الفهرس 
Anatomy of the Lower Limb VeinsOnly 14 pages are availabe for public view
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Abstract
The aim of this essay is to study new methods in treatment of varicose veins. We started by a brief review of anatomy of veins of the lower limb including ) Superficial veins:
It is further divided into:
a) Subcuticular veins.
b) Subcutaneous veins.
c) The main veins lying on the deep fascia:
These further include:
A) Venous drainage of the foot: It includes dorsal and plantar digital veins, dorsal metatarsal veins, dorsal venous arch, and medial and lateral marginal veins.
B) The long saphenous vein: It is the continuation of the medial marginal vein and ends in the femoral vein and it has many anatomical variations concerning its termination and duplication. It has many tributaries in the foot, the leg, the thigh, and the groin.
C) The short saphenous vein: It is the continuation of the lateral marginal vein and ends in the popliteal vein and it has many anatomical variations concerning site of piercing the deep fascia and the site and type of junction to the popliteal vein.
2) Deep veins:
It is further divided into:
a) Deep veins of the foot: It includes plantar digital veins, plantar metatarsal veins, deep plantar venous arch, and medial and lateral plantar veins.
b) Deep veins of the leg: It includes intra muscular veins, posterior tibial vein, anterior tibial vein, peroneal venae comitants, and the popliteal vein.
c) Deep veins of the thigh: It includes the femoral vein, profnda femoris vein, and the common femoral vein.
d) External iliac vein: It is the continuation of the common femoral vein and begins posterior to the inguinal ligament.
e) The Common iliac vein.
3) Perforating veins:
These are veins that connect veins of the superficial to the deep system of veins and pierce the deep fascia. It has valves to ensure unidirectional flow of blood from the superficial to the deep system. It may be:
a) Direct perforators: These pass straight from superficial to main deep veins.
b) Indirect perforators: These pass from a superficial vein to a muscular vein within one of the large muscle bellies of the calf or thigh and then a further of more vessel connects with the main deep vein.
We also discussed the aetiology of varicose veins which is more common in females than males, and more common in left side than right side.
A) Primary varicose veins: It is diagnosed when there is no obvious underlying etiology of valvular dysfunction can be identified. It may be due to congenital incompetence of the valves or due to congenital weak vein wall. Several factors predispose to the development of primary varicose veins including pregnancy, obesity, prolonged standing, and age.
B) Secondary varicose veins: These follow impaired venous flow secondary to deep venous thrombosis, deep vein compression, and arterio venous fistula.
Afterthat, we discussed clinical evaluation of varicose veins of the lower limb which is divided into those of uncomplicated varicose veins and those of complicated varicose veins.
1) Uncomplicated varicose veins:
Patients of this group mostly complain of:
a) Disfigurement.
b) Aching and pain.
c) Swelling.
2) Complicated varicose veins:
Complications of varicose veins are not uncommon and include:
a) Haemorrhage.
b) Thrombophlebitis.
c) Eczema.
d) Ulceration.
Then, we discussed diagnosis and investigations of varicose veins which includes:
(1) History:
(2) General examination:
(3) Local examination:
Investigations of varicose veins of the lower limb are classified into:
(1) Non invasive investigations:
(a) Continous wave Doppler examination.
(b) Duplex ultrasound:
It provides an image of tissue anatomy with that of blood flow and it is now accepted as the best method of investigating doubtful cases of saphenous reflux and perforating vein incompetence.
(c) plethysmography:
It is the determination of variations in the volume of an organ, part, or limb.
(d) Magnetic reasonance venography:
Spin-echo imaging has been shown to detect central venous thrombosis and in addition it can reveal soft tissue masses, adenopathy, and malignancies.
(2) Invasive investigations:
(a) Venography:
It is the most accurate method for evaluation of anatomical variations, congenital abnormalities, and pathological changes in veins of the leg.
(b) Vein pressure measurement:
These techniques can assess calf pump function, reflux, and obstruction, but give no anatomical information.
