1. Update on Varicose Veins Treatment
Abdullah Al-Qudah, MD
Associate Prof. of Thoracic
and vascular Surgery, Jordan University Hospital, Amman, Jordan.

3. Chronic venous disease
Most common vascular disorder
3 Billion US dollars spent a year for treatment
3 % of the total Heath care Budget
2 million USA work days lost per year

4. Definition
Telangiectasias - are a confluence of dilated intradermal venules less than one millimeter in diameter.
Reticular veins - are dilated bluish subdermal veins, one to three millimeters in diameter. Usually tortuous.
Varicose veins - are subcutaneous dilated veins three millimeters or greater in size. They may involve the saphenous veins, saphenous tributaries, or nonsaphenous superficial leg veins.

5. Abnormal Veins
Telangiectasias
Varicose vein
Reticular veins

6. Common Questions Are they dangerous? How do they form?
Why does it happen?
Did I inherit it?
What tests can we use?
What treatments are available?

7. Fascia, Veins and Cutaneous nerves of the LE
The subcutaneous tissue of the hip & thigh is continuous with that of the inferior abdominal wall and buttock.
At the knee the subcutaneous tissue loses its fat and blends with the deep fascia
Deep fascia: strong & inelastic it invests the LE; it limits outward expansion of the contracting musculature, the increased pressure “pumps” the blood proximally through the veins.

8. Deep fascia of the thigh (fascia lata)
The fascia lata attaches to and is continuous with:
1.The inguinal ligament, pubic arch, body of the pubis and pubic tubercle.
2.Scarpa’s fascia of the inferior abdominal wall attaches to deep LE fascia inferior to the inguinal ligament.
3. Iliac crest (lateral & posterior).
4. Sacrum, coccyx, sacrotuberous ligament, ischial tuberosity postreiorly.
5. Exposed parts of bones at the knee & deep fascia of the leg.

9. LE Compartments
Anterior & Posterior intermuscular septa – pass from the deep crural fascia to attach to the margins of the fibula.
Interosseous membrane traverses from tibia to fibula
(4) compartments created.
Anterior -dorsiflexors
Lateral - fibular (everter) compartment
Posterior – plantarflexor compartment
The transverse intermuscular septum divides this into a deep & superficial compartment.

10. Crural fascia
Deep fascia to the leg – continuous with the fascia lata, attaches to the anterior & medial borders of the tibia; it is continuous with the periosteum.
Thinner distally but thickens to form an extensor/flexor retinaculum both anterior & posterior to the ankle.

11. Superficial veins
Great saphenous – formed by the union of the dorsal digital vein of the great toe and the dorsal venous arch.
Ascends anterior to the medial malleolus, posterior to the medial condyle of the femur. It freely communicates with the small saphenous vein.
Proximally it traverses the saphenous opening in the fascia to enter the femoral vein.

12. Saphenous opening NAVEL
This is a gap in the fascia lata infero-lateral to the inguinal ligament, lateral to the pubic tubercle.
Medial margin is smooth
Lateral margin is sharp forming the falciform ligament
Cribiform fossa – a sleeve like membrane covering the saphenous opening

13. Small saphenous vein
Formed by the union of the dorsal digital vein of the 5th digit and distal venous arch.
Runs posterior to the lateral malleolus, lateral to the calcaneal tendon.
Runs superiorly medial to the fibula and penetrates the deep fascia of the popliteal fossa, ascends between the heads of the gastrocnemius muscle to join the popliteal vein.

14. Perforating veins
Penetrate the deep fascia, tributaries of the saphenous veins, valves are located just distal to penetration of the deep fascia.
Veins cross the deep fascia obliquely
Muscle contraction causes the valves to close prior to venous compression so blood is forced proximally (musculo-venous pump).

15. Deep Veins
Usually paired with named arteries inside a vascular sheath, this allows arterial pulsation to force blood proximally.
The popliteal vein joins the femoral vein in the popliteal fossa
Femoral vein is joined by the deep vein of the thigh. The femoral vein passes deep to the inguinal ligament to become the external iliac vein.

18. Lymphatic drainage of LE
Superficial Lymphatics
Superficial lymphatic vessels accompany the saphenous veins (great & small)
Superficial lymphatics end at the superficial inguinal nodes most of this lymph drains to the external iliac nodes, some drains to the deep inguinal nodes.
Small lymphatics drain to the popliteal nodes
Deep Lymphatics
Deep lymphatics drain to the popliteal nodes which then drain to the inguinal nodes then to the external iliac nodes.
Both deep & superficial drain into the lumbar lymphatics.

