Varicose Veins: Causes & Treatment

Varicose Veins And Deep Vein Thrombosis Introduction

Varicosity is the penalty for verticality against gravity. This is the common statement made in lecture classes. The blood has to flow from the lower limbs into the heart against gravity because of the upright posture of human beings.

Read And Learn More: General Surgery Notes

• In many cases, varicose veins are asymptomatic. Raised intra-abdominal pressure may also precipitate varicose veins, which is more common in females due to repeated pregnancy. The complications of varicose veins lead to hospitalisation.
• Examples of varicosity are long saphenous varicosity, short saphenous varicosity, oesophageal varices, fundal varices, haemorrhoids, etc. In this chapter, the varicosity of the leg is discussed.

Varicose Veins Definition

Dilated, tortuous, and elongated superficial veins of the limb due to reflux are called varicose veins. They are about 3 mm in diameter.

Primary Varicose Veins

Primary varicose veins occur as a result of congenital weakness in the vein wall due to defective connective tissue and smooth muscle.

• They may also result from muscular weakness or congenital absence of valves.
• Factors that predispose to varicose veins are given.
• Factors which Predispose Varicose Veins
  • Height: Tall individuals suffer more
  • Weight: Obesity may weaken the vein wall
  • Occupation: Hotel workers, policemen, shopkeepers, tailors
  • Side: The left is affected more than the right
  • Age and sex: Not very clear

Very often, the valve at the saphenofemoral (SF) junction is incompetent or absent. The valves may also be absent at the junction of superficial veins joining the deep veins.

• Klippel-Trénaunay syndrome is a congenital venous abnormality wherein superficial and deep veins do not have any valves. It is also called valveless syndrome. It is not a hereditary condition.
• Klippel-Trénaunay Syndrome
  • Incidence 1 in 1,00,000 population.
  • Also called angio-osteohypertrophy syndrome
  • Characterised by nevus flammeus (port-wine stain), venous malformations,
    lymphatic malformations and soft tissue hypertrophy of the affected limb.
  • Can also have large arteriovenous malformations.
  • Patients can complain of pain heaviness in the limbs, and difficulty in walking due to abnormal length of the limb.
  • Excision of veins, sclerotherapy, and laser treatment for port-wine stains are a few methods to treat the veins.

Primary varicosity may also be genetic. Some patients inherit abnormalities in the FOXC2 gene. These factors, in addition to prolonged standing (agriculturists, traffic police, hotel workers), contribute to the development of varicose veins.

Secondary Varicose Veins

Women are more prone to varicose veins because of the following reasons:

• Pregnancy and pelvic tumours cause proximal obstruction to the blood flow.
• Pills (oral contraceptive pills) alter the viscosity of blood.
• Progesterones dilate the vessel wall.
• Congenital arteriovenous (AV) fistula increases blood flow and increases venous pressure.
• Deep vein thrombosis may occur postoperatively, as a result of road traffic accidents, etc. These may lead to the destruction of valves, resulting in varicose veins.

Describe the applied anatomy of the venous system of the lower limb.

Surgical Anatomy Of The Venous System Of Leg

It may be discussed under the following headings:

1. Superficial venous system—long and short saphenous veins and their tributaries
2. Perforators
3. Deep venous system

Superficial Venous System

Anatomy of the Long Saphenous Vein (LSV)

LSV starts in the foot from the tributaries of the dorsal venous arch which runs in front of metatarsal heads in the subcutaneous tissue in the dorsal aspect of the foot. It ascends in front of the medial malleolus and runs along the medial side of the leg.

• It then ascends in the thigh and ends at the saphenofemoral (SF) junction by joining the femoral vein, which is 1.5 inches (4 cm) below and lateral to the pubic tubercle. SF junction can be variable, more superiorly located sometimes.
• Today the junction is marked before surgery during venous ultrasound which helps in placing the incision accordingly. It has 15–20 valves. Absence of valves results in varicose veins.

Superficial System—Salient Features

• As the name suggests, they are in the superficial fascia and are often visible (saphenous means easily seen).
• They are low-pressure and poorly supported systems.
• They are provided with numerous valves.
• The middle coat of these veins consists mostly of smooth muscle.
• The middle coat is also thicker than that of other veins.
• Normal blood flow is from the superficial to a deep system of veins.

Superficial Venous System Tributaries: These tributaries connect the long saphenous with the short saphenous vein (SSV). They are also known as communicators. They are as follows.

Superficial Venous System Tributaries Near its termination

1. Superficial circumflex iliac vein
2. Superficial epigastric vein
3. Superficial external pudendal vein

Tributaries in the Lower Thigh

1. Lateral superficial femoral vein
2. Medial superficial femoral vein
3. Transverse suprapatellar vein
4. Transverse infrapatellar vein

Tributaries in the Leg

1. Anterior vein of the leg—also called anterior (accessory) saphenous vein (ASV).
2. Posterior arch vein—lies parallel to and behind the main trunk of the long saphenous vein. It anastomoses with small venous arches connecting the medial perforating veins.

Perforators

These are the veins which connect long saphenous veins with the deep system of veins. Since they perforate the deep fascia, they are called perforators. There are 5 constant perforators in the lower limb on the medial side.

• Leg perforators: They are 3 in number. The lowest perforator is below and behind the medial malleolus, the middle perforator is 10 cm above the tip of the medial malleolus, and the upper perforator is 15 cm above the medial malleolus.
• Knee perforator: It is just below the knee.
• Thigh perforator: It is a palm-breadth above the knee.

A knowledge of perforators forms the basis of the multiple tourniquet test. Most of the perforators contain valves. Weakness of or damage to these valves results in varicosity.

Deep Venous System

This comprises the femoral and the popliteal veins, veins or 3 pairs of venae comitantes accompanying the anterior tibial, posterior tibial, and peroneal arteries, and the valveless veins draining the calf muscles (soleal venous sinus).

