VARICOSE VEINS OF THE LOWER LIMBS

INTRODUCTION

A) SURGICAL ANATOMY

1. Superficial Venous System

• The longest vein in the body, arising from the medial end of the dorsal venous arch of the foot
• Passes anterior to the medial malleolus, up the medial aspect of the leg and thigh
• Terminates at the saphenofemoral junction (SFJ), where it pierces the cribriform fascia of the fossa ovalis to drain into the femoral vein, approximately 3.5 cm inferolateral to the pubic tubercle
• At the SFJ, the GSV receives 4-6 major tributaries: superficial external pudendal, superficial circumflex iliac, superficial epigastric, and antero-lateral and postero-medial thigh tributaries
• A sapheno-varix at the SFJ can mimic a femoral hernia - it disappears on lying down and a fluid thrill can be elicited

• Arises from the lateral end of the dorsal venous arch
• Passes posterior to the lateral malleolus up the posterior calf
• Pierces the deep fascia in the popliteal fossa and drains into the popliteal vein at the saphenopopliteal junction (SPJ)
• The level of the SPJ is variable - typically at or above the popliteal skin crease
• The SSV system accounts for approximately 20% of varicose vein cases

2. Deep Venous System

3. Perforating (Communicating) Veins

• Dodd's perforators - medial mid-thigh (Hunter's canal level)
• Boyd's perforator - medial upper calf, just below the knee
• Cockett's perforators (I, II, III) - posteromedial lower calf (the Cockett group, 7, 10, 13 cm above the medial malleolus) - most clinically significant; incompetence causes perimalleolar varicosities, lipodermatosclerosis, and ulcers
• Paratibial perforators - medial calf
• Posterior tibial perforators
• May's perforator - posterolateral lower calf (SSV territory)

4. Fascial Compartment and Venous Physiology

B) DEFINITION

• Telangiectasias: Intradermal venules < 1 mm (spider veins)
• Reticular veins: Dilated subdermal veins 1-3 mm, not palpable
• Varicose veins: Subcutaneous veins > 3 mm, tortuous, palpable, often visible

C) CLASSIFICATION - CEAP

C - Clinical Classification

• S - Symptomatic (pain, heaviness, muscle cramps, pruritus)
• A - Asymptomatic

E - Etiological Classification

• Ec - Congenital (present since birth; e.g., Klippel-Trenaunay syndrome)
• Ep - Primary (intrinsic wall/valve defect; no identifiable cause)
• Es - Secondary (post-thrombotic; DVT-related)
• En - No venous etiology identified

A - Anatomical Classification

• As - Superficial veins
• Ap - Perforating veins
• Ad - Deep veins
• An - No venous location identified

P - Pathophysiological Classification

• Pr - Reflux
• Po - Obstruction
• Pr,o - Both reflux and obstruction
• Pn - No venous pathophysiology identifiable

D) ETIOPATHOGENESIS

Etiology

• Heredity: Autosomal dominant with variable penetrance; familial susceptibility is well-established. Risk increases significantly if both parents are affected
• Sex: Higher prevalence in females (hormonal influences - estrogen/progesterone relax smooth muscle, promote venous distension)
• Pregnancy: Multiple mechanisms - increased blood volume, hormonal effects, mechanical compression of iliac veins by the gravid uterus. Risk rises with each successive pregnancy
• Occupation: Prolonged standing (surgeons, teachers, hairdressers) - evidence is inconclusive but long-standing occupation is a recognized risk
• Obesity: Increased intra-abdominal pressure and adipose tissue compressing veins
• Age: Prevalence increases with age - from 11.5% in 18-24 year age group to 55.7% in 55-64 year age group (Edinburgh Vein Study)
• Height: Tall individuals have greater hydrostatic pressure columns

• Deep vein thrombosis (post-thrombotic syndrome) - destroyed valves cause reflux with high pressure transmitting to superficial system
• Arteriovenous fistula (congenital or acquired) - increased venous pressure
• Pelvic masses, pregnancy, or tumors compressing the iliac veins
• Klippel-Trenaunay syndrome (congenital)

Pathogenesis

• Capillary distension and leakage of fibrinogen and red blood cells into the dermis
• Pericapillary fibrin cuff formation (Browse-Burnand theory) - acts as a barrier to oxygen diffusion
• Activation of leucocytes (leucocyte trapping theory) - leucocytes release proteolytic enzymes damaging the dermis
• Iron deposition from extravasated RBCs - produces hemosiderin pigmentation
• Progressive fibrosis - lipodermatosclerosis, leading to ulceration

E) CLINICAL FEATURES

History

• Cosmetic concern - the most common presenting complaint; unsightly dilated, tortuous, prominent veins
• Aching and heaviness in the leg, worse toward the end of the day and after prolonged standing, relieved by elevation and compression
• Throbbing, burning, or bursting sensation
• Ankle swelling - particularly in the evenings, resolves overnight
• Pruritus - especially over prominent varicosities
• Nocturnal cramps - particularly in the calf
• Symptoms are independent of the severity of the disease; even mild varicosities can cause significant symptoms