20. Varicose veins
Varicose veins are a common condition in the United States, affecting up to 15 percent of men and up to 25 percent of women.
For many people, varicose veins and spider veins a common, mild and medically insignificant variation of varicose veins — are simply a cosmetic concern.
For other people, varicose veins can cause aching pain and discomfort.
Sometimes the condition leads to more serious problems.
Varicose veins may also signal a higher risk of other disorders of the circulatory system.
Callam, MJ. Epidemiology of varicose veins. Br J Surg 1994;81:167.

22. Etiology Reflux 80% Venous obstruction 18-28% Muscle Pump Dysfunction
Resultant edema and skin changes = Postthrombotic syndrome
Muscle Pump Dysfunction

23. Stasis Pathophysiology
Usually associated with venous incompetence
Primary and secondary reflux
Edema
Vein wall dilatation
Inflammation/Pigmentation (Hemosiderin deposits)
“Fibrin cuffing”
Ulceration

25. Risk factors
Age: Aging causes wear and tear. Eventually, that wear causes the valves to malfunction.
Sex: Women > Men. Hormonal changes during pregnancy or menopause. Progesterone relaxes venous walls. HRT / OCP may increase the risk of varicose veins.
Genetics
Obesity: Increases venous HTN.
Standing for long periods of time. Prolonged immobile standing impairs venous return.
Fowkes, FG, Lee, AJ, Evans, CJ, et al. Lifestyle risk factors for lower limb venous reflux in the general population: Edinburgh Vein Study. Int J Epidemiol 2001; 30:846.
Sadick, NS. Predisposing factors of varicose and telangiectatic leg veins. J Dermatol Surg Oncol 1992; 18:883.
Iannuzzi, A, Panico, S, Ciardullo, AV, et al. Varicose veins of the lower limbs and venous capacitance in postmenopausal women: relationship with obesity. J Vasc Surg 2002; 36:965.
Evans, CJ, Fowkes, FG, Hajivassiliou, CA, et al. Epidemiology of varicose veins. A review. Int Angiol 1994; 13:263.

26. Strong familial component
Not well studied
Twin studies 75% identical, 52% non identical
If both parents VVS - 90% of children VVs
If one parent was affected 25 percent for men and 62 percent for women
Cornu-Thenard, A, Boivin, P, Baud, JM, et al. Importance of the familial factor in varicose disease. Clinical study of 134 families. J Dermatol Surg Oncol 1994; 20:318.

27. Symptoms
Achy or heavy feeling, burning, throbbing, muscle cramping and swelling.
Prolonged sitting or standing tends to intensify symptoms.
Pruritis
Painful skin ulcers

28. Complications
Extremely painful ulcers may form on the skin near varicose veins, particularly near the ankles.
Brownish pigmentation usually precedes the development of an ulcer.
Occasionally, veins deep become enlarged.
Bleeding
Superficial thrombophlebitis

29. CEAP classification
1994 AVF Meeting

30. Patient Assessment History Examination Trendelenburg Test
History of symptoms and onset
History of venous complications
Desire for treatment
Comorbidities
Rule out secondary cause including DVT and HEART Failure
Examination
Patient in general
Pedal pulses
Groins
Veins
Trendelenburg Test
Venous claudication

31. Investigation All get a Duplex scan Examines – Deep veins
– Superficial veins
– Incompetence and patency
Other Tests
Physiologic testing
Phlebography
Intravascular Ultrasound

34. Duplex scan Vast majority have superficial incompetence only.
Sensitivity 95 % for identifying the competence of the saphenofemoral and saphenopopliteal junctions.
Less sensitive for identifying incompetent perforators (40 to 60 percent)
Lin, JC, Iafrati, MD, O'Donnell, TF Jr, et al. Correlation of duplex ultrasound scanning-derived valve closure time and clinical classification in patients with small saphenous vein reflux: Is lesser saphenous vein truly lesser?. J Vasc Surg 2004; 39:1053.
Jutley, RS, Cadle, I, Cross, KS. Preoperative assessment of primary varicose veins: a duplex study of venous incompetence. Eur J Vasc Endovasc Surg 2001; 21:370.

