MANAGEMENT OF VARICOSE VEINS WHEN & HOW BY DR.G.THULASIKUMAR M.S.(Gen.Surg) M.Ch. (Vascular Surgery) Department of Vascular Surgery Govt. Kilpauk Medical.

MANAGEMENT OF VARICOSE VEINS MANAGEMENT OF VARICOSE VEINS

WHEN & HOWWHEN & HOW

BYDR.G.THULASIKUMAR

M.S.(Gen.Surg) M.Ch. (Vascular Surgery)Department of Vascular Surgery

Govt. Kilpauk Medical College HospitalChennai-10

Votive offerings such Votive offerings such as these were given to as these were given to physicians by grateful physicians by grateful

patients after patients after successful treatmentsuccessful treatment

Chronic venous diseaseChronic venous disease

Most common vascular disorder3 Billion US dollars spent a year for

treatment3 % of the total Heath care Budget2 million USA work days lost per year

DEFINITIONDEFINITION

A VEIN THAT BECOMES ELONGATED,

DILATED, TORTUOUS, POUCHES AND

THICKENED DUE TO DYSFUNCTIONING

VALVES CAUSING CONTINOUS

DILATATION UNDER PRESSURE .

DefinitionDefinition

Telangiectasias - are a confluence of dilated intradermal venules less than one millimeter in diameter.

Reticular veins - are dilated bluish subdermal veins, one to three millimeters in diameter. Usually tortuous.

Varicose veins - are subcutaneous dilated veins three millimeters or greater in size. They may involve the saphenous veins, saphenous tributaries, or nonsaphenous superficial leg veins.

Subcutaneous VeinsSubcutaneous Veins

When abnormal: - Telangiectasia

(spider – 1mm) - Reticular (1- 3

mm)

Varicose (>3mm)

Abnormal VeinsAbnormal Veins

Telangiectasias

Reticular veins

Varicose vein

INCIDENCEINCIDENCE

MEN : 10-15%WOMEN : 20-25%

WHEN NON SAPHENOUS VARICOSITIES ARE INCLUDED

MEN : 45% WOMEN : 50%

RISK FACTORS

FEMALE GENDER

ADVANCED AGE

CAUCASIAN RACE

FAMILY HISTORY

ACCELERATORS

PREGNANCY

OBESITY

VENOUS SYSTEM OF LOWER LIMBSVENOUS SYSTEM OF LOWER LIMBS

SUPERFICIAL VEINSDEEP VEINSPERFORATORS

SUPERFICIAL VEINSSUPERFICIAL VEINS

LONG SAPHENOUS SYSTEMSHORT SAPHENOUS SYSTEM

LONG SAPHENOUS SYSTEMLONG SAPHENOUS SYSTEM

FROM MEDIAL LIMB THE DORSAL ARCH TO SAPHENOUS OPENING – SAPHENO FEMORAL JUNCTION

SFJ TRIBUTARIES

SUPERFICIAL EPIGASTRIC VEINSUPERFICIAL EXTERNAL PUDENDAL VEINSUPERFICIAL LATERAL CIRCUMFLEXILIAC VEIN.

