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VARICOSE VEINS
Varicose veins are dilated, tortuous and prominent superficial
veins in the lower limb (see Fig. 43.5). Varicose veins are
PATHOPHYSIOLOGY OF VARICOSE VEINS
common worldwide, being present in about 20% of people Abnormal communication between deep and superficial
aged 20, increasing to 80% at 60 years. Nevertheless, only venous systems is crucial in the development of varicose veins.
about 12% have symptoms or develop complications. The process probably begins with failure of the valve at the
sapheno-femoral junction, leading to an uninterrupted
Pubic tubercle
column of blood from the heart which progressively dilates
superficial veins down the limb (see Fig. 43.5a). Varicose veins
usually develop slowly over 10–20 years, so surgical treatment
Superficial external pudendal vein
Superficial epigastric veins is rarely urgent. The long saphenous system is involved in
Left side about 90% and the short saphenous in 25% (some have both
systems involved).
Women are affected about six times more often than men,
Inguinal ligament with most developing during or soon after the second or third
pregnancy. An important factor is probably the high level of
Femoral vein progesterone, causing changes in collagen structure (which
may not fully recover), as well as smooth muscle relaxation.
Superficial circumflex Pressure on the pelvic veins by the enlarging uterus may con-
iliac veins
tribute by restricting venous return.
Femoral artery Hereditary factors appear to play a part in some patients,
especially in men and in those who develop varicosities in
their teens. Predisposing anatomical factors may include con-
Deep external pudendal vein
Sapheno-femoral valve
genital absence of valves in iliac veins or abnormal vein wall
Lateral femoral vein elasticity. DVT plays little part in causing varicose veins. Rarely,
Long saphenous vein multiple congenital arteriovenous fistulae (Klippel–Trenaunay
Medial femoral vein and other syndromes) cause gross varicose veins. In these
patients, there is gigantism of the lower limb and often venous
ulceration (see Ch. 46). A technique of examining varicose
Fig. 43.3 Sapheno-femoral junction—anatomy veins is shown in Figure 43.6.

Absence of valves in iliac veins may predispose to

varicose veins

Failure of valve at sapheno-femoral junction is often

Perforating veins
Incompetence of mid-thigh perforating vein may
sometimes be initiating anatomical abnormality
even if sapheno-femoral junction is intact
first abnormality. This exposes succeeding valves
(1→2→3) to pressure of column of blood from heart
1 and they become incompetent in turn as vein dilates
2

3
Medial knee perforator

Thin-walled tributaries gradually become dilated

and tortuous when exposed to unaccustomed
hydrostatic pressure

Perforating veins on posterior tributary probably

play little part in uncomplicated varicose veins

Fig. 43.4 Pathophysiology of varicose veins

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4 SYMPTOMS, DIAGNOSIS AND MANAGEMENT: CARDIOVASCULAR DISORDERS
(a)
Fig. 43.5  Varicose veins
(a) Typical varicosities in the long saphenous territory (LSVVs) evident
both above and below knee and most prominent on the medial side of the
limb. The indelible black markings were made immediately prior to surgery
by the operating surgeon with the patient standing. (b) Typical short
saphenous varicosities (SSVVs), which do not extend above the knee.
These veins could not be controlled with an above-knee tourniquet and
there was gross reflux evident on hand-held Doppler examination,
confirmed on colour duplex Doppler scanning. The sapheno-popliteal
junction (SPJ) has a variable position and should be marked before surgery
using ultrasound so the surgeon knows where to site the incision
SYMPTOMS AND SIGNS OF VARICOSE
VEINS
The most common complaints related to varicose veins are:
l Aching legs, usually after standing all day
l Poor cosmetic appearance, especially in summer when
the legs are exposed
l Fear of future leg ulcers (‘like my mother had’)
l Bleeding or worry about varicosities bleeding, particularly
if traumatised
l Varicose eczema or ulcers
l Ankle oedema
l Recurrent superficial thrombophlebitis
INVESTIGATION OF VARICOSE VEINS
Traditional investigation of varicose veins includes clinical
examination and tourniquet techniques (Fig. 43.6). As a
screening investigation in clinic, hand-held ultrasound
Doppler allows assessment of reflux at sapheno-femoral (SFJ)
and sapheno-popliteal junctions (SPJ) and within the long
and short saphenous veins. The probe is placed over either
junction, the calf is pressed and the examiner can hear if there
is significant reflux outwards through the junction on release
of calf pressure. Formal duplex scanning is now advocated for
528
B
B
C
(b)
D
Fig. 43.6  A technique of examining varicose veins
Elevate limb and ensure veins are emptied by massaging distal to
proximal. Apply tourniquet tightly around upper thigh A then stand
patient up. Does tourniquet prevent veins filling and removing it cause
rapid filling from above? If so, main communication is at the sapheno-
femoral junction. If veins fill rapidly with tourniquet in place, repeat the
test with tourniquet above the knee B. If this controls filling, then main
communication is mid-thigh perforator. If this tourniquet fails to control
filling, repeat below knee C. If this controls filling, communication is likely
to be short saphenous-popliteal or medial knee perforator incompetence.
If no tourniquet controls filling, communication is probably by one or
more distal perforating veins, often post-thrombotic in origin D. Note that
80% of varicose veins involve the long saphenous system, sometimes with
short saphenous incompetence as well.
Box 43.2  Initial examination of varicose veins
l Severity—examine the extent and severity of varicose veins
with the patient standing. Many patients attend with
unsightly ‘spider veins’ which are not varicose. Others
attend for advice because they are worried they will develop
ulcers (‘like my mother’)
l Skin changes—examine the leg for swelling, ulcers and
varicose eczema. If present, could indicate a post-
thrombotic limb
l Long or short saphenous—examine the distribution of
varicose veins. Are there varicosities above knee, indicating
probable sapheno-femoral incompetence? Could these be
short saphenous system varicosities, i.e. postero-lateral calf
veins feeding towards popliteal fossa where short
saphenous may be palpable
 Venous disorders of the lower limb 43
(a) Injection sclerotherapy for minor varicose veins (after Fegan)