35. Treatment Conservative Leg elevation Exercise Compression stockings
Treatment of other underlying conditions
Nothing

36. Vein ablation therapies
Classified by method of vein destruction:
1. Chemical (sclerotherapy)
2. Thermal (laser or endovenous ablation)
3. Mechanical (surgical excision or stripping)

37. Who gets sclerotherapy
Small non-saphenous varicose veins (less than 5 mm),
Perforator veins
Residual or recurrent varicosities following surgery
Telangiectasia
Reticular veins

38. Who gets Sclerotherapy
Who else
– Good control with Trendelenburg
– Recurrent veins
– Frail with resistant/healed ulcers
O'Donnell, TF Jr. The present status of surgery of the superficial venous system in the management of venous ulcer and the evidence for the role of perforator interruption. J Vasc Surg 2008; 48:1044.
Galland, RB, Magee, TR, Lewis, MH. A survey of current attitudes of British and Irish vascular surgeons to venous sclerotherapy. Eur J Vasc Endovasc Surg 1998; 16:43.

39. Sclerosing Agents Sodium tetradecyl sulfate Hypertonic Saline
Polidocanol
Monoethanolamine oleate
Glucose combinations
Damage endothelium leading to thrombosis of the vein.
Pressure to try and reduce the amount of thrombus.
Tessari, L, Cavezzi, A, Frullini, A. Preliminary experience with a new sclerosing foam in the treatment of varicose veins. Dermatol Surg 2001; 27:58.

40. Microsclerotherapy 30 g butterfly needle 0.2% STS
Several courses required
benefit compression

41. Telangiectasias

43. Foam Sclerotherapy 1:4 Sclerosant (1% or 3%): Air Why foam?
– Induces spasm
– Disperses further
– Enhanced sclerosis
Breu, FX, Guggenbichler, S. European Consensus Meeting on Foam Sclerotherapy, April, 4-6, 2003, Tegernsee, Germany. Dermatol Surg 2004; 30:709.

44. Spider veins

45. Foam Sclerotherapy: Complications
Phlebitis
Skin staining
Failure
Residual lumps
Matting
Embolus (CVA)
DVT
Ulceration (rare)
Anaphylaxis (very rare)

46. Foam Sclerotherapy Results
Variable depending on series
Long-term recurrence rates are as high as 65 percent in five years, however, patients can also be retreated when veins recur
Large veins can be a problem
Currently randomized trial
Part of the arsenal
Belcaro, G, Nicolaides, AN, Ricci, A, et al. Endovascular sclerotherapy, surgery, and surgery plus sclerotherapy in superficial venous incompetence: a randomized, 10-year follow-up trial--final results. Angiology 2000; 51:529.

47. Catheter-based Treatments
Endovenous laser EVLA
Radiofrequency ablation RFA
Primarily to treat saphenous insufficiency (great or small)
EVLA and RFA, are equally efficacious & have similar recanalization rates.
Boros, MJ, O'Brien, SP, McLaren, JT, Collins, JT. High ligation of the saphenofemoral junction in endovenous obliteration of varicose veins. Vasc Endovascular Surg 2008; 42:235.

48. Radiofrequency ablation
Radiofrequency ablation devices (ClosureFast™, RFiTT®, ClosureRFS™) generate a high frequency alternating current in the radio range of frequency.
Weiss, RA, Weiss, MA. Controlled radiofrequency endovenous occlusion using a unique radiofrequency catheter under duplex guidance to eliminate saphenous varicose vein reflux: a 2-year follow-up. Dermatol Surg 2002; 28:38.
Rautio, T, Ohinmaa, A, Perala, J, et al. Endovenous obliteration versus conventional stripping operation in the treatment of primary varicose veins: a randomized controlled trial with comparison of the costs. J Vasc Surg 2002; 35:958.

49. Radiofrequency ablation
Heats the tissue surrounding the catheter electrode to a specified temperature. Radiofrequency works well on tissue composed primarily of collagen
Special probes have been designed for the radiofrequency device to manage non-saphenous and perforator veins.

50. Varicose veins

51. Endovenous Laser

52. Endovenous Laser Devices (EVLT®, ClosurePlus™)
Use a bare tipped optical fiber which applies laser light energy to the vein.
Therapy based on photothermolysis (light induced thermal damage).
Laser light heats the target tissue inducing thermal injury
Wavelength of light is chosen based on the target structure's chromophore.
Bush, RG, Shamma, HN, Hammond, K. Histological changes occurring after endoluminal ablation with two diode lasers (940 and 1319 nm) from acute changes to 4 months. Lasers Surg Med 2008; 40:676.