THIGH TRIBUTARIES

ANTEROLATERAL VEINPOSTEROMEDIAL VEIN

CALF TRIBUTARIES

ANTERIOR ARCH VEINPOSTERIOR ARCH VEIN

SHORT SAPHENOUS SYSTEM

SAPHENO POPLITEAL JUNCTION

BRANCHES

LATERL CALF VEIN

MEDIAL CALF VEIN

VEINS CONNECTING LSV & SSVLATERAL THIGH VEIN

INTER SAPHENOUS VEIN

ACCOMPANYING NERVESLSV – SAPENOUS NERVE

SSV – SURAL NERVE

PerforatorsPerforators

Connect deep and superficial systems

Flow normally from superficial to deep

PERFORATORSPERFORATORS

LSV PERFORATORSTHIGH –

DODD’S GROUPHUNTER’S PERFORATORDODD’S PERFORATING

VEINHACH PERFORATING VEIN

•USUALLY DOUBLE•1-2mm IN DIAMETER•UPWARD DIRECTION FROM THEIR SUP.VEIN

PERFORATORSPERFORATORS

BELOW KNEEBOYD’SSHERMAN’S - 24cmCOCKETT’S - III---18cm

II---12cm I--- 6cm

CALF PERFORATORSGASTROCNEMIUS (MAY’S)SOLEUS PERFORATORSBASSI’S VEIN- PERONEAL TO LSVFIBULAR

FOOT PERFORATORSKUSTER-------MARGINALBELOW MEDIAL + LATERALMALLEOLI

VALVESVALVES

PHYSIOLOGYPHYSIOLOGY

VIS A TERGO—LV CONTRACTION

VIS A FONTE---R A CONTRACTION

FOOT MUSCLE PUMPFOOT MUSCLE PUMP

DEEP PLANTAR ARCH

SUPERFICIAL DORSAL ARCH

BOW STRING EFFECT - FLATTENS BOTH ARCHES EMPTYING

VEINS PRESSURE > 100mg OF Hg CONTRIBUTES > 50% BLOOD LEAVING

CALF

Muscle Pump Muscle Pump CALF MUSCLE PUMP

– 200 – 300 mm OF Hg– >80 ml OF BLOOD

Contractions propel blood towards heart

Relaxation draws blood from

- superficial veins

- lower deep veins

Thoracoabdominal PumpThoracoabdominal Pump

Inspiration decreases intrathoracic pressure promoting venous return

Expiration reverses the process

Findings easily seen in US

REFILLING THE PUMPREFILLING THE PUMP

FROM ARTERIAL SYSTEM FROM SUPERFICIAL VENOUS SYSTEM

PRESSURE IN ERECT POSTURE >100mg OF Hg

INTRAVENOUS PRESSURE IN SUPINE POSTURE SELDOM < 5mm OF Hg

REFILLING TIME 20-30 S

AMBULATORY VENOUS PRESSUREAMBULATORY VENOUS PRESSURE

RESIDUAL VENOUS PRESSUREVIS –A-TERGO 0.3mm OF HgHYDROSTATIC PRESSURE 100mm

OF HgAVP (MINIMUM PRESSURE. SHOWN

DURING EXERCISE) – FALLS BY 60-80% IN FEW SECONDS.

IN CVI / CVHIN CVI / CVH

VALVULAR INCOMPETENCE

CONTINUED REFLUX

INCREASED AVP DURING EXERCISE DUE TO INCOMPLETE EMPTYING

DECREASED REFILLING TIME <10S

INDEPENDENT(PRIVATE) CIRCULATION – BLOOD IN THE DEEP SYSTEM

FLOWS UP IN THE DEEP SYSTEM

FLOWS DOWN IN THE SAPHENOUS SYSTEM

PATHOPHYSIOLOGY OF MICROCIRCULATION CHANGES IN PATHOPHYSIOLOGY OF MICROCIRCULATION CHANGES IN VENOUS HYPERTENSIONVENOUS HYPERTENSION

PRIMARY VARICOSE VEINS DEEP VENOUS INSUFFICIENCY

AMBULATORY VENOUS HYPERTENSION

VENULAR AND CAPILLARY DILATATIONDECREASED CAPILLARY PERFUSION PRESSUREINCREASED CAPILLARY PERMEABILITY

CHRONIC LYMPHATIC DAMAGE

DECREASED LYMPHATIC DRAINAGE

PATHOPHYSIOLOGY OF MICROCIRCULATION CHANGES IN PATHOPHYSIOLOGY OF MICROCIRCULATION CHANGES IN VENOUS HYPERTENSIONVENOUS HYPERTENSION

WBC TRAPPING, ADHESION, ACTIVATION

MACROMOLECULES ENTER CIRCULATION

IMPAIRED TISSUE PERFUSION AND OXYGENATION

VENOUS ULCERATION

DECREASED LYMPHATIC DRAINAGE

IMPEDANCE OF MICROCIRCULATORY FLOW PLUS RELEASE FREE RADICALS, PROTEOLYTIC ENZYMES, CYTOKINES AND CHEMOTACTIC AGENTS

PERICAPILLARY FIBRIN CUFF

CLINICAL EVALUATIONCLINICAL EVALUATION

ASYMPTOMATIC COSMETIC

SYMPTOMATIC– PAIN & SWELLING– COMPLICATION

SYMPTOMSSYMPTOMS PAIN

– THROBBING– ACHING– STINGING– BURNING– EXERCISE – VARIABLE EFFECT ON PAIN– NIGHT PAIN—CRAMPINESS

ITCHING SKIN CHANGES COMPLICATIONS EFFECTS OF PREVIOUS TREATMENTS.

