The document provides an extensive overview of varicose veins, including their definitions, classifications, pathophysiology, clinical features, examinations, investigations, and treatment options. It details the anatomy and physiology of the venous system in the lower limbs, discussing both conservative and surgical management strategies such as sclerotherapy and various surgical techniques. Additionally, it outlines potential complications associated with both the condition and its treatment methods.

3. Management of Varicose Veins
Ranjith.R.Thampi
Intern
Department of General Surgery

4. INTRODUCTION
“Varicosity is the penalty for verticality against gravity”
In man, owing to his upright posture, blood has to flow
from lower limbs to heart against gravity.
Defined as Dilated, Tortuous and Elongated
superficial veins of the lower limb.

5. Surgical Anatomy of
Venous System of the
Lower Limb
1. Superficial System
-Long saphenous vein
-Short saphenous vein
plus their tributaries
2. Perforators
3. Deep System of veins

6. Perforators
There are about 5 constant perforators in
the lower limb on medial side which
include:
-Ankle Perforators(Cockett) 3 in
number (all related to medial malleolus)
-Knee Perforator(Boyd)
-Thigh Perforator(Dodd)

7. Surgical Physiology
Blood flows in the leg because it is pumped by the heart
along the arteries. By the time it emerges from the
capillaries, it is at a low pressure, but it is enough to return
blood to the heart.
Factors helping blood return to heart include:
-Calf muscle pump
-Competent valves
-Vis-a-tergo
-Negative intrathoracic pressure
-Venae comitantes

9. Classifications
Clinical- 0-6 grades
Etiologic- congenital, primary, secondary
Anatomic- superficial, perforator, deep
Pathophysiologic- reflux, obstruction,
both

10. ETIOLOGICAL TYPES
• CONGENITAL
• PRIMARY
• SECONDARY

11. CONGENITAL
• Abnormality present since birth
• Also due to muscular weakness or congenital
absence of valves
• SYNDROME-
Klippel Trenuanay Syndrome
(Valveless syndrome)- Complete absence of
valves in superficial and deep veins
• GENETIC- Abnormalities in the FOXC2 gene

12. PRIMARY TYPE
• Venous dysfunction due to undetermined cause
• May be result of congenital weakness in the vein
wall due to defective connective tissue and
smooth muscle.
• Concomitant factors prolonged standing
(occupational)

13. SECONDARY TYPE
• Seen in people with an associated known cause
- Post Thrombotic, Post Traumatic, etc.
• In women, Pregnancy, Pelvic tumours, OC Pills,
Progesterone intake
• Congenital AV fistula
• DVT secondary to RTAs or Post-op can result in
destruction of valves resulting in varicose veins

14. Venous Pathophysiology
• Blood from the leg muscles returns through deep veins.
• Blood from skin and superficial tissues, external to deep
fascia, drains via the long and short saphenous veins
and communicating veins into deep veins.
*Valves prevent flow of blood from the deep to the superficial
system

15. Venous Pathophysiology
• On standing, blood continues to circulate even in the
absence of muscle activity.
• On walking and on exercising, foot pump and muscle
pump come into play and maintain venous return

16. Venous Hypertension
• The first source is hydrostatic pressure due to gravity, a
result of venous blood coursing in a distal direction.
It is the weight of the blood column from the right
atrium
• The second source of venous hypertension is dynamic.
It is the force of muscular contraction, usually
contained within the compartments of the leg
• If a perforating vein fails, high pressures of 150-200 mm
Hg developed within the muscular compartments
during exercise are transmitted directly to the
superficial venous system

19. Clinical Features
Symptoms:
 Patient with symptomatic varicose veins commonly
has heaviness, discomfort, and extremity fatigue
 Associated with Dragging pain, Night
cramps, Eczema, Dermatitis, Pruritis, Ulceration, Ble
eding
 Pain is characteristically dull, and is exacerbated in
the afternoon, especially after periods of prolonged
standing
 The symptoms are relieved by leg elevation or
elastic support
 Females complain of symptom exacerbation during
the early days of the menstrual cycle

20. Signs
1. Visible dilated veins in the leg with/ without blow
outs
2. Ankle flare, Pedal edema, pigmentation, dermatitis,
ulceration, tenderness, restricted ankle joint
movement.
3. Thickening of tibia due to periostitis
4. Positive cough impulse at the sapheno-femoral
junction

21. Clinical Examination
5. Brodie-Trendelenburg test: Vein is emptied by
elevating the limb and a tourniquet is tied just below
the sapheno-femoral junction (or using thumb,
sapheno-femoral junction is occuluded).
Patient is asked to stand quickly. When tourniquet or
thumb is released, rapid filling from above signifies
sapheno- femoral incompetence. This is
Trendelenburg test I
In Trendelenburg test II, after standing tourniquet
is not released. Filling of blood from below upwards
rapidly can be observed within 30-60 seconds. It
signifies perforator incompetence.
6. Perthe’s test: The affected lower limb is wrapped with
elastic bandage and the patient is asked to walk around
and exercise. Development of severe cramp like pain in the
calf signifies DVT.

