• Superficial veins - (incompetence) - Perforating veins (obstruction) - Deep veins

• Pressure in venous system relatively low, t/f need valves to prevent backflow

• Greater saphenous system: starts on inside of leg - up medial side of leg - empties into deep veins in saphenous opening (2cm lateral and 2cm below pubic tubercle) - not the same so the midinguinal point
• Lesser saphenous system: outside of goot - outside of leg - posterior part knee empties into deep vein

• There are branches that need to be careful of when operating

• Perfoating veins: inconsistent, dep on book, positions varies, names given to them (no longer important)
• Perforators on medial side of leg, around medial malleous (5cm above) - lower, middle and upper calf peforated
• Some around knee
• Some around thigh
• Sphenofemoral junction itself is a perforating vein
• Most perforating veins are joined to tributaries of long saphenous vein (not the vein itself)

• A patient with varicose veins. Diagnosis and examination
• Differential diagnosis of leg ulcers

• Superficial and Deep veins
• Long and short saphenous systems
• Blood flow is superficial to deep
• Perforator sites. The "one hand" rule
• The Sapheno-femoral junction

• Incompetence vs Thrombosis
• Superficial vs Deep veins

Chronic Venous Insufficiency (CVI): insufficiency of valves in veins

• Diag: dilatation of long sphenous system, engorgement of lower veins
• Affects esp older female Pt's who used to stand for long periods of time
• Also, ulcerations around leg, black pigmentation, c/o discharge from wounds (non-healing), swelling

The incompetent venous system:

• Muscle contracts and expands and pushes blood up, valve closes
• Muscle relaxes, blood fills same segment: t/f segmental action guarded by valves
• If faulty veins, m relaxes and there is reflux towards lower part of body and leakage to superficial veins

Anatomy valvular incompetence

1. Superficial system (most common)
2. Deep system
3. Perforator incpometence

• Most Pt's, affect all 3 systems

Diag: Sapheno-Femoral incompetence

• Primary valve failure
• Usu first valve to go because guards drainage of superficial into deep beins
• High pressure being exerted on valve (eg. Standing, increased ab pressure)

Diag: CVI secondary to DVT

• THrombus in deep vein -> months later, WBC digests clot, but macrophages also digest valves -> destroyed -> reflux downward and tranmission of pressure from deep to superficial system

• Primary: congenital, posture
• Secondary: post-thrombotic

Venous hypertension

High venous pressure even when walking

• Starling's Law
• Difusion pressure: pressure difference between arterial and venous systems
• Varicose veins: high pressure on venous side

1. Venous reflux
2. Venous hyperpressure
3. Capillary hyperpressure
4. Diffusion process + leukocyte-damaging processs
5. Lymphatics overloaded
6. Fluid accumulation -> oedema

• Haemosiderin from breakdown of RBC produces brownish pigmentation around ankles
• Accumulating of fibrinogens: skin thickens due to fibrin (inflammatory condition) (ezcema)
• If fibrin forms around capillaries - can form cuff/ seal around capillaries and prevent diffusion of nutrients from caps to tissues - skin breakdown (ulcers)
• WBC are bigger, therefore lag behind when going theourgh caps, high pressure causes stagnant flow, so WBC accuulate and stick to endothelium, activate series of events that cause inflam and thickening of skin

Diag: Leucocyte adhesion theory

CEAP: Clinical, Etiology, Anatomic, Pathophysiology

• Clinical: 0-6
• Aetiology: Congenital, primary, secondary
• Anatomic: superficial, deep, perforating
• Pathophysiology: refluex, obstruction, both

1. Mild: varicose veins (Truncal, Tributary, Reticular, Perforator varicosities)
2. Moderate: swelling, eczema, pigmentation
3. Severe: leg ulceration

• Changes tend to take place on ankles because they are lowest therefore venous pressure is highest
• Tends to be on medial leg because there are more perforators here, and there is more pressure here on skin from perforators
• Disfigurement
• Swelling, ache,
• Complications: bleeding (on minor bump), thrombophlebitis (if BF slow)

1. Axial reflux - axial veins are greater/lesser saphenous
2. Perforator location

• Handheld Continuous Wave Doppler
• Duplex US scan
• Unnecessary: venogram, plethysmograms
• If put on vein and then squeeze leg, hear venous sound, then remove hand and no sound (if hear 2 sounds, indicates reflux)
• Diag: Venous duplex: saphenofemoral incompetence (squeeze leg, blood going away from limb, release and then blood back to limb - pattern goes up then down)

• Principle: Reduce venous Pressure
• Elevation: legs up
• Postural adjustments: walk around to keep m pump working
• Graduated compression stockings: weave tightest at ankles (20 mmHg) and lowest at top (10 mmHg)

