How would you treat this patient?

A. There is no clear indication to offer any treatment.

B. Offer injection sclerotherapy.

C. Offer below-knee compression stockings.

D. Offer surgery.

The patient was advised that the "disease" progression is very slow. However, the varicosities are likely to "deteriorate" with age and therefore it is likely that some active measures would need to be taken. Patient compliance and some change in lifestyle, along with conservative measures such as compression stockings, seem to provide symptomatic relief in the majority of cases (often reducing the need for surgery).

The patient opted for surgical treatment, under general anaesthesia. On admission and after obtaining patient consent, the operating surgeon marked the position of the varicose veins, with an indelible ink pen, with her standing. The previous duplex ultrasound scan report was reviewed, with attention paid in particular to the position of the incompetent perforating vein and the saphenopopliteal junction.

An appropriate consent was obtained from the patient. On transfer to the operating theatre, the patient was placed prone. The skin was prepared with a nonalcoholic, iodine-based solution. Sterile drapes were placed as appropriate first, for exploration of the saphenopopliteal junction. A transverse incision was made above the popliteal skin crease, where the saphenopopliteal junction had been identified previously by the duplex ultrasound scan. The saphenopopliteal junction was identified formally, with the artery adjacent. The SSV was ligated and divided almost flush to the junction. A short segment of SSV was excised (although the SSV was not formally stripped). Multiple avulsions of the previously marked varicosities were performed (using an Oesch hook), through 1-2-mm skin incisions. After closure of wounds, the patient was placed supine, with the legs abducted and with head-down tilt (Trendelenburg position), to help reduce any intraoperative blood loss. The skin was re-prepared and new drapes were placed appropriately. A short, oblique incision was made in the groin crease, near to the saphenofemoral junction, and by careful dissection, the saphenofemoral junction was identified formally. Subsequently, all tributaries to the LSV were ligated (using absorbable sutures) and divided and in particular, the deep pudendal vein(s). Formal exposure of a small length of the femoral vein enabled ligation of a small tributary. Following this, the saphenofemoral junction was ligated almost flush to the femoral vein and the LSV divided. A disposable vein stripper was inserted intraluminally and advanced down the LSV, to just below the knee. A small skin incision (in Langer's lines) was made down onto the palpable tip of the stripper, to exit it. The LSV was stripped downwards. Varicose veins lower in the leg were avulsed via multiple, 1-2-mm skin incisions, using an Oesch hook. The Hunterian perforator noted and marked previously was ligated individually and subfascially through a small incision placed directly over it. The groin wound was closed (inclusive of a subcuticular suture) and Steri-Strips alone were applied to all the small stab incisions. A local anaesthetic agent was injected in the wounds to facilitate postoperative pain control. To finish and with all wounds closed, the whole leg was bandaged firmly, including the foot. Later, the bandage was exchanged for a full-length, class II graduated compression stocking that the patient was advised to wear for 6 weeks. The patient was reviewed 6 weeks postoperatively. All the wounds had healed and there were no residual varicosities.

The patient re-presented 5 years following the initial surgery with recurrent varicose veins in the same leg. She described symptoms similar to what she had prior to the initial operation, though to a lesser degree. The patient was concerned and requested treatment.

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