Varicose Veins — A Surgical Overview

1. Definition and Epidemiology

2. Anatomy of the Venous System

Key Vessels

3. Pathophysiology

Primary Varicose Veins

Secondary Varicose Veins

• Post-thrombotic syndrome (PTS) — DVT destroys valve architecture; the most common secondary cause
• Pregnancy and pelvic tumors (extrinsic compression)
• Arteriovenous fistulae
• Congenital syndromes: Klippel-Trenaunay syndrome, Parkes Weber syndrome, Ehlers-Danlos, May-Thurner syndrome

Hemodynamic Consequences

• Capillary leakage → edema
• Leukocyte adhesion and activation → fibrin cuff deposition, lipodermatosclerosis
• Eventual ulceration (CEAP C6)

4. CEAP Classification (2020 Revision)

5. Clinical Features

Symptoms

• Aching, heaviness, fatigue of the affected limb
• Pruritus over varicosities
• Mild ankle edema — worse at end of day
• All symptoms worsen with prolonged standing/sitting and are relieved by leg elevation

Signs — Progressive Severity

1. Dilated, tortuous, visible superficial veins
2. Telangiectasias and reticular veins
3. Ankle edema
4. Hyperpigmentation (hemosiderin deposition)
5. Lipodermatosclerosis (fibrotic, woody induration of gaiter area)
6. Atrophie blanche (white stellate scarring)
7. Venous ulcer (typically medial malleolus)
8. Thrombophlebitis and variceal bleeding

6. Investigations

Duplex Ultrasonography (DUS) — Gold Standard

• Maps superficial and deep venous anatomy
• Identifies sites of reflux (SFJ, SPJ, perforators)
• Rules out deep venous obstruction or post-thrombotic changes
• Mandatory before any intervention in patients with prior venous surgery, recurrent disease, or suspected deep incompetence
• Reflux is defined as retrograde flow >0.5 seconds after compression release

Other Investigations

• Venography — reserved for complex cases, deep venous reconstruction planning
• Plethysmography — measures venous reflux quantitatively
• CT/MR venography — for suspected iliac outflow obstruction (May-Thurner)

7. Management

7A. Conservative (Non-operative) Management

• First-line treatment for all symptomatic patients
• Graduated compression: 20–30, 30–40, or 40–50 mmHg
• Length: knee-high to waist-high — should cover all symptomatic varices
• Reduces ambulatory venous pressure, relieves symptoms in many patients
• Continue indefinitely to prevent progression

• Weight reduction
• Leg elevation when resting
• Avoidance of prolonged standing
• Regular walking (activates calf muscle pump)

Indications for Intervention

• Symptoms worsen despite compression therapy
• Lipodermatosclerosis or active/healed ulcer (CEAP C4b–C6)
• Thrombophlebitis, variceal bleeding
• Patient preference (cosmesis or significant quality-of-life impairment)
• Randomized trials demonstrate improved quality of life with interventional treatment over compression alone

7B. Sclerotherapy

1. Inject sclerosant into target vein
2. Apply elastic bandage immediately; worn continuously for 3–5 days
3. After bandage removal, wear compression stocking for minimum 2 weeks

• Sclerosant is aerated to form microfoam (Tessari technique)
• Displaces blood, maximizing endothelial contact
• Used for GSV/SSV under ultrasound guidance
• Up to 15 mL foam per session; sessions can be repeated in 24 hours
• Prefabricated polidocanol microfoam (Varithena/PEM) is FDA-approved (2013) for incompetent superficial veins

• Allergic reaction (rare anaphylaxis)
• Local skin hyperpigmentation (~10–30%)
• Superficial thrombophlebitis
• DVT
• Skin necrosis (if perivenous injection)
• Visual disturbances/stroke (paradoxical embolism via PFO — more common with foam)

7C. Endovenous Thermal Ablation (EVTA)

Radiofrequency Ablation (RFA) — ClosureFast™ system

1. Ultrasound-guided percutaneous access (typically at knee level for GSV)
2. Advance catheter to within 2 cm of the SFJ (or 3 cm from SPJ for SSV)
3. Infiltrate tumescent anesthesia (dilute lidocaine + sodium bicarbonate in saline) perivenously under ultrasound — creates thermal barrier, collapses vein
4. Trendelenburg positioning (empties vein of blood)
5. Activate catheter; heat for 20 seconds per segment, withdraw 6.5 cm
6. Repeat until entire treatment length is ablated
7. Apply compression from foot to thigh post-procedure

