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226
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and refilling occurs. In normal people, it occurs through
arterial inflow in 20–30 seconds. In venous incompetence
filling also occurs by venous reflux and so refilling time
is faster than normal.
Disadvantage: Site of reflux cannot be localised by this
method.
¾
Air plethysmography: Patient is initially in supine position
with veins emptied by elevation of leg. Air filled plastic
pressure bladder (inflatable polyurethane cuff filled with
air) is placed on calf to detect volume changes. Minimum
volume is recorded. Patient is turned to upright position and venous volume is assessed. Maximum venous
SRB’s Manual of Surgery
volume divided by time required to achieve maximum
venous volume gives the venous filling index (VFI). VFI
is a measure of reflux. Ejection fraction is volume change
measured prior and after single toetip manoeuvre which is
a measure of calf pump action. Residual venous fraction
is an index of overall venous function which is venous
volume in the leg after ten toetip manoeuvres divided by
venous volume prior to manoeuvre. Increased VFI and
diminished ejection fraction in a patient will benefit from
surgery.
Ambulatory venous pressure (AVP):
It is an invasive method. Needle inserted into dorsal vein of
foot and is connected to transducer to get its pressure which
is equivalent to pressure in the deep veins of the calf. Ten
tiptoe manoeuvres are done by the patient. With initial rise
in pressure, pressure decreases and eventually stabilises
with a balance. Pressure now is called as ambulatory venous
pressure (AVP). After stopping exercise, veins are allowed
to refill with return of pressure to baseline. Time required
for pressure to return to 90% of baseline is called as venous
refilling time (VRT). Raise in AVP signifies venous hyperten-
sion. Patients with AVP more than 80 mmHg has got 80%
chances of venous ulcer formation.
Arm-foot venous pressure:
Foot pressure is not more than 4 mmHg above the arm pres-
sure.
Venography:
¾
Ascending venography was very common investigation
done before Doppler period.
A tourniquet is applied above the malleoli and vein of
dorsal venous arch of foot is cannulated. Water soluble dye
injected, flows into the deep veins (because of the applied
tourniquet). X-rays are taken below and above knee level.
Any block in deep veins, its extent, perforator status can
be made out by this.
It is a good reliable investigation for DVT.
If DVT is present, surgery or sclerotherapy are contrain-
dicated.
¾
Descending venogram is done when ascending venogram
is not possible and also to visualise incompetent veins.
Here contrast material is injected into the femoral vein
through a cannula in standing position. X-ray pictures
are taken to visualise deep veins and incompetent veins.
PHLEBOGRAPHY
B
x Ascending phlebography defines obstruction
x Descending phlebography identifies valvular incompetence
x Regularly not required to be done
x MR venography is new method
Varicography:
Here nonionic, iso-osmolar, nonthrombogenic contrast
is injected directly into the variceal vein to get a detailed
anatomical mapping of the varicose veins. It is used in recurrent varicose veins.
DIFFERENTIAL DIAGNOSIS
B
x Lymphoedema; AV malformation; Orthostatic oedema
x Renal, cardiac and hepatic diseases
x Vasculitis and metabolic diseases like gout, myxoedema, and
morbid obesity
x Chronic infections like tuberculosis, syphilis
Treatment
Conservative treatment:
¾
Elastic crepe bandage application from below upwards or
use of pressure stockings to the limb—pressure gradiant
of 30–40 mmHg is provided.
¾
Elevation of the limb—relieves oedema. Two short times,
during day and full night, elevation of foot with feet above
the level of heart and toes above the level of nose is the
method.
¾
Unna boots—provide nonelastic compression therapy. It
comprises a gauze compression dressings that contain
zinc oxide, calamine, and glycerine that helps to prevent
further skin break down. It is changed once a week.
¾
Pneumatic compression method—provide dynamic
sequential compression.
¾
These methods reduce the AVP, reduce transcapillary
fluid leakage by increasing SC pressure and improve
cutaneous microcirculation.
Drugs used for varicose veins:
¾
Calcium dobesilate: 500 mg BD. Calcium dobesilate
improves lymph flow; improves macrophage mediated
proteolysis; and reduces oedema.
