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Varicose Veins — Complete MBBS Surgery Reference

Covers: Theory | Practical/Clinical Examination | Case Presentation | Differentials with Reasoning | Summary per Section

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1. DEFINITION

Key distinction: "Varix" = dilated vein. Varicosities must be >3 mm in diameter to be classified as varicose veins; smaller dilations are called reticular veins (<3 mm) or telangiectasias (<1 mm).

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2. SURGICAL ANATOMY (High-Yield for Exams)

Long Saphenous Vein (Great Saphenous Vein — GSV)

• Longest vein in the body
• Originates from the medial end of the dorsal venous arch of the foot
• Passes anterior to the medial malleolus, then runs along the medial aspect of the leg and thigh
• Passes through the saphenous opening (fossa ovalis) in the deep fascia 3.5–4 cm below and lateral to the pubic tubercle
• Drains into the femoral vein at the saphenofemoral junction (SFJ)
• Tributaries at SFJ (the "5 tributaries" — SEPIA mnemonic):
  • Superficial external pudendal
  • Epifascial circumflex iliac
  • Posterolateral (posteromedial) thigh vein
  • Inguinal (anterior femoral cutaneous) vein
  • Anterior lateral thigh vein

Short Saphenous Vein (Small Saphenous Vein — SSV)

• Originates from the lateral end of the dorsal venous arch
• Passes posterior to the lateral malleolus, then up the posterior midline of the calf
• Pierces deep fascia in the popliteal fossa to drain into the popliteal vein at the saphenopopliteal junction (SPJ)

Perforating (Communicating) Veins

• Connect superficial and deep systems, with valves directing blood superficial → deep
• Cockett's perforators (medial lower leg, 7, 12, 18 cm above medial malleolus) — most clinically important
• Boyd's perforator — below the knee medially
• Hunterian (Dodd's) perforator — mid-thigh medially

Venous Valves

• Semilunar bicuspid valves; prevent retrograde flow
• Absent in: common iliac vein, inferior vena cava
• GSV has 8–20 valves; denser distally

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3. ETIOLOGY AND RISK FACTORS

Primary Varicose Veins (Most Common — ~95%)

• Intrinsic weakness of the vein wall (structural defect in elastin/collagen)
• Congenital valve deficiency
• No identifiable secondary cause

Secondary Varicose Veins (~5%)

Risk Factors (MBBS Exam Favourite)

• Female sex (progesterone effect) — F:M ratio 3:1
• Prolonged standing (occupational — barbers, surgeons, teachers)
• Obesity (increased intra-abdominal pressure)
• Multiparity
• Positive family history (50–70% of cases)
• Constipation/straining
• Age >40

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4. PATHOPHYSIOLOGY

Valve incompetence (SFJ most common)
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Retrograde blood flow (reflux) in superficial veins
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Increased hydrostatic pressure in superficial veins
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Vein wall dilation and tortuosity
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Further valve incompetence (progressive)
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Sustained venous hypertension
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Capillary leak → Fibrin cuff deposition → Impaired O₂ diffusion
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Lipodermatosclerosis, eczema, ulceration

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5. CEAP CLASSIFICATION (Harrison's, p. 7797)

C — Clinical

• s = symptomatic
• a = asymptomatic

E — Etiologic

• Ec = Congenital | Ep = Primary | Es = Secondary | En = No venous cause identified

A — Anatomic

• As = Superficial | Ap = Perforator | Ad = Deep

P — Pathophysiologic

• Pr = Reflux | Po = Obstruction | Pr,o = Both

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6. CLINICAL FEATURES

Symptoms

Important: Pain is NOT a cardinal feature of uncomplicated varicose veins. Severe pain should raise suspicion of thrombophlebitis, DVT, or other diagnosis.

