Varicose Veins

Definition

Clinical Photograph

Epidemiology

• Adult prevalence: 30-50% of the general population
• More common in women than men
• Prevalence increases with age - from 11.5% (age 18-24) to 55.7% (age 55-64) per the Edinburgh Vein Study
• Risk factors: pregnancy, family history, increasing BMI and height, possibly prolonged standing
• Less common in primitive/rural communities (Africa, Far East)

Pathophysiology

• Inflammatory cell infiltration and activation
• Dysfunctional smooth muscle cell proliferation
• Collagen deposition, decreased elastin content
• Increased matrix metalloproteinases
• Net result: loss of compliance → dilatation → elongation (tortuosity) → secondary valvular dysfunction

• Primary: valvular incompetence, vein wall weakness
• Secondary: obstruction to venous return - pregnancy, pelvic tumours (fibroid, ovarian cyst, carcinoma cervix/rectum), ascites, abdominal lymphadenopathy, retroperitoneal fibrosis
• Congenital: arteriovenous fistula (in younger patients)

CEAP Classification

Symptoms

• Aching, heaviness, throbbing, burning, or bursting sensation in the legs
• Symptoms worsen throughout the day or with prolonged standing
• Relieved by elevation and compression hosiery
• Ankle swelling (especially by end of day)
• Pruritus (itching), especially with complications
• Night cramps
• Bursting pain on walking (suggests associated deep vein thrombosis)

Clinical Signs

• Tortuous dilated subcutaneous veins
• Distribution gives clue to axis involved:
  • Medial thigh/calf → GSV incompetence
  • Posterolateral calf → SSV incompetence
  • Anterolateral thigh/calf → AAGSV incompetence
• Saphena varix: dilated vein at the SFJ appearing as a groin lump, disappears when recumbent (can mimic a femoral hernia - impulse on coughing)
• Skin changes: pigmentation, eczema, lipodermatosclerosis, venous ulcer (medial malleolus)

Investigation

• Presence and distribution of reflux in deep and superficial systems
• Anatomy of the SFJ and SPJ
• Presence of deep vein thrombosis or obstruction
• Location of incompetent perforators

Treatment

Conservative

• Compression hosiery (first-line for symptom relief)
• Leg elevation, weight loss, exercise
• Useful as trial to confirm symptoms are venous before intervention

Interventional (current evidence)

• Endovenous Laser Ablation (EVLA): Laser fibre inserted under ultrasound guidance; perivenous tumescent anaesthesia used; energy delivered as fibre is withdrawn. Highest technical efficacy.
• Radiofrequency Ablation (RFA): Uses radiofrequency energy via catheter. Comparable efficacy to EVLA with possibly less post-procedural pain.
  • A 2024 meta-analysis (Jiang et al., J Vasc Surg Venous Lymphat Disord, PMID 38316290) found RFA and EVLA have comparable clinical outcomes; RFA may have slight advantage in post-operative comfort.

• Sclerosant (e.g., sodium tetradecyl sulphate or polidocanol) mixed with air/gas to create foam
• Ultrasound-guided for truncal veins
• Can be used alongside thermal ablation for tributaries

• Micro-incisions (2-3 mm) to remove varicosities
• Often combined with truncal ablation in same sitting

• Flush ligation of SFJ + stripping of GSV
• Now less commonly performed; reserved for recurrent disease, complex anatomy, or where endovenous techniques are unavailable

Complications

Differential Diagnosis of Varicose Veins (causes of dilated leg veins)

• Primary (idiopathic) varicose veins
• Secondary to DVT (post-thrombotic syndrome)
• Secondary to pelvic obstruction (pregnancy, tumour)
• Congenital AV fistula (Klippel-Trenaunay syndrome - port wine stain + limb hypertrophy + varicosities)
• May-Thurner syndrome (iliac vein compression)

• Bailey and Love's Short Practice of Surgery, 28th Edition, pp. 1047-1060
• S. Das: A Manual on Clinical Surgery, 13th Edition, pp. 105-109
• Pfenninger and Fowler's Procedures for Primary Care, 3rd Edition

