INVESTIGATIONS AND MANAGEMENT

OF
VENOUS DISEASES

VV NARASIMHA RAO

Varicose veins
Varicocele
thrombophlebitis
Deep venous thrombosis

VARICOSE VEINS
Defined as dilated ,usually tortuous ,
subcutaneous veins.

thread veins :0.5 -1 mm

reticular veins:1-3mm
varicose veins:>3mm
Etiologically classified as

primary

secondary

 Primary varicosities due to

- congenital incompetence or absence of
valves
- inheritance with FOXC2 gene
- weakness or wasting of musclesdefective connective tissue &smooth ms in
the venous wall.
- klippel-trenaunay syndrome ,avalvulia,
parkes-weber syndrome.

 Secondary varicosities
occupational-standing for long hours
recurrent thrombophlebitis
obstruction to venous return like abdominal
tumors,retroperitoneal fibrosis
,lymphedenopathy,ascites
pregnancy(progesterone harmone), obesity,chronic
constipation
AV malformations
iliac vein thrombosis
tricuspid valve incompetence

 Clinical features:
-dragging pain,postural discomfort
-Heaviness in the legs
-night time cramps
-Edema feet, itching
-Dicolouration,ulceration in the
feet.

Investigations
1..Venous doppler

standing position

by hearing the changes in sound,venous

flow,venous reflux.

doppler at SFJ , typical audible whoosh

signal >0.5 sec, while performing valsalva
manoeuvre sign of reflux

signal for 0.5 sec- grade I reflux

0.5 -1 sec-grade II reflux

1-1.5sec-grade III reflux

>1.5sec grade IV reflux

2..Duplex scan
- heighly reliable investigation for varicose
veins
-high resolution B mode usg and pulsed wave
colour doppler
-Which shows direct visualisation of veins,gives
functional and anatomical information and colour
map.
- blue to represent antegrade venous flow
towards heart
red -reverse

 Aim of duplex scan

- which saphanous junctions are
incompetent and their locations (SFJ,SPJ)
- extent of reflux in the saphanous vein
and their diameter
- number,location,diameter of
perforators
- competence and evidence of previous
thrombosis in deep venous system

 Micky mouse sign

3..Venography: commonly done before

doppler
- a. Ascending venography-water soluble
dye into dorsal venous arch then into deep
veins after tourniquet applied above the
malleoli
- x rays are taken below and above knee
any block in the deep veins ,its extent
,perforator status can be made out of this.
Good reliable inv for DVT

 b.Descending venography
when ascendng venogram is not
possible and also visualise
incompetent veins
contrast into femoral vein
x rays to visualize deep veins and
incompetent veins

4..Plethysmography
noninvasive
it gives functional information on
venous volume changes and calf
muscle pump insufficiency
-photo plethysmography
-air plethysmography

a.Photo plethysmography
- using probe transmission of light through the
skin,venous filling of the surface venules which
reflects the sup venous pressure is measured.
-dorsiflexion at ankle for 10times to empty the
venules
- pt takes rest and refilling occurs
- in normal people,it occurs through arterial inflow
in 20-30sec,
- in venous incompetence filing also occurs by
venous reflux and so refilling time is faster than
normal.

 B .Air plethysmography
- supine position,elevate to empty the vein.
- air filled plastic pressure bladder is placed on calf
to detect volume changes. Minimm vol is recorded.
- pt in upright position and venous vol is assessed.
VFI (venous filling index)-max venous vol divided
by time required to achieve max venous vol.
- VFI is a measure of reflux.
- Ejection fraction is vol change measured prior
and after single tiptoe manoeuvre-measure of calf
pump action.

 Residual venous fraction is an index

of overall venous function.
- which is venous vol in leg after
tiptoe manouvre divided by venous
vol prior to manouvre.
Increased VFT and diminished
ejection fraction in a pt will benefit
from surgery.

