Trendelenburg operation flush ligation varicose veins surgery steps perforators

Medical educational diagram comparing GSV (Great Saphenous Vein) stripping surgery vs modern minimally-invasive varicose vein techniques. Clean clinical illustration style on white background. LEFT SIDE - labeled "Open Surgery: GSV Stripping (Trendelenburg)" showing: - Anatomical leg outline with femoral vein, great saphenous vein running full length - Groin incision marker with label "Oblique groin incision" - Saphenofemoral junction with flush ligation shown (ligature tied flush at femoral vein, no stump) - Six tributaries labeled and tied off (superficial epigastric, circumflex iliac, pudendal veins) - Stripper instrument (flexible rod) inside the GSV running from groin to knee - Second small incision at knee labeled "Ankle/knee incision" - Arrow showing vein being pulled out downward - Small marks along leg showing perforator ligation sites - Steps numbered 1-5: 1) Groin incision, 2) Dissect & ligate tributaries, 3) Flush SFJ ligation, 4) Pass stripper, 5) Strip vein + perforator ligation RIGHT SIDE - labeled "Minimally Invasive Techniques" with three sub-panels: Panel A "Endothermal Ablation (EVLA/RFA)": - Leg outline showing laser/RF catheter inserted via needle puncture at knee - Catheter tip shown inside GSV with heat waves/energy symbol - Tumescent anaesthesia infiltration shown around vein - Result: vein wall destroyed and fibrosed (shown as collapsed vein) - Label: "No incision - catheter only" Panel B "Foam Sclerotherapy": - Syringe injecting foam into varicose vein - Foam bubbles shown displacing blood inside vein - Chemical irritation symbol causing vein wall inflammation - Result: vein obliterated Panel C "Endovenous Glue": - Small catheter with cyanoacrylate glue drops - Compression applied over vein - Vein sealed shut BOTTOM comparison table with 4 rows: Anaesthesia | Incisions | Recovery | Recurrence rate Columns: Open Surgery vs EVLA/RFA vs Sclerotherapy vs Glue Color coding: Open surgery in warm red/orange tones, minimally invasive in cool blue/teal tones. Professional medical textbook illustration quality.

mkdir -p /home/daytona/workspace/varicose-vein-guide && ls /home/daytona/workspa…

~/varicose-vein-guide/build_pdf.py

from reportlab.lib.pagesizes import A4
from reportlab.lib import colors
from reportlab.lib.styles import getSampleStyleSheet, ParagraphStyle
from reportlab.lib.units import cm, mm
from reportlab.platypus import (
    SimpleDocTemplate, Paragraph, Spacer, Table, TableStyle,
    HRFlowable, KeepTogether, PageBreak
)
from reportlab.platypus.flowables import HRFlowable
from reportlab.lib.enums import TA_LEFT, TA_CENTER, TA_JUSTIFY
from reportlab.pdfbase import pdfmetrics
from reportlab.pdfbase.ttfonts import TTFont
import os

OUTPUT = "/home/daytona/workspace/varicose-vein-guide/Varicose_Vein_Surgery_Reference_Guide.pdf"

# ── Colour palette ──────────────────────────────────────────────────────────
DARK_BLUE   = colors.HexColor("#1A3A5C")
MID_BLUE    = colors.HexColor("#2E6DA4")
LIGHT_BLUE  = colors.HexColor("#D6E8F7")
ACCENT_RED  = colors.HexColor("#C0392B")
ACCENT_TEAL = colors.HexColor("#1A7A6E")
GOLD        = colors.HexColor("#D4A017")
LIGHT_GREY  = colors.HexColor("#F4F6F8")
MID_GREY    = colors.HexColor("#BDC3C7")
TEXT_DARK   = colors.HexColor("#1C2833")
WHITE       = colors.white

# ── Document setup ───────────────────────────────────────────────────────────
doc = SimpleDocTemplate(
    OUTPUT,
    pagesize=A4,
    leftMargin=2*cm, rightMargin=2*cm,
    topMargin=2.2*cm, bottomMargin=2.2*cm,
    title="Varicose Vein Surgery: Complications & Management Reference Guide",
    author="Orris Medical Reference",
    subject="Surgical Reference Guide"
)

W = A4[0] - 4*cm   # usable width

# ── Styles ───────────────────────────────────────────────────────────────────
styles = getSampleStyleSheet()

def S(name, **kw):
    return ParagraphStyle(name, **kw)

cover_title = S("CoverTitle",
    fontSize=28, textColor=WHITE, alignment=TA_CENTER,
    leading=36, spaceAfter=8, fontName="Helvetica-Bold")

cover_sub = S("CoverSub",
    fontSize=14, textColor=colors.HexColor("#AED6F1"),
    alignment=TA_CENTER, leading=20, spaceAfter=4, fontName="Helvetica")

cover_note = S("CoverNote",
    fontSize=10, textColor=colors.HexColor("#D5D8DC"),
    alignment=TA_CENTER, leading=14, fontName="Helvetica-Oblique")

