CURRENT MANAGEMENT OF VARICOSE VEINS
___________________________________________________________________
'At the same time I wish to be understood as recommending the adoption of it, not indiscriminately, but with a due attention to the circumstances of each individual case.'
Benjamin Collins Brodie (1783-1862) on varicose vein operations. 179
INTRODUCTION
Therapeutic options available for venous insufficiency of the lower limbs are based on a precise analysis of the disease itself and the nature of the patient's complaints and expectations.178 The manifestations of superficial vein disease range from venous flare , aching varicose veins, lipodermatosclerosis, venous ulceration, oedema to, in exceptional cases, venous claudication. Comprehensive care requires a careful history, clinical examination and investigations. This paper reviews the surgical and non-surgical treatment of varicose veins. The choice of method depends on the anatomical presentation, the cause and site of venous incompetence and the importance of cosmesis to the person. The patient should be well informed of the advantages and limitations of each technique. The care of varicose vein disease should be individualised to suit the patient..1
History
Varicose veins have been recognised since antiquity. The Ebers papyrus, dated 1550 b.c., mentions serpent-shaped dilatation of the lower limbs. The Acropolis tablet of the IVth century b.c. concerning Dr Amynos allows us to visualise an enlarged lower limb clearly showing a varicosity. From 460-377 b.c., Hippocrates noted that a loose tourniquet leads to haemorrhages but that when the tourniquet is tight gangrene ensues and finally that standing up can exaggerate leg ulceration. Of course much progress has been made since Hippocrates. The school at Alexandria, with Herophilus and Erasistrates speak of vascular ligatures. Their work was unfortunately ost in the fire of the Alexandria library in 391 a.d. Galien himself described varicose vein ligatures in 200 a.d. Leonardo de Vinci's magnificent anatomic studies of veins are widely known. In 1525, Ambroise Pare described leg bandaging for ulcers beginning from the foot up to the knee. In 1585, Fabrice d'Acquapendente described venous valves. In 1676, Wiseman invented the first supportive stockings made of leather and in 1854, Unna described in Vienna the supportive boot that now carries his name. Shortly thereafter new medical and surgical techniques were developed for the treatment of varicose veins. Pravaz, in 1860, invented a syringe which now carries his name and initiated sclerotherapy.
Brodie in mid XIXth century recommended surgical management. He stated ''The case for which it is fitted are not those in which the veins of the leg generally are varicose, or in which the patient has little or no inconvenience from the complaint, but those in which there is considerable pain referred to a particular varix, or in which haemorrage is liable to take place from the giving way of dilated vessels, or in which they occasion an irritable an dobstinate varicose ulcer.'' 179
At the end of the XIXth century, Trendelenburg performed the first ligatures of the greater saphenous veins. In 1905, and 1906, Keller and Mayo performed the first ablation of the greater saphenous vein and in 1906, Carrel reported the first venous transplantation .2
Epidemiology & Extent of the Problem
In many countries "varicose veins are probably the commonest disorder presenting to general surgeons" and an average of 30% of district nursing time is estimated to be spent caring for patients with venous ulcers. For a disease of such magnitude relatively little epidemiological research seems to have been carried out.3,4 Its prevalence is very low in African and Asian or Australasian aborigen populations although immigrant subjects from these regions have the same risk as the population of their host country. Sedentarity, overweight, tight clothing may provide part of the explanation. Prevalence generally increases with ageing.1
Assessment and treatment of varicose veins comprises a significant part ofthe surgical workload. In the UK, National Health Service waiting lists suggest that there is still a considerable unmet need. Half of the adult population have minor stigmata of venous disease (50-55% of women & 40-50 % of men) but fewer than half of these will have visible varicose veins (20-25 per cent of women; 10-15 per cent of men). In one study (6% ) had evidence of deep vein thrombosis or pulmonary embolism, and 52 (5%) said that they had had phlebitis. In addition, 94 subjects (7%) had worn support stockings, and 84/1304 subjects(6%) had been treated with anticoagulants at some time.172The last two figures are from a study of 1338 random subjects from London population aged 35 - 70 years. In a very large Finnish study 139 comprising 3284 men and 3590 women. The life time prevalence of varicose veins was 18% for men and 32% for women, with an increasing prevalence in relation to age. Twenty five per cent of the men and 41% of the women who reported varicose veins had received treatment.Relatively invisible veins may cause considerable symptoms and this fact should be considered in evaluating such data.63 The validity of questionnaire surveys is not without criticism, however, these figures do allow some generalisations.46
The effects of delaying Surgery
In one group of patients who were followed up with Duplex scans while being anaged on-operatively four limbs initially unaffected developed reflux on Duplex scanning, of which three had clinical varicose veins (all four were offered surgery), and of the initial 56 involve d limbs, 10 further sources of reflux were found (18%), necessita ting alteration of the initial planned surgical procedure. No patient developed deep enous insufficiency or ulceration while on the waiting list, although there was one new case of lipodermatosclerosis. ' However, had surgery been undertaken after the irst assessment, 14 patients (25%) would potentially have required further surgery, although accepting this as justification for allowing patients to wait takes no account of patien ts suffering or quality of life while waiting for operation.' 171
Risk Factors
The data suggest that female sex, increased age141, pregnancy161, geographical site and
race are risk factors for varicose veins; some workers claim of no existent hard evidence that family history or occupation are factors. Other studies claim a significant correlation. According to one study the risk of developing varicose veins for the children w as 90% when both parents suffered from this disease, 25% for males and 62% for females when one parent was affected, and 20% when neither parent was affected.124
Body mass index (weight/height2), standing at work, and the number of births were risk factors associated with varicosities. Urban dwelling and high income correlated positively with varicose veins treated surgically in women.
Collection of such data is important, since accurate prevalence data allow provision of appropriate resources.93 Cytogenetic investigation of primary cell cultures from fragments of varicose veins of seven patients with familial varicosity and seven patients with the sporadic type revealed the presence of metaphases with structural abnormalities, clonal trisomies of chromosomes 7, 12, and 18, and monosomy of chromosome 14 only in cases with the familial type, while the sporadic cases had no similar chromosome aberrations. The immuno-phenotypi cal results are consistent with fibroblast lineage of the cultur ed cells. These results suggest that karyotypic variations in familial varicose vein tissue cultures could in some way be associated either with the genotypic constitution responsible for the familial type or a longer duration of disease on average than those with sporadic varicosities.114
Progestogen receptors in Varicose Veins
Clinical and epidemiological observations regarding varicose veins, such as their predominance in women and the occurrence of venous stasis during sex-hormone therapy, the luteal phase of the menstrual cycle, and pregnancy, suggest a sex hormone-dependency. Biopsy samples were obtained from patients undergoing stripping removal of varicose saphenous veins. Patients were men (n = 5) and premenopausal (n = 15) or postmenopausal (n = 10) women. Progesterone receptors (PR) and estrogen receptors (ER) were determined by both enzyme immunoassay (EIA) and immunocytochemistry by use of monoclonal antibodies. Ninety percent of the biopsy samples showed PR positivity by EIA (range, 5 to 53 fmol/mg cytosol protein). When present, PR staining was observed in the cell nuclei of the tunica media and the subendothelial layer ointima). No significant variation was observed in the PR content of different regions within the same saphenous vein. Results indicate that human saphenous veins from both sexes express PR, as previously described for arterial blood vessels. This observation suggests that progesterone acts directly on these veins via a classic receptor-mediated pathway.29
.
HISTOPATHOLOGICAL FINDINGS
Varicose disease is associated with a uniform connective tissue accumulation among muscle cells in the circular muscle layer.70
Varying degrees of intimal thickening composed of collagen, elastin, and smooth muscle are found in necropsy venous specimens. These changes are most noticeable in the varicose veins. Intimal changes are also seen related to valves and to adjacent arteries. No clinically relevant lipid is seen in the native veins, though atheromatous changes are seen in the grafts. Venous changes are related to venous pressure, to
local haemodynamic e ffects, and probably to hypoxia. The changes are often focal and seem to be sequential in their formation.135
A significant increase in the collagen conte nt and a significant reduction in the elastin content of VV has been demonstrated. The net increase in the collagen/elastin ratio is indicative of an imbalance in the connective tissue matrix. The biochemical profile in specimens of LSV that were normal but associated with varicosities in their distributiuon area (potential Varicosity PV )was similar.
to VV and significantly different from normal veins. These preliminary data support the presence of connective tissue abnormalities before valvular insufficiency.145
INVESTIGATIONS OF VARICOSE VEINS
Specific investigation for varicose veins aim at identifying the anatomical system involved and ascertaining the status of the deep veins. In addition attempts have been made at grading the severity of the disease.The Doppler gradeDefine this takes into account the maximum duration of the reflux wave in compression-decompression manoeuvres. The ultrasonographic grade involves the maximum diameter of the varicose175
CONTINUOUS WAVE DOPPLER
Continuous wave Doppler examination is a rapid, precise method to determine sources of reverse physiologic flow (reflux) prior to treatment of varicose and telangiectatic leg veins. This test used with appropriate tourniquets should be the minimal standard for clinical examination now.55,155 This test can be coupled with Photo-plethysmography/ Light reflection Rheography (PPG/LRR ) if Duplex Ultrasonography is not available for ore thorough evaluation. 157 PPG by itself however is not an accurate assessor of superficial venous reflux.162
Limitations & sources of error
Continuous wave (CW) Doppler in the assessment of venous disorders has recognised limitations. This is because CW Doppler is not able to distinguish reflux signals from many different veins coursing in different directions. Some regions with venous reflux suggested by CW Doppler are noted to have no reflux in any individual vein during duplex studies.