• Formation of a popliteal vein: It is formed by these 6 venae comitantes which unite and form the popliteal vein in the popliteal fossa. Short saphenous vein (SSV)
  • as the name implies short ascends behind the lateral malleolus join the popliteal vein at the saphenopopliteal junction (SP junction). Termination point can be variable often it is inferior.
  • Near the termination, it pierces the popliteal fascia. The popliteal vein also receives the Giacomini vein and gastrocnemius veins.
• Formation of a femoral vein: The popliteal vein continues upwards in the sub-sartorial canal as a femoral vein and receives a long saphenous vein at the SF junction. All tributaries mentioned above would have joined.
  • The vein and before it pierces it not only receives named 3 tributaries but also receives a deep pro-funda vein.
  • The femoral vein continues as an external iliac vein above the inguinal ligament.
• Soleal plexus of veins: These are called deep veins of the calf region or also called calf muscle pump. Blind-ended soleal sinusoids join them and help in pumping the blood. These veins are also called capacitance vessels.

This is because they have the capacity to accumulate a large volume (60%) of blood inside. Using this principle, the simple elevation of both legs is done in hypovolaemic shock patients as an initial step to resuscitate.

•  Salient Features of the Deep Venous System
  • It is a high-pressure system, well-supported by powerful muscles.
  • They are connected to the superficial veins through perforators.
  • The powerful calf muscle contraction returns blood to the heart.
  • The deep veins also contain valves.

• Venous pathophysiology: Pressure at the capillary side of the venule is very low, around 10 to 12 mmHg. The pressure becomes less and less as the vein is traced upwards.
• For example: In the inferior vena cava it is about 5 mmHg. Blood is returned to the heart from the lower limbs through the following mechanisms:
• Calf muscle pump: In standing position blood pressure at the venule is about 100 mmHg. It refers to the alternate contraction and relaxation of the muscles of the leg (the major factor). The pressure within the calf compartment rises to 200–300 mmHg during walking.

Negative intrathoracic pressure during inspiration resulting in an increase in intrathoracic volume.

• Competent valves (unidirectional) in the leg: When these valves are absent or weak, perforator incompetence develops, which results in varicose veins.
• Deep Venous System Distribution of Valves

1. Inferior vena cava : No valve
2. Common iliac vein : No valve
3. Long saphenous vein: 10–14 valves
4. Short saphenous vein: 1 valve

• Visatergo of the circulation: The pressure transmitted from the arterial tree passes the capillary bed to the venous side, which helps return blood to the heart at rest.
• Venae comitantes.

Deep Venous System A Few Terminologies for Dilated Veins

1. Telangiectasia: Confluence of dilated intradermal venules of <1 mm diameter.
2. Reticular veins: Dilated subdermal veins of 1–3 mm diameter.
3. Ankle flare: A dilated group of reticular (corona phlebectasia) veins near the medial malleolus.
4. Blowout: A localised dilatation of the vein which is ‘dome-like or ballooned out.
5. Saphena varix: A dilated long saphenous vein near the termination (SF junction) in the groin which is soft and reducible on lying down and elevating the leg.
6. Atrophic blanche: Atrophic skin with pigmentation and reticular veins—seen in the ankle region. Before we start the clinical examination of the varicose veins.

Classification of chronic lower extremity venous disease

A Few Terminologies for Dilated Veins Clinical (C)

Describe the pathophysiology, clinical features, investigations and principles of management of DVT and varicose veins.

Clinical Examination Of A Case Of Leg Varicosity

Leg Varicosity Symptoms

• The patient often complains of swelling of the legs. It is due to an increased volume of fluid in the skin and subcutaneous tissues, increased interstitial fluid, impaired lymphatic drainage, and increased hydrostatic pressure.
• Most patients present with dilated veins in the leg. They are minimal at the start of the day and are sufficiently large by the end of the day due to venous engorgement.
• Dragging pain in the leg or a dull ache due to heaviness. Night cramps occur due to changes in the diameter of veins. Aching pain is relieved at night by rest or elevating the limbs. Night cramps also occur due to the prevention of nutrients and deoxygenated blood, which results in lactic acid accumulation. Night cramps are more common in women.
• Sudden pain in the calf region with fever and oedema of the ankle region suggests deep vein thrombosis (DVT). Some patients with DVT may be asymptomatic.
• Patients may present with ulceration, eczema, dermatitis, and bleeding.
• Symptoms of pruritus or itching and skin thickening. Interestingly, pain due to varicose veins is relieved with exercise in contrast to pain due to arterial diseases, which worsen with exercise.

Leg Varicosity Signs

Leg Varicosity Inspection (should be done in a standing position)

Dilated veins are present in the medial aspect of the leg and the knee. Sometimes they are visible in the thigh.

• A single dilated varix at the SF junction is called saphena varix. It is due to saccular dilatation of the upper end of the long saphenous vein at the saphenous opening.
• Veins are tortuous and dilated.
• A localised, dilated segment of the vein, if present, is an indication of a blowout. It signifies an underlying perforator.

• Ankle flare is a group of reticular veins near the medial malleolus.
• Complications such as ulceration, bleeding, eczema, and dermatitis may be present. Pigmentation is often seen. It is due to subcutaneous microangiopathy, acute cellulitis, fasciitis, and panniculitis.
• A healed scar indicates previous ulceration.
• A dilated vein may be present over the popliteal fossa region as well.

Leg Varicosity Palpation

• First, palpate along the whole length of the vein for tenderness. If present, it indicates thrombophlebitis. A thrombosed vein will feel like a firm or hard nodule.
• The following tests are performed.

