Management of patients with varicose veins
A history should be taken from the patient to find out how long the varices have been present and if any event seemed to cause them. A history of previous lower limb deep vein thrombosis should be sought. Venous thrombosis may follow lower limb fractures, so this also should be asked about. Superficial varices which develop after a venous thrombosis may be the only route of venous drainage in the lower limb and should not be removed until the patency of the deep veins of the limb has been shown. Patients may also have received previous surgical or other treatment for their varices. Any previous treatment may greatly alter the surgical management of the patient. When the SFJ has been ligated previously, a further operation here is technically much more demanding for the surgeon and should not be performed unless recurrence at the previous operation site has been conclusively demonstrated. Unfortunately, patients often have only a vague recollection of their previous vein operations and therefore diagnostic ultrasound imaging or venography is essential to establish the anatomy and source of varices in patients with recurrent varicose veins.
Clinical examination should establish the extent and size of varices, as well as the presence of any associated skin changes. Tourniquet tests should be used to decide the location of venous incompetence. All patients considered for surgical treatment of their varices should be examined using a hand-held Doppler ultrasound device to confirm the source of the varices.
Patients with recurrent varices or a history suggestive of previous venous thrombosis and any patient with skin changes should be fully investigated using duplex ultrasonography or venography. The presence of ankle pulses should be confirmed by palpation or, if necessary, by measuring the ankle blood pressure using Doppler ultrasound.
The treatment of varicose veins following a proper assessment may include reassurance, the use of elastic compression stockings, injection sclerotherapy or surgical treatment. The treatment of choice depends on the size of the varices, their extent and the symptoms that they produce.
The symptoms of varicose veins may be relieved by the use of compression stockings. These are available for the treatment of venous disease in three grades of compression, classes 1—3. Light compression stockings may be helpful in the early stages of varicose veins but do not prevent the development of more varices or result in the disappearance of veins.
This treatment is best used in the management of small varices and those where the main long and short saphenous veins, and their major tributaries, are competent. This type of treatment is also effective where the larger varices have been removed surgically and only small varices remain. In the past, sclerotherapy has been used in the management of incompetence of the main saphenous trunks. Evidence suggests that varicose veins managed in this way recur much more rapidly than following surgical treatment.
The basis of sclerotherapy is that a solution which destroys the endothelial lining of the veins is injected. In the UK the most widely employed drug is sodium tetradecyl (STD), which chemically is a soap. To be effective, the sclerosant has to be given into an empty vein that is compressed immediately after the injection has been given to avoid the development of thrombosis within the vein. It is easy to produce thrombophlebitis which can recanalise and result in the recurrence of the varices. The aim is to produce sclerosis with the vein being replaced by a fibrous cord, incapable of recanalisation and recurrence.
The limb is examined with the patient standing and the position of the varices that should be injected marked on the skin. The needle is inserted into the vein with the patient sitting down and the leg in a horizontal position. A 23G or 25G needle is usually used for this. The position of the needle in the vein is confirmed by drawing back on the syringe. Injection of the sclerosant outside the vein causes tissue necrosis and ulceration, and must be avoided. The leg is elevated to empty the veins and a small volume of sclerosant (0.5 ml) is injected into the vein. Compression is immediately applied to the vein being treated with the fingers and a firm bandage applied. Treatment is usually commenced at the ankle so that the bandage can be applied progressively from the ankle to the groin as treatment progresses along the limb. A latex foam pad is put over the sites of the injection and incorporated within the bandage. Skin sensitivity to rubber may lead to allergic reactions if the latex pads come into direct contact with the skin. Immediately after the bandage has been completed, the patient is asked to walk to encourage the blood to circulate reducing the risk of venous thrombosis in the limb and also reducing the venous pressure in the varices of the calf.
Further sessions of sclerotherapy continue at weekly intervals until all lower limb varices have been treated. The patient should wear a compression bandage or stocking for 3—6 weeks after the completion of a course of sclerotherapy This ensures that the veins which have been treated do not suffer thrombosis and are converted into a fibrous cord, achieving sclerosis of the vein.
