VARICOSE VEINS

Introduction to the Venous Drainage System

• The venous drainage system of the lower extremity is organized into three distinct sets of veins:
  • Deep Veins: Located within the deep fascial planes and supported by the musculature of the leg.
  • Superficial Veins: Located within the subcutaneous tissue.
  • Perforating (Communicating) Veins: Connect the superficial and deep systems.
• All veins in this system contain delicate one-way valves.
• The primary function of these valves is to open to allow blood to flow toward the heart and close to prevent retrograde (backward) flow.

Anatomy of the Lower Limb Veins

Superficial Veins

• Long Saphenous Vein (LSV) / Great Saphenous Vein:

  • It is the largest and longest superficial vein in the lower limb.
  • Origin: Begins on the dorsum of the foot from the medial end of the dorsal venous arch.
  • Course: It runs approximately $1\text{ to }1.5\text{ inch}$ anterior to the medial malleolus, continues along the medial side of the leg, and passes behind the knee.
  • Anatomical Position at Ankle: Its position is constant, lying in the groove between the anterior border of the medial malleolus and the tendon of the tibialis anterior.
  • Course in Thigh: It inclines forward to reach the saphenous opening.
  • Termination: It pierces the cribriform fascia and opens into the femoral vein approximately $3-4\text{ cm}$ below and lateral to the pubic tubercle.

• Short Saphenous Vein (SSV) / Small Saphenous Vein:

  • Origin: Formed by the fusion of several small veins located below and behind the lateral malleolus.
  • Course: In the lower third of the leg, it runs alongside the large sural nerve.
  • Fascial Plane: In the lower third of the calf, it sits on the deep fascia, covered by skin and superficial fascia. In the middle third, it enters the intrafascial compartment within the aponeurotic investment of the gastrocnemius muscle.
  • Termination: In the upper third of the leg, it penetrates the deep fascia to enter the popliteal space between the two heads of the gastrocnemius muscle, roughly $1.25\text{ cm}$ below the transverse skin crease behind the knee. It then joins the popliteal vein.

Deep Veins

• These veins accompany the major arteries of the leg and are supported by the powerful leg muscles.
• Major deep veins include:
  • Anterior and Posterior Tibial veins.
  • Peroneal (Fibular) vein.
  • Popliteal vein.
  • Femoral vein.
  • Internal and External Iliac veins leading to the Common Iliac vein.

Perforating Veins

• These function as communicating vessels between the superficial and deep venous systems.
• Classification:
  1. Indirect Perforating Veins: Small superficial veins that penetrate the deep fascia to connect with vessels within the muscle, which subsequently drain into the deep veins.
  2. Direct Perforating Veins: Provide a direct connection between the superficial veins and the deep veins.
• Valvular Function: Perforators are guarded by valves that ensure unidirectional flow from the superficial system to the deep system.

Definition and Hemodynamics of Varicose Veins

Definition

• Varicose veins are defined as superficial veins that have become permanently distended and tortuous due to a loss of valvular competence.
• Common Sites:
  • Great (Long) Saphenous vein.
  • Lesser (Short) Saphenous vein.
  • Perforator veins near the ankle.

Factors Assisting Venous Return

• Negative Thoracic Pressure: During inspiration, pressure in the thorax drops to approximately $-6\text{ mm}$, creating a suction effect.
• Calf Muscle Pump: Normal venous pressure in a relaxed state is $20\text{ mmHg}$. During muscle contraction, this pressure rises to $80-100\text{ mmHg}$, propelling blood upward.
• Vis a Tergo: The remnant of arterial pressure transmitted through the capillary bed to the venous side.
• Competent Valves: Prevent gravity-induced retrograde flow.
• Venae Comitantes: Veins lying adjacent to arteries benefit from arterial pulsations which help propel venous blood.

Classification and Etiology

Types of Varicose Veins

• Primary (Idiopathic):
  • More common in women.
  • Primarily affects lower extremities.
  • Associated with a strong family history.
• Secondary:
  • Resulting from an identifiable obstruction or condition, such as a previous Deep Vein Thrombosis (DVT).
• Related Conditions:
  • Hemorrhoids (rectal varices).
  • Esophageal varices.
  • Varicocele (scrotal varices).

Etiology (Risk Factors)

• Prolonged hours of standing (increases gravitational hydrostatic pressure).
• Family history.
• Pregnancy.
• Aging.
• History of Deep Vein Thrombosis (DVT).
• Use of oral contraceptives.
• Obesity.

Pathophysiology

• The progression follows this sequence:
  1. Presence of risk factors or causes.
  2. Increased venous pressure.
  3. Dilation of the veins.
  4. Stretching of the venous walls leads to the pulling apart of valve cusps.
  5. Valvular incompetence occurs.
  6. Reverse (retrograde) blood flow begins.
  7. The calf muscle pump fails to effectively clear the blood.
  8. Chronic venous distention follows.

Clinical Manifestations and Signs

Symptoms

• Cosmetic Issues: Visible, dilated, and tortuous veins.
• Pain: Dull aches, dragging pain (worse with standing/sitting), or "bursting" pain upon walking.
• Physical Sensations: Muscle cramps, increased fatigue, nocturnal (night) cramps, and a feeling of heaviness in the legs.
• Skin Changes: Itching, edema (swelling) of the ankle, thickening of the skin, and eczema.
• Spider Veins: Appearance of small telangiectasias.
• Advanced Signs: Discoloration, ulceration, and bleeding ("blow outs").