Leg Varicosity Tests for Varicose Veins

• Cough impulse test: SF incompetence
• Trendelenburg 1: SF incompetence
• Trendelenburg 2: Perforator incompetence
• Multiple tourniquet test: Site of perforator incompetence
• Schwartz test: Superficial column of blood
• Modified Perthes’ test: Deep vein thrombosis
• Fegan’s test: To locate the perforators in the deep fascia

1. Cough impulse test (Morrissey’s test): This test should be done in the standing position. There examiner keeps the finger at the SF junction and asks the fingers, which is indicative of ‘saphenofemoral incompetence’.

2. Trendelenburg test: This test is done in 2 parts.

• Method: The patient is asked to lie on the couch in the supine position. The leg is elevated above the level of the heart and the vein is emptied. The SF junction is occluded with the thumb (or a tourniquet) and the patient is asked to stand.
• Trendelenburg 1: Release the thumb or tourniquet immediately. A rapid gush of blood from above downwards indicates saphenofemoral incompetence.
• Trendelenburg 2: The pressure at the SF junction is maintained without releasing the thumb or tourniquet. The patient is then asked to stand. Slow filling of the long saphenous is seen which indicates perforator incompetence (retrograde flow of blood).

3. Multiple tourniquet test: This is done to determine the exact site of the perforators.

• Method: The patient is asked to lie supine on the couch. The vein is emptied by elevation. As the name suggests, 3–4 tourniquets (multiple) may be applied. Applying more tourniquets is not practical. There are mainly ankle, knee, and thigh perforators. Hence, four tourniquets may be applied at the following levels:
• 1st tourniquet: At the level of the SF junction.
• 2nd tourniquet: At the level of the middle of the thigh, occlude the perforator in the Hunter’s canal.
• 3rd tourniquet: Just below the knee.
• 4th tourniquet: Palm breadth (lower third of the leg) above the medial malleolus or ankle.

Ask the patient to stand and observe the appearance of veins.

• Inference: The appearance of veins between the first and second tourniquets indicates incompetence of thigh perforators, between the second and third indicates incompetence of knee perforators, and below the fourth indicates incompetence of ankle perforators. Most commonly, below-knee and ankle perforators are incompetent.
• On releasing the tourniquets one by one from below upwards, sudden retrograde filling of the veins occurs.

4. Schwartz test: It is done with the patient in a standing position. Place the fingers of the left hand over a dilated segment of the vein and tap the vein with the right index finger. A palpable impulse suggests a superficial column of blood in the vein and incompetent valves between the segment.

5. Modified Perthes test1: It is done to rule out deep vein thrombosis. The patient is asked to stand and a tourniquet is applied at the SF junction. He is then asked to take a brisk walk-tip toe walking.

• Inference: If the patient complains of severe pain in the calf region or if superficial veins become more prominent, it indicates deep vein thrombosis and is a contraindication for surgery.

6. Fegan’s method (test): It is done to detect the site of perforators. The patient is asked to stand and the varicosity is marked with methylene blue. The patient is then asked to lie down. The leg is elevated to empty the vein and the vein is palpated throughout its course. The defects in the deep fascia have a circular, buttonhole consistency.

• Examination of varicose ulcer: It should be done by inspection and palpation.
• Evidence of deep vein thrombosis: Homan’s test must be done for chronic DVT. Moses’ test (vide infra) is not to be done.
• Examination of the abdomen: To rule out pelvic tumours. Look for inferior vena cava obstruction in the form of dilated veins in the lateral abdominal wall.

Varicose Veins Clinical Discussion

At the end of the clinical examination, you should be ready to answer the following questions:

Question 1. Which system is involved?
Answer:

• Medial veins: LSV—long saphenous vein
• Lateral veins: SSV—short saphenous vein

Question 2. Is the SF junction incompetent?
Answer:

Yes—Trendelenburg I is positive, No—Trendelenburg I is negative

Question 3. Is there perforator incompetence?
Answer:

Yes—Trendelenburg II is positive, No—Trendelenburg II is negative

Question 4. Which group of perforators is incompetent?
Answer:

According to the results of multiple tourniquet tests—usually ankle and below knee.

Question 5. Is there deep vein thrombosis?
Answer:

Yes—Perthes’ test is positive, No—Perthes’ test is negative.

Question 6. Is there any abdominal mass?
Answer:

There may be a pelvic tumour.

Question 7. Are any complications present?
Answer:

Eczema, dermatitis, ulcer, etc.

Question 8. Is it unilateral or bilateral?
Answer:

Determine by hand-held Doppler—an extension of clinical examination.

Question 9. What is the CEAP classification?
Answer:

Example: C1 Ep A-LSV Pr.

Question 10. What is the gait of the patient?
Answer:

Equinus deformity in long-standing ulcers.

Varicose Veins Investigations

1. Hand-held Doppler is the first, minimum-level investigation done before treating a patient with venous disease. The patient is asked to stand.

• When the blood flows, the wave emits a signal—the Doppler signal.
• If there is SF incompetence, forward and backward flow may be detected.
• Biphasic signal: Gently squeeze calf muscles and assess the flow in the SF junction with the Doppler probe.
• It may also pick up an accessory long saphenous vein in the groin.
• Can be used to mark the SF junction and SP junction.
• The patient can be asked to cough and reflux can be confirmed at SF junction.
• It is not used to identify perforators.
• Doppler Ultrasound
  • This investigation is carried out with the patient standing/sitting.
  • Incompetence of SFJ and saphenopopliteal junction (SPJ) can be assessed by this method—reflux.
  • The gentle squeezing of calf muscles helps in detecting saphenopopliteal incompetence.
  • To identify and locate perforators.
  • It also helps to rule out arterial diseases.
  • It can detect the patency of veins.
  • It can detect deep vein thrombosis.