The complications of this treatment include skin pigmentation and ulceration if the sclerosant is not injected within a vein. Small regions of thrombophlebitis are often seen during a course of sclerotherapy. Deep vein thrombosis develops only rarely.
Thread veins and reticular varices may he treated by injection through a very fine needle, a treatment referred to as ‘microsclerotherapy’. Very dilute sclerosing solutions are used. The most frequently employed drugs used for this are STD and polidocanol. A skilled practitioner can insert a 30G needle into dermal flares and successfully eradicate these tiny veins. Compression bandaging is usually applied after this treatment for 1—5 days. Treatment of these veins is normally regarded as a cosmetic procedure.
Surgical treatment of varicose veins
Surgical treatment of varicose veins is widely used and is effective in removing varicose veins of the main saphenous trunks, as well as their tributaries, down to a size of about 3 mm. Veins smaller than this are best treated by sclerotherapy. Surgical removal of varices is inappropriate where these form a major part of the venous drainage of the limb, for example where a deep vein thrombosis has destroyed the main axial limb veins and the patient relies on the superficial veins. This possibility may be suggested by the patient’s medical history and can be confirmed by duplex ultrasonography or venography.
The main principles of surgical treatment are to ligate the source of the venous reflux (usually the SFJ or the SPJ) and to remove the incompetent saphenous trunks and the associated varices. Sapheno-femoral ligation alone, sometimes referred to as a ‘Trendelenburg procedure’, is associated with a high rate of recurrence of varices. Recent research has shown that it is necessary to remove the long saphenous vein to ensure that as much venous reflux as possible is eliminated. Similarly, communications between the many deep veins in the popliteal fossa and the short saphenous vein mean that some patients develop recurrences in the short saphenous vein due to the re-establishment of reflux from these veins. This problem may be eliminated by removing the short saphenous vein. Removal of the saphenous veins has the disadvantage that both veins are accompanied by a nerve that may be damaged in the vein stripping operation. To avoid nerve injury the long saphenous vein should not be removed below mid-calf level and great care should be exercised in removing the short saphenous vein.
Venous anatomy is particularly variable, and for some veins preoperative vein localisation is very helpful. The termination of the short saphenous vein may lie from 2 cm below the knee to 15 cm above the knee. Its course and termination can be readily identified by ultrasound imaging and marked on the skin with an indelible pen before the operation, reducing the risk of damage to nerves and arteries in the popliteal fossa. Perforating veins in the calf and thigh, and residual segments of the saphenous veins left after previous venous surgery, can also be localised in this way.
Technique of saphenofemoral junction ligation
An oblique incision is made in the groin commencing over the femoral artery and extending 4 cm medially. The long saphenous vein is exposed and the common femoral and superficial femoral veins are identified before dividing the long saphenous vein. Having divided the long saphenous vein, all branches should then be isolated and divided. The SFJ should be tied flush with the femoral vein. Any tributary of the saphenous vein or femoral vein left in this operation may be the source of a future recurrence, so it is important that all are ligated and divided. It is important that the femoral vein is inspected carefully for at least 1 cm above and below the SFJ, and any tributaries ligated and divided.
The conventional way of removing the saphenous vein is with a Babcock stripper. This consists of a flexible wire which is passed down the long saphenous vein. The end is identified in the upper third of the calf and a 2-mm incision is made to retrieve the stripper. An olive about 8 mm in diameter is attached to the upper end and the saphenous vein is removed by firm traction on the wire in the calf.
More recently ‘inverting’ or ‘invaginating’ stripping has become popular. The aim here is to reduce the damage to the tissues around the vein leading to less bleeding and postoperative pain. This may be done in a number of different ways. A rigid metal ‘pin-stripper’ has recently been developed. This is passed down the inside of the saphenous vein and recovered through a small incision in the upper part of the calf. A strong suture is attached to the end of the stripper and firmly ligated to the proximal end of the vein. Pulling gently on the stripper, the long saphenous vein will invert and can be delivered through a 2-mm incision in the mid-calf region. No olive is used and the technique relies on the strength of the vein. Should the vein break, an instrument with a small olive on one end is used to recover the remaining saphenous vein.
No comments yet.