In a study of five hundred and fifty-one consecutive lower limbs with primary or recurrent varicose veins, CW Doppler and subsequently by colour-coded duplex ultrasound has been used to assess the source of venous reflux. The duplex ultrasound
study revealed no reflux in 44 specific regions (8%) where reflux had been indicated by CW Doppler. The explanation for this was EITHER (a) Two or more superficial veins joining the deep venous system via a common junction in 25 cases. OR (b)A descending vein joining the deep venous system in 19 cases.
Thus a bi-directional Doppler signal in a region of venous junction without any incompetent veins can be misinterpreted as venous reflux. A careful examination of veins not only at the region of the junction, but also at some distance down the stem of the vein is important during CW Doppler or duplex assessment.112
DUPLEX ULTRASONOGRAPHY
Please describe Duplex and it's mechanics
colour-coded Doppler sonography together with measurement of the peak of venous reflux enables distinction to be made between normal and varicose veins with a high level of significance (p < 0.003).In varicose segments of veins the peak velocity of venous reflux is more than 10 cm/s.2 & reflux time is >0.5 secs.
The diagnostic accuracy of ultrasonography regarding perforator positions is 92%. However, the diagnostic accuracy of ultrasonography regarding their incompetence is about 65%. Thus although the position of perforators is accurately detected using ultrasonography76, their competency may not be precisely evaluated by diameter measurement.129
Duplex ultrasound is an accurate method of assess ing primary and recurrent sapheno-femoral and sapheno-popliteal incompetence but has been criticised as being of limited value in assessing perforator incompetence. The importance of perforator disease is well recognised in many patients. In some patients other investigative modalities may have to be used.9 Please re-check this data
Duplex findings in superficial thromophlebitis
A total of 321 patients with suspected acute thrombophlebitis were examined ultrasonically. 15 control subjects with normal superficial veins and 19 with uncomplicated varicose disease were examined for comparison. The accuracy of duplex scanning in assessment of the proximal border of thrombosis in acute thrombophlebitis was 98.6% in this study. Duplex scanning in patients with superficial thrombophlebitis gives reliable and valuable information about the presence, type, and extension of the pathologic process. 141
Phlebography
Previously phlebography was the 'Gold-standard' used to investigate patients with superficial venous disease and to study patients with advanced deep vein disease who were potential candidates for deep vein reconstruction.
Presently the place of phlebography and varicography in acute and chronic venous disease is to complement other less invasive and less expensive tests of venous function .54Descending phlebography is of more use than ascending phlebography in assessing valvular competence but does involve injection into proximal veins. 'Pneumatic' ascending phlebography has been shown to help in detecting the presence of incompetent perforators, short saphenous incompetence & mid thigh perforators with greater precision.147
Pelvic phlebography may be necessary especially in recurrent vulvar varicosities. If necessary this can be undertaken through the contra-lateral femoral vein.91
Patterns of Reflux
no of people with SFJ reflux
With increasing diagnostic accuracy greater emphasis need be placed on individualised treatment. It is essential to be familiar with the various patterns of reflux and their significance.
In a Large study involving 1114 patients with venous disease it has been demonstrated that very few patients had deep venous reflux exclusively. In the vast majority there was either deep reflux associated with superficial reflux or indeed superficial reflux alone. The anatomical site of deep venous reflux may be significant. Patients with complications had greater incidence of reflux in the posterior tibial segment. Isolated perforator reflux was uncommon, however perforator reflux associated with superficial reflux was frequently seen.. Treatment directed to the superficial veins alone, which id often a simpler procedure, may be sufficient for most patients with complications.67
In another study involving 250 subjects ache, ankle oedema, and skin changes in limbs with reflux confined to the superficial venous system were predominantly associated with reflux in the below-knee veins. This included involvement of LSV below knee level without involvement of the vein in the thigh. Ulceration was found only when the whole of the LSV was involved (8%) or when reflux was extensive in both LSV and SSV (14%).102J Vasc Surg shain et al Selthiax Drake BJS 71 , 754-755
The ulcerated limbs are characterised by higher rate of reflux and higher residual volumes independent of the site of reflux. 105when compared with patients with venous disease not associated with ulceration. These data show that 86% (37/43) of the ulcers has some degree of reflux in the local area, the pattern of which may differ from the axial vein disease52.
The distribution of venous reflux in patients with skin changes associated with chronic venous insufficiency presenting to a specialist clinic was assessed. A total of 300 limbs in 153 patients were examined by Doppler ultrasonography with colour-flow imaging for the presence of venous reflux in superficial veins, deep veins and medial perforating veins, both above and below the knee. Ninety-eight limbs had skin changes, which included hyperpigmentation, lipodermatosclerosis, atrophie blanche and ulceration. Of this group, 2 per cent had no evidence of venous reflux on duplex scanning, 39 per cent had deep vein incompetence, 57 per cent had superficial vein incompetence and 2 per cent had isolated medial perforating vein reflux.
Even more significantly of 25 limbs with ulceration, 13 had superficial and 12 deep vein reflux. In the group with no skin changes in a total of 202 legs( which included 20 normal control limbs) 22.3 per cent of these had no venous reflux, 8.4 per cent had deep vein incompetence, 65.3 per cent had superficial incompetence and 4.0 per cent had isolated medial calf perforating vein incompetence.156Isolated deep venous reflux was present in only 12 limbs (15%). A combination of deep and superficial venous reflux was found in 25 limbs (32%), and in 42 limbs (53%) there was only superficial venous reflux. In just over half the patients with venous ulceration, the disease is confined to the superficial venous system. This group of patients may benefit from surgical treatment. This study emphasises the need for vascular laboratory investigation of patients with leg ulceration and emphasises the role of superficial venous incompetence in these cases.167
LSV involvement not originating at the SFJ/ Reflux as an ASCENDING phenomenon
In a study of 167 patients with primary varicose veins diagnosed clinically Duplex investigations were carried out to determine whether LSV involvement occurred without SFJ incompetence.
Of 190 limbs with LSV reflux 63 had no SFJ incompetence, of which only five had incompetent perforators; these were mid-thigh perforators in two limbs and medial calf perforators in three. LSV reflux often occurs in the presence of a competent SFJ. This indicates that, in such circumstances, sapheno-femoral ligation alone is unlikely to control varices associated with LSV reflux. It also suggests that the development of primary varicose veins may be an ascending rather than a descending phenomenon 95.
These findings also militate against the practice of tying off the SFJ alone as a means of dealing with SFJ incompetence.
Findings in Superficial Thrombophlebitis
Phlebitis and varicophlebitis are regarded as harmless diseases easily treated by compression and local measures such as incisions and applications.18 However, recent experience has revealed that they are often complicated by growth of the superficial thrombus into the deep veins, by non-contiguous calf thrombosis, and by (usually) asymptomatic pulmonary embolism. In a prospective examination of 25 consecutive patients using duplex scanning (21x) and/or ascending venography (15x). The phlebitic process involved a varicose greater saphenous vein or a branch thereof (19x), the short saphenous vein (3x) or a non-varicose superficial vein (3x). In 11 cases (44 %) direct extension to involve the deep vein system and/or non-contiguous isolated calf or popliteal vein thrombosis was found. The presence of risk factors for deep vein thrombosis and a painful calf muscle were good clinical indicators of such complications. Patients with complications were anticoagulated on an outpatient basis. The course was uneventful in most cases.
This confirms the notion that superficial thrombophlebitis is often part of a more extended thromboembolic process. This implies diagnostic and therapeutic consequences, although the prognostic significance of such complications s not clear at the moment.177
Telangiectasiae
Thirty-seven legs with lateral and/or medial thigh telangiectasiae were examined. The patients studied were those without sapheno-femoral, sapheno-popliteal, or deep venous abnormalities on Duplex examination. Altogether 53 sites were tested. In 89% 'reticular' vein incompetence was found close to telangiectasiae. Often reticular vein incompetence was associated with reflux in larger 'epifascial' veins. In 15% competent perforating veins were detected between reticular veins and the deep venous system. Thus it was found that telangiectasiae was rarely an isolated condition, but was usually associated with incompetence in other elements in the venous drainage of the subcutaneous tissue.150,151
CONSERVATIVE MANAGEMENT OF VARICOSE VEINS
This mainly involves compression of the limbs by means of custom designed stockings. The benefit accrued from these is both subjective and quantifiably objective. There is a possibility of beneficial effects from some pharmacological agents but their definitive place remains to be proven.
