Superficial Venous Insufficiency: Varicose Veins and Venous

Ulcers
Jonathan Fong, MBBS, BMedSci, PGDipSurgAnat; Iman Bayat, MBBS, MRCS,
FRACS(Vasc); Jason Chuen, MBBS, PGDipSurgAnat, FRACS(Vasc) | June 4, 2015
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Superficial venous disease broadly falls into two categories: superficial venous
insufficiency/reflux (eg, varicose veins [shown], chronic venous insufficiency) and thrombosis
(eg, superficial thrombophlebitis, deep venous thrombosis [DVT]). These conditions encompass
a wide range of symptoms/signs and presentations. In more than 50% of the general population,
superficial venous disease appears in the form of "spider" or reticular veins, but in approximately
20%-25% of the population, the disease can progress to visible varicosities at its extremes, such
as ulceration or skin changes.[1,2]
This slideshow will focus primarily on superficial venous insufficiency.
Image courtesy of Jonathan Fong, MBBS, BMedSci, PGDipSurgAnat.

Calf-Pump System
The venous supply to the leg is via a deep and superficial low-pressure system. The flow of
blood is from the peripheries toward the heart, maintained by the calf-pump system. Within the
veins, there is a system of valves that helps overcome the pull of gravity and maintains a
unidirectional flow of blood (shown). When these valves become incompetent, retrograde flow
of blood predominates and leads to venous hypertension, resulting in the changes seen with
superficial venous disease.
Image courtesy of OpenStax College. Blood flow, blood pressure, and resistance. OpenStax
CNX. June 19, 2013. [Open source.] Available at: http://cnx.org/contents/03841c4c-9e9a-482295b2-12273c843a4e@3. Accessed May 27, 2015.

Clinical Classification
The CEAP (clinical, etiologic, anatomic, pathophysiologic) criteria are used to aid classification
of chronic venous disease, particularly in clinical studies and trials; thus, they help clinicians to
stratify and communicate the severity of venous disease.[4] Typically, only the clinical portion
(shown) of the CEAP classification system is fully utilized.[3]
Table courtesy of the authors.

Superficial Venous Insufficiency

Much about the etiology of varicose veins remains unknown. These manifestations are seen more
commonly in developed countries and in women, and they are strongly associated with family
history, increasing age, pregnancy, and DVT. Weak associations include obesity and some rare
genetic abnormalities.[4]
Although few studies document the natural history of varicose veins (shown), superficial venous
insufficiency is considered to be progressive over time, typically beginning as reticular veins or
corona phlebectatica ("corona"), developing into isolated calf varicosities and, eventually,
resulting in a tortuous and distended great saphenous vein.[5]
Reticular veins are typically small (1-3 mm), highly visible, and often pose a cosmetic problem
for patients. Varicose veins are superficial and dilated; they are typically found in the calf but
may also occur in the thigh, corresponding to the course of the long saphenous vein.
Incompetence of the perforator and short saphenous veins can result in posterior calf varicosities.
Image courtesy of Wikimedia Commons/Lakeland1999.

Left untreated, superficial venous insufficiency can lead to the development of skin changes
(shown) and, eventually, ulceration. The rate of progression and risk factors for developing
chronic venous changes are still unknown.[6] Symptoms can include heaviness, swelling, aching,
cramps, and itching.[7] Venous hypertension can subsequently develop due to excessive edema
overwhelming the lymphatic system.
Venous eczema, hemosiderin staining, and lipodermatosclerosis are consequences of chronic
venous stasis. Hemosiderin staining occurs from extravasation of red blood cells, causing a
pigmented appearance to the limbs. Lipodermatosclerosis gives the affected limb a classic
"inverted champagne bottle" appearance; this is thought to be caused by extravasation of
fibrinogen or white blood cells into the dermal tissue due to capillary hypertension, thereby
resulting in chronic inflammation and fibrosis of the subcutaneous tissue.[8]
Image courtesy of Medscape.