Examination

• Tortuous, dilated, raised, bluish-green subcutaneous veins most visible in the standing position
• Distribution: Medial thigh/calf = GSV incompetence; posterolateral calf = SSV incompetence; anterolateral thigh/calf = AAGSV incompetence
• Saphena varix - soft, compressible swelling at the groin (SFJ area) that disappears on lying down; cough impulse positive; may be confused with a femoral hernia
• Skin changes in advanced disease: eczema (stasis dermatitis), pigmentation (hemosiderin), lipodermatosclerosis, atrophie blanche, ulceration around the gaiter area

• Soft, compressible veins that empty on elevation and fill on standing
• Tenderness if thrombophlebitis is present

Special Clinical Tests

• Patient lies down; leg is elevated to empty the veins
• A tourniquet is applied at the upper thigh (SFJ level)
• Patient stands up
• Interpretation:
  • Veins remain empty with tourniquet in situ, fill rapidly when tourniquet is released = SFJ incompetence (positive Trendelenburg)
  • Veins fill slowly from below despite tourniquet = perforator incompetence below tourniquet level
  • Can be performed at multiple levels to map incompetent perforators

• Tourniquet applied to the mid-thigh in the standing patient
• Patient walks to activate the calf pump
• Normal/deep vein patent: Veins empty on walking
• Deep vein obstructed: Veins become more distended and painful on walking - contraindication to surgery

• Hand placed over the SFJ; patient coughs
• A visible or palpable impulse transmitted downward along the GSV = SFJ incompetence

• One hand on SFJ, other percusses varicosity below
• Impulse transmitted upward = incompetent continuous column of blood in GSV

F) COMPLICATIONS

Chronic Complications:

1. Venous eczema (stasis dermatitis): Erythema, scaling, and weeping of the skin around the ankle; due to pericapillary fibrin deposition and leucocyte activation
2. Hyperpigmentation: Dark brownish discoloration around the gaiter area from hemosiderin deposition
3. Lipodermatosclerosis: Fibrosis and sclerosis of the dermis and subcutaneous tissue; causes an inverted champagne bottle deformity; a pre-ulcerative state
4. Atrophie blanche: White stellate scars from healed areas of ischemia; marker of severe disease
5. Venous ulcer: Occurs in the gaiter area (medial malleolus), shallow with sloping edges and a base of granulation tissue; characteristically painless unless infected; perpetuated by venous hypertension

Acute Complications:

1. Superficial thrombophlebitis: Thrombosis of a varicose vein; presents as a painful, tender, erythematous, indurated cord along the course of the vein; low-grade fever; treated with compression, NSAIDs, and analgesics; risk of extension to deep system (1-10%)
2. Hemorrhage (Bleeding): Often follows minor trauma to a dilated, thin-walled vein; can be profuse, as the combination of high venous pressure and dependent position drives bleeding; life-threatening in the elderly. Emergency treatment: Patient should lie down, elevate the limb, and apply a firm pressure bandage
3. Calcification: Phleboliths may form in long-standing varicosities
4. Secondary infection: Cellulitis over varicosities

G) INVESTIGATIONS

1. Clinical Assessment Tools (Historically used, now largely abandoned)

• Tourniquet tests, tap test, cough impulse test
• Hand-held continuous-wave Doppler (HHD) - used to detect reflux at SFJ and SPJ; now superseded by duplex

2. Duplex Ultrasonography (Gold Standard Investigation)

• Most important investigation - now mandatory before any intervention
• High-frequency linear array transducer (7.5-13 MHz)
• Provides real-time B-mode imaging combined with pulsed-wave Doppler and color Doppler
• Information obtained:
  • Presence and extent of reflux in superficial and deep systems
  • Exact distribution of reflux (which junctions, perforators)
  • Deep venous patency and obstruction
  • Diameter, extent, and tortuosity of incompetent veins (guides treatment selection)
  • Retrograde flow > 0.5 seconds on Valsalva or calf release = pathological reflux
• Enables anatomical mapping for procedure planning
• Can distinguish SVT from DVT
• Essential before endovenous ablation (laser, RFA) - maps cannulation site, vein diameter

3. Photoplethysmography (PPG)

• Non-invasive; measures dermal blood content changes as surrogate for venous pressure
• Used to differentiate superficial from deep venous disease
• Venous refill time < 20 seconds = venous incompetence

4. Venography (Phlebography)

• Contrast injection into dorsal foot vein; ascending venography for deep vein patency
• Descending venography for deep valve incompetence
• Now rarely performed; reserved for complex cases before deep venous reconstruction

5. Air Plethysmography

• Quantifies venous function: venous reflux, calf muscle pump function, residual volume fraction

6. MR/CT Venography

• For complex cases: suspected pelvic vein pathology, Nutcracker syndrome, May-Thurner syndrome