¾
Diosmin: It is micronized purified flavanoid fraction. It
protects venous wall and valve, and it is anti-inflammatory, profibrinolytic, anti-oedema, lymphotropic. Diosmin
450 mg + Hesperidin 50 mg (DAFLON 500 mg). Mainly
used in relieving night cramps but not to improve healing
of ulcers.
¾
Toxerutin 500 mg BD, TID. Antierythrocyte aggregation
agent which improves capillary dynamics.
¾
Benzopyrones, saponins, plant extracts, Ruscus (venular
α 1-adrenergic receptor partial agonist) coumarins are
different drugs used.
Note:
Benefits of all these drugs are doubtful.
Injection—sclerotherapy:
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¾
Fegan’s technique: By injecting sclerosants into the vein,
complete sclerosis of the venous walls can be achieved.
Indications
–
Uncomplicated perforator incompetence.
–
In the management of smaller varices—reticular
veins, thread veins (telangiectasis), Recurrent varices,
Isolated varicosities.
–
Aged/unfit patients.
SCLEROSANTS USED ARE:
B
x Sodium tetradecyl sulphate 3% (STDS)—commonly used
x Sodium morrhuate
x Ethanolamine oleate
x Polidocanol—3% or 1%
MECHANISMS OF ACTION
B
x Causes aseptic inflammation
x Causes perivenous fibrosis leading to block
x Causes approximation of intima leading to obliteration by
endothelial damage
x Alters intravascular pH/osmolality
x Changes surface tension of plasma membrane
–
Advantages: Cheap, technically easy, easily avail-
able, OPD procedure, can be repeated many times,
anaesthesia is not needed, can be used along with
other procedures for varicose veins. US guided foam
sclerotherapy (USFS) is the current standard.
–
Complications: Headache, transient blindness, stroke,
air embolism, thrombophlebitis, pain over injected
site, pigmentation.
–
Contraindications: Peripheral arterial disease, DVT.
A
227
CHAPTER 1N General Surgery: Venous Diseases
–
A 23 gauge needle is inserted into the vein (3–8 mm
sized) and vein is emptied. 0.5–1 m
L of sclerosant is
injected into the vein and immediately compression is
applied on the vein (prevent the entry of blood which
may cause thrombo sis, which later gets recanalised,
further worsening the condition) so as to allow the
development of sclerosis and to have proper endothelial apposition.
–
Usually injection is started at the ankle region and then
proceeded upwards along the length of the veins at
different points. Later pressure bandage is applied for
six weeks. Often injections may have to be repeated
at 2–4 weeks intervals for 2–4 sessions. Technique is
called as macrosclerotherapy.
–
Entrapped blood may require to be evacuated after 14
days which is often essential to prevent recanalisation.
¾
Foam sclerotherapy by Tessari:
–
STDS taken in a syringe is passed rapidly into another
syringe which contains air to result in formation of
foam. 1 mL of STDS is mixed with 4 mL of air to
make 5 m
L of foam which is injected to vein. Total 6
mL maximum of STDS with 30 mL foam can be used.
This foam in much larger quantity is injected into the
superficial vein. Air between foam gets absorbed
and endothelial lining is destroyed. Foam minimises
thrombosis by pushing the blood out of the site of the
vessel where action is needed. Polidocanol/STDS is
used for foam sclerotherapy.
B
C
Figs. 1.412A to C: Technique making foam and injecting into the vein.
4 mL air with 1 mL STDS is mixed vigorously using 3 way stopcock and
L syringes. Created foam is injected into the vein immediately.
two 5 m
Total of 6 mL STDS (30 mL foam) can be injected.
An ounce of action is worth a ton of theory.
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¾
Microsclerotherapy:
Very dilute solution of sclero sing agent like STDS (0.1%
of 0.1 m
L—dilute) Polidocanol is injected into the thread
veins and reticular veins followed by application of
compression bandage (30 G needle). Dermal flare will
disappear well by this method.
¾
Transillumination microsclerotherapy (vein—lite): It
is better imaging of the veins using light generated by
halogen bulb with high quality fibre illumination over the
skin uniformly and passing 30 gauge needle for microsclerotherapy.