Venous System of the Lower Limb

1. Overview

• Venous valves (preventing reflux)
• Calf muscle pump (augmenting flow during exercise)
• Respiratory/thoracic pressure changes

2. Deep Venous System

Leg (Crural Veins)

• Anterior tibial veins (paired) - accompany anterior tibial artery
• Posterior tibial veins (paired) - accompany posterior tibial artery
• Peroneal (fibular) veins (paired) - accompany peroneal artery

• Soleal veins - drain the soleus muscle (form a sinus/plexus - a common site for DVT initiation)
• Gastrocnemius veins - drain both heads of gastrocnemius

Popliteal Fossa

Thigh

Pelvis and Abdomen

• External iliac vein + Internal iliac vein → Common iliac vein
• Left common iliac vein passes behind the right common iliac artery (clinically important - site of May-Thurner compression syndrome)
• Right and left common iliac veins join on the right side of the aorta → Inferior vena cava → Right atrium

3. Superficial Venous System

3A. Great Saphenous Vein (GSV)

• Superficial external pudendal vein
• Superficial circumflex iliac vein
• Superficial epigastric vein
• Anterior femoral cutaneous vein
• Posteromedial thigh tributary
• Anterolateral thigh tributary

• One of the most common tributaries
• Originates around the lateral border of the knee (sometimes from the lateral end of the dorsal venous arch)
• Courses anterolateral to the GSV
• Drains into the GSV at or near the SFJ
• Commonly mistaken for the GSV on duplex scan ("duplex GSV" - a true duplicated GSV is rare)

3B. Small Saphenous Vein (SSV)

3C. Veins of the Foot

Because the sole bears significant weight and pressure, most venous drainage of the foot is via the dorsal venous arch rather than the plantar surface.

4. Perforating (Communicating) Veins

5. Venous Physiology - Calf Muscle Pump

• Calf muscle contraction compresses the deep veins
• Valves direct flow upward (antegrade)
• Superficial pressure falls to ~25 mmHg
• On stopping exercise, pressure rises slowly back to resting level (refilling time)

6. Summary: Flow Pathway

Foot veins (dorsal venous arch / plantar network)
         ↓
Great saphenous vein        Small saphenous vein
(medial)                    (posterior)
         ↓                          ↓
Saphenofemoral junction     Saphenopopliteal junction
(common femoral vein)       (popliteal vein)
         ↓
     Femoral vein
         ↓
  + Profunda femoris vein
         ↓
  External iliac vein
         ↓
  Common iliac vein
         ↓
  Inferior vena cava
         ↓
   Right atrium

• Bailey and Love's Short Practice of Surgery, 28th Edition, pp. 1046-1049
• Gray's Anatomy for Students, p. 671
• THIEME Atlas of Anatomy: General Anatomy and Musculoskeletal System, p. 551
• Color Atlas of Human Anatomy, Vol. 2 (Internal Organs), pp. 144-146

Treatment and Operation of Varicose Veins - Detailed

Indications for Treatment

• Symptomatic varicose veins (aching, heaviness, swelling, itching) not responding to conservative measures
• Complications: superficial thrombophlebitis, haemorrhage, chronic skin changes (pigmentation, eczema, lipodermatosclerosis)
• Active or healed venous ulceration
• Cosmetic concerns (selected cases)
• Evidence of GSV/SSV incompetence on duplex ultrasound

Pre-treatment Assessment

• Presence and location of reflux in the deep and superficial systems
• Diameter and tortuosity of incompetent truncal veins
• Patency of the deep venous system (DVT must be excluded)
• Location of the SFJ/SPJ
• Presence of incompetent perforators
• Pelvic source of reflux

Overview of Treatment Options

┌────────────────────────────────────────────────────────────┐
│              TREATMENT OF VARICOSE VEINS                    │
├──────────────────┬─────────────────────────────────────────┤
│  Conservative    │  Compression, elevation, lifestyle       │
├──────────────────┼─────────────────────────────────────────┤
│  Interventional  │  Thermal ablation (EVLA, RFA)            │
│                  │  Non-thermal ablation (MOCA, CAC, PEM)   │
│                  │  Sclerotherapy (liquid/foam/UGFS)         │
│                  │  Open surgery (ligation + stripping)      │
│                  │  Phlebectomy (ambulatory / TriVex)        │
│                  │  Perforator ligation (SEPS)               │
└──────────────────┴─────────────────────────────────────────┘