h1 = S("H1",
    fontSize=16, textColor=WHITE, fontName="Helvetica-Bold",
    leading=20, spaceBefore=4, spaceAfter=4, leftIndent=0)

h2 = S("H2",
    fontSize=12, textColor=DARK_BLUE, fontName="Helvetica-Bold",
    leading=16, spaceBefore=10, spaceAfter=4)

h3 = S("H3",
    fontSize=10.5, textColor=ACCENT_TEAL, fontName="Helvetica-Bold",
    leading=14, spaceBefore=8, spaceAfter=2)

body = S("Body",
    fontSize=9.5, textColor=TEXT_DARK, fontName="Helvetica",
    leading=14, spaceBefore=2, spaceAfter=4, alignment=TA_JUSTIFY)

bullet = S("Bullet",
    fontSize=9.5, textColor=TEXT_DARK, fontName="Helvetica",
    leading=13, leftIndent=14, spaceBefore=1, spaceAfter=1,
    bulletIndent=4, alignment=TA_LEFT)

warn = S("Warn",
    fontSize=9.5, textColor=colors.HexColor("#7B241C"),
    fontName="Helvetica-Bold", leading=13, leftIndent=14,
    spaceBefore=1, spaceAfter=1)

caption = S("Caption",
    fontSize=8, textColor=colors.HexColor("#626567"),
    fontName="Helvetica-Oblique", leading=11, alignment=TA_CENTER,
    spaceBefore=2, spaceAfter=6)

footer_style = S("Footer",
    fontSize=7.5, textColor=colors.HexColor("#7F8C8D"),
    fontName="Helvetica", leading=10, alignment=TA_CENTER)

# ── Helper builders ───────────────────────────────────────────────────────────

def section_header(title, color=DARK_BLUE):
    """Blue banner for a section title."""
    tbl = Table([[Paragraph(title, h1)]], colWidths=[W])
    tbl.setStyle(TableStyle([
        ("BACKGROUND", (0,0), (-1,-1), color),
        ("TOPPADDING",    (0,0), (-1,-1), 6),
        ("BOTTOMPADDING", (0,0), (-1,-1), 6),
        ("LEFTPADDING",   (0,0), (-1,-1), 10),
        ("RIGHTPADDING",  (0,0), (-1,-1), 10),
        ("ROUNDEDCORNERS", [4]),
    ]))
    return tbl

def sub_header(title):
    return Paragraph(title, h2)

def info_box(title, lines, bg=LIGHT_BLUE, title_color=DARK_BLUE):
    """Coloured box with title + bullet content."""
    title_para = Paragraph(title, ParagraphStyle("IB_T",
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    content = [title_para, Spacer(1, 4)]
    for l in lines:
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    inner = Table([[c] for c in content], colWidths=[W - 24])
    inner.setStyle(TableStyle([
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        ("BOTTOMPADDING", (0,0), (-1,-1), 1),
        ("LEFTPADDING",   (0,0), (-1,-1), 0),
        ("RIGHTPADDING",  (0,0), (-1,-1), 0),
    ]))
    outer = Table([[inner]], colWidths=[W])
    outer.setStyle(TableStyle([
        ("BACKGROUND",    (0,0), (-1,-1), bg),
        ("TOPPADDING",    (0,0), (-1,-1), 8),
        ("BOTTOMPADDING", (0,0), (-1,-1), 8),
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        ("RIGHTPADDING",  (0,0), (-1,-1), 12),
        ("BOX",           (0,0), (-1,-1), 1, MID_BLUE),
        ("ROUNDEDCORNERS", [4]),
    ]))
    return outer

def warning_box(title, lines):
    return info_box(title, lines,
        bg=colors.HexColor("#FDEDEC"),
        title_color=ACCENT_RED)

def two_col_table(headers, rows, col_widths=None):
    if col_widths is None:
        col_widths = [W*0.35, W*0.65]
    data = [[Paragraph(h, ParagraphStyle("TH",
        fontSize=9, textColor=WHITE, fontName="Helvetica-Bold", leading=12))
        for h in headers]]
    for row in rows:
        data.append([Paragraph(str(c), ParagraphStyle("TC",
            fontSize=9, textColor=TEXT_DARK, fontName="Helvetica", leading=12))
            for c in row])
    tbl = Table(data, colWidths=col_widths, repeatRows=1)
    tbl.setStyle(TableStyle([
        ("BACKGROUND",    (0,0), (-1,0), DARK_BLUE),
        ("BACKGROUND",    (0,1), (-1,-1), WHITE),
        ("ROWBACKGROUNDS",(0,1), (-1,-1), [WHITE, LIGHT_GREY]),
        ("GRID",          (0,0), (-1,-1), 0.4, MID_GREY),
        ("TOPPADDING",    (0,0), (-1,-1), 5),
        ("BOTTOMPADDING", (0,0), (-1,-1), 5),
        ("LEFTPADDING",   (0,0), (-1,-1), 6),
        ("RIGHTPADDING",  (0,0), (-1,-1), 6),
        ("VALIGN",        (0,0), (-1,-1), "TOP"),
    ]))
    return tbl