Signs

• Dilated, tortuous, visible veins along GSV/SSV territory
• Ankle oedema (pitting)
• Haemosiderin pigmentation (brownish discoloration around ankle — "gaiter area")
• Lipodermatosclerosis — woody induration of skin/subcutaneous tissue; "inverted champagne bottle" appearance
• Venous eczema (varicose eczema)
• Atrophie blanche — whitish, sclerotic plaques (marker of severe disease)
• Venous ulcer — typically over the medial malleolus (gaiter area)
• Corona phlebectatica — fan-shaped telangiectasias around the ankle (marker of severe CVI)

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7. CLINICAL EXAMINATION (PRACTICAL/VIVA EXAM FAVOURITE)

Sequence (IPAC — Inspection, Palpation, Auscultation, Special Tests)

7.1 INSPECTION

• Patient standing (veins fill best in standing)
• Note: distribution (GSV, SSV, or both), tortuosity, dilatation
• Skin changes: pigmentation, eczema, lipodermatosclerosis, ulcer
• Saphena varix — dilatation of the terminal part of GSV at SFJ; seen as a bluish swelling at the saphenous opening → disappears on lying down; cough impulse positive

7.2 PALPATION

• Temperature of skin over varices
• Tenderness (thrombophlebitis)
• Consistency of swellings
• Tap test (Schwartz test):
  • Tap the vein at one point; a transmitted fluid impulse felt at another point confirms continuity of the column of blood
  • Indicates: varicose veins are present and blood column is continuous
  • Limitation: Does not determine cause or competency

7.3 SPECIAL CLINICAL TESTS

A. Trendelenburg (Brodie-Trendelenburg) Test

1. Patient lies supine; leg elevated to empty veins
2. Compress the SFJ with thumb or tourniquet applied to upper thigh
3. Patient stands
4. Observe vein filling pattern

According to Harrison's Principles (p. 7796): "Filling of varicose veins within 30 s indicates varicose veins caused by deep-venous insufficiency and incompetent perforating veins."

B. Multiple Tourniquet Test (Modified Trendelenburg)

• Tourniquets applied at multiple levels (upper thigh, lower thigh, below knee)
• Identifies the specific level of perforator incompetence
• The segment between two tourniquets where veins fill = site of incompetent perforator

C. Perthe's Test

1. Apply tourniquet to upper thigh while patient standing
2. Patient walks/exercises for 5 minutes

Critical for surgery: Perthe's test must be done before surgical intervention.

D. Fegan's Method (for Perforator Mapping)

• Patient stands; mark varices
• Elevate leg; palpate along medial aspect for fascial defects (gaps)
• Fascial defects = sites of perforating vein incompetence
• Most common: Cockett's zone (4–8 cm above medial malleolus)

E. Schwartz (Percussion/Tap) Test

• As described above — confirms blood column continuity

F. Morrissey's Cough Impulse Test

• A cough impulse felt at the SFJ (saphena varix) = SFJ incompetence

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8. CLINICAL IMAGE — Advanced Varicose Veins

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9. INVESTIGATIONS

9.1 Bedside

• Ankle-Brachial Pressure Index (ABPI): Must be >0.8 before applying compression or surgery; rules out arterial disease

9.2 Imaging (First-line)

Duplex Ultrasonography (Gold Standard)

• Combines B-mode ultrasound (anatomy) + Doppler (flow)
• Identifies:
  • Site of SFJ/SPJ incompetence
  • Reflux (retrograde flow >0.5 sec on Valsalva or calf release)
  • Perforator incompetence
  • Deep vein patency/thrombosis
• Mandatory before surgery

Hand-Held Doppler

• Detects reflux at SFJ and SPJ
• Cheaper but less accurate than duplex

9.3 Invasive (Rarely needed)

Ascending Venography

• Contrast injected into foot vein; outlines deep venous system
• Done when Klippel-Trénaunay syndrome or deep venous anomaly suspected

Descending Venography

• Contrast injected at femoral level; shows reflux
• Rarely used; replaced by duplex