Elastic Stockings
In a study of patients that were classified into two groups according to the severity of venous reflux and efficiency of calf muscle action, elastic compression appeared to be beneficial in both groups. The application of the elastic stockings improved reflux and the residual volume fraction in both groups and the ejecting capacity of the calf muscle pump. Immediately after the removal of the stockings all the measurements regressed to the initial values with the exemption of the residual volume fraction. However, one week later, the latter also regressed to the original value. It is concluded that the beneficial effect of elastic stockings on the venous haem- odynamics is present mainly when the stockings are worn. It is completely abolished within a day after their removal.107 Measurements of the elastic modulus K (defined as stress/strain when the veins were full and calculated from the pressure/volume relationship) is another parameter used . The results show a clear difference in elasticity before and after elastic stockings. There was a negative linear relations hip (r = 0.88) between increase in elasticity after treatment and duration of venous disease.154
Pharmacotherapy
Increase in Glycosaminoglycan levels in the vein wall is known in varicose disease. This reflects a disregulation of the normal matrix biosynthesis by the cells of varicose vein wall, especially smooth muscle cells. Some flavonoid drugs are capable of correcting these deviations by decreasing proteolytic attack on fibrous proteins and t
the accumulation of proteoglycans and hyaluronan.7
Rutosides
The wheal vanishing (WV ) time has been used to assess the beneficial effect of therapy on capillary filtration in subjects with mild-moderate venous hypertension.94 he WV time, which was comparable in the two groups at the beginning of the study decreased significantly in the treated group. No change was observed in the WV time in the placebo group. Subjective symptoms of venous disease measured with an analogue scale improved following treatment with hydroxyethylrutosides [foot oedema (p < 0.005), ankle oedema (p < 0.001), and paraesthesia (p < 0.01)]; only night cramps were reported less in patients receiving the placebo (p < 0.05).Pitting oedema and eczema also improved significanlty.118
INJECTIONS
Injection sclerotherapy is a very useful modality either on it's own or in conjunction with other modalities. Sodium Tetra-decyl Sulphate (STD )and more recently Polidocanol are the only two sclerosants widely used. The later is a urethane which was initially used as an anaesthetic. 1% STD is an optimal concentration for treating the larger varices.121 Sclerotherapy has long been viewed as a tool for 'lesser' veins and for unfit patients83 . More recently sclerotherapy has been used as primary trearment in a variety of scenarios. Sclerotherapy has been used in cases of varicose veins in children with success.
Table 1. Indications for Sclerotherapy 120
___________________________________________________________________
Optimal indications
Telangiectasia
Reticular Varicositiies and Reticular veins
Isolated Varicosities*
Below knee varicosities*
Recurrent varicosities*
Less than optimal indications
Symptomatic reflux
In the aged & infirm
In nonsurgical candidates
Questionable indications
Greater Saphenous vein reflux
Lesser Saphenous vein reflux
Large varicosities
Contraindications
Allergy to Sclerosant
_____________________________________________________________________
* In the absence of gross saphenous reflux
Double Blind comparison Stripping Vs Sclerotherapy
Stripping the LSV has some associated complications . However sclerotherapy as an adjunct in surgical management instead of stripping has not proved very encouraging for routine use. A prospective randomised study compared the treatment of greater saphenous vein insufficiency by stripping / local avulsions of varicose veins with high ligation of the sapheno-femoral junction / sclerotherapy. Of 156 consecutive patients, 89 legs were randomly allocated to stripping and 92 to high ligation. Follow-up was carried out at 3 months and 1, 2, and 3 years after treatment. Scoring was done using clinical and Doppler ultrasound results, and complaints and cosmetic results, as judged by the patient and the surgeon. At 3 years, 69 limbs in the stripping group (78%) and 3 limbs in the ligation group (79%) were available to follow-up. The cosmetic results were significantly better (P < 0.05) in the stripped limbs than in the limbs with high ligation and sclerotherapy. Clinical and Doppler ultrasound evidence of reverse flow in the saphenous vein was significantly less (P < 0.001) after the stripping operation. The results of treatment of isolated saphenous vein insufficiency by stripping operation, therefore, were superior to those obtained by high ligation combined with sclerotherapy.110
Polidocanol Vs STD
Polidocanol is a safe sclerosant and has been shown to be more effective than STD.
In a series of more than 10,000 patients the incidence of both local as well as general side-effects was found to be lower. Lower concentrations can be used for the treatment of quite large veins.148 The effectiveness of polidocanol compared to STD is 85% and compared to hypertonic saline 84%.
In the Australian Polidocanol study ninety percent of investigators considered that polidocanol had less frequent complications than STD, and 80% considered that these were less severe. Seventy-four percent considered that polidocanol had fewer side effects than hypertonic saline, and 74% considered that these were less severe. 61Although uncommon, sensitivity reactions have been described .117
In the majority of varicose veins that had been refractory to repeated large doses of sodium tetradecyl sulfate alone, a single sequential injection treatment has been found to be effective in bringing about about sclerosis and rapid atrophy of these veins. This method should be considered for cases when it is known or anticipated that sodium tetradecyl sulfate alone will be ineffective.123
Doppler guided injections
Injection sclerotherapy used in conjunction with hand held doppler examination at the time of the actual injection has been shown to be advantageous in difficult cases. One indication is the treatment of varicose veins that are palpable while standing but difficult to detect in the supine position. Varicose veins in the groin region, lower third of the thigh, and along the axis of the small saphenous vein may be treated with this technique. In these situations it can be more accessible, faster, and economical technique, although it does not replace duplex ultrasound-guided injections.38
ECHO-SCLEROTHERAPY
Sclerotherapy has been used with satisfactory results, for several years in the treatment of varicose veins. Nevertheless sometimes sclerosis can be incomplete because of the morphology of lower limbs or because the varicose disease is not clinically evident. In addition, sclerotherapy can give rise to severe complications due intra-arterial or extra-luminal injections. 21Inadvertent intra-arterial injection is another uncommon but avoidable complication.149 The newer technique of echosclerotherapy (EST) was presented for the first time in Strasbourg (1989) by Knight and Vin. Advanced sclerotherapy of varicose veins with higher precision than using clinical means alone is possible.24,25 Larger and deeply situated veins can be injected.158 The short saphenous vein as well as perforators are amenable to injection by this technique. Duplex control is used preoperatively to evaluate the veins, during the procedure to actually guide the injection process and post-injection to monitor the extent of sclerosis actually achieved.
. In a 1993 study of 25 subjects with LSV disease a complete sclerosis was obtained, using EST in 48.4% of cases. In 38.7% a stump remained near the sapheno-femoral junction of about two centimetres; in one case the treatment was not completed and in one case a longer stump of 10 cms remained. Only in two cases Echosclerotherapy as not able to obtain sclerosis. None of the patients had major complications and nobody had deep vein thrombosis.The potential of this technique merits to be explored further.
Vulvar Varicosities of pregnancy
Typical symptoms caused by these veins are pruritis, pain caused by pressure in the vulvar area and the sensation of prolapse. According to the authors surgical treatment is unnecessary most cases and not without risk. They recommend compressive sclerotherapy as described by Fegan, using sodium tetradecyl sulphate S.T.D. to alleviate severe symptoms or prevention of dangerous haemorrhage during delivery.39
Sclerotherapy for Telangiectasiae
Because of the interconnected character of the venous system the feeding veins should always be injected in cases of telangiectasia.53Instead of randomly injecting as many veins as possible in a given period of time, venous regions or entire abnormal superficial venous networks related to incompetent perforators should be injected in a single session.
The surgical treatment of telangiectasis can be used synchronously with sclerotherapy. Adjacent veins are resected through skin incisions of about 2 mm with
the veins themselves being pulled out with crochet hooks, under local anesthesia,.133
Other Modalities
Retrograde venoscopy has been shown to have some use in diagnosis as well as in therapy. Venoscopic diathermy of the veins has been tried with some success.115
Endoscopic ligation of perforators is a well established practice in some centres. The endoscopy of the subfascial space of the calf helps to securely find all of the incompetent perforating veins and to dissect them easily and completely.5,43, 66,153, 156
This method was developed and first described by Hauer in 1985.2 Lately 3 surgeons have developed special instruments for this type of endoscopy. Hauer was the first to develop a specialised technique with the Wolf Company. He uses angulated optic system and a double cautery clamp. It permits excellent vision. Sattler works with a Storz thoracoscope and specially built instruments controlled by a monitor. This means better handling. Fischer uses direct vision through a Wolf or similar endoscope shaft and a set of instruments produced by torz and Ulrich.20 The subfascial procedure reduces delayed wound healing, especially in patients with trophic skin disorders.111
SURGICAL MANAGEMENT
The principles of VV surgery have traditionally involved tying off superficial to deep connections, avulsions of shorter varicosities & stripping of longer segments of veins. There has been some controversy in the past regarding the preservation of the LSV itself following a Trendelenburg operation. It has been claimed that high sapheno-femoral ligation combined with multiple "stab avulsions" preserves an LSV that can potentially be used as a graft. There are good early symptomatic and cosmetic results using this technique.15 However these studies lack sufficient follow-up. Most studies with a longer follow-up have suggested an increased recurrence rate consequent on preserving the LSV.
