Management
of patients with varicose veins
Clinical
examination should establish the extent and size of varices, as well as the
presence of any associated skin changes. Tourniquet tests should be used to
decide the location of venous incompetence. All patients considered for
surgical treatment of their varices should be examined using
Patients
with recurrent varices or a history suggestive of previous venous thrombosis and
any patient with skin changes should be fully investigated using duplex
ultrasonography or venography. The presence of ankle pulses should be
confirmed by palpation or, if necessary, by measuring the ankle blood pressure
using Doppler ultrasound.
The
treatment of varicose veins following a proper assessment may include
reassurance, the use of elastic compression stockings, injection sclerotherapy
or surgical treatment. The treatment of choice depends on the size of the
varices, their extent and the symptoms that they produce.
Compression
stockings
The symptoms of varicose veins may be relieved by the use of compression
stockings. These are available for the treatment of venous disease in three
grades of compression, classes 1—3. Light compression stockings may be helpful
in the early stages of varicose veins but do not prevent the development of more
varices or result in the disappearance of veins.
Injection
sclerotherapy
The
basis of sclerotherapy is that a solution which destroys the endothelial lining
of the veins is injected. In the UK the most widely employed drug is sodium
tetradecyl (STD), which chemically is a soap. To be effective, the sclerosant
has to be given into an empty vein that is compressed immediately after the
injection has been given to avoid the development of thrombosis within the vein.
It is easy to produce thrombophlebitis which can recanalise and result in the
recurrence of the varices. The aim is to produce sclerosis with the vein being
replaced by a fibrous cord, incapable of recanalisation and recurrence (Fig.
16.21).
Technique
The limb is examined with the patient standing and the position of the
varices that should be injected marked on the skin. The needle is inserted into
the vein with the patient sitting down and the leg in a horizontal position. A
23G or 25G needle is usually used for this. The position of the needle in the
vein is confirmed by drawing back on the syringe. Injection of the sclerosant
outside the vein causes tissue necrosis and ulceration, and must be avoided. The
leg is elevated to empty the veins and a small volume of sclerosant (0.5 ml)
is injected into the vein. Compression is
Further
sessions of sclerotherapy continue at weekly intervals until all lower limb
varices have been treated. The patient should wear a compression bandage or
stocking for 3—6 weeks after the completion of a course of sclerotherapy This
ensures that the veins which have been treated do not suffer thrombosis and are
converted into a fibrous cord, achieving sclerosis of the vein.
Complications
The complications of this treatment include skin pigmentation and
ulceration if the sclerosant is not injected within a vein. Small regions of
thrombophlebitis are often seen during a course of sclerotherapy. Deep vein
thrombosis develops only rarely.
Microsclerotherapy
Thread veins and reticular varices may he treated by injection through a
very fine needle, a treatment referred to as ‘microsclerotherapy’. Very
dilute sclerosing solutions are used. The most frequently employed drugs used
for this are STD and polidocanol. A skilled practitioner can insert a 30G needle
into dermal flares and successfully eradicate these tiny veins. Compression
bandaging is usually applied after this treatment for 1—5 days.
Treatment of these veins is normally regarded as a cosmetic procedure.
Surgical
treatment of varicose veins
Surgical treatment of varicose veins is widely used and is effective in
removing varicose veins of the main saphenous trunks, as well as their
tributaries, down to a size of about 3 mm. Veins smaller than this are best
treated by sclerotherapy. Surgical removal of varices is inappropriate where
these form a major part of the venous drainage of the limb, for example where a
deep vein thrombosis has destroyed the main axial limb veins and the patient
relies on the superficial veins. This possibility may be suggested by the
patient’s medical history and can be confirmed by duplex ultrasonography or
venography.
The
main principles of surgical treatment are to ligate the source of the venous
reflux (usually the SFJ or the SPJ) and to remove the incompetent saphenous
trunks and the associated varices. Sapheno-femoral ligation alone, sometimes
referred to as a ‘Trendelenburg procedure’, is associated with a high rate
of recurrence of varices. Recent research has shown that it is necessary to
remove the long saphenous vein to ensure that as much venous reflux as possible
is eliminated. Similarly, communications between the many deep veins in the
popliteal fossa and the short saphenous vein mean that some patients develop
recurrences in the short saphenous vein due to the re-establishment of reflux
from these veins. This problem may be eliminated by removing the short saphenous
vein. Removal of the saphenous veins has the disadvantage that both veins are
accompanied by a nerve that may be damaged in the vein stripping operation. To
avoid nerve injury the long saphenous vein should not be removed below mid-calf
level and great care should be exercised in removing the short saphenous vein.
Venous
anatomy is particularly variable, and for some veins preoperative vein
localisation is very helpful. The termination of the short saphenous vein may
lie from 2 cm below the knee to 15 cm above the knee. Its course and termination
can be readily identified by ultrasound imaging and marked on the skin with an
indelible pen before the operation, reducing the risk of damage to nerves and
arteries in the popliteal fossa. Perforating veins in the calf and thigh, and
residual segments of the saphenous veins left after previous venous surgery, can
also be localised in this way (Fig. 16.22).
An oblique incision is made in the groin commencing over the femoral
artery and extending 4 cm medially. The long saphenous vein is exposed and the
common femoral and superficial femoral veins are identified before dividing the
long saphenous vein. Having divided the long saphenous vein, all branches should
then be isolated and divided. The SFJ should be tied flush with the femoral
vein. Any tributary of the saphenous vein or femoral vein left in this operation
may be the source of a future recurrence, so it is important that all are
ligated and divided. It is important that the femoral vein is inspected
carefully for at least 1 cm above and below the SFJ, and any tributaries ligated
and divided.