1 Leg hung down

2 Dilated veins marked with skin marker

3 Syringes prepared containing 1–2 ml mildly

irritant solution (e.g. 1% sodium tetradecyl
sulphate —‘STD’)

4 Needle placed in each vein (position checked

by aspiration). Syringes taped to skin

5 Leg elevated with needles and syringes in situ

6 0·5–1 ml injected into each vein

7 Foam pad placed over each injection site

8 Elastic bandage applied from toes upwards over

foam pads

9 Bandages reapplied after 1 week, left in situ for

2–6 weeks then discarded

10 Patients are instructed to walk 1–2 miles per

day and to elevate leg when not walking

(b) Operations for varicose veins

(i) HIGH SAPHENOUS LIGATION

Saphenous opening
in fascia lata

4 Long saphenous vein

1 Incision at or just below
groin crease medial to
femoral artery, 2.5 cm
below and lateral to pubic
tubercle
Long saphenous vein
2 All tributaries entering
proximal part of long
saphenous vein ligated
and divided
Femoral vein ligated close to femoral
vein and divided
3 Sapheno-femoral 5 Saphenous opening
junction exposed closed with sutures to
identifying femoral vein discourage venous
below saphenous reconnection
opening in fascia lata

Fig. 43.7  (a) Treatment of varicose veins

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4 SYMPTOMS, DIAGNOSIS AND MANAGEMENT: CARDIOVASCULAR DISORDERS

(b) Operations for varicose veins

(ii) LONG SAPHENOUS STRIP

1 The stripper is a long flexible wire with a

bullet-shaped knob on the ‘business’ end.
The entry vein (proximal or distal, according
to choice) is prepared as shown and the
narrow end of the stripper passed down or
up the long saphenous vein until it can be
brought out to the surface within 15 cm below
knee, not to the ankle as was done in the
past

2 Stripping is usually downward. The vein is

ligated to the wire at the bullet end and the
narrow end is pulled smoothly and firmly,
tearing off tributaries and any perforators on
the way, emerging with the complete vein
bunched up on the stripper

3 The wounds are closed and the limb firmly

bandaged to minimise subcutaneous
bleeding. Patients should be warned to expect
postoperative bruising

(iii) AVULSION OF VARICOSITIES

2 1 Before operation, all varicosities are marked (a)

by the surgeon with the patient standing,
using an indelible spirit based fibre-tipped
pen
2 Very small incisions are made over the marks
in a longitudinal direction, or transverse around
the knee. As much vein as possible is pulled
out (‘nick and pick’) as follows:
(b)
(a) Vein grasped with artery forceps or special
vein hook

(b) Second forceps applied and vein divided

(c) One end is drawn out of wound gently and

further traction applied by means of another
forceps (c)
3 The vein will eventually break and bleeding
is controlled by finger pressure. The process
is repeated for the other end of vein