Diag: saphenofemoral cinpometence

• Truncal varicosis
• Long saphenous vein
• If remove all perforates, these veins will collapse

• Principles: Ligate incompetent perforators; Remove diseased veins
• Sapheno-femoral flush ligation: as close to the junction as possible
• Avulsion (tear)/ excision (small incision and pull out like bird pulling worm out of ground!) of varicosities
• Stripping: long saphenous vein
• Ligation of perforators (open/ endoscopic): if perforators are left unligated, they will recur

• Reticular veins: subcut veins on surface, cannot be stripped/ excised, can perform injection sclerotherapy (detergents - irritating substances) - reaction/ final/ veins collapse/ fuse/ clos
• Not recomennded at primary Tx (beacuse does not deal with primary patholog
• Aseptic thrombosis
• Compression essential

Sclerotherapy

• Irreversible full-thickenss mural denaturation
• Reabosrption
• Does not equal to thrombosis

Agents

• Sodium tetradecyl sulfat (Sotradecol, STD) 1-3%
• Sodium morrhuate

Etc

• Endovenous laser treatment
• Radiofrequency occlusion (closure)

• Aka (1) Post-thrombotic/ post-phlebitic syndrome (2) Chronic venous hypertension (3) Chronic venous stasis
• Symptoms: Pigmentation, oedema, eczema, ulcers
• Etiology of Venous ulcers: Fibrin cuff vs Leucocyte adhesion theory

• Arterial insufficiency - Signs, painful, pressure areas, do not heal
• Venous - Signs of CVI, good pulse, less painful typical site (nerves are not ischaemic), typically occur on inside of leg
• Neurogenic (rare) - Painless, neuropathy (DM, leprosy, Vit deficiency), cannot feel anything so injure without knowing
• Malignant - Squamous carcinoma, Irregular, raised edges, biopsy, Marjolin's ulcer (occurs on long-standing venous ulcer, >20y, malig change due to chronic irritation), LNs.
• Infection (rare) - Chronic osteomyelitis, syphilis
• Trauma (rare)
• Leg ulcer is a very common finding in exams (venous > artery)

• Reduce venous pressure: posture (legs raised above level of RA)
• Treat ulcers - compression bandage (absorbant dressings first), reduce infection
• Topical ulcer treatment - skin grafts (eg. From thigh)
• Venous surgery - treat superficial venous reflux (separate skin from underling high pressure system of perforating veins) (1) Subfasical Endoscopic Perforator Surgery - SEPS - b/c incision on leg with high venous pressure may cause ulcers (does not disturb superficial fasica, perform surgery away from ulcer site)
• Venous reconstruction - treat deep reflux (rarely done, mainly in Hawii)

• Differential diagnosis of unilateral leg swellings
• Understand the causes of post-operative DVT
• How to give prophylaxis against DVT and who?

• Stasis
• Trauma
• Coagulability
• Causes of DVT can be derived from Virchow's triad

• Predisposing causes?
• Silent phlebothrombosis
• Thrombophlebitis: swelling, tender, Redness, warmth, Homan's sign
• Massive: Venous gangrene

• 50% DVT are silent
• Gold standards: Duplex ultrasound; Venogram
• Significance of Iliofemoral DVT vs Calf vein DVT

1. Pulmonary embolism (early)
2. Chronic Venous Insufficiency (late)
3. Chronic venous obstruction (late)

2,3 results in venous hypertension

• From asymptomatic to potentially fatal
• Diagnosis: clinical, V/Q scans, angiogram

• Virchow's Triad:

1. Stasis: Physical Posturing - Stocking; Intermittent compression
2. Trauma: Avoid
3. Coagulability: Drugs - Heparin; Low dose; Subcutaneous

• Prophylaxis of DVT can be derived from Virchow's triad

• Posture: Rest, elevation, bandage
• Anticoagulation: Heparin; LMW heparin; Warfarin for 3-6 months
• Thrombolysis?
• Surgical thrombectomy - rare, for venous gangrene

• IVC Filters (Greenfield)
• Indications: Recurrent pulmonary embolism; Anticoagulation contraindicated

• Examine more patients with varicose veins and practice the Toruniquet test (usually in TWH)
• Observe a varicose vein operation (TWH, Tuesday pm)
• Handle a pair of elastic stockings
• See a variety of leg ulcers and make the differential diagnosis (TWH)
• Learn the indications, use, dosage, monitoring, and side effects of anticoagulant drugs in the wards
• Visit the Vascular Laboratory in K14S and observe a venous duplex examination (QMH)