Elsevier

Surgery (Oxford)

Volume 40, Issue 7, July 2022, Pages 411-419
Surgery (Oxford)

Vascular Surgery – II
Varicose veins

https://doi.org/10.1016/j.mpsur.2022.05.010Get rights and content

Abstract

Varicose veins are common and have a negative impact on people's quality of life. Treatment has been shown to improve the quality of life in those affected and is endorsed by international clinical practice guidelines. In the UK, traditional techniques of saphenofemoral and saphenopopliteal junctional ligation with or without stripping have been largely superseded by minimally invasive day surgery techniques under local anaesthesia. The most performed procedures include radiofrequency ablation and endovenous laser ablation, both of which may be associated with procedural discomfort and complications relating to the use of thermal energy. More recently, novel techniques, including mechanochemical ablation and cyanoacrylate glue, have entered the clinical arena with promising results. However, newer complications are also emerging (especially for cyanoacrylate). Saphenous sparing techniques also exist, selectively disconnecting refluxing points between the superficial and deep venous systems (CHIVA) or by removing incompetent tributaries via selective phlebectomy (ASVAL). This article discusses the epidemiology, diagnosis, and management of varicose veins, including the latest endovascular and targeted open surgical techniques.

Section snippets

Definition

Varicose veins are generally described as tortuous dilated superficial veins, with a diameter of greater than 3 mm. They affect mostly the lower limb and are considered manifestations of chronic venous disease (CVD). The latter is an all-encompassing term describing a range of signs and symptoms associated with a poorly functioning superficial and/or deep venous system. Along with causing significant clinical burden, varicose veins negatively impact the quality of life and function of patients,

Epidemiology

Epidemiological studies have shown that CVD is extremely common, with similar incidences throughout the world; spider veins (fine, dilated intradermal venules approximately 1 mm in diameter (Figure 1a) affect up to 80% of the population1 and the reported incidence of varicose veins is variable, ranging from 20% to 64%. More severe presentations of CVD include skin changes, such as lipodermatosclerosis or haemosiderin deposition (Figure 1b), and venous ulceration, which affects 1%–2 % of the

Pathophysiology

Varicose veins occur because of impairment of venous return associated with reflux, obstruction, or calf muscle-pump failure. The exact underlying pathophysiology of the condition is unclear and different theories exist to explain this. The descending theory describes valvular failure as the initiating event, resulting in an increase in venous pressures (venous hypertension) in the truncal vein, with resulting vein wall dilatation and varicosity formation. However, truncal reflux may be present

Diagnosis

Patients with varicose veins present with symptoms, including pain, heaviness, swelling, aching, restless legs, cramps and itching. These correlate well with disease severity1 and tend to be worse towards the end of the day. Leg elevation helps reduce the associated swelling, whilst walking significantly improves the symptoms, due to calf-pump action reducing venous pressure.

Assessment of the arterial, neurological and musculoskeletal systems may be relevant to rule out differential diagnoses

CEAP Classification

The CEAP (Clinical, Etiology, Anatomy, Pathophysiology) classification was developed in 1994 to describe the clinical presentation and aetiology of lower-limb venous disease.6 The adoption of this system has allowed a standardized approach, enabling correlation between different studies and units (Box 1). This classification is descriptive in nature and should not be used as an outcome measure following treatment, as it is rather static (e.g. a patient with skin changes will still be a CEAP

Imaging

The gold-standard imaging technique is colour duplex ultrasound. This non-invasive, dynamic imaging modality allows both anatomical and haemodynamic assessment of the deep and superficial venous systems, indicating the level and nature of incompetence. Guidelines of the Society for Vascular Surgery (SVS) and the American Venous Forum (AVF), the European Society of Vascular and Endovascular Surgery (ESVS) and the National Institute for Health and Care Excellence (NICE) recommend that patients

Referral to secondary care

NICE guidelines recommend referral of patients with symptomatic primary (or recurrent) varicose veins, skin changes, superficial venous thrombosis, and venous leg ulceration. These criteria recognize the significant impact of varicose vein disease on quality of life and are less restrictive than those provided by previous recommendations. Although associated with an increase in referrals,9 access to secondary care is still an issue for many patients, particularly those with venous leg

