Varicose Veins - Chiang Mai University · 4....

1

(VARICOSE VEINS)

Primary varicose veins (10 w) njl.iUt\lln~W1.JttiftJfluhm~lJn~t1~!J\Jtm ~t1~U';~~1yjWlfl~1tif11.Jn11

1m"1';1nLLY,l1!J111'll'~\-ltJ~,IIyjl1!Ji~llJ~\fl~l'iflULLyjl1!JiJ[jj\-l1U1A1rlt\lfiflm1 ~~~U~1~ (cos melic)

ilU~l11~n11fn~1~fl~IIWl1!JIL~fl~n~~n1~9 .1n1~';1UtlJdju11.J1ullu~m~Liiimn\Jt'2) 1U~1~1.J1~m~.••••1.J~1

dj\J~1l \-l(;j~~1J~!Jl'qfl~l1!mf'i1li'l!J~1u';1mL••••l1!Ji\~!'fl!Jfl~20 ~fl~F1~Ylfl~~N.,\"~\nJ~t3)l\fl~""1.J~1i1tfln1~~

'; ~Iii~dju11 LLfl~tlf'iJ~~111.Jn111n~fin~flufl ~ 20 I'1f~LL1n~~11tl1fun1~fm:t1';1n~~i11.J~~~1.Jn1~rul\Jn111m:r1t1I'leUfl!J~Ij~ ldfl~'11ml1::lijuql!~I!lTutlfULLfl~N'n111m:t11lJ~n tlffl~'41iJ"l'lUULIu~m~ 1Un1111i1a~LLll~ll1~ljjlJ~l!~IJ~ufl~nu evidence based ~~m~~1~Iln1nm:n1\J~\J11');I\j1"l~iiin~1\iii~

WU1fI11ii'l:U1ILfl~WU1ii~lI1yj

venous relum 1Un1~I>\hugravitationai force "l~~\Jfl~n1.Jn11jj1.Jf~I>i'~~tNm\'11.adfllJfl~\lfl~lyh(l'°lU

111~~ systole l~fl~"l1n sinusoids ~~~ni\'1~ldfl LLfl~"l1nl'~~u~~11Jsuperficial vein, perforators LLll~

l~i1a~ deep vein 1tif1wm:: diastoie nt'l1li••Qfl\nilll.: l~lll'l"l::1lJl~l'Iliflunli'u (reflux) ldll~"l1ni1n11

tI~~fl, bicuspid valves ~fl~~flfl"'l~~I'IYJn1~1.J1.Jt~!J\llyj1~~A1rlt\l~N perforators ~11.J1~iil11lfl1yj~ •••.•••••••••••• ..J

~fl, llUtli>l1t1~ 1U1~1.J1.J1.11::1.J1.J~U~~l-Jwm "l~IUU~1\••.•l»tl1l-J11Un11tn~111'1~1l~~lll~Vl~1'!J~1>ll1~1

(varicose vein)

~1m"l'!Jfl, 10 w ~1'11n valvular failure ~,I\l-Jljiii31U11Jn11lii~t11'lfl1';"l~ldfl~lJ1"l1n

1. Primary valve failure yj1.J~1i110 degenerative change fl!i1,lihI1tl1il'l Rfli1n1111~illl-J1ru~N fill1

I\iiiu llfl~ l'1~flfl1I';U 1u valve annulus \lfl~ leafiets

2 Secondary valve failure "l1n~U~~ftll'" \~fll'l!lflwi'~LLfl::~1i>lm1~ij~\.\~U~11~i12° widen.ing ~ll,

valve commissure Ilft::ti'i:;l1n~:: incompetence

1~U1V\~l1U1

1. l)1~ "1.J~11.J1~~1rui'fl!Jfl::40 .lft:: 30 'lJfl"yj~'lJ1!J\'fl~~tY~1U'li~~fl1~18-64 D i1 trunk w LLI'l~~fltJ. ,il:: 80 ~fl~l1~2 lWf'Ii1 reticular \.\;ll hyperweb varicose'" 1un~~Yii1fl1~~1nn~1 70 i1

2. m~~"\.1~ yj1.J~1~1~tlUvv .,\"'l'I;tlILfl~l\lJ1tln1~~1l~,N~dluj:ja,~flUfl~.P<!ll~t\htl1!J1<J1tl1Udl" w....tfln1l\~1.I1il1,;~d'hlmll!Jfl~20:s;

3. 1l~1'Ili'<JIn"~U1~\.\~-NLyjl'l~q)~~tll~f'I~1!Jl'lhr.1.J1.5-3.5 : ,.'7 81 yjlJ~1DIl11l-Jul>i'~1i11'i't\lfifl11.Jn"l~

LVltl1l1U~,"l~\.\~~flflnl-J1';1n1u'li~~~2 ~ll~ m1~,~ml'll'l~ n11i11.J1~41Liiifl'"~11,~j\nl>lpassive

d:latation ~ll, ~flfl~l~flVlIli1~1l!,Wtl~\lfl~tIJ1~mtll~!JJ11~~venous hypertension hl'l?5~ulu1'!J

n1l1~1'1"ILfl~m1fulh~l11UIJ1I')~n" ~'" n~~,n11~~ ~11f, llfl::F1flll<JItj1>l1\ol1l11J~f,iililUl\1l~ fJ)~Il~vv 1tl(

4. in~ru~"lN,1U ~1uJ,11ii::1l'1~!1u1,)~,"!l!J;Ufl~nu~ ,'tiu I'lt~;tlFi1'!J1~ ti1tl,!Jn'JJtl,~lIn~1Hii1m1l-J

vi'U1l.i'rlfl,Y,ll~L~l-J~Ul'liul:;;mn1.J

5. ~1~""~ (race) wlJ~nn1u~hl.J ILil~~L~1n1

hil'h~ n\,l 1,,1'1"ihih~Ll'~~?'ll1?Y11"lH~~ !T~hiil~ ii&i~U1J"Il"ul'il1tJ'i1'll1?r~1J"~tlYltYll1.1tl~

