49. Varicose veins of the lower limbs

1. Definition

• Varicose veins → dilated (≥ 3 mm), tortuous superficial veins of the leg with valve incompetence and reflux
• Reticular veins → 1–3 mm subdermal veins
• Telangiectasia (thread or spider veins) → < 1 mm intradermal veins
• Chronic venous insufficiency (CVI) → skin changes and ulcers from long-standing venous hypertension

2. Epidemiology

• About one-third of adults
• Women slightly more than men; rises with age
• Venous ulcers → about 1% of adults; 70% recur

3. Aetiology and risk factors

Anatomy (revision)

• Superficial veins:
  • Great saphenous vein (GSV) → in front of the medial malleolus → medial leg and thigh → saphenofemoral junction (SFJ) 2–3 cm below and lateral to the pubic tubercle
  • Small saphenous vein (SSV) → behind the lateral malleolus → back of the calf → saphenopopliteal junction (SPJ) in the popliteal fossa
  • Nerves → saphenous nerve with the GSV below the knee; sural nerve with the SSV
• Deep veins → under the deep fascia, with the arteries
• Perforators → connect superficial to deep; valves direct blood inwards
• Calf muscle pump → soleus and gastrocnemius squeeze the deep veins; valves stop backflow

Causes

• Primary (most) → weak vein wall and valves:
  • Family history
  • Female sex, pregnancy (progesterone, pressure)
  • Prolonged standing, obesity, age
• Secondary:
  • Previous DVT → deep valve damage (post-thrombotic)
  • Pelvic masses → pregnancy, fibroids, ovarian tumour
  • Arteriovenous fistula
• Congenital → Klippel-Trénaunay syndrome, absent valves

4. Pathogenesis

1. Vein wall weakens, valves fail at the SFJ, SPJ or perforators
2. Reflux → blood flows back down when standing
3. Venous hypertension in the superficial veins
4. Veins dilate, lengthen and twist → more valves fail
5. Raised pressure in capillaries → leakage of fluid, red cells and fibrinogen
6. Haemosiderin → brown pigment; white cell trapping and inflammation → lipodermatosclerosis
7. Skin breaks down → venous ulcer

5. Classification

CEAP (2020)

• C (clinical):
  • C0 → no signs
  • C1 → telangiectasia, reticular veins
  • C2 → varicose veins
  • C3 → oedema
  • C4 → skin changes: a pigmentation, eczema; b lipodermatosclerosis, atrophie blanche; c corona phlebectatica
  • C5 → healed ulcer
  • C6 → active ulcer
• E (aetiology) → congenital, primary, secondary
• A (anatomy) → superficial, deep, perforator
• P (pathophysiology) → reflux, obstruction

By vein

• Truncal (GSV, SSV), tributary, reticular, telangiectasia

6. Clinical picture

Symptoms

• Cosmetic concern
• Aching, heaviness, tiredness, itching
• Swelling, worse at the end of the day, in hot weather and before periods
• Night cramps
• Restless legs

Signs

• Examine standing
• Tortuous veins along the GSV (medial) or SSV (back of calf)
• Saphena varix → soft bluish groin lump at the SFJ; disappears lying down; cough impulse and thrill → mimics femoral hernia
• Cough impulse at the SFJ
• Skin changes at the gaiter area (above the medial malleolus):
  • Oedema
  • Brown haemosiderin pigmentation, varicose eczema
  • Lipodermatosclerosis → hard, tight skin; "inverted champagne bottle" leg
  • Atrophie blanche → white scars
• Venous ulcer → medial gaiter area, shallow, sloping edges, granulating base, not very painful

Bedside tests (now mostly replaced by duplex)

