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Varicose Veins - In-Depth (30 Marks)

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Definition

• Reticular veins: dilated intradermal veins, blue-green, 1-3 mm, do not protrude
• Telangiectasias (spider/thread veins): <1 mm, near skin surface, forming linear or spider-web patterns

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Clinical Photo

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Epidemiology

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Anatomy Relevant to Varicose Veins

Superficial Venous System

• Great Saphenous Vein (GSV): longest vein in the body; originates medial foot, ascends anterior to medial malleolus, along medial calf and thigh, drains into the common femoral vein at the saphenofemoral junction (SFJ)
• Small Saphenous Vein (SSV): originates dorsolateral foot, ascends posterior to lateral malleolus, drains into the popliteal vein at the saphenopopliteal junction (SPJ)

Deep Venous System

• Paired anterior tibial, posterior tibial, and peroneal veins converge to form the popliteal vein - femoral vein - common femoral vein - external iliac - IVC

Perforating Veins

• Connect superficial to deep system; normally allow blood flow from superficial to deep; bicuspid valves throughout direct flow centrally

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Classification

Primary vs. Secondary

• Originate in the superficial system
• Result from intrinsic weakness of the vein wall, defective valve structure/function, and high intraluminal pressure
• ~50% have a family history

• Result from deep venous hypertension
• Causes: deep-vein thrombosis (post-thrombotic syndrome), deep venous obstruction, incompetent perforating veins, arteriovenous fistulas, Klippel-Trenaunay syndrome

CEAP Classification (Clinical-Etiology-Anatomy-Pathophysiology)

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Pathophysiology

1. Valve Incompetence and Reflux

• Normal valves direct blood centrally (toward the heart)
• Valve leaflet failure allows retrograde flow (reflux) when standing
• Superficial reflux is defined as retrograde flow lasting >0.5 seconds; deep vein reflux >1 second

2. Vein Wall Changes

• Inflammatory cell infiltration and activation
• Dysfunctional smooth muscle cell proliferation
• Collagen deposition
• Decreased elastin content
• Increased matrix metalloproteinases (MMPs)
• These lead to loss of compliance, dilatation, elongation (causing tortuosity), and secondary valvular dysfunction

3. Downstream Consequences

• Venous hypertension causes increased capillary pressure
• Extravasation of fluid, red blood cells, and fibrin into tissues
• RBC breakdown leads to haemosiderin deposition (pigmentation)
• Fibrin pericapillary cuffing impairs tissue oxygenation
• Chronic inflammation leads to lipodermatosclerosis and ulceration

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Clinical Features

Symptoms

• Aching, heaviness, throbbing, burning, or bursting sensation
• Symptoms worsen throughout the day and with prolonged standing
• Relieved by elevation or compression hosiery
• Itching (more common with complications)
• Ankle swelling
• Unsightly cosmetic appearance

Signs

• Tortuous, dilated subcutaneous veins - visible and palpable
• GSV incompetence produces medial thigh and calf varicosities
• SSV incompetence produces posterolateral calf varicosities
• AAGSV incompetence produces anterolateral thigh and calf varicosities
• Saphena varix: a painless groin swelling apparent on standing, disappears on lying (can mimic a hernia; impulse on cough)

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Complications

Chronic Complications (skin changes)

Acute Complications

1. Superficial vein thrombosis (thrombophlebitis): painful, red, indurated cord along varicosities
2. Bleeding: from ruptured varicosities - can be severe and alarming (especially at night); first aid is elevation and pressure
3. Deep vein thrombosis (less common, associated with propagation of SVT)

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Investigations

Duplex Ultrasound (Investigation of Choice)

• Tourniquet tests and handheld Doppler have been abandoned in favour of duplex ultrasound
• All patients should undergo duplex scanning before intervention
• Performed with patient standing
• High-frequency linear array transducer: 7.5-13 MHz
• Aims to establish:
  1. Presence and distribution of reflux in deep and superficial systems
  2. Exact extent of reflux including affected junctions and perforators
  3. Deep venous obstruction
  4. Suitability of veins for specific treatments (diameter, extent, tortuosity)
  5. Presence of deep venous disease

Bedside Tests (Historical - now replaced by duplex)