5..Ambulatory venous pressure

-invasive method
- needle inserted into dorsal vein of foot to transducer to
get its pressure equivalent to pressure in the deep veins of
the calf.
Ten tiptoe manouvres done by pt.with initial rise in
pressure ,pressure decreases and eventually stabilises with
a balancepressure now is called ambulatory venous
pressure
Time required to return to 90%of baseline is k/a venous
refilling time
Rise of AVP signifies venous hypertension
AVP>80mm of hg has got 80%chance of ulcer formation

6..Arm foot venous pressure

foot pressure is not more than 4 mm of hg

above the arm pressure
7..Ultrasonography of abdomen
8..If venous ulcer dicharge for c/s,edge biopsy to
rule out marjolins ulcer
9.Plain x ray look for periostitis
10.Varicography-used in recurrent varicose veins

non ionic,iso osmolar,non thrombogenic

contrast inj, to get anatomical mapping of the
varicose veins

TREATMENT
CONSERVATIVE TREATMENT
Elastic crape bandage from below upwards presuure
gradient of 30-40 mm of hg is provided
1.COMPRESSION STOCKINGS

below knee stockings usually prescribed.

classified acc to the pressure exerted
class 1 stockings exert pressure of 14-17 mm of hg
class 2- 18-24mm of hg
class 3- 25-35 mm of hg
compression stockings significantly improve symp of
varicose veins.by reducing ambulatory venous pressure.
Disadvantage is incorrect application can have serious
problems like pressure necrosis,tournique effect

 Type I: light wt confirming stretch

bandages.these comprise light wt
elastomer with high elasticity but little
power. It is used to retain dressings
typeII(short stop):light support
bandages.minimal stretch.exihibit limited
elasticity but tend to lockout on minimal
extension.unsuitable for controlling edema.
typeIII(long stop): extensible elastic and
powerful to a verying degree.

 A pt with ABI(ankle brachial index)must be

>1.0 per kg per leg to wear compression
stockings, otherwise the stockings may
obstruct the pt arterial flow.
c/I
perpheral arterial disease
Heart failure

Septic phlebitis

oozing dermatitis

Advanced peripheral neuropathy.

2. ELEVATION OF LIMB it releives edema

two short times during daytime and entire
night, elevation of foot above the level of
heart and toes above the level of nose.
3.Unna boots-a triple layer compression
dressing,with a zinc oxide guaze wrap in
contact with skin, from base of the toes to
tibial tuberosity
median time to healing for individual ulcer
is 9weeks

4.Pneumatic compression method

provides dynamic sequential
compression
These methods reduce the AVP, reduce
transcapillary fluid leakage by
increasing subcutaneous pressure
and improves cutaneous
microcirculation.

 Drugs:

calcium dobesilate 500mg bd

it improves lymph flow, improves macrophage

mediated proteolysis and reduces edema

diosmin-450mg bd

diosmin 450mg+hesperidin 50mg(DAFLON 500mg)mainly to releive ngt cramps. It increases venous tone.

toxerutin 500mg bd-anti erythrocyte aggregation

agent which improves capillary dynamics

benzopyrones,saponins,plant extracts,
Benefits of all these drugs are doubtful

1.SCLEROTHERAPY :
- fegans tachnique-by injecting sclerosants into
the vein,complete sclerosis of the venous wall can
be achieved.
INDICATIONS:
- management of smaller varices
(reticular,thread veins)
- uncomplicated perforated incompetence
- recurrent varices
- isolated varicosities
- age/unfit for surgery

sclerosants used are

-sodium tetradecyl sulphate 3%mc used
-sodium morrhuate
-ethanolamine oleate
-polidocanol 1% or 3%

 Mech of action:
-causes aseptic inflammation
-causes perivenous fibrosis
-causes approximation of intima
leading to obliteration by endothelial
damage
-alters intravascular ph/osmolarity
-changes surface tension of plasma
membrane