ComplicationsComplications EXTREMELY PAINFUL

ULCERS - NEAR VARICOSE VEINS, PARTICULARLY NEAR THE ANKLES.

BROWNISH PIGMENTATION USUALLY PRECEDES THE DEVELOPMENT OF AN ULCER.

OCCASIONALLY, VEINS DEEP BECOME ENLARGED.

BLEEDING SUPERFICIAL

THROMBOPHLEBITIS

PERSONAL HISTORY

PREGNANCY MENSTURAL CYCLE PELVIC CONGESTION SYNDROMES

– (VULVOPUDENDAL VARICES ASSOCIATED WITH PELVIC & OVARIAN VARICES

PAST MEDICAL HISTORY

CONGESTIVE FAILURE RENAL & CIRCULATORY FAILURE AUTOIMMUNE DISEASES ALLERGIC HISTORY HOSPITALISATION AND IMMOBILISATION

STRONG FAMILIAL COMPONENT STRONG FAMILIAL COMPONENT

Not well studiedTwin studies 75% identical, 52% non

identicalIf both parents VVS - 90% of children VVsIf one parent was affected 25 percent for

men and 62 percent for women

Cornu-Thenard, A, Boivin, P, Baud, JM, et al. Importance of the familial factor in varicose disease. Clinical study of 134 families. J Dermatol Surg Oncol 1994; 20:318.

PHYSICAL EXAMINATIONSPHYSICAL EXAMINATIONS STANDING POSITION SKIN SHOULD BE INSPECTED,TAPPED,

TOUCHED, PRESSED & SQUEEZED

EVALUATION FOR:– COLOR– TEMPERATURE– TEXTURE– TURGOR– MOISTURE– HAIR QUALITY

SKIN CHANGESSKIN CHANGES

CORONAPHLEBECTATICA

VENOUS ECZEMA

BROWN HAEMOSIDERIN DEPOSITION

ACUTE/CHRONIC LIPODERMATO SCLEROSIS

INDURATION

ATROPHIC BLANCHE

OEDEMA

VENOUS ULCERATION

CONTRACTURES

MARJOLINS ULCER

VARICOSITIESVARICOSITIES

SPIDER NAEVI—TELENGIECTASIA

RETICULAR VEIN—VENULECTASIS

TRUNCAL VARICOSITIES

CLINICAL TESTSCLINICAL TESTS

TO KNOW

WHICH SYSTEM

WHICH PERFORATOR

PATENCY OF DEEP VEIN

TRENDELENBURG TEST I & IITRENDELENBURG TEST I & II

SCHWARTZ TEST (CRUVHEILLIER’S SIGN)SCHWARTZ TEST (CRUVHEILLIER’S SIGN)

MORISSEY’S COUGH IMPULSEMORISSEY’S COUGH IMPULSE

FEGAN’S METHOD. (PHALEN’S TEST)FEGAN’S METHOD. (PHALEN’S TEST)

PRATT’S TESTPRATT’S TEST

THREE TOURNIQUET TEST THREE TOURNIQUET TEST ((Mahorne-ochsner Mahorne-ochsner ))

PERTHE’S TESTPERTHE’S TEST

PHYSICAL EXAMINATIONPHYSICAL EXAMINATION

ABDOMINAL PELVIC EXAMINATION. AUSCULTATION.