(Multiple) Phlebectomy
Phlebectomies alone can produce extremely gratifying results159 providing the main superficial to deep venous junctions are not incompetent. A standardised technique described is Muller's out-patient phlebectomy. This implies an accurate mapping of varicosities, adequate local anaesthesia and micro-incisions which are only exceptionally sutured. An accurate elastic pressure bandage is indispensable and useful in order to improve the dynamics of the peripheral venous circulation and to avoid haemorrhages. 1
Strict adherence to proper technique, patient selection, and pre-treatment venous mapping is essential. Although in general recurrence rates are reportedly higher, most recurrences can be treated by means of sclerotherapy.50 Varicosities of the short saphenous system have been treated with 'stab' phlebectomy.
The tumescent anaesthesia technique is highly effective and is an important adjunct to the procedure of ambulatory phlebectomy .64 The technique utilises a dilute anaesthetic solution, an injection syringe, and a blunt-tipped anaesthetic probe. Large areas can be anaesthetised quickly, safely, effectively, and relatively painlessly, offering multiple advantages over simple local infiltration and eliminating the need for regional or general anaesthesia .
VEIN STRIPPING
Although it has been suggested that VVs treated by SFJ ligation alone may preserve the vein for use as a vascular conduit144, there is evidence that not stripping the LSV leads to greater recurrences .71, 146Most workers would advise stripping of the LSV on basis of this evidence in cases where reflux is present in a segment of the LSV. This is irrespective of the status of competence of the SFJ.
As discussed in another section of this review the VV pathology could in many cases be an ascending phenomenon. Hence leaving the LSV in-situ would lead to the residual vein becoming varicose eventually even in the absence of a mid-thigh perforator.
A recently published study from Sweden reports no differences in outcome at four years follow-up whether the LSV was stripped or not. However these workers rely on a more extensive dissection at the groin. In addition they resort to ligating the mid-thigh & other perforators as a means of preventing recurrences.180 These results are obviously not comparable with the standard operations usually performed in this country.
Theoretically stripping of the whole of the LSV would provide better results. This is true at least in a proportion of cases.71 However neural complications are more likely with stripping to a level lower than just below the knee. 72This practice has justifiably been abandoned. A lengthy incision is not essential below the knee for the stripper. The stripper can be pulled out through the inguinal incision using a pre-attached length of suture material.82
Two relatively new techniques of stripping the vein deserve mention here. They can potentially circumvent some of the mentioned complications.
'Rigid' Strippers
This is also known as 'Perforate-Invaginate-Stripping' (PIN). 112 operations were performed in an office setting with the patient receiving locoregional anaesthetic with use of the invaginated PIN stripping in conjunction with tributary hook-stab avulsion. In the 112 procedures performed, there were no tract hematomas or dysesthesias caused by nerve damage. Postoperative morbidity was minimal, permitting all patients to resume normal daily occupational and sporting activities almost immediately following the procedure. PIN stripping seems to be a very useful technique. There is minimal likelihood of vein tearing with this method.
Compared with conventional ankle-to- groin (or popliteal fossa) stripping, PIN stripping is minimally invasive, does not cause damage to structures around the vein, does not require convalescence, eliminates the need for a lengthy distal second incision, can be performed in an office setting with the patient receiving locoregional anaesthetic, and is most cost-efficient101
Cryo-Stripping
Saphenous neuritis & sensory damage are seen regularly with stripping the vein to ankle level. The former is irrespective of the direction of stripping.72 This involves passing the cryo-probe down to the ankle through the vein and freezing the vein at the ankle before stripping. Stripping of the vein to the ankle level is possible without a significant risk of associated neural complications. It is essential in substantial proportion of patients to deal with the LSV below the knee and Cryo-stripping may well provide a less intrusive answer.71 In addition this modality is useful where cicatrization at the ankle may make the operation almost impossible.
In a study of mare than 2000 patients treated with cryotherapy 'aesthetic' results were found to be better and surgery was possible even in patients with non-healing ulcers & severe LDS in the distal leg.42In another large series involving 3000 patients the complications rates were lower than conventional stripping. The ulcer healing rates were high. Studies with follow up of upto five years exist and report encouraging results.130
SURGERY AIMED AT CORRECTING REFLUX
Although inadequate surgery is widely known to be a source of recurrences, overambitious surgery has it's own drawbacks. As patients consult for varicose veins at an increasingly younger age and surgery for varicose veins has become quite popular, the possibility of unnecessarily extensive surgery to the venous system is present. One study found that approximately 80% of the LSV in patients consulting for varicosities are normal, slightly dilated or simply have one or more minor areas of dilatation. Segments of unaffected vein may have a use as arterial grafts. The LSV may also be used in vein transposition operations used for chronic venous insufficiency.83
In this era of minimally invasive & 'function preserving surgery' it is logical to look at new approaches to VV therapy aimed at correcting the underlying abnormality. These operations are less traumatic and are expected to have lower complications.
With corrective surgery a higher rate of recurrence must be expected at the moment. Longer follow-up studies are required than are available at the moment.97
A special Dacron sheath can be used to 'contain' these areas of dilatation. It has been demonstrated that these areas remain patent and that non-sheathed areas do not undergo undue dilatation. It is necessary to verify the calibre of the trunk of LSV during the Echo-Doppler examination before treating patients with this method.98
Another technique that has been used is Strategic ligations. Pre-operative Duplex mapping is used to identify the sites of 'leakage' precisely. Correction is achieved by means of selected ligatures of the superficial venous system.51 Although short term results of these treatments are very encouraging, longer term studies that are properly controlled are the only means of providing a final answer regarding their true place.106
VALVULOPLASTY
This procedure is performed in selected patients with primary varicose vein disease and who have sapheno-femoral reflux as the only point of regurgitation in the affected lower limb.23 There should be evidence on duplex of mobile valve leaflets. The procedure can performed under local anaesthesia as a 'Day Case'. A PTFE sleeve of specified dimensions is wrapped around the terminal valve. If the subterminal LSV valve site is also dilated a second valvuloplasty can be performed. Intra-operative video-angioscopy guide can be used in patients with valve damages not demonstrable by a Duplex scan. Furthermore angioscopy permits immediate demonstration of restored valvular function.143.
Objective parameters of venous function have been shown to improve after these procedures. Ambulatory venous pressures (AVP) was reduced and RT, measured by the means of LRR, had a prolongation after surgery. Both measurements had a highly significant difference from a statistical point of view, comparing pre and postoperative values. 95% of the operated patients had 'stable' varicose vein reduction. Continuing LSV patency was recorded in 92.5% of cases. On the contrary, after high ligation the saphenous vein becomes occluded in 21% of cases. With the valvuloplasty described symptoms of venous insufficiency disappeared completely in 80% of cases and improved in 95%.
Other techniques of valvuloplasty used and described in series of at least fifty patients a are a total plication technique of the valvular annulus either by a running suture of
prolene or a venocuff sleeve of an autogenic femorofascial band. The degree of plication was decided by angioscopic observation. Postoperative observation periods were from 2 to 28 months. There was no recurrence either of varicose veins or of prominent venous reflux in one study with this length of follow-up amongst 43 cases thus managed.143
THE PROBLEM OF RECURRENT VEINS
Sapheno-femoral junction incompetence remains the main source of recurrence. In a study of >300 patients with recurrent veins the LSV was involved in 96% of cases while SSV involvement was found in 4%.Reference Logfren 1956 please mention In a study of 244 limbs the recurrent varicose veins were classified into two types according to the presence or absence of a residual LSV. Varicose veins with a residual LSV (type I) occurred in 168 limbs (68.9%). A residual LSV with an incompetent SFJ was present in 125 limbs and one without any residual sapheno-femoral junction in 43 limbs.3
In a Duplex study of 44 limbs with recurrent varicose veins deep venous incompetence was detected in 22 patients The findings suggest an important role for deep venous incompetence in recurrent veins.78 Emphasis thus need to be placed on clinical as well as investigative means, where applicable, to rule out deep venous disease.
Another series of 128 legs with recurrent varicosities revealed (i) technically unsatisfactory surgery at the sapheno-femoral junction (66 per cent) and (ii) failure to remove the long saphenous vein in the thigh (60 per cent).69
Venograms in varicosities in 206 limbs with recurrent veins revealed several reasons for recurrence. 'Blindly' performed superficial veins only operations, low ligation of the long saphenous trunk, incomplete stripping of varicose veins, missing the short saphenous system varicosities and incomplete ligation of the perforating veins were incriminated.36
A precise assessment to identify underlying venous incompetence is important for the management of recurrent varicose veins.3 I A Duplex scan should be the preferred diagnostic test for recurrent varicose veins. Contrast examination may be reserved for patients who have equivocal results on non-invasive investigations, who have had more than one previous groin operation or who have, in addition, deep venous disease.125 With a skilled Duplex operator the need even for these latter indications may not be present.
