Update in Diagnosis and Treatment for Varicose Veins (Part 1-2)

(This Self Study Series was prepared by Dr. Tse Cheuk Chad, Specialist in General Surgery, Vascular Surgeon.)

Etiology (EC,P,S,N)

Four categories in this classification are: Congenital, Primary, Secondary, and None. Arteriovenous malformations represent an obvious congenital (C) etiology, it may be the uncommon conditions such as avalvulia (hereditary absence of venous valves). Secondary (S) designates any known cause of venous abnormality. Most commonly, it indicates veins that have been affected by thrombosis. Primary (P) refers to all others such as primary valvular reflux. None (N) indicates for no evident etiology of CVD.

Anatomy (AS,P,D,N)

Simple designation of one (or more) of the three major lower extremity anatomic venous systems (superficial, perforating, and deep veins) is sufficient to localize the site of the abnormality and will probably affect the treatment recommendations.

Pathophysiology (PR,O,R-O,N)

The veins may occur either reflux (R), obstruction (O), or in combination (R-O). Reflux is defined as reverse flow with a duration of >0.5 second by duplex analysis. Meanwhile, obstruction is defined objectively by imaging or noninvasive testing. (N) indicates no abnormality detected.

Duplex Ultrasound

Duplex Ultrasound is B-mode ultrasound with colour Doppler, usually done by using a high frequency (7.5-10MHz) transducer. It is noninvasive, and has evolved to become the most important imaging study for patients with varicose veins. Colour flow scanners allow direct visual representation of flow with a change of colour from red to blue depending on the flow is toward or away from the probe. Reflux is best demonstrated with the patient in the standing position. The duplex examination is essential in planning for treatment, and also important to identify the specific points of reflux so that treatment is appropriate and reduces the chance of recurrence.

Summary

This classification is targeted at all forms of venous insufficiency. Physicians in general practice should be aware that CVD consists of a spectrum of clinical manifestations, ranging from simple telangiectasias, to the commonly seen varicose veins and the debilitating venous ulcers. The transition from one clinical stage to the other is progressive, but the deterioration rate and symptoms depends on the underlying etiology, anatomy and pathophysiology. In the presence of minimally invasive options in addition to conventional surgery in treating CVD, treatment can now be tailored to individual patients based on their clinical status and symptoms. In the next issue, minimally invasive options will be discussed further.

Reference information: http://veno.com.hk
It is not intended as medical advice to any specific person. If you have any need for personal advice or have any questions regarding your health, please consult your doctor for diagnosis and treatment.

Update in Diagnosis and Treatment for Varicose Veins (Part 1-1)

(This Self Study Series was prepared by Dr. Tse Cheuk Chad, Specialist in General Surgery, Vascular Surgeon.)

Introduction
Venous disease has very diverse clinical presentation, ranging from simple spider veins, unsightly varicose veins to debilitating venous ulcer. All of these are now grouped under the term Chronic Venous Disorder (CVD). In the US, it is estimated that 10-35% of the adult population has some form of CVD. The problem is more common in women as a result of pregnancy and child bearing.

Although it is rarely a life- or limb-threatening problem, the disease greatly impacts quality of life. Many people affected are in their most productive years of life. They usually seek medical advice for cosmetic and health concerns.

This article will describe the current classification and diagnosis of CVD. Treatment with emphasis on minimally invasive therapy will be discussed in the next issue.

Classification of for Chronic Venous Disorder (CEAP)

The CEAP classification was introduced by the American Venous Forum in 1994 and was revised in 2004. It is now widely adopted around the world and is considered as the reporting standard for venous disease nowadays. The goal was to stratify clinical levels of venous insufficiency. The four categories selected for classification were: clinical state (C), etiology (E), anatomy (A), and pathophysiology (P). The CEAP classification helps to provide guidance in choosing the appropriate treatment for such patients.

The Clinical Classification (C1,2,3,4,5,6,A,S)

The Clinical classification is the foundation of the concept. The six CVD categories range from small, thread-like veins to edema, discoloration, induration, and ulceration. Each is clearly defined in Table 1.C-0 is appropriate for those individuals with objective evidence of venous disease (i.e. E,A, and/or P), but with no clinical manifestations. The extent of varicose disease, along with the other clinical findings is categorized in the severity score. For clinical class 4 is now subdivided into (a) pigmentation and/or eczema, and (b) lipodermatosclerosis and/or atrophie blanché, based upon observational survey data suggesting that lipodermatosclerosis or atrophie blanché (4b) was more likely to progress to more severe disease.