def multi_col_table(headers, rows, col_widths=None):
    if col_widths is None:
        n = len(headers)
        col_widths = [W/n]*n
    data = [[Paragraph(h, ParagraphStyle("MTH",
        fontSize=8.5, textColor=WHITE, fontName="Helvetica-Bold", leading=11))
        for h in headers]]
    for i, row in enumerate(rows):
        bg = WHITE if i % 2 == 0 else LIGHT_GREY
        data.append([Paragraph(str(c), ParagraphStyle("MTC",
            fontSize=8.5, textColor=TEXT_DARK, fontName="Helvetica", leading=11))
            for c in row])
    tbl = Table(data, colWidths=col_widths, repeatRows=1)
    tbl.setStyle(TableStyle([
        ("BACKGROUND",    (0,0), (-1,0), MID_BLUE),
        ("ROWBACKGROUNDS",(0,1), (-1,-1), [WHITE, LIGHT_GREY]),
        ("GRID",          (0,0), (-1,-1), 0.4, MID_GREY),
        ("TOPPADDING",    (0,0), (-1,-1), 4),
        ("BOTTOMPADDING", (0,0), (-1,-1), 4),
        ("LEFTPADDING",   (0,0), (-1,-1), 5),
        ("RIGHTPADDING",  (0,0), (-1,-1), 5),
        ("VALIGN",        (0,0), (-1,-1), "TOP"),
    ]))
    return tbl

def hr():
    return HRFlowable(width="100%", thickness=0.5, color=MID_GREY, spaceAfter=6, spaceBefore=6)

def sp(h=6):
    return Spacer(1, h)

def B(text):
    return Paragraph(f"• {text}", bullet)

def P(text):
    return Paragraph(text, body)

# ═══════════════════════════════════════════════════════════════════════════
#  BUILD CONTENT
# ═══════════════════════════════════════════════════════════════════════════
story = []

# ── COVER PAGE ──────────────────────────────────────────────────────────────
cover_bg = Table(
    [[Paragraph("VARICOSE VEIN SURGERY", cover_title)],
     [Paragraph("Complications & Management", cover_title)],
     [Spacer(1, 10)],
     [Paragraph("A Clinical Reference Guide", cover_sub)],
     [Spacer(1, 6)],
     [Paragraph("Based on Bailey & Love's Surgery 28e · Sabiston Textbook of Surgery · Schwartz's Principles · Harrison's 22e · Current Surgical Therapy 14e", cover_note)],
     [Spacer(1, 16)],
     [Paragraph("Orris Medical Reference  |  July 2026", cover_note)],
    ],
    colWidths=[W]
)
cover_bg.setStyle(TableStyle([
    ("BACKGROUND",    (0,0), (-1,-1), DARK_BLUE),
    ("TOPPADDING",    (0,0), (-1,-1), 30),
    ("BOTTOMPADDING", (0,0), (-1,-1), 14),
    ("LEFTPADDING",   (0,0), (-1,-1), 20),
    ("RIGHTPADDING",  (0,0), (-1,-1), 20),
    ("ROUNDEDCORNERS", [8]),
]))
story += [sp(60), cover_bg, PageBreak()]

# ── SECTION 1: Background & Pathophysiology ─────────────────────────────────
story += [section_header("1. Background & Pathophysiology"), sp(8)]

story += [
    P("Superficial venous pathology affects more than 55% of the Western population by age 65. "
      "Varicose veins arise from venous valvular dysfunction causing ambulatory venous hypertension "
      "(AVP). Skin manifestations are uncommon with AVP <35 mmHg but almost certain above 90 mmHg. "
      "More time is lost from work due to vein-related pathology than all arterial disease combined, "
      "including coronary artery disease."),
    sp(6),
]

story += [
    info_box("Primary Risk Factors for Valve Dysfunction", [
        "Female sex",
        "Positive family history",
        "Sedentary lifestyle or prolonged standing occupation",
        "Pregnancy (increased pelvic venous pressure)",
        "Obesity (BMI is an independent predictor of recurrence after surgery)",
    ]),
    sp(8),
    info_box("Secondary / Rare Causes", [
        "May-Thurner syndrome (left iliac vein compression)",
        "Nutcracker syndrome (left renal vein compression)",
        "Post-thrombotic syndrome (DVT sequelae)",
        "Trauma and muscle pump dysfunction",
        "Congenital: Klippel-Trenaunay, Ehlers-Danlos, clonal trisomies",
    ], bg=colors.HexColor("#EBF5FB"), title_color=ACCENT_TEAL),
    sp(10),
]

