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Varicose Veins

Varicose veins are veins that have dilated under the influence of increased venous pressure. Q


Varicose veins affect: 20-25% of adult females.10-15% of adult males


Most common site of varicose vein – Great saphenous vein.
Second most common site is short saphenous vein.

  1. Etiology:
    1. Intrinsic pathological conditions and extrinsic environmental factors combine to produce a wide spectrum of varicose disease.
    2. Most varicose disease is caused by elevated superficial venous pressures.
    3. Some people have an inborn weakness of vein walls.
    4. Reflux at the saphenofemoral junction (SFJ)
    5. Prolonged standing leads to increased hydrostatic pressures that can cause chronic venous distention and secondary valvular incompetence.
    6. If proximal junctional valves become incompetent, high pressure passes from the deep veins into superficial veins and the condition rapidly becomes irreversible.
  2. History: Common symptoms include, leg heaviness, exercise intolerance, pain or tenderness along the course of a vein, pruritus, burning sensations, restless legs, night cramps, edema, skin changes, and paresthesias.
    1. Pain caused by venous insufficiency often is improved by walking in contrast to the pain of arterial insufficiency, which is worse with ambulation and elevation. Q
    2. Acute varicose complications are variceal bleeding, dermatitis, thrombophlebitis, cellulitis, and ulceration.
    3. Poor correlation exists between symptoms and signs
    4. If history of DVT need preoperative investigation with duplex scanning  
  3. Examination
    1. Identify distribution of varicose veins - long saphenous vs short saphenous.  Q
      1. Confirm with tourniquet testing and hand held-doppler probe (5 MHz)
      2. Indications for duplex scanning
    2. Suspected short saphenous incompetence
    3. Recurrent varicose veins
    4. Complicated varicose veins (e.g. ulceration, lipodermatosclerosis)
    5. History of deep venous thrombosis  
  4. Perthes maneuver: Q
    1. The Perthes maneuver is a traditional technique intended to distinguish antegrade flow from retrograde flow in superficial varices.
    2. Antegrade flow in a variceal system indicates that the system is a bypass pathway around a deep venous obstruction.
    3. This is critically important because if deep veins are not patent, superficial varices are an important pathway for venous return and must not be sclerosed or surgically removed.
    4. If the Perthes maneuver is positive and the distal varices have become engorged, the patient is placed supine with the tourniquet in place and the leg is elevated (Linton test). Q
    5. If varices distal to the tourniquet fail to drain after a few seconds, deep venous obstruction must be suspected.
Trendelenburg test: The Trendelenburg test often can distinguish patients with superficial venous reflux from those with incompetent deep venous valves.   
  1. Indications for varicose vein surgery
    1. Most surgery is cosmetic or for minor symptoms
    2. Absolute indications for surgery :
      1. Lipodermatosclerosis leading to venous ulceration
      2. Recurrent superficial thrombophlebitis
      3. Bleeding from ruptured varix

Contraindications: Venous outflow obstruction and during pregnancy.

  1. Complications
    1. Ankle Edema
    2. Brown Pigmentation
    3. Venous Ulcer
    4. Marjolin’s Ulcer- Squamous Cell Carcinoma
    5. Champaigne Leg Defomity- (Swollen Calf and Narrow ankle)
    6. Hemorrhage

Rx-  Ensure Patency Of Deep Veins.

  1. Reassurance
  2. Elastic compression stockings
  3. Injection sclerotherapy or

Surgical Rx.

  1. LSV surgery
    1. Trendelenberg position with 20 - 30 head down
    2. Saphenofemoral junction (SFJ) found 2 cm below and lateral to pubic tubercle
    3. Essential to identify SFJ before performing flush ligation of the LSV
    4. Individually divide and ligate all tributaries of the LSV
      1. Superficial circumflex iliac vein
      2. Superficial inferior epigastric vein
      3. Superficial and deep external pudendal vein
    5. Check that femoral vein clear of direct branches for 1 cm above and below SFJ
    6. Stripping of LSV reduces risk of recurrence. Only strip to upper calf if needed. 
    7. Stripping to ankle is associated with increased risk of saphenous neuralgia
    8. Post operative care:  Elevate foot of bed for 12 hours. Varix stocking should be worn for at least 2 weeks 
  2. SSV surgery
    1. Patient prone with 20-30o head down
    2. Saphenopopliteal junction (SPJ) has very variable position
    3. Identify and preserve the sural nerve
    4. Need to identify the Sapheno-popliteal Junction
    5. Stripping associated with risk of sural nerve damage
    6. Subfascial ligation inadequate  
  3. Perforator surgery
    1. Perforator disease may be improved by superficial vein surgery
    2. Perforator surgery (e.g. Cockett's and Todd's procedure) associated with high morbidity
    3. Subfascial endoscopic perforator surgery (SEPS) recently described
    4. May have a role in addition to saphenous surgery in those with venous ulceration
    5. Sclerotherapy 

Newer techniques-

  • VNUS closure : Ablation of saphenous vein under USG control via an intraluminal catheter.
  • TRIVEX : Percutaneous technique of removing the superficial veins through Suction after injection of large quantities of fluid. 
  1. Sclerotherapy "Varicose veins: sclerotherapy" Q
    1. Only suitable for below knee varicose veins
    2. Need to exclude SFJ or SPJ incompetence
    3. Main use is for persistent or recurrent varicose veins after adequate saphenous surgery
    4. Sclerosants
      5% Ethanolamine oleate/ 0.5% Sodium tetradecyl sulphate
    5. Needle placed in vein when full with patient standing
    6. Empty vein prior to injection
    7. Apply immediate compression and maintain for 4-6 weeks  
  2. Complications of sclerotherapy
    1. Extravasation causing pigmentation or ulceration
    2. Deep venous thrombosis  
  3. Other Modalities:
    1. Endovenous laser: Endovenous laser therapy is a thermal ablation technique that uses a laser fiber placed inside the vein to destroy the vascular endothelium.
    2. Radiofrequency ablation: Radiofrequency (RF) ablation is a thermal ablation technique. This tissue heating causes protein denaturation, collagenous contraction, and immediate closure of the vessel.
    3. Ambulatory phlebectomy: The stab-avulsion technique allows removal of short segments of varicose and reticular veins through tiny incisions.
      Recurrent varicose veins "Varicose veins: recurrent"
      1. 15 - 25 % of varicose vein surgery is for recurrence  
  4. Reasons for recurrence
    1. Inaccurate clinical assessment
      i. Confusion as to whether varicosities are in LSV or SSV distribution
    2. Inadequate primary surgery
      1. 10% cases SFJ not correctly identified
      2. 20% cases tributaries mistaken for LSV
      3. Failure to strip LSV
    3. Injudicious use of sclerotherapy
      1. ​​70% of SF incompetence treated with sclero-therapy will have recurrence
    4. Neovascularisation
      1. ​​With recurrent varicose vein need to image with duplex or varicography
​​​​Complications: Deep vein thrombosis and pulmonary embolism are the most serious complications. Other complications are dysesthesias from injury to the sural nerve or the saphenous nerve, Q subcutaneous haematoma, infection and arterial injury.

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