Lastly, we discussed the lines of treatment of varicose veins which are divided into:
(1) Conservative measurements:
It is known to be the basic treatment of varicose vein and is indicated in cases of early primary varicose veins, pregnancy, patients who are unfit or refusing surgery, and secondary varicose veins if deep system is occluded. It includes:
(a) Leg elevation.
(b) Regular exercise.
(c) Medical treatment.
(d) Elasto-compressive therapy.
(2) Invasive treatment of varicose veins:
The best surgical candidates are active, healthy patients who are not over weight. Severe aching varicosities, varicose vein haemorrahge, or superficial thrombophlebities are indications for surgery.
(A) Operations for long saphenous vein incompetence:
(a) Saphenofemoral ligation (Trendelenburg’s operation).
(b) Stripping of the long saphenous vein.
(c) Stripping or stab avulsion of secondary branches (tributaries).
(B) Operations for perforator vein incompetence:
(a) Triple ligation.
(b) Extrafascial operation.
(c) Subfascial operation.
(d) Subfascial endoscopic perforator vein surgery (SEPS).
Many complications of surgical treatment of varicose veins have been recognized. It includes:
1- Intra-operative complications:
(a) Injury of common femoral vein.
(b) Injury of the femoral artery.
(c) Stripping complications.
2- Post-operative complications:
(a) Haemorrahge and bruising.
(b) Lymphocele.
(c) Wound sepsis.
(d) Post-operative saphenous neuritis.
(e) Deep venous thrombosis and pulmonary embolism.
(3) Minimally invasive procedures in treatment of varicose veins:
(A) Sclerotherapy:
It is the injection of a sclerosing agent into the varicose veins. Its objective is to produce endothelial damage and subsequent fibrosis of the entire vein wall and thus cause an aseptic thrombus which organizes and close the lumen of the vein wall.
Many sclerosing agents are used in treatment in varicose veins and it includes:
1) Sodium tetradecyl sulphate 1% and 3%.
2) Hypertonic saline 20%.
3) Hydroxypolyethoxidodecaine.
4) Dextrose 65%.
5) Ethanolamine oleate 5% solutions.
6) Sodium morrhuate 5% solution.
Complications of sclerotherapy include:
1) Allergic reactions.
2) Toxic reactions.
3) Pain.
4) Intravenous haematoma.
5) Persistent brown staining.
6) Incorrect placement of the sclerosant.
7) Deep venous thrombosis.
8) Post injectiomn gangrene.
9) Recurrent varicose veins.
(B) Foam sclerotherapy:
It is a recent modification of sclerotherapy which allows a smaller quantity of a sclerosant to cover a greater surface area and to displace blood from the greater saphenous vein.
It is a simple procedure, needs no anesthesia, no hospitalization, takes about 10 minutes per cession, and the patient can return home after15 minutes.
Foam sclerotherapy is advantageous over traditional sclerotherapy for several reasons:
(1) Allows the sclerosant increased contact between the sclerosing solution and the blood vessel as the air within the foam pushes the material snugly against the vein wall.
(2) Decreases the dilution of the sclerosant because the foam actually replaces the blood rather than mixing with blood.
(3) Foam sclerosants are able to increase the duration of treatment due to their slower wash out times compared to traditional sclerotherapy.
There are two methods of foam preparation including the Monfreux method and the Tessari technique.
Duplex ultrasound guided sclerotherapy offers an advantage over blind traditional sclerotherapy as there can be no doubt that the sclerosant has been delievered where it was intended.
(C) Radiofrequency ablation:
It is an electromagnetic radiation in the frequency range from 3 kilohertz (KHz) to 300 megahertz (MHz).
It is indicated for the occlusion of segments of the GSV and LSV, major saphenous tributaries, perforating veins, and recurrent varicosities following surgery. It is indicated in patients with early venous disease with axial reflux.