Open surgery

Open surgery has been performed for varicose veins since the late 1800s, when Friedrich von Trendelenburg performed a mid-thigh open ligation of the GSV in a patient with an incompetent SFJ. Recent advances in minimally invasive surgery have led to endovenous ablation becoming the treatment of choice, with the proportion of open surgery performed dropping from 83% in 2006 to under 25% in 2015. Surgery for varicose veins can be performed under general, local or regional anaesthesia and should be

Compression hosiery

Compression has been used to treat venous disease since biblical times and reported in the literature since the 1950s; it works by applying graded external pressure to the skin (greatest at the ankle and reducing at the calf and thigh) and the superficial venous system, reducing the venous reservoir in the dilated veins. Compression also increases venous flow in the lower limbs, reducing venous stasis and reflux. This reduction in pressure permits improved capillary pressure differentials and

Sclerotherapy

The practice of sclerotherapy involves injecting a small volume of sclerosant into a vein and applying compression, resulting in occlusive fibrosis without clot formation. There are three kinds of sclerosants: chemical irritants (chromated glycerine); osmotic (hypertonic saline); and detergent [sodium tetradecyl sulphate (STS) and polidocanol (POL)]

In the UK STS (1%–3%) and POL (0.5%–3%) are more widely used, particularly for small reticular or spider veins. Sclerotherapy was initially used in

Endothermal ablation

The use of catheter-based methods as described below has converted venous intervention from the operating theatre to the treatment room, from general anaesthetic to local anaesthetic and has hugely improved access to treatment.

Steam therapy (steam varicose System™)

In endovenous steam ablation (EVSA) a catheter delivering pulsated steam reaching temperatures of 120°C causes endothelial destruction and fibrosis. A pilot study revealed a 65% occlusion rate at 6 months, with the remaining 35% showing small-segment recanalization that was not clinically relevant. A subsequent study of 20 patients with GSV incompetence demonstrated occlusion rates of 96% at 6-month follow-up, with most patients returning to normal activity within 3 days. A 2014 randomized

Mechano-chemical endovenous ablation

Mechano-chemical endovenous ablation (MOCA), delivered by the ClariVein® device (Vascular Insights, Madison, CT, USA), is a hybrid system composed of a rotating tip with simultaneous injection of liquid sclerosant. It does not use thermal energy, thus obviating the need for tumescent anaesthesia. The procedure is performed under local anaesthetic with percutaneous puncture under ultrasound guidance. The basic principles are as for endovenous ablation, with venous cannulation via a percutaneous

Cyanoacrylate glue ablation

There are currently two cyanoacrylate glue (CAE) techniques, the VenaSeal Closure System (Medtronic, Minnesota) and the VariClose system (Biolas, Ankara, Turkey). The two systems differ in the methodology of ablation and the polymerization rates of the glue needing a segmental pull back (VenaSeal) and constant pull back technique (VariClose).

The multicentre European Sapheon Closure System Observational ProspectivE (eSCOPE) study delivering VenaSeal for GSV treatment revealed 6- and 12-month

Superficial vein thrombosis

Superficial vein thrombosis (SVT – previously called superficial venous thrombophlebitis) describes a pathological inflammatory and thrombotic process in a superficial vein. This is characterized by pain, erythema and tenderness over the affected vessel, and can be the primary presentation of varicose vein disease; importantly, it may also be associated with immobilization, trauma, active malignancy, autoimmune disease and a history of venous thromboembolism (VTE). Patients with SVT are at

Varicose vein related bleeding

Large, prominent varicosities may be prone to bleeding, either spontaneously or as a result of trauma. This is an indication for urgent treatment as they are associated with rare fatal haemorrhage.

Over the last two decades, major advances have been made in the treatment of varicose veins, with a shift from open techniques towards minimally invasive outpatient procedures. An ideal treatment for varicose veins should be effective, cheap, safe, performed in day surgery, with low recurrence rates

Conclusion

Varicose veins are a common condition, and their management is constantly evolving with the introduction of endovenous ablation methods. Endovenous ablation also offers improvement in the quality of life of patients, the possibility of day-case interventions and more rapid return to normal activities. Long-term data demonstrate that endovenous ablation may have reduced technical recurrence rates and that endothermal methods are more likely to be cost-effective. The non-thermal methods are

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