~l-lfJlHlJ1n1li'l'lnn1nij" w ~~m11141.1:~LY1J'1(7J

rnm U~~ijl'l'lltl~l-ll'tl<'lli1tl<'l1'i1'll1ll'l(classifications)

1. Primary trunk varicose veins ~;:h.ln1:'hJ~Vltl~l.l'l~I'lI'l~1l(tortuosity) 'lltl~l-ll\ll<'lli1!ll'lvi,greater

saphenous vein (GSV) U~~ lesser saphenous vein (LSV) 1?lJ~4U'll\.l~~1'll1(tributaries) ih"'i>1

Ll'ln'i, 4 jjl'li1~lJI'l1/;'1" young muscular I-lWil'un'i1 'athletic' veinS ~tlW11?~tJn:n'll"'<'l'll1l4

1-l1'1l1'l1i1tlI'l1'i1ttl~tl!l~\Yhn\,llliiln11hJ4Ylll~lll'l~ I'lNll lliilrll~~11'il'lfm'n, ,

2, Secondary trunk varicose veins VltJ'i1jjrn:'1JU1ul'i?'ll1l4superficial trunk veins ~~~~";1I-lii,~hij"

collateral venous returns 1"mru~jjn1Hj<'lI'i"'ll1l4 1-ll'l1ll'l1i111l'lI'i,i1n~~illnn1j'"jJ1l4 chronic venous

Insufficiency (CVI) ~n~ru~II~~~'llIl~~n1!~aJ~u"u1.1l'l~ l!n~~hJ~iil'ln11Ltl~11114Ul'l~I'lI'l~1l'141li

~1dJ,,~~d'Il~~11'i<'lL1l11111fl\.Illn~1n1"n1ru~1'l1?~~ij~li'u l~ft?YltJ'ilbJl~'Ii?u1"U~'ll!l~ collateralcirculalion lfttt:l)

3 Reticular veins l1tJLtI,,~J'I~,,1i1r~?1-l1!4l~"fI1l1lJJ'I,,~?tJ1~Ul'l~'ll1?lijW11?~1.1n&il1tJl~i?l1.1 hMI'l

'nnl1!n~1\11111'll!l~I-l~IlIll~i1111'l~~llijjll1n11 ~~(;j~llil\?m1lJ

4 hypr.er web veins ij~tH;tJn~frltl~tl~,h~dilated intradermal venules , thread veins, spider veins,

telangiectasia, venectasia, phlebectasia lll'l~ venous flares 1l1~~~I-l'l'lllliL~u?iimntJ truncal, ,

•• •••• , .!:' •. •.••••• ~ ••.• 1.1"" ..•.•• '" .... ....1-l1!lreticular veins YitJYl"o~Ul'l~,,"'ll1i"l-lrJ~lJl'l1111UI\~?Ul-llJl'lr~~1ll'l!l" ~4mU?'jJ1l4ntJ1~l'ItJ

~1lfu,"'llIl~i14 n1U~~1.1~lJ"U1.11\4

5, venous malformation jjn11~~lJlJl'i!l1~1-l'i14venous ntJ arterial components RIi,1t1i ~ulsation

I-l'l'tl thrill Ul'l~H Doppler ultrasound l14~~Uicontinuous 'hum' tJ1L?rAjj venous malformation

~Yi1Jli1rjjKlippel - Trenaunay syndrome Uft~ Parke - Weber syndrome

!l1n11Yl14rliiijn UI\~n1nJr~ ~jj"qtl?t

n11tJ1~Ljj"Yl14J'1i1nn'jJ1l4~tl? u LrJ'll-ll'llll'lli1tlI'l1i1'll1li>1~'jJ1 ~~1f'i''II tJ1~nll1Jrlhu

1. t11~-mF11tltJRfl ~~mrltJr;1nij" vv ul'l~nl'llnn1m;j~I'i?1l114~i1tll'l~I'I1.1n&i",'l'1l1~lnn1rufl~1l1n11

ll~1'1~ 11lJ~41"U~RT.,jJ~?U~1lJ (cosmetIcs) 1~1l""iilll.!4;" \,ln11~11'il'lfn~1

2 dJ"lJ1n",'l'll\JllU llfl~ ~n~Il.l~n1m1~~1Wr? ~ll~ l-ll'ltll'l~iltlI'l1'i1~~Il~

3. F1?1lJ1"LLNLLl'l~,hum.i~~tl4111ULrF1~";11,xLii~I11~~chronic venous insufficiency (CVI) U~~

I'l1lJlJ1rJi?u !J1n11tJ?lJ ~L~l'l~~n~ru~~!l4 ~?"'U4L1.1~!J"lltJl'l~l1.1~1nL~lJ

4, LLlJnlOw !llln~1n 20 vv ~~i1~1\"':IllJ1~1n ll'lmij" deep vein thrombosis (DVT) lJ1rill",

congenItal venous malformations (CVMs) ",'l'tJ arteriovenous malformations (AVMs)

tJ1~-m\i1~"J~l'l?ri n~1 n~l.hu LLl'l~f\l1ijjFie

1. tJ1~-m f11~tJ~fJ l~mntJn11LU" vv LL~~nl'lnn~mojj~I'i'?'jJll~lillll'ln~tJnijj",'l'lllli?

2, ,1"IU",.r4 LLI'i~jjll11? ILI'~LtI"",n;"L111u1",'l'1lhi?

2 •

3. n11;~rmJf, mill'i, i1m1~nl1\ilJ~!NmllJl11'\j1\j'li~~Yi~~\l;!lh.i?