2. Duplex ultrasound imaging: In this investigation, high-resolution B-mode ultrasound imaging and Doppler ultrasound are used.

It provides images of the veins and measures the flow in them.

• The origin of venous ulcers and varicose veins may also be assessed.
• Retrograde flow in the veins may be demonstrated by compression, release, and the Valsalva manoeuvre.
• Mickey Mouse sign: The three prominent structures—the common femoral artery the great saphenous vein above and the common femoral vein below mimic Mickey Mouse.
• Saphenous eye sign: In the fascial compartments of the thigh, the dilated saphenous vein in cross-section resembles an ‘eye’ in transverse ‘B’ mode scan.

3. Venography: Both ascending and descending venographies may be done in the case of deep vein thrombosis. It is an invasive procedure and carries the risk of spreading infection and septicaemia.

• Duplex ultrasonography has largely replaced this investigation (rarely done now). Varicography refers to injecting contrast into surface veins (indicated in recurrent varicose veins). It may be followed by sclerosant injections.

4. Plethysmography: It is based on the measurement of volume changes in the leg. By placing a light-emitting diode above the medial malleolus and having the patient perform tip-toe movements, venous recovery time may be measured.

• This is called photoplethysmography (PPT).
• With the advent of venous duplex scans, venography and plethysmography are rarely done.

Varicose Veins Treatment

Pharmacotherapy: It helps reduce oedema of the leg, and thereby improves night cramps. Flavanoids affect leucocytes and vascular endothelium, which helps heal cutaneous ulcers.

• Diosmin and hesperidin are the two commonly used vasoactive drugs. Diosmin prolongs the vasoconstrictor effect of norepinephrine on the vein wall.
• Thus, the venous tone is increased and the venous volume, distensibility, and stasis are reduced. This increases the venous return, which helps patients with CVI.

Varicose Veins Treatment Non-surgical Treatment:

1. Elastic compression stockings
2. Injection line of treatment (compression sclerotherapy)
3. Foam sclerotherapy
4. Endovenous laser ablation
5. Radio-frequency ablation (RFA)

1. Elastic Compression Stockings These are also called graduated compression stockings. It is the fundamental treatment for varicose veins. This may be advised in asymptomatic cases of varicose veins and in cases of venous oedema and secondary varicose veins.

• How Graduated Compression Stockings Work?
  • Increases the interstitial pressure
  • Promotes fluid reabsorption
  • Improves ambulatory venous pressure
  • Improves skin micro-circulation
• Usually, 20–30 mmHg stockings are sufficient.
• It should be worn from the ankle to below the knee.
• It should be worn during working hours (entire day).
• It should be removed while lying down but the legs should be kept elevated.
• Above-knee stockings should never be prescribed as they are difficult to put on and tend to roll down.

Varicose Veins Treatment Advantages

• Require minimal patient involvement
• Provide continuous compression
• Provide topical therapy

Compression Stockings

Varicose Veins Treatment Disadvantages

• Bulky and uncomfortable
• Ulcers cannot be monitored once applied
• Dermatitis

Varicose Veins Treatment Indications

• Pregnancy, pelvic tumour
• Perthes’ test—positive patient
• AV fistula

Varicose Veins Treatment Contraindication: Occlusive arterial disease.

2. Injection Line of Treatment (Compression Sclerotherapy)

• Compression Sclerotherapy
  • Endothelial cells in the vein wall are damaged
  • Effective sclerosant
  • Empty vein
  • Elastic compression stockings
  • Exercises
  • Observe 5 Es

Injection Line of Treatment Indications

Below knee varicosity and recurrent varicosity after surgery.

Injection Line of Treatment Procedure

• Varicose veins are marked in the standing position. Doppler can be used to puncture the vein. The veins are punctured with a needle attached to a syringe containing a sclerosant agent and the patient is asked to lie down.
• 3% sodium tetradecyl sulphate or 1–2 ml of ethanolamine oleate or hypertonic saline is injected into the column of the vein. Aseptic thrombosis and fibrosis occur, which shrinks the vein. A tight elastic compression bandage is applied.
• The success of sclerotherapy depends on the use of an effective sclerosant, injection into an empty vein, and compression followed by exercise.
• Injection sclerotherapy is useful in varicose veins <3 mm in diameter. Large veins require surgery.

Injection Line of Treatment Complications of Compression Sclerotherapy

Allergy, pigmentation, deep vein thrombosis, thrombophlebitis and skin necrosis.

3. Ultrasound-guided Foam Sclerotherapy by Tessari.

• 2 syringes are used here with a 3-way stopcock is used to inject the foam. It was described by Lorenzo Tessari.
• Very useful and better when there are large veins.
• Foam is visible in ultrasound, thus obliteration of veins can be visualised better.
• Foam sclerosant C (polidocanol) is used. It is prepared by mixing air with a sclerosant.
• Foam Sclerotherapy
  • Used to treat small and medium-sized varicose veins.
  • The sclerosant is mixed with air or preferably carbon dioxide plus oxygen.
  • Carbon dioxide plus oxygen is soluble in blood and hence safe.
  • Foam causes inflammation of the vein wall, obliteration of the venous lumen and vein occlusion.
  • Success rates range from 60 to 90%.
  • Complications include cutaneous ulceration, thrombophlebitis, deep vein thrombosis and allergy.
  • Foam displaces blood (unlike sclerosant which mixes with blood), and requires a small quantity to be in touch with the vein wall.
  • Extravasated foam is much better tolerated.
  • It is echogenic.
• It is injected into the superficial veins under ultrasound guidance.
• LSV should be compressed in the upper thigh to prevent entry of foam into the femoral vein.
• The leg should be elevated to prevent the entry of foam into the calf veins.

