Varicose Veins

Definition

Anatomy & Pathophysiology

• Long (great) saphenous vein (GSV) - drains into the femoral vein at the sapheno-femoral junction (SFJ)
• Short (small) saphenous vein (SSV) - drains into the popliteal vein at the sapheno-popliteal junction (SPJ)
• Perforating (communicating) veins link the superficial to the deep system

1. Competent one-way valves preventing reflux
2. The calf muscle pump during walking
3. Negative intrathoracic pressure

Aetiology

Primary (majority)

• Cause is not fully known; valves are intrinsically weak
• Familial/genetic predisposition - a 2025 meta-analysis (PMID: 40319023) identified rare variation in PTPRB gene associated with varicose veins
• Erect posture (unique to humans) - increases hydrostatic pressure in leg veins
• Standing occupation (conductors, policemen, tram drivers)
• Female sex (hormonal factor - progesterone causes smooth muscle relaxation in vein walls)

Secondary

• Deep vein thrombosis (DVT) - post-thrombotic valve destruction (most important secondary cause)
• Pregnancy - uterine compression + hormonal effects
• Abdominal/pelvic tumours (fibroids, ovarian cysts, lymphadenopathy) compressing iliac veins
• Retroperitoneal fibrosis
• Ascites
• Congenital arteriovenous fistula (in younger patients)

History Taking

Clinical Examination

Inspection (standing position)

• Distribution of dilated, tortuous veins along GSV or SSV territory
• Skin changes: pigmentation, eczema, lipodermatosclerosis
• Venous ulcers (typically at the lower third of the medial leg)
• Ankle oedema

Clinical Tests

• Elevate the leg to empty the veins
• Compress the SFJ with a finger/tourniquet
• Ask the patient to stand
• If veins remain empty on standing = sapheno-femoral incompetence confirmed
• On releasing compression, rapid filling from above confirms SFJ incompetence

Trendelenburg's test - Pye's Surgical Handicraft 22nd Ed.

• Tap the most prominent varicosity
• A fluid impulse felt at the saphenous opening indicates absent/incompetent valves between the two fingers

• Tests deep vein patency
• Tourniquet applied to the thigh; patient asked to walk briskly
• If varicosities empty = deep veins are patent (perforators functioning)
• If varicosities become more prominent or painful = deep veins are blocked (do NOT strip; it is the only venous drainage!)

• Leg elevated, then placed back down
• Patient coughs forcibly
• Expansile impulse felt at the saphenous opening = sapheno-femoral valve incompetence

• Mark points of excessive bulge while standing
• Elevate leg; palpate along the varicosities for gaps/pits in the deep fascia = sites of incompetent perforators

Investigations

• Duplex ultrasound - gold standard; identifies site of reflux (SFJ, SPJ, perforators), maps the vein anatomy, confirms deep vein patency, guides intervention
• Doppler - hand-held directional Doppler to detect reflux in superficial veins
• Venography - now largely replaced by duplex
• Ambulatory Venous Pressure (AVP) - AVP >80 mmHg predicts 80% incidence of venous ulceration - Schwartz's Principles of Surgery, 11th Ed.
• Plethysmography - non-invasive assessment of venous reflux and calf pump function

Complications

1. Haemorrhage - profuse due to high venous pressure; treat with leg elevation
2. Superficial thrombophlebitis - vein becomes tender, firm, red, hot; sometimes extremely painful
3. Venous ulceration - usually at lower third medial leg; shallow, flat floor with pink granulation; edge is sloping, pale purple-blue; surrounding pigmentation and induration
4. Pigmentation - haemosiderin deposition from RBC extravasation
5. Eczema/Dermatitis - pruritic rash overlying varices
6. Lipodermatosclerosis - skin thickening and fibrosis from fibrin accumulation and white cell activation
7. Calcification of vein wall (phleboliths)
8. Periostitis - in long-standing ulcer over tibia
9. Equinus deformity - from chronic pain causing habitual tip-toe walking -> Achilles tendon shortening
10. Marjolin's ulcer - malignant transformation (squamous cell carcinoma) in a long-standing venous ulcer (raised, everted edge; enlarged inguinal lymph nodes)