CEAP CLASSIFICATIONCEAP CLASSIFICATION

CLINICALETIOLOGICANATOMICPATHOPHYSIOLOGIC

CLINICAL CLASSIFICATIONCLINICAL CLASSIFICATION

CO NO SIGN OF VENOUS DISEASE

C1 TELENGIECTASIA AND SPIDER VEINS

C2 VARICOSE VEINS

C3 EDEMA DUE TO VENOUS DISEASE

C4 SKIN CHANGES; LIPODERMATOSCLEROSIS

C5 HEALED ULCERS

C6 ACTIVE ULCERS

ETIOLOGICETIOLOGIC

CONGENITAL ECPRIMARY EPSECONDARY ES

POST THROMBOTIC POST TRAUMATIC OTHERS

ANATOMIC SEGMENTS 18ANATOMIC SEGMENTS 18

SUP VEINS As1. LSV2. ABOVE KNEE3. BELOW KNEE4. SSV5. NON

SAPHENOUS

DEEPVEIN Ad

6. IVC16. MUSCULAR

PERFORATING VEIN Ap17. THIGH18. CALF

PATHOPHYSIOLOGIC CLASSIFICATIONPATHOPHYSIOLOGIC CLASSIFICATION

REFLUX PrOBSTRUCTION PoREFLUX & OBSTRUCTION Pro

INVESTIGATIONSINVESTIGATIONSCONTINUOUS WAVE DOPPLERCONTINUOUS WAVE DOPPLER

TO ASSES FLOW DIRECTION

QUALITATIVE ASSESSMENT OF VENOUS

REFLUX

DOES NOT GIVE ANY ANATOMIC

INFORMATION.

USEFUL FOR EVALUATION OF REFLUX IN

SFJ & SPJ

DUPLEX SCANNINGDUPLEX SCANNING

84% SENSITIVITY

88% SPECIVICITY

DIRECT DETECTION OF VALVULAR REFLUX.

VISUALIZATION OF VALVE LEAFLET MOTION

QUANTIFY DEGREE OF INCOMPETENCE

Duplex UltrasonographyDuplex Ultrasonography Replaced

plethysmography and venography

- 7-10MHz linear transducer

- Exam sitting and standing

- Superficial and deep systems evaluated

- Physiologic reflux: < 0.5 sec

- Pathologic reflux: > 0.5 sec

PLETHYSMOGRAPHY

– VOLUME CHANGE OF LIMB

– SECONDARY TO CHANGES IN VENOUS

BLOOD FLOW

PRESSURE MEASUREMENTS

– TRANSMURAL PRESSURE

– AMBULATORY VENOUS PRESSURE

—43-year-old woman with varicose veins.

Lee W et al. AJR 2008;191:1186-1191

©2008 by American Roentgen Ray Society

—43-year-old woman with varicose veins.

Lee W et al. AJR 2008;191:1186-1191

©2008 by American Roentgen Ray Society

INVASIVE PROCEDURESINVASIVE PROCEDURES

1. ASCENDING PHLEBOGRAPHY

2. DESCENDING PHLEBOGRAPHY

3. CAVOGRAPHY

4. VARICOGRAPHY

ASCENDING PHLEBOGRAPHYASCENDING PHLEBOGRAPHY

GOLD STANDARD

ANATOMIC FEATURES OF THE VEINS

AND THEIR VALVES ARE OUTLINED

POST THROMBOTIC CHANGES

PERFORATORS – INCOMPLETLY

IDENTIFIED

DESCENDING PHLEBOGRAPHYDESCENDING PHLEBOGRAPHY

GRADE 0 NO EVIDENCE OF REFLUX

GRADE 1 MINIMAL REFLUX THRO 1 OR MORE

VALVE

GRADE 2 CONSIDERABLE REFLUX IN THE

THIGH

GRADE 3 GRADE 2 + LEAKAGE IN TO

POPLITEAL VEIN

GRADE 4 GRADE 3 + LEAKAGE IN TO CALF

VEIN.

VARICOSE VEINS MAYBE DUE TOVARICOSE VEINS MAYBE DUE TO

1) PRIMARY DISEASE OF LSV

2) 1 + PERFORATOR INCOMPETENCE

3) 2 + DEEP VEIN REFLUX DUE TO VALVULAR INCOMPETENCE

4) 2 + POSTTHROMBOTIC REFLUX OR OBSTRUCTION.

5) 4 + THROMBOTIC OCCLUSION OF ILIAC VEINS

TREATMENT OPTIONSTREATMENT OPTIONS

COMPRESSION THERAPY

PHARMACOTHERAPY

SCLEROTHERAPY

SURGICAL TREATMENT

SEPS (Subfascial Endoscopic Perforator Surgery)

LASER ABLATION

RADIOFREQUENCY ABLATION

COMPRESSION THERAPYCOMPRESSION THERAPY

ELASTIC COMPRESSION

- Bandage

- Stockings – Class II PASTE GAUZE (UNNA) BOOT CIRC AID ORTHOSIS INTERMITTENT PNEUMATIC

COMPRESSION

COMPRESSION THERAPYCOMPRESSION THERAPY Action

1. HEMODYNAMIC EFFECT

Increase venous blood flow Decrease venous blood volume Reduce reflux in diseased superficial and/or deep veins Reduce a pathologically elevated venous pressure