4 Forceps can be passed subcutaneously to

retrieve nearby varices thus reducing the
number of incisions required 4

5 Each wound is left open or closed neatly with

‘steristrips’ or a fine suture, and non-adherent
gauze applied to each one. The limb is
bandaged firmly from the foot to the upper
thigh using crepe

Fig. 43.7, Continued (b) Surgical treatment of varicose veins

530

all cases where intervention is planned. This gives accurate
assessment of superficial and deep systems, determining
anatomical areas of reflux and allowing appraisal for endov-
enous therapy.
MANAGEMENT OF VARICOSE VEINS
Most patients with longstanding varicose veins do not have
venous complications. For these, surgical treatment is not
usually necessary but advice can be given to elevate the legs
when sitting and to wear supporting elastic stockings when
standing for long periods.
INDICATIONS FOR SURGICAL TREATMENT OF
VARICOSE VEINS
The main indications are aching legs after standing, relieved
by elevation or when in bed at night (particularly with uni-
lateral ankle oedema), haemorrhage from a varicose vein,
superficial thrombophlebitis and venous skin changes due
to superficial venous insufficiency. All of these can be treated
with support bandages or stockings, but surgery is often pref-
erable and more permanent.
Injection sclerotherapy (e.g. Fegan’s technique) is used for
treating small cosmetically unattractive varicose veins below
the knee but is unsuitable for major varicosities, particularly
in the thigh. This type of injection sclerotherapy and surgery
for varicose veins is shown in Figure 43.7.
ENDOVENOUS TREATMENT OF VARICOSE VEINS
Newer endovenous treatments of main trunk varicose veins
(i.e. LSV and SSV) have been introduced. These aim to ablate
the main incompetent superficial vein using foam sclero-
therapy, or laser or radiofrequency ablation. All can be per-
formed under local anaesthesia without a groin incision,
using ultrasound to give accurate guidance, and give a quicker
return to normal activities.
Foam sclerotherapy involves injecting a sclerosant into a
vein (e.g. sodium tetradecyl sulfate or polidocanol). It is first
mixed with air or a physiological gas such as carbon dioxide
in a syringe to create foam. Foaming increases the surface area
of the sclerosant and ensures it displaces the blood, allowing
it to act directly on the vein wall. For catheter ablation, the
Venous disorders of the lower limb 43
distal truncal vein is located by ultrasound and cannulated
using a Seldinger technique to place a sheath into the vein. A
laser fibre or a radiofrequency catheter is positioned just distal
to the sapheno-femoral or sapheno-popliteal junction using
ultrasound guidance. Before treatment, a tumescent mixture
of local anaesthetic and normal saline is injected around the
length of the vein for analgesia and to act as a heat sink. The
vein is then heated internally by drawing the laser fibre or the
ablation catheter along its length.
Results of all three techniques appear at least comparable
with surgery but longer-term evaluation is in progress.
PERIOPERATIVE MANAGEMENT OF THE PATIENT
HAVING VARICOSE VEIN SURGERY
Varicose veins must be marked out indelibly on the legs before
operation, ideally by the surgeon doing the operation. The
patient must stand first, often for some minutes, to allow veins
to fill, and marking performed in this position. Most surgeons
mark all prominent veins that are visible or palpable. Extra
marks are often added for areas needing special surgical atten-
tion such as suspected perforating veins. Duplex scanning is
often employed to assist marking of perforators or of the
sapheno-popliteal junction, well known to have a variable
anatomy.
Patients with a history of deep or superficial venous throm-
bosis should be prescribed low-dose subcutaneous heparin,
as should those with other risk factors for DVT, especially
obese patients. The first dose should be given 1–2 hours
before operation.
Immediately after operation, the whole leg is bandaged
firmly with an elastic bandage. The patient should then be
mobilised and encouraged to walk about. All dressings can be
removed 24 hours later, and the bandage exchanged for a
graduated elastic stocking (class 2) which should stay on for
a minimum of 2 weeks. On return home, patients should be
encouraged to be active, walking several times a day for at least
the first 2 weeks. The legs should be elevated when sitting, and
the patient should get up and walk around about every half-
hour. All these measures are designed to discourage venous
stagnation and venous thrombosis. Most patients can drive a
car 24 hours after operation and return to work after a week.
The patient should be warned that the legs will be bruised
when bandages are removed.
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