# CEAP table
story += [
    sub_header("CEAP Classification (Revised 2020)"),
    P("The CEAP system stratifies chronic venous disease on Clinical, Etiological, Anatomical, and "
      "Pathophysiological criteria. It guides treatment planning and outcomes reporting."),
    sp(6),
    multi_col_table(
        ["Class", "Description", "Clinical Significance"],
        [
            ["C0", "No visible or palpable signs", "Asymptomatic; observation only"],
            ["C1", "Telangiectasias / reticular veins", "Cosmetic; sclerotherapy if symptomatic"],
            ["C2", "Varicose veins", "Primary treatment threshold"],
            ["C2r", "Recurrent varicose veins", "Previous intervention; re-assess with duplex"],
            ["C3", "Oedema", "Compression therapy; investigate reflux"],
            ["C4a", "Pigmentation or eczema", "Skin care + compression + treat reflux"],
            ["C4b", "Lipodermatosclerosis / atrophic blanche", "High risk of ulceration"],
            ["C4c", "Corona phlebectatica", "Sign of advanced CVD (2020 addition)"],
            ["C5", "Healed venous ulcer", "Treat underlying reflux to prevent recurrence"],
            ["C6", "Active venous ulcer", "Urgent; compression + treat reflux"],
            ["C6r", "Recurrent active ulcer", "Consider SEPS or advanced interventions"],
        ],
        col_widths=[W*0.1, W*0.35, W*0.55]
    ),
    sp(4),
    Paragraph("CEAP = Clinical-Etiological-Anatomical-Pathophysiological. Also supplement with r-VCSS (Revised Venous Clinical Severity Score) for outcome monitoring.", caption),
    sp(10),
]

# ── SECTION 2: Surgical Procedures Overview ──────────────────────────────────
story += [section_header("2. Surgical Procedures: Overview"), sp(8)]

story += [
    sub_header("2.1  Trendelenburg Operation (Open GSV Stripping)"),
    P("The classic open surgical approach. An oblique incision is made at the groin crease, lateral to "
      "the pubic tubercle. The great saphenous vein (GSV) is dissected to the saphenofemoral junction "
      "(SFJ). All six SFJ tributaries are identified and individually ligated. A <b>flush SFJ ligation</b> "
      "is then performed - the GSV is tied flush with the femoral vein wall, leaving no stump. "
      "A Codman/Babcock stripper is passed from groin to knee and the GSV is inverted onto itself and "
      "removed. The leg is wrapped circumferentially before stripping to reduce haematoma."),
    sp(6),
    two_col_table(
        ["Step", "Detail"],
        [
            ["1. Incision", "Oblique groin incision at inguinal crease, lateral to pubic tubercle"],
            ["2. Dissection", "Trace GSV to SFJ; identify all six tributaries"],
            ["3. Tributary ligation", "Ligate: sup. epigastric, circumflex iliac, ext. pudendal, deep pudendal, ant. accessory GSV, posteromedial thigh vein"],
            ["4. Flush SFJ ligation", "Tie GSV flush at femoral vein wall (non-absorbable suture); no stump left"],
            ["5. Pass stripper", "Codman stripper from groin → knee incision; attach bulb"],
            ["6. Strip vein", "Invert GSV onto itself; remove en bloc groin-to-knee"],
            ["7. Phlebectomy", "Stab avulsion of remaining tributary varicosities"],
            ["8. Perforator ligation", "If indicated: open or endoscopic (SEPS) ligation at incompetent sites"],
        ],
    ),
    sp(10),
]

story += [
    sub_header("2.2  Minimally Invasive Techniques"),
    P("Endovenous ablation has replaced open surgery in most high-income settings. "
      "Efficacy is comparable to open surgery with significantly lower morbidity."),
    sp(6),
    multi_col_table(
        ["Technique", "Mechanism", "Access", "Anaesthesia", "Recovery"],
        [
            ["EVLA\n(Endovenous Laser Ablation)",
             "Laser energy heats vein wall from inside; thermal destruction + fibrosis",
             "Needle puncture at knee",
             "Tumescent local (perivenous)",
             "1-3 days"],
            ["RFA\n(Radiofrequency Ablation)",
             "RF energy at catheter tip heats and collapses vein wall in 20-sec cycles",
             "Needle puncture at knee",
             "Tumescent local",
             "1-3 days"],
            ["Foam Sclerotherapy",
             "Sclerosant foam displaces blood, chemically damages endothelium, obliterates vein",
             "Direct venous puncture / cannula",
             "None required",
             "Same day"],
            ["Mechanochemical Ablation (MOCA)",
             "Spinning wire + simultaneous liquid sclerosant; no heat, no tumescent needed",
             "Needle puncture",
             "None (usually)",
             "Same day"],
            ["Cyanoacrylate Glue",
             "Micro-droplets of medical-grade glue seal vein lumen with external compression",
             "Needle puncture",
             "None required",
             "Same day"],
        ],
        col_widths=[W*0.18, W*0.30, W*0.18, W*0.18, W*0.16]
    ),
    sp(6),
    P("<b>Key note - neovascularization:</b> This complication (new valve-less veins bridging the ligated SFJ) "
      "occurs in >30% after open surgery. It does not occur after endovenous ablation, which avoids groin "
      "dissection entirely - a major advantage of the minimally invasive approach."),
    sp(10),
]