9.4 Other

• Plethysmography (air/photoplethysmography) — measures venous refill time; not routinely used
• CT venography / MR venography — for pelvic vein assessment, May-Thurner syndrome

Pre-operative workup (Standard)

• CBC, blood grouping
• RFT, LFT
• Coagulation profile (PT/INR, aPTT)
• Blood glucose
• ECG, Chest X-ray
• Duplex ultrasound

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10. COMPLICATIONS OF VARICOSE VEINS (MBBS Exam — 5 marks commonly)

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11. MANAGEMENT

11.1 Conservative (Non-operative)

1. Compression therapy:
   • Graduated compression stockings (Class II: 18–24 mmHg or Class III: 25–35 mmHg)
   • Compression bandages
   • ABPI must be >0.8 before use
2. Lifestyle modifications:
   • Avoid prolonged standing
   • Regular walking
   • Weight loss
   • Leg elevation (30° above heart level)
3. Medications:
   • Diosmin + Hesperidin (Daflon) — venotonic agents; reduce symptoms
   • Topical steroids for eczema

11.2 Sclerotherapy

• Liquid sclerotherapy — for telangiectasias and small reticular veins
• Foam sclerotherapy (UGFS — Ultrasound-Guided Foam Sclerotherapy) — for larger veins; more effective
  • Sclerosant: Sodium tetradecyl sulphate (STD) or Polidocanol (most used)
  • Mixed with air/CO₂ in 1:4 ratio to create foam (Tessari technique)

• Skin staining (hyperpigmentation)
• Allergic reaction
• Skin necrosis
• DVT, pulmonary embolism (rare)
• Matting (new telangiectasias)
• Visual disturbances (foam)

11.3 Endovenous Thermal Ablation (NICE-recommended first line for truncal veins)

a. Endovenous Laser Ablation (EVLA/EVLT)

• Laser fibre inserted into GSV under ultrasound guidance
• Thermal energy causes vein wall destruction → fibrosis
• Wavelengths: 810–1470 nm
• Done under tumescent anaesthesia
• Day-care procedure; rapid recovery

b. Radiofrequency Ablation (RFA/VNUS Closure)

• Radiofrequency catheter generates heat → collagen contraction → vein closure
• Segmental heating at 120°C
• Comparable outcomes to EVLA; slightly less bruising

11.4 Surgical Treatment

Indications for Surgery

1. Progressive/troublesome symptoms
2. Complications (ulcer, thrombophlebitis, haemorrhage)
3. Cosmetic (patient choice)
4. Failed conservative/sclerotherapy

Pre-operative Requirements

• Perthe's test — deep vein patency confirmed
• Duplex ultrasound mapping
• Mark veins while patient standing (day before surgery)

Operations

A. Trendelenburg Operation (Flush Ligation)

• SFJ ligation: Ligation of GSV at its junction with femoral vein, flush with the femoral vein
• All 5 tributaries at SFJ are also ligated
• Done through groin incision
• Critical point: Must be flush — leaving a stump = Neovascularisation → recurrence

B. Stripping of GSV

• Babcock's stripper inserted into the GSV from groin to knee level (not below knee — risks saphenous nerve injury)
• Vein stripped out
• Combined with SFJ ligation = Trendelenburg + Stripping
• Evidence shows stripping reduces recurrence compared to ligation alone

C. Phlebectomy (Stab Avulsion / Multiple Stab Avulsion)

• Multiple small (2–3 mm) stab incisions
• Varicose tributaries avulsed using hooks
• Excellent cosmetic result
• Done for tributaries not amenable to stripping

D. Subfascial Endoscopic Perforator Surgery (SEPS)

• For incompetent perforating veins
• Endoscopic ligation through small incisions
• Indicated for venous ulcers with perforator incompetence

