Varicose Veins: Pathophysiology, Diagnosis and Right approach to Mx

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Varicose Veins: Pathophysiology, Diagnosis and Right approach to Mx

19 Oct, 2 PM

welcome dear doctor thank you for joining in I Dr Fatima on behalf of the entire team of Netflix extend the hearty welcome to each one of you tonight for tuning in to this live session coming to the session that is happening tonight varicose veins it's pathophysiology diagnosis and medical management so as we all know the exact pathophysiology is debated it involves a genetic predisposition in cognitive valves weakened vascular walls and increased intravenous pressure upon this topic to teach us more on this topic we have honor of Harris Among Us to Rajiv parak who is Chairman of peripheral vascular and endovascular Sciences medicity gurugram Dr Rajiv completed his Fellowship of Royal College of Surgeons in United Kingdom in 1986 and trained in vascular surgery in UK before returning to India to set up one of the first independent Department of vascular surgery in 1990 he is the founder member of vascular Society of India endovascular intervention Society of India also the vice president of the international Society for vascular surgery also National convener for teaching program by the national board of examiners what an honor it is to have you on the platform Dr Raji we look forward to learning from you about this super important topic uh thank you Dr Fatima thank you very much indeed the team of entire team of Netflix I think it's a great effort and a great uh uh you know honor to be set apart and be part of Faculty of this growing uh sort of community of doctors and I think through this platform we can actually meet greet and share uh a lot of what we know and try to keep learning as we go along because medicine as you know has a half-life and that is about seven and a half years which means every seven and a half years whatever you have learned is obsolete so you have to continuously upgrade yourself in a continuing medical education program such as these on your platform are extremely extremely important for all of us uh just because I have gray hair doesn't mean I know it all uh but you know but we also need to continue to to to upgrade our knowledge so without much to do I think I'll go on to uh the subject of varicose veins the papers physiology the diagnosis and the approach to management I think this is this is an extremely difficult the topic in the sense that it's very poorly understood and frequently ignored it is extremely common as as we would say sorry so it is extremely common it is frequently ignored it is usually inadequately investigated most of the times it is probably not investigated at all it just carries on and mostly mismanaged I have a little laughing uh you know sort of anecdote with most of our patients I said especially women I said this varicose veins is actually worsened in India because of the sarees and the and the selvakamis dress that we you know the ladies wear and everybody comes back with a question why is that and and that is primarily because the sarees and the and the and the Salvation keeps your legs covered which means nobody sees them and if you don't spot them nobody gets to know what it is all about so they are inadequately investigated they are mostly mismanaged and they usually cause a lot of discomfort and the swelling of the legs causes a huge amount of discomfort and and even when if they are treated which is as I said mistreated or under treated there is usually a recurrence of varicose veins which probably is the reason why most people don't want to get involved and getting this done so what are varicose veins these are dilated protruding tortuous secular superficial veins in the subcutaneous tissues as is this I'm sure this is of course uh fairly well Advanced but I mean this is probably what they become as they grow up now what is the anatomy the veins in the legs are divided into two systems The Superficial system and a deep system and of course an interconnecting system which is the perforator system so the blood which is growing back up going back from the foot back up to the heart is traveling up both the Deep And The Superficial veins The Superficial veins eventually at intermittent levels connects with the Deep veins and keeps pushing this blood from below upwards so the direction of flow is From Below upwards and that is normal now if something happens we'll talk about that how and if the direction is reversed which means that there is a downward Direction then these veins become what are called varicose and the Perforating veins allows the blood to flow the wrong way which is outwards back into the system so as I said this is the uh there is a superficial system and a deep system and this is connected by the intermittent uh by by the um perforators which get the blood from outside which is The Superficial system to the Deep system now normally the contraction of the muscles that means our calf muscles compress these veins and helps push the blood up through the veins back up to the heart and this is extremely important I don't know if you know but the calf muscles are are what are called the second heart of the human body the contraction active contraction and relaxation of these muscles is what pushes this blood from below upwards so people who don't walk can't walk cannot walk do not like to walk or just keep sitting all day with their legs hanging down will always get a swelling in their legs which means the blood which is coming down into the legs is not able to go back up and that is the reason why this this uh collection of blood occurs and the varicose veins upper so a venous normal venous pump mechanism which constricts these veins and pushes the blood upwards is extremely important for well-functioning veins so why do veins become varicose there is if the valve at the top of the vein becomes incompetent that means the valve remains open and stops working properly there is a pressure head which develops which distends the lower vein and when this vein distance the remaining valves also start getting dilated and this is what makes the next wall down incompetent and this progresses down the leg and that is how people start developing varicose veins so normally the blood flow is from outside in that means superficial to deep and the valves shut when the blood tries to go down by gravity but if the valves