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This is demonstrated most clearly in the development of a saphena varix, which can disappear following reduction in diameter and restoration of valvular competence. Symmetrical upward dilation is due to an increase in the diameter of the vein as a result of an increase in the workload; it produces reversible valvular incompetence. Thrombosis and recanalisation produce irreversible valvular incompetence. The pressure and flow changes are basically different, but they take place simultaneously, which makes it very confusing.
The physical environment in the veins determines the structure of the vein wall. A gradual increase in pressure produces hypertrophy, while a turbulent downward flow produces an asymmetrical, atrophic, bulging dilation that we recognise as a varicose vein. Valvular incompetence can be due either to dilation - it which case it is reversible - or to thrombosis and recanalisation - in which case it is irreversible. Advantage can be taken of reversible dilation in planning the treatment of varicose veins.
If we locate the incompetent lower perforators and close them with fibrosis, we then restore the pump efficiency and reduce the pressure in the superficial veins. This reduction in pressure allows the diameter of the superficial veins to reduce and the valves to recover their function.
The restoration of normal pressure can cause even a saphena varix to return to normal.
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The location and induced fibrosis of perforating veins should be carried out as soon as possible to take advantage of the ability of veins to return to normal. Superficial veins are quite different from deep veins in structure and function.
The superficial veins are the auricles of the deep veins; they collect blood and store it until the deep vein pressure is low enough to receive it. The end result of the interplay of these pressures is to advantage the osmotic pressure in the plasma proteins and to allow absorption of tissue fluid. The site of this action is in the very small venules close to the capillaries that are devoid of muscle and are semipermeable.
The arterial input in the tissues can be improved by improving the venous clearance in the capillaries and small veins. By cutting off the high pressure transmitted by the incompetent perforator, one can effect an improvement in venous clearance and arterial input. Arterial and venous ulcers are the result of inadequate perfusion.
An ulcer is not the result of varicose veins and should not be called a varicose ulcer, any more than an arterial ulcer should be called a varicose ulcer. It is purely coincidental and not a sequester. Both arterial and venous ulcers are a failure of adequate perfusion, and the inadequate arterial input can be improved by improving the venous clearance. The abnormal flow in veins in the form of turbulent retrograde flow can be associated with good pumps, which have the ability to effect adequate venous clearance. Good pumps are associated with varicose veins but not with an ulcer.
Varicosity in superficial veins is due to an abnormality of flow, while the venous ulcer is the result of the inability of the pumps to produce sustained low pressure after the commencement of walking. It is necessary to reduce the hydrostatic pressure below the osmotic pressure in order to advantage tissue fluid absorption. A favourable gradient between osmotic and hydrostatic pressure has to be maintained for the dialysis of the tissues and the prevention of ulcers.
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The function of superficial veins is to collect, store and transmit blood from the skin to the deep veins. Superficial veins are, in effect, the auricles of the deep vein pumps. The effect of turbulence on the vein wall should be investigated more widely. There are many examples of its damaging effect, and it is easy to record this effect by the disappearance of muscle in the vein wall. It is quite common to see masses of varicose veins in legs with good pumps, and it would almost appear that we have to have good pumps in order to lift and leak enough blood after the commencement of walking.
Increased velocity, reverse flow and turbulence in the medium-sized vein that is poorly supported by Sherman's fascia will produce varicosity, which will disappear when the abnormal flow is corrected. The turbulent downward flow that takes place as a result of walking is thrashing against the wall of the semi-collapsed vein and can be compared to the turbulent flow from a high mountain stream.
It is very different from the sluggish movement of blood in the standing patient, which is exemplified by the streams in the Everglades. The fact that veins are collapsible conduits suggests that it is possible to use the mountain stream and the Everglade swamps as analogous. Grass grows on the banks of the Everglades, but it does not grow alongside the fast-flowing mountain stream.
Location of Incompetent Perforating Veins The success of the technique of compression sclerotherapy is dependent largely on the practitioner's ability to find and destroy incompetent valves in perforating veins. After outlining the superficial veins in the standing patient, the patient is then asked to lie down and the leg is elevated to empty all the blood out of the superficial veins; this takes a few minutes.
When the leg is emptied, palpation of the leg reveals a very different limb from the standing limb. It is easy to palpate the bones, the fascia, the muscles, and any unsuspected thrombosed veins. This palpation reveals either holes or soft spots in the deep fascia surrounding the muscles; these points are marked with different coloured skin pencils.
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The tips of the fingers are pressed into these points, and the patient is asked to stand up; the fingers are then released one by one, moving from below upwards, and filling of the superficial complex reveals the presence of an incompetent perforator. The superficial veins related to these sites are the veins of choice for injection. One's knowledge of the anatomy of a patient's superficial and deep veins is, of course, basic. Compression Bandaging Bandaging is assumed to be within the competence of any doctor or nurse, but superb bandaging is an art.
The compression applied by the superb bandaging is uniform but changes hourly with the change in the volume of the leg and is frequently inadequate compression to obliterate the vein. It is absolutely necessary to have localised specific compression by the bevelled rubber pads over the injected segments of the veins.
One should observe the mark of the pad on the leg after the bandaging is removed as proof of the efficiency of the specific compression of the vein by the pad and bandage. Success of the technique depends on adequate, specific, uninterrupted and prolonged compression bandaging. The technique depends on the fibroblasts which normally does not enter the vein to produce the necessary fibrosis after the intima is stripped. Fibroblasts do not appear in histological examination until the seventh day.
It is followed by a blood supply from the outer periphery of the vein wall. This invasion of fibroblasts and their blood supply are the essential healing process of fibrosis. This produces the permanent fibrotic segment of vein that restores the leaking pumps and takes approximately six weeks. The end point of localised specific compression is indicated by the production of a hard, painless, cord-like vein.
Areas of thrombosis indicate poor technique and poor bandaging. Proprioceptive tactile palpation of the limb while bandaging is of great importance to the production of superb bandaging. Walking The time schedule of maturation of fibroblasts and osteoblasts is similar.
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Both mature rapidly as a result of walking, but walking also improves the peripheral pumps. The difference between the peripheral pumps and the central pump the heart, which is working every minute of every hour of every day is that the periph-. When we stand, we damage the peripheral pumps. Walking is an important adjunct to compression sclerotherapy. The help that the peripheral pumps give to the central pump is now beginning to be appreciated.
An additional heart in the circulation, which is what we have if we walk regularly, is of great benefit to the dialysis of many other organs of the human body. George Fegan.
Our Priority. Page 2 of 7 Varicose Veins There are no accurate figures for the number of people with varicose veins. Some studies suggest that 3 in people. If you suffer from varicose and spider veins, you are not alone.