# ── SECTION 3: Complications ─────────────────────────────────────────────────
story += [section_header("3. Complications of Varicose Vein Surgery", color=ACCENT_RED), sp(8)]

story += [
    P("Overall minor and major complications occur in <b>up to 20%</b> of patients undergoing traditional "
      "open varicose vein surgery (Bailey &amp; Love's 28e). The rate is substantially lower with endovenous "
      "techniques."),
    sp(8),
]

# 3.1 Nerve injury
story += [
    sub_header("3.1  Nerve Injury (Most Common Serious Complication)"),
    sp(4),
    multi_col_table(
        ["Nerve", "Operation", "Incidence", "Presentation", "Management"],
        [
            ["Saphenous nerve",
             "GSV stripping",
             "Up to 7% (knee stripping)\nHigher with ankle stripping",
             "Medial calf/ankle paraesthesia, neuralgia",
             "Conservative: analgesia, physiotherapy, nerve blocks\nUsually resolves over months"],
            ["Sural nerve",
             "SSV (small saphenous vein) surgery",
             "Up to 20%",
             "Lateral foot/ankle paraesthesia or pain",
             "Avoid ankle-level SSV stripping\nConservative management"],
            ["Common peroneal nerve",
             "SSV surgery (popliteal region)",
             "Up to 4%",
             "Foot drop, lateral leg weakness",
             "Urgent surgical review if complete palsy\nUsually neuropraxia - watch and wait"],
        ],
        col_widths=[W*0.16, W*0.18, W*0.18, W*0.24, W*0.24]
    ),
    sp(6),
    warning_box("Prevention of Nerve Injury", [
        "Strip GSV from groin to knee only (NOT ankle) - saphenous nerve diverges from vein above knee",
        "For SSV: preoperative duplex marking of saphenopopliteal junction (SPJ) is mandatory",
        "Consider endovenous ablation for SSV - avoids popliteal dissection entirely",
        "Careful patient positioning in prone for SSV (protect common peroneal nerve at fibular head)",
    ]),
    sp(10),
]

# 3.2 Wound complications
story += [
    sub_header("3.2  Wound Infection (Most Common Overall Complication)"),
    P("The most frequently reported complication following open varicose vein surgery. Risk is higher "
      "in the groin incision due to proximity to skin flora and lymphatics."),
    sp(4),
    two_col_table(
        ["Aspect", "Details"],
        [
            ["Incidence", "Most common overall complication after open surgery"],
            ["Common organisms", "Staphylococcus aureus (including MRSA), gram-negative enteric organisms (groin)"],
            ["Prevention", "Prophylactic antibiotics (single pre-operative dose reduces risk significantly)"],
            ["Management", "Wound swab + cultures; flucloxacillin / co-amoxiclav empirically; MRSA cover if risk factors"],
            ["Groin-specific risk", "Lymphatic disruption in the groin can lead to lymphorrhoea or lymphocele in addition to infection"],
        ]
    ),
    sp(10),
]

# 3.3 Haematoma
story += [
    sub_header("3.3  Haematoma & Bruising"),
    two_col_table(
        ["Aspect", "Details"],
        [
            ["Cause", "Stripping tears vein tributaries along the course of the GSV; blood collects in the fascial tunnel"],
            ["Prevention", "Circumferential leg compression bandaging immediately before and after stripping; tumescent anaesthesia in endovenous techniques"],
            ["Management", "Most resolve spontaneously with compression; large haematomas may rarely require evacuation"],
            ["Hyperpigmentation", "Brown skin discolouration from haemosiderin deposition if blood extravasates into subcutaneous tissue - often permanent; more common with inadequate compression"],
        ]
    ),
    sp(10),
]

# 3.4 DVT / VTE
story += [
    sub_header("3.4  Venous Thromboembolism (DVT / PE)"),
    P("The incidence of VTE following varicose vein surgery is approximately <b>0.5%</b>, but individual "
      "patient risk must be carefully assessed."),
    sp(4),
    two_col_table(
        ["Aspect", "Details"],
        [
            ["Overall incidence", "~0.5% following varicose vein surgery"],
            ["Risk factors", "Thrombophilia, malignancy, immobility, OCP/HRT, obesity, prior DVT, long operative time"],
            ["DVT specific to endovenous", "Endovenous heat-induced thrombosis (EHIT) - thrombus can propagate from treated vein into deep system; classified EHIT 1-4"],
            ["EHIT classification", "Class 1: thrombus at junction; Class 2: into femoral vein <50%; Class 3: >50% occlusion; Class 4: complete occlusion"],
            ["Prophylaxis", "Risk-stratify with local guidelines (NICE/ACCP); mobilise early; TEDS; LMWH in high-risk patients"],
            ["EHIT management", "Class 1-2: duplex surveillance ± anticoagulation; Class 3-4: anticoagulation; recheck duplex at 1 week"],
        ]
    ),
    sp(10),
]

