Varicose Veins

Definition

• Harrison's Principles of Internal Medicine 22E, p. 2224
• Gray's Anatomy for Students, p. 44

Epidemiology

• Adult prevalence of visible varicose veins: 30-50% (Bailey & Love); ~15% in men and ~30% in women in the United States (Harrison's).
• Chronic venous insufficiency with edema affects ~7.5% of men and 5% of women.
• ~20% of patients with chronic venous insufficiency develop venous ulcers.

• Bailey and Love's Short Practice of Surgery 28th Ed., p. 1052

Anatomy and Pathophysiology

• Superficial veins: great saphenous vein (GSV) - longest vein in the body, medial side from foot to common femoral vein; small saphenous vein (SSV) - posterolateral calf to popliteal vein.
• Deep veins accompany arteries (tibial, popliteal, femoral, iliac).
• Perforating veins connect the two systems; normally allow flow from superficial to deep only.

1. Venous valves in perforating and axial veins become incompetent.
2. This allows retrograde (reflux) blood flow under raised hydrostatic pressure.
3. The increased volume and pressure cause progressive dilation and tortuosity of the superficial veins.
4. Continued venous hypertension leads to capillary leak, edema, inflammatory cell infiltration, and eventual skin changes (lipodermatosclerosis, pigmentation, ulceration).

• Harrison's, p. 2223-2224
• Gray's Anatomy for Students, p. 44

Clinical Features

Symptoms

• Aching, heaviness, throbbing, burning, or bursting sensation in the legs
• Symptoms worsen throughout the day and with prolonged standing
• Relieved by leg elevation and compression hosiery
• Itching (especially with complications)
• Ankle swelling

Signs (on examination - patient standing)

• Visible, distended, tortuous surface veins along the GSV or SSV territory
• Ankle edema (pitting in early stages, later indurated)
• Skin changes:
  • Hyperpigmentation (hemosiderin deposition)
  • Lipodermatosclerosis - induration + inflammation, just above the ankle
  • Atrophie blanche - white scar patches near the medial malleolus
  • Stasis eczema/dermatitis
  • Phlebectasia corona - fan-shaped intradermal veins near ankle
  • Venous ulcer - shallow, irregular border, near medial/lateral malleolus

Complications

• Chronic: skin changes, venous ulceration
• Acute: superficial vein thrombosis (thrombophlebitis), bleeding
• Bailey and Love, p. 1052
• Harrison's, p. 2224

CEAP Classification

• Harrison's Table 293-1

Investigations

Duplex Ultrasound (Gold Standard)

• Combines B-mode imaging with spectral/color Doppler
• Identifies reflux (retrograde flow >0.5 sec in superficial/crural veins; >1 sec in proximal deep veins) and obstruction
• Performed with patient standing
• Maps the SFJ/SPJ, full length of GSV/SSV, and perforators
• The "Mickey Mouse" sign on transverse groin scan: GSV and common femoral vein (CFV) medial to common femoral artery (CFA)

Bedside Tests (largely replaced by ultrasound)

• Brodie-Trendelenburg test: tourniquet applied to thigh after elevating leg; fast refilling after tourniquet release = SFJ incompetence; rapid filling before release = deep vein incompetence.
• Perthes test: tourniquet at mid-thigh, patient walks; collapse of below-knee varices indicates competent deep system; distension indicates deep vein obstruction.

Other imaging (rarely needed)

• MR/CT/conventional venography for IVC/iliofemoral disease, May-Thurner syndrome, post-DVT obstruction.
• Bailey and Love, p. 1053
• Harrison's, p. 2224

Treatment

1. Conservative (Supportive) Measures

• Leg elevation periodically, avoid prolonged standing
• Compression hosiery:
  • British Class 1: 14-17 mmHg; Class 2: 18-24 mmHg; Class 3: 25-35 mmHg
  • 20-30 mmHg suitable for simple varicose veins; 30-40 mmHg for venous ulcers
  • Relieves symptoms but does not prevent progression or cure varicose veins
  • Poor long-term patient compliance
• Exercise, weight loss, skin care

2. Endothermal Ablation (Current Gold Standard for axial reflux)

3. Foam Sclerotherapy

• Sclerosant foam (e.g., sodium tetradecyl sulfate or polidocanol) injected under ultrasound guidance
• Destroys vein endothelium and causes fibrosis
• Used for axial veins, tributaries, residual/recurrent veins, and as an alternative to ablation
• Higher recurrence rates than endothermal ablation

4. Mechanochemical Ablation (MOCA) and Cyanoacrylate Glue

• Newer non-thermal, non-tumescent techniques
• Avoid tumescent injection and thus reduce procedure time/discomfort
• MOCA combines mechanical abrasion with sclerosant

5. Surgical Treatment (where endovenous techniques not suitable)

• High ligation and stripping (Trendelenburg operation):
  • SFJ flush ligation at groin + stripping of GSV to knee
  • Stripping below the knee increases sural nerve injury risk
  • SPJ ligation + SSV stripping/resection for small saphenous disease
• Phlebectomy (avulsions):
  • Removal of varicose tributaries via multiple small stab incisions using mosquito forceps/phlebectomy hooks
  • Can be performed alone under local anaesthetic or combined with axial vein treatment
• Complication rates: wound infection, haematoma, nerve injury (sural nerve with SSV surgery), DVT, popliteal vein injury
• Bailey and Love, pp. 1054-1060
• Harrison's, pp. 2224-2225
• Schwartz's Principles of Surgery 11th Ed.

Venous Ulcer Management

• Compression bandaging (multilayer) is standard of care
• Wound dressings: low-adherent absorptive (first-line); hydrocolloid, hydrogel, foam, or alginate as alternatives
• Debridement of necrotic tissue
• Antibiotics only if ulcer is infected
• Treat underlying reflux once ulcer healed (reduces recurrence)

Key Points Summary

• Bailey and Love's Short Practice of Surgery, 28th Ed. (Chapter 62)
• Harrison's Principles of Internal Medicine, 22nd Ed. (2025) (Chapter 293)
• Gray's Anatomy for Students
• Schwartz's Principles of Surgery, 11th Ed.
• Jiang W et al. EVLA vs RFA meta-analysis. J Vasc Surg Venous Lymphat Disord, 2024 Sep (PMID 38316290)