Fig. 10.1.1a-c Different types of varices. a Stem varicosis of greater saphenous vein. b Reticular varices in the area of the popliteal fossa, with pigmentation. c Telangiectasia due to venous stasis, agenesia of valves, deep venous thrombosis (post-thrombotic syndrome) or progressive primary varicosis.
• The most common cause is varicose disease.
• Varicose veins are dilated, tortuous and superficial veins occurring mainly in the lower limb area. Three types exist (Fig. 10.1.1):
• dilated saphenous (stem) veins
• reticular varices (dilated tributaries of saphenous veins)
• dilated venules (telangiectasia).
• Based on their pathogenesis, varicose veins are divided into primary varices, which are more common (95%), and secondary varices, which develop as collateral pathways and essentially as a result of deep venous thrombosis [14,16, 25].
• More than 50% of patients with diagnosed post-thrombotic syndrome have no knowledge of previous deep venous thrombosis, for it often remains clinically silent.
• Therefore, the pathogenetic centre of CVI is valve dysfunction with permanent venous hypertension of subcutaneous tissue and skin.
• Subsequently, typical lesions form.
• The disease develops in stages over the years with the following factors worsening its course as in a vicious circle:
• Eczematoid changes of skin and subcutaneous tissue (more than 50% of patients)
• Recurrent deep venous thrombosis (about 20% of patients)
• Primary and secondary varicosis.
• The prevalence of CVI is 15% of the general population.
• Females are affected three times as much as men [1,9, 16,18, 22, 25].
• Based on insufficient perforating veins and valve incompetence ofthe deep venous system, blood does not flow unidirectionally to the heart, but moves between the deep and superficial venous systems in a pendular way (pendular blood, private circulation).
• This leads to the so-called crash syndrome: inward and outward flowing blood collides in the perforating veins. Erythrocytes are thus damaged mechanically with subsequent deposit of haemosiderin in the skin (hyperpigmentation) [5, 6,10,14].
• Lower leg ulcerations and eczematoid dermatitis may develop.
• Eventually, the chronic volume overload creates rigidity of the vein wall.
• Venous tone can no longer be regulated.
right ventricular failure, renal dysfunction, local trauma) have to be excluded.
• Swelling without simultaneous varicosity can be a sign of acute or chronic deep venous thrombosis.
• On the other hand, acute thrombosis of the iliofemo-ral and calf veins is closely related to pulmonary embolism, which is often lethal. Therefore, if suspected, Duplex ultrasonography or ascending venography is needed.
• This is true as well if other risk factors exist, such as an incidence of thrombosis in the family, coagulation disorder and immobility (e.g. long-distance flights or economy-class syndrome) [1,14, 21].
• Signs of CVI may be present in the form of hyper- or depigmentation of the skin, eczematoid dermatitis and ulcerations, most common at the medial side of the lower leg, resulting from progressive varicosity or deep venous thrombosis.
• Long-term venous hypertension with secondary dysfunction of the deep venous system is mainly responsible for the severity of skin changes [9,14,16,18, 25].
• The typical changes of the skin and veins can be subdivided into three stages, often overlapping:
• Stage I has been referred to as corona phlebectatica paraplantaris (Figs. 10.1.2, 10.1.3) - the dilatation of venules at the side aspect of the foot as well as stasis oedema at the end of day, particularly in warm temperatures.
• A typical early symptom of post-thrombotic syndrome and CVI is a tendency for the lower extremity to swell.
• Leg ulcer is a leading sign of full extent of the disease .
• In the case of primary varicosis, unilateral stasis-oedema, generally appearing at the end of the day, may occur prior to the development of varicose veins.
• Aching heaviness is associated with it.
• At the early stage of CVI, considering differential diagnostic aspects, other disorders causing oedema (e.g.
Fig. 10.1.2 Corona phlebectatica as an early symptom of chronic venous insufficiency (CVI)
Fig. 10.1.2 Corona phlebectatica as an early symptom of chronic venous insufficiency (CVI)
Stage II is characterized by stasis eczema. Based on the oedema, the skin tends to allergic reaction (ec-zematoid dermatosis) and hyper- or depigmenta-tion up to the development of atrophie blanche [14, 16, 25].
Florid and healed cutaneous ulceration represent stage III of CVI (Fig. 10.1.4).