¾
Echosclerotherapy:
SRB’s Manual of Surgery
Sclerotherapy is done under duplex ultrasound image
guidance.
¾
Catheter directed sclerotherapy:
It is devised at Miami vein clinic with specific catheter for
sclerotherapy. This catheter has got side holes all around
REMEMBER ABOUT SCLEROTHERAPY
B
x Current place of sclerotherapy is mainly for recurrent varicosities
and thread/telangiectatic veins
x Sodium tetradecyl sulphate (STDS) is most commonly used
sclerosant
x Hyperpigmentation is common after STDS
x Anaphylaxis is common after sodium morrhuate
x Anaphylaxis is least with polidocanol
x Extravasation (presence of pain/irritation/burning) should be
avoided as it will cause skin necrosis
x Postsclerotherapy walking immediately after injection for
30 minutes with elastic bandage in place prevents/minimises the
chances of DVT
x Compression bandage should be worn for minimum period of
6 weeks
x Sclerotherapy can be—macrosclerotherapy; microsclerotherapy;
echo (ultrasound guided) sclerotherapy; foam sclerotherapy;
transilluminated sclerotherapy
the specific length for uniform contact of venous wall with
the foam. It also has got a balloon at the tip which after
Interventions
inflation blocks the SFJ thus preventing embolization of
foam. It has got three external ports one for balloon inflation; one for bladder valve port; one for injection. This
technique is under trial.
INDICATIONS FOR INTERVENTIONAL PROCEDURES
B
x To relieve Complaints which are relevant like pain, discomfort;
x To reverse Complications like skin changes, ulcers, bleeding,
superficial thrombophlebitis, lipodermatosclerosis;
x Cosmesis; prophylaxis.
Fig. 1.413: Catheter directed sclerotherapy.
Advantages of sclerotherapy
¾
It can be done as an outpatient procedure.
¾
It does not require anaesthesia.
Disadvantages of sclerotherapy
¾
Inadvertent subcutaneous injection can cause skin
necrosis or abscess formation.
¾
Anaphylaxis, vasovagal shock, allergy.
¾
Hyperpigmentation.
¾
Thrombophlebitis.
¾
Deep venous thrombosis can occur.
¾
Inadvertent intra-arterial injection—serious complication.
¾
Intravenous haematoma.
¾
Temporary ocular disturbances.
¾
Skin staining, injection ulcers, persistent local pain.
CONTRAINDICATIONS FOR SCLEROTHERAPY
B
x Saphenofemoral incompetence
x Deep venous thrombosis
x Huge varicosities—may precipitate DVT
x Peripheral arterial diseases
x Hypersensitivity/immobility
x Venous ulcer—relative contraindication
Fig. 1.414: Veins should be marked just prior to
surgery using marking ink.
Surgery:
¾
Trendelenburg operation (Crossectomy)
It is juxtafemoral flush ligation of long saphenous vein (i.e.
flush with femoral vein), after ligating named (superficial
circumflex, superficial external pudendal, super ficial
epigastric vein), deep external pudendal vein and unnamed
tributaries. All tributaries should be ligated, otherwise
recurrence will occur. Double saphenous vein is the
most common anomaly occurring near saphenovenous
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CHAPTER 1N General Surgery: Venous Diseases
A
A
B
Figs. 1.415 and B: Photo of Myer‘s stripper with Olive tips and also
diagrammatic look of the same.
B
C
Figs. 1.417A to C: Saphenofemoral junction and its ligation.
Tributaries are well seen.
Fig. 1.416: Incision for juxtafemoral flush ligation of long saphenous
vein (Trendelenburg operation).
A
B
Figs. 1.418A and B
Know more than others; work more than others; expect less than others.
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–
Stripping of the short saphenous vein is done from
ankle below upwards after passing stripper from above
downwards. It obliterates the mid calf perforator vein
which is the common reason for recurrences.
–
Complications of stripping: Saphenous neuralgia
(1–7%) due to saphenous nerve injury/avulsion;
numbness and tingling along femoral nerve distribution; haematoma; infection; ulceration; recurrence of
the disease is common (30%) which is not due to any
technical default but due to progression of disease
itself by neo-angiogenesis and re-vascularisation.