 2. EFFECT ON TISSUE

Reduce an elevated water content of the tissue Increase the drainage of nocious substances Reduce inflammation Sustain reparative processes Improve movement of tendons and joints 

ELASTOCREPE BANDAGEELASTOCREPE BANDAGE

GRADIENT COMPRESSION STOCKINGSGRADIENT COMPRESSION STOCKINGS Class I – 20–30(18-22) mmHg (Asymptomatic varicose)Class I – 20–30(18-22) mmHg (Asymptomatic varicose)

II – 30-40(23-32) mm Hg (Symptomatic varicose)II – 30-40(23-32) mm Hg (Symptomatic varicose)

III - 40–50(34-40) mm Hg ( For III - 40–50(34-40) mm Hg ( For

IV - 50 – 60 mm Hg Lymph Edema)IV - 50 – 60 mm Hg Lymph Edema)

INTERMITTENT PNEUMATIC COMPRESSIONINTERMITTENT PNEUMATIC COMPRESSION

NEW LEGGING ORTHOSIS (CIRC – AID)NEW LEGGING ORTHOSIS (CIRC – AID)

UNNA BOOTUNNA BOOT

PHARMACOLOGIC THERAPYPHARMACOLOGIC THERAPY

DIURETICS – limited use ZINC FIBRINOLYTIC AGENTS

STANOZOLOL – Androgenic steroid OXYPENTIPHYLLINE – Cytokine Antagonist

PHLEBOTROPHIC AGENTS– HYDROXY-RUTOSIDES

CALCIUM DOBESILATE TROXERUTIN

PHARMACOLOGIC THERAPYPHARMACOLOGIC THERAPY

HAEMORRHEOLOGIC AGENTS PENTOXIPHYLLINE ASPIRIN

FREE RADICAL SCAVENGERS TOPICAL ALLOPURINOL DIMETHYL SULFOXIDE

PROSTAGLANDINS PROSTAGLANDIN E PROSTAGLANDIN F

PHARMACOTHERAPYPHARMACOTHERAPY

TOPICAL THERAPIES– ANTIBIOTICS

Application counter-productive– IODOSORB– KETANSERINE– AMNION– OCCLUSIVE DRESSINGS

GROWTH FACTORS AND CYTOKINES SKIN SUBSTITUTES

– APLIGRAFT

SCLEROTHERAPYSCLEROTHERAPY

THE LOWEST APPROPRIATE CONCENTRATION AND VOLUME OF SOLUTION AT THE SLOWEST RATE AND LOWEST PRESSURE CAN MINIMISE COMPLICATIONS