# 3.5 Skin burns (endovenous)
story += [
    sub_header("3.5  Skin Burns / Thermal Injury (Endovenous Techniques)"),
    two_col_table(
        ["Aspect", "Details"],
        [
            ["Cause", "Insufficient tumescent anaesthesia - heat from laser/RF catheter conducts to overlying skin"],
            ["Prevention", "Adequate perivenous tumescent infiltration creating a 'cold halo' around vein; ultrasound-guided technique; patient feedback during procedure"],
            ["Temperature monitoring", "Catheter tip thermistor should register temperature drop when tumescence reaches the tip"],
            ["Management", "Small superficial burns: wound care, dressings; deep burns: specialist review; document and report"],
        ]
    ),
    sp(10),
]

# 3.6 Intraarterial injection
story += [
    warning_box("3.6  Intraarterial Injection (Sclerotherapy - EMERGENCY)", [
        "Accidental injection of sclerosant into an artery - rare but devastating",
        "Highest risk areas: popliteal fossa, dorsal foot, medial malleolus",
        "Presentation: severe burning pain immediately on injection + bone-white cutaneous blanching in arterial distribution",
        "Progression: cyanosis within minutes → skin necrosis",
        "IMMEDIATE management: stop injection; massage, aspirin, warm compresses, oxygen; flush artery with saline/heparin; urgent vascular surgery review; IV heparin anticoagulation",
        "Inactivate STS with 1-3% procaine injection if sodium tetradecyl sulphate was used",
    ]),
    sp(10),
]

# 3.7 Neurological (foam)
story += [
    sub_header("3.7  Neurological Events (Foam Sclerotherapy)"),
    two_col_table(
        ["Aspect", "Details"],
        [
            ["Events reported", "Headache, visual disturbances, transient ischaemic attack, stroke (rare)"],
            ["Mechanism", "Micro-emboli via patent foramen ovale (PFO); endothelin release; gas embolism from foam"],
            ["Risk factors", "Known PFO, migraine with aura"],
            ["Incidence", "Symptomatic stroke extremely rare; cerebrovascular micro-emboli detectable on imaging in ~0.4%"],
            ["Management", "Screen for PFO history; limit foam volume; use CO2/O2 foam rather than air; aspirin; neurology review if neurological deficit"],
        ]
    ),
    sp(10),
]

# ── SECTION 4: Recurrence ────────────────────────────────────────────────────
story += [section_header("4. Recurrent Varicose Veins", color=ACCENT_TEAL), sp(8)]

story += [
    P("Recurrent varicose veins are a major long-term challenge. Approximately <b>10-20%</b> of patients "
      "presenting to hospital with varicose veins have had a previous intervention. Clinical recurrence "
      "at 5-10 years occurs in <b>10-35%</b> of patients; duplex-detectable recurrence reaches "
      "<b>70%</b>."),
    sp(6),
    sub_header("Causes of Recurrence"),
    multi_col_table(
        ["Cause", "Description", "Prevention / Significance"],
        [
            ["Neovascularisation",
             "New valve-less veins grow across the ligated SFJ and reconnect tributaries. Incidence >30% after open surgery.",
             "Does NOT occur after endovenous ablation. Major argument for avoiding groin dissection."],
            ["Residual axial vein reflux",
             "GSV not fully stripped; segment below knee left in situ continues to reflux.",
             "Strip to lowest point of reflux. Endovenous ablation of residual segments."],
            ["Inadequate initial surgery",
             "Missed tributaries at SFJ; non-flush ligation leaving GSV stump.",
             "Flush ligation is essential. Preoperative duplex mapping."],
            ["New junctional reflux",
             "Previously competent junctions (e.g., SSV) develop reflux after GSV surgery.",
             "Long-term surveillance duplex."],
            ["High BMI",
             "Independent predictor of recurrence after surgery.",
             "Weight loss counselling preoperatively."],
        ],
        col_widths=[W*0.22, W*0.42, W*0.36]
    ),
    sp(6),
    warning_box("Management of Recurrent Varicose Veins", [
        "Duplex assessment is MANDATORY before any re-intervention - anatomy is atypical",
        "Open redo surgery carries a 40% complication rate (most common: lymph leak, wound infection)",
        "Endovenous interventions are strongly preferred for recurrence where technically feasible",
        "Neovascularisation vessels are thin-walled and amenable to foam sclerotherapy",
        "Recurrence after SSV surgery is MORE common than after GSV surgery",
    ]),
    sp(10),
]