are defective we'll talk and discuss as to why do they become defective but if the valves remain open at all times blood blood instead of going up will go down because of gravity and this will cause dilatation of these veins and give rise to what is called what is called varicose veins so the descending valvular incompetence causes varicose veins and that is because the valves don't close properly and the blood keeps flowing down and these walls will also weaken the wall walls below so there is some amount of evidence that the amount of collagen and the quality of the elastin which is the uh what gives the strength to the vein and the the the the elasticity to the vein it becomes it is abnormal in a few people and this is what causes the primary varicose veins to develop in some of these patients some of these patients who have varicose veins they don't have primary varicose veins but they probably have either a deep in thrombosis which has blocked the Deep veins and thereby directing the pressure in the reverse direction or if there is a compression or a tumor in the pelvis which is pressing the varicose veins and pushing the blood from below upwards this actually causes uh this this actually causes a lot of the blood flow to to to to sort of flow down into the towards the ankle causing what are called varicose veins and this is exactly what happens the blood should actually be traveling upwards but because of a faulty valve or a uh you know sort of a dilating vein the blood flow starts to go down and when that happens these veins become tortuous they become lodged and large and the skin starts to bulge and this is something which continues and these veins and valves keep becoming worse and worse so that is what affects these veins and that is why these veins become tortuous and this affects both the long and the short saphenous system as you know and these are the ones which are present under the skin and you can actually see these veins dilating as and when the patient stands up but the shots happiness veins also dilate they also form varicose veins but much more frequent uh less info frequently as compared to the uh long saphenous veins so who are the people who develop varicose veins it's commoner in women in the 20 to 30 percent age group I mean commoner in in women 20 to 30 cases it's commoner over the age of 40 It's Not Unusual to run in families you'll find father mother brothers sisters uncles aunts uh you know grandparents anybody has uh varicose veins and this can actually run down into the family it is much commoner and very obese and very tall people again because of the pressure hurt that is generally is exerted on on into the um into the foot and pregnancy because of the basically the pressure on the pelvic veins causing pressure on the femoral veins because of the growing fetus this causes a lot of varicose veins this is I mean in a person who is predisposed to because of some familial or hereditary factors if there is this lady becomes pregnant she has a very high chance of developing varicose veins and of course people who keep sitting and standing for long periods of time will obviously develop varicose veins so people I mean teachers policemen army men and hairdressers and anybody who is standing for long periods of time is at risk of developing varicose veins so there are two types of varicose veins one is primary and the secondary the primary ones are the ones which develop because of no reason really they are familiar which means they run in families or because of incompetent valves which have been there right from birth or since birth the secondary varicose veins are usually which start off after pregnancy and childbirth which is the commonest in India I mean in women worldwide and of course if there's any compression or constriction or pressure on the pelvic veins by either a tumor or any other space occupying lesion they would form varicose veins because of the shear the hydrostatic pressure exerted on the pelvic veins are down into the foot into the leg if anybody has a deep vein thrombosis that means there is an occlusion of the veins pelvic veins or the femoral veins then all the veins be low and we say that means so the risk factors as I said again we capitulate long hours of sitting and standing patients with a family history people with family histories of course developed or are at a risk of this to anybody with a dilated heart a congestive cardiophilia which causes a lot of venous dilatation and venous hypertension these patients would also be at risk of developing varicose veins so increasing age a family history congestive heart failure obesity long hours of standing and sitting and pregnancy would be the risk factors for this uh for these varicose veins so the clinically how would they present themselves they can either be asymptomatic very early disease a little bit of swelling a little bit of uh you know sort of a compression ring left by your elastic the elastic of your socks that would be like could be the first and the earlier sign of asymptomatic varicose veins this is primarily cosmetic at that time then of course this can progress on to dull aching Comfort discomfort in the lower extremities it it can be exacerbated with high with with you know long-standing especially in hot weather when there's a lot of venous dilatation and this causes a lot of varicosities to develop and then of course there is a lot of itching and tingling then the skin becomes dry and hard and then eventually ulcerates and forms ulcers so sorry so how would you recognize them when you see a patient with varicose veins these are dilated tortures superficial veins anywhere in the leg in the thighs in the ankles around the ankles on the foot or up to and behind the knee or behind in the calf area then because of repeated uh sort of stasis there is a lot of what is called venous permeability that means these veins become like a sieve and blood and pigment and uh fibrin sort of you know permeates out of the vein walls and then this starts off a pigmentation in the in the you know in the gator area or the ankle area of the of the foot which causes a lot of the pigmentation which is so characteristic of prolonged long-standing varicose veins then eventually the skin becomes weak and then ulcerates and then this this ulceration kanaka so these are a few of the uh patients that we've had these are patients who have ruptured their veins then a repeated rupturing of