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44 Gonadal Vein Reflux: Varicocele and Pelvic Congestion 443
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Chapter 45
Varicose Veins
David West
Definition
Varicose veins are abnormal dilated veins secondary to abnormal flow due to venous
insufficiency. Varicose veins can occur at many sites; this chapter will focus on
varicose veins in the lower limb.
Clinical Features
• Varicose veins are very common affecting up to 40% of the population.
• Classically affect medial aspect of the limb (great saphenous vein territory)
(Fig. 45.1) or posterior calf (small saphenous vein territory) but many variations
exist.
• Patients complain frequently of aching, itching, restless legs, aching and tiredness
which are worst when standing.
• May lead to severe skin discoloration due to the deposition of hemosiderin.
• Some patients may present with skin ulceration.
• Occasionally mild trauma will cause severe hemorrhage.
Causes of Venous Insufficiency
• Valve failure (genetic and by far the most common)
• Muscle pump failure
• Deep venous obstruction, e.g., secondary to deep vein thrombosis (DVT) or
proximal venous obstruction, e.g., May-Thurner syndrome.
All these are normally permanent but can occasionally be temporary (e.g.,
pregnancy-induced).
Transcatheter Embolization and Therapy,
Techniques in Interventional Radiology, DOI 10.1007/978-1-84800-897-7_45,
C
Springer-Verlag London Limited 2010
445
446 D. West
Fig. 45.1 (a) Gross great saphenous varicose veins pre-treatment. (b) Same patient after EVLA
ablation of great saphenous vein
Natural History of Varicose Veins
• Varicose veins do not spontaneously disappear except sometimes following
pregnancy.
• Progression is highly variable. Some progress rapidly over weeks whereas others
remain static for many years.
• Serious skin changes (e.g., ulceration 0.5–1.5%) which cannot be predicted.
Diagnostic Evaluation
If involved in the treatment of varicose veins, it is important to be able to assess the
patient clinically.
History: to elicit the following:
• How seriously the problem is affecting patient’s life.
• Past medical history of DVT, congenital venous problems.
• Details of previous treatment for varicose veins. Veins that have not undergone
previous therapy are the simplest to manage.
45 Varicose Veins 447
Physical examination
• Patient standing position with bare legs.
• Visual inspection to detect and record
◦ Ulceration and other skin changes.
◦ Appearance and distribution of varicosities.
◦ Scars from previous surgery.
◦ Birth marks.
• Palpation to detect defects in fascia which may indicate incompetent perforators.
• Measure the circumference of both legs.
• Do not attempt to detect presence of reflux by physical examination.
Imaging
• The aim of imaging varicose veins is to establish and document the following:
◦ Patency of deep veins
◦ Anatomy and size of the superficial and deep venous systems
◦ Distribution of varicosities
◦ Presence, degree, and sites of reflux
• Color duplex scanning with the patient standing is the gold standard.
◦ Concentrate on the sapheno-femoral vein junction (SFJ) and sapheno-popliteal
vein (SPJ) junction in primary varicose veins.
◦ Use adjunctive compression and Valsalva maneuvers.
◦ Look for sustained reflux.
• In complex cases exquisite images can be obtained using CT and MR venography
but these do not demonstrate abnormal flow.
• Direct venography is occasionally necessary and usually only performed at the
time of therapy.
• Consider deep venous stenosis as a contributory cause. This should be treated by
angioplasty or stenting before treating the reflux symptoms.
Indications for Treatment
Varicose veins are benign and treatment is aimed at symptom relief (e.g., cosmetic,
pain relief etc.)
• Varicose veins associated with ulceration or impending ulceration should be
actively treated.
• Other symptoms should be treated according to patient preference and local
expertize.
448 D. West
Alternative Therapies
Surgery
The gold-standard surgical technique is to tie-off all superficial branches at the SFJ
or SPJ, strip the refluxing saphenous vein, and avulse the varicosities.
Occlusion techniques: these are established as alternatives to surgery.
• There are two principal mechanisms and are as follows:
◦ Heating (laser and radiofrequency)
◦ Chemical (sclerotherapy)
• Catheter-based techniques may be used in primary varicose veins or recurrent
varicosities.