Fig. 10.1.4a,b Swelling as a sign of CVI, healed ulceration. Pigmentation of the skin, atrophie blanche and central ulceration at the stage of progressive CVI
Cramp-like pain may also be a manifestation of CVI, aggravated by prolonged standing and similar to a muscle ache.
By elevating the legs, the pain can be decreased. This is typical of CVI [1,9,14,16,18,21].
• The most common location of spontaneous haemorrhage of varices is the medial aspect of the ankle.
• External haemorrhage is a frequent indication for varicose vein treatment [16, 25].
Fig. 10.1.5a,b Classification of truncal varicosity as described by Hach. a Different stages - stage I: saphenofemoral incompetence; stage II: varicosity of greater saphenous vein between groin and upper calf; stage III: varicose veins from saphenofemoral junction to proximal lower extremity; stage IV: varicosity of entire great saphenous vein. b Distal termination of incompetence below knee (stage III)
Recommended European Standard
Diagnostic Steps of Investigation
• In all patients with varicosity, the extent of the damage to superficial and deep veins has to be determined.
• Classification of truncal varicosis of the greater saphenous vein according to Hach depicts the different categories ofvalve dysfunction (Fig. 10.1.5) [9,10].
• Today, traditional functional tests (Perthes' test, Trendelenburg test) are seldom used.
• In addition to thorough clinical examination, diagnostic modalities such as Doppler ultrasonography (Fig. 10.1.6b), Duplex scanning in particular (Figs. 10.1.6a,
Fig. 10.1.6a,b Ultrasonography for determination of competent and incompetent venous segments. a Duplex scanning with visible reflux into the greater saphenous vein during a Valsalva manoeuvre. b Determination of distal location of insufficiency with Doppler ultrasonography
10.1.7), and, in critical cases, ascending venography can be performed to assess venous dysfunction .
• Because of its reliability, use of Duplex scanning in combination with a functional haemodynamic measurement technique is accepted as the preoperative standard diagnostic procedure.
• The technique permits anatomical examination as well as assessment of the haemodynamic status of the veins [1,11,21].
• If determination of the patency of venous drainage and differentiation between incompetent and healthy venous segments by Duplex scanning is not sufficient, ascending venography has to be performed.
• This invasive method may cause complications [9, 10, 21,25].
• Phlebodynamometry. Peripheral phlebodynamom-etry is a highly sensitive method of assessing venous disorders. It enables statements to be made concerning prognosis - including those for legal and insurance purposes - and also the disease progression to be monitored. By using this technique, peripheral venous pressure in the unbandaged and bandaged limb is measured. An indication for surgery on incompetent epifascial veins is given when the measurement curve improves after tight dressing with elastic bandages [5, 14,16,18].
• Photoplethysmography. Nowadays the invasive method of phlebodynamometry has been virtually su perseded by photoplethysmography. Measurement of reflecting light documents the speed of venous refill in the foot .
Conservative Therapy of CVI
• Indispensable in the therapy of chronic venous insufficiency is external compression of the limb.
• Nonsurgical treatment is based on sufficient compression to prevent oedema and on acceleration of the venous blood flow by using compression stockings of strength type II.
• After lower limb ulcerations have healed, type III stockings are necessary.
• Compression is especially important in the periulcer-ous area, when ulcus cruris is present [22, 25].
Conservative Treatment of Varicose Veins
• If the greater and lesser saphenous veins are not affected by a varicose condition, conventional sclerotherapy can be performed.
• Today, sclerotherapy with its modification by using foam maybe an alternative to operative treatment.
• The method gives better results than the conventional treatment of injection of highly concentrated saline solutions or aethoxysclerol, because under control of Duplex scanning the foam can be applied close to the saphenofemoral or saphenopopliteal junction.
• This way obliteration of the greater and lesser saphenous veins and side branches is possible.
• It should be pointed out that reflux into the stem veins may cause recurrent varicosity [8,16,18].
Application of Drugs
• If risk factors for recurrent thrombosis exist, life-long anticoagulation therapy is indicated.
• The application of agents influencing venous tone or reducing oedema (flavonoids, chestnut seed extracts) does not correct the underlying cause [1,18, 21, 25].
• If removal of varicose veins is possible, healing of ulcerations is significantly accelerated.
• This includes dissection of venae perforantes, nowadays primarily done endoscopically to avoid traumatizing the skin already affected by trophical lesions.
