vascular surgery pdf - د. عبد الأمير

Dr. Abdul Ameer M.
Hussein
Lec. 1

DISEASE OF THE VEINS

Tues. 2 / 12 / 2014

Published by : Ali Kareem

مكتب اشور لالستنساخ

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Disease of The Veins Dr. Abdul Ameer M. Hussein

2–12-2014

DISEASE OF THE VEINS

 Venous disease refers to all conditions related to or caused by veins that

become diseased or abnormal.

 Venous disease is quite common.
 Mild venous disease is usually not a problem for patients, but as venous

disease worsens, it can become crippling chronic venous insufficiency.

VEINS

Divided into Superficial and Deep System

Deep System

  Named for by associated arteries
  Found running along the arteries
  Predictable anatomy
  Causes most of the Morbidity

1-  DVT
2-  PE
3-  Severe Leg Swelling
4-  Ulcerations

 Little Surgical interventions (IVC Filter)
 Medical Management

Superficial Venous System

  These are the veins we see
  Perforators connect superficial and deep systems
  Highly variable anatomy
  Many unnamed branches and Tributaries

Disease of The Veins Dr. Abdul Ameer M. Hussein

2–12-2014

Named perforators along the greater saphenous distribution

Venous Disease

- Superficial System

  Varicose Veins
  Spider  Veins
  Venous Malformation
  Venous Reflux
  Leg Swelling
  Venous Ulceration

Superficial Anatomy

Disease of The Veins Dr. Abdul Ameer M. Hussein

2–12-2014

Deep System = Light

blue

Superficial System =

Dark blue

Complex and variable

anatomy

Physiology



Arteries deliver blood to tissue



Veins return blood to the heart



Heart is the arterial pump

o What pumps the venous blood back to the heart ?

 Venous pressure is about 25mmHg at the foot
 Pressure needed 80mmHg to return blood

o Two unique features of veins accomplish this

 Most important is one-way Venous Valves
 Easily compressible by surrounding muscle (calf pump)

Disease of The Veins Dr. Abdul Ameer M. Hussein

2–12-2014

Calf Muscle Pump

Normal venous flow in the Leg

Normal Flow



Superficial veins drain into the deep

veins



From the foot up to the heart

Superficial vein disease always starts with

abnormal valves and interruption to normal

flow called venous reflux

Disease of The Veins Dr. Abdul Ameer M. Hussein

2–12-2014

Abnormal flow = Venous Reflux

Damaged Valves

1-  Blood flows to the skin
2-  Blood is pushed distally and proximally
3-  Close loop recirculation
4-  Blood is retained in the leg



Increased volume of blood (heaviness Fatigue)



Increased venous pressure



Veins Dilate (varicose veins)

Causes of Venous Reflux

Disease of The Veins Dr. Abdul Ameer M. Hussein

2–12-2014

Symptoms of venous reflux



Leg Fatigue



Leg Heaviness



Itching and pain along veins



Varicose Veins



Spider veins (not always 2

to reflux)



Leg swelling( think DVT 1

)



Skin Discoloration (lipo dermatosclerosis)



Venous ulceration

Varicose Veins

Definition: Swollen and enlarged veins that you can see just under the surface of
the skin. These veins usually occur in the legs, but they also can form in other parts
of the body.

  Located in the Subcutaneous(between skin and fascia)
    Remember this is only a manifestation of the underlying disease
  Mild Disease is cosmetic issue
  Advanced Disease significant medical problem

i) -

Pain

ii) Swelling

iii) Ulcerations



Incidence Increases with age



Females to male 3 to 1



50% of the population will affected in their

life time

Disease of The Veins Dr. Abdul Ameer M. Hussein

2–12-2014

Spider Veins

The proper term is Telangiectasia

 These are non raised dilated veins located in the dermis (deep layer of the

skin)

 Single layer endothelium, minimal muscle

 Can be Red or Blue in color depending on the origin

 Do not cause major medical complications

 Appears earlier than varicose veins

 More common in females

 Reticular Veins are lager feeding veins

Etiology : Multifactorial



Venous Hypertension associated with varicose veins



Congenital: vascular nevi, neonatal hemangiomatosis.



Collagen Vascular Disease: lupus



Hormonal factors: pregnancy, estrogen therapy, topical steroids



Trauma: contusion, incisions



Infections

Venous Stasis Ulcers

Etiology

1- Venous Hypertension



Venous reflux



DVT



Varicose veins

2- Edema
3- Biological factors



Leakage of proteins impedes O2 diffusion

Disease of The Veins Dr. Abdul Ameer M. Hussein

2–12-2014



Aggregation of white cells

 Block capillary flow
 Release on inflammatory proteins

Symptoms :

  Itching
  Discoloration
  Redness or swelling in the affected area
  Pain or a feeling of heaviness in the affected leg
  More common in elderly population
  Venous ulcerations   50% are non healing ulcers

Differential Diagnosis

1-  Arterial ulcers
2-  Malignancy : basal and squamous cell, lymphoma
3-  Infections: HIV, fungal
4-  Collagen vascular disorders
5-  Lymphatic obstruction

Diagnosis of venous disease

 Physical exam



Appearance



Trendelenburg test



Palpation



Hand Doppler

 Duplex Examination



DVT



Size of veins



Map out superficial veins



Locate the site of reflux



Find refluxing perforators

Disease of The Veins Dr. Abdul Ameer M. Hussein

2–12-2014

Duplex Anatomy



Locate GSV Junction(FSJ)



Look for Mickey's

Normal venous flow

Look at valve

Venous flow is opposite the artery

Treatments

 Conservative management techniques
 Ultrasound guided Sclerotherapy with foam

Conservative management

 This can offer relief from burning, itching, and general discomfort caused by

large, unhealthy veins.

 requires minimal lifestyle changes and can alleviate symptoms without

requiring a medical procedure

Common techniques include :

o Compression stockings.
o Periodic elevation of legs during the day.

o Medication.

Disease of The Veins Dr. Abdul Ameer M. Hussein

2–12-2014

Treatment of Varicose Veins

 Conservative management

o Exercise
o Leg elevation

o Compression stocking

 Surgical treatment

o Standard Ligation and stripping
o Phlebectomies

 Minimally invasive procedures

o Laser Ablation
o Radio Frequency ablation

o Sclerotherapy

Surgical ligation and Stripping

 Standard treatment for a century
 General anesthesia

 Pain

 Long recovery

 Some complications

 Good cosmetic results

Vein Ablation

 Laser Ablation (EVLA or EVLT)

 Uses light to heat the vein

 Radio Frequency

 Uses radio frequency to heat the vein
 Office based procedure

 Done under local anesthesia

 One needle puncture at the level of the knee

 Takes about 1 hour

Disease of The Veins Dr. Abdul Ameer M. Hussein

2–12-2014

 Patient resumes normal activity same day

Sclerotherapy



Cumulate vein with needle



Inject Sclerosing Solution

o Sotradecol (Sodium tetradecyl sulfate)
o Pilodocanol

o Hyper tonic Saline

o Foam



Intravenous injection causes intima inflammation and thrombus formation

Sclerotherapy Use

 Neovascularization
 Perforators

 Spider veins

 Reticular veins

 GSV : has high recurrence rate

Done By

Ali Kareem