53. Wavelengths of light used for venous laser therapy
Mozes, G, Kalra, M, Carmo, M, et al. Extension of saphenous thrombus into the femoral vein: a potential complication of new endovenous ablation techniques. J Vasc Surg 2005; 41:130.

56. Surface laser therapy
Telangiectasias, reticular veins and small varicose veins <5mm
Not used for larger varicose veins

57. Post op care
Graduated compression stockings are worn following the procedure.
F/U duplex ultrasound is performed within one week to evaluate for thrombus in the common femoral vein.
Pt recovery averages two and four days
Significantly shorter interval than is seen with surgical ligation and stripping
Mozes, G, Kalra, M, Carmo, M, et al. Extension of saphenous thrombus into the femoral vein: a potential complication of new endovenous ablation techniques. J Vasc Surg 2005; 41:130.
Darwood, RJ, Theivacumar, N, Dellagrammaticas, D, et al. Randomized clinical trial comparing endovenous laser ablation with surgery for the treatment of primary great saphenous varicose veins. Br J Surg 2008; 95:294.

58. Endovenous complications
Pain, bruising, hematoma
Skin changes: burns, induration, pigmentation, matting, dysesthesia, & superficial thrombophlebitis.
Nerve injury
DVT
Wound infection
Mozes, G, Kalra, M, Carmo, M, et al. Extension of saphenous thrombus into the femoral vein: a potential complication of new endovenous ablation techniques. J Vasc Surg 2005; 41:130.
VAN DEN Bos, RR, Neumann, M, DE Roos, SP, Nijsten, T. Endovenous laser ablation-induced complications: Review of the literature and new cases. Dermatol Surg 2009;

59. Surgery
Thermal ablation techniques are limited by an upper limit of vein diameter (>1.5 cm)
Procedure is performed under general or spinal anesthesia
Indications include management of superficial thrombophlebitis, and venous hemorrhage
Perala, J, Rautio, T, Biancari, F, et al. Radiofrequency endovenous obliteration versus stripping of the long saphenous vein in the management of primary varicose veins: 3-year outcome of a randomized study. Ann Vasc Surg 2005; 19:669.

60. Surgery Saphenous vein stripping Cryostripping High saphenous ligation
Ambulatory phlebectomy
Stab/avulsion phlebectomy
Transilluminated phlebectomy TIPP
Perforator ligation
Subfascial endoscopic perforator vein ligation (SEPS)
Dwerryhouse, S, Davies, B, Harradine, K, Earnshaw, JJ. Stripping the long saphenous vein reduces the rate of reoperation for recurrent varicose veins: five-year results of a randomized trial. J Vasc Surg 1999; 29:589.
Menyhei, G, Gyevnar, Z, Arato, E, et al. Conventional stripping versus cryostripping: a prospective randomised trial to compare improvement in quality of life and complications. Eur J Vasc Endovasc Surg 2008; 35:218.

61. Saphenous vein stripping
Traditional surgical approach
Involves first ligation then division of either the great saphenous (incision in the groin) or small saphenous vein.
Duplex ultrasound to identify the saphenopopliteal junction.

62. Cryostripping Variation of traditional saphenous stripping
Limited to Great Saphenous vein
Vein freezes adhering to the device and the vein is stripped
Less postoperative bruising than conventional stripping
Requires specialized instrumentation

63. High saphenous ligation
Ligation of the saphenous vein at the saphenofemoral junction only
Uncommonly performed in treating saphenous incompetence b/c of higher varicose vein recurrence rates.
Technique for patients who develop superficial phlebitis (idiopathic or iatrogenic from endovenous therapies) w/ extension of clot to the saphenofemoral junction
Performed if PT cannot be anticoagulated

64. Other Techniques Ambulatory phlebectomy Stab/avulsion phlebectomy
Transilluminated phlebectomy TIPP
Perforator ligation
Subfascial endoscopic perforator vein ligation (SEPS)

65. Subfascial endoscopic perforator vein ligation (SEPS)
Indicated for pts with refractory symptoms, ulceration, recurrent ulceration. Pt who failed Cath based treatment
Two ports each placed subfascially
Perforators divided electrocautery, harmonic scalpel or clipped
20 studies involving 1140 limbs in total, found overall ulcer healing in 88 percent of treated limbs
Repeat SEPS if perforators persist
Kalra, M, Gloviczki, P. Surgical treatment of venous ulcers: role of subfascial endoscopic perforator vein ligation. Surg Clin North Am 2003; 83:671.

