Chronic Venous Disorders of the Lower Limbs

Chronic Venous Disorders of the Lower Limbs

Binni John Chronic Venous Disorders of the Lower Limbs A Surgical Approach

General Surgery Amrita Institute of Medical Sciences Kochi, Kerala India General Surgery Amrita Institute of Medical Sciences Kochi, Kerala India General Surgery Amrita Institute of Medical Sciences Kochi, Kerala India Binni John General Surgery Government Medical College Kottayam, Kerala India 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, specifically the rights of translation, reprinting, reuse of illustrations, recitation, broadcasting, reproduction on microfilms 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 specifically 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 specific 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)

Foreword This book is a chronicle of an ancient disease, once considered a poor second cousin to arterial disease. It starts with a glimpse into the history, portraying 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 scholarly 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 insufficiency, the night of venous diseases. 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 finally 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 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 postgraduates 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 disorder they might encounter. For the venous enthusiasts, this book is a mustown classic. v

vi Foreword 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

Preface Venous diseases of the lower limbs are extremely common conditions in clinical 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 garner 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 graduate 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 classification 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 field. In fact, this is our first venture 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 difficult 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. vii

viii Preface 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 specific individual, it was our collective effort that brought it to its final format. A word about the diagrams. The ideas for the different diagrams were conceived by one of us with inspiration from different 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 manuscript 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 colleagues 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 submitting the manuscript. To our families, we owe a lot in supporting us when we were busy neglecting 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 Kochi, Kerala, India Kochi, Kerala, India Kottayam, Kerala, India Subramonium Vaidyanathan Binni John

Contents Part I Basics 1 Venous Diseases: A Historical Survey.................... 3 2 Lower Limb Venous Anatomy.......................... 9 3 Venous Physiology and Hemodynamics of Lower Limbs..... 17 4 Chronic Venous Disorders: Classification, Severity Assessment, and Nomenclature.................. 25 Part II Primary Varicose Veins -C2 Clinical Class 5 Epidemiology and Risk Factors......................... 35 6 Primary Varicose Veins: Symptoms and Diagnosis......... 41 7 Open Surgery for Primary Varicose Veins................ 55 8 Endovenous Thermal Ablation.......................... 69 9 Sclerotherapy........................................ 81 Binni John 10 Recurrent Varicose Veins.............................. 95 Part III Chronic Venous Insufficiency and Leg Ulcer: C3 C6 Clinical Class 11 Chronic Venous Insufficiency and Venous Ulcers: Pathophysiology...................................... 107 ix

x Contents 12 Chronic Venous Insufficiency: Clinical Features and Investigations..................................... 119 13 Principles of Treatment of Chronic Venous Insufficiency.... 129 14 The Post-thrombotic Syndrome: Pathophysiology, Clinical Features, and Management...................... 139 15 Care of Ulcer and Compression Therapy................. 153 16 Pharmacotherapy of CVI.............................. 169 17 Strategies for the Management of Incompetent Perforating Veins..................................... 175 and 18 Deep Vein Valve Reconstruction......................... 183 19 Deep Vein Obstruction: Management Strategies........... 195 Part IV Assorted Venous Problems 20 Venous Telangiectasia and Reticular Veins: Clinical Class C1..................................... 207 21 Pelvic Venous Syndromes.............................. 215 22 Nonthrombotic Iliac Vein Lesion (May-Thurner Syndrome)................................ 223 23 Klippel-Trenaunay Syndrome........................... 229