Varicose vein

Varicose vein

Dr.Atul Kumar MishraM.S. (Gen. Surgery)

HistoryDescription of varicose vein as clinical entity can be traced back as early as 5th century BC.

Forefathers of medicine including Hippocrates and Galen described the disease and treatment modalities, which are still used.

Royle J et al Varicose vein ANZ J Surg. D2007;77(12):1120-7

Throughout centuries, surgical treatments have evolved from large, open surgeries to minimally invasive approaches.

Problem

vein is significant clinical problem and not just a “ cosmetic “issue because of their unsighty nature

Problem arises from fact that varicose vein actually represent underlying chronic venous insufficiency with ensuing venous hypertension

Venous hypertension leads spectrum of clinical menifestations, ranging from symptoms to cuteneous findings like varicose veins, reticular veins, telangiectasias, swelling, skin discolouration, and ulcerations

Varicose veins and even chronic venous insufficiency can be managed conservatively with stockings and compression

Aggressive management can be pursued for cosmesis, worsening cuteneous findings or symptoms despite conservative management, or if patients prefer surgical management

Most procedures are elective, emergent treatment and workup usually reserved for bleeding or if DVT is suspected

Biemans AA et al J Vasc Surg. Sep 2013;58(3):727-34.e1

Pathway leading to varicose veins and other clinical manifestations of venous hypertension

Varicose vein Telangectesia

Reticula vein

Varicose vein

LipodermatosclerosisVenous statis ulcer

Epidemiology Incidence and prevalence in 1973, United States Tecumseh community health study estimated about 40 million persons (26 million females) in US were affected

Coon WW et al Circulation. Oct 1973;48(4):839-46

In 1994, a review by Callam found half of adult poppulation have minor stigmata of venous disease (women 50-55%; men 40-50%) and fewer than half have visible varicose veins (women 20-25%; men 10-15%)

Callam MJ. Br J Surg. Feb1994;81(2):167-73

In 2004, these finding also seen in a French cross- sectional study that found odds ratio per year for varicose veins 1.04 for women and 1.05 for men

Carpentier PH et al J Vasc Surg. Oct 2004;40(4):650-9.

Age and gender have been the only consistently identified risk factors for varicose veins

Coon WW et al Circulation. Oct 1973;48(4):839-46

Carpentier PH et al J Vasc Surg. Oct 2004;40(4):650-9.

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Etiology Primary varicose veins - incompitent venous valves result venous hypertension

Secondary varicose vein - DVT and its sequelae or congenital anatomic abnormalities

Etiology of varicose veins can be classified three group

Primary - Valvular insufficiency of superficial veins, most commonly at saphenofemoral junction

Secondary -Mainly by DVT that leads chronic deep venous obstruction or valvular insufficiency. Long term clinical sequelae from this is called post thrombotic syndrome

Catheter- associated DVTs

Pregnancy- induced and progestrone – induced venous wall and valve weakness worsen by expanded circulating blood volume and enlarged uterus compresses IVC and venous return from the lower extremites

Trauma

Congenital - Any venous malformation

Klippel-trenaunay variants Avalvulia

Biemans AA et al J Vasc Surg. Sep 2013;58(3):727-34.e1

Pathophysiology Dilated, tortuous veins of subcuteneous/superficial venous system

Pathophysiology is complicated and involves concept of ambulatory venous hypertension

Two venous system in lower extrimity, deep and superficial

Deep system ultimately leads back to IVC, then to heart

Superficial system found above deep fascia of lower extrimity, within subcuteneous tissue

Many superficial veins exist, but they all drain into two largest, the great saphenous and short saphenous vein

Schematic diagram of deep and superficial venous system of lower limb (1) Normal venous drainage; arrows dipict flow of venous blood,

(2) Venous HTN bold arrows are pathway of venous reflux

Superficial venous system connected to deep system at following locations

1) Perforator veins- These veins transverse deep fascia of lower extrimity. Number of named perforators found at thigh, knee and leg

Named perforators along Greater saphenous distribution

2) Saphenofemoral junction(SFJ)- Located proximally at groin where GSV meets femoral vein

Saphenofemoral junction

Major tributeries of GSV

3) Saphnopopliteal junction- Behind knee where SSV join Popliteal vein

Normaly, flow of venous blood is through superficial system to deep and up the leg and toward heart

One-way venous valve in both systems and perforating veins

Incompetence in any of these valves lead disruption in unidirectional flow result in ambulatory venous HTN

Incompetence in one system can lead incompetence in another

In a study by Shami et al, limbs of 59 patients with venous ulceration accessed by colour duplex ultrasound scanning. In 53% only superficial venous reflux found, in 15% isolated deep venous reflux found, and in 32% combination of deep and superficial venous reflux was found.

