1. Varicose vein
Dr.Atul Kumar Mishra
M.S. (Gen. Surgery)

2. History
Description 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.

4. 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

6. 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

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

8. Varicose vein
Telangectesia
Reticula vein

9. Lipodermatosclerosis
Varicose vein
Venous statis ulcer

10. 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.

11. 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

12.  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

13. 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
extrimity, within subcuteneous tissue
lower
Many superficial veins exist, but they all drain into two
largest, the great saphenous and short saphenous vein

15. 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

16. 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

17. 2) Saphenofemoral junction(SFJ)- Located proximally at groin where GSV
meets femoral vein
Major tributeries of
GSV
Saphenofemoral
junction

18. 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

20.  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
 Incompetence of
pressure
perforating veins leads to hydrodynamic
 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

21. 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

23. Presentation
Subjective 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)

24. 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

25. 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

26.  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”

27. Examination
(Properly exposed, standing and supine position, both in front and behind)
 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

28. For all tests
SaphenoFemoral
incometence
1) Trendelenberg I
2) Modified Perthes test
Perforator incompetence
1) Tourniquet test
2) Pratt’s test
3) Fegan’s test
4) Trendelenberg II
Deep vein thrombosis
1)
2)
3)
4)
Perthes’test
Modified Perthes
Homan’s sign
Moses sign

29. Indications
 Often for cosmetic reasons
 Noncosmetic indications
fatigability,
heaviness,
thrombophlebitis, bleeding)
varicosities
recurrent
(e.g. pain,
superficial
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.

30. 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

31. Laboratory Studies

No lab test useful in diagnosis or therapy
Patients with varicose veins may have spuriously positive Ddimer test because of chronic low-level thrombosis within
varices

Diagnostic 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

33. 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.

34. 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.

35. 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

36. 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

37. 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.

38. 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.

39. Tests used to define anatomy
Duplex 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

40. 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.

41. Classification of chronic lower extremity
venous disease
C
C
Clinical signs (grade0-6), supplemented by
(A) for asymptomatic and (S) for
symptomatic presentation
E
Etiologic Classification (Congenital,
Primary, Secondary)
A
Anatomic Distribution (Superficial, Deep,
or Perforator, alone or in combination)
P
Pathophysiologic Dysfunction (Reflux or
Obstruction, alone or in combination)

42. Staging
 CEAP classification from American Venous Forum, last revised 2004
 Used to standardize recording of venous disease
Clinical
C0 - No visible or palpable signs of venous disease
C1 - Telangiectases or reticular veins
C2 - Varicose veins
C3 - Edema
C4a - Pigmentation or eczema
C4b - Lipodermatosclerosis or atrophie blanche
C5 - Healed venous ulcer
C6 - Active venous ulcer
S – Symptomatic, includes: ache, pain, tightness, skin irritation,
heaviness, and muscle cramps
A – Asymptomatic
Eklöf B et al. J Vasc Surg. Dec 2004;40(6):1248-52

43. Etiologic classification
Ec - Congenital
Ep - Primary
Es - Secondary (post-thrombotic)
En - No venous cause identified
Anatomic classification
As - Superficial veins
Ap - Perforator veins
Ad - Deep veins
An - No venous location identified
Pathophysiologic classification
Pr - Reflux
Po - Obstruction
Pr,o – Reflux and obstruction
Pn - No venous pathophysiology identifiable

44. 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)

45. 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).

46. 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

48. 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

49.  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

50. 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.

51. 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
2012;21(3):181-6
C
et
al.Int
J
Angiol.
Sep

52. Trendelenberg’s Sapheno-Femoral Flush Ligation

53. GSV saphenectomy
Evolved 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

54. Stripping of Long Saphnous Vein

55.  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.

57. 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

58. 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
Weiss RA segments of veinsApproach New York, NY: McGraw-Hill;2001.
Short et al, A Comprehensive can be removed through tiny incisions

59. Endovascular techniques
Endovenous (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

61.  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

62. Radiofrequency (RF) ablation
RF thermal energy delivered directly to vessel wall, causing
denaturation, collagenous contraction, and immediate closure of vessel
protein
 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

64.  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.

65. 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

66. 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

67. 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

68. 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

69. 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

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

71. 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.

72. Postoperative Details
After 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 et al, Brocclusion, phlebitis, skin
vein J Surg. May 2010;97(5):650-6.
O’Hare JL
discoloration, or pain at 2 and 6 weeks with the two

73.  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

74. 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]

75. 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
2003;38(2):207-14.
F
et
al
J
Vasc
Surg.
Aug

76. 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 qualityof-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.

77.  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 belowknee 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.

78. 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.

79. 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
68.2% in Varisolve. Sclerotherapy
closure rates for Varisolve group
efficacious, Varisolve caused less
normal more quickly.
87.2% in saphenectomy versus
without foam versus Varisolve,
93.8%. Although surgery more
pain and patients returned to
 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.

80. 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