• Trendelenburg (tourniquet) test:
  1. Lie down, raise the leg, empty the veins
  2. Tourniquet high on the thigh (or press on the SFJ)
  3. Stand up
  4. Veins stay empty, then fill on release → SFJ incompetence
  5. Veins fill with the tourniquet on → incompetence below it (repeat lower)
• Perthes' test → tourniquet on, patient walks; veins empty → deep veins patent; veins fill with pain → deep vein obstruction
• Tap test → impulse felt below → incompetent valves (unreliable)
• Handheld Doppler → reflux > 1 s at SFJ or SPJ

7. Diagnosis

• Venous duplex ultrasound → gold standard before any treatment:
  • Reflux > 0.5 s in superficial veins (> 1 s in deep veins)
  • Site of reflux → SFJ, SPJ, perforators
  • Deep vein patency and previous DVT
  • Vein diameter, maps the treatment
• ABPI → before compression (exclude arterial disease; compression unsafe if ABPI < 0.8)
• CT or MR venography → pelvic or iliac vein obstruction
• Varicography → recurrent veins, rarely

8. Differential diagnosis

• Saphena varix versus femoral hernia, lymph node, femoral aneurysm, psoas abscess
• Leg swelling → DVT, lymphoedema, heart failure, hypoproteinaemia
• Leg ulcer → arterial, mixed, diabetic, vasculitic, Marjolin's ulcer (squamous cell carcinoma in a long-standing ulcer)
• Venous malformation (young patient, Klippel-Trénaunay)

9. Treatment

• Indications → symptoms, skin changes, ulcers (C2 symptomatic to C6), bleeding, superficial thrombophlebitis; cosmetic treatment is usually not funded

Conservative

• Lifestyle → weight loss, exercise, leg elevation
• Graduated compression stockings:
  • Class I (< 25 mmHg) → mild symptoms
  • Class II (25–35 mmHg) → varicose veins, CVI
  • Class III (35–45 mmHg) → severe CVI, after ulcers
  • Check ABPI first
• Venous ulcer → four-layer compression bandaging if ABPI > 0.8 (heals about 70% in 12 weeks)

Surgical: endovenous (first-line for truncal reflux)

1. Endothermal ablation → first choice:
   • Radiofrequency ablation (RFA) or endovenous laser ablation (EVLA)
   • Catheter into the GSV under ultrasound, tumescent local anaesthetic, vein heated from inside → closes
   • Done as a day case; quick return to work
2. Non-thermal → cyanoacrylate glue, mechanochemical ablation
3. Ultrasound-guided foam sclerotherapy → sodium tetradecyl sulphate or polidocanol foam; tributaries, recurrent veins
4. Ambulatory phlebectomy (stab avulsions) → removes branch varicosities at the same time
5. Microsclerotherapy → thread and reticular veins

Surgical: open

• High ligation and stripping → if endovenous treatment is not suitable:
  1. Groin incision over the SFJ
  2. Flush ligation of the GSV at the SFJ with all tributaries (superficial epigastric, superficial circumflex iliac, external pudendal)
  3. Strip the GSV to the knee only (to protect the saphenous nerve)
  4. Stab avulsions of varicosities
• SSV → SPJ ligation in the popliteal fossa (mark it with duplex); protect the sural and common peroneal nerves
• Perforators → subfascial endoscopic perforator surgery (SEPS), now rarely
• ESCHAR trial → superficial surgery + compression reduces ulcer recurrence; EVRA trial → early ablation heals ulcers faster

10. Complications

Of disease

• Superficial thrombophlebitis
• Bleeding → from a thin vein at the ankle; lie flat, raise the leg, press
• Eczema, lipodermatosclerosis, venous ulcer
• DVT (raised risk)

Of treatment

• Bruising, pain
• Recurrence → about 20–30% at 5 years (up to 50% at 10 years after surgery)
• Nerve injury → saphenous (ablation, stripping), sural (SSV)
• Thermal skin burn, skin staining (sclerotherapy)
• DVT, endovenous heat-induced thrombosis
• Groin wound infection, lymphocoele
• Femoral vein or artery injury (rare, serious)