Varicus venous
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"varicose veins" AND treatment
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Varicose Veins
Definition
Varicose veins are subcutaneous dilated, tortuous veins 3 mm or more in diameter in the lower limb, defined by the presence of retrograde blood flow (reflux). They are frequently elongated and tortuous with intermittent "blowouts," but may also appear as straight, uniform tubes morphologically.
Pathophysiology
Varicose veins result from venous incompetence - failure of venous valves allowing retrograde flow with gravity. The underlying vein wall changes include:
- Inflammatory cell infiltration and activation
- Dysfunctional smooth muscle cell proliferation
- Collagen deposition and decreased elastin content
- Increased matrix metalloproteinases
- Loss of compliance, dilatation, and elongation (causing tortuosity)
- Secondary valvular dysfunction
These changes are not caused by a primary mechanical valvular failure alone - the mechanism is more complex and can be initiated anywhere in the venous tree. Secondary varicose veins develop in post-thrombotic limbs and in congenital conditions (e.g., Klippel-Trenaunay syndrome, multiple arteriovenous fistulae).
(Bailey and Love's, p. 1049)
Aetiology
- Valve incompetence - the most important factor; may be a sequel of venous thrombosis
- Erect posture - not seen in other animals; occurs in those who stand for prolonged periods (policemen, tram drivers, conductors)
- Pregnancy - progesterone-related smooth muscle relaxation plus uterine compression of pelvic veins
- Obstruction to venous return: abdominal tumours, fibroids, ovarian cysts, abdominal lymphadenopathy, retroperitoneal fibrosis, ascites
- Congenital arteriovenous fistulae - particularly in younger patients
- Hereditary - runs strongly in families
(S. Das, p. 105)
Clinical Features
Epidemiology
- Middle-aged individuals most commonly affected
- Women > men (ratio approximately 10:1)
- Less common in primitive civilisations (Africa, Far East)
Symptoms
- Aching pain in the leg, worst toward the end of the day, relieved by elevation
- Ankle swelling by end of day
- Itching of the skin over the leg
- Night cramps
- Bursting pain on walking (suggests coexisting deep vein thrombosis)
- Varicose ulcer on medial malleolus
Note: Symptoms do not necessarily correlate with the degree of visible varicosity. Asymptomatic varicose veins on one side and severe symptoms with minimal visible veins on the other side are both possible.
Clinical Classification (CEAP)
| Class | Features |
|---|---|
| C0 | No signs of venous disease |
| C1 | Telangiectasia or reticular veins |
| C2 | Varicose veins |
| C3 | Oedema |
| C4a | Pigmentation or eczema |
| C4b | Lipodermatosclerosis (LDS) or atrophie blanche |
| C4c | Corona phlebectatica |
| C5 | Healed venous ulcer |
| C6 | Active venous ulcer |
Classes can be further labelled: s (symptomatic), a (asymptomatic), or r (recurrent).
Aetiological: Ec (congenital), Ep (primary), Es (secondary/post-thrombotic), En (none identified)
Anatomical: As (superficial), Ap (perforator), Ad (deep), An (none)
Pathophysiological: Pr (reflux), Po (obstruction), Pr,o (both), Pn (none)
(Bailey and Love's, p. 1051)
Examination
Inspection
- Note which system is involved - long (great) saphenous or short (small) saphenous, or both
- Great saphenous: trunk on medial side of leg from in front of medial malleolus to saphenous opening in groin
- Small saphenous: trunk from behind lateral malleolus up the posterior calf to popliteal fossa
- Look for skin changes: eczema, pigmentation (haemosiderosis), lipodermatosclerosis, ulceration, scarring
Clinical Tests (Palpation)
| Test | Method | Interpretation |
|---|---|---|
| Brodie-Trendelenburg test | Empty veins in recumbent position; compress SFJ; stand patient up; release compression | Rapid fill from above = SFJ incompetence (positive) |
| Tourniquet test | Tourniquet applied at various levels after vein emptying; patient stands | Identifies level of incompetent perforator |
| Perthes' test | Elastic bandage applied; patient exercises | Crampy pain = deep vein obstruction |
| Modified Perthes' test | Tourniquet at upper thigh; patient walks briskly | Veins shrink = deep veins patent; veins distend = deep veins blocked |
| Schwartz test | Tap varicose vein distally; feel impulse at saphenous opening | Indicates continuous column (absent/incompetent valves) |
| Pratt's test | Esmarch bandage toe to groin; tourniquet at groin; re-apply bandage from groin downward | "Blowouts" at perforator positions |