7. Blood Investigations

• Routine blood count, coagulation studies (before surgery)
• Thrombophilia screen in patients with history of DVT or recurrent thrombosis

H) MANAGEMENT

1. Conservative Management

• Elevation of the limb: Reduces venous pressure; limb elevated above heart level during rest
• Compression hosiery: Graduated compression stockings (20-30 mmHg class I; 30-40 mmHg class II; 40-50 mmHg class III). Applied in the morning before rising, compress superficial veins, reduce venous pooling, and improve calf pump efficiency
• Lifestyle modifications: Weight reduction, regular calf exercise (walking), avoiding prolonged standing, avoiding constricting garments
• Leg exercises: Calf-raise exercises augment the muscle pump
• Provides symptomatic relief but does not cure the underlying incompetence and does not prevent long-term progression

BISGAARD'S METHOD OF TREATMENT

• Complete rest with the limb elevated above the level of the heart (45 degrees or higher) for a period, to reduce venous hypertension, resolve edema, and allow skin healing (particularly important in cases with venous eczema, lipodermatosclerosis, or pre-ulcerative changes)

• Application of non-elastic (inelastic) compression bandaging over the elevated limb
• The Unna boot or zinc paste bandage may be applied; the bandage is changed periodically
• Creates high working pressure during ambulation (calf muscle contraction against the inelastic bandage) and low resting pressure

• Once the limb swelling has resolved and skin changes have improved, below-knee graduated compression elastic stockings (Class I-III as needed) are fitted
• Long-term wear of stockings is the cornerstone of ongoing management

• Active ankle and calf exercises (dorsiflexion/plantar flexion) and walking to activate the calf muscle pump
• These exercises maximize venous return and maintain improvements achieved by compression

• Mild-to-moderate varicose veins in elderly/unfit patients
• Active venous ulceration (preparation for surgery or as definitive treatment)
• Pregnant patients
• Patients refusing surgical intervention
• As post-operative adjunct following surgical treatment

2. Injection Sclerotherapy

• Sodium tetradecyl sulfate (STS / Sotradecol) - detergent
• Polidocanol (Aethoxysclerol)
• Ethanolamine oleate
• Hypertonic saline (23.4%)

• Foam sclerotherapy (Tessari method) - air and liquid sclerosant mixed to form foam; greater contact with vein wall; more effective for larger veins; can be ultrasound guided

• Patient standing; vein entered with fine needle; patient lies supine; sclerosant injected; limb immediately compressed with firm bandaging (to press vein walls together and prevent thrombosis)
• Bandage worn for 3-7 days; compression stocking for 2-6 weeks

3. Endovenous Thermal Ablation (Minimally Invasive)

• Laser fiber (810-1470 nm) inserted percutaneously under ultrasound guidance into the GSV or SSV
• Perivenous tumescent anaesthesia injected
• Laser energy applied during catheter withdrawal - heats vein wall to 75-80°C; causes denaturation of collagen and endothelium; vein wall contracts, lumen obliterates
• No incisions; minimal bruising; rapid return to normal activity
• Closure rate >95% at 5 years

• Radiofrequency energy applied segmentally (20-second cycles) heating vein to 120°C
• Similar efficacy and safety to EVLA; often less post-procedure pain

• Rotating wire mechanically damages endothelium + simultaneous liquid sclerosant delivery
• No tumescent anaesthesia required; suitable for needle-phobic patients

• Cyanoacrylate adhesive applied endoluminally; no tumescent anaesthesia
• Promising early results; highest consumable cost

4. Open Surgical Treatment

• Symptomatic varicosities with SFJ or SPJ incompetence
• GSV or SSV truncal reflux unfit for endovenous ablation
• Failed endovenous treatment, recurrent disease
• Tortuous or very large veins unsuitable for catheter passage

• Ligation and division of the GSV flush at the SFJ
• All SFJ tributaries (typically 4-6) must be individually identified, ligated, and divided - a "flush ligation" prevents neovascularization and recurrence
• Done under general or regional anesthesia

• A flexible wire stripper is passed into the GSV from the groin incision down to just below the knee
• The vein is stripped out (invagination / PIN stripping technique preferred) - removes the vein along with mid-thigh perforators (Dodd's perforators)
• Stripping below the knee is generally avoided (risk of damage to the saphenous nerve)

• Small (2-3 mm) stab incisions over marked varicose tributaries
• Vein hook used to deliver segments of vein, which are then avulsed
• Performed at same sitting as high ligation and stripping

• SPJ flush ligation through a transverse popliteal crease incision
• Stripping of the SSV

• Endoscopic ligation of incompetent Cockett's perforators
• Used in advanced disease (C4b-C6) with medial gaiter ulceration resistant to conservative therapy
• Has largely been replaced by ultrasound-guided foam sclerotherapy of perforators

• Compression bandaging immediately post-operatively
• Compression stockings for 4-6 weeks
• Early ambulation encouraged
• Return to activity within 1-2 weeks

Indications Summary for Intervention

SUMMARY