veins and the pressure exerting in this area causes a lot of pigmentation with a lot of ulceration and you can see this ulcer which is a long-standing chronic ulcer and this carries on with a lot of underlying fibrosis leading to what is called uh you know lipodermis dermatosclerosis I'll show you that sometimes these veins become extremely inflamed and they form what is called a a very tight corded painful uh vein which can be felt unrolled under your skin under your fingers and this is called thrombophlobitis extremely painful condition as a result of prolonged standing and and varicose veins which are getting inflamed this is lipo lipodermatous sclerosis this is in a patient who's had repeated attacks of ulceration and skin healing and ulceration and fibrosis in the gator area of the ankle as long as a reason for I mean as a corollary to long-standing varicose veins now how do you examine these patients if we make this patient stand and notice what their venous filling pressure is normally the veins do not fill within 30 seconds that means when you stand these veins do not fill if there is no rapid filling if you Tire Tunica as we've seen if you tie a Tunica there is not a wrap there is no rapid filling with the removal of the Tunica the minute you remove the Tunica if the blood gushes down that means there is a junctional incompetence at the safino femoral or the sapphinophobitial junction depending on where you've applied the Tunica but if the vein starts the veins start to fill even before the removal of the Tunica that means there is what is called an incompetent valve in the perforator vein so those perforator veins if you remember I told you the ones which connect the soup which is in the Deep veins if you tie a Tunica and you suppose there's a prominence of the veins above the Tunica that means some perforator above is incompetent if there is a prominence of the veins below the Tunica then obviously there is an incompetence of the valves in the lower Tunica in the lower area now how do you assess the sapphoon function you can ask the patient to lie down lift up the lift up the leg at about a 40 to 60 degree ankle and stroke the blood down so that it goes back and empties the leg then you compress the long saphenous vein wherever you can feel it and you ask the patient to gently step when the patient stands up if you maintain that pressure over the calf or the long speed is the reflux is the minute you remove this thumb pressure the vein you know appears immediately which means there is a gross Leaf Flux Of The Junction at that area and this confirms the presence of varicose veins with venous incompetence at the junction so there are multiple tests there are multiple tunicates you can tie tunica's at different levels and you can identify where exactly the reflux is whether it is junctional reflux whether it is a perforated reflux and you can do that very carefully very easily with all this but of course the uh you know the we have to be absolutely sure that there is no Associated deep vein thrombosis there is what is called apothesis test in which we tie a page a tire to Nick and ask the patient to walk if there is severe bursting pain and makes the patient stop walking which means that there is an obstruction to the outward flow this would confirm deep vein thrombosis and this patient should not be subjected to any treatment meaning any surgical or other treatment of his varicose veins so how would you investigate these patients so once you've examine them and you confirm that there is a there is varicose veins in that um in that patient you would investigate the gold standard here is the duplex scan a Doppler color Doppler Venus can done by any uh you know uh knowledgeable ultrasonologist who has the complete knowledge of Venus anatomy of the legs that is the operating Point that's the most important thing you have to be fully conversant the ultrasonologist and the operating surgeon has to be fully conversant with the with the with the venous anatomy of that patient of his patient we need to confirm the patency of the deep winds that's extremely extremely important because obviously for obvious reasons if the Deep veins are blocked that means there is a deep end thrombosis and The Superficial veins are treated by by uh ignorant clinician that would be disastrous because there will be no venous return and the leg could undergo venous gangrene so you have to be extremely careful that there is no deep in thrombosis whenever you are treating the soup of silence and of course we need to identify the competency of the valves which can be picked up on a color Doppler examination the site of exact site of incompetence can be picked up by a color Doppler examination and of course at that time if there is a chronic ulcer about there are ulcerations in the leg you can also assess the arterial system because sometimes an ischemic leg uh I mean an ischemic arterial system can also contribute to the ulceration which is non-healing so this is a doctorate ultrasound examination you can see the reflux which is which is in the opposite direction the blood is actually instead of going up is actually flowing down into the into the leg and confirming uh what is called a valve Salva maneuver which confirms that there is Venous reflux this is vinography which is a contrast phenography very rarely used unless there is some confusion and there is something that we really need to know we usually do not do a direct contrast or a digital subtraction binography magnetic resonance resonance venography is again something which is not are done routinely unless we are locating or trying to locate uh uh you know some uh some tumor or some compression or some Venus endovenous uh occlusion now how do you classify these patients you have a lot of these patients and and and we need to know what is this class at at what is the stage at which these patients are so the clinical signs that is class 0 to 6 there are no visible signs as I've said this is the primary the class zero which means just minimal signs and it goes up with tail injectors very very thin spider veins then the varicose veins come up with class two then a lot of Edema without skin changes class three skin changes which come up with pigmentation and venous eczema is class 4 and then if there is an ulcer which is healed it's class five and if there is an active ulcer in conjunction with skin changes that is class six so that's the seed