Varicose Veins

Christopher R. Lattimer and George Geroulakos

A 67-year old man presented with left leg discomfort and gaiter itch which interfered with his retirement lifestyle. His symptoms were worse after prolonged standing and towards the end of the day. Below knee graduated compression stockings (GCS) provided him with some relief. He suffered with poliomyelitis at 12 years old which caused leg muscle wasting. Seven years previously he had his left great saphenous vein (GSV) stripped with multiple avulsions with removal of all varicosities. This alleviated similar symptoms but resulted in persistent ankle edema.

Question 1

Which of the following are recurrent varicose veins?

A.  Varicose veins emptying into a neovascularisation following crossectomy. B.  Residual veins after incomplete phlebectomy.

C.  Remaining varicosities after endovenous laser ablation. D.  Remaining varicosities after foam sclerotherapy.

E.  Primary short saphenous varicosities after a GSV strip.

The patient had already undergone surgical treatment for his varicose veins in the same leg so he has recurrences.

Question 2

Which investigation is the most useful in the management of recurrent varicose veins and why?

A.  CT Venography

B.  Venous Duplex

C.  Air plethysmography D.  Contrast venography

C.R. Lattimer ( )

Department of Vascular Surgery, Ealing Hospital NHS Trust, Middlesex, UK

A venous Duplex scan demonstrated a large varicosity 5 mm in diameter in the calf which was fed by an incompetent medial calf perforator. There was no communication with the below knee GSV remnant which was patent, only 1 mm in diameter and without reflux. All deep veins were patent and all without reflux.

Question 3

The treatment aims can best be described as:

A.  Prophylaxis against venous ulceration

B.  Normalisation of calf muscle pump function C.  Improvement on quality of life

D.  Improvement of cosmetic appearance E.  Removal of all duplex abnormalities

The patient was told that he had recurrent varicose veins and that his symptoms were typical. Treating them was therefore likely to improve matters. He was warned that he may require further injections to completely eradicate his varicose veins, and a DVT and PE risk of less than 1%. Varying degrees of phlebitis with pain, hyperpigmentation and induration were likely and reflected the treatment process.

Question 4

Why is foam better than liquid sclerotherapy?

A.  Through a transmural chemical injury to the vein wall.

B.  It causes thrombosis of the injected vein.

C.  It displaces venous blood.

D.  Through improved surface contact.

E.  Foam is compressible, liquids are not.

Question 5

What is the recommended maximum amount of foam that can be injected in a single treatment session?

A.  10 ml. B.  12 ml. C.  16 ml. D.  24 ml.

E.  The volume depends on the size of the varicose reservoir on ultrasound.

The patient was scanned by ultrasound whilst standing to confirm the extent of superficial venous reflux and determine a suitable site for cannulation. A medial calf perforator was identifiedandmarkedwithapen(Fig.48.1).Thepatientwasplacedsupineandadistalpart

Fig. 48.1  The varicosity distends as foam is injected up to the site of a perforator (marked)

Fig. 48.2  The treated varicosity is isolated between a partially applied stocking and direct digital pressure on the perforator

of the varicosity was cannulated with a 21 gauge butterfly needle and secured with tape. A high thigh GCS was partially applied over the foot and ankle and the leg was elevated to empty the veins. The leg was then injected with foam under ultrasound guidance. After 5 ml, syringe resistance increased and further injections were stopped. Digital pressure was applied over the perforator for 2 min and the patient remained resting for a further 10 min (Fig. 48.2). The rest of the stocking was applied and the waist attachment was secured.

Question 6

Which of the following methods may improve the efficacy of foam?

A.  Multiple small dose injections. B.  Type of gas used.

C.  Leg elevation. D.  Gas/liquid ratio.

E.  Elastic graded compression bandaging.

Foam was prepared in 6 ml aliquots by agitating 1.2 ml of 1% liquid sodium tetradecylsulphate (STD PharmaceuticalsTM) with 4.8 ml of air in separate syringes connected by a partially opened three way stopcock. The syringes were alternately depressed in rapid succession for several cycles immediately prior to injection.

Question 7

Suggest a possible cause for ankle swelling after long saphenous stripping and why this complication may be avoided by using foam for recurrences?

The ankle swelling could have been related to a DVT following the last operation but there was no evidence of this on the venous Duplex examination.

Question 8

Place the following complications and side effects of foam in ascending order of incidence?

