Vascular
education
examination:
varicose veins
Varicose veins are a common problem that
also comes up frequently in clinical
examination stations. Lisa Jeavons and
Suneeta Kochhar take you through the
history, examination, and treatment
V
aricose veins are dilated,
tortuous, and prominent
veins of the superficial
venous system seen in
the distribution of the
long and short saphenous veins.
Varicose veins are common: esti-
mates imply that 25% of women and
15% of men will get them.1 The most
common cause is incompetent valves
in the veins and increasing age, preg-
nancy, obesity, and family history all
increase the risk.
Anatomy
The venous drainage of the legs con-
sists of a superficial and a deep system
of veins. The superficial venous sys-
tem drains the skin and subcutaneous
tissue; its vessels form the long and
short saphenous veins (figure). The
long saphenous vein travels from the
foot, in front of the inner ankle
(medial malleolus), along the inner
(medial) part of the leg, and joins the
Saphenofemoral femoral vein at the saphenofemoral
junction junction. The short saphenous vein
Femoral vein
Saphenous vein
448
travels from the foot, behind the
outer ankle (lateral malleolus), along
the midline of the calf, ending when it
joins the popliteal vein at the
saphenopopliteal junction.
The deep venous system lies deep
within the muscles of the legs and
consists of both veins and sinusoids
(small blood vessels—like large capil-
laries). Both the sinusoids of the deep
system and the superficial veins drain
into the deep veins through perforat-
ing veins, which traverse the deep
fascia and prevent backflow of blood
from the deep to the superficial sys-
tem. These veins have valves, and
contraction of the muscles surround-
ing the deep venous system pushes
blood towards the heart, whilst the
valves prevent backflow.
Drainage of the venous system of
the legs therefore requires three
components: competent valves,
patent venous outflow tracts, and an
efficient muscle pump.
Taking a history
You should take a full history from
any person presenting with varicose
veins, bearing in mind that pelvic
masses, trauma, and previous deep
venous thrombosis are recognised
causes. You should ask about if they
have aching leg pain; if their legs
fatigue easily or feel heavy; and if
there is any swelling. All of these
symptoms become worse as the day
progresses especially with long peri-
ods of standing. In severe cases,
people may describe acute, bursting
pain on walking that is relieved by
rest and leg elevation. This is called
venous claudication. People with
severe venous hypertension may
complain of skin changes including
venous eczema and ulceration, classi-
cally in the gaiter region of the lower
leg. You should also ask about any
previous treatments. For some
people, cosmetic issues may be the
most important, but you should
remember that some people with
symptoms might have few visible
varicose veins.
Examination
Inspection
You should start the examination by
inspecting the patient standing—if he
or she is able to stand—with both legs
appropriately exposed to the groin. If
varicose veins seem present then
gently press on the affected areas,
release, and watch the varicosities
refill. By doing this, you are simply
confirming that the areas are vascu-
lar. Consider whether the affected
areas are warmer than the surround-
ing skin by using the back of your
hand. Next try to see if the varicosi-
ties follow the long or short saphe-
nous vein distribution. Varicosities in
the short saphenous vein are seen
only below the knee and are usually
at the back and to the outer edge of
the leg (posterolateral). Long saphe-
nous varicosities may be found along
the length of the leg, usually on the
medial aspect. Some people have a
large accessory vein on the back (pos-
terior) part of the thigh, which may
become varicose. This is the acces-
sory vein of Giacomini.
On inspection, look for:
G Venous stars (venulectasias).
These are bluish vessels that may
distend above the skin surface
and are usually 1-2 mm in
diameter
G Superficial thrombophlebitis,
which shows as a red, painful
lump
G The brown pigmentation of
haemosiderin deposition charac-
teristic of increased venous
pressure
G Venous eczema
G Ulceration and scarring from pre-
vious ulceration, especially in the
gaiter area
G Lipodermatosclerosis; this is
caused by chronic venous hyper-
tension when fibrin deposition
results in progressive sclerosis of
the skin and subcutaneous fat
G Scars from previous vein surgery
(look for harvesting of vein grafts
for coronary artery bypass
grafting).
Locating the saphenofemoral
junction
Once you have finished the inspec-
tion, ask the patient to lie down and
identify the saphenofemoral junc-
tion. One good way to do this is by
locating the femoral artery—which
lies between the anterior superior
iliac spine and the pubic tubercle—by
feeling for the pulse. The vein is
medial to the artery and the saphe-
nofemoral junction about two fin-
gers’ breadths below the inguinal
ligament.
Next ask the patient to stand if he
or she can. You then should place
one hand on the varicosities and tap
on the saphenofemoral junction. If
the saphenofemoral junction is
incompetent you may feel a fluid
thrill. You can confirm the incompe-
tence with a handheld Doppler ultra-
sonograph if you put it at the
saphenofemoral junction and press
on the varicosities. You should be
able to hear blood flowing up the
vein to the junction and with an
incompetent valve at the saphe-
nofemoral junction, you can hear the
blood flowing back again.
Trendelenberg test
Again ask the patient to lie down,
raise his or her leg, and empty the
engorged varicosities. To do this,
press on the saphenofemoral junc-
tion to occlude it. Then ask the
patient to stand up and see if the
varicosities refill immediately. If by
putting pressure at the saphe-
nofemoral junction the vari-
STUDENTBMJ | VOLUME 12 | DECEMBER 2004
 education
cose veins are controlled saphenofemoral incompetence
is present. If the veins simply refill then there is a leaky
perforating vein further down. This is known as the Tren-
delenberg test.