Subscripts are applied to designate S (symptomatic) from A (asymptomatic) limbs. Complaints qualifying for the S subscript include aches, pain, tightness, skin irritation, heaviness, muscle cramps, and other complaints that may be attributable to venous dysfunction.

(continue...)

Reference information: http://veno.com.hk
It is not intended as medical advice to any specific person. If you have any need for personal advice or have any questions regarding your health, please consult your doctor for diagnosis and treatment.

隱蔽的定時炸彈: 腹主動脈瘤(4)

如果有個動脈瘤……

超聲波檢查主動脈若是正常，不需要年年做，因為血管瘤不是一天長成的，可以隔5年，甚至10年再做，但若是檢查腹主動脈時發現有個小血管瘤，也不必恐慌，只要小於5cm，便沒有太大的破裂危險。醫學定義主動脈膨脹超過3cm才能稱為血管瘤，而血管瘤大約每年增大10%，舉例說現時是4cm，一年後便大約4.4CM，兩年便接近5cm。

預防

腹主動脈瘤是倨死亡率相當高的疾病，通常動脈瘤要膨脹至一定的大小才有機會摸得到。我們的主動脈直徑大約只有2-3cm，血管瘤的直徑若是高於5cm的話便有破裂可能，醫學界常以此為分界線，即是說超過5cm以上的血管瘤便需要醫療處理，而5cm以下則以監察為主。

治療腹主動脈瘤主要是手術，雖然現時的手術風險很低，但再安全的手術都存在一定風險。大部份人（尤其長者）都會認為主動脈瘤並非癌症，在身體內沒有危險性，不切冒險手術。

問題是，腹主動脈瘤是會隨著時間增大，大於5cm的腹主動脈瘤每年平均破裂率約為15%，醫生認為，平衡利害後，應考慮先做手術治療。

如果能早作預防，在破裂前手術，在良好醫療監控下，風險是可控的，亦免破裂時救治不及而迥成遺憾。

絕對值得的超聲波檢查

面對腹主動脈瘤的威脅，謝卓華醫生認為，以個人健康角度來考慮，反正我們每年都會做健康檢查，不妨多做一個腹部的超聲波。

「香港人對腹主動脈瘤的認識較少，所以警覺性不高，又因為沒有特別不適症狀，沒有對生活造成困擾，故此沒有主動做檢查的意欲。若是50歲以上，每年都會做簡單身體檢查，可以多做一個腹部的超聲波，檢查並不是只為看看有沒有腹主動脈瘤，亦可以看看肝膽情況，一舉多得。」

謝卓華醫生認為，做腹部的超聲波檢查可排除一些可以早期發現﹑致命卻又能根治的疾病。

腹主動脈瘤隱蔽性強，殺傷力高。超聲波檢查花費不大卻可有效檢測，是擁有高危因素，或是年紀不輕的人士，絕對值得做的檢查。

(完)

謝卓華 外科專科醫生

以上所提供的資訊僅作為教育及參考用途，如果你有任何醫療問題，

應向醫生查詢，而不應單倚賴以上提供的資料。資料來源:醫藥人 ISSUE 145

隱蔽的定時炸彈: 腹主動脈瘤(3)

動脈瘤是惡性腫瘤？
腹主動脈瘤雖然稱為「瘤」，但並不是惡性腫瘤，動脈瘤只是血管壁脹大所致而非細胞轉變成為會擴散至其他器官組織的惡性細胞，與坊間所理解的「瘤」等如癌症並不相同，不過，殺傷力卻一點也不遜於癌症。腹主動脈瘤最大的危險是破裂後會大量出血，可以短時間內奪命。

症狀

事實上在未破裂之前，腹主動脈瘤通常是沒有症狀的，所以常被患者忽略，要察覺腹主動脈瘤很大程度需要患者自我警覺。當腹主動脈瘤長到一定大小時，有些患者是可以在腹部肚臍附近用手觸摸得到，最常見是晚間靜止時候，平躺在床上時可發現一個隨著心臟速度跳動的硬塊，但若是主動脈瘤的體積只有3-4cm的話，則較難察覺。而且，身形若是較為肥胖的患者，通常都是觸摸不到。除或可能摸得到之外，主動脈瘤沒有其他特異症狀，只有在接近破裂之前，患者會出現肚痛或是背痛。

