Varicose veins are dilated, tortuous, elongated deformities of the superficial venous system that commonly affect the lower limbs. They are usually caused by degenerative changes in venous valves (primary) or obstruction from deep vein thrombosis (secondary). Risk factors include female sex, age, obesity, and family history. Clinically, varicose veins may be asymptomatic or cause symptoms like heaviness, itching, and swelling. Examinations like duplex ultrasound and air plethysmography can identify reflux and assess severity. Treatment options range from compression stockings and sclerotherapy to open surgery or minimally invasive procedures like radiofrequency or laser ablation to close off veins.

1. Varicose veins
Chea Chan Hooi
Surgeon
Department of Surgery
Sibu Hospital

2. Contents
• Introduction
• Definition
• Pathophysiology
• Predisposition
• Clinical features
• Classification
• Investigations
• Principles of management

3. Introduction
• Half of adult population
– 80% reticular veins
– 30 – 50% varicosities
– 10% chronic venous insufficiency skin changes
– 1% venous ulcer
• Very low priority for treatment & research

5. Definition
• Varicose vein – dilated, tortuous, elongated
deformity of superficial venous system of the
lower limb

6. Pathophysiology
• Primary (95%)
– Degenerative changes of valve annulus and
leaflets
• Secondary (5%)
– Obstructive (post DVT)

8. Predisposition
• Female
• Age
• Lower socio-economic status
• Obesity
• Hypertension
• Congestive heart failure
• Lower limb trauma
• History of deep venous thrombosis

9. Clinical features
• Symptoms
– Typical of venous pooling
• Asymptomatic at the beginning of the day
• Calf heaviness after prolonged standing
– Itchiness, swelling
– Superimposed infection
• Any known abdominal pathology
• History to suggest previous DVT/trauma
• Family history

10. Physical examination
• Abdominal mass
• Peripheral pulses
• Pattern of varicosities
– LSV / SSV
• Brodie-Trendelenburg test
– SFJ or perforators incompetence
• Tourniquet test
– Assess perforators incompetence
• Hand held continuous wave Doppler
– Reflux in the groin / popliteal fossa
• Complications
– Venous hypertension
– Bleeding

11. Additional examinations
• Modified Perthes test
– Without emptying the vein
– Tourniquet to SFJ
– Walk 5 minutes
– Cramping pain suggests underlying DVT
• Tapping test
– Without emptying the vein
– Tap at inferior aspect of varicosity, transmitted to
SFJ

12. • Pratt’s test
– To know the sites of leg perforators
– Esmarch elastic bandage applied to empty the vein
– Tourniquet at SFJ
– Remove Esmarch
– Then reapply from above
– At the positions of perforators, visible varices/blow
outs are seen
– The sites are marked

13. • Morriyssey’s cough impulse test
– Empty the vein by elevating the limb to 30o
passive elevation
– Place a finger at SFJ
– Ask the patient to cough forcibly
– Expansile impulse felt at the saphenous opening if
SFJ valve incompetent
– Bruit may be heard

14. • Fegan’s method of palpation
• Excessive bulges within the varicosities are
marked on standing
• Lie the patient down
• Elevate the limb to empty the veins
• Palpate along the line of marked bulges to find
out the pits/defects in the deep fascia which
transmits the incompetent perforators

15. • Homan’s sign
– Passive forceful dorsiflexion of foot produce calf
pain
– Pain & risk of embolism

16. CEAP Classification
• Clinical Signs
0 – No clinical signs
1 – Telengiectasia, Reticular veins, Maleolar flare
2 – Varicose veins
3 – Edema without skin changes
4 – Skin changes ascribed to venous disease
5 – Skin changes with healed ulcer
6 – Skin changes with active ulcer
Post script A (asymptomatic) or S (symptomatic)

17. • Etiology
C – congenital
P – primary
S – secondary
• Anatomy
AS – superficial
AD – deep
AP – perforators
• Pathology
R – reflux
O – obstruction
C – combination
e.g. C2A EP AS3 PR

18. Investigations
• Duplex scan
– All patients
– Gold standard
– Sensitivity
• 95 % for identifying SFJ and SPJ incompetence
• 40-60% for identifying incompetent perforators
• Ultrasonography abdomen
• Venography
• Air plethysmography
– Venous refilling time
• Ulcer swab C+S

19. Treatment modalities
• Conservative
– Graded compression stocking
– Medication – micronised flavonoids (only if ulcerate)
• Open surgery
– SFJ ligation, LSV stripping & multiple stab avulsions
• Endovenous surgery
– Energy
• RFA
• EV laser ablation
– Chemical
• Foam sclerotherapy

20. Graded compression stockings
• 20 – 30mmHg at ankle
• Below knee
• At all times upright
• Compliance is an issue

21. SFJL + LSVS

23. Endovenous surgeries
• Percutaneous placement of catheter into variosities to damage its
intimal layer
• Then compressed temporarily with compressive dressings to
obliterate its lumen
• Pros
– Under LA & tumescent
– Less morbidity, less pain
– Less wounds, SSI, scars
– Shorter hospital stay, earlier return to work
• Cons
– Only for less tortuous vein
– Not readily available (equipment & expertise)
– Technically demanding
– Expensive

24. Surgery RFA Laser Foam
1-year recurrence rate
(%)
4.8 4.8 5.8 16.3
Mean post
intervention pain
score (0 – 10)
2.25 1.21 2.58 1.6
Median time return to
normal function
(days)
4 1 2 1
Time off work (days) 4.3 2.9 3.6 2.9

26. Perforators surgery
• Open
• Endoscopic
– Subfascial endoscopic
perforator surgery
(SEPS)

27. Thank you.
Q&A?