4 lJ1~-win1niilll~IJLi\~?'llllli>1\j~lLii~1uil"nl;n.I~~~~~lJ\~~lIlIl1lli>1\j1\j\l!l~1Il\ii~1IlI1iliin[Deep Vein

Thrombosis( DVT)J 1A"~ ~~ai\~lIltlllli>1\j1u\l!l~lIlLii!lllll1il11Jlj1wJ~(superficial thrombophlebitis)

~l.h~ w !'h\jl\lt\i~~i1l.i1~-mYl1~I'i'\j~n111JIL!l=1'I1!llJl'lf110 w !ll'l'l~l'ilJtflil"'l'lm~~t1iI'i'\j~LL!l~1Ail"~

1'I!l~1Il1.j11l1lJ~m\j~\il\jPi~~lLL!l~ti!l~\'I1~(/h\jl\j (GSV) ~lhlJ w ei1\jl\lt\i'l~i1l.i1~-mYl1~I'i'\j~nmJlL!l~

1'11~Ul'lf110 w ~1~~~l'ilJ1f1il\j1'm~;t1iI'i'\j~LI!l~1Ail"~Pll'l!llll1.j11l1lJ;L1n.1~dj\jPi!l~111l'l~ti~~\'I1~ilh\j1\j

(GSV) ~U1~ w ei1\jl1At\i~~i11J1~-mYl1~I'i'\j~n11lJLL!l~Pl1~Ul'1h10 w ~l~'l~l'ilJtflil\j1'm'l;t1iI'i'\j~

L\!l~1Aft~I'I!l~1Il1.jl1l1lJ;L1n.1?\il\jPi!1~11i!l~ti~~YI1~Ji'1\jl\j(GSV) LL!l~n!ll~U~~(LSV) localized cluster

~U"N l1'mii"''lln incompetent perforator l'hdl\j1\j!l1!l~~!J\\!l~lJln~lIll.1n~ Hiilnii~ congenital

Arteriovenous Malformation (AVM) 1'11111111'l~1.11\j(birth marks) 11I1lJ:l~n1lJ

10

vv 1\j01At\i~jjn11Ll.1~lJ\jLLl.1M~~~ij11Au~(pigmentation, cutaneous atrophy, subcutaneous

fibrosis l\!l~ ulceration) U1"~LL\j postphlebitic syndrome (PPS) ~~Liilllm~\lil"~DVT

Iil~U~!l,n11LiiIll1~lJt1l"i11'11-llJlil"t1ibn11LLlJn1~wjl~ 10 w nu 20 w TIIllJ~10 w ~1l1~'l~jj

'Ml~lIli~~~.<>il~~lIlvi~1lJ1LtI\l1~~~\1!l1\jl\j n!l\j~11Au~i1n11Ll.i~m,ml.1!l~ril\lfu 20 w ~U1lJ!J1~~~"'1

hj1~ 1A;~1;.il.1nn{)~11r1ULtI\jDVTlJln!J\j ~~iIi!llJ1'll1'l=lJ1lJ~11Atl'~\1.1~lJ\jLLl.1!l~lL!l~I1I1lJlJ1tlf1lJ1A!l1lIII

Lii!llll<>il~!l'MllJ1Aft~n11i>Jn'lil~nl~ LL!lmlnJ1~Ljj\l~!l ''In Trendelenberg test, perthes test

lk ~ 1'0)LLI'l~n11~ hand-held Doppler ultrasound LYi!l~reflux, forward LLI'l~reverse fiow

n11I11n~ii\j~ilIll1lJin~1i1i~;1~n1~(Noninvasive venous assessment)

\j~m\lil!J'llnn11H' hand - held Doppler 1\jn11i>Jn'l~1l1lJ w "'1nnm\~1 !T~jj1iln11I11n'lljil'lli'lJ

~\j~~i11.h~tlJ~IIPi~

I. Photoplethysmography LU\j screening test H'~11AflJulJn1~1A~1~superficial nlJ peep

venous insufficiency<11l -~II. Duplex ultrasound imaging :.tM

13 - mode ultrasonography t"1lJH Doppler nlJ~~ duplex ultrasonography L~~~

mllJ~lIll.1nii\.,r, GSV ••!l~ LSV 11lJ.,r, deep vein"" nl1l11n'l deep vein m1L~lJ"J

i>\'~ulJiiliac, femoral, popliteal Lll'l~catfveins 1'111lJijllll.1n~lJi1'1L'!l\ll~lJLtI\j\l;Ili1

partial thrombosis, superficial 1l;!J deep venous insufficiency m1U\jYimmlo1

.nll 1i11~!ln11I11n'lI\\j'!lil~hi~nJ 1~!Jh~ n1lJ .,r~\llJ~U~1~~11~U~\jnl1fm;1 1\jn1rn ~'t'<lJ~l~1l11Ji1

reflux 11J deep venous system \~I'l~DVT Ul'l~~il1J 20 w t'htJl'l Doppler ultrasound (\I'l~ duplex

scan 1lJi1 DVT lLI'l~1l.i't'<urefiux b deep venous system Ul'l~Ltl1J10 w 11Jn~lJ 10 w "il"~'lln

i>J11'lM~n1tJUI'l~1tlf~i\n1111111'll!i\J~il~1lJinJli1iIlM~nllJU~1i\lm1mLU,n~lJ~L11!J~llntcll ;'~lJi!J11.1~

1. "M)I1\L~!J~~l'!1~~~!J~GSV

2. \l1'l!l~I~!J~Il,hlllllll~!l,lSV

3. \l!l~~L~!l",l1il'lJ~~'l1n incompetent

3

4

perforator

4. 1-IflfJ"'LihHi\lii''llfJ",~nri'uLjj\J~'( recurrent varicose veins)

rnrfn1:r1•

1iin1r1mnj:ji~n1Hhlli"" sclerotherapy, radio frequency ablation, cryosurgery LLfl~laser _ high

intensity light treatment. (Photoderm) LLIi~subfascial endoscopic peforating vein surgery (SEPS)