半急症與急症

香港的急症室通常分急症與分急症，腹主動脈瘤可說是急中之急，由破裂出血而至死亡的時間非常短。急症室對緊急病症，例如腹主動脈瘤這一類疾病具有相當高的警覺，病人若出現腹部劇痛﹑低血壓暈厥這些主動脈瘤破裂症狀，急症人員會即時為病人做超聲波檢查，其中包括主動脈，若發現主動脈大於正常，便會立即安排檢查或手術。

若是患者已經有確診腹主動脈瘤的病史而出現肚痛﹑背痛症狀，在醫療處理上會判別為半急症，需盡快處理。如果已開始出血，患者會感到劇痛，則是非常緊急的急症。

不過，當病人被送到急症室，就算醫護人員如何爭分奪秒，過程如何毫無耽誤，病人被送進手術室，可能都需要半個小時，有些病人很可能已經等不及。

曾經有調查研究腹主動脈瘤破裂後的存活率，發現部分患者根本來不及送院便已死亡，而能夠到達醫院且趕及送進手術室的，就算手術完善進行，死亡率仍高達40-50%。

＊腦血管瘤：腦血管瘤亦很常見，但發病群組與腹主動脈瘤並不一樣，腦血管瘤與血管硬化關係不大，與年齡關係亦不大，故此腦血管發病的病人群組與腹主動脈瘤的並不相同。

高危因素
臨床上，腹主動脈瘤要長到一定大小才會出現症狀，醫生才有可能抉到，但如果沒有症狀的話，無論病人或是醫生都很難從表面偵察它的存在。想知道是否有腹主動脈瘤很白簡單，只要做個超聲波檢查便可知道，如果具有以下高危因素就應做檢查了。

l   高齡（６０歲以上）

l   高血壓

l   高膽固醇

l   糖尿病

l   抽煙

對於腹主動脈瘤的預防，香港較為落後，英國很早已實行全民篩檢，條件是60歲以上男性，有吸煙習慣，建議進行超聲波檢查望動脈。這是因為英國政府認為與其投放資源在腹主動脈瘤破裂後挽救生命，不如投放資源作為預防，減低死亡率之餘亦減少命失去對社會造成損失。

(續...)


謝卓華 外科專科醫生

以上所提供的資訊僅作為教育及參考用途，如果你有任何醫療問題，

應向醫生查詢，而不應單倚賴以上提供的資料。資料來源:醫藥人 ISSUE 145

腹主動脈瘤治療 (下)

跟進與監察

血管腔內手術也有局限性，因為支架中含有金屬，用久之後有機會出現金屬疲勞情況，現時所設計的支架大概可用７－１０年，太久便有機會出現鬆脫滲漏，需定時監察修補。

雖然開腹手術換血管可維持較長年期，但一般血管疾病的患者以長者居多，與其承受大型手術的風險，置入金屬支架的使用期雖然短，對年邁長者來說可能更為適合。另一方面，對於較年輕患者，例如只有４０歲，微創手術或許不及開腹手術切底。因為開腹手術置換人造血管雖然風險較高，卻沒有鬆脫滲漏等等的長遠隠憂。所以若是遇上這類病人，醫生需與病人詳細解釋手術的優缺，從而作最好的選擇。

一般若是急症進入急症室，如果情況太過緊急，就是患者適合做微創手術，但醫護人員也許趕不及在短時間內為患者尋覓適合支架，所以開腹手術仍有存在的價值。

無論是開腹手術或是微創手術，都必須定期監察，開腹手術若是情況理想，在完全康復後，或可減少覆診次數，但微創置入支架一類，則需要終身覆診，因而置入的支架隨著時間愈長，總可能有些小問題出現，所以需要定期監察，每年做一次電腦掃描以確定有沒有充血滲漏。傳統的開腹手術則無此需要。