. 0.5 ml of sclerosant is injected and immediately

compression is applied on the vein.
Inj started at the ankle region and proceeded
upwards along the length of the vein at diff
points
Pressure bandage applied for 6 weeks
Inj repeated at 2-4 weeks intervals for 2-4
sessions.
Entraped blood may require to be evacuated
after 14 days which is essential to prevent
recanalisation

2.Micro sclerotherapy:
- Very dilute soln of sod tetradecyl
sulphate(0.1% of 0.1ml),polidocanol
is injected into the thread veins and
reticular veins
- f/b application of crape bandage
- Dermal flares will dissappear well
by this method

3. Transillumination microsclerotherapy

imaging of the veins using light

generated by halogen bulb with high
quality fibre illumination over the
skin uniformly and passing 30G
needle for sclerotherapy

4. Foam sclerotherapy:
- 1ml sclerosant with 4ml of air to
make 5ml foam by rapidly injected
into another syringe.
-5ml foam injected into sup vein.
-Total 6ml sclerosant with 30ml
foam can be used
-Air get absorbed between foam and
endothelial lining is destroyed

 Advantages:

cheap,opd procedure,easy

can be repeated many times

aneasthesia not needed

Disadvantages:headache, transient
blindness,stroke,air embolism,
thrombophlebitis,pigmentation.
c/i:peripheral arterial ds,DVT

5. Echosclerotherapy:

sclerotherapy done under duplex usg

image guidance
6. Catheter directed sclerotherapy:
- this catheter has got side holes all around
the specific length for uniform contact With
venous wall with foam
-Ballon at the tip,which after inflation
blocks the sfj thus preventing embolization
of foam.

 It has got three ext ports

one for ballon inflation,one for
bladder valve port,one for injection.

 Advantages of sclerotherapy:
opd procedure, doesnt require anaesthesia
.Disadvantages:
- inadvertent subcut inj>skin necrosis
-thrombophlebitis, hyperpigmentation
-anaphylaxis,vasovagal shock,allergy
-DVT, intravenous hematoma
-Temporaray ocular disturbances
-Intra arterial inj>serious complications
-Skin staining,inj ulcers,persistant local pain

 Contraindications for sclerotherapy:

saphanofemoral incompetence

DVT

huge varicosities

peripheral arterial ds

hypersensitivity/immobility

venous ulcer-relative
contraindication

 Anaphylaxis is least with polidocanol

Anaphylaxis is common after sod
morrhuate
Post sclerotherapy walking immed
after inj for 30 min with elastic
bandage in place prevents/minimises
the chance of DVT.

 Surgery:
1. Trendelenburg operation:
- juxtafemoral flush ligation of LSV after
ligating tributaries.
2-Trendelenburg+Stripping of vein
-extraluminal collission technique using myers
stripper
-inverting or invaginating stripping using
codmans stripper
Stripping is more effective than just ligation at the
junction.

 Complications of stripping
- hematoma,infection, ulceration,
- saphanous neuralgia(1%)
- recurrence(30%) by
neoangiogenesis and
revascularization

3.Subfacial ligation of cockett and

dodd:
-perforators ligated deep to deep
fascia through incision in
anteromedial side of the leg.
4. Ligation of short saphanous
vein
- at saphanopopliteal
jn,variations of spj is common,
Stripping is better than ligation

5. Lintons vertical approach-subfascial

ligation of perforators by vertical incision
6. Stab avulsion of varicose veins and
perforators:
-avulsion is done using mosquito foreceps
or avulsion hooks-hook phlebectomy.
-most popular method.
-Multiple incisions are made and veins are
carefully and gently avulsed.postoperative
compressive bandage is must.