SRB’s Manual of Surgery
C
D
Figs. 1.418C and D
Figs. 1.418A to D: Long saphenous vein stripping. Note the stripped
vein. Stripping is better than just ligation at the junction.
junction. Anterior accessory saphenous vein (AASV) and
posteromedial thigh vein are also often seen distally as
tributaries.
¾
Stripping of vein
–
Using Myer’s stripper vein is stripped off. Stripping
from below upwards is technically easier. Immediate
application of crepe bandage reduces the chance of
bleeding and haematoma formation. Stripping avulses
the vein as well as obliterates the tributaries. Babcock’s
stripper and rigid metal pin stripper can also be used.
–
Two methods of stripping are used: (1) Extraluminal
collision technique using Myer’s stripper (Acorn head
stripper, 73 cm long) is practiced since long time;
but it damages the adjacent tissue, causes infection,
postoperative pain, discomfort and haematoma along
the stripped tract with possibility of revascularisation
of the tract haematoma. (2) Invagination technique is
better with less damage to adjacent tissue. Codman’s
stripper is used for invagination technique.
Note:
• Stripping of LSV up to knee level reduces the need for
re-intervention for recurrent varicose veins; stripping up to
the ankle will not benefit additionally but may increase the
chance of saphenous nerve injury. So stripping is not at all
done in lower part of the leg for LSV.
• Stripping of the vein is more effective than just ligation of
the vein at the SFJ/SPJ.
• Stripping of SSV reduces the recurrence but may damage
sural nerve.
–
‘Inverting or invaginating stripping’ using rigid Oesch
pin stripper is better as postoperative pain and haematoma is less common and also tissue damage. Vein
should be very firmly fixed to the end of the stripper
and pulled out to cause the inverting of the vein.
–
Stripping of short saphenous vein is more beneficial
than just ligation at saphenopopliteal junction. It is
done from above downwards using a rigid stripper to
avoid injury to sural nerve.
¾
Subfascial ligation of Cockett and Dodd (1938):
–
Perforators are marked out by Fegan’s method.
Perforators are ligated deep to the deep fascia through
incisions in anteromedial side of the leg.
¾
Ligation of short saphenous vein at saphenopop liteal
junction. It is done in prone position with horizontal
incision. Variations in SP junction are common. But
stripping is better.
¾
Linton’s vertical approach (1938)—subfascial ligation
of perforators.
A B
Figs. 1.419A and B: A. Cockett and Dood subfascial ligation of
perforators using multiple small horizontal incisions. B. Linton’s vertical
approach for subfascial perforator ligation in the leg.
¾
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Stab avulsion of varicose vein and perforators: Avulsion
is done using mosquito forceps or avulsion hooks—hook
phlebectomy. It is popular method, also used along
with other minimal invasive techniques like EVLA, RFA.
Multiple incisions are made and veins are carefully and
gently avulsed/teased to clear it. Postoperative compression bandage is a must.
Fig. 1.420: Typical perforator ligation.
A B
Figs. 1.421A and B: Avulsion of the perforator using hook or
mosquito forceps through a small skin incision—stab avulsion.
Minimally invasive methods:
a. Subfascial endoscopic perforator ligation surgery (SEPS)
–
A special telescope is introduced deep to deep fascia
through a single small vertical incision at proximal
leg selecting healthy skin. Potential space between
muscle and deep fascia with loose areolar tissue is
easy to dissect using endoscope. Technique is done
under tourniquet 300 mmHg pressure. Endoscope is
advanced down along the medial border of the tibia.
Perforators travelling in subfascial plane are identified
and fulgurated using bipolar cautery or clips can be
applied into the perforators. It is recommended in
chronic venous insufficiency (CVI). But its limitation
is difficulty in getting ‘lift off’ skin in cases with severe
lipodermatosclerosis to identify the perforators.