• If CVI is based on isolated obliteration of the iliac vein, venous by-pass procedures may be indicated.
• In incompetence of the deep venous system, the method of transposition of valves may be useful to prevent lower limb ulceration [1, 2,11,13, 21].
Surgical Treatment of Varicose Veins
• Removal of varicose veins is one of the most common surgical procedures and can be performed in day-case surgery [1, 3, 6, 20, 21, 24-26].
• The intention is to completely remove veins with incompetent valves in order to prevent long-term damage such as leg ulceration.
• Depending on the time of the surgery, secondary changes such as swelling, thrombophlebitis or ulceration may regress.
• In general, skin pigmentation remains.
• There is differentiation between carriers of asymptomatic varices and patients actually suffering from varicose disease.
• The first group has no subjective complaints except for occasional heaviness of the legs (relative indication for surgery). The other develops complications up to chronic venous insufficiency (absolute indication for surgical treatment).
• In primary varicosity, surgical therapy is indicated for saphenous, perforating and branch vein varicosis [16,18,21].
• The decision on surgical treatment of secondary varicosities has to be made carefully! Sufficient blood flow from the lower extremities to the heart has to be ensured after surgery. Preoperative use of high-compression bandages over a period of several weeks simulates removal of varices. If the patients experience improvement of symptoms, surgical intervention is justified [16,18, 25].
• Surgical treatment is indicated according to the severity and pathophysiological significance of the varicosity.
• Absolute contraindications are the incidence of peripheral arterial occlusive disease and angiodysplasia, particularly arteriovenous fistulas as in Parkes-Weber syndrome.
• Systemic connective tissue disorders (e.g. Marfan's syndrome), dysfunction of venous flow (e.g. post-thrombotic syndrome, agenesia of valves) and progressive degenerative joint disease are relative contraindications .
Risks and Complications of Surgery
• Trauma of the femoral and popliteal artery and vein is a rare complication.
• More commonly, lesions of lymphatic vessels occur.
• The saphenous nerve in the calf area and sural nerve (medial ankle), which are close to the saphenous veins, can also be injured [3,16,18].
• Generally, resulting postoperative sensory dysfunction disappears, only occasionally appearing as permanent paraesthesia.
• Infection is a rare but serious complication often based on haematomas, which are an ideal prerequisite for colonization of microorganisms.
• In principle, surgeons should only perform techniques whose complications they are able to manage.
Preparation for Operation
• Different opinions exist about general thrombosis prophylaxis with heparin in varicose surgery.
• Peri-operative application in high-risk patients reduces the incidence of deep venous thrombosis.
• Patients under permanent anticoagulation therapy take heparin instead .
• Meticulous marking of the varicose veins with indelible ink precedes surgical procedure.
• The high ligation and stripping procedure as described by Babcock may be performed in truncal varicosis of the greater saphenous vein (saphenus = hidden) with or without perforating varices.
• The entire incompetent vein is extracted by intraluminal stripper from groin to ankle.
• Healthy segments of the saphenous vein are preserved [21,25].
• With regards to future arterial by-pass surgery, the saphenous veins play a major role as physiological vascular grafts.
• Analogously, this procedure is performed for varicosity of the lesser saphenous vein with incision at the lateral aspect of the ankle and the popliteal fossa. Prior to operation, identification of the exact termination of the lesser saphenous vein with the help of Duplex scanning is advisable. Active preparation of the sural nerve is necessary in order to protect it from injury .
Dissection of Perforating Veins
• By using the method of endoscopic dissection, an endoscope is inserted in the area of healthy skin (Fig. 10.1.8).
• In this way, further damage to existing trophical lesions of the skin can be avoided.
• Perforating veins are interrupted by clipping or coagulation under visual control.
• If no pathological skin conditions exist, open preparation with ligation of the incompetent perforating vein (blow out phenomenon) can be done [11,21].
Fig. 10.1.8a,b Endoscopical ligation of perforating veins. a Endoscope inserted subfascially. b Vena perforans, which will be interrupted
Removal of Local Varices
• Larger varicosites of the side branches are extirpated locally by stab avulsion through incisions, which may lead to scars.
• When using a phlebextractor, a modified hook instrument, only small punctual incisions are required, which do not need to be sutured, thus optimizing cosmetic results [4, 8,11,21].
• After applying the wound dressing, the leg has to be bandaged elastically with sufficient compression from the basal toejoints up to the groin.
