Management of patients with varicose veins

     A history should be taken from the patient to find out how long the varices have been present and if any event seemed to cause them. A history of previous lower limb deep vein thrombosis should be sought. Venous thrombosis may follow lower limb fractures, so this also should be asked about. Superficial varices which develop after a venous thrombosis may be the only route of venous drainage in the lower limb and should not be removed until the patency of the deep veins of the limb has been shown. Patients may also have received previous surgical or other treatment for their varices. Any previous treatment may greatly alter the surgical management of the patient. When the SFJ has been ligated previously, a further operation here is technically much more demanding for the surgeon and should not be performed unless recurrence at the previous operation site has been conclusively demonstrated. Unfortunately, patients often have only a vague recollection of their previous vein operations and therefore diagnostic ultrasound imaging or venography is essential to establish the anatomy and source of varices in patients with recurrent 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 a hand-held Doppler ultrasound device to confirm the source of the varices.

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

  This treatment is best used in the management of small varices and those where the main long and short saphenous veins, and their major tributaries, are competent. This type of treatment is also effective where the larger varices have been removed surgically and only small varices remain. In the past, sclerotherapy has been used in the management of incompetence of the main saphenous trunks. Evidence suggests that varicose veins managed in this way recur much more rapidly than following surgical treatment.

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 immediately applied to the vein being treated with the fingers and a firm bandage applied. Treatment is usually commenced at the ankle so that the bandage can be applied progressively from the ankle to the groin as treatment progresses along the limb. A latex foam pad is put over the sites of the injection and incorporated within the bandage. Skin sensitivity to rubber may lead to allergic reactions if the latex pads come into direct contact with the skin. Immediately after the bandage has been completed, the patient is asked to walk to encourage the blood to circulate reducing the risk of venous thrombosis in the limb and also reducing the venous pressure in the varices of the calf.

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).

  Technique of saphenofemoral junction ligation

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 retrieve the stripper. An olive about 8 mm in diameter is attached to the upper end and the saphenous vein is removed by firm traction on the wire in the calf.

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 notoriously variable. A skin incision is made over the junction and the deep fascia incised to reveal the short saphenous vein beneath. The vein is followed to the SPJ, where the short saphenous vein enters the side of the popliteal vein. The vein can then be ligated and divided close to the popliteal vein. This operation may not be enough to eliminate venous reflux in the short saphenous vein because communication with the gastrocnemius (muscle) veins in the calf is often present and may lead to further varicosities arising from the short saphenous vein. Many surgeons now routinely strip the short saphenous vein to prevent this problem. This is best done using an inverting technique as the sural nerve lies close to the vein and may be damaged if a large olive is used.

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.

  Removing superficial varices

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 incisions of only 1—2 mm (Fig. 16.26). The hook is used to capture a small section of a varicosity and bring it to the surface where is may be grasped using a large artery forceps; the remaining vein is then teased through the tiny incision. The aim is to remove all the varicosities through incisions that require no suture. Closure of the incisions is achieved using adhesive strips or dressings. The cosmetic outcome from this procedure is excellent.

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!

  Postoperative management

  Compression bandaging is applied to the limb at the end of the operation to prevent excessive bruising. In fact, some surgeons apply compression to the limb before stripping the long saphenous vein. After 1 or 2 days the bandages may be replaced by a thigh-length high compression stocking (class 2 compression is appropriate). This can usually he removed easily to allow the patient to take a shower and can then be reapplied.

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 with venous obstruction venous bypass procedures can be performed. Simple bypass with vein or prosthetic material may be used in the larger vessels, such as the iliac veins and vena cava. One problem is to find a vein of large enough calibre to insert in this region. These are sometimes constructed from opened out sections of saphe­nous vein reconstructed as a spiral graft (Fig. 16.27). Alternatively a Palma operation can be carried out. This involves mobilising the long saphenous vein in the opposite leg, tunneling the distal end of the long saphenous vein across suprapubically and inserting it into the femoral vein below the obstruction. Blood then drains from the affected leg via the long saphenous vein into the femoral vein in the opposite leg (Fig. 16.28).

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.