Tourniquet test
If there is a leaky perforating vein—or as an alternative to
the Trendelenberg test—you can do the tourniquet test.
For this you ask the patient to lie down and lift the
affected leg. By doing this, the veins will empty and you
should put on the tourniquet, in turn, to the thigh, the
lower thigh, and then below the knee. If the tightened
tourniquet controls the varicose veins then the defect is
above the tourniquet, if the veins refill then the defect is
below. Reflux from venous valvular incompetence
accounts for most chronic venous disease.
Once you have diagnosed varicose veins, you should
consider the cause (aetiology). You should also do a full
abdominal and scrotal examination to rule out intra-
abdominal or pelvic pathology and do an arterial exami-
nation.

Investigations
You may need to do further investigations to clarify the
area of valvular incompetence. This is best done by using
Duplex ultrasonography.2 With the patient standing, cuffs
are placed on the thigh, calf, and foot. The cuffs are
inflated and then rapidly deflated to create retrograde
venous blood flow in segments of valvular incompetence.
It is possible to map valvular incompetence at the com-
mon and superficial femoral, long and short saphenous,
popliteal, posterior tibial, and perforator veins.

Treatment
Surgery is indicated in people with saphenofemoral
incompetence and in those with significant symptoms
such as superficial thrombophlebitis, bleeding from
varicosities, or skin changes. This entails identifying the
saphenofemoral junction in the groin and ligating it. The
long saphenous vein is then disconnected in the groin
and stripped to remove its tributaries. Isolated varicosities
in the leg can be removed through small incisions (avul-
sion).
Sclerotherapy can be effective in treating small vari-
cose veins without reflux. If reflux occurs at the saphe-
nofemoral junction the surgeon should correct this first.
Sclerotherapy entails marking varices while the patient is
standing and then injecting a sclerosant, such as sodium
tetradecylsulfate, into the lumen of larger veins to cause
an inflammatory reaction. Compression stockings are
worn after sclerotherapy.
Conservative management may include:
G Reassurance and advice
G Weight reduction
G Exercise and avoidance of long periods of sitting or
standing
G Elevation of the legs
G Compression stockings may be used to manage
chronic venous insufficiency, with the greatest com-
pression at the ankle. However, people with periph-
eral vascular disease should not wear compression
stockings unless an ankle brachial pressure index is
satisfactory.

Suneeta Kochhar preregistration house officer,

suneetakochhar@doctors.org.uk, St Thomas’ Hospital, London

Lisa Jeavons senior house officer,, Queen’s Medical Centre, Nottingham

We thank Reyad Al-Ghnaniem, specialist registrar in general sur-

gery, Queen Mary’s Hospital, Sidcup, for his help.