A. Conservative Treatment

1. Compression Therapy

• Elastic compression stockings (class I: 14-17 mmHg; class II: 18-24 mmHg; class III: 25-35 mmHg)
• Mechanism: reduces superficial venous pressure, augments calf muscle pump, reduces oedema
• First-line for symptom relief and in patients unsuitable for intervention
• Also used as a trial to confirm symptoms are venous before committing to surgery
• Worn after all interventional procedures to improve results

2. Lifestyle Modifications

• Leg elevation (above heart level when resting)
• Regular walking (activates calf muscle pump)
• Weight loss (reduces venous pressure)
• Avoid prolonged standing

3. Pharmacotherapy

• Venoactive drugs (phlebotonic agents): horse chestnut seed extract (aescin), ruscus extract, micronized purified flavonoid fraction (diosmin + hesperidin), pentoxifylline
• Some evidence for reduction in leg heaviness and oedema; insufficient evidence for routine recommendation
• No FDA-approved drugs specifically for chronic venous insufficiency
• Diuretics: may reduce oedema but risk volume depletion and renal compromise
• Topical steroids: short-term use for stasis dermatitis only

B. Endovenous Thermal Ablation

General Procedure (Common to both EVLA and RFA)

1. Pre-procedure: Patient stands; duplex scan marks the truncal vein and varicosities
2. Positioning:
   • GSV treatment: supine, hip externally rotated, slightly flexed
   • SSV treatment: prone position
3. Percutaneous access: Ultrasound-guided cannulation at the lowest point of reflux
4. Catheter/fibre advancement: Tip positioned under ultrasound guidance just below the SFJ (position is controversial - some place several cm distal to junction, others aim for flush occlusion)
5. Perivenous tumescent anaesthesia (PVTA): Critical step - dilute local anaesthetic (e.g. lignocaine + adrenaline in saline) injected around the vein under ultrasound guidance, creating a "halo" around the vein. Purposes:
   • Anaesthesia
   • Compresses vein around catheter (reduces diameter, improves contact)
   • Heat sink (protects surrounding tissues)
6. Energy delivery during catheter withdrawal
7. Compression applied immediately after

1. Endovenous Laser Ablation (EVLA)

• Bare-tip (forward firing): concentrates energy in a small area
• Divergent forward-firing: spreads energy over larger area
• Divergent side/radial firing: even distribution, postulated to reduce vein wall perforations, pain and bruising

• Better for very large diameter veins (>15 mm) - can increase energy delivery
• Lower consumable costs
• Catheter can be used to treat perforators without additional devices

• Requires specific laser safety protocols for room design and staff training
• More operator-dependent (power settings and pullback speed must be manually controlled)
• Marginally more peri-procedural pain and bruising

2. Radiofrequency Ablation (RFA)

• Metal coil at catheter tip (3 cm and 7 cm coil options)
• Generator maintains 120°C for a 20-second treatment cycle
• Catheter withdrawn a set distance → next cycle commenced
• Single button press per cycle - automated, frees operator's attention

• Shorter learning curve - automated treatment cycle, less chance of energy delivery error
• Marginally less post-procedural pain and bruising
• Frees operator to communicate with patient and perform concurrent phlebectomy
• No laser safety protocols required

• Less suitable for very large diameter veins
• Higher consumable cost than EVLA (device-specific catheter)
• Specific additional device needed for perforator treatment

EVLA vs RFA Comparison

C. Non-thermal, Non-tumescent Ablation (NTNT)

1. Mechanochemical Ablation (MOCA) - ClariVein®

1. Mechanically abrades the venous endothelium
2. Simultaneously infuses liquid sclerosant via catheter → deeper penetration into wall
3. Combined mechanical + chemical injury causes fibrosis and occlusion

• No tumescent anaesthesia needed
• Less painful than thermal ablation (for axial treatment alone)
• Suitable for patients with needle phobia