• Unlike surgery, the refluxing venous source is left in situ but the lumen is
permanently occluded.
• Subsequent therapy may be needed to deal with troublesome residual varicosities.
• Normally only two truncal veins can be treated at one session.
Contraindications
• Occluded deep vein. This leaves the superficial veins as the sole route of venous
return and is an absolute contraindication. Note that in the presence of deep
venous reflux the condition of the leg can be dramatically improved by treating
the superficial reflux.
• Procoagulant conditions (e.g., oral contraceptive pill) are a relative contraindica-
tion to foam sclerotherapy.
Special situations that may increase difficulty: although with experience most
patients can be treated by endovascular means, some cases present special
challenges.
• Young fit women who exercise regularly have veins which are prone to spasm.
• Very tortuous and very superficial veins.
• Short wide communications with the deep veins (e.g., in the popliteal fossa) can
still be treated using either laser or RF SEPS (Fig. 45.2) but require special
attention to prevent damage to deep veins. The use of foam sclerotherapy blocked
by an occlusion balloon catheter can also be useful in this situation.
• Thermal treatment of a duplicated truncal vein can cause the second vein to go
into spasm. To prevent this, catheterize both before heating either.
General Complications of Venous Ablation Therapy
• Superficial thrombophlebitis
• Deep vein thrombosis
45 Varicose Veins 449
Fig. 45.2 RF SEPS needle in
position in perforator
Specific Complications of Thermal ablation
• Burns, nerve injuries
• Aching and bruising (worse after laser)
Specific Complications of Foam Sclerotherapy
• Transient visual loss.
• Skin discoloration is common although usually lasts less than 1 year.
• Ulceration and allergy are rare.
Anatomy and Physiology
Normal Venous Anatomy
• Contain bicuspid valves allowing flow only from superficial to deep and toe to
heart.
• Deep veins anatomically follow the arterial supply. Deep veins lie between the
muscles of the legs. The deep system comprises calf veins, popliteal vein, femoral
vein, external and common iliac veins.
• Superficial veins. Lie between two layers of fascia.
◦ Great saphenous vein drains into common femoral vein at the SFJ in the groin.
◦ Small saphenous vein drains into popliteal vein in popliteal fossa (SPJ).
◦ Anterolateral thigh vein coursing across the thigh from lateral to medial and
joining the great saphenous vein at or near the SFJ.
• Perforating veins.
◦ Communicate between superficial and deep systems at several points on the
lateral and medial sides of the leg.
450 D. West
Aberrant anatomy: Many variants exist including the following.
• Parallel duplicate channels of the femoral vein are very common.
• Giacomini vein—extension of small saphenous vein to join the great saphenous
vein.
Awareness of this variable anatomy is essential to the proper management of
varicose veins.
Normal Lower Limb Venous Physiology
• Calf muscle contraction compresses the deep veins.
• In presence of competent valves, blood is forced toward the heart.
• Calf muscles relaxation reduces pressure in the deep veins, blood passes from
superficial to the deep veins.
• Cycle repeats enabling blood to pass against gravity from foot to heart.
Equipment
Imaging
• Color duplex ultrasound scanner 7.5–12 MHz linear probe.
• Access to fluoroscopy if possible.
Needles
19G for initial venous puncture.
Micropuncture sets for small veins or those prone to spasm, e.g., young fit
women, tortuous, and superficial branches.
Guidewires
• 0.035double-ended J/straight standard wire.
• 0.035
• 0.025
hydrophilic wire for tortuous veins and those in spasm.
or 0.018for use with VNUSclosureFastR system.
Catheters/Introducer Sheaths
• 7F 9 cm sheath for VNUSclosureFastR.
• 4–6F 45–80 cm sheath for introduction of laser fibers. These should have visible
markings at least every centimeter to judge pullback rate (Fig. 45.3).
• Diagnostic angiographic catheters as necessary.
45 Varicose Veins 451
Fig. 45.3 Laser fiber in
position in calibrated sheath
Miscellaneous
• Luer-lock syringes and three-way taps for sclerosant foam production.