Incompetence of perforating veins leads to hydrodynamic pressure

Calf pump mechanism helps to empty deep venous system, but if perforating vein valves fail, then pressure generated in deep venous system are transmitted into superficial system via incompetent perforating veins

Recek C et al Angiology. Oct-Nov 2006;57(5):556-63

Incompetence in superficial venous system alone usually result from failure at valves located at SFJ and SPJ

Gravitational weight of blood column along the length of vein creates hydrostatic pressure, which is worse at distal aspect of the length of vein

Complications

Thrombophlebitis Pigmentation- black to brown due to hemosiderin

from RBC breakdown Eczema- Extravasated RBC –> itching –> scratch

–> eczema Lipodermatosclerosis -Induration and fibrosis of

skin and sub cuteneous tissue Haemorrhage Equinus deformity

PresentationSubjective symptoms

Usually caused by venous HTN rather varicose vein Often, symptoms are purely aesthetic, and patients desire treatment of unsighty nature of varicosities

Pain, soreness, burning, aching, throbbing, heavy legs, cramping, muscle fatigue, pruritus, night cramps, and “restless legs” are usuallly secondary to venous HTN

Pain and other symptoms may worsen with menstrual cycle, with pregnancy, and in response to exogenous hormonal therapy (oral contraceptives)

History Age Usually in older people Sex

Female > male Occupation

Prolonged standing Symptoms

Cosmetic, pain, ankle swelling, superficial thrombophlebitis, skin changes (thickening, pigmentation, ulceration and eczema)

Past history Similar complaints, treatment and

DVT especially during pregnancy Family history

Similar complaints

Clinical features Age : Any Sex : F:M 10:1 Occupation : Jobs demanding prolong standing person doing muscular work Leg heaviness, exercise intolerance, pain in lower

limb. However, bursting pain means DVT Ankle swelling usuallly at the end of day Tortous dilated visible vein Pruritus, restless legs, and paresthesias Skin changes : pigmentation, ulcer Dermal flare/thread veins Reticular vein

Pain of venous HTN is dull ache that worsen after prolonged standing, improves by walking or by elevating legs

Subjective symptoms more severe early in progression of disease, less severe in middle phases, and more severe again with advancing age

Patients who become acclimatized to chronic disease may not volunteer information about symptoms. After treatment, patients often surprised to realize how much chronic discomfort they had accepted as “normal”

Examination

Inspection Visible veins (site, size and extent, effect of elevation and

dependency) Skin of the lower 3rd medial aspect of calf (swelling, redness,

pigmentation, eczema and ulceration)

Palpation Skin and subcutaneous tissue (texture, oedema, thickening

and tenderness) Course of the veins (defect) SFJ and SPJ (cough impulse and thrill) Special tests (to be demonstrated separately)

Percussion For percussion impulse conducting up or down

Auscultation Bruit

(Properly exposed, standing and supine position, both in front and behind)

For all tests

Sapheno-Femoralincometence

1) Trendelenberg I2) Modified Perthes test

Perforator incompetence

1) Tourniquet test2) Pratt’s test3) Fegan’s test4) Trendelenberg II

Deep vein thrombosis

1) Perthes’test2) Modified Perthes3) Homan’s sign4) Moses sign

Indications Often for cosmetic reasons

Noncosmetic indications varicosities (e.g. pain, fatigability, heaviness, recurrent superficial thrombophlebitis, bleeding)

For treatment of venous hypertension after skin or subcutaneous tissue changes, (lipodermatosclerosis, atrophie blanche, ulceration, or hyperpigmentation)

Nonetheless, a patient's desire for surgical management over conservative treatment or for cosmetic purposes alone are reasonable relative indications for surgery.

Naoum JJ et al Vascular. Sep-Oct 2007;15(5):242-9.