• Some patients find it uncomfortable
• Device can "snag" on tortuous veins, occasionally tearing or stripping the vein
• Similar early efficacy to thermal ablation but increased medium/long-term recanalisation rates
• Catheter length limits treatment of long veins
• When combined with phlebectomy, the pain advantage over thermal ablation is lost

2. Cyanoacrylate Adhesive (CAC) - VenaSeal™

• Ultrasound-guided catheter access (micropuncture system)
• Catheter advanced to SFJ; pulled back 3 cm distal to junction
• Glue applied at 2-3 cm intervals during catheter withdrawal
• Continuous manual compression with ultrasound probe at SFJ during injection (to prevent glue embolisation to deep system)
• Catheter captured within sheath before removal (prevents glue extravasation into subcutaneous tissue)

• No tumescent anaesthesia
• Minimal intra-procedural pain
• Can access distally (near ankle) without nerve injury concern

• Highest consumable cost of any venous ablative technique
• Allergic reactions to cyanoacrylate (ranging from mild inflammation to tissue necrosis) - screen for prior adhesive allergy
• Long-term data still limited

3. Polidocanol Endovenous Microfoam (PEM) - Varithena®

• Ultrasound-guided access (micropuncture system) placed as distally as possible
• PEM injected 1-2 mL/second through sheath
• Limb elevated >45° during injection to reduce DVT risk
• Digital occlusion of perforator veins during injection
• Compression at SFJ during treatment
• Post-procedure: 20-30 mmHg compression stocking; ambulate within the hour
• Duplex scan at 2-5 days post-procedure

D. Sclerotherapy

1. Liquid Sclerotherapy

• Sodium tetradecyl sulphate (STS / Fibrovein)
• Polidocanol (Aethoxysclerol)
• Sodium morrhuate
• Glycerin (for telangiectasia)

• Telangiectasia and reticular veins
• Small varicose tributaries
• Residual veins after truncal ablation

2. Ultrasound-Guided Foam Sclerotherapy (UGFS)

• Displaces blood from vein (maximises endothelial contact)
• Larger volume effect with smaller drug dose
• Echogenic under ultrasound - visible during injection

• Two syringes connected by a three-way tap
• 1:3 or 1:4 sclerosant:air drawn into one syringe
• Vigorously oscillated between syringes 10-20 times
• Foam stable for ~2 minutes - inject immediately

1. Leg elevated to empty veins
2. Cannulate vein under ultrasound guidance
3. Inject foam into superficial varicosities first, then the GSV/SSV
4. Maximum 1-2 mL per injection; distribution monitored with ultrasound probe
5. Stop when foam visualised at junctional incompetence
6. Maximum total dose: 10-12 mL per session (complication risk rises with larger volumes)
7. Apply compression after

• No tumescent anaesthesia (less painful procedure)
• All veins suitable regardless of tortuosity
• Can treat calf veins beneath damaged/ulcerated skin without needle puncture through the damage
• Very low consumable cost
• Useful adjunct for treating neovascularisation, residual tributaries

• Significantly lower long-term efficacy → higher re-intervention rates
• Higher rates of phlebitis and post-procedural pigmentation
• Complications: DVT, haematoma, nerve injury (saphenous/sural), hyperpigmentation, skin necrosis (if inadvertent subcutaneous injection), anaphylaxis (rare but severe)

E. Open Surgery

1. Saphenofemoral Junction (SFJ) Ligation and GSV Stripping (Trendelenburg Operation)

Figure: SFJ ligation showing flush ligation at femoral vein with tributaries divided - Bailey & Love, p.1059

Figure: GSV stripping - flush SFJ ligation (upper inset) and pin stripping at knee (lower inset) - Bailey & Love, p.1059

