Varicose Vein Treatment Mumbai | Dr Himanshu Shah

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Welcome toVaricose Vein Center

• By
• Dr. Himanshu Shah
• M.B.B.S. DMRD. VASCULAR RADIOLOGIST AND VARICOSE
  CONSULTANT

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Varicose veins
DR. HIMANSHU SHAH M.B.B.S.D.M.R.D., VARICOSEVEIN
CONSULTANT

• Varicose veins are veins that have become
  enlarged and twisted. The term commonly refers to
  the veins on the leg, although varicose veins can
  occur elsewhere. Veins have pairs of leaflet
  valves to prevent blood from flowing backwards
  (retrograde flow or venous reflux). Leg muscles
  pump the veins to return blood to the heart (the
  skeletal-muscle pump), against the effects of
  gravity. When veins become varicose, the leaflets
  of the valves no longer meet properly, and the
  valves do not work (valvular incompetence). This
  allows blood to flow backwards and they enlarge
  even more. Varicose veins are most common in the
  superficial veins of the legs, which are subject
  to high pressure when standing. Besides being a
  cosmetic problem, varicose veins can be painful,
  especially when standing. Severe long-standing
  varicose veins can lead to leg swelling, venous
  eczema, skin thickening (lipodermatosclerosis)
  and ulceration. Life-threatening complications
  are uncommon, but varicose veins may be confused
  with deep vein thrombosis, which may be
  life-threatening

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ulcer varicose veins in legs

• Non-surgical treatments include sclerotherapy,
  elastic stockings, leg elevation and exercise.
  The traditional surgical treatment has been vein
  stripping to remove the affected veins. Newer,
  less invasive treatments which seal the main
  leaking vein are available. Alternative
  techniques, such as ultrasound-guided foam
  sclerotherapy, radiofrequency ablation and
  endovenous laser treatment, are available as
  well. Because most of the blood in the legs is
  returned by the deep veins, the superficial
  veins, which return only about 10 of the total
  blood of the legs, can usually be removed or
  ablated without serious harm.
• Secondary varicose veins are those developing as
  collateral pathways, typically after stenosis or
  occlusion of the deep veins, a common sequel of
  extensive deep venous thrombosis (DVT). Treatment
  options are usually support stockings,
  occasionally sclerotherapy and rarely, limited
  surgery.

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Signs and symptoms
DR. HIMANSHU SHAH M.B.B.S.D.M.R.D., VARICOSEVEIN
CONSULTANT

1. Aching, heavy legs (often worse at night and
   after exercise).
2. Appearance of spider veins (telangiectasia) in
   the affected leg.
3. Ankle swelling, especially in evening.
4. A brownish-yellow shiny skin discoloration near
   the affected veins.
5. Redness, dryness, and itchiness of areas of skin,
   termed stasis dermatitis or venous eczema,
   because of waste products building up in the leg.

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DR. HIMANSHU SHAH M.B.B.S.D.M.R.D., VARICOSEVEIN
CONSULTANT

1. Cramps may develop especially when making a
   sudden move as standing up.
2. Minor injuries to the area may bleed more than
   normal or take a long time to heal.
3. In some people the skin above the ankle may
   shrink (lipodermatosclerosis) because the fat
   underneath the skin becomes hard.
4. Restless legs syndrome appears to be a common
   overlapping clinical syndrome in patients with
   varicose veins and other chronic venous
   insufficiency.
5. Whitened, irregular scar-like patches can appear
   at the ankles. This is known as atrophie blanche.

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Complications
DR. HIMANSHU SHAH M.B.B.S.D.M.R.D., VARICOSEVEIN
CONSULTANT
Most varicose veins are reasonably benign, but
severe varicosities can lead to major
complications, due to the poor circulation
through the affected limb.
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1. Pain, tenderness, heaviness, inability to walk or
   stand for long hours, thus hindering work
2. Skin conditions / Dermatitis which could
   predispose skin loss
3. Skin ulcers especially near the ankle, usually
   referred to as venous ulcers.
4. Development of carcinoma or sarcoma in
   longstanding venous ulcers. Over 100 reported
   cases of malignant transformation have been
   reported at a rate reported as 0.4 to 1.
5. Severe bleeding from minor trauma, of particular
   concern in the elderly.
6. Blood clotting within affected veins, termed
   superficial thrombophlebitis. These are
   frequently isolated to the superficial veins, but
   can extend into deep veins, becoming a more
   serious problem.
7. Acute fat necrosis can occur, especially at the
   ankle of overweight patients with varicose veins.
   Females are more frequently affected than males.