22. 7. Modified Perth’s test: Tourniquet is tied just below the
sapheno – femoral junction without emptying the
vein. Patients is allowed to have a brisk walk which
precipitates bursting pain in the calf and also makes
superficial veins more prominent. It signifies DVT.
DVT is contraindicated for any surgical intervention of
superficial varicose veins. It is also contraindicated for
sclerosant therapy.
8. Three tourniquet test: To find out the site of
incompetent perforator, three tourniquets are tied
after emptying the vein.
1. at sapheno- femoarl junction
2. above knee level
3. another below knee level.
Patient is asked to stand and looked for filling of veins
and site of filling. Then tourniquets are released from
below upwards, again to see for incompetent
perforators

23. 9. Schwartz test: In standing position, when
lower part of the long saphenous vein in leg is
tapped, impulse is felt at the saphenous
junction or at the upper end of the visible part
of the vein. It signifies continuous column of
blood due to valvular incompetence.
10. Pratt’s test: Esmarch bandage is applied to the
leg from below upwards followed by a
tourniquet at sapheno – femoral junction.
After that the bandage is released keeping the
tourniquet in the same position to see the
“blow outs” as perforators.

24. 11. Morrissey’s cough impulse test: The varicose veins are
emptied. The leg is elevated and then the patient is asked
to cough. If there is sapheno- femoral incompetence,
expansile impulse is felt at saphenous opening.
12. Fegan’s test: On standing, the site where the perforators
enter the deep fascia bulges and this is marked. Then on
lying down, button like depression in the deep fascia is
felt at the marked out points which confirms the
perforator site.
13. Ian- Aird test: On standing, proximal segment of long
saphenous vein is emptied with two fingers. Pressure
from proximal finger is released to see the rapid filling
from above which confirms sapheno – femoral
incompetence.

25. Summary of examination
System involved- LSV/SSV
SFJ incompetent? Yes- T1 +/ No- T1 –
Perforator incompetence? Yes- T2 +/ No- T2 –
Group of perforators incompetent?-MTT
Is there DVT? Yes- Perthes’ +/ No- Perthes’ –
Any abdominal mass? Pelvic pathology/ tumors
Any complications? – Eczema/ Dermatitis/ Ulcer
Unilateral or Bilateral?

26. INVESTIGATIONS
• THOROUGH HISTORY
• BRODIE TRENDELENBERG TEST
• TOURNIQUET TEST
• ASSESS SKIN CHANGES
• PERIPHERAL PULSES
• ABDOMINAL EXAMINATION
• DOPPLER ULTRASOUND
• DUPLEX ULTRASOUND
• VENOGRAPHY

27. Duplex Scan

28. Treatment
1. Conservative
2. Injection line of treatment
3. Foam Sclerotherapy
4. Surgery

29. Conservative Management
• Limb Elevation + Elastic compression
bandage
• Elastic compression stockings
• Unna Boot

32. Unna Boot- Gauze impregnated with a thick,
creamy mixture of zinc oxide and calamine to
promote healing. It may also contain acacia,
glycerin, castor oil and white petrolatum

33. Injection line of treatment
Indicated in Below knee varicosity and recurrent
varicosity after surgery
Complications:
Allergy, pigmentation, DVT,
Thrombophlebitis, Skin
necrosis
Sodium tetradecyl sulfate 1.5–3.0%
Polidocanol 3–5%
Polyiodinated iodine 2–12%
Sodium morrhuate 5%
Hypertonic saline 11.7 – 23.4%
Chromated glycerin 50%

35. US Guided Foam
Sclerotherapy
Foam sclerosant C
(Polidocanol) used in few
centres in the UK
Air mixed with sclerosant and
injected into veins by US
image
Complications:
-Extravasation: Skin
ulceration
-Escape into deep veins: DVT
-Entering brain: Stroke,
Headache