E. Open Surgery for Perforators — Cockett's Operation

• Direct ligation of Cockett's perforators through a medial incision

Post-operative Care

• Compression bandaging for 1 week, then stockings
• Early ambulation (prevents DVT)
• Analgesics
• Monitor for: haematoma, nerve injury, DVT, wound infection

11.5 Comparative Summary of Treatments

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12. VENOUS ULCER (Important Exam Topic)

Features of Venous Ulcer

Management of Venous Ulcer

1. Four-layer compression bandaging (Charing Cross technique) — cornerstone
2. Wound care: regular dressing, debridement
3. Treat underlying varicose veins (after ulcer healing)
4. Skin grafting (pinch grafts / split-skin grafts) for large ulcers
5. SEPS / perforator ligation if perforator incompetence identified

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13. DIFFERENTIAL DIAGNOSIS WITH DETAILED REASONING

13.1 Deep Vein Thrombosis (DVT)

13.2 Superficial Thrombophlebitis

• A complication of varicose veins rather than a differential
• Presents as painful, tender, cord-like, erythematous superficial vein
• Management: NSAIDs, compression, warm soaks
• Rule out by: tenderness along exact vein cord, no deep swelling, duplex confirms superficial thrombus only

13.3 Lymphoedema

13.4 Klippel-Trénaunay Syndrome (KTS)

• Congenital condition: triad of port-wine stain + limb hypertrophy + varicose veins
• Varicosities are congenital and often involve unusual distributions (lateral aspect)
• Deep veins may be absent or hypoplastic
• Critical: Surgery/stripping CONTRAINDICATED if deep veins are absent (Perthe's test will be abnormal)
• Diagnosed by MRI venography showing deep venous abnormality

13.5 Arteriovenous (AV) Fistula

• Can cause secondary varicose veins with pulsatile flow
• Affected limb may be longer and warmer (due to increased blood flow stimulating bone growth)
• Bruit/thrill over the fistula
• Branham's sign: bradycardia on compression of feeding artery
• Reason to rule out: AV fistula requires separate treatment; vein surgery alone will not correct the cause and varices will recur.

13.6 Arterial Ulcer (vs. Venous Ulcer)

13.7 Marjolin's Ulcer

• Squamous cell carcinoma arising in chronic venous ulcer
• Suspect when: raised, everted edges; rapid growth; failure to heal; bleeding; foul odour
• Reason to rule out: Requires excision with wide margins ± radiotherapy, not just wound care

13.8 Phlebitis Migrans (Migratory Thrombophlebitis)

• Recurrent thrombophlebitis at different sites
• Associated with Buerger's disease, malignancy (Trousseau's syndrome)
• Differentiates from varicose veins by: migratory nature, absence of varicosities, systemic associations
• Reason to rule out: Points to underlying systemic/malignant condition

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14. CASE PRESENTATION — MBBS PRACTICAL EXAMINATION

Model Case

"I am presenting a case of Mr. X, a 45-year-old male, a bus driver by occupation, presenting with dilated, tortuous veins over the medial aspect of the right leg for 10 years, associated with aching pain and heaviness of the right leg, worse after prolonged standing and relieved by limb elevation."

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History

• Onset: Gradual, insidious
• Site: Medial aspect of right leg, extending from ankle to upper thigh
• Duration: 10 years
• Progression: Initially small, now markedly prominent
• Associated symptoms:
  • Aching pain and heaviness — worse after standing, relieved by elevation
  • Ankle swelling in the evening
  • Itching over the inner ankle (venous eczema)
  • Occasional cramps at night
• No sudden severe pain (rules out acute thrombophlebitis)
• No history of DVT, previous leg swelling with fever

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Physical Examination

• Conscious, oriented, afebrile
• BMI: 29 kg/m² (overweight)
• No pallor, icterus, lymphadenopathy

• Dilated, tortuous, prominent veins along the medial aspect of right leg in GSV distribution
• Hyperpigmentation around medial malleolus
• No active ulcer (C4a CEAP)
• No lipodermatosclerosis visible

