Venous and lymphatic diseases of the limbs: Varicose veins
Varicose veins are a common condition occurring in 20% of adults. The characteristics of varicose veins are that they are
Varicose veins result from incompetent valves in the venous system.
Anatomy of the venous system
The veins of the lower limb can be classified into three groups: superficial, deep and perforating.
The superficial veins are collected in two major systems. These are the tributaries and main trunks of the long and short saphenous veins.
The long saphenous system begins on the dorsum of the foot and runs anterior to the medial malleolus, along the medial aspect of the calf and thigh and ends at the saphenofemoral junction, where it joins the common femoral vein. This junction is 2–3 cm below and lateral to the pubic tubercle. A major tributary, the posterior arch vein, joins the long saphenous vein just below the knee. This drains blood from much of the medial side of the calf and communicates with the deep venous plexus of the calf by way of several perforating veins - so named because they ‘perforate’ the deep fascia. In the thigh, there are large medial and lateral tributaries and thigh perforating veins. A number of tributaries join the long saphenous vein close to its termination. These are important in the surgery for saphenofemoral incompetence since failure to deal with these will result in recurrence of the varicose veins.
The short saphenous system begins behind the lateral malleolus of the ankle and then runs along the lateral and then the posterior aspect of the calf to penetrate the deep fascia in the upper calf. It terminates in the popliteal fossa by joining the popliteal vein in the vicinity of the knee crease. The exact level of the junction is variable and may be either a few centimetres above or below the knee crease.
The deep veins run as venae comitantes of the major arteries in the foot and calf, where they receive tributaries from the muscles of the calf, including the venous sinusoids in the calf muscles. The venous sinusoids within the calf muscles are important as part of the venous pump mechanism. They are a frequent site of origin for venous thrombosis. The deep system also receives the perforating veins from the superficial system. At about the level of the knee joint a single popliteal vein is formed in most cases. This runs proximally in company with the main artery to become the femoral vein and then the external iliac vein as it passes beneath the inguinal ligament.
The perforating veins join the superficial and deep systems. They contain valves which direct blood flow from the superficial to the deep system. Perforating veins are variable in number and position, but usual sites are the medial side of the lower third of the calf between the posterior arch vein and the posterior tibial veins and at about the junction of the middle and lower thirds of the thigh between the long saphenous vein and the femoral vein. Other perforating veins join the anterior tibial veins, the peroneal veins and the superficial veins. The inconstancy of these veins makes precise localisation difficult and is an important reason for the development of recurrent varicose veins following treatment.
The superficial veins collect blood from the superficial tissues. During the relaxation phase of the calf muscle cycle, the pressure in the superficial veins is greater than the pressure in the deep veins thus blood flows from superficial to deep. Each contraction of the calf muscles results in high pressure (approximately 250 mm Hg) being generated in the calf compartments. This empties the veins in the muscles and transmits a pulse of blood proximally.
Retrograde flow, or reflux, due to gravity is prevented by valves. If the valves in the veins directing venous return proximally or if the perforating veins are incompetent the venous return from the leg is less efficient. This results in higher pressures in the superficial system and progressive dilatation occurs, causing more valves to become incompetent. This is accompanied by elongation of the superficial veins, which results in tortuosity. The high pressure in the superficial veins, particularly in the most gravitationally dependent part of the leg around the ankle, may be sufficient to impair the nutrition of the subcutaneous tissue and dermis and contribute to ulcer formation.
Varicose veins are a disorder of the superficial and perforating veins. In most cases the disorder is inborn although the mode of inheritance is uncertain. Varicose veins often first appear in young adults. Females are affected more commonly and the veins are more prominent during pregnancy due to the combined effects of the muscle-relaxing effects of hormonal (especially progesterone) changes and the pressure effects of the pregnant uterus, which also acts as an arteriovenous fistula in the pelvis. Partial regression occurs following delivery but there is a progression of the varicosities with succeeding pregnancies. Tributaries of the internal iliac vein and even the ovarian vein may be involved, producing posterior thigh and vulval varices.
Patients with varicose veins most commonly present for cosmetic reasons. Some patients present with tiny veins - telangiectasia or venous flares. Others present with huge veins that may have been present for 10–20 years or longer.
Symptoms result from fluid congestion of gravitationally dependent superficial tissues due to inadequate venous return and increased venous pressure. Patients may complain of tiredness and aching of the lower legs at the end of the day. This is relieved by rest and elevation of the legs. They may develop mild ankle swelling, particularly in warmer weather. Leg pain is a common complaint and the presence of varicose veins may be coincidental.