Contraindications

Patients with venous outflow obstruction because they are important bypass pathways that allow blood to flow around the obstruction

Who cannot remain active enough to reduce risk of postoperative DVT

Surgery during pregnancy because many varicose veins of pregnancy spontaneously regress after delivery

Laboratory Studies

No lab test useful in diagnosis or therapy

Patients with varicose veins may have spuriously positive D-dimer test because of chronic low-level thrombosis within varicesDiagnostic Procedures

Duplex ultrasound Most useful tool for workup, replaced many of physical examination maneuvers and physiological tests

Tests used to rule out deep vein thrombosis obstruction as a cause of varicose veins

Noninvasive imaging with good sensitivity and selectivity

Maximum venous outflow (MVO)

Functional test, detect obstruction to venous outflow

It can help detect more proximal occlusion of iliac veins and IVC, as well as extrinsic causes of obstruction in addition to DVTs

MVO uses plethysmography (technique to measure volume changes of leg) to measure speed at with which blood can flow out of a maximally congested lower leg when an occluding thigh tourniquet is suddenly removed Hafner J et al. New York, New York: Karger Publishers; 1999.

Magnetic resonance venography (MRV)

Most sensitive and most specific test to find causes of anatomic obstruction

Particularly useful because unsuspected nonvascular causes for leg pain and edema may often seen when clinical presentation erroneously suggests venous insufficiency or venous obstruction

Expensive test used as adjuvant, when doubt exists.

Hafner J et al. New York, New York: Karger Publishers; 1999.

Tests used to demonstrate reflux

Duplex US with color-flow imaging (sometimes called triplex ultrasound) Special type of 2-dimensional ultrasound that uses Doppler-flow information to add color for blood flow in the image

Vessels in blood are colored red for flow in one direction and blue for flow in other, with a graduated color scale to reflect the speed of flow

Venous valvular reflux is defined as regurgitant flow with Valsalva that lasts great than 2 seconds

Doppler auscultation

Doppler transducer is positioned along the axis of vein with probe at angle of 45° to skin When distal vein is compressed, audible forward flow exists

If valves competent, no audible backward flow is heard with the release of compression If valves incompetent, an audible backflow exists.

These compression-decompression maneuvers repeated while gradually ascending the limb to a level at which reflux can no longer be appreciated

Venous refilling time (VRT)

Physiologic test, using plethysmography

VRT is time necessary for lower leg to become infused with blood after the calf-muscle pump has emptied the lower leg as thoroughly as possible

In healthy subjects, venous refilling >120 seconds

In mild and asymptomatic venous insufficiency between 40 -120 seconds

In significant venous insufficiency 20-40 seconds. Such patients have nocturnal leg cramps, restless legs, leg soreness, burning leg pain, and premature leg fatigue

If < 20 seconds markedly abnormal, and nearly always symptomatic

If < 10 seconds, venous ulcerations are likely

Hafner J et al. New York, New York: Karger Publishers; 1999.

Muscle pump ejection fraction (MPEF)

Detect failure of calf muscle pump to expel blood from lower leg Results are highly repeatable but require skilled operator

Patient performs ankle dorsiflexion 10-20 times, and plethysmography is used to record change in calf blood volume

In healthy patients, venous systems will drain, but in patients with muscle pump failure, severe proximal obstruction, or severe deep vein insufficiency, amount of blood remaining within the calf has little or no change.

Hafner J et al. New York, New York: Karger Publishers; 1999.

Tests used to define anatomyDuplex US Two-dimensional ultrasound forms an anatomic picture

Normal vessel appears as a dark-filled, white-walled structure. Doppler-shift measurement of flow direction and velocity.

Structural details that can be observed include – most delicate venous valves small perforating veins reticular veins as small as 1 mm in diameter and (using special 13-MHz probes) even tiny lymphatic channels

Direct contrast venogram

Intravenous catheter placed in dorsal vein of foot, and radiographic contrast material is infused into the vein

X-rays used to obtain image of superficial venous anatomy

If deep vein imaging is desired, superficial tourniquet is placed around leg to occlude superficial veins and contrast is forced into deep veins

Assessment of reflux can be difficult because it requires passing a catheter from ankle to groin, with selective introduction of contrast material into each vein segment

Labor-intensive and invasive venous imaging technique with a 15% chance of developing new venous thrombosis from the procedure itself. Rarely used, and has been replaced by duplex ultrasound.

Reserved for difficult or confusing cases.