Difficulty in grading clinical disease severity has been one of the factors responsible or the discrepancy in publications regarding recurrent VV. Precise data of surgical treatment undertaken are often not detailed. Duplex-Scan is currently accepted as the gold standard investigation. Phlebography or (and) plethysmography can be helpful in some cases. In selected patients redo surgery is strongly recommended since excellent results can be obtained.
In Short Saphenous recurrence pre-operative colour-coded duplex examination revealed an abnormally high sapheno-popliteal junction with persistent reflux in 11 out of how many patients? patients and a Giacomini vein in one. When comparing these results with venographic and operative findings an accuracy of 100% was reached in these specific cases. It is concluded that for patients with recurrent varicosis of the short saphenous vein, preoperative colour-coded duplex examination provides a reliable non-invasive alternative to venography in the exact localisation of the sapheno-popliteal junction.132Recurrence may be more likely if the stab avulsion technique for removal of the SSV is employed .160
Is Recurrence unavoidable?
Four main reasons for recurrence have been described (1)insufficient understanding of venous anatomy and haemodynamics, (2)inadequate preoperative assessment, (3)incorrect or insufficient surgery and (4)development of new locations of superficial-to- deep insufficiency. Better insight into the variable anatomy of the venous system and better training of junior surgeons in this matter may improve the results of venous operations. Strict adherence to rules for placing incisions 84is not as important s Accurate preoperative assessment. This may involve using (colour) duplex sonography .This permits the surgeon to give the patient a differentiated, individualised treatment. Careful dissection of the sapheno-femoral junction combined with additional stripping of the long saphenous trunk to just below the knee appears o be the best way to prevent recurrence from the long saphenous vein in the thigh.
Inadequate ligature of the tributaries at the groin is sometimes responsible. This may include overlooking tributaries opening directly into the femoral vein.81It has been recommended that the Femoral vein should be dissected proximal and distal to the SFJ and all tribtaries medial and lateral tributaries ligated.181 Angio-neogenesis is another mechanism for recurrence at the groin. These can connect either to the LSV remnant or to a missed large superficial vein of the thigh (e.g. the accessory saphenous vein). Suturing the fascia over the cribriform opening has been advised as a measure countering these recurrences.83
Concerning the short saphenous vein preoperative location of the exact level of the sapheno-popliteal junction is of major importance in the prevention of recurrence. In this way, all diagnostic and surgical effort should aim to minimise recurrence to about only 5% of patients.68
Prevention of recurrence after surgical treatment of varicose veins can not be complete. Strict observance of several rules can ,however, reduce it.90
Operating for recurrent veins at the groin
Re-exploration of the sapheno-femoral junction for recurrent varicose veins presents many problems. The lateral approach to the sapheno-femoral junction via a groin incision is currently regarded as the preferred technique. In a study of 109 recurrent veins operated upon utilising this technique the outcome was satisfactory in 106 cases (97.2%) and only in three (2.8%) did recurrent varicose veins recur again in the upper thigh. Complications were mainly lymphorrhoea (six cases, 5.5%). Cosmetic results were also satisfactory.
This surgical procedure allows an easy and safe approach to the sapheno-femoral junction and avoids damage to femoral vessels. Further recurrence was rare and caused by incompetent communicating veins in the upper thigh. These characteristics make the lateral approach the preferred technique for re-exploration of the sapheno-femoral junction.79
Precise imaging is vital in management of recurrent Vvs. Varicography and other contrast examinations may be reserved for patients who have equivocal results on non-invasive investigations, who have had more than one previous groin operation or who have, in addition, deep venous disease.125
PATIENT SATISFACTION
Cosmesis plays an undeniably important role in VV surgery. Patient satisfaction with the eventual outcome is therefore important. A total of 311 patients (68% of all questionnaires sent ), who underwent varicose vein surgery during a 10-year period, replied to a postal survey sent to 456 patients [National Health Service (NHS) 327: private patients (PP) 129]. Of those 311, 19% of the NHS patients compared with 34% of the PP were completely satisfied with the surgery and had no post-operative complications (P < 0.01). Twenty-six per cent of the NHS patients were very dissatisfied with their treatment compared with 13% of the PP (P < 0.025). The majority of dissatisfied patients were female (P < 0.005). These results suggest that while varicose vein surgery is regarded as a safe and often minor procedure, it is associated with a significant surgical morbidity and patient dissatisfaction. Patients should be made aware of the potential outcome prior to surgery.11
These relatively disappointing levels of patient satisfaction indicate a need for further improvements in standardisation of the the delivery of VV surgical care. However even at the present level, the benefit to the population from VV surgery has been adequately demonstrated. In a questionnaire survey of 150 patients undergoing varicose vein surgery questionnaires were sent pre-operatively and at 1 and 6 months post surgery. Eighty-nine (59%) patients answered all three questionnaires. Pre-operatively their overall health was similar to that of the general population. The "cost" to the patient of the operation was demonstrated by an increased pain and reduced role function at 1 month post-operation (p < 0.01). By 6 months post-operation, when compared with reparative values, all dimensions except social function and health perception were improved (p < 0.01). Overall symptoms improved (p < 0.01) by 1 month and were further improved at 6 months. The general good health of varicose vein patients may justify the low priority given to their treatment, but the improvement in symptoms and general health that these relatively simple surgical operations provides should ensure its continued provision as a health care service48
In another study 33 in which most case underwent sapheno-femoral ligation, above-knee stripping of the long saphenous vein and multiple stab avulsions. A 73.8% response rate resulted in 155 replies, and revealed a high incidence (65.8%) of perceived complications within the first two weeks after surgery. The commonest of these were bruising, pain and numbness. Over a third of patients consulted their general practitioner (GP) post-operatively. Half of these required further management or treatment and the rest, reassurance alone. At six months 79.4% were satisfied with the outcome of their surgery, although some still claimed problems with residual veins, skin discoloration, numbness, and ankle or foot discoloration. Eleven percent were referred to hospital for further opinion, mostly because of perceived residual
varicose veins. No patient felt that the standard 2.5 day admission was too long, and 12.9% thought it too short. In other studies the findings suggest that most patients are happy to have the surgery done as a day-only procedure.109
The level of patient satisfaction varies immensely in various studies and underlines the need to improve both individual communications and VV care itself.
COMPLICATIONS OF VARICOSE VEIN SURGERY
Reported major complications after varicose vein operations are rare. The rate of minor complications is quite significant, however 33 . Minor complications include lesions of cutaneous nerves, e.g. saphenous or sural nerve, haematomata, lymphogenic fistulas or postoperative oedema are reported 176 and can be treated conservatively. Major complications like injuries to the femoral vein must be considered in about 1% and injuries to the femoral arteries in 0.02%.175
Of the complications that were studied in a series of 1000 patients the most frequently seen were. I.Haematomata & Haemorrage. This was dependent on the site of surgery, type of patient & the stripping technique. Use of Local anaesthetic containing Adrenaline does reduce wound haematomata. Haematomata are most frequently seen following LSV stripping but depend on various other variables. Results show that adequate compression bandaging can decrease subcutaneous haematoma formation after stripping of varicose veins152. Perforating veins of the thigh cause more haemorrhage than other venous tributaries. Superficial vein of the thigh Hematomata are more and more numerous and obvious because these veins have thinner, more fragile walls and are more superficial. In obese patients, hematomata seem to be more prevalent. II.Wound Abscess. Only 4 cases out of 1,000 operated legs have been reported. No related pathology has been observed (particularly concerning any lymphatic disorders erysipelas or lymphoedema), these patients had no previous infection known which could have explained such complications.137
Mention must be made here of two relatively uncommon complications III.Erectile dysfunction & IV.Lymphatic Complications. In addition V.Venous thrombosis is reported but not common.12 Post-surgical erectile dysfunctions caused by surgery of superficial veins of the lower limbs is seldom reported. In most cases their origins isan abnormality of arterial distribution to the genitalia: one or several of these latter come from common femoral arteries and their collaterals (the external pudendal arteries) and not from hypogastrics (and internal sexual arteries). It is would seem prudent to avoid damaging the external Pudendal aa. If possible during dissection of the groin in male patients in order to avoid the possible occurrence of a partial secondary or total impotency.138
In the practice of 23 surgeons who responded to a questionnaire the lymphatic complication rate was about 8.7%, 5.4% of which were lymphorrhea, 2.6% of lymphocele, 1.09% of lymphangitis and 0.5% of lymphoedema. Lymphoedema may be a rare but long-lasting lymphatic complication of the varicose veins surgery. It would seem that sclerotherapy would be the procedure of choice in case of signs, even benign, of lymphatic insufficiency.139
Thrombotic risk of varicose vein surgery is low in properly selected patients. In a questionnaire survey of surgeons there was a wide variation in opinion regarding the extent of DVT prophylactics considered appropriate for patients having varicose vein surgery. This has both clinical and medico-legal implications.5 In general the guidelines followed for other surgical procedures should be followed for varicose vein surgery as well.