# ── SECTION 5: Management Algorithm ─────────────────────────────────────────
story += [section_header("5. Management Algorithm & Decision Framework"), sp(8)]

story += [
    sub_header("5.1  Initial Assessment"),
    two_col_table(
        ["Assessment Step", "Details"],
        [
            ["History", "Duration, symptoms (ache, heaviness, itch, bleeding, ulceration), occupational factors, family history, prior DVT, OCP/HRT use, previous interventions"],
            ["Examination", "Standing examination of both legs; map distribution (GSV/SSV/perforators); skin changes (CEAP grading); ankle pulses"],
            ["Duplex ultrasound", "Mandatory for all patients before intervention. Map reflux at SFJ/SPJ, axial vein competence, perforator incompetence, deep vein patency. Standing examination with Valsalva and calf squeeze."],
            ["ABPI", "Ankle-Brachial Pressure Index if clinical concern for arterial disease (if ABPI <0.8 - do not use compression stockings)"],
            ["Venous severity scoring", "Aberdeen Varicose Vein Score (AVVS); r-VCSS for outcome monitoring"],
        ]
    ),
    sp(8),
    sub_header("5.2  Conservative Management"),
    info_box("Non-operative Options", [
        "Lifestyle: weight loss, avoid prolonged standing, regular moderate exercise, leg elevation 30 cm above heart (shown to enhance micro-circulation 45%)",
        "Compression therapy: class II compression stockings (23-32 mmHg); first-line for C3-C4 disease; absolute contraindication if ABPI <0.8",
        "Pharmacological: venoactive drugs (e.g. micronised purified flavonoid fraction) - modest symptomatic benefit; not universally recommended",
        "Wound care: for active ulcers (C6) - four-layer compression bandaging is gold standard; treat underlying reflux once wound is clean",
    ]),
    sp(8),
    sub_header("5.3  Intervention Indications"),
    two_col_table(
        ["Indication", "Comment"],
        [
            ["Symptomatic varicose veins (C2+)", "Pain, heaviness, aching, cosmetic - all valid if patient requests treatment"],
            ["Bleeding varicose veins", "Urgent referral; bleeding can be profuse; surgical or endovenous treatment"],
            ["Superficial thrombophlebitis", "Treat reflux to reduce recurrence"],
            ["Skin changes (C4)", "Treat reflux to arrest progression to ulceration"],
            ["Venous ulceration (C5/C6)", "Evidence that treating reflux accelerates ulcer healing and prevents recurrence (ESCHAR trial)"],
            ["Symptomatic perforators", "Incompetent perforators with localised symptoms or overlying ulcer"],
        ]
    ),
    sp(8),
    sub_header("5.4  Technique Selection Guide"),
    multi_col_table(
        ["Clinical Scenario", "Preferred Technique", "Rationale"],
        [
            ["Primary uncomplicated GSV reflux (C2-C3)", "EVLA or RFA", "Best evidence; lowest recurrence; rapid recovery"],
            ["GSV reflux + skin changes (C4-C6)", "EVLA/RFA ± perforator ablation", "Endovenous preferred; SEPS if skin changes severe"],
            ["SSV reflux", "EVLA/RFA (or foam if tortuous)", "Avoids nerve injury risk of open SPJ dissection"],
            ["Isolated tributary varicosities", "Phlebectomy or foam sclerotherapy", "No axial reflux; address tributaries only"],
            ["Needle phobia, very tortuous vein", "MOCA (mechanochemical ablation)", "No tumescent required; no heat"],
            ["Recurrent varicose veins", "Foam sclerotherapy / endovenous if feasible", "Avoid open redo - 40% complication rate"],
            ["Venous ulcer (C6)", "Compression + duplex-guided ablation", "NICE recommends treating reflux early to aid healing"],
            ["Resource-limited setting / no endovenous equipment", "Open Trendelenburg + stripping", "Effective long-term; flush ligation essential to minimise recurrence"],
        ],
        col_widths=[W*0.28, W*0.28, W*0.44]
    ),
    sp(10),
]

# ── SECTION 6: Postoperative Care ────────────────────────────────────────────
story += [section_header("6. Postoperative Care & Follow-up"), sp(8)]

story += [
    multi_col_table(
        ["Timepoint", "Open Surgery", "Endovenous Ablation"],
        [
            ["Immediate post-op",
             "Compression bandage groin to foot; mobilise same day; elevate limb",
             "Compression stocking applied immediately; walk home same day"],
            ["Day 1-7",
             "Change dressings; start Class II compression stocking at 48h; analgesia (NSAIDs)",
             "Continue compression stocking for 7-14 days; regular walking encouraged"],
            ["1-2 weeks",
             "Wound check; remove sutures at 10-14 days; assess for haematoma/infection",
             "Duplex ultrasound to confirm vein ablation and exclude EHIT"],
            ["4-6 weeks",
             "Clinic review; assess bruising resolution; duplex if recurrence suspected",
             "Clinical review; CEAP/AVVS reassessment; compression reassessed"],
            ["6-12 months",
             "Clinical and duplex assessment for recurrence",
             "Duplex to confirm sustained closure; treat any missed tributaries"],
            ["Return to work",
             "Sedentary: 1-2 weeks; manual: 2-4 weeks",
             "Sedentary: 2-3 days; manual: 1 week"],
            ["DVT prophylaxis",
             "TEDS + LMWH if high-risk; all patients: early mobilisation",
             "TEDS; LMWH only if high-risk; duplex at 1 week if EHIT suspected"],
        ],
        col_widths=[W*0.16, W*0.42, W*0.42]
    ),
    sp(10),
]