Physical Signs

• Ankle Flare: A fan-shaped pattern of small intradermal veins near the ankle.
• Spider Veins (Telangiectasias): Small ($0.5-1\text{ mm}$) widened blood vessels in the skin. Also called "venulectasias" or "corona phlebectatica" when appearing as blue spider veins on the medial aspect of the ankle.
• Reticular Veins: Subcutaneous dilated veins ($1-3\text{ mm}$), larger than spider veins but smaller than varicose veins. Often referred to as "feeder veins."
• Saphena Varix: A dilation at the top of the long saphenous vein (saphenofemoral junction). It is soft, compressible, disappears on lying down, and exhibits an expansile cough impulse and fluid thrill.
• Champagne Bottle Sign: An "inverted beer bottle" appearance where the ankle and lower leg skin/subcutaneous tissue contract (lipodermatosclerosis) while the calf remains edematous.
• Atrophic Blanche: White, star-shaped scarring of the skin.
• Talipes Equinovarus: A possible structural deformity associated with chronic cases.

Diagnosis

• Anamnesis: Comprehensive history collection.
• Physical Examination: Including specific clinical provocative tests.
• Hand-held Doppler Examination: Probe angled at $45\text{ degrees}$ to detect flow signals.
• Duplex Ultrasonography: The gold standard for non-invasive evaluation of flow and anatomy.
• Venography:
  • Ascending: To visualize the venous anatomy upward.
  • Descending: To assess valvular incompetence and retrograde flow.

Management

Conservative Management

• Elevation of the legs above the heart level.
• Avoiding prolonged periods of sitting or standing.
• Use of graduated compression stockings.
• Regular exercise.
• Weight loss.

Sclerotherapy

• Agent: Sodium tetradecyl sulphate.
• Dosage: $0.25-1\text{ ml}$ per site, with a maximum of $4\text{ ml}$ across 4 different sites.
• Mechanism: Irritates the intima (inner lining) of the vein wall, causing fibrosis and hardening (sclerosis) so the vein no longer fills with blood. The body eventually absorbs the resulting scar tissue.
• USG-Guided Sclerotherapy: Foam sclerosant is monitored under ultrasound. The saphenous opening is compressed by the probe to prevent foam from entering the deep system. The leg is elevated and wrapped in elastic bandages for $24-72\text{ hours}$.

Surgical and Minimally Invasive Procedures

• High End Ligation and Stripping: Ligation of the entire vein at the junction and surgical removal (stripping) of the vein and its tributaries.
• Endovenous Laser Ablation (EVLA):
  1. The LSV is cannulated above the knee under ultrasound guidance.
  2. A guide wire is passed beyond the Saphenofemoral Junction (SFJ).
  3. A catheter tip is placed $1\text{ cm}$ distal to the SFJ.
  4. A laser fiber (diode laser) is inserted.
  5. Heat from the laser causes the vein to collapse and close as the catheter is withdrawn.

Complications and Theoretical Models

General Complications

• Bleeding and superficial thrombophlebitis (thrombosis with inflammation, often occurring spontaneously or after trauma/injection).
• Venous Hypertension leading to venous ulcers.
• Calcification of the vein walls.
• Eczematoid dermatitis and hyperpigmentation.
• Lipodermatosclerosis (hardening of subcutaneous fat).
• Marjolin’s Ulcer (malignancy arising in a chronic ulcer).

Reasons for Complications (Theories)

• Fibrin Cuff Theory: Valvular incompetence $\rightarrow$ venous stasis $\rightarrow$ ambulatory venous hypertension $\rightarrow$ capillary endothelial damage $\rightarrow$ excessive release of fibrin and hemosiderin $\rightarrow$ formation of a "fibrin cuff" around capillaries $\rightarrow$ lack of nutrient exchange and anoxia $\rightarrow$ ulceration.
• WBC Trapping Theory: Raised venous pressure $\rightarrow$ reduced capillary perfusion $\rightarrow$ trapping of White Blood Cells (WBCs) $\rightarrow$ expression of leukocyte adhesion molecules $\rightarrow$ adhesion of WBCs to endothelium $\rightarrow$ release of proteolytic enzymes and free radicals $\rightarrow$ tissue destruction and local ischemia.

Varicose Ulcers

• Most common at the medial malleolus within "Gaiter’s zone" (a handbreadth area around the ankle).
• Appearance: Shallow and flat with sloping, pale blue edges.
• Ulcer Floor: Filled with pink granulation tissue in acute cases; fibrous with seropurulent discharge in chronic cases.
• Surrounding Skin: Characterized by induration, tenderness, and pigmentation.

Special Clinical Tests

• Trendelenburg Test:
  • Procedure: Patient lies flat, leg is elevated to empty veins, and pressure is applied to the SFJ. The patient then stands.
  • Findings: Rapid filling after releasing pressure indicates SFJ incompetence. Filling from below upward while pressure is maintained indicates distal incompetent perforators.
• Tourniquet Test: A variant of the Trendelenburg test using a tourniquet at different levels (thigh or leg) to pinpoint the exact level of incompetent communicating veins.
• Perthes Test: A tourniquet is applied to the thigh of a standing patient who then performs repeated toe-raises. If superficial veins fail to empty or if pain occurs, it indicates deep venous incompetence or occlusion.
• Schwartz Test: Tapping the lower part of the vein while the patient is standing; if an impulse is felt at the SFJ, it indicates incompetence.
• Pratt’s Test: An Esmarch bandage is applied from the foot to the thigh with a tourniquet at the SFJ. As the bandage is released from the top down, incompetent perforators are identified by localized "blow outs."
• Morrissey’s Cough Impulse Test: An expansile impulse felt at the SFJ when the patient coughs.
• **Fegan