GenSurg.nz

Varicose veins

Section: Vascular Sub-section: Curriculum, page 101

Definition

  • Abnormal tortuous dilated lengthened superficial veins - usually affect the legs
  • Spider veins = Fine, thin cutaneous veins, diameter ≈ 1mm and are visually prominent
  • Lower limb vascular anatomy

Incidence

  • Overall prevalence (Europe & North America)
    • 22% men
    • 35% women
  • 3-11% have clinical signs of chronic venous insufficiency

CEAP Classification

Aetiology

  • Primary / Familial
    • Most Common
    • Failure of the unidirectional valves of the deep or superficial system
    • Usually begins with SFJ valve failure → Abnormal dilatation of superficial veins
    • ↑ Venous pressure 2° to damage to valves between superficial & deep systems (e.g. SFJ / SPJ / perforators)
    • 70% saphenous incompetence (80-90% GSV, 10-20% SSV)
    • 20% incompetent perforators
  • Secondary
    • Post-thrombotic
    • ↑ Venous pressure 2° to obstruction of blood flow – e.g. from Pelvic thrombosis, AVM, DVT → Valvular / perforator incompetence
    • Congenital malformations of veins (Klippel-Trenaunay Syndrome)
    • Iatrogenic = Varicosities deliberately created in patients with renal failure: AV fistulae for dialysis

Risk Factors

  • Caucasians
  • Obese
  • Age > 50
  • Pregnancy – Progesterone causes venous dilation ⇒ Incompetence
    • Oestrogen – softening collagen
  • Strong FHx
  • COC
  • Occupations involving long periods of standing

Pathology

  • Aetiology
    • Primary - Valve incompetence
      • Phlebectasia of saphenous veins near their terminations → Valve leaflets don’t meet
      • ? Due to alterations in gene expression & metalloproteinases & extracellular matrix components
    • Secondary:
  • Sequele
    • Venous reflux → venous hypertension → capillary distension
    • Increased hydrostatic pressure leads to:
      • Extravasation of red cells → breakdown to hemosiderin → pigmentation and further inflammation
      • Chronic inflammation due to extravasation and activation of the immune system leads to fibrin cuff formation around capillaries → impaired oxygen/nutrient diffusion
      • Leukocyte activation and adhesion → inflammatory mediator release → endothelial damage → microvascular thrombosis → tissue ischemia
  • Tissue effects contributing to ulceration
    • Edema → impaired clearance of inflammatory products → further tissue injury
    • Hypoxia at the microcirculatory level despite intact arterial flow
    • Skin changes: lipodermatosclerosis, atrophie blanche, eczema, induration

Clinically

  • Symptoms
    • Dull aching leg pain & heaviness; most severe in evening; exacerbated by long periods of standing & relieved by lying down/leg elevation & support stockings
    • Cutaneous itching, throbbing and night cramps may also occur
    • Worse first few days of menstrual cycle
    • Swelling
    • Bleeding
  • Asymptomatic

Examination

  • Look

    • Areas
      • Examine in standing position with groin and leg exposed
      • Externally rotate each leg then turn around
      • As with the post-thrombotic limb, an incompetent GSV disrupts the capillary circulation around the ankle, which may lead to venous hypertensive changes in gaiter area
      • Distribution and extent of varicosities – esp. Saphenovarix
    • Presence of skin changes of chronic venous stasis
      • Varicose eczema
      • Lipodermatosclerosis = Fibrosis of s/c tissues with fat necrosis & chronic inflammatory changes → Hard tissue
      • Champagne leg
      • Hemosiderin pigmentation / hyperpigmentation
      • Induration
      • Ulceration (esp. at med ankle) ± surrounding white scarred areas (atrophie blanche)
      • Corona phlebectatica = Cluster of telangiectasia over the medial ankle (distended subdermal & intradermal venules)
      • Look for thrombophlebitis – 40% associated with DVT

  • Feel:

    • Pulses
      • Check arterial status – distal pulses
      • If not palpable – ABPI
    • Other
      • Feel for temperature differences
      • Check for pitting oedema
      • Look for scars from previous repairs/abdominal surgery
      • Veins tense on palpation & cough impulse may be elicited at SFJ
      • Saphena varix - soft compressible dilatation of GSV adjacent to SFJ

  • Special Tests

    • Cruveihier’s Sign
      • Thrill over saphena varix on coughing
    • Chevrier’s Sign
      • Impulse felt over SFJ if saphenous vein is distally percussed
    • Trendelenburg Test
      • Direct digital pressure over the SFJ preventing retrograde filling of the GSV
    • Brodie-Trendelenburg Test
      • Tourniquet test to identify the sites of reflux from deep to superficial vein systems
        • With pt lying:
        • Tourniquet applied to elevated limb just below groin
        • Patient stands up
        • Normal: vein fills within 35secs from below with tourniquet in situ
        • Rapid filling of veins below the tourniquet indicates short saphenous vein incompetence or an incompetent perforator distally
        • Tourniquet removed after 60 secs
        • If rapid filling from above, it is due to incompetence above the tourniquet (i.e. SFJ)
        • Tourniquet can then be repositioned distally to find the level of incompetence or two tourniquet can be used to define an incompetent communicating vein
        • Trendelenburg test becoming obsolete
        • Sensitivity for GSV incompetence = 55%, SSV incompetence = 35%
    • Perthes Test
      • Assesses patency of deep veins
        • Pt standing and veins filled
        • Tourniquet is applied to mid-thigh
        • Pt walks for 5 minutes
        • If Saphenous Veins collapse below the tourniquet = Deep veins are patent and the communicating veins are competent
        • If unchanged = Both saphenous and communicating veins are incompetent
        • If the veins ↑ in prominence and pain occurs = Deep veins are occluded
    • Hand-held Doppler Test:
      • Traditional tests have poor diagnostic value
      • Using hand-held doppler the examiner ask pt to wt bear on the contralateral leg
      • Locate femoral pulse then move medially – confirm vein by squeezing and releasing the calf to hear antegrade flow. Move inf to locate SFJ – squeeze calf to get antegrade flow and listen for reflux – can test SSV also
    • Pressure Changes
      • Normal
        • P drops from 90mmHg to < 20mmHg on 10s exercise
        • P returns to 90mmHg over > 20sec rest
      • Primary Varicose Veins
        • P drops from 90 mmHg to 20-40mmHg on 10s exercise
        • P returns in about 10s
      • Post thrombotic syndrome
        • P drop if present is minor (perhaps down to 60-70)
        • P returns in about <10s

        • 60 – risk of ulceration > 50%

    • Incompetent perforators
      • May be found clinically as gaps in the fascia → Aneurysm-like distension can be palpated as a soft compressible lump
        • INDIRECT – to a muscular deep vein
        • DIRECT – to one of the main deep veins
      • “Horny dogs breed chaos”
      • Hunterian – middle 1/3 of thigh (level of adductor canal)
      • Dodd – distal 1/3 of thigh
      • Boyd – around knee & upper 1/3 of medial calf – MOST COMMON
      • Cockett (I-III)– distal calf – connects to Posterior Arch Vein
      • Inframalleolar

  • Percussion impuls

    • Can palpate for a transmitted percussion impulse from above downwards → Implies absent / incompetent valves

  • NB: Relying on examination alone

    • Inappropriate surgery in 12-25%
    • Recurrence & re-op rate of 10% after 2 yrs (cf 2% if scanned)
    • Most pts with venous ulcers have incompetent communicating veins