積極面對疾患

由於腹主動脈瘤屬於慢性疾病，終身僅需檢測一兩次，若檢測出有罹患的前兆，就必須每年定期追蹤。腹主動脈瘤雖然可怕，只有生活作息規律，定時定量運動，飲食注意少油少鹽少糖，控制血脂﹑血糖與血壓水平，應可避免腹主動脈瘤的威脅。不過，就是罹患腹主動脈瘤也毋須恐慌，亦毋須逃避，定期追蹤，生活也可與一般人無異。及早檢查，樂觀面對，積極治療，是維持健康的最佳方法。

資料來源: veno.com.hk

以上所提供的資訊僅作為教育及參考用途，如果你有任何醫療問題，

應向醫生查詢，而不應單倚賴以上提供的資料。

腹主動脈瘤治療 (上)

開腹手術VS腔內手術

腹主動脈瘤在初期並不會對身體產生危害，但是當長大至一定程度時，就會有破裂危險，一旦主動脈瘤破裂，會造成大量失血，若未及送院，死亡率高達９０％，即使在主動脈瘤破裂後即時就醫，仍有機會產生呼吸衰竭﹑中風等併發症，死亡機率亦高達４０－５０％。

腹主動脈瘤我危害相當高，有人稱之為腹中的定時炸彈，一般無病徵，只在瀕臨破裂時才見腹痛﹑背痛。
現時沒有藥物可作預防，治療亦只有手術一途。如果在普通檢查中早已發現主動脈瘤，患者必須戒煙，如有高血壓﹑高膽固醇及糖尿病之類，必須使用相關藥物治療，控制誘發腹主動脈瘤的底因。

如果腹主動脈瘤的直徑大於５ｃｍ﹑主動脈已經破裂﹑主動脈即將破裂，或是患者持續性地出現胸痛﹑背痛或腹痛等等，必須手術治療。

若準備手術，醫生需要關於患者動脈瘤更多詳盡的資料來幫助手術進行，患者除了要做超聲波檢查之外，亦需要做電腦掃描。治療手術分開腹式及微創兩大類。

傳統開腹手術

傳統開腹手術是治療腹主動脈瘤的標準手術，亦是最廣為使用的手術。
一般由腹部中央進入，先在腹部切開一道約２０公分長度的切口，在主動脈上找出血管瘤，然後切除，再換上口徑大小及長度適合的人造血管，用以代替切除的主動脈血管，重建動脈血流之後縫合傷口。簡單來說，就是把舊血管移除，換上人造血管，如手術良好，人造血管可供多年使用。

傳統開腹手術的好處是重置新血管，避免主動脈瘤繼續擴大或是破裂的危險，缺點是手術創傷大，病人需要接受深度麻醉及剖腹，而且手術時間長，復原期亦長，對患者的身體要求較高，長者或是體弱患者的風險較大，就是可以手術，亦容易出現併發症。

現時傳統的開腹手術已經非常完善，死亡率大約為４％。

血管腔內手術

血管腔內手術(Endovascular Surgery)，亦稱為主動脈瘤修復手術(Endovascular Aneurysm Repair)，是較新的微創手術，即是在動脈血管腔內放進支架，目的是隔阻血流進入動脈瘤，使動脈瘤不再脹大。手術需全身麻醉，不需開腔剖腹，只要在病患者的大腿（腹股溝位置）切開一個切口，從股動脈進入，注射顯影劑，再放進導線與導管等儀器，在Ｘ光引導下在動脈血管瘤內置入支架，並固定在血管腔內。

血管腔內手術並沒有移除動脈瘤，而是把人造血管（支架）奪在血管之內，這樣血流便不會衝擊動脈血管，血流不經過動脈瘤，便不會有膨脹破裂的危險，假以時日，動脈瘤或會變小。

血管腔內手術的優點是無需開腹，傷口小，失血量亦小，疼痛亦較輕，大幅降低手術併發症的風險，死亡率約為１％，康復及住院時間亦大大縮短。

微創手術因為創口小，減低病人內臟器官產生併發症的可能，對高齡長者又兼有慢性疾病者尤有助益。在腹主動脈瘤患者來說，微創手術是較為優先的考慮。但是，亦並非所有患者皆可以或適合做微創手術，有個別情況是不能放置支架的，例如動脈血管太過彎曲，或動脈瘤的形狀不能鞏固支架或不適宜罝入支架等便不適合使用，否則可能有滲漏或不穩問題。

(續...)