• Veins are soft and compressible
• No tenderness
• Fascial defect palpable 8 cm above medial malleolus (Cockett's perforator)
• No saphena varix felt

1. Schwartz (Tap) Test: Positive — fluid impulse transmitted from ankle to thigh = confirms continuous varicose veins
2. Trendelenburg Test:
   • Leg elevated → veins empty
   • Tourniquet applied at upper thigh → patient stands
   • Result: Veins remain empty with tourniquet → fill rapidly when tourniquet released
   • Conclusion: SFJ incompetence (positive Trendelenburg)
3. Multiple Tourniquet Test:
   • Tourniquet at upper thigh (empty) + below knee (veins fill in between)
   • Conclusion: Perforator incompetence at mid-thigh level
4. Perthe's Test:
   • Tourniquet applied → patient walks for 5 minutes
   • Result: Veins become less prominent
   • Conclusion: Deep veins are patent — safe to operate
5. Fegan's Test:
   • Fascial gap palpable 8 and 14 cm above medial malleolus
   • Conclusion: Cockett's perforator incompetence

• Duplex Doppler: SFJ incompetence + reflux in GSV; deep veins patent; Cockett's perforator incompetence
• ABPI: 1.0 (normal — no arterial disease)

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Diagnosis

Primary varicose veins of the right lower limb in the GSV distribution with SFJ and Cockett's perforator incompetence — CEAP C4a, Ep, As+Ap, Pr

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Treatment Plan

1. Pre-operatively:
   • Compression stockings (class II)
   • Vein marking while standing (by surgeon, day before surgery)
   • Duplex mapping confirmed
   • Routine pre-op workup (CBC, coagulation, ECG, CXR, blood glucose, renal function)
   • ABPI confirmed >0.8
   • Perthe's test confirmed positive (deep veins patent)
2. Surgery:
   • Trendelenburg operation (flush SFJ ligation) via groin crease incision
   • Babcock's stripping of GSV from groin to just below knee
   • Multiple stab avulsion (phlebectomy) for tributary varices
   • Subfascial ligation of Cockett's perforators (or SEPS)
   • Under spinal/GA
3. Post-operative:
   • Compression bandaging for 1 week
   • Early ambulation from day 1
   • Graduated compression stockings for 6 weeks
   • Review at 6 weeks for residual varices

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15. COMPLICATIONS OF SURGERY

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16. SPECIAL TOPICS (High-Yield Short Notes)

Saphena Varix

• Dilatation of terminal GSV at saphenous opening (SFJ)
• Mimics femoral hernia — bluish, soft, cough impulse positive
• Differentiating features:
  • Disappears on lying down (hernia may not reduce)
  • Fluid thrill transmitted to leg veins
  • No bowel sounds
  • Below and lateral to pubic tubercle (femoral hernia is medial to femoral artery)

Venous Gangrene

• Occurs when deep veins are thrombosed AND superficial veins are removed
• Catastrophic complication — Perthe's test prevents this

Phleboliths

• Calcified thrombi within varicose veins
• Seen on plain X-ray as circular calcific densities
• No treatment needed unless symptomatic

Ankle Flare / Corona Phlebectatica

• Fan-shaped cluster of intradermal varices at the ankle
• Indicates severe chronic venous insufficiency
• CEAP C4 marker

Recurrent Varicose Veins (REVAS — REcurrent Varicose veins After Surgery)

• Causes:
  1. Neovascularisation at SFJ (new vessels grow across ligation)
  2. Inadequate initial surgery (missed tributaries, incomplete stripping)
  3. New disease (different site)
  4. Technical error (ligation not flush)
• Management: UGFS (foam sclerotherapy) is first choice for recurrence; redo surgery if needed

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17. QUICK REVISION TABLE — EXAMINATION SUMMARY

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18. EXAMINATION-STYLE SHORT ANSWERS

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