classification ceap stands for clinical e for etiology etiological and a for anatomical and P for pathophysiological so c e a p classification this is a universal worldwide classification to identify the the the leg swelling the chakras in these patients so this is what teal inject Aces or spider veins look like and these are of course Frank varicose veins as you can see and this is the edema without any skin changes because of prolonged standing and patience uh you know causing a lot of venous hypertension and swelling no skin changes at this point of time but here the uh some amount of fibrin and and you know hemocidrine has started getting deposited Under the Skin causing lipo dermatosclerosis and of course the skin changes once the ulcers start are very obvious and nobody misses them because these are ulcers which will will uh you know you know which will which will be there for all to see and these are of course the skin changes with active ulceration with a lot of inflammation cellulitis and ascending inflammation and lymphangitis can occur with with active ulceration so how do you treat this this is obviously something anybody who comes to you in any of these complicated positions the way uh it has uh it has come through would obviously require would require uh you know treatment and the treatment is in two parts one part one is to get rid of the reflux so wherever the blood is refluxing you have to get rid of this reflux and of course if uh you know once you've gotten rid of the reflux then you have to get rid of the varicose veins which is what is bothering the patient so if we get rid of the reflux that means further uh recurrences can be can be avoided but uh once once the varicose veins reflux is uh is is removed then we must get rid of the varicose veins itself so there are various stages of treatment so they initially you use what are called compression stockings these are medical compression so talking these are graduated medical compression stockings they have they are very specially made and they are they are manufactured with gradient with a pressure gradient From Below upwards maximum pressure at the ankle and the pressure reduces as the as the calf moves up and these have to be worn in the elevated position so whenever you have to wear the stockings never ask the patient to stand or put his foot down and wear them ask them to elevate their leg against the wall so that the blood flow is reversed the swelling is reduced and then they should wear the stockings they should never wear a stocking never advise a stocking to be born when there is a lot of swelling the swelling is never reduced by stockings swelling is prevented by stockings not reduced so reduction of swelling is only achieved by elevation which is something that has to be done prior to wearing the stockings then of course then you have Surgical and non-surgical or endolubinal or endovascular treatment the surgical is that is the is you know is used to be uh the the open surgery in which we used to open up the groin disconnect the vein and and and pull it out which is called vein stripping and now of course we have very very good Alternatives and options which are interluminal without any surgery without any Cuts without any hospitalization then patients can actually get up and walk off the table and go home with with the with the you know with the pair of stockings or compression bandaging and of course sclerotherapy is the procedure which is required which is done by by which we can actually inject these veins and and and uh get rid of the varicosities which are there which can be either done directly or under ultrasound guidance so these are the compression stockings these have to be worn there is a way of wearing them and you know so that they are slid up and going up these are of course below the knee but if the reflux starts from the groin you need to wear them at least mid thigh or groin level now once the vein has been ligated the groin has been opened we do a vein stripping it is typically it requires general anesthesia and the uh I mean you know usually because there is there is one there requires two incisions one in the groin one around the below the knee and this can and then then the vein can be stripped I'll show you the procedure in a while and of course this can sometimes be painful postoperative we do not ever strip a vein down to the ankle because you will strip the long saphenous nerve along with it giving rise to lifelong paresthesia and Agony so never strip the vein down to the ankle only strip it up to the knee and below below that you can do what is called phlebectomies or uh you know sclerotherapy and I'll show you that as well so this is a procedure of sex this is by which we can actually make a small cut just below the knee and introduce an instrument which can go up and invaginate this Vein from from uh from the groin which has been opened and we can pull this vein out with the wire stripper and this can come out as as we have uh talked about so this is ligation and slipping ankle to groin is never to be done it is to be avoided and the the uh segmental from the groin to the knee is what is done other as a usual uh procedure now this is something which would interest everyone would any one of us any one of the surgeons like to enter these coins for varicose veins surgery how many of us will put their hands up for this I don't think anybody would want to get into these groins so when patients are in this position this saphenofemoral Junction ligation which is which requires a cut in the groin and ligation and then a stripper is introduced that's the head of the stripper which is introduced into the distal vein and this is pulled out completely uh from the group you know just just below the below the knee that's the knee you can see the wire coming coming through and once this is pulled out this vein comes out as you can see either one or two segments and small phlebectomies can be done around to remove these veins uh as far as possible meaning the the varicosities as well sometimes of course you get loads and loads of varicosities and you can have a tray full of varicose veins which can be removed but requires obviously multiple Cuts multiple surgeries and a lot of the patients would not be very happy with the multiple cuts and the pain and the discomfort that ensures so what do we what is it that we can offer to these patients other than surgery so today we have a lot