Now considered a 'bottom up' disease rather than a 'top down'
disease (ie starts in the low leg)
Superficial system collects blood from superficial tissues.
When calf muscle pumps (250 mmHg), deep system is emptied north
When calf muscle relaxes, pressure gradient means the blood flows
from superficial to deep.
Valves prevent retrograde flow into the superficial system during
Primary problem is incompetence of the perforating system, or
failure of their valves
This allows blood to reflux into the superficial system Progressive dilation follows
--> progressive failure of superficial vein valves
--> elongation of superficial veins, causing them to
High pressure in superficial veins may be sufficient to impair the
nutrition of the subcut tissue and dermis
--> contributes to ulcer formation.
Varicose veins = disorder of superficial and perforating veins
- strong genetic predisposition.
- female distribution due to muscle-relaxin effects of progesterone,
pressure effects of uterus.
- may get better with delivery then worsen with the next pregnancy.
It is possible to get vulval and posterior thigh varices with
involvement of tributaries of the internal iliac vein.
- superficial thrombosis in a varicose vein; inflammation from a
- inflamed; may be confused for an infection
- extension to deep veinous system is a major threat
--> if >15cm or clincal signs of concerning spread, arrange
urgent duplex then +/- operative ligation of the saphenofemoral jx
--> consider full anticoagulation if thrombophlebitis continues
up the knee.
- rupture is accompaneid by profuse bleeding while limb dependent.
- may exsanguinate
--> lie down immediately and elevate limb; pressure to bleeding
point; avoid tourniquets for venous bleeding or worsens.
- see chronic venous
Thrombosis in the deep veins increases pressure in the deep system.
This reverses the normal flow.
Ie from deep to superficial.
In this situation the muscle pump is ineffective and blood collects
the superficial leg veins.
The increased pressure and volume dilates the superficial system
Removing these superficial veins would only make it all much worse. Chronic venous stasis
Spectrum from tiny venous flares / spider veins
To huge veins present many years
Result from fluid congestion and inadequate venous return
85% have aching in the leg, worse as the day goes on.
- throbbing occurs with same frequency.
50% get cramp at night (ask).
30% get swelling of ankles and feet.
10% get an ache in the groin, sometimes confused for hernia pain.
Take a careful DVT history.
- if male, and no family history, may be secondary, even without a
1. Duplex USS is exam of choice
- Venography is no longer used; poor risk to benefit ratio.
Provides an image and information about hte blood flow velocity.
- defining incompetence of the major saphenous systems
- identifying level where SSV enters popliteral (operative planning)
- locating incompetent perforators
- excluding DVT
Major causes of recurrence are:
- incompetence developing in second system (e.g. SSV after GSV
- incompetence of perforating veins at jx of middle and lower thirds
- recurrence following saphenofemoral ligation
--> this is probably NOT failure to treat major tributaries
--> rather, probably neovascularization; ie. multiple tiny
channels develop between deep and superficial systems through scar
Few sequelae if untreated --> treatment not essential
Unless pre-ulcerative secondary venous tissue changes, or with
1. Elastic Compression Stockings
Do not cure
But provide relief from symptoms of swelling adn tiredness, and
Particularly useful in the pregnant.
Range of stockings are available
- low, medium, high grade
- for most varicose vein patients, want a grad 2 (20-30 mmHg)
A good diagnostic challenge
- if relieves symptoms, then likely due to the veins
- if fail to relieve, consider other causes.
Beware patients with inadequate pedal pulses.
2. Injection-Compression Therapy (Slerotherapy)
Not an option for major uncontrolled sites of deep to superficial
Injected with chemical irritant then compression applied to stick
inflamed vein together
- inhibits recanalization
Can inject small amounts of hypertonic saline into superficial
telangiectatic veins / spider veins for cosmetic control.
3. Surgical Removal See notes Treat the junction, the trunk, and the branches
Preop uss to define nerve position and locate
1. Saphenofemoral ligation
- skin crease 3cm long below and lateral to the pubic tubercle, 1cm
above groin crease
Dissect LSV and tributaries
2cm above and below FV
*High tie now no longer considered essential in
principles in era of RF ablation / laser, where top
tributaries are not treated.
- as above, the proximal recurrences are probably
- though obviously must be done in
conjunction with stripping
2. Saphenopopliteal ligation
Similar to above
duplex to guide knowledge of jx.
avoid sural nerve, which runs with the SSV
- limited to groin to knee
- below this level may get troublesome neuritis of the saphenous
- incise over perforating vein as passes to deep fascia
- pre-op duplex to localise
- ligate and divide beneath deep fascia
- usually reserved for recurrent veins or patients with secondary
venous tissue changes or ulceration.
5. Multiple stab avulsions of tributaries
- crochet hook and extract with serial hemostats
- next one 2-4cm away and proceed
4. Radiofrequency or endovenous laser ablation
Now considered standard of care over surgical stripping with US
Heat treatment to destroy trunk of long superficial vein
Additional treatments for enlarged and superficial branching veins.
Risks are bleeding / haematoma, lymphatic
lymphoedema, and nerve injury.
Recurrence rate 15-20% at 5y
bandage after surgery to promote hemostasis
Prevent DVT with early mobilization and heparin
Outer bandages removed at 24-48h and elastic stockings applied for
2w while tendence to swell.