Ultrasound-guided Foam Sclerotherapy by Tessari Complications of Foam Sclerotherapy

• Skin ulceration due to extravasation.
• Deep vein thrombosis is due to escape into deep veins.
• Headache and stroke due to air entry into the brain.

4. Endovenous Laser Ablation (EVLA)

• It is a minimally invasive, outpatient procedure that uses lasers to ablate varicose veins. It gives excellent cosmetic and functional results and is ideal for veins >12 mm in diameter.
• It is done after giving tumescent anaesthesia. Tumescent means tissue is swollen and firm. It is done by extensive regional anaesthesia of the skin and subcutaneous tissue with a high total dose (200 ml of 0.1% lignocaine with adrenaline and bicarbonate) but a low risk of systemic toxicity. Thus it avoids skin burns and other reactions.

Endovenous Laser Ablation Advantages

• Simple outpatient procedure
• Ideal for junctional and truncal incompetence
• Less expensive than radiofrequency ablation

Endovenous Laser Ablation Disadvantages

Expensive and not ideal for smaller, tortuous, and or thrombophlebitic veins.

5. Radiofrequency Ablation (RFA)

• Ideally suited for long saphenous veins with a diameter <12 mm.
• It is also a minimally invasive ablation technique that uses a bipolar catheter electrode at a temperature of 110–120°C with a power of 2–4 W. It is a high-frequency alternating radiofrequency current that leads to venous spasm, collagen shrinkage and physical contraction.
• The position of the patient, accurate marking of the veins, and tumescent anaesthesia are similar to that of EVLA. The vein is cannulated with a 7F sheath.
• The catheter tip should be placed 2.0 cm inferior to the saphenofemoral or saphenopopliteal junction.
• A vein segment >7 cm long may be ablated in 20-second cycles.
• Compression stockings are to be used after the RFA.
• Complications include thrombophlebitis, pain, and skin burns.
• It is a safe and effective treatment for varicose veins.

6. Surgery

1. Trendelenburg’s operation:

• An inguinal incision is made, the long saphenous vein is identified, and the 3 tributaries are ligated. The long saphenous vein is ligated close to the femoral vein and divided. This step is called the Trendelenburg operation (juxta femoral flush ligation).
• An incision is made on the medial side of the upper leg and the long saphenous vein is isolated. The lower end is ligated and the vein is incised. A long metallic stripper is introduced within the vein and brought out from the long saphenous vein below a knee incision.
• A metallic head is connected to the stripper and the vein is avulsed. A tight crepe bandage is applied, the inguinal incision is sutured, and the limb is elevated (retrograde avulsion).
• Wisdom in Juxtafemoral Flush Ligation
  • Demonstrate T junction—long saphenous vein joining femoral vein.
  • Demonstrate 3–4 tributaries before ligation.
  • Double saphenous veins can be present as an anomaly.
  • Receives large anterolateral thigh veins and posteromedial thigh veins.
  • Demonstrate the femoral vein for a centimetre both above and below the SF junction.
• During the procedure, a few tributaries of the long saphenous vein get avulsed and thrombosed (ligation with stripping operation). It is indicated in cases of saphenofemoral incompetence.
• Once stripping is done, small incisions are given where perforators are marked. They are ligated and excised.

2. Subfascial ligation of Cockett and Dodd: In this operation, the perforators are identified deep to the deep fascia and ligated subfascial. This is indicated in cases of perforator incompetence with saphenofemoral competence. This may also be done endoscopically.

3. Subfascial endoscopic perforator surgery (SEPS)

• Small port incisions are made in the skin over the calf region and deepened through the fascia.
• Carbon dioxide insufflation is done. A balloon expander may also be used to distend the subfascial plane.
• 2–6 perforators are identified and ligated.
• The procedure is simple and quick with the least morbidity and is becoming popular.
• It is indicated for below-knee perforators.

4. Smaller veins have also been treated with phlebectomies.

Describe the pathophysiology, clinical features, investigations and principles of management of DVT and varicose veins.

Complications Of Varicose Veins

1. Eczema and dermatitis: It occurs due to extravasation and breakdown of RBCs in the lower leg. It gives rise to itching, which precipitates varicose ulcers. It is treated by applying zinc oxide cream or silver sulfadiazine cream (stasis dermatitis).

2. Lipodermatosclerosis refers to various skin changes in the lower leg associated with varicose veins such as thickening of subcutaneous tissue, indurated wood-like feel, pigmentation, etc.

• It is due to increased venous pressure resulting in capillary leakage with extravasation of blood and fibrin into the surrounding tissues.
• Blood is broken down and haem is released, which combines with iron to form haemosiderin, which is responsible for pigmentation. Classically, this affects the gaiter area of the leg just above the malleoli.

3. Haemorrhage: It occurs due to trauma or eczema. It may be controlled by elevating the leg and applying a crepe bandage. Do not try to catch bleeders with artery forceps.

4. Thrombophlebitis: It refers to inflammation of a superficial vein. The vein is tender, hard and cord-like. The skin is inflamed and pyrexia is usually present. It is treated with bedrest, elevation, crepe bandage, antibiotics, and anti-inflammatory drugs.

• Thrombophlebitis—Causes
  • Spontaneous TAO, malignancy
  • Trauma
  • Blood transfusion
  • 4 fluids, chemotherapeutic drugs
  • Varicose veins

5. Venous ulcer: It is also called gravitational ulcer. Its precipitating factors are venous stasis and tissue anoxia. Deep vein thrombosis is also an important cause of venous ulcers wherein valves are either destroyed or incompetent due to damage.

• Sustained venous pressure results in extravasation of cells and activation of capillary endothelium, resulting in the release of free radicals. These free radicals cause tissue destruction and ulceration.
• Lipodermatosclerosis and tissue anoxia are the other factors. The following hypotheses may explain the genesis of varicose ulcers.