Extensive evidence has been gathered in the past ten years to show that patients with varicose veins and venous ulcers suffer from significant quality of life impairment.
Deep Vein Thrombosis (DVT) and Pulmonary Embolus (PE)
Varicose veins are associated with a relative risk 4.3 for DVT and PE.
Thrombophlebitis or Superficial Venous Thrombosis (SVT)
Thrombosis in a segment of varicose vein is common. The patient presents with signs of inflammation spreading from a hard lump, which is the thrombosed vein. The redness, pain and heat falsely suggest the presence of infection.
Traditionally thought of as benign and without significant consequence unless there is propagation into the deep venous system leading to DVT and PE. However, up to 30% of patients with an SVT has a concomitant DVT, and 5-33% have an asymptomatic PE.
Standard treatment should now be considered to include full anticoagulation with low molecular weight heparin for 6 weeks after the start of episode and compression hosiery.
Thrombus extending from the long saphenous vein into the common femoral vein can be very dangerous. The thrombus often extends 15 cm or more proximal to the clinical signs of inflammation, and a duplex scan will readily demonstrate the true level of the clot. Urgent operative ligation of the saphenofemoral junction or prolonged therapeutic anticoagulation needs to be considered for thrombophlebitis extending above the level of the knee joint.
The subcutaneous varices of the lower calf and around the ankle may rupture through the skin causing profuse bleeding. This bleeding will continue unabated whilst the limb remains dependent, even to the point of exsanguination. The patient should lie down immediately and elevate the limb. Pressure should be applied over the bleeding point. This pressure can be reinforced by a firm bandage. A tourniquet must not be used. The rise in venous pressure produced by a tourniquet may worsen the bleeding.
Prior to the advent of duplex scanning, which enabled noninvasive evaluation of the venous system, it was mistakenly believed that superficial varicose veins rarely caused venous ulceration. It is now realised that severe, long-standing varicose veins are a common cause of leg ulcers. Before the development of frank ulceration, secondary venous tissue changes occur. These tissue changes include pigmentation due to haemosiderin deposition, lipodermatosclerosis, and atrophe blanche.
Rare presentations occur in children and are associated with major congenital abnormalities of the venous system, often associated with arteriovenous malformations.
The examination is directed at identifying the sites of incompetent valves that allow reflux of blood from the deep to the superficial veins. The patterns of disease are:
- long saphenous incompetence
- short saphenous incompetence
- incompetence of thigh or calf communicating veins
- combinations of the above
The patient is examined standing. The size and distribution of varicose veins are examined. If the veins are predominantly medial and if they involve the thigh, it is likely that the long saphenous vein is involved. If they are posterior and lateral in the calf, it is likely that the short saphenous vein is involved. Remember that there are many communications between the two systems so that, for example, incompetence in the long saphenous system may fill varices on the posterior and lateral aspects of the calf. The presence of any secondary venous tissue changes is noted. If long saphenous incompetence is suspected a cough impulse over any prominent vein confirms the diagnosis of saphenofemoral incompetence.
The examiner should also be aware of findings which signify that the patient does not have ‘straightforward’ varicose vein problem. For example:
- varices of the medial aspect of the upper thigh may indicate pelvic venous insufficiency
- the presence of significant leg oedema is unlikely to be due to varicose veins alone
- prominent superficial veins extending above the level of the inguinal ligament in the suprapubic area suggests that these veins are dilated collaterals which have formed in response to deep venous obstruction
- ulcers sited proximal to the mid-calf level are unlikely to have a venous aetiology
A tourniquet test is performed to systematically search for the sites of incompetence. The findings on inspection will indicate where these are likely to be. The patient lies on an examination couch. The leg to be examined is elevated to drain the blood from the superficial venous system. It is convenient to rest the patient's heel on the examiner's shoulder. A narrow tourniquet is placed around the thigh as high as possible. A narrow tourniquet is used because it occludes the superficial veins but does not affect the deep veins. A length of rubber tubing makes a good tourniquet. With the tourniquet in place, the patient is asked to stand. The leg is inspected to see if the veins that had been seen previously are full or empty. The veins will fill slowly (30–60 seconds) because of arterial inflow or rapidly because of venous reflux. If the veins remain empty during the first 30 seconds it means that there are no incompetent valves allowing reflux into the superficial veins below the level of the tourniquet. The most likely cause of the patient's varicose veins is incompetence at the saphenofemoral junction. The tourniquet is released and rapid refilling of the superficial veins can be seen.