of procedures which are available which do not require any surgery no cuts no stitches no operation no hospitalization not even anesthesia you can do these procedures under anesthesia I mean under local anesthesia and what we can do is one once how it started was there was a procedure by which we could actually ablate or sclerose these veins completely and this would actually cause uh you know closure of the veins so this is called laser ablation a a catheter which is introduced from uh you know just below the knee and it goes up all the way to the sapeno family junction which is confirmed by a Doppler examination on the operating table and then a laser fiber is introduced all the way I'll show you a schematic diagram uh animation of this and a laser fiber is introduced all the way and this sclerosis the veins as the keep pulling the vein uh back Dr Fatima can you play the video please okay doctors I'm just going to stop the presentation for a bit and play a video that has brought in for us giving her a moment here under ultrasound guidance provides a minimally invasive and less traumatic solution to this condition [Music] can you see the tip of the uh the 980 nanometer laser energy causes retraction or destruction of the vein wall with no damage observed to perivenous tissue the laser fiber is withdrawn around three millimeters between each laser pulse the pulse width of the 980 nanometer serverless D laser is adjustable in both length and frequency to achieve the correct treatment parameters with respect to the vein physiology foreign [Music] okay so uh you you saw the way you know the laser 5 was introduced around the pictures below the knee and it is under ultrasound guidance Advanced up to this afternoon Premier Junction you stay about two centimeters away from the Japanese Junction because obviously you do not want to uh sort of sclerose the uh the long the the you know the Deep femoral vein or the common femoral vein and and you keep it in this afternoon femoral Junction I mean you know just below the sapno primary Junction in the long sapness vein and completely obliterate this and this causes a complete closure of these veins then while you're coming back up again uh wild while you're coming coming down you know you remove the catheter and the entire vein can be screws up to the knee joint you never go beyond the knee because the long saphenous nerve is extremely close in approximation in in proximation to the the long sap in his vein and if thermal energy is is applied in this area the nerve can undergo neuropathy and that can be an extremely painful condition there's another thermal energy which can be applied by what is called radio frequency ablation it is actually a similar technique it's just that the energy is different the source of energy is different this is a catheter which is induced just the same way all the way up into the varicosity uh into the sapeno femoral Junction and then withdrawn regularly at fixed intervals there are seven centimeter probes and two centimeters probes and you can pull them down and you can make sure that the vein is getting obliterated as you go down and you can see on the right hand side the vein is completely obliterated so so uh can we have the video on this one as well please slide which I will be playing now so I'm just stopping this presentation and starting that short clip yeah thank you so here there is uh what is called a surgical glow so uh okay so essentially can I talk yes sir yeah okay so essentially what we're doing is there is this catheter which is placed under ultrasound guidance about 2.5 centimeters three centimeters Beyond The saponofemoral Junction that means in the long saphenous vein and then there is a special Contraption like a gun which injects roughly 0.1 mL of cyanoacrylate glue which is a specialized glue in this area and by ultrasound compression or by by you know hand compression you can actually cause these veins to coapt and close off completely it's a glue which actually makes them stick together the walls stick together and the wind can be completely obliterated the difference between the endovenous laser the radio frequency and the glue treatment is that in the other two because they are heat sensitive treatments that means they generate a lot of heat there is a treatment I mean there is a procedure which needs to be done and that is called introduction introduction of the of the of saline tumorescence that means you have to inject uh you know some normal saline along with some uh you know little bit of adrenaline and a little bit of um methylprednisolone and this can be injected to reduce the inflammation and the heat which is generated around the catheter which is either the radio frequency or the or the or the uh laser and this does not cause thermal damage to the surrounding tissues in this treatment which is the venous seal glue treatment which is one of the latest treatments now here no tubescence is required because as you see there is no heat being generated it is just a simple application of the glue and withdrawal of the catheter so that the vein closes completely and stops refluxing next please yes such as getting your presence yeah thank you yeah Rebecca okay so and you can see the difference this is before a patient was subjected to a laser treatment and this is after the laser treatment with uh injection of either uh sclerotherapy or or surgical glue and you can see there's a complete difference and there is no surgical uh scars or incisions uh there after about six in about three to four months so there's a great advancement as you can see no surgery no cuts no stitches the patient literally gets up and walks off to table and without any Cuts or stitches uh we can even do what is called catheter directed phones sclerotherapy that means we introduce a catheter go up all the way up to the junction sometimes you can ligate the junction and introduce this uh the you know the the sclerotherapy uh the the sclerosis which is either an injection of one to three percent solution of sodium Tetra sulfate STD as it is called or we can even use polydocanol and this can actually cause sclerosis of the veins the intimate lining and this also causes these veins to stick together and close off completely and and that is how sclerotherapy is done now sometimes these veins are I mean you know the varicosities that we see are huge they are really really big now and and they may not really respond