Chapter 154 - Varicose vein surgical treatment Flashcards
Varicose vein definition
Subcutaneous veins in LE dilated > 3 mm diameter in upright position
Treatment types of varicose veins
1) high ligation
2) ligate and strip
3) endovenous ablation
4) sclerotherapy
5) ambulatory phlebectomy
Compression stocking grade for CEAP 2-4 and CEAP 6
2-4: 20-30 mmhg
6: 30-40 mmHg
Varicose vein guidelines from SVS and AVF recommendations 8 points
1) 20-30 mmHg for symptomatic varicose veins
2) compression first line for healing ulcers
3) endovenous procedure > open surgery when possible
4) stripping to knee of GSV only
5) SSV incompetence high ligation 3-5cm distal to SPJ
6) CHIVA and ASVAL to be done in select patients only
7) ambulatory phlebectomy to be done concurrent with stripping
8) people who are candidates for ablation should get them instead of compression alone
Course of GSV
1) anterior to medial malleolus
2) obliquely and posteriorly across anteromedial calf
3) posterior arch vein joins at the knee
4) anterior accessory vein merges around knee joint
5) GSV lies in superficial fascia
Rate of a duplicate GSV in calf
33%
U/S finding of variations in GSV
60% GSV normal with single medial-dominant system
1) Complete double system 10%
2) closed loop system 10%
3) lateral-dominant system 8%
Kupinski three anatomic variants of GSV
I type: GSV within fascial envelope long entire length
H type: subcutaneous collateral running parallel and superficial
S type: caudal portion atretic and extrafascial tributary dominant
SSV variabilities
1) termination at above knee popliteal 33%
2) low termination site < 10%
SSV notable branches
1) posterolateral tributary vein (runs along SSV)
2) anterolateral superficial thigh vein
3) intersaphenous vein
4) posteromedial superficial thigh vein
Nerves in popliteal fossa
1) tibial nerve
2) common peroneal nerve
3) lateral cutaneous sural nerve (off common peroneal)
4) medial ramus of tibial nerve
Gastronemius veins track
1) arise from medial and lateral head of gastronemius muscle
2) join with SSV or popliteal vein directly
3) sometimes SSV joins gastrocnemius vein instead
Incidence of incompetence of gastrocnemius veins
20%
Intersaphenous vein course
prev. Giacomini
1) posterior medial aspect of thigh off SSV
2) joins GSV 64%
3) join deep system 45%
Relationship of the sural nerve to SSV
sensory
superficial to SSV or intertwined
Motor nerves near SPJ
1) tibial (medial popliteal nerve)
2) low lying sciatic nerve
Location of incision for high ligation gsv
1) 1cm above and parallel to groin crease
2) oblique
3) start where palpable femoral is and extend medially
6 main tributaries of the SFJ
1) inferior epigastric vein
2) superficial circumflex iliac vein
3) lateral accessory saphenous vein
4) deep external pudendal vein
5) superficial external pudendal vein
6) medial accessory saphenous vein
Artery that runs between GSV and FV
External pudendal artery
Rate of GSV incompetence in patients with CVI and symp VV
2/3
Direction of stripping to minimize saphenous nerve injury
Downward direction
Pro and con of inversion technique
1) smaller distal incision needed
2) tunnel diameter smaller
3) reduced local trauma
4) vein can tear resulting in incomplete removal
Tumescent anesthesia
1) 1% lidocaine + epi 40 ml
2) sodium bicarb 10 ml
3) normal saline 450 ml
Clinical situations suggestive of SSV incompetence
1) persistent varicosity after GSV treatment
2) posterior calf varicosities
3) isolated lateral malleolar ulcer
4) ulcer recurrence after perforating surgery