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Diagnosis
DR. HIMANSHU SHAH M.B.B.S.D.M.R.D., VARICOSEVEIN
CONSULTANT

• Clinical tests

• Investigations

• Clinical tests that may be used include
• Trendelenburg testto determine the site of
  venous reflux and the nature of the sapheno
  femoral junction
• Multiple tournique testto more accurately
  localize the site of the venous reflux
• Fegan's testto assess the nature of any
  perforating vein blow outs
• Perthes testto check the patency of the deep
  veins
• Other more historical/ academic tests include
  Scwhartz test, and Morrisey's cough impulse test.
• Lower limbs venous ultrasonography has replaced
  most of the rest.

• Traditionally, varicose veins were investigated
  using imaging techniques only if there was a
  clinical suspicion of deep venous insufficiency,
  if they were recurrent, or if they involved the
  sapheno-popliteal junction. This practice is not
  now widely accepted. Patients with varicose veins
  should now be investigated using lower limbs
  venous ultrasonography. The results from a
  randomised controlled trial on patients with and
  without routine ultrasound has shown a
  significant difference in recurrence rate and
  reoperation rate at 2 and 7 years of follow up.

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According to the CEAP classification C0 no
visible or palpable signs of venous disease C1
telangectasia or reticular veins C2 varicose
veins. C3 edema C4a pigmentation or eczema C4b
lipodermatosclerosis, atrophie blanche C5
healed venous ulcer C6 active venous ulcer
Each clinical class is further characterised by
a subscript depending upon whether the patient is
symptomatic (S) or asymptomatic (A) e.g. C2S.
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Causes
DR. HIMANSHU SHAH M.B.B.S.D.M.R.D., VARICOSEVEIN
CONSULTANT
Varicose veins are more common in women than in
men, and are linked with heredity. Other related
factors are pregnancy, obesity, menopause, aging,
prolonged standing, leg injury and abdominal
straining. Varicose veins are unlikely to be
caused by crossing the legs or ankles. Less
commonly, but not exceptionally, varicose veins
can be due to other causes, as post phlebitic
obstruction or incontinence, venous and
arteriovenous malformations. More recent research
has shown the importance of pelvic vein reflux
(PVR) in the development of varicose veins. Hobbs
showed varicose veins in the legs could be due to
ovarian vein reflux and Lumley and his team
showed recurrent varicose veins could be due to
ovarian vein reflux. Whiteley and his team
reported that both ovarian and internal iliac
vein reflux causes leg varicose veins and that
this condition affects 14 of women with varicose
veins or 20 of women who have had vaginal
delivery and have leg varicose veins. In addition
evidence suggests that failing to look for, and
treat pelvic vein reflux can be a cause of
recurrent varicose veins.
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There is increasing evidence for the role of
incompetent Perforator veins (or "perforators")
in the formation of varicose veins and recurrent
varicose veins.
Varicose veins could also be caused by
hyperhomocysteinemia in the body, which can
degrade and inhibit the formation of the three
main structural components of the artery
collagen, elastin and the proteoglycans.
Homocysteine permanently degrades cysteine
disulfide bridges and lysine amino acid residues
in proteins, gradually affecting function and
structure. Simply put, homocysteine is a
'corrosive' of long-living proteins, i.e.
collagen or elastin, or lifelong proteins, i.e.
fibrillin. These long-term effects are difficult
to establish in clinical trials focusing on
groups with existing artery decline.
Klippel-Trenaunay syndrome and Parkes-Weber
syndrome are relevant for differential
diagnosis. Another cause is chronic alcohol
consumption due to the vasodilatating side effect
in relation to gravity and blood viscosity.
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Treatment
DR. HIMANSHU SHAH M.B.B.S.D.M.R.D., VARICOSEVEIN
CONSULTANT
Treatment can be either conservative or active.
Active treatments can be divided into surgical
and non-surgical treatments. Newer methods
including endovenous laser treatment,
radiofrequency ablation and foam sclerotherapy
appear to work as well as surgery for varices of
the greater saphenous vein.