66. Subfascial endoscopic perforator vein ligation (SEPS)

67. Contraindications Systemic illness Tortuous vein Hypercoagulable state
Pregnancy
Obstructed Deep veins

68. Which is Better ???
Endoluminal thermal ablation versus stripping of the saphenous vein: Meta-analysis of recurrence of reflux.
ES Xenos, G Bietz, DJ Minion, et al

69. Endoluminal thermal ablation versus stripping of the saphenous vein: Meta-analysis of recurrence of reflux.
Method: Systematic search of Medline/Pubmed, OVID, EMBASE, CINAHL, Clinicaltrials.gov and Cochrane central register
in all lanuages

70. Method Randomized prospective clinical trials with > 365 days f/u.
Analyzed outcomes included recurrence of varicosities and reflux, as documented by duplex ultrasound, and recurrence of signs and symptoms

71. Results 8 randomized controlled trials were included
497 patients total
226 L/S
271 endoluminal thermal ablation
F/U 584 SD182 days.

72. Conclusion
Catheter-based treatments and traditional venous stripping with high ligation have similar long-term results
Catheter-based treatments have a decreased post op pain, shorter recovery time to work and normal activity.
Poster Presented at American Venous Form 21st Annual Meeting Phoenix, Arizona Feb 2009

73. Questions ?

74. Which is Better ???
RFA & laser ablation are highly successful in achieving vein closure and have high patient satisfaction rates as well.
Laser>RFA treating perforator veins.
A meta analysis evaluating stripping, foam sclerotherapy, and endovenous therapies in the treatment of the saphenous vein concluded that minimally invasive therapies were as effective as surgical stripping with long term success rates of 78 to 84 percent [72].
Endovenous laser therapy was found to be significantly more effective than stripping, foam sclerotherapy and radiofrequency ablation. However, the early technical success rates for radiofrequency ablation were inferior to laser ablation and newer radiofrequency catheter technology (ClosureFast®) achieving higher temperatures has achieved improved results [77].
Endovenous ablation (EVLA, RFA) is associated with less perioperative pain compared to surgical vein stripping, with patients requiring fewer days out of work and less pain medication [67-69]. Radiofrequency ablation compared to laser ablation is associated with greater improvement in these periprocedural recovery parameters [77]. Laser ablation is consistently associated with more pain and bruising than radiofrequency ablation and continued evaluation of varying

75. EVLA The key to success with EVLA is making the
correct diagnosis and careful patient
selection.
The straighter the vein the easier it will be to
pass the laser fibre across the length of the
segment which requires therapy.
Large diameter veins

76. Early technical success RFA & foam sclero http://www. sawma. org

77. Discussion thoughts
For both the radiofrequency and endovenous devices, the endovenous catheter is placed percutaneously with local anesthesia via a sheath typically placed at the level of the knee and advanced with ultrasound guidance to the proximal vein. After additional local anesthesia is injected along the vein, the device is activated. Energy transferred to the blood and vein wall results in immediate intimal loss and subsequent thrombosis of the vein [69]. Vein wall thickening, inflammatory change and ultimately fibrotic closure of the vein occurs over time
Saphenous vein stripping - The traditional surgical approach involves first ligation then division of either the great saphenous (incision in the groin) or small saphenous vein (incision based upon duplex ultrasound to identify the saphenopopliteal junction). The procedure is performed under general or spinal anesthesia, and the patient typically goes home the same day [78].
Cryostripping is a variation of traditional saphenous stripping and is limited to the treatment of the great saphenous vein. It involves the placement of a special instrument to the level of the previously ligated and divided saphenous junction and supercooled. The vein freezes, adhering to the device and the vein is stripped. The advantage of this method is less postoperative bruising compared to conventional stripping but it requires specialized instrumentation [79].
High saphenous ligation - Ligation of the saphenous vein at the saphenofemoral junction alone without additional treatment of the saphenous vein is uncommonly performed in treating saphenous incompetence because of higher varicose vein recurrence rates.