, "'l.j~"lJ1tJ1IJn1rfnrn;i!l LUIJn1n11fl1@1'fJ LfJ'''fl fJl'ailtl",lii'~fJ '"1ilf;:h",r~tlfJn 1V:m,,,, LV;tlutl~ri'un1r

nl1'uLjjIJ~' LLfl~Ii\1l.JJli1tJn1r;fIJ:II1tJlhtJ1~1i",(compression therapy)

• ,.)01 •'llIlU~~ Un1rm1:r1LLUU intervention

{mjA~,riOJ1IJn1rfnM'LLUU intervention ~ll~ 10 vv ;itl significant edema, ii~1"ll'~LLfl~l1'nhN~~Il~

~1"ll'~j:jn1mJ~!JuutJfl~fJEiWj''''L''lIJ (secondary skin changes) Ufl~n1rLiiil~~flLifJ1~ I'llitl"'''lIJn1rLii~,

superficial thrombophlebitis LLfl~bleeding''''

111n1rtJ1"'~1IiLuIJ{!llj~~lhI'1OJlun1r~11'1'",fm~, L\lf1'~~L~miitl~ri'u w 1l'n1ru11'1l.J1nL1fl11iU

111n1N ~iii;~1i1-.i'nLL~1li'~,,1'tlIJIlIJ!Jn~l~ ~ 1i1tJ101l~~~1l.J1nilO1ltJnjjjmrH1\1l.J~~LVl1tJ1~1i01l(elastic

stocking hV;fJUnm'1l1n1rtJ101l 1i1dlu vv lJ1IJ1IJLL~1LLfl~tJ1"''ll1~IJiIJY;I1IJ101lFnr~'i1t\1L"iijLii01l"l,n

ii!ltlf1LtlU ,,1'fJhiL~IlIV:n1rfnh1\lnilfll~ LLfl~-.i'IJ1iI1!J~hmU!J1~1i", "l~IJr~fljjjIUf\IJi3~~llJ Lilu vv ll4).nn

iitl"l{m~!J~l.J1nl1illn1r~1Jli'", ~Li,~j:jfJ1n,r~ll~ CVI

U[lJ",1'11riOJ~~O1l'llfJ~~lh!J vv ;ifJ 1IJLL~Fn1;.J111m,l.J ~~tJr~ri'IJ:n:i1'lLLfl~tJr~ri'u~'ll1l1f11l4f\rfJuPlIjl.J~~

iillU ~;1 IJ11rfn""J»,l.Jiillu~;fi'u\l llEi,~hii1'I1l.J1IJn,rfn",,~ n1ii n1rj:j~~ii!liiiLLfl~iillLii!J"l~JIi!l~Il~Ul!J1v:qlhm ii11"lfJEi,~mi':l'",'i1ii1l11~LLYIlwl'fJIJ1uLL~r.11lJtl1 !J~1l.J1'Ifll101l'lULL~1i~ In ",~u ••.•li'~~1;T", !l~~"l~1l4iiiI'I1W"'01lWi~L!llB ttln1t1nl1'1J1UIJ~,mJrl'fJtJfl~ 20''''

hqlhtJ lOw Ju 1i1q1l1!J1l4l'1~!ll,~1ii1'1iI••.•1'!lIl4L""l.J'~I1l.Jlun1n;ln1r~-,;i.., tl1l.Jlro1V:nlrfnh1t01ltJ

n,rI11l.J~~ L\\'1tJ1~1i'" (compression therapy) LU\Jn1rfn""LLU1Jlh~ riutJr~Pltl~ IJrt",mlm1~n1r IV:

ri1LLu~lhLfl~ LUIJ1IJn1rtJ1i~ ii1"~Il~~1l1tJ""

n1r~lii1'",fn""hPl

qll'tJ~ii junctional incompetent '~111 saphenofemoral valve incompetent IIJii1U long segment

~ll~ superfic,al vein ~~ii refiux n1r~lii1'li1fn1:r1'l~IJ1i~fliii'"'''' IiIN saphenofemoral junction Fn1Lfl1~

IV:LiiuLL~IJWflll'iailIl01l";1\'mtl1'1nlV:oj''''L'llJrifJU~nl'1'v,mn11 GSV stripping Lym~~~I-nlln1t1Lii01ldlu w• •iiU:i3~n'i1~1Jli'Ii1LfJ1fJ!ln"'''23) n1n1' venous stripping ~~U'h1Nii!JL"'h tfJn1t1U,Ii1L~ULLa~

nr~\'Iu n r~ LYim~I1i!JL\\'IJtJr~t\l\'l'lll\'hrtl iit</ii3~l.J1n"'''' f'111\~mItJYi,urL1 N1ill,' ••.•1~ 11i111',L'Ih 'I~

tJall~ri'tJn'i1:"".'91 'iiin17Ufl~Lf\~fJ~iill~1flUU'l"lu\J;itlH flexible stnpper ••.•1'1l rigid (PIN) stripper

jllfl ~'"lln'(i1'l;lJ1J\.FB ..<til

..