Radiofrequency ablation (RFA) method (VNUS closure
b.
method) (VNUS medical technologies Inc; Sunnyvale, CA,
USA) (by Goldman 2000):
This procedure is done under general or regional
anaesthesia. A RFA catheter is passed into long/ short
saphenous vein near saphenofemoral or saphenopopliteal junction under guidance. 85°C temperature
is used for longer period of time to cause endothelial
damage, collagen denaturation and venous constriction. 7
French catheter is used and 7 cm segment vein is ablated
sequentially. Phlebectomy is done while withdrawing the
catheter. Wall of the vein is destroyed through its full
thickness. Vein forms a cord, which gets dissolved by
macrophages and immune cells.
CELON RFITT—Radio Frequency Induced Thermal
Therapy (2007) is newer type.
c. Trivex method:
Under subcutaneous illumination and local anaesthesia, a
large quantity of fluid is injected percutaneously to identify
the superficial veins under. Tumescent anaesthesia created
causes hydrodissection. Trivex resector and illuminator are
placed under the skin. Resector gently extracts veins by
suction and morcellation. Further stages of tumescence
flushes all blood and delivers vasoconstriction solutions.
Solution is passed through 18 gauze needle to clear all blood
underneath. Method is cosmetically acceptable; removes
all sized veins; achieves good pain relief; with minimal
complications like bruising, induration which gets resorbed
eventually; and can be used when there are venous ulcers.
231
CHAPTER 1N General Surgery: Venous Diseases
Fig. 1.422: Subfascial endoscopic perforator ligation surgery (SEPS).
d. Endovenous laser ablation (EVLA):
It is done as an outpatient procedure or as day-care
surgery. Patient lies supine with diseased leg flexed, hip
externally rotated and knee flexed. With aseptic precaution, under U/S guidance LSV is cannulated guide wire is
passed beyond SFJ and 5- French catheter is passed over
guide wire and tip is placed 1 cm distal to the junction. 200
ml of 0.1% lignocaine (crystalloid with local anaesthetic)
is infiltrated along the length of the LSV. Laser flexible
glass fibre is inserted up to the tip of the catheter and
catheter is withdrawn for 2 cm and laser fibre protrudes
A man without purpose is like a ship without rudder.
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for 2 cm. Laser fibre is fired step by step using diode laser
(810–1470 nm diode laser energy), 1 mm withdrawal in 2
seconds. Once procedure is over catheter is removed and
pressure bandage is applied for 2 weeks. Heat produced
(729–1000°C at tip) by the laser produces steam bubbles
with thermal damage of endothelium leading into occlusion of the vein. Laser energy acts on the blood within the
vein rather directly through the wall and heats the blood
and in turn heats the vein wall. Drawback of laser therapy
is inability to create flush occlusion allowing tributaries
to open up to cause possible recurrence.
Complications of EVLA: Pain; ecchymosis, haematoma,
skin burns, difficulty in cannulating the unsuitable vein if
SRB’s Manual of Surgery
selected; DVT; sensory disturbances, infection.
A
e. Other methods:
–
Transilluminated phlebectomy is done by passing
transilluminating light under the skin and passing a
rotating blade through another small incision. Veins
are grasped and removed by rotating movements.
–
Ambulatory phlebectomy is done through tiny small
incisions using special phlebectomy instruments.
–
Electrodessication using weak electric current through
a fine needle directly into the spider veins (telangiectasis) is also used.
–
Endovenous glue (cyanoacrylate—0.1 mL) injection
through a guided venous catheter to seal the lumen.
COMPLICATIONS (20%) OF VARICOSE VEIN SURGERIES/
B
INTERVENTIONS
x Infection—most common complication
x Haematoma formation, bruising, oedema limb
x Nerve injury is the most common serious complication:
– Saphenous nerve injury in LSV stripping is 1–7%
– Sural nerve injury in SSV stripping is 20%
– Common peroneal nerve injury in SSV stripping is 4%
x Recurrence of varicose veins—20–30%.
– Causes are—angiogenesis and revascularisation; improper
surgery; reflux in residual axial vein; new reflux; axial vein
recanalisation
– Recurrence is more with SSV disease than LSV; in obese
patient
– Complications are high in surgeries for recurrent varicose
veins—40%
x DVT is rare complication — <0.5%.