Summary
The choice among the therapeutic options available for chronic venous insufficiency of the lower limbs should be based on a precise anatomical & physiological analysis of the disease itself and the exact nature of the patient's complaints and expectations. a careful clinical examination including hand-held Doppler examination should be the minimal evaluation tool. Complex vein, veins of uncertain origin, recurrent veins and
VV invloving the SSV should have Duplex evaluation in adddition.. Knowledge of the personal, social and professional situation of the person has bearings on the outcome. The long term results and effects of any modality of treatment must be kept in mind. The limitaions of any treatment must be explained to the patient. Elastic support, if prescribed correctly is useful for all degree of clinical severity. Vasculoprotective or venotonic drugs need to be evaluated further. More intrusive treatment of VV, whether surgical or by sclerosis, depend on the anatomic presentation, the degree of venous stasis and the importance of the symptomatology to the patient. Comprehensive care for varicose veins requires personalised care120
References
1. Stio F. Giacomelli L. Minocchi L. De Vita M. Iavarone C. Gallinacci
E. Braccioni A. La flebectomia ambulatoriale: nostra esperienza.Giornale di Chirurgia; 16(10):459-60.
2. Evers EJ. Wuppermann T. Ultraschalldiagnostik beim postthrombotischen Syndrom. Vergleichende Untersuchung mittels Farbduplex, CW-Doppler und B-Bildsonographie. Ultraschall in der Medizin. 1995 Dec; 16(6):259-63.
3. Tong Y. Royle J.Recurrent varicose veins following high ligation of long saphenous vein: a duplex ultrasound study. Cardiovascular Surgery. 1995 Oct; 3(5):485-7.
5. Campbell WB. Ridler BM.Varicose vein surgery and deep vein thrombosis.British Journal of Surgery 1995 Nov; 82(11):1494-7.
7. Drubaix I. Viljanen-Tarifa E. Robert AM. Robert L.Role des glycosaminoglycannes dans la maladie veineuse. Mode d'action de medicaments flavonoides. Pathologie Biologie. 1995 Mar; 43(5):461-70.
9. Phillips GW. Paige J. Molan MP.A comparison of colour duplex ultrasound with venography and varicography in the assessment of varicose veins.Clinical Radiology. 1995 Jan; 50(1):20- 5.
11.Davies AH. Steffen C. Cosgrove C. Wilkins DC.Va ricose vein surgery: patient satisfaction.Journal of the Royal College of Surgeons of Edinburgh. 1995Oct; 40(5):298-11.9. .
12. Bohler K. Baldt M. Schuller-Petrovic S. Grunwald C. Sellner W. Watzke H. lff K. Varicose vein stripping--a prospective study of the thrombotic risk and the diag nostic significance of preoperative color coded duplex onography.Thromb osis & Haemostasis. 1995 Ap; 73(4):597-600.
15. Fligelstone LJ. Salaman RA. Oshodi TO. Wright I. Pugh N. Shandall AA.
Lane IF. Flush saphenofemoral ligation and multiple stab phlebectomy preserve a
useful greater saphenous vein four years after surgery. Journal of Vascular Surgery. 1995 Nov; 22(5):588-92.
18. Leu HJ. Throm bose und Phlebitis der oberflachlichen Venen. Histopathologische Differentialdiagnose. Pathologe. 1995 No; 16(6):386-90.
20 Fischer R.Chancen der endoskopischen Perforantensanierung (EPS) beim ostthromb otischen Syndrom (PTS).Wiener Medizinische Wochenschrift.
1994. ;1 44(10- 11):258-60..
21. Tretbar LL. Treatment of small bleeding varicose veins with injection sclerotherapy. Bleeding blue blebs.Dermatologic Surgery. 1996 Jan; 22(1):78-80.
23. Zamboni P. Marcellino MG. Murgia AP. Fabi P. Ortolani M. Mari C.Eff etti clinici ed emodinamici della plastica esterna delle valvole del giunto safeno-femorale. Minerva Chirurgica. 1995 Mar; 50(5):463-8.
24. Baccaglini U. Pavei P. Spreafico G. Sorrentino P. Fontebasso V. C astoro C. Gongolo A. Ancona E.La sclerosi ecoguidata nel trattamento delle va rici degli arti inferiori. Minerva Cardioangiologica. 1995 Mar; 43(5):191-7.
25. Baccaglini U. Pavei P. Spreafico G. Sorrentino P. Fontebasso V. C astoro C. Gongolo A. Ancona E.La sclerosi ecoguidata nel trattamento delle va rici degli arti inferiori. Minerva Cardioangiologica. 1995 Ma; 43(5):191-7.
29. Perrot-Applanat M. Cohen-Solal K. Milgrom E. Finet M. Progesterone receptor expression in human saphenous veins. Circulation. 1995 Nov 15; 92(10):2975-83.
31. Solomon C. Munro AR. Van Rij AM. Christie R.The use of video image analysis for the measurement of venous ulcers.Source British Journal of Dermatology. 1995 Oct; 133(4):565-70.
33. Mackay DC. Summerton DJ. Walker AJ.Th e early morbidity of varicose vein surgery. Journal of the Royal Naval Medical Service. 1995 Sprin; 81(1):42-6.
36. Gu X. Yang Z. Chen J.[Causes of postoperative recurrent varicose veins of lower tremities]. [Chinese] Chung-Hua i Hsueh Tsa Chih [Chinese Medical Journal]. (6):349- 51, 83, 1995 Jun.
37. Kanter A. Gardner M. Isaacs M. Identification of arteriovenous anastomoses by duplex ultrasound. Implications for the treatment of varicose veins.Dermatologic Surgery1995 Oct; 21(10):885-9.
38. Cornu-Thenard A. de Cottreau H. Weiss RA.Sclerotherapy. Continuous wave Doppler-guided injections.Dermatologic Surgery 1995 Oct 21(10):867-70.
39. Labas P. Michalko L. Svec R. K problematike vulvalnych varixov. Ceska Gynekologie 1995 Aug; 60(4):200-1.
3. Sisto T. Reunanen A. Laurikka J. Impivaara O. Heliovaara M. Knekt P. A romaa A. Prevalence and risk factors of varicose veins in lower extremities: mini-Finlan d health survey.European Journal of Surgery. 1995 Jun; 161(6):405-14.
42. Etienne G. Constantin JM. Hevia M. Le cryo-eveinage: une avancee dans le traitement de la maladie variqueuse. 3,811 membres operes. Presse Medicale. 1995 Jun 17; 24(22):1017-20.
43.Pierik EG. Wittens CH. van Urk H. Department of Surgery, Sint Franciscus Gasthuis, University Hospital Rotterdam-Dijkzigt, The Netherlands.Subfascial endoscopic ligation in the treatment of incompetent perforating veins. European Journal of Vascular & Endovascular Surgery1995 9(1):38-41.
46. Laurikka J. Laara E. Sisto T. Tarkka M. Auvinen O. Hakama M.Mis-classification in a questionnaire survey of varicose veins.Journal of Clinical epidemiology. 1995 Sep; 48(9):1175-8.
48. Baker DM. Turnbull NB. Pearson JC. Makin GS. How successful is varicose ein urgery? A patient outcome study following varicose vein surgery using the SF- 36 ealth Assessment Questionnaire. European Journal of Vascular & Endovascular Surgery. 995; 9(3):299-304.
50. Garde C.Ambulatory phlebectomy.Dermatologic Surgery1995 Jul; 21(7):628-30.
51. Zamboni P. Marcellino MG. Feo C. Berta R. Vasquez G. Pansini GC.When CHIVA treatment could be video guided.Dermatologic Surgery. 1995 Jul; 21(7):621-
52. Labropoulos N. Giannoukas AD. Nicolaides AN. Ramaswami G. Leon M. B urke P.New insights into the pathophysiologic condition of venous ulceration with color-flo w duplex imaging: implications for treatment?.Journal of Vascular Surgery. 1995 Jul; 22(1):45-50.
53. Weiss RA. Goldman MP.Advances in sclerotherapy.Dermatologic Clinics. 1995 Apr; 13(2):431-45.
54. Kistner RL. Kamida CB. 1994 update on phlebography and varicography.Dermatologic Surgery. 21(1): 71-6, 1995 Jan.
55.Continuous wave venous Doppler exam ination for pretreatment diagnosis of varicose and telangiectatic veins. Dermatologic Surgery. 1995 Ja; 21(1):58-62.
---
58. Hansson C. Hoborn J. Moller A. Swanbeck G.The microbial flora in venous leg ulcers without clinical signs of infection. Repeated culture using a validated standardised microbiological technique.Acta Dermato-Venereologica. 1995 Jan; 75(1):24-30.
61. Conrad P. Malouf GM. Stacey MC. The Australian polidocanol (aethoxysklerol) study. Results at 2 years.Dermatologic Surgery 1995 Apr. 21(4):334-6; discussion 337-8.