5

LSVstripping rilJw.h1iIilF;11\noilU\.l1l1~mJ"lJ"'lI111 saphenopopliteal Junction t,xUIl"IlWilurill"<'" I "'" (Ul ••...•• ..:1".1'" .• ,llilUI'll dup ex ultrasound 1-l111venography ~n.I~~11J111l""U1!J1lJl-ll'lmI'lU1lJ .l-ln,-YllJn1~'YIllW'Jll

popliteal nerve Yi!J1U1lJLI'l1~1-l1Giacomini vein ~1~~~1t\'lJlJlJ1Y111~1"1-li1'1~lJ1tli"'lI1UI'l~Il~lJ"~1l

fascia L1f<1~nl>1lilLSV rill"Yi1 stripping oi1LL"nl1~~ni>llil~~Il~~ln~1Giacomini vein '\\lJlJ

1l<nU~YflJ calf varicosity ;1lJnlJ GSV varicosity m~~~nl>1l'\ vein 01Giacomini IilN

saphenopopliteal junction?;~u llJmn'1 stripping iNlJ11i1lJ1L~tuolimyhlYfn~tlJml'\m~YllJm~,Yill"

LL~~lJ1IilL!.ilJfJi\J1i\'''1.J1~\\lYl'llf~(suralnerve) il1i11lJln

",1\'1chl>1lil;;1stripping LlJ1 truncal varicosity \Jllmdh 1-l~IlI1l,illll1l~1'lJlll'\~""~1L""iI\JA'1111~m~:~11>1I1lL\J1\Jllntl1lu:Wm1ministab avulsionl"2&291 LL~~~lf.I'\'lI"l"Liln 2-3 iJl1iiLlJIJI1~11~lJ;(lJ1LijlJillil

1-l1\Jillill1i~!JYi~1\\LIJI\JfiJlJILi~~'lI"lIilLiln

",1\'1cJ11>11il~mwlJlh,mlJ!J11ijl1l LiI'l:~lJiIi'1Utj1LYl1U11iilil(elasticstocking )ll!h1\.lIlU 10 1lJ m\1:i\1

-:llulJi'l1l1I-llJLi,,~ul1,x~tJ1U1oDelastic stocking Iilll"n~111lJ nlll1llJ!lm1111lJlllJ1.Jr~lJ1nJ3-6 L~lllJLL~11

~1:>T1il"~I'I~m1!JlJ,\~~1\Jnll'1nilJ LiJu~l (recurrent) ili.llJUMfJOI

1111:LiYl1ni\Ju~lnm1cJllJi' Iil

Vi1'iu1i7:i11. mru1fil';';lJlJilJ L~UU1~I'I1\'l(neurologic complications) 1i1,YlFlUFlm1:hl>i'lil~1111~I\YlTnoii\Ju'lIu:1ld1lJ, - ~ < .•.• 1 1 ' , .• ,,~ ~,.l~:m",'lI" \l1lm'ilYf1~L"lJu1~\'l1'1'l1Ull1lmil l'liU lateral popliteal nerve 'lI1,,1'l11IilmlJn1~\'l1.Jn1~L\'lIlU

~~,nl1l loot drop'''' m1Yi1 ministab avulsion mllmI'lLnliln11lJ1I1lL!.i1.JlJilJLi\'uu1~1'I1Yli\lJtr\'l1t1m1""l!11'"

n11;;1 stripping 'lI\J~ GSV UI'l: LSV ~1lJ1ii~lJ1L~nJ;rjm'i1~:m:Y1lJn1~LYi\JlJlJi\J,iI'lJU1:\'llYl'lllWl!1'I

L/i"1.Jr:\'ll'i''l:f~ li11'''.33'

2. 1.Jllili;';1.JfJi\J""~j)Iil,iI\J,,1>i1Lii'l~I-l'il\JIil'~IllilUIM,n 11l~1mYlFlUf1n11cJ1lJi'l1lllJiii~~••.•1.J"hilnU11,.m11.J111l,;';1.J