Classification of chronic lower extremity venous disease

CCClinical signs (grade0-6), supplemented by

(A) for asymptomatic and (S) for

symptomatic presentation

EEtiologic Classification (Congenital,

Primary, Secondary)

AAnatomic Distribution (Superficial, Deep,

or Perforator, alone or in combination)

PPathophysiologic Dysfunction (Reflux or

Obstruction, alone or in combination)

Staging CEAP classification from American Venous Forum, last revised 2004

Used to standardize recording of venous diseaseClinicalC0 - No visible or palpable signs of venous diseaseC1 - Telangiectases or reticular veinsC2 - Varicose veinsC3 - EdemaC4a - Pigmentation or eczemaC4b - Lipodermatosclerosis or atrophie blancheC5 - Healed venous ulcerC6 - Active venous ulcerS – Symptomatic, includes: ache, pain, tightness, skin irritation, heaviness, and muscle crampsA – Asymptomatic

Eklöf B et al. J Vasc Surg. Dec 2004;40(6):1248-52

Etiologic classification

Ec - CongenitalEp - PrimaryEs - Secondary (post-thrombotic)En - No venous cause identified

Anatomic classification

As - Superficial veinsAp - Perforator veinsAd - Deep veinsAn - No venous location identified

Pathophysiologic classification

Pr - RefluxPo - ObstructionPr,o – Reflux and obstructionPn - No venous pathophysiology identifiable

Advanced CEAP Same as basic CEAP, with addition that any of 18 named venous segments can be used as locators for venous pathology

Superficial veins (1) telangiectasias or reticular veins, GSV (2) above knee or (3) below knee, (4) small saphenous vein, or (5) nonsaphenous veins

Deep veins (6) Inferior vena cava, (7) common iliac vein, (8) internal iliac vein, (9) external iliac vein, (10) pelvic veins - gonadal, broad ligament veins, other, (11) common femoral vein, (12) deep femoral vein, (13) femoral vein, (14) popliteal vein, (15) crural veins (anterior tibial, posterior tibial, peroneal veins (all paired)), or (16) muscular veins - gastrocnemial, soleal veins, other.

Perforating veins (17) Thigh or (18) calf

Example:

Patient has painful swelling of leg, and varicose veins, lipodermatosclerosis, and active ulceration.

Duplex scanning on 17th May 2014 showed axial reflux of GSV above and below knee, incompetent calf perforator veins, and axial reflux in femoral and popliteal veins.

No signs of post-thrombotic obstruction.

Classification according to basic CEAP: C6,S, Ep,As,p,d, Pr

.Classification according to advanced CEAP: C2,3,4b,6,S, Ep,As,p,d, Pr2,3,18,13,14 (2004-05-17, L II).

Treatment Conservative

– For elderly unfit patients or with mild symptoms– Elastic support, weight reduction, regular exercise, avoidance of

constricting garments and prolonged standing

Sclerotherapy

– For small varices below the knee or recurrent varices after surgery

– Vein is injected with sclerosant (sodium tetradecyl sulphate) and compression bandage applied for 2 week

Surgery

– Aims to remove varices and intercept incompetant perforators

– SFJ or SPJ is ligated flush– Long saphenous vein stripped out from knee to groin– Short saphenous vein may be but normally not stripped out

for fear of sural nerve injury– Remaining varices are avulsed via tiny stab incisions

Surgical Therapy

Under development for more than 2000 years, but until present era, relatively little weight was given to cosmetic outcome

Current therapies becoming less invasive with improved recovery, but long-term outcomes are uncertain

Therapies aim to remove superficial venous system either through surgery, endovenous ablation, or sclerotherapy ablation

Biemans AA et al J Vasc Surg. Sep 2013;58(3):727-34.e1

In 90% cases where venous hypertension is from superficial and perforator vein reflux, removal or obliteration of GSV alone can resolve venous hypertension. In remaining 10%, additional treatment to incompetent perforator veins may be needed

Kalra M et al Surg Clin North Am. Jun 2003;83(3):671-705.

Additionally, if severe deep venous incompetence exists, treatment of GSV alone usually does not resolve venous hypertension. Additional interventions with subfascial endoscopic perforating vein surgery (SEPS), perforator vein ablation, and/or venous reconstruction can be attempted

Prior intervention, Duplex US to map reflux pathways, and skin marker to mark surface vessels to be removed

Open techniques

Rindfleisch-Friedel procedure of early 1900s involved one incision to level of deep fascia that wrapped around leg 6 times, creating a spiral gutter that brought into view a large number of superficial veins, each one of which was ligated. This wound was left open to heal by granulation.