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Conservative
DR. HIMANSHU SHAH M.B.B.S.D.M.R.D., VARICOSEVEIN
CONSULTANT
The National Institute for Health and Clinical
Excellence (NICE) produced clinical guidelines in
July 2013 recommending that all people with
symptomatic varicose veins (C2S) and worse should
be referred to a vascular service for treatment.
Conservative treatments such as support stockings
should not be used unless treatment was not
possible.
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The symptoms of varicose veins can be controlled
to an extent with the following Elevating the
legs often provides temporary symptomatic
relief. Advice about regular exercise sounds
sensible but is not supported by any
evidence. The wearing of graduated compression
stockings with variable pressure gradients (Class
II or III) has been shown to correct the
swelling, nutritional exchange, and improve the
microcirculation in legs affected by varicose
veins. They also often provide relief from the
discomfort associated with this disease. Caution
should be exercised in their use in patients with
concurrent arterial disease.
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DR. HIMANSHU SHAH M.B.B.S.D.M.R.D., VARICOSEVEIN
CONSULTANT
The wearing of intermittent pneumatic compression
devices have been shown to reduce swelling and
increase circulation Diosmin/Hesperidine and
other flavonoids. Anti-inflammatory medication
such as ibuprofen or aspirin can be used as part
of treatment for superficial thrombophlebitis
along with graduated compression hosiery but
there is a risk of intestinal bleeding. In
extensive superficial thrombophlebitis,
consideration should be given to
anti-coagulation, thrombectomy or sclerotherapy
of the involved vein. Topical gel application,
helps in managing symptoms related to varicose
veins such as inflammation, pain, swelling,
itching and dryness. Topical application-noninvasi
ve has patient compliance.
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Surgical Surgeries have been performed for over
a century, from the more invasive saphenous
stripping, to less invasive procedures like
ambulatory phlebectomy and CHIVA.
DR. HIMANSHU SHAH M.B.B.S.D.M.R.D., VARICOSEVEIN
CONSULTANT

• Stripping

• Other

• Stripping consists of removal of all or part the
  saphenous vein (great/long or lesser/short) main
  trunk. The complications include deep vein
  thrombosis (5.3), pulmonary embolism (0.06),
  and wound complications including infection
  (2.2). There is evidence for the great saphenous
  vein regrowing after stripping. For traditional
  surgery, reported recurrence rates, which have
  been tracked for 10 years, range from 560. In
  addition, since stripping removes the saphenous
  main trunks, they are no longer available for use
  as venous bypass grafts in the future (coronary
  or leg artery vital disease)

• Other surgical treatments are
• Ambulatory phlebectomy
• Veinligation is done at sephenofemoral junction
  after ligating the tributeries at sephanofemoral
  junction without stripping the long sephenous
  vein provided the perforater veins are competent
  and absent DVT in the deep veins.With this method
  long sephenous vein is preserved.
• Cryosurgery- A cryoprobe is passed down the long
  saphenous vein following saphenofemoral ligation.
  Then the probe is cooled with NO2 or CO2 to -85o
  F. The vein freezes to the probe and can be
  retrogradely stripped after 5 seconds of
  freezing. It is a variant of Stripping. The only
  point of this technique is to avoid a distal
  incision to remove the stripper.