# ── SECTION 7: Quick-Reference Summary ──────────────────────────────────────
story += [section_header("7. Quick-Reference: Key Numbers to Know"), sp(8)]

story += [
    multi_col_table(
        ["Parameter", "Value", "Source"],
        [
            ["Overall complications (open surgery)", "Up to 20%", "Bailey & Love's 28e"],
            ["Saphenous nerve neuralgia (knee stripping)", "Up to 7%", "Bailey & Love's 28e"],
            ["Sural nerve neuropraxia (SSV surgery)", "Up to 20%", "Bailey & Love's 28e"],
            ["Common peroneal nerve injury (SSV surgery)", "Up to 4%", "Bailey & Love's 28e"],
            ["VTE / DVT incidence", "~0.5%", "Bailey & Love's 28e"],
            ["Clinical recurrence at 5-10 years (open)", "10-35%", "Bailey & Love's 28e"],
            ["Duplex-detected recurrence", "~70%", "Bailey & Love's 28e"],
            ["Neovascularisation incidence (open surgery)", ">30%", "Sabiston 21e"],
            ["Complication rate - redo open surgery", "40%", "Bailey & Love's 28e"],
            ["Prevalence of venous disease by age 65", ">55% (Western population)", "Current Surgical Therapy 14e"],
            ["AVP threshold for skin manifestations", ">90 mmHg (almost certain)", "Current Surgical Therapy 14e"],
            ["Time lost from work (veins vs arterial)", "Vein > all arterial disease combined", "Current Surgical Therapy 14e"],
        ],
        col_widths=[W*0.50, W*0.25, W*0.25]
    ),
    sp(10),
]

# ── SECTION 8: References ─────────────────────────────────────────────────────
story += [section_header("8. References & Sources", color=colors.HexColor("#4A235A")), sp(8)]

refs = [
    "Bailey and Love's Short Practice of Surgery, 28th Edition - Chapter 62: Venous Disease",
    "Sabiston Textbook of Surgery: The Biological Basis of Modern Surgical Practice, 21st Edition - Chapter 108: Venous Disease",
    "Schwartz's Principles of Surgery, 11th Edition - Venous Disease chapter",
    "Harrison's Principles of Internal Medicine, 22nd Edition (2025) - Chapter 293: Chronic Venous Disease",
    "Current Surgical Therapy, 14th Edition - Superficial Venous Disease chapter",
    "Fischer's Mastery of Surgery, 8th Edition - Varicose Veins chapter",
    "Fitzpatrick's Dermatology, 9th Edition - Minimally Invasive Approaches for Varicose Veins",
    "Mulholland and Greenfield's Surgery: Scientific Principles and Practice, 7th Edition",
    "AVF/SVS/AVLS Clinical Practice Guidelines for Management of Varicose Veins (2022)",
    "CEAP Classification System and Reporting Standard Revision 2020 - J Vasc Surg Venous Lymphat Disord 2020;8(3):342-352",
]
for i, r in enumerate(refs, 1):
    story.append(Paragraph(f"{i}.  {r}", ParagraphStyle("Ref",
        fontSize=9, textColor=TEXT_DARK, fontName="Helvetica",
        leading=13, leftIndent=20, firstLineIndent=-20,
        spaceBefore=3, spaceAfter=3)))

story += [sp(16), hr(),
    Paragraph("This document is a clinical reference guide for educational purposes. Always apply clinical judgement and refer to local guidelines. Not a substitute for formal medical training.", caption)]

# ── Build ────────────────────────────────────────────────────────────────────
def on_page(canvas, doc):
    canvas.saveState()
    # Header bar
    canvas.setFillColor(DARK_BLUE)
    canvas.rect(doc.leftMargin - 0.5*cm, A4[1] - 1.4*cm, A4[0] - 3*cm, 0.55*cm, fill=1, stroke=0)
    canvas.setFillColor(WHITE)
    canvas.setFont("Helvetica-Bold", 7.5)
    canvas.drawString(doc.leftMargin - 0.3*cm, A4[1] - 1.1*cm, "VARICOSE VEIN SURGERY: COMPLICATIONS & MANAGEMENT")
    canvas.setFont("Helvetica", 7.5)
    canvas.drawRightString(A4[0] - doc.rightMargin + 0.5*cm, A4[1] - 1.1*cm, f"Orris Medical Reference | July 2026")
    # Footer
    canvas.setFillColor(MID_GREY)
    canvas.rect(doc.leftMargin - 0.5*cm, 1.2*cm, A4[0] - 3*cm, 0.3*cm, fill=1, stroke=0)
    canvas.setFillColor(colors.HexColor("#7F8C8D"))
    canvas.setFont("Helvetica", 7.5)
    canvas.drawCentredString(A4[0]/2, 0.8*cm, f"Page {doc.page}  |  For educational use only")
    canvas.restoreState()

doc.build(story, onFirstPage=on_page, onLaterPages=on_page)
print(f"PDF created: {OUTPUT}")

cd /home/daytona/workspace/varicose-vein-guide && python build_pdf.py 2>&1

ls -lh /home/daytona/workspace/varicose-vein-guide/Varicose_Vein_Surgery_Referen…