Linton procedure, introduced in late 1930s, used a large linear medial leg incision that brought into view all the superficial and perforator veins of leg. Incompetent superficial veins were removed, and perforating veins were interrupted.

Caggai A, et al The vein book New York; Elsevier;2006:1-14.

Friedrich Trendelenburg, in late 1800s, introduced a midthigh ligation of GSV. Outcomes were variable

This procedure modified by Trendelenburg's student Perthes, who advocated a groin incision and a ligation of GSV at SFJ

Later, better outcomes were found if saphenectomy (removal of the GSV) with ligation at SFJ was performed over ligation alone

In a randomized trial, two thirds patients with ligation without saphenectomy expected to need reintervention within 5 years for recurrent reflux, either through recanalization or collateral formation around the ligated GSV Recek C et al.Int J Angiol. Sep 2012;21(3):181-6

Trendelenberg’s Sapheno-Femoral Flush Ligation

GSV saphenectomyEvolved from large open incisions to less invasive stripping

Original methods of stripping used different devices and variations of techniques.

Mayo stripper was an extraluminal ring that cut the tributaries as it was passed along the vein

Babcock device was an intraluminal stripper with an acorn-shaped head that pleated up the vein as it pulled the vessel loose from its attachments

Keller device an internal wire used to pull the vein through itself, as is done today with perforation-invagination (PIN) strippers

Stripping of Long Saphnous Vein

PIN stripping begins with 2- 3 cm incision at groin crease. Femoral vein and SFJ exposed and all tributaries of SFJ identified and flush-ligated to minimize incidence of reflux recurrence

Then, stripping instrument passed into GSV at groin and threaded through incompetent vein distally to level of upper calf

Stripper brought out through a small incision (5 mm or smaller) approximately 1 cm from the tibial tuberosity of knee.

An inverting head is attached to stripper at groin and secured to the proximal end of vein. Vessel is then inverted into itself, tearing away from each tributary and perforator as stripper is pulled downward through leg and out through the incision in upper calf.

If desired, epinephrine-soaked gauze or ligature may be secured to the stripper before invagination, allowing hemostatic packing to be pulled into place after stripping is complete.

SSV saphenectomy

Removal of SSV is complicated by variable local anatomy and risk of injury to popliteal vein and peroneal nerve

SPJ must be located by duplex before dissection

After ligation and division of junction, stripper passed into distal calf, where it is brought out through small incision (2-4 mm)

Stripper secured to proximal end of vein, which is invaginated into itself as it is pulled downward from knee to ankle and withdrawn from below

Stab phlebectomy (or ambulatory phlebectomy)

Performed by Galen as early as second century, procedure came back into modern favor during 1960s

Useful for treatment of residual vein after saphenectomy and for removal of nontruncal tributaries when the saphenous vein is competent

Microincision made over vessel, phlebectomy hook introduced into microincision, and vein delivered through incision

With traction, as long a segment as possible is pulled out until vein breaks or cannot be pulled further

Another microincision made and process begun again and repeated along the entire length of vein to be extracted

Short segments of veins can be removed through tiny incisions without ligatures, and skin closure not necessary

Weiss RA et al, A Comprehensive Approach New York, NY: McGraw-Hill;2001.

Endovascular techniquesEndovenous (EV) laser

Laser fiber produces endoluminal heat that destroys vascularendothelium

Seldinger technique used to advance long catheter along entire length of truncal varicosity (usually the GSV) to be ablate

Position confirmed by ultrasound and by use of laser guide light

Under ultrasound guidance, tumescent solution with local anesthetic is injected around the entire length of vessel, separating it from its fascial sheath. This serves to insulate the heat from damaging adjacent structures, including nerves and skin, as well as pain control

Firm pressure applied to collapse vein around the laser fiber, and laser fired generating heat, leading intraluminal steam bubbles and irreversible endothelial damage and thrombosis

Fiber and catheter withdrawn approximately 2 mm, and laser is fired again

Process repeated along entire course of vessel Biemans AA et al J Vasc Surg. Sep 2013;58(3):727-34.e1

Radiofrequency (RF) ablation

RF thermal energy delivered directly to vessel wall, causing protein denaturation, collagenous contraction, and immediate closure of vessel