78. Efficacy of endovenous techniques — Both radiofrequency and laser ablation are highly successful in achieving vein closure and have high patient satisfaction rates as well [60-62,74,75,75]. Success rates in treating perforator veins (RFA) are worse compared to the treatment of the saphenous vein [76].
A meta analysis evaluating stripping, foam sclerotherapy, and endovenous therapies in the treatment of the saphenous vein concluded that minimally invasive therapies were as effective as surgical stripping with long term success rates of 78 to 84 percent [72].
Endovenous laser therapy was found to be significantly more effective than stripping, foam sclerotherapy and radiofrequency ablation. However, the early technical success rates for radiofrequency ablation were inferior to laser ablation and newer radiofrequency catheter technology (ClosureFast®) achieving higher temperatures has achieved improved results [77].
Endovenous ablation (EVLA, RFA) is associated with less perioperative pain compared to surgical vein stripping, with patients requiring fewer days out of work and less pain medication [67-69]. Radiofrequency ablation compared to laser ablation is associated with greater improvement in these periprocedural recovery parameters [77]. Laser ablation is consistently associated with more pain and bruising than radiofrequency ablation and continued evaluation of varying laser parameters (wavelength, fluence) is needed to determine optimal settings.
Surgery — Surgical methods have largely been supplanted by the lesser invasive ablation therapies discussed above. However, patients with very large veins are best treated with surgical therapy. Thermal ablation techniques are limited by an upper limit of vein diameter (>1.5 cm) that can be treated effectively and endovenous treatment of these larger veins is associated with a higher incidence of venous thromboembolism. Surgerical options are limited in patients with a high risk for anesthesia.
Additional indications for surgical management include management of superficial thrombophlebitis, and venous hemorrhage. (See "Varicose vein complications" above).
Several surgical techniques are available and are chosen based upon the location, size, and extent of the patient's varicosities and reflux.
Saphenous vein stripping - The traditional surgical approach involves first ligation then division of either the great saphenous (incision in the groin) or small saphenous vein (incision based upon duplex ultrasound to identify the saphenopopliteal junction). The procedure is performed under general or spinal anesthesia, and the patient typically goes home the same day [78].
Cryostripping is a variation of traditional saphenous stripping and is limited to the treatment of the great saphenous vein. It involves the placement of a special instrument to the level of the previously ligated and divided saphenous junction and supercooled. The vein freezes, adhering to the device and the vein is stripped. The advantage of this method is less postoperative bruising compared to conventional stripping but it requires specialized instrumentation [79].
High saphenous ligation - Ligation of the saphenous vein at the saphenofemoral junction alone without additional treatment of the saphenous vein is uncommonly performed in treating saphenous incompetence because of higher varicose vein recurrence rates.
Some advocate this technique for patients who develop superficial phlebitis (idiopathic or iatrogenic from endovenous therapies) with extension of clot to the saphenofemoral junction, and who cannot be anticoagulated.
Ambulatory phlebectomy - Various methods of vein excision and/or ligation are applied to non-saphenous veins.
Stab/avulsion phlebectomy removes varicose vein segments through very small (<5 mm) incisions often with the use of special fine surgical hooks (eg, Muller). Incisions (only as large as needed to remove the vein) are made along its course. The veins are avulsed and removed and pressure is applied to the incisions to control bleeding. This technique is used to treat non-saphenous varicose veins or residual varicose veins following saphenous ablation.
Transilluminated powered phlebectomy (TIPP) is a minimally invasive technique which uses an illuminator (light source) placed subcutaneously through a stab incision enhancing the visualization of the veins. Non-saphenous veins targeted for removal are suction aspirated with a separate device with rotating blade and suction port [80,81]. The only advantage identified with this device was the need for fewer incisions [82,83].
Perforator ligation - Endovenous perforator ablation and subfascial perforator ligation are preferred over a direct incisional technique.
Open perforator ligation is uncommonly used in the treatment of severe venous skin changes or ulcer because it necessitates placing an incision in a region of venous stasis. The surgical wound is often a source of secondary ulceration if perforator ligation is not successful in reducing venous pressures in the skin. (See "Liquid and foam sclerotherapy" above and see "Endovenous catheter ablation" above).
Subfascial endoscopic perforator vein ligation (SEPS) - Subfascial endoscopic perforator vein ligation is indicated for patients with refractory symptoms or ulceration, or recurrent ulceration associated with venous incompetence in patients who have failed minimally invasive approaches [37,84-87].