| Fegan's method | Mark bulges standing; then elevate leg and palpate for fascial defects | Identifies perforator locations |
| Morrissey's test | Ask patient to cough | Cough impulse at saphenous opening = saphena varix |
Complications
- Haemorrhage - may be profuse due to high venous pressure; elevation of the limb is first aid
- Superficial thrombophlebitis (phlebitis) - spontaneous or post-trauma; vein becomes tender and firm, overlying skin red and oedematous, may have pyrexia
- Venous ulceration - typically on the medial malleolus, often associated with underlying deep vein thrombosis; follows lipodermatosclerosis
- Eczema / dermatitis - erythematous, itchy, may progress to blistering
- Lipodermatosclerosis - chronic inflammation and fibrosis resulting in "woody," contracted leg
- Haemosiderosis - brownish skin discoloration around ankle from haemoglobin breakdown
Investigations
Duplex ultrasound is the gold standard investigation. The patient stands for scanning. Key features:
- Reflux defined as retrograde flow lasting ≥ 0.5 seconds in superficial/crural veins
- Reflux in proximal deep veins requires ≥ 1 second
- The SFJ is identified in the groin using transverse view - the "Mickey Mouse sign" (CFV + CFA + GSV)
- Elicited by calf/foot squeeze release, Valsalva, or pneumatic cuff deflation
(Bailey and Love's, p. 1053)
Treatment
1. Conservative
- Compression hosiery (not a curative treatment but reduces symptoms)
- Elevation, weight loss, mobility
2. Endothermal Ablation (First-line for truncal incompetence)
Endovenous Laser Ablation (EVLA)
- Catheter placed under ultrasound guidance to the lowest point of reflux
- Perivenous tumescent anaesthesia administered
- Energy delivery ~60-80 J/cm used; catheter withdrawn during energy delivery
- Post-procedural compression applied
Radiofrequency Ablation (RFA)
- Similar principle using radiofrequency energy instead of laser
- Slightly less painful than EVLA; similar efficacy
3. Non-Thermal, Non-Tumescent Techniques
Ultrasound-Guided Foam Sclerotherapy (UGFS)
- Sclerosing agent (sodium tetradecyl sulphate most common) made into foam via Tessari method (1:3 or 1:4 sclerosant:air ratio, oscillated ~20 times)
- Foam stable for ~2 minutes; injected with leg elevated
- Effective for trunk and tributaries; higher recanalisation rates than thermal ablation
Mechanochemical Ablation (MOCA)
- Spinning wire physically damages endothelium while sclerosant is simultaneously injected
- No tumescent anaesthesia usually required
- Good option for needle-phobic patients; higher long-term recanalisation than endothermal
Endovenous Cyanoacrylate Glue
- Adhesive applied in 0.1 mL increments via catheter; vein compressed to seal lumen
- Minimal procedural pain; no tumescent anaesthesia
- Higher consumable cost; long-term data still emerging
4. Open Surgery (Traditional)
Saphenofemoral Junction (SFJ) Ligation + Great Saphenous Stripping
- Complete dissection of SFJ with flush ligation + stripping of GSV
- Usually under general anaesthesia
- Now superseded by endothermal techniques in most centres; reserved for complex or recurrent cases
Saphenopopliteal Junction (SPJ) Ligation + Small Saphenous Stripping
- Preoperative duplex marking of SPJ highly recommended
- Prone position; risk of sural nerve and popliteal vein injury
Phlebectomy (Ambulatory / Stab)
- Small stab incisions using mosquito forceps or phlebectomy hooks
- Used as adjunct to truncal ablation or as sole treatment for isolated tributary incompetence
(Bailey and Love's, p. 1054-1060)
Summary of Key Points
| Feature | Details |
|---|---|
| Definition | Dilated superficial veins ≥3 mm with reflux |
| Commonest system | Great saphenous vein (medial leg) |
| Key investigation | Duplex ultrasound (standing position) |
| First-line treatment | Endothermal ablation (EVLA or RFA) |
| Complication to fear | Bleeding (high pressure), DVT, venous ulcer |
| Key test | Brodie-Trendelenburg (SFJ incompetence) |
Recent evidence (2024): A network meta-analysis (PMID 38679141) compared polidocanol foam (Varithena) to endovenous thermal ablation, finding similar effectiveness. A meta-analysis (PMID 38316290) comparing RFA vs laser ablation for lower extremity varicose veins found similar outcomes. A systematic review (PMID 39559844) specifically addressed recurrent varicose veins at the saphenofemoral junction. No evidence currently suggests a need to revise the core management principles in the textbooks above.
Sources: Bailey and Love's Short Practice of Surgery 28th Ed., pp. 1049-1060; S. Das Manual on Clinical Surgery 13th Ed., pp. 105-110
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