to either the sclerosin or the glue or or any of this so in these cases you have to remove these varicosities otherwise they would cause a lot of thrombophlebitis so there are a couple of techniques one is a staphylobectomy with a vulture and the other is a suction phlebectomy as I can show you this is a very tiny micro incision it is made on the skin just first you mark the vein with an ultrasound and then you make a very tiny incision under local anesthesia over that vein and with these Special hooks you can actually pick up the vein as you can see here if you can see this we can make a tiny incision you can introduce a hook which can actually hook this vein and bring it out of the skin and then when you start rotating or revolving the hook the vein actually gets entwined along and over the hook and and gets pulled out as far as possible you can then actually ligate both I mean you know clamp ligate both the sides and divided the middle and then keep pulling them out and believe it or not these veins can actually be pulled out like you know you know like a like a little rope Under the Skin and you can pull out as much as you can whatever is Left Behind does bleed but usually because there are veins and once you tie a compression bandage they all stop bleeding so there is not uh there isn't a difficult situation in which these veins if they are huge and they are big they can actually also be removed and of course we can do then if there are veins which are deeper you can use what is called an ultrasound guided sclerotherapy technique by which you can see here the probe entering the vein under sound guidance and you can the you know the the needle can actually be injected and then of course sclerosin agent can be injected into this and you can see the before and after needless to say these veins completely disappear there is a initially there is a bit of thrombophlebitis there is a little bit of pain and swelling but over four to six weeks everything settles down the phlebitis settles down the pain and the discomfort settles down the swelling settles down and the patient becomes yeah yeah you know very relieved of these symptoms a lot of times there are what are called very very minor veins or called spider veins this is uh these are spiders they're very thin veins which are just in the skin in the dermal regions and this you obviously cannot remove them you cannot surgically remove them and and uh so they they respond usually to sclerotherapy a very diluted uh sclerosis sodium sulfate or STD as it is called you use a very dilute portion even 0.5 or polytechnology 0.5 to 1 and hypertonic saline usually uh you know infrequently but you can use polydocrinol which is probably the least staining of these two and you can actually cause uh you know uh and obliterate these veins so the commonest location of the spiders that you can see are both on the medial and lateral side of the lower thigh around the knee area and this is because the maximum perforators in this area give rise to a lot of cutaneous uh spiders which is what bothers a lot of uh people especially ladies and so you can actually inject these reticular veins you can be very very careful you have these uh special Loops by which you can actually amplify you can magnify the the veins and inject them with micro needles and inject this sclerosin and you can see them and watch them disappear sometimes it causes a little bit of swelling and and and and and a little bit of staining but that usually settles down and this is here you can see a needle introduced into a spider vein being treated you can see the veins completely disappear in front of your eyes and you can see the before and after here on the left top you can see the big spider veins and then within about a couple of months about six to eight weeks you can see that this is completely obliterated with very good results so of course uh like any procedure whenever you are operating on these patients or when you're doing phlebectomies there is a possibility of a wound infection you can sometimes even cause a hematoma as we talked about there is some amount of blood which is uh you know sort of which collects under the skin after uh the phlebectomy has been done a little bit of blood has been removed so you can get a hematoma which sometimes need to be evacuated more usually they they sort of uh you know subside on their own and very very rarely if you are not careful and you have gone and obliterated or injected as sclerosant or injected glue or done a radio frequency or a laser right up very very close to the PTL Junction this can actually cause a thrombus which can extend into the deep veins and give rise to Serious deep pain thrombosis usually it's extremely extremely rare because it is done always under ultrasound guidance and this is something which can be done and this can of course as I said because of the hereditary factors and if the patient does not wear the stockings and walk around with them these patients can develop a recurrence so the approach to management as we talked about we must be fully conversant with the leg venous Anatomy the ultrasonologist must tell us exactly where these veins are where the perforators are and which are the Junctions which are which are you know incompetent and we must get a detailed venous Doppler in the standing position see when you're lying down there isn't much of a reflux but when you are standing in the standing position that is when there is a there is a uh you know the the the pleasure can be picked up the reflux can be picked up in the standing position so it's extremely important to do the doctorate examination the line down as well as the standing position to identify the Junctions and the major incompetent perforators and of course the therapy which is either whether it is a laser or radio frequency or surgical glow that is Venous heal must be performed under ultrasound guidance to ensure complete cessation of reflux because that is Paramount so the take home message now I would say is we must identify the reflux if we have a good knowledge of the anatomy we will be able to do so and the procedure whatever we do we must do it under ultrasound guidance because that is the only way to know exactly where we need to be and exactly treat the offending reflux points which is extremely important and of course the follow-up which has to be done these patients as I told you most of these are primary varicose veins most