Venous insufficiency is the most common underlying etiology of chronic ulcers (shown) (range,
54%-75% in some observational studies).[9] Other conditions that should be considered in the
differential diagnosis as a cause of such ulcers include arterial insufficiency, mixed venous and
arterial disease, and vasculitic processes.
Venous ulcers take longer to heal, are often recurrent, and occur more frequently in older
patients.[10] The Bonn Vein Study found a prevalence of 0.6% of healed and 0.1% of active
venous ulcers in those younger than 79 years. These ulcers frequently affect the medial "gaiter"
region but can also occur on the lateral aspect or the dorsum of the foot.[11] Venous ulcers rarely
occur de novo but often manifest secondary to triggers such as cellulitis, injury, dermatitis, and
rapid development of edema.[12]
Image courtesy of Jonathan Fong, MBBS, BMedSci, PGDipSurgAnat.

Imaging Studies
Duplex ultrasonography (shown) remains the gold standard for investigation of venous disease.
This imaging modality allows assessment of the pattern of reflux and whether there is
saphenofemoral junction incompetence, incompetent perforating veins, or anatomic variants.
Venography via computed tomography (CT) scanning or magnetic resonance imaging (MRI) is
most useful for identifying ovarian or pelvic vein incompetence. Catheter-directed venography is
typically reserved for direct evaluation of anatomic variations such as May-Thurner syndrome, in
which the left common iliac vein is compressed by the right common iliac artery.
The longitudinal duplex ultrasonogram of the saphenofemoral junction is shown during the
positioning of the tip of a laser fiber during an endovenous laser ablation (EVLA). The laser tip
(arrow) is in the great saphenous vein (GSV) just beyond the superficial epigastric vein (SEV)
origin. FV = femoral vein.
Image courtesy of Medscape/Steven E Zimmet, MD, FACPH.

Ligation of Varicose Veins

Since it was first described in 1890, ligation of the great saphenous vein has been used to treat
varicose veins to good effect. The saphenofemoral junction, where the great saphenous vein
enters the femoral vein through the cribriform fascia, is identified through a transverse incision
(1). The junction and the surrounding tributaries are ligated (2). Typically, the great saphenous
vein is then stripped to reduce the risk of recurrence (3).[13] Depending on the surgeon's
preference, the vein can be stripped to the knee or the ankle; however, the risk of injury to the
saphenous nerve is higher with the more distal strip.[14] If saphenopopliteal junction incompetence
is present, the short saphenous vein can also be ligated. Then, calf varicosities are removed by
stab avulsions (ambulatory phlebotomy) (4).
The procedure is typically done as a day surgery, under general or spinal anesthesia;
postoperatively, the patient is encouraged to be mobile immediately. The leg is also compressed
with bandages for 7-10 days to reduce the risk of bruising; once these compression bandages are
removed, they are typically replaced by compression stockings (5).[15]
Image courtesy of Jonathan Fong, MBBS, BMedSci, PGDipSurgAnat.

Complications of open surgery traditionally include bleeding, DVT, nerve injury, and recurrence.
Bruising along the route of the vein strip is common, but bleeding that requires intervention is
exceedingly rare. DVT is an uncommon (0.5%- 5.3% in the literature) but concerning
complication.
The saphenous nerve in the calf, the sural nerve behind the knee, and the peroneal nerve at the
fibular head are all at risk of injury during stripping, ligation, and avulsion; sensory loss occurs if
these nerves are injured. Although recurrence rates vary between 5% and 25% at 5 years and up
to 80% at 20 years, patients have reported a high satisfaction rate (92%) on review at 5 years.[16,17]
Image courtesy of the authors.

Endovenous Ablation
An alternative to traditional surgery is the minimally invasive approach offered by endovenous
ablation. Endovenous ablation can be performed in the outpatient setting using the technique of
"tumescent anesthesia," in which local anesthetic is injected around the vein to allow treatment.
In ideal veinswhich are straight, broad (>3 mm), and deep (>1 cm from skin)an ablation
catheter is inserted under ultrasonographic guidance (1). Thereafter, either a laser or a
radiofrequency catheter delivers thermal energy to the intima to ablate the vein (2,3).
The advantages of this procedure lie in avoiding the use of general anesthesia and in reducing the
rates of bruising, bleeding, and nerve injury. Endovenous ablation can therefore promote an
earlier return to work for patients.[18] However, this technique can also cause skin burns and DVT,
known as endovenous heat-induced thrombosis, with an incidence below 1%.
Image courtesy of the authors.