,~ ~. - I'" P. ~ • , '" - ~1JIj)Yl1""~\JIil,~\J1'\1il1\tl1~~\JIilL~\JI1lLiIil1m1Lu1.J~j)lJLL'!IlJL'ilYf1~'11l1.J1I1lL~1.J1JI1llemoral vein "lLnIil~U

~~~lJ~~ill jill l1l~Fl~11""i'le'!Jn~l nLL~11~1i>1l1lIJl~\JIil'11'l11lJ""!j11lmnii1.J'lifllJ""~1l1ilt~j) 11l1>i1"fJi1i1lJ1(Ill;';1.JfJill

popliteal vein LlJ1n~ntil1"i~~j)I1l:i\o\!j!i\1",1'l llJoi1Luwlill1LiilJ'lilllJL\'lIlJ""~j)liltfi'll1l

SCLEROTHERAPY

Pillm1;'i"I'I111:I'11!JLPi\J~Lih1u~i\'lJLiltl~1>i1L~\J;;11'11U~i'llJ'lIfl~1YhmUL~u~ F111lJ.(U~lJ~lJ1'lI\J~

"1'lj)~'L~\Jl1lLL~: ,iiu1Iilyh~ulJ 1Iilu~~il lvilJru Ln1:1lJlJ~l!~l-lflj)(IlLilj)1il1>i1";11,xilu5m!J1n1wnL\'\u

mh1ilJILT1 LLi'l~,nlil1vi11.Jlil'l 'lJj)~~l!1""~j)l1l,ilj)1il11i11"~~(Il'"'''''1JI~~""lJ1U'lIj)~sclero therapy Pill

;;11i(Lnlil fibrous obliteration 'lIj)11-l~j)Iil,iI\JIil~1"fJillJ;/fMn111,x,1iI1l~lJl~fll1lL~n~lil,n" ~lJL~Il"

,,- . ~ 1" • '''' ~ 1/( . ,~, -",,1~:LnIil recanalization 'lIlJ ~ll1U""i'l~ n1~ L~j)n " sclerOSing agents 111111'l:"Il1Jn1.J'lI"11il~j)1

1-l1'lj)11l,~j)l1l';;lUT~\'\1.Jn11ruLL~~n111i11fum1~ncJu~1l1LLYfYlUI'Il~~li1um~;i", n Polldocanol, Iodine,

SodIum tetradecylsullate ,Sodium salicylate ~I'l~

{:'f)tJ~~~1y;f1Jsclerotherapy ~'fI(34,3a.3\l:

6

1. vv ~1111~!J1iill~ri'lJjunctional '-I1lJtruncal reflux

2. dJUn111m:nl!l1lJm!J'-IIt~n11~1(;i~Illidi vv ~~Fh~L'-liillll~

sclerotherapy 1i''-1fu'-llill~Liil)~Iii''IJU'11lt",hhn1J 4 ~lii\llJ"'1 Uli~ microsclerotherapy (Itl~23 .13)

1i''-lflJ dermal nares, telangiectasia 111i~spider veins""

iVilln11UIi~'-Iltnn11i,h.ri'u1t11uLI~~~!lmUUl'liU Fegan (Irish), Sigg (Swiss) Ill\~ Tourney

(French) ~~ll~Ii~\'lmuuMh~i\~~lilil1h'J6."J

Fegan method ~~i'i~ sclerosing agents lii,1u empty vein '11l*'-IlJ1!Jfill-.i,1~lnlll endothelial

obliteratioo 1lJ1'11-.i,1~ln~thrombosis '-Ift~~lnJu mlJl1i1!Jcompressive therapy ilill'li'ulli1!Jelastic

stocking,J9.40)

1111:; L~V11n-n 'fIU~ Ln til~\.l139,41J1. In~ stain ~ll~i:h'-ll!~ffilJlJ111n.~ii",-.il\I\'I'JUi\'l1mllJ

2. Inject,on ulcer liill~~,njjn11h'IJll. Sclerosing agent llllm,mmll~liill",lii, uIi~:jlJfJI.i1arn1'-11!~

3. lIYi~lI\'l11Viiii>1

Sclerotherapy \uu~,!UU iVilln11 echosclerotherapy, nl1H polidocanol foam LII\~endoscopic

sclero,therapy -.i,11\'~1\n11fmnh:':;'l,uuiii;" m1~1\\'1miill\.I\ill!Jl\~"m-.iltril!JqjjmllJ-:ilU1C\1UI\~

1~funl1~n~UlJ,rillU

LASERI PHOTODERM

Laser L'I\~ high intensity light (Photodenm) \iiti,'-Ifufmn residual flares Illi~ reticular veins

tril!J1i1l~11l,,~,n thermocoagulation ~1,:J~llU~Ln~~u~~-.i,I\,!J liilli>1Llii~~I!~'-Il\lli>1liill"''IJU,~IIIn''''

SUBFASCIALLIGATIONOF PERFORATINGVEINS

1'Itnm1fillmllii,i\~Lll\~YW1!JllJ interrupt incompetent perforators 1;j'i,"I~1ullilL'1'1l~\i>111'11U

Dodd's Ll';jll1l'1L~,LI1i~Boyd \iIi~ll1l'1L~,""YllJ'i,lIilL''-Ill~~li-,\~Ln",CVI lJ,n~l\lI\ fill CockeU's

perforators 'illn1,ilillli~jj"'~,~lI\vn. medial side ~ll~m ll"lluiiiLlJ""'-I1t~'lJlllJtibia 1"djUL'U1!J0115

l"lluiiiLlJ"'1"lui\~ medial malleolus'''' (Linton's flap) l'ffit'i,!l,lJ"n'-l,IIi"I\1ll~~llllullU~ll~

incompetent perforators 1i1liil\~jji>1dJuiI'm:tr~~step ladder l~miili\~\1i1'~~lnLl\,~Lii,i\.{u fascia

LIl\~YllJperforators 1~l;jnLlft~~11l\1i1'~~111i'~llJtliMIUlJi:!(;,fascia IUlJi:!"'LLrirh\1l!~

Ci,1j1\1I!~lJ1m\.lLili~ll1l'1L,hft~l.I,,,ui\~iillLYiltJ1l.1~~LiJulJuilf\~,jjil'n~N~ Iipodermato-sclerosis

LIl\~brawny induration m'l\~jjl1llJ1L1N;jLl~ftf,hlli'i>1"1~1'1!J"LiJUI'lli,1-3 Liiillu