63. Isaacs MN.Sy mptomatology of vein disease.Dermatologic Surgery. 1995 Apr; 21(4):321-3.
64. Cohn MS. Seiger E. Goldman S.Department of Dermatology, Pontiac Osteopathic Hospital, Pontiac, Michigan, USA.Ambulatory phlebectomy using the tumescent technique for local anesthesia.Dermatologic Surgery 1995 Apr; 21(4):315-
66. Lang W. Bockler D. Meister R. Schweiger H.Endoskopische Dissektion der Perforansvenen. Chirurg. 1995 Fe; 66(2):131-4.
67. Myers KA. Ziegenbein RW. Zeng GH. Matthews PG. Duplex ultrasonography scanning for chronic venous diseas e: patterns of venous reflux.Journal of Vascular Surgery. 21(4):605-12, 1995 Apr.
68. De Maeseneer MG. Van Schil PE. Philippe MM. Vanmaele RG. Eyskens EJ.Is recurrence of varicose veins after surgery unavoidable? Acta Chirurgica Belgica. 95(1):21-6, 1995 Jan-Feb.
69. Stonebridge PA. Chalmers N. Beggs I. Bradbury AW. Ruckley CV.Recurrent varicose veins: a varicographic analysis leading to a new practical classification. British Journal of Surgery. 1995 Jan; 82(1):60-2.
70. Porto LC. da Silveira PR. de Carvalho JJ. Panico MD.Co nnective tissue accumulation in the muscle layer in normal and varicose saphenous veins. Angiology. 1995 Mar.; 46(3):243-9.
71. 4. S Sarin JH Scurr & PD Coleridge Smith. Stripping of the long saphenous vein in the treatment of primary varicose veins. British Journal of Surgery 1994 ; 81: 1455-1458.
72.JG docherty JJ Morrice G Bell. Saphenous Neuritis following varicose vein surgery. British Journal of Surgery 1994.;81 :698.
76. Rabe E.Be urteilung der insuffizienten Venae perforantes mit der farbkodierten
Duplexson ographie.Zeitschrift fur Lymphologie - Journal of Lymphology. 1994 De; 18(2):31-3.
77. Walsh JC. Bergan JJ. Beeman S. Comer TP.Femoral venous reflux abolished by greater saphenous vein stripping.Annals of Vascular Surgery 1994 Nov; 8(6):566-70..
78. Quigley FG. Raptis S. Cashman M.Duplex ultrasonography of recurrent varicose veins. Cardiovascular Surgery. 1994 De; 2(6):775-7.
79. Belardi P. Lucertini G. Advantages of the lateral approach for re-exploration of the sapheno-femoral junction for recurrent varicose veins.Cardiovascular Surgery. 1994 Dec.; (6):772- 4.
82. NL Browse KG Burnand ML Thomas. Diseases of the Veins Pathology,diagnosis and Treatment. Edward Arnold London 1988: 201-251.
83. DJ Tibbs Venous disorders, vascular malformations and chronic ulceration in the lower limb in Eds PJ Morris & RA Malt Oxford Textbook of Surgery. Oxford University Press 1994; 541.
84. Royle JP & Eisner R The Sapheno-Femoral junction. Surg Gynecol Obstet 1981; 152: 282-284.
91. Firsov EF. Sukovatykh BS. Nazarenko PM. Belikov LN.Diagnosticheskie vozmozhnosti retrogradnoi tazovoi flebografii cherez kon tralateral'nuiu konechnost' pri varikoznoi bolezni. Khirurgiia. 1994 Se; (9):20-3.
4. Evans CJ. Fowkes FG. Hajivassiliou CA. Harper DR. Ruckley CV.
Epi demiology of varicose veins. A review. International Angiology. 1994 Sep.; 13(3):263-70.
93. Callam MJ. Epidemiology of varicose veins.British Journal o f Surgery. 1994 Fe; 81(2):167-73.
94. Renton S. Leon M. Belcaro G. Nicolaides AN.Irvine Laboratory for Cardiovascular Investigation and Research, St. Mary's Hospital Medical School, London, England. The effect of hydroxyethylrutosides on capillary filtration in moderate venous hypertension: a double blind study.Internatio nal Angiology. 1994 Sep; 13(3):259-62.
95. Shields DA. Andaz SK. Sarin S. Scurr JH. Coleridge Smith PD. Plasma elastase in venous disease. British Journal of Surgery. 1994 Oc; 81(10):1496-9.
96. Abu-Own A. Scurr JH. Coleridge Smith PD.Saphenous vein reflux without incompetence at the saphenofemoral junction British Journal of Surgery. 1994 Oct; 81(10):1452-4.
97. Melliere D. Baudin V. Martin-Jonathan C. Le traitement personnalise des varices. Indications dans trente-deux observations.Journal des Maladies Vasculaires. 1994; 19(3):223-41.
98. Melliere D.Pourquoi et quand preserver les saphenes des malades variqueux pouvant servir a un pontage arteriel? Journal des Maladies Vasculaires. 1994; 19(3):216-21.
2. Janbon C. Laborde JC. Quere I. Apercu historique du traitement des varices.Journal des Maladies Vasculaires. 1994; 19(3):210-5.
101. Goren G. Yellin AE.Invaginated axial saphenectomy by a semirigid stripper:
perforate-invaginate stripping. Journal of Vascular Surgery. 1994 Dec; 20(6):970-7.
102. Labropoulos N. Leon M. Nicolaides AN. Giannoukas AD. Volteas N. Chan P.Superficial venous insufficiency: correlation of anatomic extent of reflux
with clinical symptoms and signs.Journal of Vascular Surgery. 1994 Dec; 20(6):953.
105. Van Rij AM. Solomon C. Christie R. Anatomic and physiologic characteristics o f venous ulceration. Journal of Vascular S urgery. 1994 No; 20(5):759-64.
106. Schanzer H. Skladany M. Varicose vein surgery with preservation of the saphenous vein: a comparison between high ligation-avulsion versus saphenofemoral banding valvuloplasty-avulsion.Journal of Vascular Surgery. 1994 Nov; 20(5):684-7.
107. Labropoulos N. Leon M. Volteas N. Nicolaides AN.Acute and long-term effect of elastic stockings in patients with varicose veins.International Angiology. 1994 Jun; 13(2):119-23.
109. Liew SC. Huber D. Jeffs C.Day-only admission for varicose vein surgery.
Australian & New Zealand Journa l of Surgery. 1994 Oct; 64(10):688-91.
110. Rutgers PH. Kitslaar PJ.Randomized trial of stripping versus high ligation combined with sclerotherapy in the treatment of the incompetent greater saphenous ve
in.American Journal of Surgery 1994 Oct; 168(4):311-5.
111. Sachs G. Thiele H. Gai H. Erste Erfahrungen mit der endoskopisch subfaszialen Dissektion der Perforansvenen (ESDP) nach 100 Eingriffen.Zentralblatt fur Chirurgie. 1994; 119(7):501-5.
112. Tong Y. Royle J. An anatomic source of false venous reflux with continuous wave Doppler.Journal of Dermatologic Surgery & Oncology 1994 Oct. 20(10):676-8.
114. Scappaticci S. Capra E. Cortinovis M. Cortinovis R. Arbustini E.
Diegoli M. Fraccaro M.Cytogenetic studies in venous tissue from patients with varicose veins. Cancer Genetics & Cytogenetics. 1994 Jul ; 75(1):26-30.
115. Gradman WS.Venoscopic obliteration of variceal tributaries using monopolar electrocautery. Pr eliminary report.Journal of Dermatologic Surgery & Oncology. 1994 Jul; 20(7):482-5.
117. Feied CF. Jackson JJ. Bren TS. Bond OB. Fernando CE. Young VC.
Hashemiyoon RB. Allergic reactions to polidocanol for vein sclerosis. Two case reports. Journal of Dermatologic Surgery & Oncology 1994 Jul. 20(7):466-8.
118. MacLennan WJ. Wilson J. Rattenhuber V. Dikland WJ. Vanderdonckt J.
Moriau M.Hydroxyethylrutosides in elderly patients with chronic venous
insufficiency: its efficacy and tolerability.Gerontology1994; 40(1):45-52,
120.Bergan JJ. Sclerotherapy: Technique and Appllication in Ed. Rutherford RR Vascular Surgery Fourth Edition; WB Saunders Company Philadelphia 1995: 1831.
1. Carpentier P. Priollet P.Epidemiologie de l'insuffisance veineuse chronique.
Presse Medicale. 1994 Feb 10; 23(5):197-201.
123. Miller D. Biegeleisen K.Sequential injection of 3% sodium tetradecyl sulfate and 20% sodium chloride in the treatment of refractory varicosity of the greater saphenous vein. Journal of Dermatologic Surgery & Oncology1994 May 20(5):329-31..
124. Cornu-Thenard A. Boivin P. Baud JM. De Vincenzi I. Carpentier PH.Importance of the familial factor in varicose disease. Clinical study of 134 families. Journal of Dermatologic Surgery & Oncology1994 May. 20(5):318-26.
125. Bradbury AW. Stonebridge PA. Callam MJ. Walker AJ. Allan PL. Beggs I.
Ruckley CV.Recurrent varicose veins: assessment of the saphenofemoral junction.