Investigations

  • Aim
    • Identify the site(s) of incompetence and confirm deep venous patency
  • Duplex USS – Gold standard
    • Confirm site of incompetence & for assessment of deep veins
    • Reflux = Reversed flow > 0.5 s after release of distal calf squeeze
  • Indications:
    • Recurrent varicose veins
    • Hx of DVT
    • Popliteal reflux (difficult to characterise which vessel it is in this region)
    • Venous HT skin changes
    • Now generally accepted to be required for all pts in whom surgery is being considered
    • Re-op rate for recurrence is less (< 2% vs ≈ 10%) if pre-op Duplex was done

Treatment

Conservative

  • Preferred for:
    • Pregnant pts
    • Elderly with significant comorbidities
    • Mild symptoms
    • Pts not wanting invasive treatment
  • Weight loss
  • Elevation – 2 times per day “toes above the nose”
  • Exercise
  • Compression Stockings
    • Good evidence for healing ulcer (C6) and preventing recurrence (C5)
    • Need to exclude PVD (arterial disease) - ideally ABPI
    • Classification
      • NB: TEDS (Thrombo-embolism Deterrent Stockings) = 10mmHg
      • Class 1: 14 - 17mmHg at ankle
        • Not very effective, maybe use in pregnancy
      • Class 2: 18 - 24mmHg
        • Commonly used, especially post-procedural
      • Class 3: 25 - 35mmHg
        • Often difficult to put on or remove
      • Class 4: 35 - 50mmHg
        • For Lymphedema & Elephantiasis
    • Contraindications: PVD (ABPI < 0.8)
    • Actions
      • ↓ Stasis / ↑ Venous return
      • Improves incompetent valves, lymphatic return & fibrinolytic activity of venous wall
    • Practicalities:
      • Worn continuously when not in bed
      • Stockings can be washed
      • Replace stockings every 6 months
    • Compliance major issue - < 50% compliance in some studies

Invasive

  • Anatomy realting to ablation
    • Axial - SV and SSV
    • Non-axial - all the other small veins that flow into the SV and SSV
    • Perforators
  • Indications for axial ablation
    • Edema, dilated veins or varicosities
    • Documented axial venous reflux on USS
      • retrograde flow >0.5 second
    • Symptomatic
    • Persistent symptoms despite 6-8 weeks of conservative care
  • Indications for perforator ablation
    • Issues despite axial ablation and proven perforator on USS
  • Surgical vs endovenous
    • Long-term outcomes (recanalization, recurrence) are similar
    • Immediate postoperative outcomes are improved for endovenous ablation

Surgery

  • Saphenous ligation with stripping
    • Pre-op marking indicated as reduces recurrence rate (definitely need it if want to deal to SSV as its course & termination highly variable)
    • Procedure
      • Mark all sx varicosities to be avulsed
      • Groin crease incision over the SFJ
      • Dissection down to SFJ and isolate the SV + tie of tributaries as required
      • Ligation of SFJ
        • Should involve flush saphenofemoral ligation/disconnection (also expose femoral vein 2cm proximal & distal to ensure there are no accessory vessels which may lead to recurrence) and long saphenous vein stripping (with ‘phlebectomies’ of venous side branches)
      • Create a venotomy in the SV and pass the flexible stripper
      • Pass the stripper to the level of the knee
      • Make a small incision at this level
      • Dissect and ligate and divide the SV at this level
      • The SV is then attached to the stripper by either suturing it to it or attaching the removable tip
      • It is then removed in a proximal to distal direction
      • Strip GSV to below knee, avulsion of perforators
        • Don’t strip GSV below knee - Perforators probably drain to Posterior Arch Vein & increased risk of Saphenous Nerve damage
      • Strip down, also apply inversion stripping – reduces risk of lymphatic or nerve damage
      • Perforators
        • Ligate incompetent perforators
  • Considerations
    • Appropriate in pts with reflux isolated to superficial veins
    • May be beneficial for pts with mixed superficial and segmental deep reflux
    • Segmental reflux in the deep veins is reversed in ≈ 50% of cases by ablative superficial venous surgery, as is reflux in calf perforating veins
    • Surgery to correct venous reflux in the deep veins is complex and of unproven value
    • Surgery for perforators should be reserved for the few (2-3%) with isolated calf perforator incompetence & ulceration
    • Pregnancy: Delay Rx for > 6 months after delivery, as may resolve
  • Post-op:
    • Leg elevation
    • Bandages or stockings 7/7 day and night
    • Then supportive stockings during the day for 2-6/52 post op
    • Aim for return to work within 10/7
  • Complications
    • Bleeding
    • Bruising
    • Healing fibrosis → Firmness under the scars
    • Wound infections ≈ 1%
    • VTE – 1-5% - Generally recommend LMWH during surgery
    • Neuropraxia: numbness, Saphenous Nerve – Mild changes in sensation up to 40% but true saphenous injury (5-10% after LSV strip)
    • Sural Nerve injury if SSV stripped
    • Recurrence – 20-80% at 5-20 yrs but pts usually still happy with results

