Varicose veins

  • Varicose veins affect
    • 20-25% of adult females
    • 10-15% of adult males
  • 75,000 operations are performed annually in United Kingdom
  • 20% of operations are for recurrent disease

Assessment of varicose veins

  • History
    • Poor correlation exists between symptoms and signs
    • Cough, tap and thrill tests are inaccurate
    • Important to identify those with history of DVT or lower limb fracture
    • If history of DVT need preoperative investigation with duplex scanning
  • Examination
    • Identify distribution of varicose veins - long saphenous (LSV) vs short saphenous (SSV)
    • Confirm with tourniquet testing and hand held-doppler probe (5 MHz)
    • Recurrent varicose veins need duplex ultrasound
    Varicose veins Varicose veins

Indications for duplex scanning

  • Suspected short saphenous incompetence
  • Recurrent varicose veins
  • Complicated varicose veins (e.g. ulceration, lipodermatosclerosis)
  • History of deep venous thrombosis 

Indications for varicose vein surgery

  • Most surgery is cosmetic or for minor symptoms
  • Absolute indications for surgery :

    • Lipodermatosclerosis leading to venous ulceration

    • Recurrent superficial thrombophlebitis

    • Bleeding from ruptured varix

LSV surgery

  • Trendelenberg position with 20 - 30° head down
  • Legs abducted 10 -15°
  • Saphenofemoral junction (SFJ) found 2 cm below and lateral to pubic tubercle
  • Essential to identify SFJ before performing flush ligation of  the LSV
  • Individually divide and ligate all tributaries of the LSV
    • Superficial circumflex iliac vein
    • Superficial inferior epigastric vein
    • Superficial and deep external pudendal vein
  • Check that femoral vein clear of direct branches for 1 cm above and below SFJ
  • Stripping of LSV reduces risk of recurrence
  • Only strip to upper calf. 
  • Stripping to ankle is associated with increased risk of saphenous neuralgia
  • Post operative care:
    • Elevate foot of bed for 12 hours
    • Class 2 varix stocking should be worn for at least 2 weeks

SSV surgery

  • Patient prone with 20-30° head down
  • Saphenopopliteal junction (SPJ) has very variable position
  • Preoperative localisation with duplex ultrasound is strongly recommended
  • Identify and preserve the sural nerve
  • Need to identify the SPJ
  • Stripping associated with risk of sural nerve damage
  • Subfascial ligation inadequate

Perforator surgery

  • Significance of perforator disease is unclear
  • Perforator disease may be improved by superficial vein surgery
  • Perforator surgery (e.g. Cockett's and Todd's procedure) associated with high morbidity
  • Subfascial endoscopic perforator surgery (SEPS) recently described
  • Not indicated for uncomplicated primary varicose veins
  • May have a role in addition to saphenous surgery in those with venous ulceration

Sclerotherapy

  • Only suitable for below knee varicose veins
  • Need to exclude SFJ or SPJ incompetence
  • Main use is for persistent or recurrent varicose veins after adequate saphenous surgery
  • Sclerosants
    • 5% Ethanolamine oleate
    • 0.5% Sodium tetradecyl sulphate
  • Different to sclerosants used for haemorrhoids
  • Needle placed in vein when full with patient standing
  • Empty vein prior to injection
  • Apply immediate compression and maintain for 4-6 weeks
  • Do not exceed maximum volume 
  • Injection about 5 sites possible

Complications of sclerotherapy

  • Extravasation causing pigmentation or ulceration
  • Deep venous thrombosis

Recurrent varicose veins  

  • 15 - 25 % of varicose vein surgery is for recurrence
  • Outcome of recurrent varicose veins surgery is less successful
  • Can be avoided with adequate primary surgery

Reasons for recurrence

  • Inaccurate clinical assessment
    • Confusion as to whether varicosities are in LSV or SSV distribution
    • Can be avoided with use of hand held doppler
  • Inadequate primary surgery
    • 10% cases SFJ not correctly identified
    • 20% cases tributaries mistaken for LSV
    • Failure to strip LSV
  • Injudicious use of sclerotherapy
    • 70% of those with SF incompetence treated with sclerotherapy alone will develop recurrence
  • Neovascularisation
    • With recurrent varicose vein need to image with duplex or varicography

Bibliography

Bradbury A,  Evans C J,  Allan P et al.  The relationship between lower limb symptoms and superficial and deep venous reflux on duplex ultrasonography:  the Edinburgh vein study.  J Vasc Surg 2000;  32:  921-931.

Campbell B.  Short saphenous varicose veins.  Curr Pract Surg 1995:  7; 195-199.

Campbell B.  Clinical and hand-held doppler examination of primary varicose veins.  Ann R Coll Surg Eng 2001:  83:  289-291.

Coleridge-Smith P D.  Modern approaches to venous disease.  In: Johnson C D, Taylor I. eds.  Recent advances in surgery 23.  Edinburgh,  Churchill Livingstone, 2000:  125-140.

Gillies T E,  Ruckley C V.  Surgery for recurrent varicose veins.  Curr Pract Surg 1996:  8:  22-27.

Kim J,  Richards S,  Kent P J.  Clinical examination of varicose veins - a validation study.  Ann R Coll Surg Eng 2000;  82:  171-175.

Sarin S,  Scurr J H,  Coleridge-Smith P D.  Stripping of the long saphenous vein in the treatment of primary varicose veins.  Br J Surg 1994:  81; 1455-1458.

Tennant W G,  Ruckley C V.  Medicolegal action following treatment for varicose veins.  Br J Surg 1996:  83;  291-292.

Wolf B,  Brittenden J.  Surgical treatment of varicose veins.  J Roy Coll Surg Ed 2001;  46:  150-153.

 

 
 

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