MINIMAL INVASIVE METHODS:

1. subfascial endoscopic perforator ligation
surgery( SEPS)
- special telescope is introduced deep to deep fascia
through a single small vertical incision at prox leg.
-Technique is done under tournique 300mm of hg
pressure .endoscope advanced down
-Perforators identified and fulgurated using bipolar
cautery or clips can be applied.
-It is recommended in chronic venous insufficiency.
Limitation-difficulty in lift off skin in cases with
lipodermatosclerosis.

2. Radiofrequency ablation method:

- general or regional anaesthesia
-RFA catheter passed into LSV or SSV near SFJ
or SPJ
-85 C temp is used for longer period of time to
cause endothelial damage,collagen degeneration
and venous constriction.
-Phlebectomy done while withdrawing the
catheter.
-CELON RFITT-radiofrequency induced thermal
therapy(newer type)

3. Trivex method:
-under subcut illumination and local anesthesia ,
large quantity of fluid inj percutaneously to identify
sup veins under.
-Tumulescent anaesthesia causes hydrodissection
-Trivex resector and illuminator placed under skin,
resector gently extract vein by suction and
morcellation
-Remove all sized veins,achieve good pain
relief,with minimal complications like
bruising,induration

4. Endovenous laser ablation:

- day care surgery
-supine position,hip ext rotated,knee flexed.
-Under u/s guidence LSV is canulated above the
knee,guide wire is passed beyond SFJ and 5-french
catheter is passed over guide wire & tip is placed 1cm
distal to the junction.
-200ml of 0.1%lignocaine is infiltrated along the
length of LSV.
-Laser fibre inserted up to the tip of catheter
&catheter withdrawn for 2cms ,laser fibres protruds
for 2cms

 Laser fibre is fired step by step using diode

laser (810-1470nm diode laser energy)
Catheter removed,pressure bandage is
applied for 2weeks.
Heat produced by laser produces steam
bubbles with thermal damage of
endothelium leading into occlusion of vein
Disadvantage is inability to create flush
occlusion allowing tributaries to open upto
cause recurrence

 Complications:
Bruising(51%),hematoma,temporary
numbness,induration,skin
burns,difficulty in cannulating
unsuitable vein,sensory
disturbances,infection, DVT.

 Problems in varicose vein surgery

recurrence

hematoma

infection

DVT(0.01%)

saphanous neuralgia,sural
neuralgia

Varicocele
Dilatation and tortuosity of pampiniform
pluxes of veins & so also the testicular veins.
Lt side tesicular vein drais into lt renal vein
Rt side it drains the IVC.
Varicocele common in tall ,thin people.
Mc- left side, often b/l.
Lt testicular vein join lt renal vein
perpendicularly ,lt side vein is longer and
liable to get compressed by loaded sigmoid
colon, often compressed by aorta and SMA.

 Primary/Idiopathic:95%
Absence or incompetence valve at the jn
of testicular vein & lt renal vein causing
inefficient drainage of blood.
secondary:
Lt sided renal cell carcinoma,tumor
proliferates into lt renal vein& blocks the
entry of lt testicular vein-which is irreducible.
It causes increased temp in the scrotum,
which depress spermatogenesis-infertility.

 c/f:swelling in the root of scrotum,

bag of worm feeling, dragging pain,
impulse on coughing, reducible on
lying down.
Bow sign:holding the varicocele b/w
thumb and finger,pt asked to
bow.varicocele gets reduced in
size.bowing reduces the blood flow of
testicular vein and pampiniform
plexus reduction in size.

 Grading:
grade1- no dilated intrascrotal veins,

reflx in spermatic cord vein of the inguinal

region in valsalva menouvre.
grade 2-prominent veins at upper pole of testis,
Reflux at upper pole during valsalva menouvre
grade 3-no major dilatations in supine position,
dilated veins upto lower pole of testis seen only
on standing,
Reflux at lower pole veins during valsalva
menouvre

 Grade 4-dilated veins even in supine

position
reflux during valsalva menouvre
Grade 5-dilated veins
reflux without valsalva menouvre

 Investigations:
venous doppler of the scrotum and
groin
u/s abdomen to look for kidney
tumor
semen analysis

 Treatment:
indications for surgery:

pain

oligospermia-usually in 6-12
weeks oligospermia improves very
well and also the conception rate.