1 Min RJ, Khilnani NM, Golia P. Duplex ultrasound evaluation of lower

extremity venous insufficiency. J Vasc Interv Radiol 2003;14:1233-41.
M A ANSARY/SPL

2 Bergen JJ, Kumins NH, Owens EL, Sparks SR. Surgical and endovascular
treatment of lower extremity venous insufficiency. J Vasc Interv Radiol
2002;13:563-8.

studentbmj.com 449
 Surgical treatment of varicose veins

B. WOLF and J. BRITTENDEN

Vascular Surgery Unit, Aberdeen Royal Infirmary, Aberdeen, UK

INTRODUCTION

Varicose veins are present in 20-25% of adult females and 10-15% of men.1 This common condition represents a considerable
surgical workload, with an estimated 75,000 operations being performed each year in the United Kingdom (UK).2 Up to 20% of
varicose vein surgery is performed for recurrent veins, which have often arisen due to a technically inadequate first
operation.3 Although the pathophysiology is multifactorial, in primary varicose veins the main abnormality is valvular
dysfunction. This may occur in the deep, perforating or superficial long and short saphenous veins.

CLINICAL FEATURES

Presenting complaints

The Edinburgh vein study has demonstrated that in the general population there is poor correlation between the presence of
varicose veins detected on clinical examination and lower limb symptoms. The presence of reflux on duplex scanning, also has a
weak association with symptoms.

Varicose veins may be associated with a sensation of heaviness and itching and, in the presence of deep and superficial reflux,
cramps and aching. However, all too often generalised aches and pains in the leg may be attributed to visible varicosed veins.
Patients may present with complications such as bleeding, phlebitis and ulceration.

Indications for surgery

A large proportion of patients may wish surgery for cosmetic reasons or due to anxiety that their disease may progress to
chronic venous insufficiency and ulceration. It should be emphasised that varicose vein surgery is not curative, and early
surgery in uncomplicated veins will not prevent development of future varicosities. However, it has been shown, that quality of
life is reduced in patients with varicose veins compared with the general population, and that this is improved by surgery.5 Clear
indications for surgery are signs of chronic venous insufficiency, superficial thrombophlebitis and bleeding.

Relative contra-indications

Before embarking on surgery it is important to elicit a history of previous deep venous thrombosis, major lower limb fracture,
prolonged immobilisation or the so-called ‘white leg of pregnancy’. Clearly, surgery should not be performed on the superficial
veins if they are acting as collaterals for occluded deep veins. These patients should, therefore, undergo further imaging to
assess the patency of the deep veins. Arterial insufficiency is also a relative contraindication to varicose vein surgery and
compression.

Clinical assessment

The general health of the patient should be assessed, to determine if they are suitable for surgery and whether this can be done
on a day case basis. Appropriate pre-operative anaesthetic work-up should be performed as indicated by the age and co-
morbidity of the patient. Clinical examination will allow assessment of the distribution of varicosities and indicate whether
reflux is present in the long or short saphenous system or both. Tests such as the cough, tap and thrill tests have been shown to
be inaccurate.6 However, the combination of a hand-held doppler and tourniquet allows reliable identification of sapheno-
femoral incompetence.7 However, at the popliteal junction it is difficult to differentiate between short saphenous and popliteal
reflux with the use of the hand held doppler, and a duplex scan is justified.

It is important to look for signs of complicated varicose veins such as thrombophlebitis, lipodermatosclerosis, eczema and
ulceration. The presence of extensive angiomatosis visible on the skin as a dark purple swelling in young adults should raise the
possibility of the Klippel-Trenaunary syndrome. This is associated with absent or defective deep veins, the persistence of a
lateral vein and increase in limb length. Treatment for this condition should, in most cases, be conservative. Clinical
examination should allow detection of pathology in the arterial, neurological and musculoskeletal systems that may be a cause
of symptoms.

The role of duplex scanning

Ideally, all patients with varicose veins would undergo duplex scanning, so that optimal surgery could be planned and
performed. However, currently there is no clear evidence that such a policy reduces the rate of recurrence. In the presence of
limited resources, duplex scanning is indicated in (1) patients with suspected short saphenous incompetence, allowing
confirmation of the diagnosis and identification of the junction, (2) recurrent veins, (3) complicated veins - such as
lipodermatosclerosis and ulceration, and (4) patients with a history suggestive of a previous deep venous thrombosis (Figure 1).
Varicography and ascending phlebography are now infrequently performed.