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A 1996 study reported a 76 success rate at 24
months in treating saphenofemoral junction and
great saphenous vein incompetence with STS 3
solution. A Cochrane Collaboration review
concluded sclerotherapy was better than surgery
in the short term (1 year) for its treatment
success, complication rate and cost, but surgery
was better after 5 years, although the research
is weak. A Health Technology Assessment found
that sclerotherapy provided less benefit than
surgery, but is likely to provide a small benefit
in varicose veins without reflux. This Health
Technology Assessment monograph included reviews
of epidemiology, assessment, and treatment, as
well as a study on clinical and cost
effectiveness of surgery and sclerotherapy. Compli
cations of sclerotherapy are rare but can include
blood clots and ulceration. Anaphylactic
reactions are "extraordinarily rare but can be
life-threatening," and doctors should have
resuscitation equipment ready. There has been one
reported case of stroke after ultrasound guided
sclerotherapy when an unusually large dose of
sclerosant foam was injected.
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Sclerotherapy
DR. HIMANSHU SHAH M.B.B.S.D.M.R.D., VARICOSEVEIN
CONSULTANT
A commonly performed non-surgical treatment for
varicose and "spider" leg veins is sclerotherapy,
in which medicine (sclerosant) is injected into
the veins to make them shrink. The medicines that
are commonly used as sclerosants are polidocanol
(POL branded Asclera in the United States,
Aethoxysklerol in Australia), sodium tetradecyl
sulphate (STS), Sclerodex (Canada), Hypertonic
Saline, Glycerin and Chromated Glycerin. STS
(branded Fibrovein in Australia) liquids can be
mixed at varying concentrations of sclerosant and
varying sclerosant/gas proportions, with air or
CO2 or O2 to create foams. Foams may allow more
veins to be treated per session with comparable
efficacy. Their use in contrast to liquid
sclerosant is still somewhat controversial.
Sclerotherapy has been used in the treatment of
varicose veins for over 150 years. Sclerotherapy
is often used for telangiectasias (spider veins)
and varicose veins that persist or recur after
vein stripping. Sclerotherapy can also be
performed using foamed sclerosants under
ultrasound guidance to treat larger varicose
veins, including the great saphenous and small
saphenous veins.
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Endovenous thermal ablation
DR. HIMANSHU SHAH M.B.B.S.D.M.R.D., VARICOSEVEIN
CONSULTANT
There are three kinds of endovenous thermal
ablation treatment possible  laser,
radiofrequency and steam.
The Australian Medical Services Advisory
Committee (MSAC) in 2008 determined that
endovenous laser treatment/ablation (ELA) for
varicose veins "appears to be more effective in
the short term, and at least as effective
overall, as the comparative procedure of junction
ligation and vein stripping for the treatment of
varicose veins." It also found in its assessment
of available literature, that "occurrence rates
of more severe complications such as DVT, nerve
injury and paraesthesia, post-operative
infections and haematomas, appears to be greater
after ligation and stripping than after EVLT".
Complications for ELA include minor skin burns
(0.4) and temporary paraesthesia (2.1). The
longest study of endovenous laser ablation is 39
months.



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DR. HIMANSHU SHAH M.B.B.S.D.M.R.D., VARICOSEVEIN
CONSULTANT
BEFORE
AFTER
BEFORE
AFTER
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Two prospective randomized trials found speedier
recovery and fewer complications after
radiofrequency ablation (ERA) compared to open
surgery. Myers wrote that open surgery for small
saphenous vein reflux is obsolete. Myers said
these veins should be treated with endovenous
techniques, citing high recurrence rates after
surgical management, and risk of nerve damage up
to 15. By comparison ERA has been shown to
control 80 of cases of small saphenous vein
reflux at 4 years, said Myers. Complications for
ERA include burns, paraesthesia, clinical
phlebitis and slightly higher rates of deep vein
thrombosis (0.57) and pulmonary embolism
(0.17). One 3-year study compared ERA, with a
recurrence rate of 33, to open surgery, which
had a recurrence rate of 23.
Steam treatment consists in injection of pulses
of steam into the sick vein. This treatment which
works with a natural agent (water) has similar
results than laser or radiofrequency. The steam
presents a lot of post-operative advantages for
the patient (good aesthetic results, less pain,
etc.)
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DR. HIMANSHU SHAH M.B.B.S.D.M.R.D., VARICOSEVEIN
CONSULTANT
ELA and ERA require specialized training for
doctors and special equipment. ELA is performed
as an outpatient procedure and does not require
an operating theatre, nor does the patient need a
general anaesthetic. Doctors use high frequency
ultrasound during the procedure to visualize the
anatomical relationships between the saphenous
structures. Some practitioners also perform
phlebectomy or ultrasound guided sclerotherapy at
the time of endovenous treatment. Follow-up
treatment to smaller branch varicose veins is
often needed in the weeks or months after the
initial procedure. Steam is a very promising
treatment for both doctors (easy introduction of
catheters, efficient on recurrences, ambulatory
procedure, easy and economic procedure) and
patients (less post-operative pain, natural
agent, fast recovery to daily activities). THA
NK YOU


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