• In order to avoid pressure damage, the bandaged leg has to be observed during the day of surgery.
• In some cases wound drainage is necessary, because the above-mentioned surgical techniques can cause extensive haematomas.
• Certainly, haematomas should not be mistaken for haemorrhage demanding instant revision [16,18].
• Excellent cosmetic and functional results of 95% have been reported using a combination of surgical treatment and postoperative sclerotherapy [3, 20, 26].
• The appearance of recurrent varices based on incomplete removal of the greater saphenous vein is rare.
• However, development of varicosities in the area of healthy side branches after a period of years is common.
• In this case, once again therapeutic methods have to be taken into consideration and surgical intervention is carried out if indicated [1, 3, 6, 9,11,12, 20, 21, 25].
• Manifestations of injury to the femoral and popliteal artery or vein, deep venous thrombosis and pulmonary embolism are considered serious complications.
• With meticulous surgery technique and proper perioperative management they rarely occur.
• Minor complications include lesion of local sensory nerves in 8-10% (mainly the saphenous nerve, often reversible), lymphatic fistulas in the groin in 5% and impaired wound healing.
• Modern therapeutic methods compete with conventional stripping operations [e.g. endovenous ablation using radiofrequency or laser, transluminal phlebec-tomy (TriVex), CHIVA (cure conservatrice et hemo-
dynamique de l'insuffisance veineuse en ambulatoire)] and reconstructive techniques such as "banding" (external valvuloplasty). These methods are the subject of controversial discussion [11,15,17, 21].
Surgical Treatment of Venous Thrombosis
• The operative therapy of deep venous thrombosis requires special indication.
• However, in a number of cases it reduces the risk of developingpost-thrombotic changes [16,18].
Rare Operations for CVI
• Today, the procedure described by Palma is the only operation which may be carried out in the case of severe post-thrombotic syndrome or unilateral occlusion of the common iliac vein (Fig. 10.1.9).
• Criteria for indication are pressure measurements in the iliac vein that are three times higher during exercise than while resting.
• A prerequisite is patency of the deep venous system of the lower and upper leg.
• The by-pass consists of autologous vein or alloplastic material [4,16,18, 23].
• The technique of the Palma procedure is to transfer the greater saphenous vein of the healthy side through a suprapubic subcutaneous tunnel to the contralateral, occluded side. An end-to-side anastomosis with the
Fig. 10.1.9a,b a Post-thrombotic syndrome with CVI and decompensated venous stasis: extensive oedema, skin pigmentation and florid ulcer. b Radiograph of patient after by-pass operation according to Palma without significant improvement femoral or iliac vein is performed. Simultaneously, distal to the anastomosis, a temporary arteriovenous fistula is made. It remains for 3-6 months, preventing recurrent thrombosis, particularly when the calibre of the vein is small .
Reconstruction and Transposition of Valves
• Kistner  suggested direct reconstruction of insufficient deep veins to re-establish patency of the deep venous system.
• As an alternative, transposition of healthy venous segments (mainly axillary vein) is described.
• Transposition of leg veins from the side not affected by thrombosis is not considered favourable, because lesion to the healthy side might occur.
• Likewise, by-pass procedures with normal epifascial veins as described by May  have not proven to be useful.
• The operation consists of by-passing an occluded superficial femoral vein by using the greater saphenous vein.
• Nature takes advantage of this physiological collateral pathway. Elevated pressure in the deep venous system leads to reversal of flow in the perforating veins.
• Prior to venous reconstruction, arterial lesions have to be treated if the arterial system is affected at the same time (combined ulcer) [14,16, 21].
• After proper elimination of venous stasis, adequate additional treatment of the ulceration must follow.
• Debridement of the ulcer with subsequent skin grafting leads to improved healing, provided that subcutaneous tissue and the muscle fascia show no extensive lesions (as in dermatoliposclerosis) caused by permanent venous hypertension.
• If deep subdermal layers are already indurated and degenerated, generous excision and closure of the wound by applying skin graft is the method of choice.
• Medial or lateral paratibial fasciotomy may reduce pressure in the different compartments and support the healing process .
• CVI can be avoided if varicose veins are treated in time.
• If the cause of CVI is post-thrombotic syndrome, an adequate form of therapy has to be chosen. In some cases surgical therapy is required.
• It is difficult to treat CVI when severe damage of tissue or ulceration has already developed.
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