Chronic Venous Insufficiency, Varicose Vein and Management Options

Lower limb venous physiology and function

• The lower limb venous system overcomes gravity to return blood to the heart.
• Calf muscle pump and the vein-valve system accomplish this efficiently.
• Superficial veins function as principal collection system, dilating to accommodate large volumes of blood from tissue and skin before draining to the deep system for return to the heart.

The 2 major veins of the superficial system namely the Great Saphenous and Short Saphenous (GSV and SSV).

• GSV originates medially from the dorsal vein of the foot and continues proximally along the medial aspect of the calf and thigh before joining the deep vein at the sapheno-femoral junction.
• An anterior accessory is common in up to 14%
• SSV originates inferior and posterior to the lateral malleolus, ascends the posterior aspect of the calf between the gastrocnemius and heads to the popliteal fossa.
• In 60%, it drains into the deep popliteal vein at the sapheno-popliteal junction located within 5-7cm of the popliteal skin crease.
• In the remaining, the SSV may drain into other veins such as the GSV or have several termination points.

Chronic Venous Insufficiency (CVI) and Varicose veins (VV)

Primary venous disease occurs as a result of focal or diffuse structural weakening of the vein wall. The exact nature and cause are not completely understood. Valvular incompetence in the superficial veins can occur due to disruption by thrombotic events, be congenitally absent, atretic or dysfunctional over time.

Symptoms and complications from CVI may include:

• Lower extremity pain
• Swelling
• Heaviness after prolonged standing

Complications include:

• Superficial thrombophlebitis
  
• Acute bleeding in one of the thinned wall varices
• Eczema
  
• Skin ulceration
  

Varicose veins are defined as “subcutaneous” veins in the lower extremities dilated to >3mm in diameter in the upright position. More often their appearance may be alarming but they are benign and treatment is sometimes done for aesthetic reasons.

Venous Duplex ultrasound of standard study for evaluation. They map the superficial veins and identify the location and degrees of reflux.

Treatment depends on patient choice, severity and fitness. Options include:

• No treatment – not a life-threatening condition especially for varicose veins
• Conservative – trial of compression stockings

In patients who are considering or unsure about surgery, a trial of compression treatment can be employed. Recommendations include:

• (20-30mmHg) for C2- C4 disease of the CEAP classification
• (30-40mmHg) compression therapy with garment for C6 ulcer disease

Most chronic discomfort and skin changes can be ameliorated by judicious use of compression garments, skin care, lifestyle changes and topical dressings.

Surgery may be:

• Open – ligation and stripping of saphenous vein with multiple stab avulsions of varicose tributaries.
• Endo-venous – with or without multiple stab avulsions of varicose tributaries including energy devices such as Laser, Radiofrequency ablation, Microwave ablation and Chemical ablation or sealant with or without mechanical destruction such as Veneseal or Clarivein.
• Injection Sclerotherapy is — for small reticular “spider veins” (Aesthetic procedure).
  • Reticular veins are the thin walled blue vennules lying within the superficial compartments. They have diameter ranging from 1- 3mm.
  • Telangiectasia are dilated venule/ capillaries or arterioles measuring 0.1 to 1mm in diameter. Their color depends on the origin of the vessel.

When considering surgery, anatomy and general medical status are key. Endo-venous therapies are standard of care today. The obvious advantages include no incisions, no need for general anaesthesia, earlier return to work and higher likelihood of being performed as a day procedure. Nevertheless, there are instances where open surgery still proves advantageous. These include:

• Superficial saphenous tributaries
  When a superficial saphenous vein or tributary is closely adherent to the skin; be it an extra-fascial continuation of the main GSV, superficial branch or a separate anterior accessory or a true duplicate, the inability to provide a 1cm buffer zone between skin and vein with tumescent anaesthesia risk skin burns.
  
  Similarly, non-thermal techniques can result in inflammation and pigmentation issues when the vein is very superficial
• GSV dilatation or aneurysm greater than 2.5 – 3cm or along the GSV course are relative indications for open
• Chronic thrombophlebitis with formation of synechiae can prevent advancement of RFA catheter, laser sheath or glue catheter
• Excessive tortuosity likewise
• Acute clot with extension to the femoral junction

Treatment selection

Speak with your friendly vascular surgeon today to discuss treatment options.