m11-n'illn" subfascial endoscopic perforator vein surgery (SEPS) ~~jjIL~ftI11Yll~I\'lll~nl\'ll.1tliIi'1

L~"Yilt!Uq1.l1!J\lJ i/!~~Ullut:~YlmtJll\ "l\~fnl;'1 Ll~1\U1Ul\1i1llu11lm'~1~ IIILi:!~"5.'"

...• •... ..1~nl11O~,llUl

Harris ",.~"N~ 1t1i'1l"ll111in".

rad:o frequency - heat catneter ;J11n1Y'i 1 VV{4tH 11lJ~-31;n11

cryostripping 'IJll.~~ GSV Ill\~ LSV'''' 1J~n'l,ni1 u~jj endovascuiar laser photecoagutat,on (EVLP)

7

"'50IUI\~ endovascular sclerotherapy 'l~!.IH sclerosing foam rIi~!.I~~'1~ii1!l~LIl11!l~~l\n11fm:n

ri!lIj~'1d1lJ11ii lLl'dl.ll\1!.11i!l11J,

vv Vii:iperforating LII\:::deep vein incompetent "~1fnl;1u'lJlJ conservative 'l11l!Jn1111~lJelastic

stocking 1jjmnhi,i'11l1m:n

RECURRENT VARICOSE VEINS

1;j£~'11n~U~!J w 1r1iflJn11fm:nl'lf~um '11mLYi\'lEJl.Iln!Ju~un~~i:iLLIj~l'I1~lll\::::jfin1f1m:n1i1~1nlj

LI1l!J~~1uuft~ '1~YilJ~1i:iL!ln111InM lud1 \Min U1:::lJ1Nl'!l!JI\::: 20"4} ~lb!J~n.rlJ LtJU~1ll1'1'1~nil'lJlJ1l'jlJ

u,YiI'1rJ~111n111m:n " f~u,m\-lrllfn'l 'I~\UYilJUYi1'1rJl'11Ij~ Ij1;' l;:illfum nJ1m:n II1j~'YI1~1\.Im1U1:::LnIj~ tl~!Jlmhd fi!l ii1!l~im.h:::~m1fnl;1"f~rilllj~1f1h!J~mill illYl'lfNn1!J!l!h~I\~L~!J'I ~~ Trendelenberg test

UI\~ Perthes teSn11 noninvasive tests tl1l!!\IlYi1~Doppler ultrasound LII\~ duplex scanning 1\.1lJ1,~ • .J " • ISlI11!Jfn'l'l~"'!l,1'11 varicography LYlll\-l1ill1u'\-l\.l~~Il,Incompetency

l\11\-l~mlln:>'lLUU~1~!l~ w Irt£~lJ1'11n(5"

1, n1~ihli'!JP1f~ LLmilt'lYil\111l1111IXII\.I~Yl1~mffnl;1\-lrllc.h ~t'l1jj IU\.I11Jt'\1lJu,lj~l'I1~'lfl'l~m1'1:::dllj

2. m1c,h~l'I\jj1r1iI11mf1;jn~I'lu'~\.I,l\1~1~!l,l.II\!lI1lLil!lI11~1GSV lJ1L~N saphenofenoral junction

f1flJl'jmt\u

3, ~n~11l GSV \-If!l LSV 1jj'll11rllJ saphenofemoral junction \-l'1!l sapheno - popliteal Junction

4. m1l';1 venous stripping \jj~n~!l~\-l1llil~Lt\U

":IUI'l~!l, recurrent w Lll\:::Lllj~Yl1,m1fnl;1(5J.!i51

1. w ~1'I~r'f1,~~l.IiI'~'11nm1Ch~~ \IiIILril.ll\!l1'lLilllI1111i1":1U11'l1~nl.l1'!1":1U1I'lnl\1,~lJll~\jjli\Ij":lN~ch~l'I

LYi11:::~tl~t;~!l\.lr1lJ Lllli'l:::I""'!'l11\-lil'~~11i'111~1!T~I'I~"h~ L\-lii!lll~ ~1in11LLm~~ll m r'I~Yi11P1'hJ~\-llJ1!J

~~\-llJ[i\lJ1L~N\-ll\!l1111il!l111iii1U~\.I~1\1~11i1'1 ~'1~ch~t'\ Lfnll!ln \ :m1til~Li'i I11;U\-lil'~~1~iIlu,«; 11m~LI1l!J

mnh ambulatory phlebectoncy LIl\~ sclerotherapy

2.mmil'lJLjj~~1'11n IYll'lul'lmfch i>!111\jj iii\-l1!lUm'lJ\~ I/lN' 111lnl1l'11nn1~ij'lli' Elhl'lilril~~LI1iu'111i>11~'1

h~m!Ju'I\:::lLUl\CJl\n11I/lYl'l~U'IIi'!Jill11\jjYlntJ~11!l!J h"ll ~\ \.If~lJlJ111l~!l~\-lil!lt'llii!l11l~1~~1 1111IX~1~

Il\.l~1'11~1ljn11~1~t'\ilI11YiI\111l1jj\"'Yi1complete high ligation ~!l~ GSV i>lN saphenofemoral junction

\jj\iK~n~11l perforators Yi1 stripping ~!l~ GSV Ul\~ LSV 1jjlllJ\l1nJ Yi11\\'lnl1lreconnect 'lJ!l,\-ll\!l'l

lil!l11l1li1~~1I>i't'\\lJl\lJ\l1nJLnl1l"cavernoma" ;"

3. lnl11'11n progression of the disease L;j!l,'I1nm1lJil~tJniii~!l~\-lI\Il"'Lil!li>lIli1L!l~Yl1~fIi'1Ugenetic,

bioche'Tlical UI\::: endocrine Yi1Hi.•1i111 "neovascularization" i\~LL,:r~,'1~li1m1~1~I1l!lti1~~lJ\l1nr

Qml(!l~1/l1lJ~1in11(6"

4. secondary vv L"liuln~'11n postthrombotic syndrome (PTS) \-l'1!l primary deep valve insufficiency

n11~1~l11fnl;1 vv ,,:::\jjmlJ~'H'l "~1111IXmmnl'l~l\~ mrfm:n1"'lJm11if compressive therapy

~1J~lJ recurrent vv ~11\-l1'l!l1'1'1~I1i~"1nmIlJ1I1lLVI'l\-lC~\-l:1l11lJn\.ll-2~n",\iJ( LLI'l~111lIXfi'i>lr1~Il,