of them will develop recurrence which must be told to them right in the beginning that they have to be cautious they have to wear the stockings they have to walk with the stockings and of course if and when they do develop a recurrence it will be definitely very minor as compared to the ones which have been treated but whenever it does happen they can be treated very easily with sclerotherapy serial service therapy underwear to some guidance and that is something which can take care of these veins if there is a recurrence because recurrence is the Achilles heels of varicose veins so if we have taken care of this and talked about this to the patient explained him that this patient needs to be wearing stockings and walking do not stand in one position keep moving your legs up and down keep tiptoeing your your ankles and toes and keep walking around as much as possible and do not put on weight that is extremely important because if if somebody just keeps sitting down and the weight increases that causes venous hypertension and gives rise to a recurrence so thank you very much for a patient hearing I am uh it's it's it's it's it's extremely uh you know interesting because uh I've been seeing a lot people actively contributing to to the the conversation going on and encouraging me to to go on and tell me as to exactly uh you know how to treat these varicose veins so thank you thank you very much over to Dr Fatima thank you so much so beautifully right from the leg Venus Anatomy to the management of every aspect also treat recurrence and uh guide to guide our patient to the ideal line of treatment and the reactions and emojis are just pouring in just going to stop your presentation for a while here yeah yeah dear doctors please put in your queries and comments in the comment box we will take them up and also you can raise hand if you want to come on stage and ask a question uh directly to Dr Rajiv and that is also on the table so you should be able to see these hand option on the right side and the comment box so please be sure to put in all your comments and queries there uh so a question from my end uh so when can we initiate pharmacotherapy in varicose vein uh varicose veins actually uh you know once once they are huge they are big blown up and uh you know they are causing a lot of symptoms these patients definitely need fully given adjective adjunctive therapy that means you can add on some venotonics some medicines to reduce the venous hypertension and that is something that should be used not only when you are treating them not only before the treatment but even after the treatment because this causes reduction in the venous hypertension at the micro circulatory level reducing the edema and the pain and the discomfort okay thank you uh so your thoughts on the conservative line of management like uh some people of physiotherapy stockings your thoughts on the efficacy of this line of management uh see Physiotherapy and any conservative management is something that needs to continue hand in hand I think the most important thing is for people to realize that if there is a confirmed junctional reflux either the saphenofemoral junction or at the sapeno popliteal Junction no amount of physiotherapy no amount of any conservative management is ever going to help this treatment has to be the junctional reflux has to be treated if there is an incompetent perforator you can maybe you know tied over the time with varying stockings elevating your legs maybe taking on you know some flavonoids and you know these these venotonic drugs but if there is a junctional reflux nothing else is going to work other than removing or stopping that reflux so that is extremely important yeah oh okay so um so we have a question from Dr Shashank he asks what grade of stockings to be given after evla okay so that's a very good question this is essentially you know there are class there are three three grades of stockings one is class one class two and class three class one is also what are called thromboembolic deterrent which is basically just giving you about under 15 millimeters of circumferential pressure what we are talking about post eblt evla or any ablative procedure you need between 15 to 25 millimeters of mercury which is class 2 stockings anybody who has serious lipodermatous sclerosis serious uh you know fibrotic edema they would require 35 millimeters and above which is class 3. another question if uh saphenofemoral Junction and saphenous populatal Junction is competent and only perforator are reflexed reflexed will you go for evla uh well it depends on what the size of the of the perforator is but if the junction is competent and the patient has very limited isolated varicosities we have a special technique of what is going actually which is called a perforator location localization and actually just treating that perforator reflux either with a radio frequency probe or or or or actually with this sclerosis sclerotherapy can be done just for the perforator at that low collection if the saphenofemoral or the sapno popital junction is completely normal and then of course treat them up with with you know with the stockings and uh uh leg elevation follow-up is also equally important yes [Music] okay uh the management exercises and diet for cellulitis related to varicose veins okay so the cellulitis is actually because of the Venous stasis and the edema which is developing as a result of outflow obstruction that means the blood which is not able to return back from the legs into the heart causes a lot of swelling the swelling causes a cracking of the skin which results in a lot of itching the itching starts off in inflammatory and an infective pathology which causes the cellulitis so the treatment is to reverse these changes the one most important thing that has to be done is to reduce the swelling there is no other treatment which is which is which is helpful in reducing the swelling other than leg elevation when we say leg elevation the elevation should start from the hips onwards so the hips and the ankles they should be elevated and the best way to elevate your legs is lift up your mattress the foot end of the mattress lift up the mattress put two three four pillows under the mattress and let the mattress be and and then when you lie down on it your ankles and your and your calf muscles I mean your calf and legs will automatically get elevated in whichever position you like to sleep so leg