• Brodie-Trendelenburg test: Leg elevated to empty veins, tourniquet applied to proximal thigh, patient stands. Rapid refilling after tourniquet removal = superficial incompetence. Filling while tourniquet is on = deep venous insufficiency
• Perthes test: Tourniquet applied, patient walks. If veins empty = deep system patent. If veins distend = deep obstruction

Other Investigations

• Plethysmography (photoplethysmography/air plethysmography) - assesses overall venous function
• Venography - reserved for complex/recurrent cases
• CT/MRI venography - for pelvic venous insufficiency or suspected outflow obstruction

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Differential Diagnosis

• Lymphoedema: non-pitting, no varicosities, Stemmer's sign positive
• Deep vein thrombosis: acute, painful, warm
• Congestive cardiac failure: bilateral pitting oedema
• Hypoalbuminaemia (nephrotic syndrome, liver disease): bilateral oedema
• Lipoedema: bilateral, spares the foot, painful
• Arteriovenous fistula (secondary varicosities with bruit/thrill)
• Klippel-Trenaunay syndrome: port-wine stain + varicosities + limb hypertrophy

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Management

Conservative (Non-operative) Management

1. Compression hosiery (stockings):
   • Graduated compression: 20-30 mmHg, 30-40 mmHg, 40-50 mmHg
   • Knee-high to waist-high
   • Relieves symptoms in many patients; does not cure the underlying reflux
2. Lifestyle modifications:
   • Weight reduction
   • Avoid prolonged standing
   • Regular walking (calf muscle pump activation)
   • Leg elevation

Indications for Active Intervention

• Symptoms worsening or unrelieved by compression
• Lipodermatosclerosis
• Venous ulcer (healed C5 or active C6)
• Recurrent superficial thrombophlebitis
• Bleeding varicose veins
• Significant cosmetic concern

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Interventional Management Options

1. Endovenous Thermal Ablation (FIRST-LINE - minimally invasive)

• Flexible glass fibre inserted into the vein
• Laser energy (typically 1470 nm wavelength) transmitted to the tip
• Vigorous thermal energy generation causes vein wall destruction
• Suitable for any vein accepting a guidewire
• Higher efficacy in large diameter veins (>15 mm)
• Requires laser safety protocols

• Uses metal coil catheter (e.g. ClosureFast)
• Automatic treatment cycle on single button press - shorter learning curve
• Slightly less pain and bruising post-procedure
• Less suitable for large diameter veins

2. Foam Sclerotherapy (Ultrasound-Guided Foam Sclerotherapy - UGFS)

• Sclerosant solution made into foam using Tessari method (1:3 or 1:4 ratio of sclerosant to air oscillated between two syringes via 3-way tap)
• Common agents: sodium tetradecyl sulfate, polidocanol
• Destroys venous endothelium; vein fibroses
• Leg elevated before injection; maximum 10-12 mL per session
• Advantages: no tumescent anaesthetic, treats tortuous veins, can treat over damaged skin, low cost
• Disadvantages: lower efficacy than thermal ablation, higher reintervention rates, risk of phlebitis and pigmentation
• Liquid sclerotherapy used for telangiectasias (smaller concentrations)

3. Mechanochemical Ablation (MOCA - e.g., ClariVein)

• Rotating wire disrupts endothelium mechanically; sclerosant delivered simultaneously
• No tumescent anaesthetic required
• Good for smaller veins; does not require thermal energy

4. Cyanoacrylate Glue Ablation (VenaSeal)

• Medical adhesive injected into the vein, sealing it shut
• No tumescent anaesthetic
• No compression hosiery required post-procedure

5. Surgical Treatment (Still indicated in selected cases)

• Under general or spinal anaesthesia
• Groin crease incision to expose SFJ
• Tributaries ligated (superficial inferior epigastric, superficial circumflex iliac, external pudendal veins)
• Flush SFJ ligation performed
• GSV stripped retrogradely to the knee using a stripper
• Concurrent avulsion phlebectomy (stab avulsion) of varicosities via 2-3 mm incisions

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Complications of Surgery / Treatment

Complications of Standard Varicose Vein Surgery

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Varicose Veins in Special Circumstances

Varicose Veins and Pregnancy

• Hormonal changes (progesterone) cause vein wall relaxation
• IVC compression by gravid uterus raises venous pressure
• Management: compression hosiery throughout pregnancy; definitive treatment deferred until 3-6 months after delivery