Note:
Contraindication for surgery is deep vein thrombosis (DVT).
B
C
D
Figs. 1.423A to D: Endovenous laser ablation (EVLA) for
Note:
EVLA has got 95% efficacy. Tumescent anaesthesia is prepared by
mixing 500 mL of normal saline, 30 mL of xylocaine 1% with adrenaline, 10–30 mL of 8.4% sodium bicarbonate. It is injected using
long needle along the length adjacent to vein to cause tamponade
and to prevent heat burn on the surface. It also empties the venous
blood to create compression of the vein on to the device tip; causes
hydrodissection to keep nerves away from the procedure area.
varicose veins.
VENOUS ULCER (Gravitational Ulcer)
It is the complication of varicose veins or deep vein thrombosis.
Pathogenesis of Venous Ulcer
Varicose veins or DVT which are recanalised, even tually causes
chronic venous hypertension around ankle
↓
Causes haemosiderin deposition in the subcuta neous plane
from lysed RBC’s
↓
Eczema
↓
Dermatitis
↓
Lipodermatosclerosis
↓
Fibrosis
↓
Anoxia
↓
Ulceration
Ambulatory venous hypertension is the prime cause of
venous ulcer formation. Venous hypertension may be gravi-
Fig. 1.424: Venous ulcers around both ankles (bilateral).
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CHAPTER 1N General Surgery: Venous Diseases
tational which is due to hydrostatic pressure by weight of
blood column from the right atrium (hydrostatic reflux) which
is maximum at foot and ankle OR dynamic which is due to
muscular contraction across the incompetent perforator with
a high pressure up to 200 mmHg (hydrodynamic reflux). There
is a peculiar recycling of blood from deep veins → femoral vein
→ spillage of blood across incompetent SFJ into LSV/GSV
→ passage of same blood across perforators into the deep
veins to reach femoral vein → again to enter the LSV as
spillage.
White cell trapping’ theory and ‘fibrin cuff’ theory; release of free
radicals; increased matrix metalloproteinases (MMPs); abnormal
fibroblast activity; inhibition of growth factors; are other causes
of venous ulcer formation.
Area where venous ulcer commonly develops, is around
and above the medial malleoli because of presence of large
number of perforators which transmit pressure changes
directly into superficial system. This area is called as Gaiter’s
zone. It can also be on both malleoli.
Ulcer is often large, nonhealing, tender, recurrent with
secondary infection. Vertical group of inguinal lymph nodes
are usually enlarged and tender.
Often it leads to scarring, ankylosis, Marjolin’s ulcer forma-
tion. Slough from the ulcer bed may give way causing venous
haemorrhage.
Periostitis is common which also prevents ulcer from
healing.
Most of the venous ulcers have surrounding lipodermato-
sclerosis. Lipodermatosis is chronic inflammation, fibrosis,
thickening, induration of the skin and subcutaneous tissue of
the lower leg (calf) and ankle with pigmentation and a tight
contracted woody leg often with Achilles tendon contracture.
It suggests severe chronic venous disease.
Fig. 1.4 25: Gaiter’s zone. It is handbreadth area around malleoli where
complications of venous disease occurs. Word gaiter (French) is a
leather/cloth covering for lower leg and ankle.
Fig. 1.426: Champagne bottle sign/inverted beer bottle sign is seen in
lipodermatosclerosis due to prominent calf with narrow ankle, contracted
skin and subcutaneous tissue. Sign is often observed in DVT also.
Fig. 1.427: Marjolin’s ulcer in a chronic venous ulcer.
Due to regular walking on toes so as to relieve the pain causes
contraction and extra-articular fibrosis of achilles tendon.
Proper exercise is the remedy for—talipes equinovarus.
Note:
70–80% of leg ulcers are venous ulcers.
Strong convictions precede great actions.
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Differential diagnosis: Ischaemic ulcer, diabetic ulcer; Rheu-
matoid ulcer; Traumatic ulcer; Neuropathic ulcer; Neoplastic
ulcer.
Investigations
¾
Discharge from the ulcer for culture and sensitivity.
¾
X-ray of the area to look for periostitis.
