CASE REPORT

VARICOSE VEINS

Oleh:
Irene Qitta Pranindita
132011101100

Pembimbing:
dr. Setiadi Drajat Kurniawan Sp. BTKV

SMF/Lab Ilmu Bedah RSD dr. Soebandi Jember

Fakultas kedokteran Universitas Jember
2018
INTRODUCTION

Varicose Expensive
medical
Veins treatment
Often in
pregnancy
Rotated
Elongated
dilated
Varicose Veins

Varicose veins are tortuous, widened veins in the

subcutaneous tissues of the legs and are often easily
visible
Classification
Primary : Congenital valve dysfunction
Secondary : thrombosis/thrombophlebitis, tumor, trauma,
arterovenosa fistule

CEAP
• C0 : No visible or palpable sign of venous disease
• C1 : Telangiectasias or reticular veins
• C2 : Visible and palpable varicose veins
• C3 : Venous edema (without tropic changes)
• C4 : Tropic changes of venous origin : atrophie blanche,
pigmented purpuric dermatitis, varicose eczema
• C5 : Healed ulcer with tropic changes
• C6 : Presence of one or more active leg ulcer, often
accompanied by tropic changes
 Etiology

• Congenital
• Pregnancy
• Obstruction
• Degenerative
Pathophysiology
Clinical Manifestations
• Swelling
• Hyperpigmentation/discoloration
• Heavy legs
• Painful
• Itchy sensation
• Burn sensation
• Bleeding
 Diagnosis
Anamnesis
• History of varicose veins, DVT, superficial thrombophlebitis in patient
and their family
• Onset of the disease and things that can aggravate the disease
• Predisposing factors (heredity, trauma to the legs, or work that requires
standing for a long time)
• Wear tight clothing
• The habit of sitting with legs crossed
• In women, varicose veins get heavier when pregnant
• There is a history of swelling, changes in the skin, ulceration, or pain
• History of other vascular diseases (peripheral artery disease, coronary
artery disease, lymphedema, lymphangitis)
• There is an increase in the size and number of varicose veins

Bartholomew, J. K. (2005). Varicose Veins: Newer, better treatments available. Cleveland Clinic Journal of Medicine, Vol 72, 312-327.
Physical Examination
• Inspection : ulcer, telangiektasis, cyanosis,
discoloration, brown spot, varicose veins, surgery
scar
• Palpation :
from anteromedial (GSV)  lateral (GSV
branch)  posterior (SSV)
Palpate pulse distal and prox artery. Pain?
ABI
• Percussion : distal vein  waves traveling to
proximal vein
Perthes test

Standing : varicose veins are full, groin is

tied so that the GSV is closed

Walk in place : so the leg muscle pump

functions well

If the varicose veins gradually disappear,

means the venous system still adequate
Trendelenburg Test
1st phase :
the leg is elevated so the vein is empty then
the leg is tied with rubber band

2nd phase :
the leg lowered or the patient is asked to stand
while the pressure in the groin is maintained

3rd phase :
rubber band release

(+) : when the GSV filled immediately

from the upper part, that caused the
varicose veins in GSV and SSV
Examination

• Doppler Auscultation
• Imaging (Venografi, MRI, USG, MRV)
Treatment

• Pharmacotherapy : to relieve symptoms

(analgetics)
• Compression therapy : to constrict veins, decrease
venous volume, reduce venous reflux, increase
venous pump ability
• Sclerotherapy : resulting endothelial reaction,
fibrosis, complete venous destruction
• EVLASER : give heat injury to close the vein
• Surgery
 Surgery

Many surgical therapies have been developed

• Ligation and stripping

• Ambulatory and stab phlebectomy : used to treat larger

varicose veins branch tributaries of the legs

• TIPP (Transilluminated powered phlebectomy)

• SEPS (subfascial Endoscopy Perforator Surgery)

CASE REPORT
Patient identity

Name : Mrs. Siti Zahro

Birthdate : 29/08/1960 (58 yo)
Sex : female
Address : Gajah mada st. XII
Job : housewife
Date of hospitalization : 02/08/2018 – 09/08/2018
Date of examination : 03/08/2018
 Anamnesis
• Main complaint : bleeding from right leg
• Current disease history :
The patient complained of bleeding from his right leg 4 days ago. Blood
suddenly came out without pain but only felt sore and slightly swollen.
When the blood comes out the patient usually immediately examined so
she doesn’t know how long the blood is coming out. The patient didn’t
know what triggered the blood discharge. The patient doesn’t have much
activity before. Blood outflow also not occur after a long resting. The
patient first experienced the same complaint 4 years ago and then the
patient immediately go to the general practitioner and then just bandaged
and given medicine and then she went home. 2 years ago the blood came
out, the patient returned to the general practitioner, was given medication
and went home. 1 year ago blood came out and the patient was
eventually referred to the surgeon and recommend to do surgery
treatment. But the patient refused, then the patient went home and just
taped her feet with plester. 4 days ago the blood came out again, the
patient then went to the surgeon and was referred to a thoracic and
cardiovascular surgeon. The patient then recommend to do a surgery and
the patient agreed then hospitalized in dr. Soebandi hospital. Pain (-)
Burning in the legs (-) Tightness in the legs (+) night cramps (-) tingling (-)
• Past illness : Hypertension since 5 years ago, no routine
treatment