SEPS is performed through two ports each placed subfascially via skin incisions in a location away from areas of active skin change or ulceration [85]. Insufflation with carbon dioxide and balloon dissection of the subfascial space helps visualize calf perforators, which are divided (electrocautery, harmonic scalpel) or clipped.
A systematic review of 20 studies involving 1140 limbs in total, found overall ulcer healing in 88 percent of treated limbs, with a 13 percent recurrence rate at a mean of 21 months [86]. Risk factors for nonhealing and ulcer recurrence were similar and included the presence of postoperative incompetent perforators, larger ulcer size (>2 cm), and secondary venous insufficiency (eg, postthrombotic).
Patients with recurrent ulcers following SEPS should have a duplex scan and repeat SEPS if perforators persist. [87].
Postoperative care and complications — Postoperative pain is common and typically relieved with acetaminophen with codeine. Patients are encouraged to ambulate immediately after surgery. Bruising along the tract of the excised or stripped veins is common and can last for up to six weeks following surgery. Regardless of the surgical method used, the application of compression therapy in the form of elastic wraps (eg, Ace) or graduated compression stockings helps limit bruising and swelling (show table 3). (See "Medical management of lower extremity chronic venous disease", section on Compression stockings).
Time off work varies between one and three weeks depending upon the patient's job requirements and the magnitude of the operation.
The most common complications of vein ablation surgery are bruising and hematoma formation. The use of a tourniquet during surgery helps to limit blood loss [88]. Other complications include wound infection, hyperpigmentation, telangiectatic matting, phlebitis (superficial or deep) and saphenous nerve injury (frequency 10 percent) [89].
Post-surgical telangiectatic matting and hyperpigmentation typically improve over time, however, can be treated with surface laser therapy if persistent [90].
Efficacy of surgery — Surgical therapy is the standard to which the more minimally invasive techniques are compared.
Surgical intervention improves symptoms, and the overwhelming majority of patients are satisfied with their procedure. As an example, 150 symptomatic patients who underwent varicose vein surgery in Britain were found at six months after surgery to have significant improvements in pain, energy, physical function, and mental health compared with preoperative levels [18]. Symptoms resolved completely in 22 percent and most patients felt their surgery was successful (64 percent). Disease-specific and general quality of life improvements persisted for at least two years [91].
The traditional surgical technique is associated with vein recurrence rates of at least 20 percent [26] and is even higher if great saphenous ablation is not performed [89]. The cause of recurrences is not clear and may include surgical technique, development of new veins (neovascularization), or progression of the underlying disease. In randomized trials, ligation plus stripping was found to have lower recurrence rates than high ligation alone and is the preferred surgical technique for patients with saphenofemoral reflux and extensive great saphenous disease [78,92].
The cost-effectiveness of surgery for patients with severe varicose veins and reflux, compared to conservative management, was evaluated in a randomized trial of 250 patients [93]. Surgery provided improved outcomes (quality of life, symptomatic relief and anatomical extent) and was cost-effective at two years, with projected continued cost benefit at 10 years.
SUMMARY AND RECOMMENDATIONS
Varicose veins are palpable, dilated subcutaneous veins, due to genetic and environmental factors. They may be associated with aching, cramping, itching and fatigue, though are often asymptomatic. (See "Clinical evaluation" above).
Varicose veins may predispose to superficial thrombophlebitis and venous hemorrhage. Venous ulcers are associated with presence of venous incompetence. (See "Varicose vein complications" above).
The goals of treatment are improved symptoms and appearance. Initial treatment for varicose veins is conservative including leg elevation, exercise and graduated compression stockings. (See "Clinical management" above).
Symptomatic patients should be sent for duplex ultrasonography to assess the extent of venous involvement and the location and severity of any reflux. (See "Duplex ultrasound" above).
Patients found to have significant venous reflux, as well as patients who develop complications (including ulceration, hemorrhage, or recurrent superficial thrombophlebitis) should be referred to a vein specialist for further evaluation and management. (See "Clinical management" above).
Injection liquid sclerotherapy is typically reserved for patients with small varicose veins (less than 5 mm), without evidence of venous incompetence, and for residual or recurrent varicosities following surgery. Foam sclerotherapy is an alternate method available. (See "Liquid and foam sclerotherapy" above).
Endovenous ablation techniques (radiofrequency ablation and endovenous laser ablation) are highly successful in achieving vein closure and have high patient satisfaction rates. (See "Endovenous catheter ablation" above).
Traditional surgical techniques include ligation/stripping of the great or short saphenous vein, ambulatory phlebectomy, perforator ligation and SEPS. (See "Surgery" above and see "Endovenous catheter ablation" above).