資料來源: veno.com.hk

以上所提供的資訊僅作為教育及參考用途，如果你有任何醫療問題，

應向醫生查詢，而不應單倚賴以上提供的資料。

Varicose Veins

1. What are varicose veins?Veins are the blood vessels that carry blood back to the heart. Varicose veins are abnormally enlarged and tortuous veins that are visible just below the surface of the skin. Smaller veins in the skin itself are sometimes called ‘thread veins’ or ‘spider veins’. Sometimes, spider veins can also be due to underlying varicose veins. It is advisable to seek medical advice for these conditions before complications arise.

2. What causes varicose veins?Varicose veins are due to weakness in the wall of superficial veins, and this leads to stretching. The stretching causes failure of the one-way valves inside the veins. These valves normally only allow the blood to flow up the leg towards the heart. If the valves leak, then blood can flow back the wrong way when standing. This reverse flow (venous reflux) causes increased pressure on the veins, which bulge and become varicose. They may also be caused by occupations that require prolonged standing or weight bearing which increase pressure on the leg veins. They often appear during pregnancy and while they may become less prominent in the weeks after delivery, they tend not to disappear completely. Varicose veins often run in families (the precise form of inheritance is not well understood) and as you get older, they are more likely to occur.

3. How common are varicose veins?Approximately 50 per cent of the population has some form of venous disease, and varicose veins affect up to 15 per cent of all adults. Both men and women can get varicose veins.

4. What problems do varicose veins cause?The raised pressure in the vein system caused by the leaky valves frequently gives rise to aching, throbbing, itching and a feeling of fullness. Inflammation and bleeding from the veins can occur if they are traumatised. The increased pressure can sometimes cause complications such as eczema, brown discolouration, ulceration and scarring.

5. How is the diagnosis of varicose vein make?Besides the requirement of a detailed patient history and physical examination by a specialist doctor, a Duplex Ultrasound Vein Scan can accurately map the anatomy and function of your veins and determine how best to treat them. This is a painless investigation that is performed with the patient standing.

6. What can be done about my varicose veins?Many different treatments are available for varicose veins. No two patients' varicose veins are quite the same so treatment plans should be tailor-made by a specialist doctor who is experienced in treating leg veins.

Reference information: http://veno.com.hk
It is not intended as medical advice to any specific person. If you have any need for personal advice or have any questions regarding your health, please consult your doctor for diagnosis and treatment.

Spider Veins

1. What are Spider Veins?Spider veins or thread veins are red and purple blood vessels that occur in patches on the legs and face. They look like small spider webs, which is how they get their name. Spider and varicose veins are not the same condition. Varicose veins are large, swollen veins usually affecting the legs, whereas spider veins are delicate and tend to develop in clusters

2. Why do I got spider veins?Spider veins can be isolated or associated with ‘feeder’ veins or venous reflux due to leaky valves. Women develop spider veins nearly four times as frequently as men. About 70 per cent of adult women are afflicted with spider veins at some time in their lives. Spider veins appear to be hormonally induced and often are associated with pregnancy and use of the oral contraceptive pill.

3. Do spider veins need to be treated?
Spider veins do not usually pose any major health problems. However, they may cause aching and discomfort especially when associated with underlying varicose veins. In rare cases, they may be a result of serious liver or other intra-abdominal problems.


Many women do find spider veins unsightly and prefer to have them treated.

4. Is there any treatment for my spider veins?
a) Sclerotherapy involves the use of a very fine needle to inject a solution (sclerosant) directly into the affected vein. The solution causes the lining of the vein to swell and eventually seals off the diseased blood vessel.

Each vein may require several injections and most disappear in two weeks to two months. Following each treatment, we suggest the wearing of medium support tights for approximately two to three weeks.


b) Transcutaneous Radiofrequency This is a treatment for the tiny spider veins at the very surface of skin. The principle is based on the use of a very high frequency wave (4 million Hertz), which causes a thermocoagulation to the spider veins, with subsequent disappearance of the veins.


Reference information: http://veno.com.hk
It is not intended as medical advice to any specific person. If you have any need for personal advice or have any questions regarding your health, please consult your doctor for diagnosis and treatment.