¾
Wedge biopsy from the ulcer edge to rule out Marjolin’s
ulcer.
¾
Investigations to rule out other causes of leg ulcers like
arterial; neurological; diabetes; sickle cell disease and
other haemolytic diseases.
¾
SRB’s Manual of Surgery
Erythrocyte sedimentation rate; C-reactive protein,
Fig. 1.428: Skin graft is done over a venous ulcer once ulcer has
shown healthy granulation tissue.
peripheral smear; red cell counts.
¾
Doppler—venous and often arterial.
Treatment
¾
Bisgaard method of treating venous ulcer:
–
Measures to reduce oedema, increase venous
drainage, so as to promote ulcer healing.
–
Elevation.
–
Massage of the indurated area and whole calf.
–
Passive and active exercise.
¾
Care of ulcer by regular cleaning with povidone iodine,
H2O2. Dressing with EUSOL.
¾
Four layer bandage (45 mmHg pressure) technique to
achieve high compression pressure. It is changed once
COMPLICATIONS OF VENOUS ULCERS
B
x Haemorrhage
x Marjolin’s ulcer
x Infection
x Talipes equinovarus
Note:
x Periostitis is common over
the tibia
x Disability
x Calcification
• Present concept is to treat the ulcer first by compression bandage; regular
dressing; skin grafting. Once ulcer has healed definitive procedure for
varicose veins is done. Studies show that rapidity of healing of ulcer
perse is not dependent on the surgery for varicose veins.
• Recurrence rate of venous ulcer after proper therapy is 30%. Reulcer
formation is more in post-phlebitic/ thrombotic limb.
• EUSOL is Edinburgh University solution of lime containing boric acid,
sodium hypochlorite, calcium hydroxide.
a week.
¾
Antibiotics depending on culture and sensitivity of the
discharge.
¾
Once ulcer bed granulates well, split skin graft (SSG) is
placed (Thiersch Graft), or pinch graft.
¾
Specific treatment for varicose veins should be under-
taken—Trendelenburg operation, stripping of veins,
perforator ligation.
COMPRESSION THERAPY FOR VARICOSE VEINS
Compression reduces the venous wall tension; prevents
reflux; controls the venous over-distension.
Compression diverts the blood towards deep veins through
perforating veins; prevents the outward flow of blood in
perforator incompetence; improves the efficacy of calf muscle
pump. Compression reduces the oedema and improves the
venous and lymphatic drainage; improves venous elasticity;
DIFFERENT BANDAGES USED ARE:
B
x Charing—Cross (hospital London) elastic multilayered compres-
sion bandage, once a week
x Low compression bandaging
x Graduated elastic compression stockings with a leak proof absor-
bent dressing beneath
x Unna boots
x Crepe bandage/stockings
improves the microcirculation and more important is it
prevents further damage of the venous wall.
Compression may be elastic/inelastic/combination of
elastic and inelastic (Unna boot)/multilayered (four layered)
compression system which can provide sustained high
compression for several days—usually up to a week/intermittent pneumatic compression. Unna boot is three-layered
paste gauze compression dressing containing calamine, zinc
oxide, glycerin, sorbitol, gelatin and aluminium silicate which
Fifty percent of venous ulcer occurs as a result of recanalisation
of DVT, and the leg is commonly called as postphlebitic
limb (leg). It presents with all compli cations of venous
diseases like eczema, ulceration, lipodermato sclerosis and
venous ulcers. Here surgery for superficial varicose veins
are contraindicated. Venous valve repair (Kistner’s valvulo-
plasty) or valve transplantation or drugs like Stanazolol,
which reduces the fibrous tissue thereby increasing the
oxygenation are beneficial.
has mainly inelastic inner component with partly elastic outer
layer wrap.
Recommended pressure in mild varicose veins, pregnancy
and postoperative period is 20 mmHg; in symptomatic varicose veins and after sclerotherapy is 30 mmHg; in venous
ulcer and post-phlebitic leg it is 40–45 mmHg; in phlebolymphoedema (venous oedema with lymphatic oedema which is
more dangerous) it is more than 45 mmHg.
