- 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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