Instead of thermal ablation, chemical ablation can also be used to obliterate the varicose vein.
Foam sclerotherapy, initially devised to treat small reticular veins, can now be used to sclerose
incompetent great saphenous veins with only a slightly lower efficacy than traditional surgery,
according to a meta-analysis.[19]
The procedure is performed on an outpatient basis under local anesthesia; often, multiple
sessions are required to achieve a full result. A chemical agent is selected and produced into a
foam, which is then injected under ultrasonographic guidance into the varicose vein (1). The
sclerosing agent forms a hard lump as it takes effect, and it is usually compressed with bandaging
or with a stocking (2,3).[20-22] Patients recover rapidly following the procedure.
Common complications include skin pigmentation and thrombophlebitis, but chemical ablation
rarely causes DVT or pulmonary embolism (PE) (0.19%-0.7%).[20-22]
Image courtesy of the authors.

Compression Stockings
Compression stockings (shown) have long been the mainstay of nonoperative management for
varicose veins. However, there is a lack of good evidence to show their efficacy, and patient
compliance is a significant hurdle, as many find the stockings to be itchy, hot, and difficult to put
on and take off.
Although a number of studies outline the potential of pharmacotherapy in reducing symptoms,
particularly the use of horse chestnut extract, thus far, the benefit of such treatment has been
shown to be limited.
Image courtesy of Wikimedia Commons/Frank C. Mller.

Considerations in Treatment Selection

When selecting the appropriate treatment for patients with superficial venous disease, many
factors must be taken into account. The severity and extent of the venous disease, the anatomy of
the varicosities, the presence of ulceration (shown) and/or comorbid conditions, the type(s) of
previously administered treatments, as well as the aim of treatmentcosmetic or symptom
managementmust be elicited via a thorough history and physical examination.
The availability of therapeutic options and the expertise of the treating surgeon also have roles in
the decision-making process. For example, EVLA and radiofrequency ablation (RFA) treatments
are more financially costly than traditional surgery because they often require a heavier
investment in instruments. Another factor that patients should be made aware of is that surgery
for varicose veins can result in bruising and short-term pain but, most importantly, recurrence is
common. Moreover, although the bulk of the varicosities is removed, residual small veins are
often left behind and may require further intervention.
Image courtesy of Jonathan Fong, MBBS, BMedSci, PGDipSurgAnat.

A number of systematic reviews and meta-analyses have compared the three main procedures for
the treatment of varicose veins (ie, open surgery, endovenous ablation, foam sclerotherapy).
Note, however, that the results of these analyses must be considered against the heterogeneity in
the methodology of the randomized controlled trials used in the analyses.
Open varicose vein surgery is still considered the gold standard to which other treatments are
compared. A Cochrane review found little difference between treatments in terms of the risk of
early clinical recurrence (shown) or recanalization of the great saphenous vein on the basis of
early duplex sonograms.[19] EVLA and RFA typically cost more, but they have the benefit of
reduced rates of wound infections and hematoma, as well as an earlier return to work.[23]
Although the Cochrane review showed equal effectiveness with sclerotherapy,[19] other studies
have reported that, at 5-year follow-up, those who underwent surgery were more likely to remain
recurrence free.[24]
Table courtesy of Jonathan Fong, MBBS, BMedSci, PGDipSurgAnat. Data from Nesbitt et al.[19]

Venous Ulcers
Venous leg ulceration is a common yet difficult condition to treat, particularly in the elderly.
Management of these ulcers is costly. The treatment objectives are twofold: to create an
environment for healing of the ulcer and to prevent recurrences.
First-line management is always to address the presence of sepsis through debridement,
antibiotics, and bed rest. Often, consideration must be made to improve the patient's overall
medical condition, including administration of adequate and appropriate nutrition and patient
cessation of smoking, and management of cardiac failure, diabetes, and/or peripheral edema. If
the ulcer has a good chance of healing, skin grafts or local flaps can be used to cover the defects
(shown).
Image courtesy of the authors.

Compression therapy has also been the mainstay of preventing recurrence of venous ulcers.
However, there is evidence that, in the presence of great saphenous vein or small saphenous vein
incompetence, surgical intervention is associated with improved rates of healing as well as lower
recurrence as compared to compression therapy alone.[25] In terms of outcomes, there does not
appear to be any difference on the basis of the type of surgery performed (ie, open, endovenous,
and sclerotherapy).
Image of chronic medial leg ulceration associated with long-standing venous insufficiency
courtesy of Medscape.
http://reference.medscape.com/features/slideshow/superficial-venousinsufficiency#page=16