• History of drug use :

Amlodipin 5 mg 1-0-0
Bisoprolol 5 mg ½ -0-0
Tranexamic acid 3x500 mg
Mefenamic acid 3x500 mg

• Family disease history : -

General Status

General Adequate

Awareness/GCS Alert/E4V5M6

BP 140/90 mmHg

HR 76x/min

RR 18x/min

Temperature 36,8°C
Head :
head: normocephal
eyes: anemis conjunctiva -/-, icteric sclera -/-, pupil reflect +/+
Nose: rhinorrhea (-)
Ears : otorrhea (-)

Neck :
Deviation of the trachea (-), mass (-), enlargement of lympnodes (-)

Thorax :
Inspection : symmetric, retraction (-), no visible IC
Palpasi : normal fremitus tactile
Percussion : sonor
Auscultation :
Cor : S1S2 tunggal, regular, murmur (-), gallop (-)
Pulmo : Vesicular +/+, rhonci -/-, wheezing -/-
Abdomen
• Inspection : Flat, Distended (-), DC (-), DS (-)
• Auscultation : Bowel sounds (+) normal
• Palpation : Soepel, nyeri tekan (-), muscular defans (-)
• Percussion : timpany in all abdomen regio, hepar dullness (+)

Extremity : WE (+), edema (+) cruris (D)

Local status (cruris dextra region)

Inspection : dilated vein in cruris around popliteal (D), black ulcer in cruris (D)
edema (+), bleeding (-), cyanosis (-)
Palpation : pain (-) dilated vein (+) around popliteal region

ABI
ABI dextra 170/140 = 1,2
ABI sinistra 160/140 = 1,1

Trendelenburg test (+)

Clinical photos
USG doppler
USG Doppler
V. Femoralis, V. Femoralis superficialis, V. Poplitea, in normal caliber, the
spectral Doppler pattern appears monophasic with waves consistent with
inspiration breath pattern, on compression looks totally compressed,
there is no thrombus.
Vein valve in saphenofemoral junction still looks good
Vein valve in saphenopopliteal junction not moving in systole and diastole,
with dilatation in popliteal vein.
Vein dilatation along superficial vein in popliteal region (perforator vein).
Varicose veins appears in the popliteal and cruris regions

Conclusion:
Right saphenopopliteal junction valve insufficiency.
Vein dilatation in right perforator vein.
Varicose vein in superficial vein in cruris dextra.
No thrombosis / calcification on veins / varicose.
Laboratory test
Item examination 26 Juli 2018 Normal range
Haematology
Haemoglobin 13,5 12,0-16,0 gr/dL
LED 27/51 0 - 25 mm/h
Leucocytes 9,8 4,5-11,0 109/L
Hitung jenis 2/-/-/67/25/6 0-4/0-1/3-5/54-62/25-
Hematocrit 41,0 33/2-6 %
Thrombocyte 262 36-46 109/L
PTT Patient: 10,6 150-450
Control: 10,2 Difference with control < 2
APTT Patient: 29,1 sec
Control: 28,7 Difference with control < 7
sec
Liver function
 SGOT 39 10-31 U/L
 SGPT 47 9-36 U/L
 Albumin 4,5 3,4-4,8 gr/dL
Blood Sugar Nature 122 <200 mg/dL

Electrolite
 Natrium 143,9 135-155 mmol/L
 Kalium 4,11 3,5-5,0 mmol/L
 Chlorida 106,0 90-110 mmol/L
Renal Function
 Creatinin Serum 1,1 0,5-1,1 mg/dL
 BUN 16 6-20 mg/dL
 Urea 34 12-43 mg/dL
Diagnosis
Varicose vein grade II cruris (D)

Planning
Pro varicose stripping + ligation D
Inj antrain 3x1 gr
Inj ceftriaxone 1 gr
Prognosis
Ad Vitam : ad bonam
Ad Functionam : dubia ad bonam
Ad Sanationam : dubia ad bonam
OPERATION REPORT

Operation date : 3rd August 2018

Time out : 13.10
Operation finish : 14.30
Diagnosis : Varicose veins grade II (D)
Action : Varicose ligation + stripping
Anastesi : Regional anestesi: SAB

