A 48-year-old male was referred by his primary care physician (PCP) for evaluation of varicose veins (VV) in his right leg. The patient noted the varicosities in his twenties. Initially, he was not concerned with the cosmetic appearance and decided not to seek medical attention. The VV became progressively more prominent. He started to complain of right leg pain and fatigue associated with mild edema 6 months prior to referral. The pain increased during the day and was unbearable in the evening after work. The patient works as a barber and needs to stand most of the day. His past medicalhistoryissignificantforamotorvehicleaccident10yearsago.Heonlytakes NSAIDs occasionally to relieve his leg pain. The patient finally decided to seek medical attention. His primary care physician prescribed him compression stockings that he used for 3 months with minimal improvement.

Question 1

At this point, what other information would you like to obtain?

A.  What where the circumstances of the motor vehicle accident? B.  Does the patient have family history of VV?

C.  Was the diagnosis of deep vein thrombosis (DVT) entertained by the PCP and was there any duplex ultrasound (DU) performed?

D.  Was the patient compliant with the compression stocking, and did he wear the appropriate stocking?

The patient recalled the car accident. He was a front seat passenger and the car was hit on his side at a moderate speed. He remembers receiving a CT scan. The doctors told him his only injury was a rib fracture on the right side. He did not require hospitalization and was ambulating the same day. The patienthas two sisterswith VV thatwerefirstnoticedduring

C.I.N.O. Chaar ( )

General Surgery Department, Yale New Haven Hospital, New Haven, CT, USA

pregnancy but did not require surgical intervention. He denies receiving an ultrasound recently. He shows you the compression stockings which were fitted by the same company you routinely refer your patients to. He tells you:

I wear those socks as soon as I wake up in the morning and take them off before sleeping.

Question 2

Which statement(s) is/are true regarding VV?

A.  VV are extremely common and are present in 90% of the population. B.  Risk factors are age, female sex hormones, and hereditary.

C.  Most patients present because of leg pain.

D.  Venous ulcers typically occur over the metatarsal heads and other weight baring spots in the foot.

Question 3

Which of the following statement(s) is/are true regarding compression stockings?

A.  Stockings decrease venous reflux and leg swelling but increase veno-muscular efficiency. B.  Prescription of stockings is classified according to the pressure level required – Class 1

stockings exert the least sub-bandage pressure (14–21 mmHg).

C.  The classification of compression stockings is internationally standardized.

D.  The application of compression stockings is safe and has no reported complications. E.  The treatment of VV with compression stockings as first line modality is supported by

level 1 evidence.

You examine the patient and you notice significant dilatation along the antero-medial aspect of the right thigh and leg as shown in Fig. 47.1. There is no ulceration or pigmentation. The left leg is normal.

Question 4

How would you like to proceed with the evaluation? What information would you like to obtain?

A.  Hand held Doppler can help to assess reflux. B.  DU will provide most of the information needed. C.  Rule out the presence of a DVT.

D.  Assess saphenofemoral junction (SFJ) and sapheno-popliteal junction (SPJ) for reflux. E.  Look for incompetent perforators.

You obtain a DU that does not show evidence of DVT. There is reflux only at the SFJ without the presence of incompetent perforators.

Fig. 47.1  Patient’s right leg with VV upon presentation

Question 5

What treatment options can you offer to the patient?

A.  High Ligation and Stripping

B.  Endovenous laser therapy (EVLT)

C.  Endovenous radiofrequency ablation (RFA)

Initially the patient asks you to explain to him what would be the most conservative treatment modality. He has a conservative mentality and does not want to “try anything new.”

Question 6

The True statement(s) about high ligation and stripping is (are):

A.  High ligation without stripping predisposes patient to recurrence.

B.  High ligation and stripping of the small saphenous vein (SSV) is associated with a higher rate of complications as compared with high ligation alone.