A.  Headache

B.  Deep vein thrombosis

C.  Induration and skin discolouration/hyperpigmentation D.  Pulmonary embolism

E.  Visual disturbance

There were no side effects at the time of injection. At a 3 week follow up there was induration and mild hyperpigmentation along the course of the destroyed varicosity but no tenderness or concerns from the patient. His symptoms had all resolved and the ankle edema had disappeared.ThismayhavebeenrelatedtotheGCS.AroutinevenousDuplexscandemonstrated complete obliteration. The femoral, popliteal and deep calf veins were all patent.

48.1  Commentary

Ultrasound guided foam sclerotherapy (UGFS) has become an effective and safe treatment option for symptomatic recurrent varicose veins. A single sclerotherapy session is adequate in over half of patients. Over an 18 month period with repeated sessions, 87% of legs may achieve immediate elimination of all varicosities. Potential complications such as deep vein thrombosis or systemic side-effects are rare. The superficial nature of recurrenceshoweverpredisposetothrombophlebitisin8.2%ofpatientswithoutproximalreflux and up to 33% of those patients with reflux.1

Recurrent varicose veins following open surgery range from 20% to 80% between 5 and 20 years.2 A formal definition of recurrence is imprecise. The international consensus meeting defined recurrent varicose veins after surgery (REVAS) as the presence of varicose veins in a lower limb previously treated surgically for varices with or without adjuvant therapies. This definition is clinical and includes “true recurrences,” residual veins and varicose veins as a consequence of disease progression.2 [Q1: A, B, C, E] Foam sclerotherapy is now both a primary therapy as well as an adjuvant treatment and it is not clear

if it should be considered as an operation. Furthermore, several treatment sessions are often required to complete a treatment period which makes this definition grey between individual treatment sessions.

Venous duplex imaging should be considered mandatory in the investigation of recurrent varicose veins. It provides anatomy and quantifies reflux in varicosities and individual superficial and deep veins following a manual calf compression and release manoeuvre. It is also an essential tool in the classification of surgical recurrences.3,4 [Q2: B] CT Venography is rarely necessary but may be helpful in the diagnosis of unilateral limb swelling such as occult pelvic vein thrombosis or May Thurner Syndrome.5 Air plethysmography is a non-invasive investigation in the assessment of calf muscle pump function and global venous reflux. A rapid venous filling index (>2.5 ml/s) or large venous reservoir may help in the assessment in patients with complex symptoms and concomitant pathologies.6 A diminished ejection fraction would suggest weakness of the calf muscle. Contrast venography is the most invasive of all the tests and useful for the assessment of the deep venous system in patients with malformations such as Klippel-Trenaunay syndrome7 or deep venous obstruction prior to stent insertion.

The aim of any individual treatment should be to improve the quality of life during the everyday activities of a patient. The treatment of recurrent varicose veins is no exception. [Q3: C] Both generic and venous disease specific assessments are complimentary and advocated as a reporting standard.8 Patient satisfaction depends on the success of treating the presenting complaint in parallel with the patients expectations and the potential sideeffects or complications of any proposed treatment. The Aberdeen Questionnaire has been validated as a measurement of disease specific health outcome in patients with varicose veins and is scored from 0 to 100.9

The mechanism of action of foam is through a chemical injury to the vein endothelium resulting in a chemical phlebitis. The injury is endothelial but the inflammation is transmural. External compression with a GCS is required to prevent luminal thrombosis and subsequent thrombothlebitis. Foam is far more effective that liquids because of the increased surface area provided by the micro bubbles which make contact with the venous endothelium. Foam also has the property of displacing any remaining blood within its path as it is being injected. Furthermore, the compressible nature of foam hampers its progression within the circulation. [Q4: C, D, E]

Current European safety recommendations limit foam administration to 10 ml.10 [Q5: A]This is 2 ml less than the recommended maximum in 2004.11 Despite this advice, serious complications can still occur after an injection of only 10 ml as illustrated in a 52 year old woman with a patent foramen ovale who suffered a TIA for 30 min.12 When the volume of injected foam becomes excessive, strokes are possible.13

Foam is prepared using the three way tap technique described by Tessari.14 A vigorous movement is required over a partially occluded tap to ensure maximal agitation of liquid and gas. The foam should be used immediately before the micro bubbles have a chance of uniting and enlarging. The sclerosant is usually polidocanol or sodium tetradecylsulphate which are both detergents and come in concentrations from 1% to 3%. With larger caliber and relatively straight veins a catheter is advised to facilitate foam delivery because there is a diminished risk of intra-arterial injection and extravasation.15 There is evidence that thephysiologicalgascarbondioxideissaferthanairwithareductioninoverall­side-effects