 Tratment:
palomas operation: supra inguinal
extraperitoneal ligation of the testicular veins.
Inguinal approach:easy and safe
Marc-goldstein(subingunal approach):

sub inguinal approach at superficial inguinal

ring ouside the ext oblique aponeurosis.
Scrotal approach:in grade 4
Laporoscopic approach.

 Complications :
hemorrhage& scrotal hematoma
infection,pyocele
injury to testicular artery
injury to ilio inguinal nerve and
pain
recurrence- 5-10%.

Thrombophlebitis
Inflammation of veins usually superficial
veins.

it is actually superficial thrombosis with

inflammation.
Acute: iv cannulation,trauma,minor
infections,hypercoagulability
Recrrent,spontaneous-polycythemia
vera,buergers ds.
Thrombophlebitis migrans-seen in visceral
malig like pancreas,stomach

 c/f:pain,redness,fever,cord like
thickening.
Treatment: limb elevation

anti inflammatory
drugs,antibiotics

compressive therapy

anti coagulants-LMWH for

SVT>3cms in length.

Deep vein thrombosis

Also k/a phlebothrombosis.
It is a semisolid clot in the vein which
has got high tendency to develop pul
embolism and sudden death.
Etiology:virchows triad: stasis,
hypercoagulability
vein wall
injury

 Sites:

leg veins:most common.

veins of soleal muscle in calf.

pelvic veins:internal iliac veins

mc in PID in females

prostatic veins are the site of

origin

upperlimbs:axillary vein
thrombosis

 Phlegmasia alba dolens: DVT of

femoral vein
(deep femoral vein commonly) causing
painful congesion and edema of leg
with lymphangitis,which increses
edema and worsen(white leg)
Phlegmasia caerulea dolens:DVT of
iliac and pelvic veins causing blue leg
with venous gangrene or areas of
infarction.

Investigations
1. Venous doppler
2.Duplex scan: test of choice for diag DVT
it shows non compressible vein which is wider than
normal.on compression over calf muscles, does not
show any augmentation of flow.
3.venogram: ascending venogram
most accurate method of confirming DVT.
occlusive and non occlusive thrombus can be
differentiated by this.
4.MR venogram costly
useful test for imaging the iliac veins and IVC.where
the use of duplex is limited.

5.Impedence plethysmography:measure rate

of venous emptying.
sluggish flow of wave is seen in DVT
6. Radioactive I125 fibrinogen therapy:
sod iodide 100mg orally given 24hrs beforethe
test to block thyroid activity.
I125 labelled fibrinogen 100micro curies is
injected i.v. 1st radioactivity of heart is measured
by placing scintillation counter over precordium.
reading obtained by this is adjusted as 100%.

 After legs are elevated to prevent venous

pooling,scintillation counter over calf.
Counting in the leg is done from below upwards
at 5cms interval.
Procedure done preop,post op 1 st ,3rd,6th days.
20% or more raise in percentage value suggests
DVT in leg
7. D dimer test:measurment of cross linked
degradation products which interprets the
plasmin activity on fibrin.
-ve d dimer value is more value

 Ventilation perfusion scanning

Pulmonary artery ct scan
Pulmonary angiography

Treatment
-Rest, elevation of limb,bandaging the
entire limb with crape bandage.
-Anti
coagulants:LMWH,warfarin,phenindio
ne.
-Incidance of recurrence venous
thrombo embolism increases if the
time to therapeutic anticoagulation
prolonged.
Imp to reach therapuetic levels with in