SCLEROSANTSSCLEROSANTS

DETERGENT SOLUTIONS SODIUM TETRADECYL SULFATE POLIDACANOL SODIUM MORRHUATE ETHANOLAMINE OLEATE

OSMOTIC SOLUTIONS HYPERTONIC SALINE HYPERTONIC SALINE AND DEXTROSE SODIUM SALICYLATE

CHEMICAL IRRITANTS POLYIODINATED IODINE CHROMATED GYLCERINE

MicrosclerotherapyMicrosclerotherapy

30 g butterfly needle0.2% STSSeveral courses required

benefit compression

FOAM SCLEROTHERAPYFOAM SCLEROTHERAPY

TESSARI TECHNIQUE

1 PART (2ml) DETERRGENT & 4 PARTS AIR (8ml) AIR AGITTATED USING TWO 10 ml SYRIGES, CONNECTED BY A 2/3 WAY CONNECTOR

SURGICAL TREATMNETSURGICAL TREATMNET

GOAL: PERMANENT REMOVAL OF VARICOSITIES

WITH THE SOURCE OF VENOUS HYPERTENSION

AS COSMETIC A RESULT AS POSSIBLE MINIMUM NUMBER OF COMPLICATIONS

SAPHENOUS VEIN LIGATIONSAPHENOUS VEIN LIGATION

INCISION 1 CM ABOVE VISIBLE SKIN CREASE

TO DRAW EACH OF THE TRIBUTARIES INTO THE INCISION INORDER NOT TO LEAVE INTER ANASTOMOSING INGUINAL TRIBUTARIES BEHIND

TO AVOID EXTRAVASATION OF BLOOD SUBCUTANEOUSLY

TO INTRODUCE STRIPPER FROM ABOVE DAMAGED VALVES ALLOW PASSAGE

STAB AVULSION TO BE DONE BEFORE STRIPPING

SAPHENOUS VEIN LIGATION SAPHENOUS VEIN LIGATION – GROIN INCISION– GROIN INCISION

SAPHENOUS VEIN LIGATIONSAPHENOUS VEIN LIGATION

LSV

SHORT SAPHENOUS VEINSHORT SAPHENOUS VEIN

TO MARK TERMINATION IMMEDIATE PREOPERATIVELY

PRONE POSITION

POPLITEAL SPACE RELAXED BY KNEE FLEXION

SURAL N. IDENTIFIED AND PRESERVED

STRIPPING LIMITED TO PROXIMAL LESSER SAPHENOUS VEIN ABOVE MID-CALF

PERFORATOR VEIN INCOMPETENCEPERFORATOR VEIN INCOMPETENCE

LINTON’S RADICAL OPERATION SUBFASCIAL LIGATION– INCISION

– LONG MEDIAL

– ANTEROLATERAL

– POSTEROLATERAL CALF INCISIONS

COCKETT SUPRAFASCIAL LIGATION

DEPALMA– MULTIPLE PARALLEL BIPEDICLED FLAPS

– LIGATION OF VEINS ABOVE OR BELOW THE FASCIA

SEPS– SINGLE PORT TO VIEW AND WORK

– TWO PORTS – ONE TO VIEW; ANOTHER TO WORK

LINTON’S RADICAL OPERATION LINTON’S RADICAL OPERATION SUBFASCIAL LIGATIONSUBFASCIAL LIGATION

Sural N. Perforator V.

MODIFIED LINTON’S PROCDUREMODIFIED LINTON’S PROCDURE

TO AVULSE THE INCOMPETENT PERFORATORS UNDER DUPLEX GUIDANCE

SEPSSEPS

ABLATIVE PROCEDURESABLATIVE PROCEDURES

ENDO VENOUS THERMO ABLATION

- LASER

- RADIO - FREQUENCY

ENDOLUMINAL OBLITERATION BY HEAT - INDUCED COLLAGEN CONTRACTION & DENUDATION OF

ENDOTHELIUM - FIBROSIS

810 nm DIODE LASER ENERGYTUMUSCENT ANAESTHESIA

ADVANTAGENO GROIN DISSECTIONNO NEOVASCULARISATION

1470 nm DIODE LASER

ENDOVENOUS LASER SURGERY

EVLT – EEVLT – Endondovvenous enous LLaser aser TTreatmentreatment

RADIOFREQUENCY ABLATIONRADIOFREQUENCY ABLATION RADIOFREQUENCY INDUCED

THERMO THRAPY (RFiTT)

RADIOFREQUENCY ABVLATIONRADIOFREQUENCY ABVLATION

SEGMENTAL ABLATION

SURGERY FOR DEEP VEIN VALVE SURGERY FOR DEEP VEIN VALVE INCOMPETENCEINCOMPETENCE

VALVE RECONSTRUCTION INTERNAL VALVULOPLASTY EXTERNAL AND TRANSCOMMISURAL

VALVULOPLASTY ANGIOSCOPIC VALVULOPLASTY PROSTHETIC SLEEVE IN SITU

AXILLARY VEIN TRANSFER

SURGERY FOR CHRONIC VENOUS SURGERY FOR CHRONIC VENOUS HYPERTENSIONHYPERTENSION

SAPHENO POPLITEAL BYPASS MAY HUSNI OPERATION

CROSS PUBIC VENOUS BYPASS PALMA DALE PROCEDURE CONTRALATERAL SAPHENOUS VEIN IS USED

PROSTHETIC FEMOROCAVAL, ILIOCAVAL OR IVC BYPASS

ILIAC VEIN DECOMPRESSION

CAVOATRIAL BYPASS

ENDOVENOUSENDOVENOUS

ANGIOPLASTY AND STENTING OF STENOSED / OCCLUDED THROMBOSED ILIAC VEIN (MEY THURNER’S SYNDROME)

CORRECTION OF CONGENITAL WEBS