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A Surgical Approach
Subramoniam Vaidyanathan
Riju Ramachandran
Pradeep Jacob
Binni John
123
Chronic Venous
Disorders of
the Lower Limbs
Chronic Venous Disorders
of the Lower Limbs
Subramoniam Vaidyanathan
Riju Ramachandran Menon
Pradeep Jacob • Binni John
Chronic Venous
Disorders of the Lower
Limbs
A Surgical Approach
ISBN 978-81-322-1990-3 ISBN 978-81-322-1991-0 (eBook)
DOI 10.1007/978-81-322-1991-0
Springer New Delhi Heidelberg New York Dordrecht London
Library of Congress Control Number: 2014951524
© Springer India 2015
This work is subject to copyright. All rights are reserved by the Publisher, whether the whole or
part of the material is concerned, specifi cally the rights of translation, reprinting, reuse of
illustrations, recitation, broadcasting, reproduction on microfi lms or in any other physical way,
and transmission or information storage and retrieval, electronic adaptation, computer software,
or by similar or dissimilar methodology now known or hereafter developed. Exempted from this
legal reservation are brief excerpts in connection with reviews or scholarly analysis or material
supplied specifi cally for the purpose of being entered and executed on a computer system, for
exclusive use by the purchaser of the work. Duplication of this publication or parts thereof is
permitted only under the provisions of the Copyright Law of the Publisher's location, in its
current version, and permission for use must always be obtained from Springer. Permissions for
use may be obtained through RightsLink at the Copyright Clearance Center. Violations are liable
to prosecution under the respective Copyright Law.
The use of general descriptive names, registered names, trademarks, service marks, etc. in this
publication does not imply, even in the absence of a specifi c statement, that such names are
exempt from the relevant protective laws and regulations and therefore free for general use.
While the advice and information in this book are believed to be true and accurate at the date of
publication, neither the authors nor the editors nor the publisher can accept any legal responsibility
for any errors or omissions that may be made. The publisher makes no warranty, express or
implied, with respect to the material contained herein.
Printed on acid-free paper
Springer is part of Springer Science+Business Media (
www.springer.com)
Subramoniam Vaidyanathan
General Surgery
Amrita Institute of Medical Sciences
Kochi, Kerala
India
Riju Ramachandran Menon
General Surgery
Amrita Institute of Medical Sciences
Kochi, Kerala
India
Pradeep Jacob
General Surgery
Amrita Institute of Medical Sciences
Kochi, Kerala
India
Binni John
General Surgery
Government Medical College
Kottayam, Kerala
India
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v
This book is a chronicle of an ancient disease, once considered “a poor sec-
ond cousin” to arterial disease. It starts with a glimpse into the history, por-
traying the transformation of venous disease into, as the authors write, “if not
an emperor, a prince among vascular maladies”. The book goes on to a schol-
arly narration of the basics of venous disease, displaying the gems of anatomy
and physiology. It depicts the evolution of the treatment for primary varicose
veins from the traditional through contemporary to avant garde. The book
intensely dwells on chronic venous insuffi ciency, the “night of venous dis-
eases”. This section on chronic venous disease is a combination of surgeon’s
micro precision, teacher’s passion, researcher’s brilliance and storyteller’s
allure. The book fi nally has a peek into the pot-pourri of venous disorders.
Above all, this book is an autobiography of the authors’ immense experience
over the years. Valuable Indian data, though much of it unpublished hitherto,
given along with international statistics is indeed a breath of fresh air.
Professor Vaidyanathan, undoubtedly the superman of venous diseases in
Kerala, has inspired me and taught me. This book is in essence, a collection
of his adventures. Dr Riju, once my earnest student, never showed off his
artistic talents. All the pictures in the book are conceived and drawn by him,
simple, colourful yet demonstrative. Dr Pradeep Jacob and Dr Binni John are
“physicians”, Hippocrates would have been proud to introduce; they have
true and total commitment to the profession and their patients. All these four
extraordinary surgeons are known to work in silence; their success is making
melodious music though this book. It is there for everyone to hear and
relish.
Who is this book meant for? It may perhaps be a bit loud for the post-
graduates of surgical training. For the practicing general surgeon, it would be
an invaluable guide. The tips and tricks for diagnosing, medically treating
and surgically intervening for an assortment of chronic venous disorders are
distinctly described. It will help not only in their daily “bread and butter”
varicose vein work, but additionally for the occasional complex venous dis-
order they might encounter. For the venous enthusiasts, this book is a “must-
own” classic.
F o r e w o r d
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vi
By asking me to write a foreword, I had the opportunity to read this book.
As a vascular surgeon, I learnt a lot. My debts to the authors, particularly Prof
Vaidyanathan accrue even more. Thank you all.
S. Sudhindran , MS, FRCS (Gen)
Department of Vascular and Transplant surgery,
Amrita Institute of Medical sciences , Kochi , Kerala , India
Foreword
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vii
Venous diseases of the lower limbs are extremely common conditions in clin-
ical practice. They are considered trivial but irksome issues and are often
neglected. The face of venous diseases has transformed in recent times thanks
to the advances made in the diagnosis and treatment of these problems. For a
practising surgeon, a huge volume of literature is available on these matters.