Endovenous options

  • Options
    • Thermal
    • Non-thermal
      • Most common is sclerosing agents
  • Contraindications
    • Acute DVT
    • Thrombophlebitis
    • Pregnancy
    • Relative
      • In patients with deep venous insufficiency
      • PVD

Thermal Ablation

  • Advantage:
    • Avoids GA
    • Office based procedure
    • Early mobility and return to work
    • Low risk of nerve injury
    • Lower risk of recurrence (Success at 5 yrs = 95%)
  • Disadvantages:
    • Tumescent аոеsthesia
    • Some pts unsuitable
  • Two methods of ablation therapy
    • Endovenous Laser Ablation (EVLA) Therapy – Delivers > 1000 temps to vein and damages intima
    • RFA – Delivers temps > 100 degrees to damage intima
  • Complications:
    • Bleeding/bruising – less than open surgery
    • VTE – very low <1% - can get a tongue of thrombus from superficial vein into deep vein – usually no occlusion but can occur
    • Skin burns – inadequate tumescent anaesthesia
    • Nerve injury – Actual injury to sensory nerves is rare however can get area of abnormal sensation over where therapy performed

Non-thermal ablation

  • Options
    • Mechanical ablation
      • Mechanical occlusion chemically assisted (MOCA) ablation
        • Uses both mechanical damage to vein endothelium with a rotating wire and simultaneous chemical injury with installation of a liquid sclerosant
    • Cyanoacrylate embolisation
      • Using catheter access, a glue is delivered into the saphenous vein that induces a foreign body reaction leading to iոflаmmаtiοn and fibrotic occlusion of the vessel.
    • Sclerotherapy - USS guided
      • Polidocanol endovenous microfoam (PEM)
        • PEM uses a proprietary gas mixture of O2:CO2 (65:35) with 1% рοliԁοсaոοl solution within a pressurized sterile canister to create uniform microfoam bubbles that can be delivered into the saphenous vein under սltrаѕоund guidance.
      • Detergent (Sodium Tetradecyl Sulphate)
      • Osmotic – Hypertonic saline
      • Chemical irritant – Chromated Glycerine
  • Technique for sclerotherapy:
    • Cannulation of vein to be treated
    • Sclerosant is injected under USS guidance
    • Elevate leg to empty vein and inject foam – monitor movement in leg with USS
    • Compress veins with bandage or stockings
  • Complications:
    • Thrombophlebitis – common
    • Occasionally need to aspirate retained thrombus
    • Local ulceration
    • Discolouration (Haemosiderin)
    • VTE low ~ 1% - reduce by encouraging ankle flexion to promote deep vein flow
    • Neurological symptoms
      • Transient in 1%
      • CVA is extremely rare with sclerotherapy transient visual disturbance
    • Hypersensitivity and anaphylaxis
  • Post op care:
    • Pressure dressings for 72 hours – 2 weeks of compression stockings at skin institute
    • 2-3 weeks later – regular clinic review
    • May need up to 4 treatments

Graph View

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