In contrast to laser therapy, RF catheter actually comes into contact with lumen walls

Introducer sheath inserted into proposed vein of treatment (usually GSV)

RF ablation catheter passed through sheath and along the vein until active tip is at SFJ

Like endovenous laser, tumescent local anesthetic is injected

Metal fingers at tip of RF catheter are deployed until they make contact with vessel endothelium

RF energy is delivered, both in and around vessel to be treated. Thermal sensors record the temperature within vessel and deliver just enough energy to ensure endothelial ablation

RF catheter withdrawn a short distance, and process repeated along length of vein

Subramonia and Lees found that, compared with conventional high ligation and stripping, radiofrequency ablation of great saphenous varicose veins took longer to perform, but patients returned to their normal activities significantly earlier and had significantly less postoperative pain. Johnson CM et al, Vascular. Sep-Oct 2007;15(5):250-4.

Minimally invasive techniques

Cutaneous electrodesiccation

Old technique involving electrical cautery for destruction of small vessels that is rarely used today because of disfiguring cutaneous injury

Sclerotherapy

Chemical sclerosis of varicose veins has waxed and waned in popularity since late 1800s

Modern sclerosants with acceptable risk profile became widely available in 1930s, and, since that time, there use expanded

Initially, sclerotherapy was used as surgical adjunct after saphenectomy to treat residual varicosities, reticular veins, or telangiectasias. Now being used to treat GSV and main tributaries

Under US guidance, sclerosing substance injected into abnormal vessels to produce endothelial destruction followed by formation of fibrotic cord and eventual reabsorption of all vascular tissue layers

Caution used when using sclerosing agents

inadvertent injection into arteriovenous malformation or directly into unrecognized artery can cause extensive tissue loss or loss of entire limb

Inadvertent injection of concentrated sclerosants into deep system can cause DVT, pulmonary embolism, and death.

Most commonly used sclerosants are polidocanol (Asclera) and sodium tetradecyl sulfate

Both are known as detergent sclerosants because they are amphiphilic substances, inactive in dilute solution, but biologically active when they form micelles

These agents preferred because they have low incidence of allergic reactions, staining and adverse cutaneous effects, and relatively forgiving if extravasated

Polidocanol, most forgiving sclerosing agent, originally developed as local anesthetic agent

Polidocanol approved by FDA in March, 2010

Other agents that have fallen out of favor include sodium morrhuate, high incidence of anaphylaxis

 Ethanolamine oleate, weak detergent, excessively soluble, decreasing its ability to denature cell surface proteins

Hypertonic saline in 20% or 23.4% solution, because of dilutional effects with injection, difficult to achieve adequate sclerosis of large vessels without exceeding a tolerable salt load. If extravasated, it causes significant necrosis

Addition of foam with sclerosing agents has allowed for decreased amounts of sclerosing agent injection and improved efficacy Rabe E et al, Eur J Vasc Endovasc Surg. Feb 2008;35(2):238-45.

 Foam pushes blood out of vein, allowing for less dilution and more contact of sclerosant with endothelium

Varisolve (BTG, West Conshohocken, PA) is one such product using carbon dioxide foam and polidocanol sclerosant

Biemans AA et al J Vasc Surg. Sep 2013;58(3):727-34.e1

Ultrasound image of GSV after foam sclerotherapy treatment, Hyperechogenicity within vein is from foam

In US, sodium tetradecyl sulfate, sodium morrhuate, and ethanolamine oleate were all developed prior to establishment of FDA

These agents never been submitted to FDA for approval, but available in United States as grandfathered agents

No FDA–approved foam/sclerosing agents available; however, Varisolve is currently under clinical trials in United States after being used extensively in Europe

Wright D et al Europian randomized controlled trial.Phlebectomy. 2006;21:180-90.

Postoperative DetailsAfter treatment by any method, 30-40 mm Hg gradient compression stocking applied and patients instructed to maintain or increase their normal activity levels

Most practitioners also recommend use of gradient compression stockings even after treatment of spider veins and smaller tributary veins

O'Hare et al found that compression bandaging for 24 hours, followed by use of thromboembolus deterrent stockings for remainder 14 days, gave results comparable to compression bandaging for 5 days

In a randomized trial in patients undergoing foam sclerotherapy for primary uncomplicated varicose veins, no significant difference noted in vein occlusion, phlebitis, skin discoloration, or pain at 2 and 6 weeks with the two techniques.