• Treat four quadrants for 60 seconds each
• Withdraw 5 mm and repeat

Endovenous Laser Ablation (EVLA)

1. Ultrasound-guided access with microsheath and 0.035-inch guidewire
2. Position laser fiber tip ≥2 cm distal to epigastric vein at SFJ (for SSV: ≥3 cm from SPJ)
3. Tumescent anesthesia + Trendelenburg
4. Pull back fiber+sheath 1 cm every 3–5 seconds
5. Energy delivery: 40 J/cm (1470 nm) or 80 J/cm (810 nm)

• Duplex ultrasound at 2–5 days to confirm GSV ablation and exclude DVT/EHIT
• Compression stocking applied immediately and continued

7D. Nonthermal Endovenous Techniques

7E. Open Surgical Management

Saphenous Vein Ligation and Stripping

• GSV diameter >2 cm (too large for thermal ablation)
• Failed endovenous treatment
• Patient/surgeon preference
• Incompetent veins not suitable for catheter-based access

1. Groin incision (medial, over SFJ)
2. Identify and flush ligate the GSV at the SFJ — all tributaries divided (prevents neovascularization/recurrence)
3. Small incision at medial knee or ankle
4. Pass a blunt-tip catheter or invagination pin stripper from groin to knee incision
5. The GSV is invaginated onto the stripper and removed
6. Below-knee stripping is controversial (risk of saphenous nerve injury)

Stab Avulsion Phlebectomy (Ambulatory Phlebectomy)

• Used for large tributary varicosities after axial vein treatment
• 2-mm stab incisions made directly over marked varicosities
• Vein is dissected from subcutaneous tissue and avulsed (pulled out) proximally and distally — no suture ligation required in most cases
• Bleeding controlled by leg elevation + manual compression + tumescent anesthesia
• Performed under local anesthesia; outpatient

SEPS (Subfascial Endoscopic Perforator Surgery)

• Endoscopic division of incompetent perforating veins via ports placed away from diseased skin
• Used in CEAP C4b–C6 patients with perforator incompetence
• Now largely supplanted by ultrasound-guided percutaneous perforator ablation

7F. Pre- and Post-operative Duplex Mapping

• Confirm axial vein obliteration
• Detect EHIT (Endovenous Heat-Induced Thrombus) — classified by Kabnick:
  • EHIT Class 1: Thrombus in GSV only
  • EHIT Class 2: Thrombus at SFJ, not entering femoral vein
  • EHIT Class 3: Partial non-occlusive extension into deep vein → usually anticoagulate
  • EHIT Class 4: Occlusive DVT → 3-month anticoagulation
• EHIT resolves in 7–10 days in most cases

8. Complications of Surgical/Interventional Treatment

9. Management of Complications — Venous Ulcer (CEAP C5/C6)

• Multilayer compression bandaging (≥40 mmHg ankle pressure) — ESVS 2022 Class I recommendation
• Wound care and dressings
• Treat underlying superficial reflux (ablation improves ulcer healing and reduces recurrence)
• Compression stockings lifelong after healing

10. Special Surgical Scenarios

Recurrent Varicose Veins (CEAP C2r)

• Most common cause: neovascularization at the SFJ or missed tributaries at initial surgery
• Re-do surgery in groin is hazardous (lymphatic and nerve injury risk)
• Foam sclerotherapy or EVTA preferred for recurrence
• Always re-map with duplex before re-intervention

Varicose Veins in Pregnancy

• Conservative management (ECS) for duration of pregnancy
• Majority improve postpartum — defer definitive treatment for 3–6 months post-delivery
• Intervention only if thrombophlebitis, ulceration, or severe symptoms

Bleeding Varicose Vein (Emergency)

• Leg elevation is the single most effective emergency maneuver
• Direct firm pressure
• Rarely requires emergency surgery; consider injection sclerotherapy under elective conditions once bleeding controlled

11. Summary: Treatment Algorithm

Varicose Veins (Symptomatic)
         |
         ▼
Duplex Ultrasonography
         |
     ┌───┴────────────────────────┐
     │                            │
Deep venous disease?       Superficial reflux only
(post-thrombotic)           (GSV/SSV)
     │                            │
 Conservative                     ▼
 + treat                  CEAP C1: Sclerotherapy /
 underlying DVT            transcutaneous laser
                                  │
                          CEAP C2–C6: Endovenous ablation
                          (EVTA = RFA or EVLA) — preferred
                                  │
                          Adjunct: Phlebectomy for tributaries
                                  │
                    Surgical stripping (GSV >2 cm or failed EVTA)
                                  │
                          Compression therapy lifelong