SURGICAL ASPECTS

Informed consent should entail an explanation of the complications of varicose vein surgery. In the UK, varicose vein surgery is
the most common source of medico-legal action directed against general and vascular surgeons.8 Many cases arise as a result of
poor communication between surgeon and patient. It is important to determine the patients expectations of surgery, to outline
a realistic picture of outcome and to ensure that informed consent is obtained. Patients must be warned of possible
complications. Common complications include minor haemorrhage, ‘track thrombophlebitis’, haematomas and wound
problems (infection, lymph leak). Less commonly, damage may occur to the sural or saphenous nerves. Rare complications
include direct injuries to underlying structures (deep veins, arteries and major nerves), permanent lymphoedema and
thromboembolism.

Patient preparation

Pre-operative marking should be performed with an indelible pen. This may be in the form of tramlines on either side of the
vein. If the lines are placed directly on top of the varicosities, it is important to remove the ink before making avulsions
otherwise tattooing may occur.

Routine antibiotic prophylaxis is not indicated in primary varicose vein surgery. It may have a role in patients undergoing redo-
groin dissections or with overt ulcers at the time of surgery.

Heparin prophylaxis

A survey of the members of the vascular surgical society, showed marked variation in the use of heparin prophylaxis, with only
12% of members using it routinely and 71% on a selective basis.9 In general, patients with complicated veins or other known
risk factors such as obesity, increasing age and poor mobility should receive heparin prophylaxis.

Sapheno-femoral ligation

The patient is placed prone, with a degree of head down and the leg abducted. The incision should be made in the groin skin
crease below and parallel to the inguinal ligament at the site of the sapheno-femoral junction (2 cm below and lateral to the
pubic tubercle). The subcutaneous fat is spread out by the use of a self-retaining retractor. This usually allows identification of
the long saphenous vein or one of its tributaries. The main tributaries are the superficial circumflex iliac, superficial inferior
epigastric, superficial and deep external pudental veins. The superficial tributaries should be dissected, and followed were
possible back to the secondary branch points and divided and ligated.10 The long saphenous vein must not be divided until the
sapheno-femoral junction has been clearly identified and dissected (Figure 2). Be aware of the superficial external pudendal
artery that usually passes between the long saphenous and common femoral vein. It is important to ensure that the junction is
well displayed (1 cm above and below the junction will usually suffice) and the small, usually medially located tributaries are
divided. The long saphenous vein should be ligated flush to the junction. Most people either doubly ligate the long saphenous
vein or transfix it. Before proceeding to stripping, the lower end of the wound should be retracted and the posterior-medial
thigh vein identified and ligated.
Stripping of long saphenous vein

It has been clearly demonstrated that stripping reduces the rate of recurrence.11 It is disappointing, therefore, that it is not
universally performed. It is advisable to strip from above down as the reverse technique may result in the stripper being passed
inadvertently into the deep venous system. The stripper can be passed either directly into the long saphenous vein by holding
the end open with an arterial forceps or the end may be ligated and the stripper passed by a small side-hole. A ligature should
be placed to prevent back bleeding. The leg is straightened and the stripper is gently manipulated down the vein. Stripping is
usually performed to a hands-breath just below the knee; below this the saphenous nerve is more closely related to the vein
resulting in an increased risk of injury. An incision is made in Langer’s lines over the distal end of the stripper that is then
retrieved. Pressure should be applied over the stripper tract and any haematoma evacuated before wound closure. Inversion
stripping has been shown to reduce the risk of haematoma as has multiple avulsions, although the latter may be less
cosmetically appealing.

Multiple avulsions

Small 3-5 mm incisions may be made by an 11-scalpel, and the vein retrieved with the use of a phlebectomy hook and avulsed.
Care should be taken to avoid nerve damage, in particular the common peroneal nerve at the neck of the fibula, the sural nerve
in the midline of the calf posteriorly, and the long saphenous nerve in the lower medial calf. The avulsions may be closed with
the use of steristrips.