British Journal of Surgery1994 Mar. 81(3):373-5.
129. Ogi S. Kanaoka Y. Mori T.[Diagnosis of incompetent perforators in primary varicose veins by high resolution ultrasonography]. [Japanese] Nippon Geka Gakkai Zasshi. Journal of Japan Surgical Society. 1994 Ja; 95(1):34-9 .
130. Garde C.Cryosurgery of varicose veins.Journal of Dermatologic Surgery & Oncology. 1994 Jan; 20(1):56-8.
132. De Maeseneer MG. De Hert SG. Van Schil PE. Vanmaele RG. Eyskens EJ.
Preoperative colour-coded duplex examination of the saphenopopliteal junction in recurrent varicosis of the short saphenous vein.Cardiovascular Surgery. 1993 Dec; 1(6):686-9.
133. Miyake H. Langer B. Albers MT. Bouabci AS. Telles JD. Tratamento irurgico das telangiectasias.Revista do Hospital das Clinicas; Faculdade de Medicina Da Universidade de Sao Paulo. 1993 Sep-Oct ; 48(5):209-13.
134.Scurr JH/ Varicose Veins and the Ulcerated leg. Surgery Feb 1996; 14, 2: 40-1.
135. Charles AK. Gresham GA.Histopathological changes in venous grafts and in varicose and non-varicose veins [see comments].Journal of Clinical Pathology. 1993 Jul; 46(7):603-6.
137. Millien JP. Coget JM. Complications de la chirur gie veineuse superficielle des membres inferieurs: les hematomes et abces de cuisse.Phlebolog ie. 46(4):583-90, 1993 Oct-Dec.
138. Henriet JP. Les complicati ons sexuelles de la chirurgie veineuse superficielle.Phlebo logie. 1993 Oct-Dec; 46(4):569-75.
139. Ouvry PA. Guenneguez H. Ouvry PA. Complications lymphatiques de la chirurgie des varices. Phlebologie. 46(4):563-8, 1993 Oct-Dec.
141. Kirienko AI. Zubarev AR. Kolesnikov AL. Bogachev VIu. Al'bitskii AV. Ul'trazvukovaia diagnostika ostrogo tromboflebita bol'shoi podkozhnoi veny bedra.
Grudnaia i Serdechno-Sosudistaia Khirurgiia. 1993 Nov-Dec; (6):49-53.
142. Laurikka J. Sisto T. Auvinen O. Tarkka M. Laara E. Hakama M.Varicose veins in a Finnish population aged 40-60. Journal of Epidemiology & Community Health. 47(5):355-7, 1993 Oct.
143. Hoshino S. Satakawa H. Iwaya F. Igari T. Ono T. Takase S. Valvuloplastie externe sous controle angioscopique pre-operatoire. Phlebologie1993 Jul-Sep; 46(3):521-9.
145. Gandhi RH. Irizarry E. Nackman GB. Halpern VJ. Mulcare RJ. Tilson MD.Analysis of the connective tissue matrix and proteolytic activity of pri mary varicose veins. Journal of Vascular Surgery. 1993 No; 18(5):814-20.
146. Neglen P. Einarsson E. Eklof B.The functional long-term value of different types of treatment for saphenous vein incompetence.Journal of Cardiovascular Surgery. 1993 Aug; 34(4):295-301.
147. McBride KD. Gaines PA. Beard JD.Pneumatic phlebography: a possible new technique for the assessment of recurrent varicose veins.European Journal of Radiology. 1993 Sep; 17(2):101-5.
148. Guex JJ. Journal of D ermatologic Surgery & Oncology. 1993 Oct; 19(10):959-61.
149. Biegeleisen K. Neilsen RD. O'Shaughnessy A.Inadvertent intra-arterial injection complicating ordinary and ultrasound-guided sclerotherapy.Journal of Dermatologic Surgery & Oncology 1993 Oct; 19(10):953-8.
150. Weiss RA. Weiss MA.Dop pler ultrasound findings in reticular veins of the thigh ubdermic lateral venous system and implications for sclerotherapy. Journal of Dermatologic Surgery & Oncology. 1993 Oct; 19(10):947-51.
151. Somjen GM. Ziegenbein R. Johnston AH. Royle JP. Anatomical examination of leg telangiectases with duplex scanningJournal of Dermatologic Surgery & Oncology. 1993 Oct; 19(10):940-5.
152. Travers JP. Rhodes JE. Hardy JG. Makin GS.Postoperative limb compression in reduction of haemorrhage after varicose vein surgery.Annals of the Royal College of Surgeons o f England. 1993 Ma; 75(2):119-22.
153. Muller S. Schreiber R. Marty A.Vergleich der klinischen und apparativen mit der intraoperativen endoskopischen Lokalisation von insuffizienten Venae perforantes. Helvetica Chirurgica Acta. 1993 Jun; 59(5-6):825-8.
154. Leon M. Volteas N. Labropoulos N. Kalodiki E. Chan P. Belcaro G. colaides AN. The effect of elastic stockings on the elasticity of varicose veins. International Angiology. 1993 Jun; 12(2):173-7.
155. Bradbury AW. Stonebridge PA. Ruckley C V. Beggs I.Recurrent varicose veins: correlation between preoperative clinical and hand-held Doppler ultrasonographic examination, and anatomical findings at surgery.British Journal of Surgery. 1993 Jul; 80(7):849-51.
156. Lees TA. Lambert D.Patterns of venous reflux in limbs with skin changes associated with chronic venous insufficiency.British Journal o f Surgery. 1993 Jun; 80(6):725-8.
157. Weiss RA.Evaluation of the venous system by Doppler ultrasound and photoplethysm ography or light reflection rheography before sclerotherapy.Seminars in Dermatology. 1993 Jun; 12(2):78-87.
158. Raymond-Martimbeau P.Dallas Non-Invasive Vascular Laboratory, TX.Advanced sclerotherapy treatment of varicose veins with duplex ultrasonographic guidance.Seminars in Dermatology. 1993 Jun; 12(2):123-8.
159. Fratila A. Rabe E. Kreysel HW.Percutaneous minisurgical phlebectomy.Seminars in Dermatology. 1993 Jun; 12(2):117- 22.
160. Georgiev M. Ricci S. Carbone D. Antignani P. Moliterno C.Stab avulsion of the short saphenous vein. Technique and duplex evaluation. Journal of Dermatologic Surgery & Oncology. 1993 May; 1 9(5):456-64.
161. Dindelli M. Parazzini F. Basellini A. Rabaiotti E. Corsi G. Ferrari A. Risk factors for varicose disease before and during pregnancy. Angiology. 1993 May; 44(5):361-7.
162. Rutgers PH. Kitslaar PJ. Ermers EJ.Photoplethysmography in the diagnosis of uperficial venous valvular incompetence. British Journal of Surgery. 1993 Mar; 80(3):351-3.
167. Shami SK. Sarin S. Cheatle TR. Scurr JH. Smith PD.Venous ulcers and the superficial venous system. Journal of Vascular Surg ery. 1993 Mar; 17(3):487-90.
171. Sarin S. Shields DA. Farrah J. Scurr JH. Coleridge-Smith PD.Does venous function deteriorate in patients waiting for varicose vein surgery?.Journal of the Royal Society of Medicine. 1993 Jan ; 86(1):21-3.
172. Franks PJ. Wright DD. Moffatt CJ. Stirling J. Fletcher AE. Bulpitt CJ. McCollum CN.Prevalence of venous disease: a community study in west London.European Journal of Surgery. 1992 Mar; 158(3):143-7.
174. Schadeck M.Phlebologie. 1992 Nov; 45(4):509-12.
175. Cornu-Thena rd A. Boivin P. Garde C . Sentou Y.Evaluation des resultats des therapeutiques curatives des varices par trois scores: clinique, Doppler et echographique. Phlebologie. 1992 Nov; 45(4):389-99.
176. Hagmuller GW.Komplikationen bei der Chirurgie der Varikose.Langenbecks Archiv fur Chirurgie - Supplement - Kongressband. :470-4, 1992.
177. Blattler W. Frick E.Komplikationen der Thrombophlebitis superficialis.Schweizerische Medizinis che Wochenschrift. Journal Suisse de Medecine. 1993 Feb 1; 123(6):223-8.
178. DP O'Leary, SM Jones, JF Chester. Management of varicose veins according to reason for presentation. Ann R Coll Surg Engl 1996; 78: 214-216.
179.H Ellis. Case Histories from the past: Benjamin Collins Brodie-Varicose Vein Surgery. Surgery 1996; 14, 8: ii-iii.
180. M Campanello, J Hammarsten, C Forsberg, P Bernland, O Henrikson, J Jensen. Standard Stripping Versus Long Saphenous vein-Saving Surgery for Primary varicose Veins. A Prospective, Randomized Study With the patients as their own Controls. Phlebology 1996; 11: 45-49.
181. CV Ruckley in Ed CW Jamieson & JST Yao. Vascular Surgery 5th Edition. Chapman & Hall Medical London 1994; 552-57.