A 53-year-old constable has presented with swelling and dull aching pain in the veins of his left lower limb, symptoms that have persisted for 15 years. Physical examination indicates varicosity involving the great saphenous vein due to sapheno-femoral junction and perforator incompetence, specifically at 10 and 15 cm above the medial malleolus, without any evidence of deep vein thrombosis. The patient is classified as CEAP cs4aepasppr, indicating skin changes but no active venous ulcers.

1. Varicose veins
Dr Avijit Banerjee, 2nd year surgery resident,
Dr Ashwani Kumar Malhotra, Chief Surgeon,
South Eastern Railway Hospital, Kolkata

2. HISTORY
 53 years old gentleman, constable by profession presented with chief
complaint of swelling along the veins of left lower limb for last 15 years
 There is dull-aching pain in left calf for last 1 year
 Pigmentation of skin over the medial aspect of left lower leg for last 1
year

3.  The swelling is insidious in onset and is prominent on standing up and
walking and reduces on lying down.
 The pain is dull aching in nature and aggravates on prolonged standing.
 There is presence of skin pigmentation in left lower limb for last 1 year.
 There is no associated night cramps
 There is no history of ulceration or bleeding.
 There is no history suggestive of DVT

4. General survey
 Patient is alert, conscious and cooperative.
 Patient is of average built and nutrition
 Decubitus of choice
 P0I0CCE
 P- 78/min
 BP- 110/70mm Hg
 RR- 16/MINUTE
 Temp- Normal
 Neck veins are not engorged ,neck glands are not palpable.

5. Physical Examination
 On inspection , the right lower limb is essentially normal
 There is dilatation and tortuosity along the course of GSV of left lower
limb from dorsum of foot to upper thigh.
 There is no visible deformity or local gigantism
 There is pigmentation in the Gaiter’s area without any ulceration or
eczema.
 Morrissey’s cough impulse is present

6. Palpation
 Cough impulse present at the sapheno-femoral junction
 Trendelenberg test suggests incompetence of the sapheno-femoral
junction as well as perforator.
 Multiple tourniquet test reveals perforator incompetence at 10 and
15cms above the medial malleolus.
 Fegan’s test reveals fascial defects at the level of incompetent
perforators.
 Swartz test is positive revealing reflux of blood.
 Modified Perthes test is negative revealing there is no associated DVT

7.  All peripheral pulses are normally palpable
 There was no bruit heard upon auscultation
 Examination of other limb was normal

8. Summary
 53 years old constable presented with swelling of veins along the inner
aspect of left leg and thigh for last 10 years. There is associated dull
aching pain in the calf along with pigmentation in the Gaiter’s area.
 On examination there is varicosity involving GSV of left lower limb due to
SFJ and perforator incompetence at 10 and 15cms from medial malleolus.

9.  This is a case of varicose vein affecting great saphenous system in left
lower limb with SFJ incompetence and perforator incompetence at 10 and
15 cms above the medial malleolus without any clinical evidence of DVT.
 As per CEAP classification – CS4aEPASPPR

15. VENOUS ULCERS