Sapheno-popliteal ligation

It should be emphasised that the location of the saphenopopliteal junction is very variable and in 25% of cases the short
saphenous vein will enter the deep veins at a higher level than the popliteal fossa. It is important, therefore, to mark the
sapheno-popliteal vein pre-operatively with Doppler or more preferably by duplex scanning.

The patient is placed prone and a transverse incision is made over the previously marked site and the fascia divided. The short
saphenous vein is identified and dissected carefully to the junction with the popliteal vein. There is usually an upward extension
of the short saphenous vein known as the Giacomini vein which, if mistaken for the short saphenous, may make identification
of the sapheno-popliteal junction difficult. In addition, gastrocnemius veins in the popliteal fossa may cause confusion. Care
should be taken to avoid damage to the common peroneal nerve, and it should be noted that it is easy to tent up the popliteal
vein. Once the T-junction is identified, the small tributaries should be ligated and divided and the short saphenous doubly
ligated proximally. By flexing the knee it is usually possible to dissect 5-10 cm of short saphenous vein distally which may then
be ligated and excised. It should be noted that stripping the short saphenous vein is associated with a high incidence of sural
nerve injury.

Perforator ligation

The significance of perforating vein disease remains unclear even in patients with venous ulceration. Studies have shown that
incompetence in perforating veins may be reversed following superficial saphenous vein surgery in the presence of a normal
deep venous system.12 In the past, surgery designed to divide the perforating veins, such as Cockett and Linton procedures,
were associated with considerable morbidity. The recently developed technique of subfascial endoscopic perforator surgery
(SEPS) has allowed perforating veins to be divided effectively with minimal morbidity through a small incision. SEPS is not
indicated in primary uncomplicated veins but may have a role in addition to saphenous ligation in patients with venous ulcers
and who have no evidence of previous deep vein thrombosis.13

Redo-groin surgery

A classification of recurrent varicose vein has been devised by Stonebridge et al (1995).14 The majority of recurrences are due to
inadequate groin surgery, i.e. failure to divide the saphenous vein flush with the common femoral vein, or to perform stripping.

The main principal with redo-groin surgery is that the sapheno-femoral junction (CSFJ) should not be approached directly
through the previous scar tissue. This may lead to significant bleeding, which is difficult to control, inadvertent damage to the
common femoral vein and an increased likelihood of inadequate surgery. The junction should be approached usually by a
lateral approach. The artery is exposed and the dissection continued medially to the CSFJ that is ligated and divided, before
more superficial dissection is commenced. It is important to strip the long saphenous vein if this has not been performed at the
primary operation.

ADDITIONAL SURGICAL TECHNIQUES

Tourniquets

The use of tourniquets in varicose vein surgery has been shown to reduce blood loss, duration of surgery and subsequent
haematoma formation in a randomised controlled trial.15

Formation of barrier at sapheno-femoral junction

Cribriform fascia, Gortex® or Mersilene mesh® have all been used at the junction in an attempt to reduce the rate
of recurrence. 16,17 Results appear promising but to date there are no published randomised controlled trials of patching
techniques in primary varicose veins. Disappointingly, a randomised-controlled trial involving patients with recurrent varicose
veins has shown no reduction in recurrence following the use of a barrier.

Bandages

Bandages are applied at the end of the procedure in an attempt to curtail bruising. Patients are advised to wear compression
stockings for a period of one week post-operatively.18

Local anaesthetic

The wounds should be infiltrated with local anaesthetic.

NEW DEVELOPMENTS

Currently, other promising techniques that may act as an alternative to surgical treatment are being evaluated. Closure of the
long saphenous vein with endoluminal radio-frequency thermal heating of the vein wall in combination with phlebectomy, has
been shown to be feasible, safe and effective at limited follow-up. Phase III trials are currently evaluating a microfoam that is
injected directly into the long saphenous vein under duplex surveillance, which results in occlusion of the vein.

KEY POINTS

Varicose vein surgery is the most common source of medico-legal action in surgical practice

20% of varicose vein surgery is performed for recurrent disease

The sapheno-femoral junction should be clearly displayed

The long saphenous vein should be stripped to just below the knee

The sapheno-popliteal junction should be imaged and marked pre-operatively

Subfascial endoscopic perforator surgery is not indicated in primary uncomplicated varicose veins