Phillip D. Coleridge Smith
Modern Approaches to venous disease
Recent Advances in Surgery-23, Year-2000
Varicose veins are managed by a wide range of surgeons who employ numerous diffedrent techniques.
Tourniquet tests add some information about the location of venous valvular incompetence but are notoriously unreliable, even in experienced hands.
The state of competence of the superficial veins can be assessed with greater confidence using continuous wave [CW] ‘hand-held’ Doppler ultrasound.
Where a skilled technologist is available with experience in venous imaging colour duplex ultrasonography is the investigation of choice.
All lower limb vessels can be readily assessed using this method providing both anatomical as well as functional information.
Venography is an invasive investigation and, although excellent anatomical detail is provided, functional information is much less satisfactory.
For patients who have large [> 3 mm diameter] varices with or without truncal incompetence of the saphenous veins, surgery should be considered.
Where there is a history of previous deep vein thrombosis [DVT] or any clinical feature suggestive of deep vein obstruction or incompetence, the state of the deep veins should be assessed using duplex ultrasonography.
In patients in whom the deep veins have been destroyed by a previous DVT, the superficial varices may be the only route of collateral venous drainage. Removing these veins will lead to no symptomatic improvement and may make matters considerably worse.
Where deep veins have been damaged by a previous DVT and recanalization has occurred [demonstrated by duplex ultrasonography], there is no specific contra-indication to varicose vein surgery. However, such patients are at high risk of developing further DVT following varicose vein surgery and will probably derive little symptomatic benefit from surgical removal of varices. In some patients, deep vein incompetence occurs without evidence of previous venous
thrombosis but in association with these large superficial varices. It has been found that deep vein reflux occurring in these circumstances often resolves when the varicose veins are removed.
Patients with primary [non-thrombotic] deep vein incompetence combined with superficial venous incompetence are in the only group in which varicose vein surgery is appropriate.
The three main principles which should be applied whenever operating to remove varicose veins are first to ligate any incompetent junction or incompetent communication with the deep veins [sapheno-femoral junctions [SFJ], sapheno-popliteal junction [SPJ], perforating veins.
Next, the associated saphenous trunk is removed [long or short saphenous vein.
Finally, all visible varicosities are removed.
Failure to ligate all sources of venous reflux during a varicose vein operation will usually result in rapid reappearance of varices.
All tributaries of these junctions should be ligated flush with the vein, leaving none as the source of possible recurrence.
There has been debate over the years as to the need for stripping the long or short saphenous vein. The increased bruising and risk of cutaneous nerve injury are reasons for not stripping these veins.
However, if the SFJ is ligated without stripping the long saphenous vein, the LSV remains patent and incompetent, filling from its tributaries. This results in a higher rate of recurrence than for LSV stripping operation.
The risk of saphenous nerve injury can be reduced by limiting the stripping procedure to the thigh and upper calf.
Postoperative management includes the use of compression stockings or bandages.
Compression stockings worn for 1-3 weeks postoperatively.
The most frequent cause of recurrent varices following surgery to the SFJ is further varices arising from the SFJ. This is caused by residual tributaries or poor surgical technique in the original operation.
The sapheno-popliteal junction is more difficult to dissect a second time since the several motor and sensory nerves in the region are easily damaged leading to far worse problems than the original veins.
The management of leg ulcers has been greatly assisted by the availability of duplex ultrasonography.
Large proportion of patients with a venous cause for their leg ulcer have superficial venous incompetence alone, that is they have varicose ulcers.
Deep vein incompetence is often caused by previous venous thrombosis. In some patients, deep vein incompetence is found without evidence of previous thrombosis.
For these patients, there is no advantage in removing superficial varices, even if any are present. The mainstay of treatment here should be compression treatments.
Compression applied to the skin appears to accelerate flow in the microcirculation deterring leukocytes from adhering, to endothelial cells. This is a possible mechanism by which compression protects the microcirculation of the skin from damage and achives leg ulcer healing in patients with venous disease.
No drug currently available will cure varicose veins.
Venous ulceration often arises in patients with superficial venous incompetence alone.
Patients with superficial venous incompetence alone or isolated perforating incompetence should be offered operation.
Compression treatment remains effective in the management of venous ulceration and should be the primary treatment in all other patients with venous leg ulceration.
No drug is as effective as good compression in achieving healing. No topical treatment, whether simple or active, speeds ulcer healing.