Description :
• Preparation of operations : CIE, inj. Ceftriaxone 1 gr
• Patient position : supine
• Desinfection : povidone iodine
• Skin incision and opening of operations field : poplitea region along GSV
• Exploration : dilatation of GSV, perforator incompentence
• Description : ligation in SPJ perforator vein, stripping GSV cruris (D)
• Name of operation : Stripping and varicose ligation
• Post op instruction : Inj. Ceftriaxone 2x1gr
Inj. antrain 3x1gr
Inj. ranitidine 3x1 amp
Drip neurobion 5000
Venosmil tab 3x1
4-8-2018
S/ pain in wound post operated
O/ general: cukup BP : 120/80 RR : 22x/menit
awareness: CM HR : 88x/mnt Tax : 36,6 °C
h/n : a/i/c/d -/-/-/-
tho :
cor : S1S2 singular, e/g/m -/-/-
pulmo : symmetric, ves +/+, rh -/-, whe -/-
abd : flat, Bowel sound + normal, soepel, tympani
ext : AH ++/++ , OE --/--
Local status regio cruris dextra
I : dressing (+) elastic bandage, oedem (+) leakage (-), pus (-), bleed (-)
P : pain (+)

A/ Varicose veins grade II post op ligation and stripping varicose H-1

P/
Inj. Ceftriaxone 2x1 gr
Inj Antrain 3x1 gr
Inj Ranitidin 3x1 amp
Drip neurobion 5000 1x1
Venosmil tab 3x1
5-8-2018
S/ pain in wound post operated, better than before
O/ general: cukup BP : 130/90 RR : 18x/menit
awareness: CM HR : 83x/mnt Tax : 36,5 °C
h/n : a/i/c/d -/-/-/-
tho :
cor : S1S2 singular, e/g/m -/-/-
pulmo : symmetric, ves +/+, rh -/-, whe -/-
abd : flat, Bowel sound + normal, soepel, tympani
ext : AH ++/++ , OE --/--
Local status regio cruris dextra
I : dressing (+) elastic bandage, leakage (-), pus (-), bleed (-)
P : pain (+)

A/ Varicose veins grade II post op ligation and stripping varicose H-2

P/
Inj. Ceftriaxone 2x1 gr
Inj Antrain 3x1 gr
Inj Ranitidin 3x1 amp
Drip neurobion 5000 1x1
Venosmil tab 3x1
6-8-2018
S/ pain in wound post operated, better than before
O/ general: cukup BP : 130/80 RR : 18x/menit
awareness: CM HR : 78x/mnt Tax : 36,5 °C
h/n : a/i/c/d -/-/-/-
tho :
cor : S1S2 singular, e/g/m -/-/-
pulmo : symmetric, ves +/+, rh -/-, whe -/-
abd : flat, Bowel sound + normal, soepel, tympani
ext : AH ++/++ , OE --/--
Local status regio cruris dextra
I : dressing (+) elastic bandage, leakage (-), pus (-), bleed (-)
P : pain (+)

A/ Varicose veins grade II post op ligation and stripping varicose H-3

P/
Inj. Ceftriaxone 2x1 gr
Inj Antrain 3x1 gr
Inj Ranitidin 3x1 amp
Drip neurobion 5000 1x1
Venosmil tab 3x1
7-8-2018
S/ patient said there were no complaints
O/ general: cukup BP : 140/90 RR : 20x/menit
awareness: CM HR : 86x/mnt Tax : 36,5 °C
h/n : a/i/c/d -/-/-/-
tho :
cor : S1S2 singular, e/g/m -/-/-
pulmo : symmetric, ves +/+, rh -/-, whe -/-
abd : flat, Bowel sound + normal, soepel, tympani
ext : AH ++/++ , OE --/--
Local status regio cruris dextra
I : dressing (+) elastic bandage, leakage (-), pus (-), bleed (-)
P : pain (+)

A/ Varicose veins grade II post op ligation and stripping varicose H-4

P/
Inj. Ceftriaxone 2x1 gr
Inj Antrain 3x1 gr
Inj Ranitidin 3x1 amp
Drip neurobion 5000 1x1
Venosmil tab 3x1
8-8-2018
S/ patient said there were no complaints
O/ general: cukup BP : 140/80 RR : 18x/menit
awareness: CM HR : 80x/mnt Tax : 36,5 °C
h/n : a/i/c/d -/-/-/-
tho :
cor : S1S2 singular, e/g/m -/-/-
pulmo : symmetric, ves +/+, rh -/-, whe -/-
abd : flat, Bowel sound + normal, soepel, tympani
ext : AH ++/++ , OE --/--
Local status regio cruris dextra
I : dressing (+) elastic bandage, leakage (-), pus (-), bleed (-)
P : pain (+)

A/ Varicose veins grade II post op ligation and stripping varicose H-5

P/
Inj. Ceftriaxone 2x1 gr
Inj Antrain 3x1 gr
Inj Ranitidin 3x1 amp
Drip neurobion 5000 1x1
Venosmil tab 3x1
THANK YOU