nerves (most common in GSV and SSV surgery).
• Complications of Varicose Veins:
  • Bleeding.
  • Calcification of veins.
  • Superficial thrombophlebitis.
  • Pigmentation.
  • Lipodermatosclerosis.
  • Ulceration.
  • Marjolin's ulcer.

Varicose/Venous Ulcers

• Most commonly occur in the gaiter area (above the medial malleolus).
• Shallow ulcers with sloping edges, pale granulation tissue, pigmented margins, and non-healing.

Saphenous Veins

• GSV (Great Saphenous Vein): Begins in the dorsal venous arch of the foot, ascends along the medial side of the leg, and terminates at the saphenofemoral junction.
• SSV (Short Saphenous Vein): Originates from the lateral side of the dorsal venous arch, ascends along the posterior aspect of the leg, and terminates at the sapheno-popliteal junction.

Perforators

• Connect the superficial and deep venous systems.
• Different perforators are named based on location, including Hunterian perforators, Dodd's perforator, Boyd's perforator, Cockett's perforators, and May/Kuster's perforator.

Giacomini Vein

• Connects the GSV and is a cause of recurrence after surgery.

Important Considerations for Surgery

• Careful anatomical marking of the sapheno-popliteal junction is crucial.
• Surgeons should be mindful of the sural nerve's proximity to the GSV.

Types of Lower Limb Ulcers

Management of Venous Ulcers

• Bisgaard Regime: Education, limb elevation, elastic compression stockings (Grade III), multi-layer compression bandage, surgery, and pentoxifylline.

Marjolin's Ulcer

• Malignant transformation of long-standing venous ulcers or burns.
• Commonly squamous cell carcinoma (SCC).
• Characterized by raised and everted edges (cauliflower-like).
• Wide local excision is the treatment of choice.

Associated Syndromes

• Klippel-Trenaunay Syndrome: Mesodermal abnormality, non-familial, characterized by absent deep veins and cutaneous naevus.
• Parkes-Weber Syndrome: Multiple arteriovenous (A-V) fistulas, high output cardiac failure, and limb hypertrophy.

CEAP Classification

• A clinical, etiological, anatomical, and pathophysiological classification system for venous disease.
  • Clinical (C): Co, Cl, Ca, Car, C3, CA, C4a, C4b, C4c, C5, C6, Clor, etc.
  • Etiological (E): Congenital, Primary, Secondary, No venous etiology identified.
  • Anatomical (A): Superficial veins, Perforator vein, Deep vein, No venous location identified.
  • Pathophysiological (P): Reflux, Obstruction, Reflux & Obstruction, No venous pathology identified.

Clinical Tests and Investigations

• For SFJ incompetence: Trendelenburg test, Morrissey's cough impulse, Schwartz test.
• For perforator incompetence: Trendelenburg test, Multiple tourniquet test, Fegan's method.
• For DVT: Modified Perthes test.

Doppler/Duplex Scan

• Used to assess flow direction and presence of reflux (retrograde flow lasting ≥0.5 sec).

Management

• Adjunctive Management:
  • Compression Garments: Class III compression garments (25-35 mmHg).
  • Horse Chestnut Seed Extract: Safe and efficacious in treating chronic venous hypertension, improves symptoms and reduces leg volume.

Varicose Vein Treatment Methods

• Endovenous Laser Therapy (EVLT): Utilizes 1470 nm laser to generate heat (60 J/cm).
• Radiofrequency Ablation (RFA): Generates heat at 120°C over 20-second cycles.
• Dodd and Cockett Procedure: Multiple sub-fascial procedure.
• SEPS (Sub-fascial Endoscopic Perforator Surgery): Multiple perforator ligation with a single incision.

Newer Modalities

• Endovenous Glue Therapy: Cyanoacrylate glue collapses dilated veins.
• Trivex: Transilluminated powered phlebectomy to visualize and identify varicose veins subcutaneously.
• Foam Sclerotherapy: Injecting a sclerosant (e.g., air, sodium tetradecyl sulphate) that collapses the dilated vein.

Other Clinical Findings

• Corona phlebectasia/malleolar flare: Fan-shaped pattern of telangiectasia at the ankle.
• Atrophic blanche: White, porcelain-like plaques, typically occur in the lower leg, result of poor tissue oxygenation.

Acute Arterial Occlusion

• Most commonly caused by an embolus, often originating from the heart.
• Risk factors: History of coronary artery disease (CAD) and atrial fibrillation.
• Clinical features: 6 P's - Pain, Pallor, Paresis, Pulselessness, Paresthesia, Poikilothermia (cold limbs).
• Investigations: Duplex scan (Color Doppler + 8 mode USG).
• Management:
  • Early presentation (within 6-8 hours): Thrombolysis using Fogarty's balloon.
  • Late presentation with gangrene: Amputation.
• Reperfusion injury:
  • Anaerobic metabolism initially due to arterial block.
  • Free radical injury after restoration of blood flow.

Tests for Varicose Veins

• Trendelenburg Test: Assesses rapid filling from above versus gradual filling from below.
• Fegan's Method: Identify incompetent perforator sites by feeling along the vein and marking blowouts.
• Morrissey's Cough Impulse: Check for incompetence at SFJ by observing a cough impulse.
• Multiple Tourniquet Test: Localize incompetent perforators by applying tourniquets at various levels.
• Modified Perthes Test: Rule out DVT by observing pain and swelling changes after walking with a tourniquet below the SFJ.

Investigation

• Doppler/Duplex Scan: Assesses flow direction and presence of reflux.
  • Red = flow away from heart.
  • Blue = flow towards heart.

Management

• Adjunctive Management:
  • Compression garments: Class III compression garments (25-35 mmHg), but can be challenging with co-existing arterial disease.
  • Horse Chestnut Seed Extract: Safe and effective for chronic venous hypertension.

This quiz explores varicose veins, including their definition, types, and pathophysiology. It covers risk factors, clinical features, and the body's mechanics in maintaining blood flow. Test your knowledge on this common vascular condition.