CEAP Classification (Chronic Venous Disease)

Treatment

1. Conservative

• Compression stockings (graduated elastic support) - suitable for elderly/unfit, pregnant patients, mild disease
• Weight reduction, regular exercise, leg elevation
• Avoid prolonged standing

2. Injection Sclerotherapy

• Sclerosant (e.g. ethanolamine, sodium tetradecyl sulphate, or foam sclerotherapy using polidocanol/STS) is injected into the vein lumen
• Vein is immediately compressed and firmly bandaged for at least 7 days
• Causes fibrosis and obliteration of the lumen
• Limitation: does not address the source of incompetence at the junction - higher recurrence rate than surgery
• Best for: reticular veins, telangiectases, small residual varicosities

3. Endovenous (Minimally Invasive) Techniques - now first-line

• Laser (EVLA/EVLT) - 810-1470 nm diode laser; heat destroys vein wall endothelium
• Radiofrequency Ablation (RFA/EVRF) - e.g. ClosureFAST; RF energy causes collagen contraction and fibrosis
• Requires tumescent anaesthesia (perivenous instillation of dilute local anaesthetic + adrenaline)
• Protects surrounding structures and causes vein compression
• A 2024 meta-analysis (PMID: 38316290) comparing RFA vs EVLA found similar efficacy; RFA associated with less post-procedure pain and bruising

• Spinning angled wire damages endothelium + simultaneous liquid sclerosant injection
• No tumescent anaesthesia required
• Useful for needle-phobic patients; similar early efficacy to endothermal, but higher medium-term recanalisation rates

• Cyanoacrylate adhesive injected to seal the lumen
• Minimal intraprocedural pain, no tumescent needed
• Highest consumable cost; long-term data still emerging

4. Open Surgery (traditional - now largely second-line)

• High ligation of GSV flush at SFJ (Trendelenburg operation)
• All tributaries at the SFJ are ligated (reducing neovascularisation and recurrence)
• GSV is then stripped (invagination technique) using a wire stripper
• Followed by phlebectomy (stab avulsions) of varicose tributaries through 2-mm incisions

• Preoperative duplex marking of SPJ is mandatory
• Patient prone; transverse incision over SPJ; SSV ligated flush or proximally
• SPJ stripping vs proximal resection - risk of sural nerve injury

• Minor and major complications in up to 20% of patients
• Wound infection (most common) - reduced by prophylactic antibiotics
• Nerve injury (saphenous nerve after GSV stripping; sural nerve after SSV procedures)
• Haematoma, DVT, recurrence (from neovascularisation at the SFJ)

Special Considerations

• Pregnancy: Treat conservatively with compression stockings until 6 weeks post-delivery; then re-evaluate
• Deep vein obstruction: If Perthes' test is positive (deep veins blocked), surgical stripping is absolutely contraindicated - the varicose veins are the only route of drainage
• Venous ulcers: Treat the underlying incompetence surgically; local wound care, four-layer compression bandaging; skin grafting for resistant cases
• NICE guidelines (UK): Endothermal ablation is the first-line treatment; foam sclerotherapy second; open surgery third

• S Das Manual on Clinical Surgery, 13th Ed.
• Pye's Surgical Handicraft, 22nd Ed.
• Bailey and Love's Short Practice of Surgery, 28th Ed.
• Schwartz's Principles of Surgery, 11th Ed.
• Current Surgical Therapy, 14th Ed.
• RFA vs EVLA meta-analysis: Jiang et al. 2024 (PMID: 38316290)
• PTPRB genetics: Rämo et al. 2025 (PMID: 40319023)