If the veins are not controlled by this manoeuvre, the examination is repeated with the tourniquet placed above the patella. This tests for the middle lower third of thigh perforator. If the veins are not controlled, the tourniquet is placed below the knee to test the short saphenous system. If no measure controls the filling of the veins, the site of incompetence is below the tourniquet and therefore involves the calf communicating veins.
This examination is sufficient in many cases of untreated varicose veins. More elaborate clinical tests, usually described with the name of their originator, may be used. The accuracy of these clinical tests have been called into question when compared with the results of ultrasound examination as detailed below.
Doppler ultrasound probe
A hand-held Doppler ultrasound probe may assist in identifying incompetence of the long and short saphenous systems. With the patient standing and the muscles of the leg relaxed, the probe is placed over the upper end of the vein. The limb is compressed distally by squeezing the calf with the hand in the case of the short saphenous system. This produces a sharp augmentation of the flow of blood in the vein. The compression is relaxed and if the valves in the vein are competent blood flow stops. If the valves are incompetent, the flow signal continues indicating reflux of blood in the vein.
Hand-held Doppler is a basic test that is only of use in the initial diagnosis of reflux at the sapheno-femoral junction and sapheno-popliteal junction (the descending theory). It ignores that patients that have segmental disease (the ascending theory).
The gold standard investigation.
More information is provided by duplex ultrasound, which provides both an image and information about the blood flow velocity. All patients should have duplex scanning prior to any varicose vein surgery, as this improves efficiency, reduces litigation and because distribution of varicosities is notoriously unreliable.
It also provides further evidence for:
- which of the major saphenous systems is incompetent
- for identification of the level at which the short saphenous vein enters the popliteal vein (this level may be variable and performance of the operation is much easier with precise information about the level of the junction)
- for locating incompetent perforating veins (duplex ultrasound is the best method because the veins can be seen and the direction of blood flow in them identified)
- for patients with recurrent varicose veins as information about the sites of recurrence is critical to planning treatment.
There are three major causes of recurrence, all of which remain controversial in the literature. First, recurrence in a system not previously treated (e.g. short saphenous incompetence that has developed later or was not initially detected). Second, recurrence in the groin following saphenofemoral ligation. This may be due to inadequate surgery where a major tributary in the groin has been missed or sometimes due to ‘neovascularisation’ where the recurrence is due to the development of multiple tiny channels between the deep and superficial systems through scar tissue at the site of the saphenofemoral ligation. Finally, recurrence due to incompetence of perforating veins (e.g. at the junction of the middle and lower thirds of the thigh).
CT and MR Venography
These investigations are reserved for patients with significant venous changes which are not explained by lower limb incompetence such as IVC agenesis (prevalence approximately 1%) and for investigation of patients for stenting or deep venous bypass.
Venography is an investigation which is not required for the vast majority of superficial venous disease.
However it has a role in the management of deep venous incompetence where stenting and deep venous bypass is being considered.
Ascending and descending venograms are essential components for interpretation.
There are few serious sequelae of untreated varicose veins (see ‘Complications’) so treatment is not essential, except in those patients with pre-ulcerative secondary venous tissue changes in the lower calf or with complications (see ‘Symptoms’).
However, varicose veins cause a significant quality of life impairment and should not be assumed to be cosmetic.
Elastic stockings will not cure varicose veins but will provide relief from symptoms of swelling and tiredness in the legs and prevent complications. They are particularly helpful for the pregnant patient with varices. A range of stockings are available - low-, mediumand high-grade compression and below- and above-knee lengths. For patients with varicose veins, a below knee stocking of moderate compression (European RAL Grade 2, 20–30 mm Hg pressure) will suffice. If there is doubt that the veins are the cause of the symptoms in a particular patient, relief of symptoms while wearing stockings supports the diagnosis of varicose veins and, conversely, failure of stockings to relieve symptoms suggests that other causes should be sought. Graduated compression stockings should be prescribed with caution for patients in whom pedal pulses are not palpable.
Stockings are expensive (£50 for below knee and £100 for above knee RAL class 2), must be replaced 3-6 monthly and are poorly tolerated by patients especially in summer.