elevation is extremely important if you keep sitting down with your legs hanging down your cellulitis will never never improve so reduction of swelling is extremely important and then of course the usual antibiotics and the anti-inflammatory and the painkillers and of course uh you know the the local applicants can be used thank you sir coming to the next question we have a couple of questions on one is on does dry needling work and the other does acupuncture treatment your thoughts on that uh you see as I said the most important thing is you need to evaluate and ascertain if there is a junctional reflux that means if the sapeno femoral and the sapphoon popliteal Junction is leaking it is refluxing it is incompetent no treatment nothing is going to work unless you occlude that reflux if there is a localized isolated perforator incompetence causing a little bit of pain and discomfort I guess needling or acupressure or acupuncture would probably help in the localized treatment I mean in the in the treatment of the localized varicosity but as I said if there is a junctional reflux on the top nothing is going to work short of uh you know blocking off the reflux and stopping the requests okay so thank you we have a couple of questions I mean you're sure to you're free to Omit this question if uh it's not one that you can answer but couple of questions regarding the economic uh the figures related to the cost of treatment at the price of treatment right on a smaller scale and then the higher up okay so uh as far as surgical options are concerned surgical options means it's an open surgical procedure it can be done uh you know with the with a what is called a spinal or an epidural anesthesia you don't have to give general anesthetic and this can be done in smaller nursing homes or smaller hospitals with a small cut in the groin and you can remove and strip the veins only up to the knee and no further and you can inject sodium tetra-d cell sulphate which is STD or polydocanol for this for the remaining residual varicosities this procedure would cost at medanta hospital in gurgaon in uh in the NCR that which is where I am this would cost about 45 to 60 000 rupees depending on whether it's one leg or both legs if you are using and one of the laser or the radio frequency or the glue treatments there is a cost to the treatment the I mean the the cost to the uh to the disposables which are used in this treatment if there is is a probe there is a laser fiber which has to be used there is a cost to that if there is a radio frequency ablation there is a cost of the radio frequency fiber and if they are using blue there is a cost of the catheter as well as the surgical glue surgical glue can cost about one lakh over a one lakh because the cost of the of the glue the kit which we get from venous seal which is from Medtronic it's about 1 lakh 10 000 odd rupees so the cost of this would be about 1 lakh 60 000 rupees uh well sorry one lakh 50 000 rupees for the whole procedure if you are using a laser or radio frequency it can be about 1 lakh 10 000 odd rupees with everything as a daycare procedure to walk in and walk out the same day thank you so much we really appreciate your transparency on the matter here last question we are taking here uh what tumors and anesthesia you prefer in ablations treatment I yeah okay so that's uh that's a good treatment I mean that's it that's a very good question I thought I I was hoping somebody would ask that that means that whoever's asked that question is actually listening to what I'm saying so tumison tum isn't anesthesia is basically it is a bag full of normal saline and if you can uh freeze it that means reduce the temperature you can sort of make it into cold saline you can add some adrenaline which is uh and and and and some uh Xylocaine into it which is the local anesthetic and this can be introduced into the bag and then you use a pressure injector and you can inject this vein I mean inject the uh this solution with under ultrasound guidance against basically to try and obliterate not obliterate but but to sort of co-ap the walls of the veins when you are injecting uh this tubus and anesthesia this is the idea is to surround the abstract the you know the vein with cold salines so that the heat generated by either radio frequency or by laser is not transmitted to the surrounding structures and tissues causing any thermal damage so essentially it's normal saline which is which is frozen or I mean you know cool cool uh normal saline with uh xylicane and 30 ml of xylican in a 500 mL bag and and roughly you know about one one uh one percent of the you know xylophone solution can be can be used thank you sir did want to hear a replay of this will be available in two days so you can just revisit the lecture and make down your notes if you wish uh with that uh Dr goyal says so sad I missed this great session half of it Dr Goya you will be able to see it in the replay session no worries Dr Ashwini says great session sir thank you thank you sir says Dr Adam yes so with that we come to the end of the session we heartily thank you for the time you took out to teach us about this topic and we hope to see you on Netflix many many more times uh we hope you've had a good time as well with us thank you thank you very much thank you Dr Fatima and I I think I must uh you know commend you for your persistence I have been extremely uh tied up and I think you know you really followed up with this so I'm grateful for you to give me a chance to to sort of you know do this this is teaching is something that I love I really do so thank you thank you very much and uh thank you for all your uh time and and efforts thank you Father thank you sir good night bye-bye


Varicose veins (VV) are dilated, tortuous subcutaneous veins that permit reverse flow. They are most commonly found in the lower limb and may be primary, or secondary to deep venous pathology. The exact pathophysiology is debated, but it involves a genetic predisposition, incompetent valves, weakened vascular walls, and increased intravenous pressure. Treatment options for varicose veins include conservative management, external laser treatment, injection sclerotherapy, endovenous interventions, and surgery. We have Dr. Rajiv Parakh, a prominent vascular surgeon, on Medflix to provide expert insights into the diagnosis and appropriate management of Varicose Veins.


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