Skin maceration, excoriation, dryness, infection, ulceration
and failure are the complications of compression therapy.
Fig. 1.429: Compression stockings should be worn in varicose vein
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disease even after intervention to reduce the chances of recurrence.
REMEMBER
B
x Compression improves ulcer healing rate
x Supplementation of phlebotonic drugs in conjunction with
compression therapy is accepted
x Inelastic compression (<50% stretch) causes more improvement
(reduction) in venous filling index (VFI) than elastic compression.
But elastic compression (>50% stretch) is more commonly used
because it is better accepted
x Multilayered bandage system is most effective
x Ankle-arm pressure index less than 0.6 is contraindication for
compression therapy as it may precipitate ischaemic ulcer formation
x Exercise may improve the muscle—pump action
COMPRESSION GARMENTS STANDARD
B
British standard
x Class I: 14–17 mmHg
x Class II: 17–24 mmHg
x Class III: 24–35 mmHg
International (European)
standard
x Class I: 20–30 mmHg
x Class II: 30–40 mmHg
x Class III: 40–50 mmHg
x Class IV: 50–60 mmHg
c. Spontaneous: Polycythaemia vera, polyarteritis, Buerger’s
disease.
d.
Thrombophlebitis migrans (Trousseau’s sign, 1876): It is
spontaneous migrating thrombophlebitis seen in visceral
malignancy like pancreas, stomach.
Mondor’s disease.
e.
It can be—SVT with varicose veins (V-SVT) or SVT without
varicose veins (NV-SVT). It can also be—primary or secondary.
Duplex ultrasound Doppler of both limbs is a must.
Fig. 1.4 30: Superficial thrombophlebitis with clot and infection.
Features
Pain, redness, tenderness, cord like thickening of veins, fever.
It can be seen either in upper limb or lower limb.
Complications: Destruction of venous valves resulting in
varicose veins. DVT, embolism, infection.
Treatment
¾
Elevation.
¾
Anti-inflammatory drugs, antibiotics.
¾
Application of crepe bandage—compression therapy.
¾
Anticoagulation—LMWH for SVT >3 cm in length.
KLIPPEL-TRENAUNAY SYNDROME
235
CHAPTER 1N General Surgery: Venous Diseases
COMPRESSION BANDAGES
B
x Type I: Light weight confirming stretch bandages. These comprise
light weight elastomer with high elasticity but little power. It is
used to retain dressings
x Type II (short stop): Light support bandages. Minimal stretch.
Exhibit limited elasticity but tends to lock out on minimal extension. In ambulant patient CVI they form an essentially inelastic
covering to the leg which will exert pressure during calf systole
but not during diastole. They are unsuitable for control of oedema
x Type III (Long stop): These are extensible elastic and powerful
to a varying degree
THROMBOPHLEBITIS
It is the inflammation of veins, usually of superficial, veins due
to different causes. It is actually superficial vein thrombosis
(SVT) with inflammation (slight).
Types
a. Acute: Due to IV cannulation, trauma, minor infections,
hypercoagulability.
b. Recurrent.
Everything has its beauty but not everyone sees it.
It is a nonfamilial mesodermal anomaly with skin naevus, varicose veins, soft tissue and bone hypertrophy. Deep veins are
often aplastic. It is usually managed with compression bandages. If patient is undergoing surgery for some other condition,
then LMWH should be started. Condition itself occasionally can
be treated with EVLA for varicose veins if only deep veins are
normal; bone length discrepancy correction of leg is done.
Parkes-Weber syndrome is a differential diagnosis. PW
syndrome presents with varicose veins, multiple AV fistulas,
chronic venous hypertension, high output cardiac failure and
ulceration.
ANTICOAGULANTS
These are the agents used to prevent and treat thrombosis and
thromboembolic events. It may be used in arterial thrombus
(white in colour) like in myocardial infarction, stroke, ischaemia
of different parts; or in venous thrombosis of limb veins or pelvic
veins or mesenteric veins or neck veins. Embolism is the eventual
problem along with perfusion changes. Thromboembolism is a
major problem in venous thrombosis.
Anticoagulants may be in vivo—parenteral (heparin, LMWH,
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