However, the practitioner has to refer various books and publications to gar-
ner information relating to any aspect of the disease. There is no single source
to provide comprehensive information, indeed a state of poverty in the midst
of plenty! This book was conceived with the idea of providing comprehensive
information on common chronic venous problems encountered in surgical
practice under one roof. The clinical experience and data for this book were
gained by us in two different settings. From 1980 to 2000 some of us (SV, PJ
and BJ) were working at Medical College Hospital, Kottayam, Kerala. This
is a 1,000 bedded Government sector teaching hospital in the state of Kerala
in South India with a huge patient population and providing free treatment for
the poor and the needy. From 2000 onwards three of us (SV, RRM and PJ)
shifted to Amrita Institute of Medical Sciences, Kochi Kerala. This is a state
of the art hospital in the private sector, providing undergraduate, post gradu-
ate and super speciality training. This hospital functions under the Amrita
Viswa Vidya Peetham, a deemed University in the private sector. Apparently
we had the best of both worlds.
This book has basically followed the CEAP classifi cation pattern and is
divided into four sections, basics, C2 clinical class, C3–C6 class and an
assorted group of venous problems. We have considered only the chronic
venous problems affecting the lower limbs. Hence we have not included
acute deep vein thrombosis and venous injuries in this work. We must frankly
admit that we are novices in the publication fi eld. In fact, this is our fi rst ven-
ture as authors of a monogram. Although we have taken lot of pains to present
authentic information, there could be omissions and errors in this work. We
crave for your indulgence.
The literature on chronic venous problems of lower limbs is voluminous.
To pick and choose from this mountain of knowledge has been one of the
most diffi cult tasks for us. The best source of reference for us has been ‘The
Handbook of Venous Disorders: Guidelines of the American Venous Forum’
edited by Peter Gloviczki (3rd Edition, Hodder Arnold, London: 2009). We
would like to acknowledge this work.
Pref ace
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viii
It would be better to say that this book was written through us rather than
by us. It is a supreme example of team work in action. Although each chapter
was contributed by a specifi c individual, it was our collective effort that
brought it to its fi nal format. A word about the diagrams. The ideas for the
different diagrams were conceived by one of us with inspiration from differ-
ent sources (SV); they were executed by two members from our group (RRM
and PJ). They may not look very professional but we have the owner’s pride
in displaying them.
We would like to acknowledge the following personalities for providing
excellent help and assistance:
Dr.B.Rajammal, Professor of Obstetrics and Gynaecology, Amrita Institute,
Kochi- for reading and correcting the manuscript of the Chapter, Pelvic
Venous Syndromes.
Dr.Jacob Thomas (Professor and Head) and Dr.Vinitha Varghese Panicker
(Associate Professor) of the Dermatology department, Amrita Institute,
Kochi – for the help in the preparation of the chapter on the treatment of
telangiectasia and reticular veins. They have also previewed the manu-
script of this Chapter.
Dr.PK. Nazar, Associate Professor, Department of Radiology, Amrita
Institute of Medical Sciences, Kochi- for providing images of our patients
for inclusion in the text.
Dr. Rajashekaran Pillai, Dr.(Brig) K.J.Philipose, Dr.C.Gopalakrishnan Nair
(Professors) and Dr. Misha J C. Babu (Associate Professor), our col-
leagues in the Department of General Surgery, Amrita Institute of Medical
Sciences, Kochi, have previewed and corrected the manuscript of the text.
We thank all of them.
Finally, our profound gratitude to Dr.S.Sudhindran, Professor of Vascular and
Transplant Surgery, Amrita Institute of Medical Sciences, Kochi. He read
through the entire manuscript and gave us valuable suggestions for
improvement . He was also gracious enough to write the Foreword for this
book.
We would also like to thank our publishers, the Springer group. Special
thanks to Dr Naren Aggarwal, Executive Editor, Clinical Medicine, Springer.
The whole concept of publishing this work started with his powerful support
for us. Thank you Dr. Naren, especially for putting up with our delay in sub-
mitting the manuscript.
To our families, we owe a lot in supporting us when we were busy neglect-
ing them for months together.
We would like to dedicate this book to all our patients with chronic lower
limb venous disorders. They have shown us the way!
Kochi, Kerala, India Subramonium Vaidyanathan
Kochi, Kerala, India Riju Ramachandran Menon
Kochi, Kerala, India Pradeep Jacob
Kottayam, Kerala, India Binni John
Preface
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ix
Part I Basics
1 Venous Diseases: A Historical Survey . . . . . . . . . . . . . . . . . . . . 3
Riju Ramachandran Menon
2 Lower Limb Venous Anatomy . . . . . . . . . . . . . . . . . . . . . . . . . . 9
Riju Ramachandran Menon
3 Venous Physiology and Hemodynamics of Lower Limbs. . . . . 17
Riju Ramachandran Menon
4 Chronic Venous Disorders: Classifi cation,
Severity Assessment, and Nomenclature . . . . . . . . . . . . . . . . . . 25
Subramoniam Vaidyanathan
Part II Primary Varicose Veins -C2 Clinical Class
5 Epidemiology and Risk Factors . . . . . . . . . . . . . . . . . . . . . . . . . 35
Pradeep Jacob
6 Primary Varicose Veins: Symptoms and Diagnosis . . . . . . . . . 41
Pradeep Jacob
7 Open Surgery for Primary Varicose Veins . . . . . . . . . . . . . . . . 55
Pradeep Jacob
8 Endovenous Thermal Ablation. . . . . . . . . . . . . . . . . . . . . . . . . . 69
Riju Ramachandran Menon
9 Sclerotherapy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 81
Binni John
10 Recurrent Varicose Veins . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 95
Pradeep Jacob
Part III Chronic Venous Insuffi ciency and Leg Ulcer:
C3–C6 Clinical Class
11 Chronic Venous Insuffi ciency and Venous Ulcers:
Pathophysiology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 107
Subramoniam Vaidyanathan
Contents
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