1. Anaesthesia: General or spinal (rarely local alone)
2. Patient position: Supine; varicosities marked preoperatively while standing
3. Groin incision: Oblique incision lateral to pubic tubercle, above the groin crease
4. Dissection: GSV identified and traced to SFJ; anatomy confirmed before any division
5. Tributaries ligated at SFJ (the 6 tributaries encountered):
   • Laterally: superficial inferior epigastric vein, superficial circumflex iliac vein
   • Medially: superficial external pudendal vein, deep external pudendal vein
   • Distally: anterior accessory GSV, posteromedial thigh vein
6. Flush SFJ ligation: GSV ligated flush with the common femoral vein
7. Retrograde stripping: A stripper passed from the groin down to approximately the knee (stripping to ankle increases saphenous nerve injury risk)
8. Phlebectomy of remaining varicosities via stab incisions
9. Closure: Cribriform fascia closure does not reduce groin recurrence

Note on neovascularisation: Surgical trauma in the groin triggers formation of new, valve-less veins that may bridge the ligated junction to tributaries - a major cause of recurrence. This theoretical concern has led some surgeons to avoid flush junction ligation, though there is no clear clinical evidence to support this.

2. Saphenopopliteal Junction (SPJ) Ligation and SSV Stripping

Figure: Preoperative duplex marking of the SPJ and SSV - Bailey & Love, p.1059

• Duplex mapping of the SPJ is mandatory before surgery (highly variable anatomy)
• Position: Prone
• Incision: Transverse over pre-marked SPJ
• Dissection: Fascia divided, SSV exposed; SPJ dissected and ligated (flush or proximal to SSV)
• Flush ligation: avoids leaving a stump (common recurrence site), but risks popliteal vein and nerve injury
• Simple SSV ligation: safer for nerves and popliteal vein, but higher recurrence from residual stump
• SSV stripping: reduces recurrence but increases sural nerve injury risk
• Phlebectomy performed after SPJ ligation

F. Phlebectomy (Ambulatory / Stab Avulsion)

• Adjunct to truncal ablation for removal of varicose tributaries
• Sole treatment for isolated tributary incompetence

1. Varicosities marked preoperatively while standing
2. Local tumescent anaesthesia injected
3. 2-3 mm stab incisions along Langer's lines at 2 cm intervals over varicosities
4. Vein retrieved through incision with mosquito forceps or phlebectomy hook
5. Continuous traction to maximise vein removal
6. Direct pressure after avulsion
7. Compression dressing applied; patient walks same day
8. Compression stockings worn for 2 weeks

TriVex (Transilluminated Powered Phlebectomy)

• Useful for extensive branch varicosities
• 2 mm incisions at varicosity boundaries
• Transilluminator: illuminates veins from below AND delivers tumescent anaesthesia
• Resector: rotating blade transects and aspirates veins
• Requires fewer incisions than standard phlebectomy but associated with more bruising and haematoma

G. Perforator Ligation

• Endoscope introduced subfascially via two small ports remote from damaged skin
• Incompetent perforators identified and clipped/divided
• Mainly used in patients with venous ulcers or significant skin changes
• Evidence for benefit is limited - most randomised data are lacking
• Perforators can also be ablated with endovenous laser (EVLA through a stab incision)

H. EHIT (Endovenous Heat-Induced Thrombus)

Complications of Surgery

Recurrent Varicose Veins

1. Neovascularisation - new valve-less veins bridging ligated junction to tributaries
2. Reflux in residual axial vein (inadequate initial treatment)
3. Inadequate initial surgery
4. New junctional reflux

Treatment Algorithm (Current Best Practice)

Symptomatic varicose veins
        ↓
Duplex ultrasound assessment
        ↓
   Truncal incompetence?
    /              \
   YES              NO (isolated tributaries)
    ↓                     ↓
First line:         Phlebectomy or
Endovenous          sclerotherapy
thermal ablation
(EVLA or RFA)
   +
Concurrent/staged phlebectomy
or foam sclerotherapy for tributaries
        ↓
Unsuitable for thermal ablation
(very tortuous, needle phobic)?
        ↓
MOCA or CAC (NTNT) or
UGFS or open surgery

• Bailey and Love's Short Practice of Surgery, 28th Edition, pp. 1046-1060
• Sabiston Textbook of Surgery, 21st Edition, pp. 2410-2412
• Harrison's Principles of Internal Medicine, 22nd Edition, pp. 2225-2226
• S. Das: A Manual on Clinical Surgery, 13th Edition, pp. 105-109