Side effects following radiofrequency are minimal and may include transient tenderness and numbness. The mechanics of the surgical procedure are relatively straightforward with a few caveats. The treated vein should be relatively straight, free of severe tortuosity or thrombus, and without aneurysm.
Contraindications include a postphlebitic vein that cannot be accessed, a mega saphenous vein(>12mm). The procedure is greatly enhanced by
preoperative ultrasound-guided marking of the entire length of the vein to be treated.
Clinical observations suggest that patients are much more comfortable in the postoperative period and experience quicker recovery after saphenous vein ablation compared with surgical stripping. Ninty-eight percent of patients reported treatment satisfaction.
(D) Ambulatory phlebectomy:
This safe, aesthetic, effective, and economical operative technique enables the physician to remove nearly any incompetent vein below the sapheno-femoral and the sapheno-popliteal junctions, although the junctions themselves cannot be treated by simple phlebectomy.
The main indication for ambulatory phlebectomy is removal of the primary branch of the GSV or the LSV, major tributaries, perforators, reticular veins plus small reticular veins assosciated with telangiectasias, and large tortuous distal varicosities can all be removed by ambulatory phlebectomy. This is the preferred procedure for large tortuous distal veins because radiofrequency and laser cannot easily pass along a tortuous vein. Other indications for ambulatory phlebectomy include vein biopsy and treatment of veins around the eyes.
In the multifocal pull-through approach, varicose veins are removed by combining a multifocal incisional and endovascular cannulation approach which allows efficient avulsion of large vein segments with fewer puncture sites.
Ambulatory phlebectomy is contraindicated in the case of reflux at the saoheno-femoral or sapheno-popliteal junctions, infectious dermatitis to the area being operated on, severe peripheral edema, serious cardiovascular or pulmonary problems, allergy to local anesthesia, and very elderly patients.
The chief complications assosiated with ambulatory phlebectomy include excessive hemorrhage, superficial haematoma, neotelangiectasia, blisters caused by wound dressing, transient hyperpigmentation, nerve injury with sensory disturbances, scarring contact dermatitis, superficial phlebitis, and rarely keloids and hypertrophic scars.
(E) Transilluminated power phlebectomy (TIPP):
The Trivex system uses a light source beneath the skin for varicose vein visualization and a powered suction resector to perform the phlebectomy. The concept of TIPP is to improve excision accuracy with direct visualization of the varicose veins and to decrease operative time with specialized resector.
TIPP is a safe, effective, and cosmetically accepted procedure. Patients did suffer significant ecchymosis, however, by the 6th week this will resolve in all patients.
Compared to conventional phlebectomy, patients who undefwent TIPP reduired fewer incisions and there was a trend towards a lower operating time.
(F) Endovenous Laser Ablation:
Endovenous laser therapy (EVLT) and radiofrequency ablation (RFA) have recently been introduced as alternative, minimally invasive techniques for the treatment of saphenous vein incompetence. These procedures were designed to ablate the GSV through a percutaneous approach to minimize the discomfort and complications associated with conventional stripping.
EVLT is a minimally invasive, painless, bloodless, quick procedure that leaves no scarring, has a short and pain free postoperative recovery period, and low recurrence rate.
EVLT is indicated in patients with varicose veins caused by SFJ incompetence with GSV reflux. Exclusions include patients with nonpalpable pedal pulse, inability to ambulate, DVT, and pregnancy.
Extremly tortuous veins are also contraindicated because laser catheters cannot easily pass along these types of veins.
The commonest complication following EVLT is thrombophlebitis of the treated vein. A further minor complication of EVLT is local bruising along the line of treated vein. Numbness or paraesthesia in the distribution of either the saphenous or sural nerves may also occur which resolve by three months in contrast to surgery which is associated with permanent neurological damage.
To reach our aim in treatment of any patient with varicose vein is to select the optimal case to be treated with the best method of treatment to achieve best results with best cosmetic appearance and least complications.