• Avulsion hooks (for stab phlebectomy).
• Occlusion balloon catheters.
• Tilting couch.
• Class-2 compression hosiery/compression bandaging.
Medication
Pain control: Diclofenac 500 mg SR OD as required (post-procedure).
Local anesthetic.
Initial cannulation: 5 ml 1% lidocaine without adrenaline.
Tumescent analgesia: 20 ml 2% lidocaine with adrenaline diluted with saline to
100 ml (0.4%) and 400 ml (0.1%).
Treatment Plan and Technique
Treatment principles: regardless which technique is used, there are three elements
to consider and are as follows:
1. To abolish all sources of reflux starting with the most proximal (cranial): gonadal
vein, iliac vein, SFJ, SPJ, perforating vein.
2. To occlude the main incompetent vein.
3. To treat residual varicosities.
Thermal Ablation Therapy
This includes laser and RFA. Many of the principles are common to either technique
as are many of the complications.
452 D. West
Laser Therapy
Laser Equipment
• Diode laser of at least 15 watts power and emitting in the range 810–980 nm
wavelength or Nd/YAG laser (1064 or 1340 nm wavelength).
• Laser fiber: 3 m bare-ended glass fiber of appropriate notional aperture (NA) and
with appropriate fitting for the laser. Normally 600 μm but can use 400 μmor
even 200 μm diameter especially for small veins.
Access
• Plan according to duplex ultrasound findings.
• Access vein just below the last significant varicose branch using 19G needle or
cannula or micropuncture set.
• Guide needle into vein lumen using ultrasound in a longitudinal scanning plane.
Treatment Technique
• Advance guidewire to the proximal site of reflux (usually the SFJ or SPJ).
• Position the sheath to at least 2 cm beyond the junction within the deep vein.
• Advance laser fiber to tip of sheath.
• Withdraw sheath 2 cm to expose 2 cm of the fiber.
• Fix fiber to sheath using a Tuohy Borst adapter or sterile sticky tape.
• Inject tumescent anesthesia solution (Fig. 45.4),using ultrasound guidance and a
spinal needle, around the whole length of the vein ensuring that there is a good
volume of fluid around the whole circumference of the vein. This usually requires
about 400 ml per meter of vein.
Fig. 45.4 Ultrasound-guided injection of tumescent analgesia. Note the set-up of the room with
the ultrasound clearly visible to the operator
45 Varicose Veins 453
• Withdraw the sheath under ultrasound guidance until the tip of the laser fiber is
at least 2 cm away from the deep veins.
• Fire laser and withdraw fibre/sheath at a rate of about 2 mm per second achieving
at least 70 J energy per cm.
• Stop firing the laser at least 1 cm from skin puncture.
• Repeat with further veins as necessary.
• Apply dressings and compression stockings.
Technical tips. In difficult cases:
• Try hydrophilic wire and catheter techniques.
• Use ultrasound and external pressure to direct tip of catheter through tortuous
segments.
• Consider fluoroscopic guidance with contrast injection.
• If severe spasm prevents visualization of vein try
◦ Waiting for 15 minutes
◦ Getting patient to walk around
◦ Elevating head of bed
Radiofrequency Ablation Therapy
Radiofrequency Devices
• RF generator
• RF catheter supplied by generator manufacturer
• RF SEPS needles for perforators
Technique
• Essentially similar to laser technique.
• But use conventional 7F vascular sheath.
• No need for guidewire in most cases; just advance RF catheter through sheath to
the proximal portion of the vein to be treated.
• Apply pressure over the tip of the catheter during energy deposition.
• Follow manufacturer’s instructions regarding withdrawal rate. The withdrawal
rate is typically significantly slower than the laser withdrawal rate.
• If difficulty use a 0.25
sheath along whole length of vein using techniques above.
guidewire through the catheter or first place a long 7Fr
Foam Sclerotherapy
• Most practitioners do not recommend this as a primary means of closing a truncal
vein as there is a high recanalization rate compared to laser or RF.
• Insert 18G cannula below the origin of t he last significant varicosity.