Complications Of Varicose Veins Fibrin cuff hypothesis: The combination of capillary proliferation and inflammation (in the form of macrophages) is a major factor in the development of venous ulcers.

• As a result of chronic inflammation, a perivascular cuff develops around the capillaries.
• This perivascular cuff is made up of many connective tissue proteins, including fibrin, collagen 4, and fibronectin. Slowly, a venous ulcer develops.

Complications Of Varicose Veins White cell trapping hypothesis: Venous hypertension causes the trapping of leucocytes, which become activated and release proteolytic enzymes that cause damage to the capillary endothelium.

• Whatever the exact mechanism of ulceration, ambulatory venous hypertension is the only accepted cause of ulceration.

Complications Of Varicose Veins Features of a venous ulcer

• Typically situated just above the medial malleolus.
• Oval, small, painless, and superficial with surrounding pigmentation.
• Dilated veins above the ulcer give a clue to the diagnosis.

Complications Of Varicose Veins Factors Predisposing to Nonhealing Venous Ulcers

• Ambulatory venous hypertension.
• Perivascular fibrin cuff resulting in poor diffusion of oxygen to the tissues.
• White cell trapping.
• Reactive oxygen species are increased and they generate free radicals leading to tissue damage.
• Inhibition of growth factors leads to poor repair.

Complications Of Varicose Veins Treatment of venous ulcers: Bisgaard’s method (Nowadays, it is not recommended)

• Rest with an elevated limb.
• An elastic crepe bandage helps in venous return.
• Active exercises should be taught to the patients (to contract calf muscles).
• Passive exercises
• The correct method of walking is with the heel down first.
• If the ulcer is infected, antibiotics are given and a four-layered dressing is applied. Once the ulcer heals, Trendelenburg’s operation is performed.

Varicose Veins Four-Layered Dressing

6. Calcification may be seen in the walls of the vein.

7. Periostitis of the tibia may occur due to the location of the ulcer on the medial surface of the leg. Due to the involvement of the periosteum, there is severe pain.

8. Equinovarus deformity occurs due to improper habit of walking on the toes which results in shortening of the tendon-Achilles.

9. Marjolin’s ulcer is a squamous cell carcinoma arising from a healed varicose ulcer with scarring.

Short Saphenous Varicosity

The short saphenous vein originates from the lateral part of the dorsal venous arch and ends in the popliteal vein in the popliteal fossa.

• The incompetence of the saphenopopliteal valve results in short saphenous varicosity.
• It produces prominent veins on the lateral aspect of the leg with or without ulceration. These are treated by ligation of the short saphenous vein in the popliteal fossa.

Short Saphenous Varicosity Ligation of the Saphenopopliteal Junction

• Preoperative ultrasonographic marking is essential.
• The vein should be ligated deep to the deep fascia.
• Branches—the Giacomini vein and gastrocnemius veins may be seen. They must be ligated.
• It may be stripped up to the mid-calf to avoid injury to the sural nerve.
• It is important to close the deep fascia to avoid an unsightly cosmetic bulge behind the knee.

Ligation of the Saphenopopliteal Junction Ten Commandments Of Venous Ulcer Treatment

1. Should lose weight
2. Should perform venous Doppler to rule out deep vein thrombosis or thrombophlebitis
3. Should take rest with the leg elevated above the level of the heart
4. Should receive antibiotics if infection is present
5. Should apply a wound cover with suitable dressings
6. Should apply compression stockings
7. Should consider surgery only once the infection is under control
8. Should ligate long or short veins if they are incompetent
9. Should ensure that all perforators are ligated
10. Should look for an accessory long saphenous vein near the termination of the vein—if present, it should be ligated to avoid recurrence

Recurrent Varicose Veins

• Incidence is about 10–30%.
• Important causes of recurrence include failure to ligate the LSV at the SF junction, failure to ligate tributaries at the SF junction, and a possible accessory long saphenous vein.
• Other factors for failure include neovascularisation and reflux in residual veins.
• Recurrence is less after stripping of veins than after multiple ligation.
• Injection sclerotherapy and EVLA/RFA may be done.
• Re-surgery may be performed. However, wound infection, wound gaping, and lymph leaks are more common.

Deep Vein Thrombosis(DVT) Acute Deep Vein Thrombosis

It is also called phlebothrombosis. It can be acute or chronic. Acute deep vein thrombosis is very common in Western countries, the exact cause of which is unknown.

• Postoperative immobilisation, pressure on the calf muscles, sluggish blood flow, and prolonged bedrest are some of the precipitating factors for deep vein thrombosis.
• It commonly affects venous sinuses in the sole muscles. It is a common starting place. It may also involve pelvic veins. The various factors responsible for deep vein thrombosis can be remembered as THROMBOSIS.
• It should be suspected in the postoperative period when the patient complains of pain in the calf region or complains of limb oedema. The maximum incidence occurs on the 2nd and 5th–6th postoperative days.
• Thrombosis—Virchow’s Triad
  • Endothelial injury
  • Stasis
  • Increased coagulability
• Causes of Deep Vein Thrombosis (Lower Limb DVT)
  • Trauma—injury to the vessel wall
  • Hormones—increased coagulability
  • Road traffic accidents
  • Operations—cholecystectomy
  • Malignancy—sluggish blood flow
  • Blood disorders—polycythaemia
  • Orthopaedic surgery, obesity, old age
  • Serious illness—stroke, MI
  • Immobilisation
  • Splenectomy
  • Remember as THROMBOSIS

Signs of Acute DVT

1. Homan’s test: Forcible dorsiflexion of the foot results in severe pain in the calf region.
2. Moses’ test (ideally should not be done due to risk of embolism): Tenderness over the calf muscle on squeezing the muscle from side to side.
3. Pitting oedema
4. Low-grade fever with an increased pulse rate is characteristic.
5. Phlegmasia alba dolens refers to the white leg. It occurs when the thrombus extends from the calf region to the iliofemoral vein.
6. Phlegmasia coerulea dolens refers to a blue leg with loss of superficial tissues of the toes.
7. Superficial blebs in the skin—can be confused with necrotising fasciitis.

