The official website of the Egyptian Society of Vascular Surgery

Definition: Dilatation and tortuosity of superficial veins of the lower  Limb.
Aetiology:
(1) 2ry varicose vein:
a) Deep venous thrombosis "Post-phlebitic leg".
b) Pelvic tumours.
c) Congenital or acquired arterio- venous fistula.
d) Congenital abnormalities (Klippel-Trenaunay-Weber syndrome, Valvular agenesis)
(2) 1ry varicose vein: "more common"
The Long saphenous and/or short saphenous veins will be dilated and tortuous with no underlying specific disease.
Aetiology: It is due to familial polygenic inheritance pattern resulting in structural weaknesses in the vein wall and of the venous valves. 9% of people above the age of 45 has incompetence at the saphenofemoral or saphenopopliteal junctions while varicose veins are present in 6%.
Several risk factors contribute to their development:
(a)   Increased height and weight.
(b)   Female gender especially with repeated pregnancy.
(c)   Prolonged standing occupations stagnation with subsequent dilatation. So, V.V. is common in barbers and surgeons.
Complications:
(1) Thrombosis due to slow circulation.
(2) Pigmentation: due to extravasation of stagnant R.B.CS destructed with haemosedrin deposition in tissues pigmentation with itching.
(3) Eczema  itching.
(4) Bleeding: due to injury of V.V. with scratching or trauma resulting in severe bleeding "due to valve incompetens so bleedind coming directly from the heart while the patient is standing". It is easily controlled by elevation of the limb and slight pressure on the bleeding point.
(5) Oedema:
a- at the end of the day in 1ry varicose V.
b- Marked constant oedema in 2ry V.V.
c- Lymphoedema if 2ry infection of V. ulcer occurred resulting in lymphangitis with Lymphatic obstruction.
 (6) Varicose ulcer:
Causes: Theories:
1- Stagnation  venous congestion  Anoxia & itching  Scratching and 2ry infection.
2- Leukocytes trapping theory
Leukocytes are trapped in the tissues initiatig a destructive inflammatory process  ulceration.
 Site: Above the med. malleoulus.
 Margin: Pigmented (Pathognomonic)
 Edge: Sloping.
 Floor: Infected granulation tissue.
 Base: Minimal indurations.
 (7) Malignant change: in long standing varicose ulcer  Marjolin ulcer.
m Clinical Features:
Symptoms:
1- Discomfort or dull aching pain in the limb.
2- Cosmetic disfigurement "especially in females".
3- Slight pain in the foot towards the end of the day [V.V. or F.F (Flat foot)].
4- Symptoms of complications.
[II] Examination:

Perth's test
(A) Is it 1ry or 2ry:
1. Unilateral varicose vein with constant oedema and short duration with pigmentations and sometimes ulceration are in favor of diagnosis of 2ry VV.
2. History suggesting D.V.T. or abdominal tumour.
3. Palpation of thrill or accompanying congenital vascular malformation (CVM)
4. Dilated veins in the pupic region usually direct the attention to D.V.T. with dilated veins to by pass high obstruction in the iliac veins.
 
5.  Perthes'test: a bandage is applied to the leg from the toes  to groin then ask the patient to do excersis for 20 min.
If pain occurs this means that there is obstruction of deep system
If no pain but some relieve occurs this means that the deep system is patent = 1ry varicose vein
 It is subjective test depends on patient's  threshold of pain.

Modified Perth's test
6- Modified perthes' test:
 Tourniquet is applied immediately below the saphenous opening after evacuation of veins. Then, ask the patient to do excersise :
w If marked engourgemt of saphenous system occurs = Obstruction of deep system =2ry V.V.
w If No engorgement = Patent deep system = 1ry V.V.
7- Phlebography:
Ascending venography can detect the presence of D.V.T and descending venography can check the condition of perforators and incompetent valves by regurge of the dye into superficial system at its site "Blowout site).
8 -  Duplex Ultrasonography: Recently it replaces venography and it gives all data needed especially in above knee lesions and below knee in skilled operator hands. It is less invasive and cheaper than phlebography.
 (B) If 1ry  where is the level of incompetence?
(1) Palpation of thrill while gentle palpation over the site of saphenofemoral junction and asking the patient to cough violently indicates incompetence at saphenofemoral junction.
(2) Schwartz test: While the patient is standining and if the saphenous vein is dilated, put your finger at the lower part of the vein and a finger of the other hand at the upper part of the vein. Normally if you do percussion by the lower finger, you can feel transmitted thrill with the upper one and the reverse does not work due to saphenous vein valves. If you feel transmitted thrill by the lower finger while doing percussion with the upper one this means that there is incompetence of the saphenous vein valves.
(3) Trendlenburg test:
w The patient lie supine while elevating his limb and evacuating veins by milking.
w Obstruct the saphenous opening 1.5" below & lat. to pubic tubercle by applying tourniquet just below it.
w Ask the patient to stand. Normally the veins shows slow filling from down upwards.
a- If there is rapid filling of veins from below.
 The incompetence is below the saphenofemoral valve.
b- If no filling occurs except after removal of the finger.
 The incompetence is at sapheno- femoral valve.