recurrent w lJ~;\.I\-l~~~1~t'\1m:n ::;,m1U1~ln\.l~tl~!J1iiLLtl\.l!lU 'l~lJm1in1J1~~ I/lYl"h~n1!J Ul\:::n1'

~,f~'I~U'IIi'!JyiLi'I1:trillUft~LLU~l'11'hom 1fm:n ~'!I\1J

8

tl1~~un1rnr~~\.IiiT~hn11fnh1 w

qL~u\.I1~\'i1n1r~hiiTflfnh110 w l\.1'1i~~il2525-2542 l"l~ 17 il oI~<lillltl;lvenous stripping ~ll~ GSV

132 nu ~~'1n11u\'i1 complete high ligation 1'IU'hjjn11m::YlUm::l~Il\.l<lillsaphenous nerve U:l1tU

~lllyh 611IJ djUn1l'1.J1I1lL9U01~1~1ntll'lJtl1~111'r1Qnlli'l1lUI'l~1l~\l1J~~12 11Uiin 4 nu U1I1lL9Ui~~11~~.k _

llfl~tl1n1111l'tl1JJl1U\liN(4.5%) venous stripping 'tIll~ LSV22 l'1!Jm~'r1Un1~L~lllJ<lillsural nerve 3

11!J111n11~~lJlll~I11!J\l~~(13.6%) J~\llJl1llnl1lhematoma 3 nu (2%) djlJ1l-i1J1nL/J111ltl1n11Ui\'~iii;j'u•

Lnl1lrecurrent vv 7 n!J (4.5%) fnhltl1l!Jn11l'i1~111i'1'lre - complete high ligation 2 l'1!J hlJr1U

excision tll~LI:J11(l1l1n11ui\'~iii~lJdil1l recurrent w 711U (4.5%) fm~1LI1l!J01:-\'i1~111i'1'lre _ complete

high ligation 2l'1U hlJr1U excision 'tI11~"carvernoma" iin 5 l'1Ufnh1LI'l!Jn11\'i1 phlebectomy (stab

avulsion) i~~r1U sclerotherapy Ufl'h stab avulsion 141 l'1UllJ~1lJ'llJ;lLijlJ recurrent w 2211U

~I1lLijlJ~ll!Jfl::15.6( 7 n!J'tIll~ql~UlJUfl~ 15 11!J~lnl'1'~!JLL1'I'r1Uli1lJ~lJl'l~1J111\'\'i1n11fnh1)YiU'l1Lnl'ln11

m~'r1Um~L~llw,ill saphenous nerve l\l;jIl1l'~L'li12 11UlJ1r1l'~l'lh3 n!J jjIl1m1',ni~P111~ LLI'l::l.I1!JLll,

llJ~~11l(U1I1lL9UllillLi\'lJtl1::~1'r1~IlEm::3.5) incompetence perforator 15 l'1!J ~hlli'l'l\'i1Linton's

procedure 12 11UYiU'l1Ll~mhlli'l1ll.l1!J-n1~1nH'~fl1 3-6 lii1!llJli11\'i1subfascial endoscopic

perforator vein surgery (SEPS) 3 nu U~~\l1!JL1~LL~~1l1011iithuiii;lJIJ1n\l«,mn.hlli'l'l '1h~' .1::!J~L~fl13il ~~1lJIJ1l'i'~LL<li1'1.1'12543-25451~L1.l~!JlJlIlJ~'r11~1lJm1fm:nqtJ'l!Jvaricose vein oI~;l \iII

\'i1 venous stripping 'tI11~GSV 44 11U t~!JfI~1J1n,U:l~nJ1l'~L'Ih\l-in~{f~Lyhi~IJr1U stab avulsion Uil~

m~<iI~u sclerotherapy 1l-iYiU'l1i:i01m1~'r1Um~LiilllJ<lillli\'lJtl1~111'r1YiU hematoma LLfI~1l~\l1J~LillJ~1

~1nn1nhlli'l1l LUI::ill'lsclerosing agent 6 nu 111n11iii~lJL~~f11'J\'«~u~1l.iYiUrecurrent R1\lfu

stripping 'tIll~ LSV7 l'1U 1l-iYiU'l1Lnl1lf11~~U'r1m-nlllJ\'i1 sublascial endoscopic perforator vein

surgery (SEPS) 811!J Ll~l'lcJ111i'11l\l1ul~Llfl~~1011'ill~qtJ~!Jiii~lJ~1n ..

~pJ

lllJ~'r11,lum1fnh1 lOw ~~tlfll,l.l1~n~uoli'~un111'll"l~h~n1!J '3'mh::'iii UiI::n111'l1~~:jil~~Uyhl'lb'

ri!llJtl1~LjjlJlIlJ~m~011fnh1 t1\'llEh~L\l1J1::111J~::cJ111i'",fnb'1rildlli:iiilltl~~~mJlJlllJ lLfI::01T~111i'1'l~::ilill~

lIri1'lJI'lNffi!JL1~t1\'Qn,1'llLlJ~LulJ';1\lfun1Tfnb'11lJ1J~,lilJ;ill high ligation Llfl:; stripping 'tIll~ GSV

hi 1i~1f1~n~1~i>ilJiillLyhml'\'i1 n~1~oIUtili1li1l1l'1l'li1Lllml1m::'r1Um~1~~UIli!ll~lJl.l1::111'r1'111i'11l'111nI'lUllU

';1\lfu vv ~L\lftll~1nI11'111U'tIlJ~mr\'i1 stab avulsion lift:: sclerotherapy L'lilJliii!J~r1l.Jm1\'i1

stripping ~ll~ LSVhJiIf~~fI~l1.JO~ii!llyhLYil'1~Li\'U1.l1:;1111'l'lfilll~iiiI'lUI'l:;~'IJlJ1'..l11.lri'uLSV l'i'~LLllinfl1~

lill~ ~~iillLyh"" R1\lru perforator LlU~L1JlJn11\'i1SEPS jj~1~~lJLYi11::1il1tJ~~jj UtJfI~111i'!i1LY;U~LL~iI

d;;!J111Eh~hrl'l1~m1fnh11 0 vv ~~Yiulr!i~1n lLIII'\~M1IJR1A'tI!UllmLfI::tJl\ll!J1..:iLLYi'r16~'bJjjm1~• - 157', - il t ~.1~ A .,., 1 - ~ "81~1lJ1t1JmWl ,llml1\nlllL U'II11J"'~~ ~~Pl~1~nllU1IJLL~::~1~1J111l1:J1UlJn111nb'1"'1U

9

u~m.n\jnnJ

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10

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