Liquid and foam sclerotherapy use detergent and hypertonic solutions to cause sclerosis in veins. Liquid sclerotherapy is effective in smalls veins such as telangectasia and foam sclerotherapy is suitable for truncal vein treatment. In experienced hands foam sclerotherapy offers equivalent closure rates to surgery and endovenous ablation.
An important part of injection therapy is compression, which keeps together the surfaces irritated by the sclerosant. This facilitates fibrous organisation and inhibits re-canalisation of the vein.
Operation is the most appropriate method of control for major sites of incompetence. The aims of operation are to obliterate the major sites of deep to superficial incompetence and to remove the larger varicose veins. The presence of varicose veins predisposes to the development of post-operative deep vein thrombosis so appropriate prophylaxis should be undertaken.
Traditional open surgery has largely been superseded by endovenous ablation under local anaesthetic.
Endovenous thermal ablation
Using seldinger technique under ultrasound guidance a catheter is passed inside the vein to just distal to the saphenofemoral junction. Then tumescent local anaesthesia is applied around the vein and catheter. Using either laser energy or radiofrequency energy heat is applied to the vein to seal it using fibrosis.
Treatment time is approximately 20 minutes.
Endovenous mechanochemical ablation
As per thermal ablation except a combination of mechanical damage and liquid sclerotherapy cause the vein to fibrose. Local anaesthetic is only required at the cannulation site.
Endovenous chemical occlusion
As per thermal ablation except a proprietary glue is used to seal the vein and cause soft tissue ingrowth to seal th vein permanently. Local anaesthetic is required only at the cannulation site.
Saphenofemoral ligation (high tie)
Saphenofemoral ligation is the open surgical procedure performed most commonly. The saphenofemoral junction is exposed through a skin crease incision about 3 cm long placed below and lateral to the pubic tubercle and 1 cm above the groin crease. The long saphenous vein and its tributaries are dissected. All tributaries are ligated and divided. Once the junction between the long saphenous and femoral veins has been clearly identified, the long saphenous vein is divided and ligated flush with the femoral vein. The femoral vein is explored for 2 cm proximal and distal to the junction to ensure that there are no more tributaries entering the vein. Any that are found are ligated and divided.
Saphenopopliteal ligation is carried out in a manner analogous to saphenofemoral ligation. The dissection may be difficult because of the fat in the popliteal fossa and is greatly facilitated by precise knowledge from duplex ultrasound scanning of the exact level of the saphenopopliteal junction. Care is necessary to avoid inadvertent injury to the sural nerve which runs with the short saphenous vein.
Stripping of the long saphenous vein from the groin to the knee removes a large dilated vein which, if left, may be the site of thrombophlebitis or recurrence. A varicose long saphenous vein is not useful for later coronary or leg artery bypasses. Stripping the long saphenous vein between the ankle and the knee should not be performed since it is unnecessary and may result in troublesome neuritis of the saphenous nerve.
Multiple Phlebectomies or Avulsions
Most of the obvious varicosities are removed through multiple small incisions. The veins are then grasped either by small artery forceps or specially designed hooks. As much as possible of the dilated vein is removed. The next incision is made 2–4 cm away and the process repeated until all the major varices have been removed.
Ligation of incompetent perforating veins
This usually involves an incision over the perforating vein as it passes through the deep fascia. Pre-operative duplex scan provides accurate localisation. Endoscopic techniques have been developed particularly for patients with multiple incompetent perforating veins. The vein is ligated and divided beneath the deep fascia. Ligation of perforating veins is usually reserved for patients undergoing operation for recurrent veins or patients who have significant secondary venous tissue changes or ulceration. It is not a cosmetic procedure.
The leg is firmly bandaged to promote haemostasis from the extraction sites. Early and continued mobility is encouraged to reduce the risk of DVT. Patients having bilateral operations or operation for major recurrences usually stay in hospital overnight. The outer bandages are removed 24–48 hours after operation and elastic stockings are applied. These are worn for about 2 weeks while there is a tendency for the leg to swell. There is no evidence to guide this.
Prognosis and results of surgery
Endovenous treatments offer better preoperative experience for the patient and equivalent or better ablation rates than open surgery. Recurrence is approximately 10% at 5 years for technical (duplex proven) recurrence.
The result of surgery that has been carefully planned and carried out should be good. The immediate cosmetic result should satisfy the patient. With well performed surgery the recurrence rate is 15–20% at 5 years. Injection therapy may be used to obliterate telangiectatic vessels that it is not possible to remove surgically.
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