• 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

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

Radiofrequency ablation

• Uses high frequency alternating current delivered via a bipolar catheter
• Placed intraluminally under duplex guidance
• Local heating results in venous spasm and a collagen seal
• Performed under general anaesthesia
• Long saphenous vein accessed at the knee using Seldinger technique
• 90% vein occlusion achieved in first week after treatment
• Associated with less pain than open surgery
• Improved quality of life and earlier return to work
• Complications include paraesthesia and skin burns
• Recurrence rates are similar to open surgery

Endovascular laser treatment

• Laser energy deliver via narrow laser fibre to obliterate the vein
• Causes heat injury to vessel wall
• Usually performed under local anaesthesia
• Clinical and symptomatic improvement seen in 95% patients
• Patient satisfaction high and early return to work is possible
• Complications include paraesthesia and skin burns
• Recanalisation seen in less than 10% patients

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
• Recently foam ( mixture of air / sclerosant) has been shown to be more effective
• 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

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