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Venous disease

1.  What is this condition?
2.  How should it be assessed pre-operatively?
3.  How would you surgically manage the patient?

This slide shows significant varicosities in the distribution of the long saphenous vein. This man had not had previous surgery. There were no features of venous hypertension. Percussion and tourniquet tests showed sapheno-femoral incompetence.  Varicose veins affect approximately 20% of the adult population. They are more prevalent in women and overall they represent a significant health problem that consumes a large amount of health care funding. Approximately 20% of varicose veins are recurrent, a proportion of which result from an inadequate initial operation.

A complete assessment of a patient with varicose veins should be based on the history, examination and hand-held doppler assessment. Additional investigations such as duplex ultrasound or varicography might also be required. The history will highlight cosmetic concerns, pain and possible night cramps. Other important factors are - periods of immobilisation, lower limb fractures or 'white limb of pregnancy'' which might suggest a previously unidentified deep venous thrombosis. On examination of the distribution of the varicose veins might suggest the site of valvular incompetence. This can be confirmed clinically by the use of percussion or tourniquet tests. The site of valvular incompetence can also be identified by the use of a hand-held doppler probe. When placed over the sapheno-femoral or sapheno-popliteal junction, calf compression produces an identifiable forward flow. On release of the compression a transient (<1 second) retrograde flow signal is normally identified. In patients with valvular incompetence a prolonged retrograde signal is audible. In most patients with primary LSV varicose veins the above constitutes an adequate assessment. However, in patients with recurrent varicose veins, SSV varicose veins, calf perforators or doubts over the deep venous system, duplex ultrasound should be considered. Primary sapheno-popliteal ligation should not be performed without pre-operative mapping as the position of termination of the SSV is highly variable and in up to 25% of patients it does not enter the popliteal vein.

The treatment of varicose veins varies between surgeons but a few general comments can be made. In a proportion of patients with minor varicosities and no features of venous hypertension (varicose eczema, lipodermatosclerosis or ulceration) reassurance might be all that is required. Compression hosiery with a pressure of 40, 30 and 20 mmHg at the ankle, mid-calf and knee respectively will reverse venous hypertension and prevent complications. However, most patients find stockings uncomfortable and are often not satisfied with them as a long-term treatment option. The role of sclerotherapy is controversial. It often fails in the presence of major valvular incompetence but may be useful for the treatment of small residual varicosities after surgery. Complications of sclerotherapy include pain, ulceration, thrombophlebitis and skin staining.

Surgery is the mainstay of treatment for varicose veins in many patients. LSV varicosities are often treated by sapheno-femoral flush ligation, LSV strip and avulsions. Adequate ligation of all tributaries of the sapheno-femoral junction, beyond their first branch reduces the risk of recurrence. Most surgeons will strip the LSV to the knee. Whether it should be stripped proximally or distally is unproven. Stripping to the ankle is associated with an increased risk of damage to the saphenous nerve resulting in a persistent saphenous neuralgia. Stripping increases the risk of haematoma formation, but reduces the risk of recurrent varicose veins. As mentioned above, sapheno-popliteal ligation requires preoperative marking. Stripping of the SSV is performed less frequently as it is associated with a significant risk of sural nerve damage. Open ligation of perforator vessel is performed rarely today as it often results in delayed wound healing. Recent interest has been shown in endoscopic sub-fascial ligation of these vessels.

Recent papers

Bradbury A W, Stonebridge P A, Callam M et al. Recurrent varicose veins: assessment of the saphenofemoral junction. Br J Surg 1994; 82: 60-62.

Callam M J, Epidemiology of varicose veins. Br J Surg 1994; 81: 167-173.

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

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

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