37. Surgery
I. Trendelenburg’s Operation
II. Subfascial ligation of Cockett and Dodd
III. Subfascial endoscopic perforator surgery(SEPS)

38. Trendelenburg’s Operation
a. Trendelenburg operation: It is a juxta femoral flush
ligation of long saphenous vein (i.e. flush with femoral
vein), after ligating named (superficial
circumflex, superficial external pudendal, superficial
epigastric vein) and unnamed tributaries. All tributaries
should be ligated, otherwise recurrence will occur.
b. Stripping of vein: Using Myer’s stripper vein is stripped
off. Stripping from below upwards is technically easier.
Immediate application of crepe bandage reduces the
chance of bleeding and haematoma formation.
Complication is injury to saphenous nerve
causing saphenous neuralgia.

39. Trendelenburg’s Operation
Stripping is not usually done for the veins in the lower part of
the leg.
Stripping of the vein is more effective.
‘Inverting or invaginating stripping’ using rigid Oesch pin
stripper is better as postoperative pain and haematoma is
less common and also there is tissue damage. Vein should
be very firmly fixed to the end of the stripper and pulled
out to cause the inverting of the vein.
Stripping of short saphenous vein is more beneficial
than just ligation at sapheno popliteal junction. It is done
from above downwards using a rigid stripper to avoid injury
to sural nerve.

41. Subfascial Ligation of
Cockett and Dodd
Perforators are marked out by Fegan’s method.
Perforators are ligated deep to the deep fascia
through incisions in antero medial side of the
leg.

42. SEPS
• Video techniques that allow direct visualization through
small-diameter scopes have made endoscopic subfascial
exploration and perforator vein interruption possible
• Minimal morbidity and wound complications
• The connective tissue between the fascia cruris and the
underlying flexor muscles is so loose that this potential
space can be opened up easily and dissected with the
endoscope
• This operation, done with a vertical proximal incision,
accomplishes the objective of perforator vein interruption
on an outpatient basis

43. SEPS

44. Recent Techniques in management
• VNUS closure- Ablation catheter
Complications: DVT, recurrence, damage to
overlying skin
• TriVex
Complications: Induration, Bruising,
Subcutaneous grooves
• Radiofrequency ablation- Metal prongs
• Endovenous laser ablation- Laser probe

45. VNUS Closure
Also known as endovenous radiofrequency
ablation, it is a minimally-invasive procedure
used to treat the great saphenous vein
(GSV), small saphenous vein (SSV) and other
superficial veins. It uses a patented
radiofrequency catheter inserted into the
vein, which applies RF energy to heat the vein.
This causes the vein to collapse and seal shut.

46. VNUS closure

47. TRIVEX
Involves a novel technique called transilluminated powered
phlebectomy. While most varicose vein surgery is done
without directly visualizing the varicose veins, the TRIVEX
system transilluminates the veins requiring removal via
advanced fiberoptic technology (much like a flashlight can
shine through your skin).
Once the surgeon has visually confirmed the location of the
diseased varicose vein(s), a local anesthetic is delivered
under pressure into the area. A powered vein resector is
then guided next to the vein and suction is used to draw up
and remove the vein (much like ‘liposuction’). This varicose
vein treatment allows accurate removal of large clusters of
varicose veins with a minimal number of incisions.

48. TriVex
Disadvantages:
It may cause bruising,
grooves, skin induration.

49. Radiofrequency Ablation

51. Complications of Varicose Veins
i. Eczema & Dermatitis
ii. Lipodermatosclerosis
iii. Haemorrhage
iv. Thrombophlebitis
v. Venous Ulcer- Fibrin cuff hypothesis & White
cell trapping hypothesis
vi. Calcification
vii. Periostitis
viii. Equinovarus deformity
ix. Marjolin’s ulcer

53. Marjolin’s Ulcer
Lipodermatosclerosis

54. Doctors at the China Rehabilitation Research Centre in Beijing have
developed an egg cup-like casing for a miracle survivor who was cut
in half in a freak accident back in 1995. It took 20 doctors to save his
life and nobody thought he'd be able to do anything again, but when
doctors at the CRRC heard about his case, they created these robotic
legs for him.

55. Thank You

56. References
• Bailley & Love
Textbook of Surgery
• The Mayo Clinic- Vascular Surgery
• The Merck Manual of Diagnosis & Therapy, 18th
Edition
• Oxfor Handbook of Clinical Surgery,
3rd Edition
• The Internet
• Learning Surgery
The Surgery Clerkship Manual
Stephen F. Lowry, MD, FACS, FRCS Edin (Hon.)