For fixed thrombus:

initially high dose of heparin 25000 u/day for 7 days
Initial bolus of 80u/kg or 5000u followed by 18 u/kg /hr
Low molecular wt heparin is preferred
Warfarin should be started (same day of heparin) on
day 1 and 2-10mg each day
Day 3-5mg, on day 3 PT should be done
Warfarin continued for 3mths ,dose adjusted acc to
INR value
INR maintained b/w 2.0 to3.0

 Mech
Halflife
Clearance
Reversal
Moniterin
Dosing
To cuause HIT
Tt for HIT

UFH

1-2hrs
Hepatic
Protamin
apTT
Iv drips
Yes

No

LMWH

2-7hrs
Renal
Protamin
None
Bd
Yes

no

Fondop
(ARIXTA)

17-21hrs
renal
none
None
od
no

yes

 For free thrombus:

fibrinolysins

thrombectomy using fogartys

catheter

IVC filter.

Fibrinolysins:
steptokinase -2.5 to 6 lakhs to start ,later
one lakh hourly,which is directly infused into
affected vein through a venous catheter
urokinase:1,20,000-2,50,000units/hr..
Derived from human urine
reptilase:0.5 to 1 unit/hr
tissue plasminogen activator directly into
the thrombus through popliteal/femoral vein.

 Venous thrombectomy using fogarty

venous ballon catheter
IVC FILTERS :
thromboemboli is prevented from
reaching the heart by intracaval
filters

greenfield filter,suture
sieve plication, stapler
plication,venacaval ligation,mobin
umbrella filter

 Indications for vena caval filters:

- recurrent thrombo embolism despite
adequate anti coagulation
-DVT in a pt with contraindication to
anticoagulation
-chronic pulmonary embolism and
resultant pulmonary hypertension
-complications of anti coagulation
-propagating ileofemoral venous thrombus
in anticoagulation

 Special thrombectomy device of 7-9

french sheath is passed thriugh the
thrombosed segment, thrombolytics
infused,
Thrombus can be removed by
balloon angioplasty tube.
Open venotomy, thrombectomy also
can be done.

 palma operation:
-In ileofemoral thrombosis,common
femoral vein below the block is
communicated to opp femoral vein through
opp long saphanous vein.
May-husni operation:
Blockade in popliteal vein,popliteal vein
below the block is anastomosed to long
saphanous vein,so as to bypass the blood
across the popliteal block.

 Axillary vein thrombosis:

can occur spontaneously,following
compression by cervical rib, by various causes of
thorasic inlet syndrome.
Or arm in abducted position(painting the ceiling)
After axillary lymphnode block dissection,after
radiotherapy to axilla.
5% of all DVTs
But 30% of all upper limb DVTs can cause
pulmonary embolism

 Pagets-schroetter syndrome-primary upper

limb DVT ,due to subclavian vein
compression occurs in thorasic outlet
syndrome.
idiopathic upper limb DVT is rare, occult
underlying malignancy should be thought of.
Investigations:duplex scan,MR
venography,bt,ct,pt,aptt,platelet count
estimation.
Treatment is similar with LMWH,stockings.

 Prevention of DVT:
mechanical-compression
bandage,elevation,ext pneumatic bandage
pharmacological-LMWH
catogorize pts
low risk:minor sx <30min,any age,no risk
factors

major sx >30min,age <40.no other

risk factor

 Moderate risk: major sx,age >40.othr

risk factors

major medical illness,major

trauma,
High risk:major orthopedic sx,
major abd sx for cancer
lower limb paralysis

 LMWH -5000 Units preop and postop

period till pt ambulated.
Dextran 70-i.v 500ml during sx
,another 500ml postop in 24hrs can
also be used to prevent DVT
Smocking increases the viscosity of
blood, so should be stopped
Stop oral contraceptives 6-8 weeks
prior to elective sx.

 Sequele of DVT:
-pulmonary embolism(15%)
-infection,venous gangrene
-chronic venous insufficiency
-recurrent DVT(30%)
-propagation of thrombus
proximally-20-30%

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