The
conventional way of removing the saphenous vein is with a Babcock stripper. This
consists of a flexible wire which is passed down the long saphenous vein. The
end is identified in the upper third of the calf and a 2-mm incision is made to
More
recently ‘inverting’ or ‘invaginating’ stripping has become popular. The
aim here is to reduce the damage to the tissues around the vein leading to less bleeding
and postoperative pain. This may be done in a number of different
ways. A rigid metal ‘pin-stripper’ has recently been developed (Fig.
16.23). This is passed down the inside of the saphenous vein and recovered
through a small incision in the upper part of the calf. A strong suture is
attached to the end of the stripper and firmly ligated to the proximal end of
the vein (Fig. 16.24). Pulling gently on the stripper, the long saphenous vein
will invert and can be delivered through a 2-mm incision in the mid-calf region
(Fig. 16.25). No olive is used and the technique relies on the strength
of the vein. Should the vein break, an instrument with a small olive on one end
is used to recover the remaining saphenous vein.
Technique
of saphenopopliteal junction ligation
Accurate preoperative ultrasound localisation of this junction makes the
operation easy, as the position of the SPJ is
A
pin-stripper (Oesch) is passed down the short saphenous vein as described above
for the long saphenous vein. This is recovered through a 2-mm incision made at
the mid-calf level. A heavy suture is used to attach the vein to the upper end
of the stripper and gentle traction applied to the stripper. The inverted vein
appears in the calf incision.
Varicose veins do not disappear following saphenous vein stripping and
should be removed through small incisions. It was standard practice to insert
artery forceps through the incision in order to remove varices. However, this
necessitates long incisions in the leg which require suturing and are
unsightly. European phlebologists have developed instruments to minimise the
size of incision required for this procedure. The technique is referred to as
‘hook phlebectomy’ and uses small hooks which may be inserted through
The
results of varicose vein surgery depend on the care taken with the preoperative
assessment, the preoperative marking and the determination of the surgeon to
remove all the superficial varicosities. Patients may complain of symptoms of
varicose veins, but most remain unsatisfied until they achieve a good cosmetic
result following treatment!
Complications
of varicose vein surgery
Bruising and discomfort are common following removal of varices,
especially where the veins were of very large diameter. However, the pain
usually requires only mild analgesics.
Sensory nerve
injury is seen occasionally after removal of varicose veins. The saphenous nerve
and its branches accompany the long saphenous vein in the calf, the suraJ
nerve accompanies the short saphenous vein. Damage to the main part of these
nerves occurs in about 1 per cent of operations, but small areas of anaesthesia
may occur more frequently (in up to 10 per cent of patients). The adoption of
inverting stripping techniques and avoidance of stripping the long saphenous
vein below mid-calf level have reduced the risk of damage to these nerves. All
patients should be warned before surgery that they may experience small areas of
numbness and tingling after the operation. These changes are usually reversible
but can be quite persistent.
Motor
nerve injury is an uncommon complication of varicose vein surgery and may
occur during exploration of the popliteal fossa if care is not taken to protect
the nerves in this region. Preoperative ultrasound localisation of the short
saphenous vein helps in limiting the extent of the dissection in this region and
risk to the nerves during dissection. Venous thrombosis is often seen in
residual varices following varicose vein surgery and resolves without the need
for specific treatment. The risk of this is reduced if all visible varices are
removed at the time of surgery. Deep vein thrombosis occurs in about one
operation per 1000 following varicose vein surgery. The factors which result in
increased risk are described below. Patients who have previously suffered a
deep vein thrombosis seem to be particularly at risk and should receive full
prophylactic measures, usually low-dose subcutaneous heparin in addition to
compression stockings. Patients receiving oestrogen treatment may also be at
increased risk of venous thrombosis, and heparin prophylaxis should be
considered.
Venous
reconstructive surgery
Surgery to the deep veins is limited by the absence of suitable prosthetic grafts or any satisfactory way of creating a venous valve. Surgery may be carried out for venous occlusion and for deep venous insufficiency. Patients who might be considered for these procedures include those who have persisting swelling of the lower limb after a previous venous thrombosis, even when a number of years has passed and collateral veins have had the opportunity to develop. The presence of a functional obstruction must be confirmed using direct venous pressure measurements. In the case of suspected iliac vein obstruction, the pressure in the femoral vein is measured with the patient lying supine. If there is a substantial rise in venous pressure during exercise then venous obstruction is confirmed. An alternative method is to measure the venous pressure in the hand and foot veins with the patient lying supine (the Raju test). Normally the foot venous pressure is the same as the hand venous pressure or no more than 5 mmHg greater. If venous obstruction is present the pressure difference is greater, with pressure differences of 10—15 mmHg indicating significant venous obstruction
Venous
obstruction
In
patients who have obstruction of the superficial femoral vein, the long
saphenous vein may be connected to the popliteal vein in the same limb, allowing
blood to flow along the superficial veins more easily (May—Husni procedure).
However, in the majority of patients with chronic superficial femoral vein
obstruction, the blood flows along the long saphenous vein to reach the groin
and therefore this operation is not required.
Venous
incompetence
The surgical treatment of deep venous insufficiency remains a difficult
problem that is dealt with in a few centres. Venous valves in the deep veins may
be repaired if their incompetence is a consequence of primary valve failure.
Kistner has described two methods of repairing incompetent valves, and
successful completion of this operation may lead to long-term maintenance of leg
ulcer healing. However, the operations are technically difficult and there is a
risk of thrombosis which may destroy the reconstructed valve (Fig.
16.29). In
patients who have previously suffered a deep vein thrombosis, transplantation
of a segment of axillary vein has been carried out. This is usually attempted in
patients who have damage to the deep veins following a previous venous
thrombosis. The risk of further episodes of venous thrombosis makes the likely
success of such operations as low as 50 percent.