Bleeding Varicose Veins

• May be life-threatening in elderly patients on anticoagulants
• First aid: lie patient flat, elevate limb, apply firm pressure
• Definitive treatment: injection sclerotherapy or surgery

Venous Ulcers

• C6 CEAP; typically near medial malleolus
• Shallow, irregular border, granulation tissue base
• Management: compression bandaging (multilayer), treatment of underlying reflux, wound care
• Compression increases healing rates (Cochrane Review)
• Physiotherapy (leg exercises, calf pump activation) also beneficial

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Summary Table: Treatment Options

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Recent Evidence (2024-2025)

• A 2025 systematic review (PMID 41390389) comparing endovenous ablation vs surgical stripping found that endovenous techniques achieve comparable or superior clinical effectiveness with better patient-reported outcomes, supporting their use as first-line intervention.
• A 2024 systematic review (PMID 39025298) on anatomical reflux patterns confirmed that GSV reflux is the most common pattern in primary chronic venous disease, informing targeted treatment planning.
• A 2025 systematic review (PMID 40504402) confirms physiotherapy (calf exercises, compression, positioning) improves venous ulcer healing alongside standard wound care.

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Key Points for Exam

1. Varicose veins = dilated superficial veins ≥3 mm with valvular reflux
2. Prevalence 30-50%; increased risk with female sex, age, pregnancy, family history, obesity
3. Primary (intrinsic valve/wall defect) vs. secondary (DVT, AV fistula)
4. CEAP classification C0-C6 is the gold standard for clinical staging
5. Pathophysiology: valve failure → retrograde flow → chronic venous hypertension → skin changes → ulceration
6. Investigation of choice: duplex ultrasound standing with augmentation
7. Management ladder: compression → endovenous thermal ablation (first-line) → foam sclerotherapy → surgery
8. EVLA and RFA are equally effective; RFA has slightly lower pain; EVLA better for very large veins
9. Complications include thrombophlebitis, bleeding, chronic skin changes, and venous ulceration
10. Saphenous nerve injury is the key nerve injury in GSV stripping below the knee

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• Bailey & Love's Short Practice of Surgery, 28th Edition
• Harrison's Principles of Internal Medicine, 22nd Edition (2025)
• Schwartz's Principles of Surgery, 11th Edition
• Gray's Anatomy for Students
• Lim EQ et al. BMC Surg 2025 [PMID 41390389]
• Tan MKH et al. J Vasc Surg Venous Lymphat Disord 2024 [PMID 39025298]

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• Title block with colour-coded section pills
• Section 1 - Definition & Classification: venous spectrum table (telangiectasia → reticular → varicose), primary vs secondary side-by-side comparison boxes

• Section 2 - CEAP Classification: full C0–C6 table with colour-coding (red for C6, green for C5, amber for C4) and management actions per class
• Section 3 - Clinical Assessment Algorithm: 5 step-by-step numbered flowchart steps (History → Examination → Duplex USS → Secondary causes → CEAP grading) with a clinical pearl banner on duplex replacing tourniquet tests

• Section 4 - Management Algorithm: visual flowchart-style layout - conservative vs intervention branches, deep system patent/obstructed decision tree, intervention selection
• Section 5 - Treatment Modalities Table: EVLA, RFA, UGFS, MOCA, VenaSeal, Surgery, Compression - mechanism, anaesthesia, best use, key points

• Section 6 - Special Situations: colour-coded boxes for venous ulcer, thrombophlebitis, bleeding varicosities, pregnancy, recurrence
• Section 7 - Complications Table: chronic + acute + post-treatment complications with management
• Section 8 - Duplex USS Quick Reference: protocol checklist + reflux definitions side-by-side
• Section 9 - Clinical Pearls: 15 high-yield facts including 2025 evidence (PMID 41390389)
• References from Bailey & Love 28th Ed, Harrison's 22nd Ed, Schwartz's 11th Ed

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Structure

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The 10 Cases & 15 Questions

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Answer Key Features

• Quick reference answer grid at the top (all 15 answers at a glance)
• Full explanation for each correct answer (mechanism + clinical reasoning)
• Explanation for each distractor (why each wrong option is wrong)
• Self-assessment scoring guide (Excellent/Good/Average/Needs Improvement)
• Referenced to Bailey & Love, Harrison's, Schwartz's, and 2024-25 PubMed evidence