Varicose Veins

Varicosity means dilated, enlongated and tortuous vein. Varicose veins may occur in any part of body but is more commonly seen in lower limb. Varicosities may present in esophagus as esophageal varices, in scrotum as varicocele and in haemorrhoids as varicosity of hemorrhoidal veins.

Varicose vein of legs is common, affecting 1-15 % of adult men and 20-15% of adult women. Varicosity of lower limb mainly involves the great saphenous vein and occasionally, small saphenous vein also along with their tributaries. The involvement of great saphenous vein (GSV) is about 8-10 times more common than small saphenous vein (SSV). Occasionally, some small superficial veins may show varicosity even without involvement of saphenous veins. The leg vein normally contains multiple valves which helps the blood flow in direction of the heart. When these valves get damaged, veins get dilated and results in varicose veins.

Computer professionals, receptionists, security guards, traffic policemen, salesman working at counter in shops and departmental stores and person doing desk jobs day in and day out are the worst suffers of varicose veins.

This is because of following factors :
1 Defect in Venous wall
2 Defect in Venous Valves
3 Thrombosis
4 Weakness of muscles and deep fascia
5 Compression or occlusion of vein
6 Hormonal factors : Progesterone has been studies to cause pelvic congestion and relaxation of tissues of venous wall.
7 Heredity : Abnormality of Fox C-2 gene has been linked to varicose veins.
8 AV Fistula : In AV fistula, the venous part of fistula becames dilated & tortous.

Pain, swelling and cramps in calf and ankle region are the commonest symptoms. Such symptoms may present in one low limb or may be in both lower limbs : depending on involvement of the limbs. The aching pain and swelling become more prominent after prolonged standing or sitting (sitting with hanging legs). This aching pain occurs because of increased weight of lower limb (i.e. Increased weight of leg and ankle) due to increased volume of blood & eematous fluid. While cramps occur due to over-contraction (i.e. Painful contraction) of muscles especially of calf and foot and even of thigh. The feeling of muscle cramps may be in the form of muscle spasm or muscle tightness. The duration of muscle cramps may be for a few seconds to few minutes. These cram usually start after a few hours of sleep hence also known as night cramps.

According to the CEAP classification :
C0 – no visible or palpable signs of venous disease
C1 – telangectasia or reticular veins
C2 – Varicose veins
C3 – Edema
C4a – Pigmentation or eczema
C4b - Lipodermatosclerosis, atrophie blanche
C5 – Healed venous ulcer
C6 – Active venous ulcer.

1 Brodie – Trendelenberg Test (compression test)
2 Torniquet test
3 Four Tourniquet Test
4 Schwartz Test
5 Modified Perthe's Test
6 Pratt's Test
7 Morriyssey's Cough Impulse Test
8 Fegan's Method of palpation
9 Homan's Sign
10 Moses Test

1 Duplex Scan
2 Magnetic Resonance Images
3 Venous Plethysmography
4 Phlebography (Venography)

Invasive treatment for Varicose Veins should be done only if deep vein thrombosis is not present. Basic treatments for varicose veins are :
1 Conservative
2 Invasive Procedures

a Elevation of limb
b Compression stockings
c IpnCD (Intermittent pneumatic compression device)
d Exercise

a: High ligation and Stripping of varicose veins with ligation of perforators- Indications for surgery are-

b Sclerosant Therapy (Injection-Compression Procedure)-

Before injecting the sclerosant the patient is asked to stand for 10 minutes, so that varicose veins get distended.Then distended varicose veins are marked with a marker pen.Then the patient is asked to lie down and to elevate his/her affected leg to empty the distended veins.Now,a sclerosant is injected at various sites of emptied varicose veins.Sclerosant should be given in emptied vein so that intimal walls of veins easily adhere to each others.If sclerosant will go to deep vein it may cause Deep Vein Thrombosis(DVT).Hence to prevent DVT, sapheno-femoral junction and sapheno-popliteal junction should be compressed.After giving he sclerosant, simultaneously crepe bandage(i.e. Pressure bandage) is applied. To obtain the proper pressure , the pressure bandage is applied from the base of toes upto upper thigh region.

c U/S Guided Foam Sclerotherapy -

Under duplex U/S guidance a needle is inserted into a varicose vein.Then via this needle a foam sclerosant is pushed into the vein.Such sclerosant may be STS or polidocanol.The air is mixed in such sclerosant, hence it is known as foam sclerosant.(The foam sclerosant is also known as detergent.)

d Endovenous laser treatments-

As with radiofrequency ablation, endovenous laser treatment involves having a catheter inserted into the affected vein and uses an ultrasound scan to guide it into0 the correct position.A tiny laser is passed through the catheter and positioned at the top of varicose vein.

The laser delivers short short bursts of energy that heat up the vein and seal it closed.The laser is slowly pulled along the vein using the ultrasound scan to guide it, allowing the entire length of the vein to be closed.

e Radio-frequency Ablation (RFA)-

Radiofrequency ablation (RFA) is the latest and most effective and non-surgical treatment for varicose vein using multipolar RFA machine. Under color-doppler ultrasound vision, a radiofrequency catheter is inserted into the abnormal vein and the vessel treated with radio-energy, resulting is closure of the involved vein.Once the vein has been sealed shut,blood will naturally be redirected to one of the healthy veins.

f SEPS (Subfascial Endoscopic Perforator Surgery)-

Under endoscopic vision , subfascial perforators located, clipped and divided.

Dr. Kumar Manish (Sr. Consultant Surgeon)
Dr. Manish Kaushik (DNB Resident)