1. Varicose Veins and Superficial
Venous Insufficiency
Mark A. Smith, MD
Department of Surgery
Division of Vascular Surgery
University of California, Irvine Medical Center
Orange, California
3. Definitions
• Varicose Vein- dilated tortuous vein
• Venous Insufficiency- condition,
typically chronic, of abnormal blood
flow in vein leading to local damage
and potentially regional/global
effects.
8. Long History of Varicose Veins
• 1550 B.C.- Elbers Papyrus from
Egypt- described the condition,
recommended not treating
• Hippocrates- noted venous
hypertension in ulcers-
recommended compression
• Da Vinci- described venous anatomy
• 1603- Fabricius- described venous
valves
9. Incidence and Prevalence
• Incidence- Recent large U.S. cohort
• 3% Women
• 2% Men
• Prevalence- Review of Studies since
1942
• CVI-
• Females- 1-40%, Males 1-17%
• Varicose Veins-
• Females 1-73%, Males 2-53%
Ann Epidemiol. 2005 Mar;15(3):175-84.
12. Risk Factors
• Familial tendency
• Female Sex associated with
pregnancies
• Obesity
• Age – greatest number >age50
• Prolonged standing or sitting
• Prior DVT
• Tight fitting clothes- tourniquet effect
13. Classification- CEAP
• C- 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
• Add S- Symptomatic or A- Asymptomatic
14. Classification- CEAP
• E- Etiology
• Ec – Congenital
• Ep – Primary
• Es - Secondary (post-thrombotic)
• En - No venous cause identified
• A- Anatomic
• As - Superficial veins
• Ap - Perforator veins
• Ad - Deep veins
• An - No venous location identified
15. Classification- CEAP
• P- Pathophysiologic
• Pr – Reflux
• Po – Obstruction
• Pr,o – Reflux and obstruction
• Pn - No venous pathophysiology
identifiable
16. Diagnosis- History
• Appearance of enlarged veins of any
size
• Heaviness, Aching, Pruritus
• Symptoms progress through the day
• Mild to moderate edema
• Severe Symptoms- Phlebitis,
Hyperpigmentation, lipodermatosclerosis,
Ulceration, Bleeding
17. Diagnosis- Physical Examination
• Identification of varicosities and
extent- skin, deeper tissue or both
• Look for the pigment changes and
ulcerations
• Tests for Venous Insufficiency
• Brodie- Trendelenberg Tourniquet-
separate deep from superficial venous
insufficiency
• Bedside doppler- with Valsalva
18. Diagnosis- Laboratory Studies
• Ambulatory Venous Pressure- Gold
Standard Physiologic test
• Duplex Ultrasound Scanning- Gold
Standard Anatomic
19. Treatment
• Conservative
• Do nothing
• Compression
• Large Varicose Veins (Insufficiency)
• Open Surgery
• Endoluminal Closure
• US Guided Foam Sclerotherapy
• Smaller Varicose Veins (<8mm)
• Sclerotherapy
• External Laser, Pulsed Light
• Ulcers
21. Compression Treatment
• Over the Counter products
• Prescription Stockings- (e.g. Jobst,
Sigvaris)
• Can vary pressure, area covered,
material
• Unna Boots- “Soft Cast”- Zinc Oxide
• Multilayered Wraps- Profore System
22. Open Surgery
• Great Saphenous Vein Ligation and
Stripping
• High Ligation of Sapheno-Femoral
Vein Junction and Ligation of
Tributaries
• Phlebectomy- Ambulatory or Stab
Phlebectomy
23. Surgical Treatment
Stripping and Ligation
Once the “stripper” is tied in place, the surgeon rips
the stripper and the vein from the leg
Groin incision, ligation and tying
off of tributaries and GSV
30. Tumescent Anesthesia
• Idea is to circumferentially compress
the vein so that it surrounds the fiber
uniformly.
• Described as a tubular anesthetic
affect along the course of the vein.
• Injections with a long 22+/- gauge
needle every 2+/- cm.
• Must be done with Ultrasound
Guidance,
• Must be in Perivenous space
32. Completion of Ablation Procedure
• Pull back of laser at 1-2 mm/sec.
• Goal is to deliver 80-85 joules/cm. of
treated vein
• Preserve the Superficial Epigastric
Vein
• Ideally treat GSV to below knee
position
• Can treat GSV, SSV and Perforators
with the Ablation method
35. EVLA- The Results
• 495 GSV’s treated in 423 Patients
• 98% initial technical Success, more than 93%
remain closed over 2 years
• Well tolerated by all patients under strictly
local anesthesia
Endovenous Laser Treatment of Saphenous Vein Reflux: Long-Term Results
Robert J. Min, MD, Neil Khilnani, MD, and Steven E. Zimmet, MD
J Vasc Interv Radiol 2003; 14:991–996
36. EVLA Results
Combined Results
Min, et al.
• > 3000 GSVs treated with endovenous laser
• Up to 28 month follow-up
• > 97% of GSVs have remained closed
• Bruising & mild/moderate tenderness (< 2 wks)
• No other minor or
major complications
42. US Guided Foam Sclerotherapy
• Frullini and
Cavezzi- 93.3%
success rate
• Bergan et al.-
Complete absence
of reflux in 79.8%
• Almeida and
Raines- GSV
closure rate of
100%
43. Venous Ulcers
• Compression is primary treatment
• Wound care particulars becoming
more important
• Treat underlying pathology such as
feeding perforator to decrease
recurrence rate
44. Conclusions
• Varicose Veins and Superficial
Venous Insufficiency should be seen
as conditions on a continuum.
• It is treatable, not curable. Need a
long term follow-up mind set.
• Fit the treatment to the individual
situation- there is no one size fits all.
