BEST CARDIAC SURGERY

Why Varicose Veins should be treated!

Varicose veins are caused by increased pressure in the superficial venous system of the legs. Normally, there are valves in the veins that ensure uni-directional flow from the peripheries to the centre. However, these valves may get diseased by episodes of deep vein thrombosis or by infection(thrombophlebitis) or by natural deficiency of the valve competence. Peristant exposure to high pressure such as due to prolonged standing or because of deep venous reflux may cause a long term exposure of the valve and then the vein to this high pressure.In pregnancy, there is the factor of the uterus having the baby pressing on the veins and venous dilatation due to the hormonal effects of the pregnancy.

Rarely, there may be abnormal channels connecting the arteries to the veins and this may give a high flow situation leading to dilatation of the vein. In some patients, the dilated veins may be congenital or familial. This is again not very common. Mostly, varicose veins develop in those

As varicose veins develop, they cause dilatation under the skin and these large veins may be seen in the legs. There may be small spidery veins also that are just under the skin or part of the dermis and these are called telangectasia. As the pressure keeps on increasing, there may be swelling of the legs and this will usually dissappear on lying down or elevation of the legs. Sometimes, the red blood cells come into the subcutaneous tissue and as the hemoglobin gets digested by the macrophages (cells), the hemoglobin or iron pigment gets converted to hemosiderin and this gives a black colour to the skin which is called (wrongly so) as pigmentation. Tattooing would be a better word.

Gradually, all this causes localised inflammation and that leads to thickening of the subcutaneous fat and it converts from the soft fat feel to a hardened and tough layer which is called lipodermatosclerosis. From this stage or even from the stage of pigmentation, it is difficult to come back to normal. The hemosiderin pigment gives irritation and itching and that is very troublesome to the patient. Gradually, the abrasions caused by itching give rise to skin rash and superficial dermatitis called eczema. This need the help of a dermatologist to treat.

Repeated infection and exzema may lead to complete breakdown of the skin and a varicose ulcer will present itself. These ulcers are usually in the lower leg near the ankle on the medial side. Also the subcutaneous tissue may get repeatedly infected and gice cellulitis. Many patients suffer from the repeated attacks of cellulitis and I know of some physicians who administer agents that are used for Rheumatic fever prophylaxis to these (although there is no literature based study on this use).

Management of Varicose Veins

1. Conservative management: Most of the patients do not need surgery or any other intervention hence they should be given conservative management. The mainstay of conservative management is physical therapy with elevation of legs when possible, calf exercises and pressure on the venous system when standing by using high pressure stokinets or crepe bandage. Medications such as calcium dobesilate, diosmin and others may help but there is no proven value

2. stripping of veins is not used in our unit nowadays as there are better options

3. Endovenous ablation of the vein with either radiofrequency power of laser are both useful and there is not much difference in these modalities

4. Sclerotherapy: Injecting Polidonacol into the vein can help in closing the peripheral branch dilatations of the vein. This injection should not be given under the skin and should go strictly in the vein lumen. This is an useful adjunct so that the branches that are beyond the main veins can be sclerosed and they will shrink with time.

5. Trendelenburg operation: this is takedown of the sapheno-femoral junction at the level of the groin will all the branches of the vein. This is useful if there is a saphenofemoral reflux as just doing ablation will definitely lead to recurence.

6. Perforator ligation: It is very important that the perforators are identified by ultrasound and dealt so that the recurrence can be minimised. The size of the incision is about 8-10mm only and can be closed by inverted subcuticular sutures. The perforators lie on the vein of Leonardo da Vinci and usually not on the main saphenous vein so blindly ablating the main vein will not be useful and recurrence or continuation of the problem will plague the patient. This is why the knowledge of anatomy is important to physicians who are doing interventions

 

Postoperative care of the Varicose Veins

OR: what you should do after surgery for Varicose Veins

• elevation of leg when possible especially at night or resting

• wearing of stockinets (high pressure and class II) in daytime, remove at night

• normal bath

• use of ointments on the wounds as advised

• use of skin lotions/ ointments if advised

• calf exercises

• antibiotics and pain killers to be used as advised.



INVESTIGATION PROTOCOL FOR DEEP VEIN THROMBOSIS

1. venous doppler
2. USG abdomen to rule out hidden malignancies
3. ECHO for RA/ RV dilatation
4. chest xray
5. complete blood picture, platelet count, PT&INR APTT
6. sr homocysteine level  blood sugars, fasting lipid profile
7. serum vitamin D and TSH (both optional)
8. protein C & S levels