 Acute Deep Vein Thrombosis Treatment

Acute DVT

1. Bedrest and limb elevation.
2. Injection heparin 10,000 units IV bolus with continuous infusion of 30,000–45,000 units/day. During heparin therapy, activated partial thromboplastin time (APTT) should be maintained at twice the normal value. Heparin is given for 7–10 days.
   • Warfarin, an oral anticoagulant, is started 2–3 days before heparin is withdrawn because of its slow onset. Treatment with warfarin should continue for 6–12 months. A repeat Duplex scan should be done to look for recanalisation of the veins.
   • The dose of warfarin should be 10 mg twice a day. Treatment is monitored with prothrombin time and international normalized ratio (INR). INR should be 2.0–3.0.
3. Low molecular weight heparin (LMWH) is given once or twice a day, in the form of injection. No blood monitoring is required. The incidence of bleeding is less with LMWH. More details are given at the end of the chapter.
4. Inferior vena cava filters indicate if the thrombus is extensive and recurrent. They can be inserted percutaneously via the femoral vein in patients who have contraindications for lytic therapy.
5. Compression stockings.

Chronic Deep Vein Thrombosis

DVT lasting for >4 weeks is defined as ‘Chronic DVT’. Signs and symptoms include pain, oedema, telangiectasia, hyperpigmentation, lipodermatosclerosis,
ulceration, and venous claudication.

• The clinical manifestations are secondary to postthrombotic sequelae (PTS) and occur after an episode of DVT, as thrombosis leads to venous hypertension from venous obstruction and reflux.
• Classically, the limb is described as having an inverted beer bottle or champagne bottle appearance.

Chronic Deep Vein Thrombosis Investigations

1. Doppler study: It is ideal for femoral vein thrombosis or if the thrombus extends into the popliteal vein. The normal femoral vein gives a wind storm sound which completely disappears at the end of inspiration. No sound is heard if there is femoral thrombosis.

• Duplex Scanning in Deep Vein Thrombosis (B-Mode)
  • The vein is larger than normal because of occlusion
  • Not completely compressible
  • Lacks respiratory variation
  • Does not show flow augmentation with calf compression
  • May have collateral flow
• Chronic thrombosis is diagnosed by a luminal filling defect on grey-scale images, noncompressible vein, narrow vein, absence of colour Doppler, and loss of augmentation.

2. Contrast venography: This is done by injecting a radioopaque dye into the dorsal venous arch with an inflatable cuff both above the ankle and above the knee. The clot appears as a filling defect. However, venography is not routinely done because it is expensive and invasive.

Chronic Deep Vein Thrombosis Treatment

Chronic DVT

• Graded compression stockings and anticoagulation therapy. Compression stockings (30–40 mmHg) should be worn daily for 2 years from the onset of DVT.
• Parenteral anticoagulation initially, followed by oral anticoagulation titrated to the INR. Vitamin K antagonist (warfarin 5–10 mg/day) is given and INR is monitored (INR should remain between 2.0 and 3.0).
• Patients with proximal DVT (iliofemoral), recurrent episodes, or DVT secondary to malignancy should be treated for 6 months–1 year. Indefinite therapy is recommended for patients with recurrent episodes of venous thrombosis, regardless of the cause.
• Post-phlebitis limb with ulcers may heal with aspirin and pentoxifylline.
• Chronic thrombosed veins are treated by balloon dilatation—venoplasty, and thrombolysis. Venous stenting is frequently needed in the IVC and iliac veins to maintain flow and venous patency.
• Surgery is not done routinely. However, in chronic cases, venous bypass has been attempted with moderate success. Palma operation is performed for iliofemoral thrombosis wherein the common femoral vein is below.
• The block is anastomosed to the opposite femoral vein using the long saphenous vein from the opposite side. May-Husni operation, wherein the popliteal vein is anastomosed to the long saphenous vein above.

Chronic Deep Vein Thrombosis Complications

1. Permanent oedema of the limb. The limb has an inverted beer bottle appearance.
2. Pulmonary embolism because the thrombus is not attached to the vessel wall.
3. Secondary varicosity and nonhealing ulcer.

Prophylaxis Of Dvt

• Decrease obesity and advise exercises before surgery.
• Low dose heparin 5,000 units subcutaneously, 2 hours before surgery and 24 hours after surgery, then 12 hourly for 5 days in cases of major surgeries
• like cholecystectomy, abdominoperineal resection, etc. Low molecular weight heparin decreases the chances of bleeding.
• Intermittent pneumatic compression of the calf throughout the operation maintains blood flow in the lower limbs. Inflation pressure is around 30–50 mmHg.
• Dextran 40 inhibits the sludging of red blood cells and platelet aggregation.
• Aspirin with dipyridamole has been used (antiplatelet agents).
• Early mobilisation, walking, and adequate hydration.
• Prophylaxis: Risk Groups
  • Low risk : >40 years Minor illness, Operation <30 minutes
  • Moderate : >40 years, risk Debilitating illness, Major surgery <30 minutes
  • High risk : >50 years, medical conditions—MI, stroke, recent thromboembolism, orthopaedic surgeries, major surgery, malignancy, obesity.

More Details Of Anticoagulation And Dvt

Treatment should be initiated as soon as possible. The main aims are to reduce the morbidity and risk of pulmonary thromboembolism (PTE) and to decrease postthrombotic sequelae.