Tredlenburg test   

Multiple tourniquet test   

Two bandage test
(4) Multiple tourniquet test:
w After evacuation of engorged veins while patient is supine.
w Apply 3-4 tourniquet at upper thigh, mid-thigh.
w Ask the patient to stand and detect the sites of blow out.
(5) 2 bandage test:
w Apply one bandage from the toe upward to the groin.
w Then ask the patient to stand.
w Remove the bandage from above while applying another one at the sites of removed bandage and detect the sites of blow out.
(6) Duplex Ultrasound: can give full data as discussed before.
a.   It can comment on both saphenofemoral and sphenopopliteal if they are competent or not. Also the degree of incompetence can be evaluated.
b.   It can detect the sites of incompetent perforators and mark them on the skin to facilitate surgery.
c.   It can detect incompetence of the deep veins and superficial veins.
(7) Venography: as mentioned before it can map the varicosities and its origin. Recently its role is deteriorating in comparison to the less invasive duplex scanning.
Treatment:
Varicose vein treatment depends on the patient's complaint and the degree of the disease.
Palliative treatment:
Indications:
1- 2ry V.V.
2- Spider varices with normal saphenous system.
Methods:   
1- Removal of the cause or predisposing factor by changing the lifestyle of the patients. They should leave sedentary life, avoid longstanding and reduce their weight.
2- Wearing elastic stocks during the day time.
[II] Injection treatment:
Indications:
1- Early cases of 1ry V.V with competent valves.
2- Residual varices after operation.
Drugs:
1- Na morrhuate              2- Ethanolamine.
3- Sclerovein (polydodecan)
Method:
Ä The patient stand  the veins will be engorged.
Ä   The needle is introduced to the  engorged veins.
Ä   Then the patient lie down to evacuate the vein from blood.
Ä   Inject 2cm of the sclerosing material to destruct the intima of vein and obstruct it.
Ä Apply bandage from the toes level to above the injection level. This bandage should not removed before one week.
Ä   Maximum dose is 6cm at different levels in one setting.
Ä   Repeat after 2-3 weeks till all V.V. are obliterated.
In most situations it is used for cosmetic disfigurement. Recently some techniques are described to inject the main saphenous trunk and the incompetent perforators guided by duplex ultrasonography.
For this purposes a foam material is prepared using the sclerosing agent by repeated injection of it through narrow muzzle syringe into another syringe using 3 way connection till it become mixed with air and attain foam character.
This technique thought to replce surgery in cases with advanced varicose vein. The foam is lighter than blood so, the limb should be elevated with slight head down to avoid air embolism 

Complications:
1-Extravenous leakage  inflammation & abscess.
2- The dye reach deep system  D.V.T.           
3- Allergic reaction.
4- Permanent pigmentation at sites of injection.
[III] Surgical treatment:
Indications:
1- Large primary V.V. with incompetent valves.   
2- Pain and heaviness of the diseased limb or complication occurs.
Operations:
1- Ligation.       2- Stripping.       3-Laser photocoagulation.
1- Ligation:
(a) Trendlenburg's operation:
w   Indication  Incompetent saphenofemoral valve with healthy saphenous vein valves.
w   Technique  Ligation of the saphenous V. in flushing with femoral vein and ligation of its 5 tributaries which are:
1- Superficial epigastric V.     2- Sup. circumflex iliac V.
3- Sup. Ext. Pudendal V.          4- Two unnamed veins (posteromedial and posterolateral vein.
(b) Multiple ligation:
w Indication  when multiple perforators are incompetent despite healthy saphenous systems.
w Technique   Through multiple small incisions exposing the marked sites of incompetent perforators do ligature of the perforator and excision of the involved segment.
2- Stripping: It is the only radical treatment in case of incompetent saphenofemoral and diseased saphenous vein valves. It is the most popular method of treatment.
w Technique:
Ä   Expose the vein at saphenofemoral junction .
Ä   Ligate the 5 tributaries of the saphenous vein and the saphenofemoral junction.
Ä   Expose the saphenous vein above the ankle joint.
Ä   Introduce the stripper into the vein and advance it till you feel at the saphenous opening.
Ä   Ligate the upper end of the vein over the stripper.
Ä   Do firm traction on the stripper to strip the vein.
Ä   Apply crepe bandage from toes to the groin for 2 weeks but the patient can walk from the 2nd day.
3- Laser photocoagulation:
It is a recent technique done by specially designed laser set. Through small incision over the saphenous vein above the ankle a fine wire with laser source at its head is introduced into the saphenous vein and advanced till reach the saphenofemoral junction. During slow withdrawal it works to coagulate the diseased saphenous.
 (B) Treatment of varicose ulcer:
1-   Repeated dressing until the ulcer become clean.
2-   Surgical treatment of varicose veins according to the situation.
3-   Elastoplast bandage: longitudinal straps covered by circular turns from the toes to below the knee. The longitudinal strap protect the skin from edges of transverse one. These straps can be changed every 10 days.
4-   Excision and grafting of the ulcer may be needed.
FN.B. Gravitational ulcer is that ulcer at the region of ankle joint caused by incompetent perforators and treated by ligation of these perforator below the deep fascia. "Cockett's operation".
Cocket described his operation through long incision along the medial side of the leg with elevation of skin, superficial and deep fascia to ligate perforators below deep fascia (Subfascial ligation). High incidence of complications of this wound limits its use as the skin at this area usually has lipodermatosclerosis.
Subfascial Endoscopic Perforator Ligation (SEPS) can be done through small incision in the healthy skin below the knee.

SOURCE: DR AYMAN SALEM'S BOOK