O’Hare JL et al, Br J Surg. May 2010;97(5):650-6.

Activity is important after treatment because all modalities of treatment have potential to increase risk of DVT

Activity is strong protective factor against venous stasis

Activity is so important that most venous specialists not treat a patient who is unable to remain active following treatment

Most annoying minor complications of any venous surgery

Dysesthesias from injury to sural nerve or saphenous nerve

Subcutaneous hematoma is common complication, regardless of treatment technique. Managed with warm compress, NSAIDS, or aspiration if necessary

At SFJ, accidental treatment of femoral vein by inappropriate RF or laser catheter placement, or spread of sclerosant, or inappropriate surgical ligation can all lead to endothelium damage at deep vein, causing DVT with potential of pulmonary embolism and even death.[18]

Postoperative infection

Arterial injury (less common and may be kept to minimum through strict attention to good technique

Endovenous techniques have potential of excessive tissue heating, lead skin burns. Avoided if sufficient volumes of tumescent anesthetic injected to elevate the skin away from vein.[18]

Outcome and Prognosis

With appropriate treatment, majority of patients have good outcome and progression is arrested

Surgical stripping of GSV, or saphenectomy, standard to which most therapies compared

In a randomized trial entitled endovenous radiofrequency obliteration versus ligation and stripping (EVOLVeS) study, 68 legs randomly assigned to undergo RFA or surgical stripping of GSV. Immediate success for RFA versus stripping on day of treatment was 95% versus 100%, respectively. At 3 weeks, duplex ultrasonography confirmed closure of GSV in 90.9% of RFA group. Lurie F et al J Vasc Surg. Aug 2003;38(2):207-14. 

In extended 2-year follow-up, there was nonsignificant difference of cumulative rates of recurrent varicose veins: 14% for RFA and 21% for stripping. However global quality-of-life scores were still in favor of RFA. Rasmussen LH et al Br J Surg. Aug 2011;98(8):1079-87.

In a randomized trial of 137 legs, endovenous laser ablation was compared with saphenectomy. Both methods were equally efficacious at obliterating GSV, but saphenectomy group had higher postoperative pain scores. Other similar results between saphenectomy and endovenous laser groups included time to resume normal physical activity (7.7 d vs 6.9 d), time to resume work (7.6 d vs 7 d), and total cost of procedures ($3948 vs $4347 USD). Rasmussen LH et al J Vasc Surg. Aug 2007;46(2):308-15.

In a trial of 280 patients randomized to endovenous laser ablation compared with saphenectomy, follow up extended to over a year. The authors found at 1 year, lower rates of clinical recurrence with endovenous laser ablation versus surgery (4% vs 20.4%, P < .001). Twelve of 23 surgical recurrences related to incompetent below-knee GSV and 10 to neovascularization. In endovenous laser group, 5 recurrences reported. Two related to neoreflux in groin tributaries and 1 to recanalization. Carradice D et al Br J Surg. Aug 2011;98(8):1117-23.

In a more recent randomized trial of 500 patients and 580 legs, endovenous ablation, RFA, foam sclerotherapy, and surgical stripping were compared. At 1 year, Highest failure rates seen in foam ablation (16.3%) and endovenous ablation (5.8%) groups. Lowest seen in RFA (4.8%) and stripping groups (4.8%), although these 2 groups also had highest postintervention pain scores. Rasmussen LH et al Br J Surg. Aug 2011;98(8):1079-87.

Foam sclerotherapy used in Europe, and phase III randomized clinical trials compared it with saphenectomy and sclerotherapy without foam

At 12 months, GSV closure rates 87.2% in saphenectomy versus 68.2% in Varisolve. Sclerotherapy without foam versus Varisolve, closure rates for Varisolve group 93.8%. Although surgery more efficacious, Varisolve caused less pain and patients returned to normal more quickly.

In 710 patients enrolled, no pulmonary embolus found, and DVTs found in 2.5% of Varisolve, none in surgery, and 0.8% in sclerotherapy without foam

Wright D et al European randomized controlled trial. Phlebectomy. 2006;21:180-90.

Future and Controversies

Management of varicose veins has evolved over the centuries and will continue to do so

Less invasive techniques continue to be refined but long-term efficacy must always be questioned and compared with criterion standard of surgical saphenectomy