Treatment Modalities

1. Anti-thrombotic therapy:

Heparin: It is a natural anticoagulant. It is also unfractionated heparin (UFH). Initial 4/SC heparin therapy is continued for a minimum of 5 days. Heparin acts by binding to antithrombin, which in turn inhibits factors 2a, 10a, 11a, and 12a.

• • It also binds to tissue factor pathway inhibitor, which inhibits the conversion of 10 to 10a and 9 to 11a.
  • It also catalyses the inhibition of thrombin by cofactor 2, independent of the antithrombin mechanism.
• Dose of heparin: 80 U/kg 4 bolus infusion at 18 U/kg/hour or 10000 units 4, 8th hourly. The route is later changed to subcutaneous.
• Complications of heparin:
• Haemorrhage, which may be reversed by protamine sulphate (up to 50 mg 4 over 10 mins)
• HIT (heparin-induced thrombocytopaenia) due to heparin-associated antiplatelet antibodies directed against platelet factor 4
• Osteopenia
• Rarely—skin necrosis or hypersensitivity
• Hypoaldosteronism and osteoporosis
• Contraindications to heparin therapy:
• Eye surgery, neurosurgery
• Bleeding disorders
• Uncontrolled, severe hypertension
• Cirrhosis, renal failure

Low molecular weight heparin (LMWH): They are safe and efficacious. They may be administered easily once or twice daily subcutaneously. Enoxaparin and dalteparin are a few drugs. Enoxaparin 0.5 mg/kg is given for prophylactic dosing.

• The therapeutic dose is 100 U/kg twice daily. They act by selectively inhibiting factor 10a. They do not require laboratory monitoring.
• Compared to heparin, they have a very low chance of resulting in thrombocytopenia. Since they have lesser anti-platelet action, there are fewer chances of haemorrhage.

Fondaparinux: It is a synthetic pentasaccharide factor Xa inhibitor. The dose depends on the weight of the patient—5 mg OD (once daily) for 50 kg, 7.5 mg OD for 50–100 kg, and 10 mg OD for ≥100 kg given as subcutaneous injections.

Direct thrombin inhibitors: Examples include hirudin, agatroban, and bivalirudin. They are indicated in patients with HIT.

• They are usually given for 7 days till platelet counts normalize and then heparin is re-introduced.
• Dosing is as follows. Hirudin 4 mg/kg IV bolus f/b infusion T½— 30–60 min with APTT at 1.5 to 2.5 times. Agatroban 2 µg/kg/min infusion, T½—40–50 min with APTT at 1.5 to 3 times.

Warfarin (Wisconsin Alumni Research Foundation coumARIN): It is given orally, 2–10 mg/day. It interferes with the hepatic synthesis of vitamin K-dependent soluble anticoagulation factors. An advantage of warfarin is that it is given orally. Its disadvantage is that it requires more frequent monitoring than heparin. Bleeding may occur if the INR ratio is high.

Acitrom (Acenocoumarol) is another anticoagulant used in the treatment and prevention of abnormal blood clots. It is similar to warfarin but has a longer half-life and less interactions. It does not dissolve formed blood clots but may prevent them from becoming larger leading to more serious problems like embolism.

2. Thrombolysis: It is popularly called catheter-directed thrombolysis. Streptokinase, urokinase, etc. are used. They convert plasminogen to plasmin which in turn degrades fibrin, thereby dissolving the clots.

• Advantages of thrombolysis include early recovery of symptoms and signs, early prevention of pulmonary thromboembolism, and prevention of post-phlebitis syndrome.
• However, clot propagation and re-thrombosis cannot be prevented. Alteplase: Recombinant tissue plasminogen activator (tPA). It is given as a 10 mg IV bolus, followed by a 90 mg infusion over 90 minutes.

3. 4C (inferior vena cava) filters: Patients with recurrent embolism, pelvic vein thrombosis, or large calf venous thrombosis may be treated with 4C filters. The 4C filter is placed through a small incision in a vein in the groin or neck. A thin, flexible tube (catheter) is inserted inside the vein.

• The catheter is then gently guided into the 4C. A 4C filter is introduced into the vein in a collapsed state. The filter is left in place, and the catheter is removed. The filter then expands and attaches itself to the walls of the 4C.
• In a few cases of recurrent thromboembolism, it may be left in place permanently. In some cases, it may be removed after a period of time.

4. Operative thrombectomy: It is definitely indicated for pulmonary embolism but is rarely performed for leg veins.

Miscellaneous Pelvic Congestion Syndrome

A few premenopausal patients complain of dull aching or severe pain in the pelvis. Clinical examination may reveal tenderness in the hypogastrium. A few salient features are given below.

• Premenopausal patients
• Excessive micturition, excessive bleeding during menstruation
• Leg varicosity in atypical sites, such as the thigh
• Varicosity of the ovary, vulva, and pelvic veins
• Increased on standing
• Chronic, noncyclical pelvic pain
• Remember as PELVIC

Pelvic Congestion Syndrome Management

• Ultrasound, CT, and MRI may be necessary to rule out a pelvic pathology.
• Psychotherapy and nonsteroidal anti-inflammatory drugs are of some help.

Pulmonary Thromboembolism

Mostly thrombus originates in the leg veins—from deep veins and causes pulmonary embolism. Prolonged immobilisation, postoperative patients, and major fractures of long bones are a few important causes.

• Patients present with the following features. Recently COVID-19 infections have been associated with many cases of thrombosis.
• Tachypnoea and tachycardia
• Chest pain cough with or without streaks of blood
• Breathlessness
• ECG may show an S1Q3T3 pattern (S wave in lead 1, Q and inverted T waves in lead 3).

Pulmonary Thromboembolism Investigations

• Ventilation perfusion scan (V/Q)
• CT angiography of the thorax

Pulmonary Thromboembolism Treatment

• Rest, compression bandage, elevation
• Anti-DVT treatment