Postgraduate Medicine
ISSN: 0032-5481 (Print) 1941-9260 (Online) Journal homepage: http://www.tandfonline.com/loi/ipgm20
Varicose veins Karl A. Lofgren To cite this article: Karl A. Lofgren (1979) Varicose veins, Postgraduate Medicine, 65:6, 131-139, DOI: 10.1080/00325481.1979.11715178 To link to this article: https://doi.org/10.1080/00325481.1979.11715178
Published online: 07 Jul 2016.
Submit your article to this journal
View related articles
Citing articles: 16 View citing articles
Full Terms & Conditions of access and use can be found at http://www.tandfonline.com/action/journalInformation?journalCode=ipgm20
©
1978 Mayo Foundation
Varicose veins Their symptoms, complications, and management
Karl A. Lofgren, MD
Consider What conditions lead to varicose veins? When are nonsurgical approaches warranted? What alternatives to surgery are available? What method of surgical correction produces the best long-term results?
VOL 65/NO 6/JUNE 1979/POSTGRADUATE MEDICINE
Varicose veins are a common problem that still presents a major challenge to the physician and the patient. Complete surgical removal of the malfunctioning veins has proved to be the most effective management for significant varicosities, although several nonsurgical methods are available for mild cases or those not suitable for surgery. Since ancient times, varicose veins have been recognized as an important cause of chronic leg symptoms and disabling complications. Many patients afflicted with this common disorder have been discouraged by the need for repeated treatments and by the less-than-satisfactory results. The many modes of treatment still advocated today are a revealing indictment of the refractory nature of varicose veins, and the importance of the problem is underscored by the high incidence of varicosities and their tendency to recur. lt is estimated that approximately I0% of the adult population have significant varicose veins, ie, those causing symptoms or complications of varying degrees. Many more, perhaps 40% to 50% of adults, have minimal and insignificant varicosities or dilated cutaneous venules that are unsightly but of cosmetic concern only. This superficial venous disorder afflicts twice as many women as men, undoubtedly because of the untoward effects of pregnancy on leg veins. A positive family history can be elicited in more than half the patients who have varicosities that need treatment. The term "varicose veins" includes all abnormally dilated super-
ficial veins of the lower extremities, ranging in size from minute spiderbursts of the skin to large protruding vessels in the subcutaneous layer. Whereas the former do not disrupt venous physiology, the latter usually do interfere with normal venous circulation because of valvular insufficiency. Between these extremes are the more numerous but milder varicosities that often, although not necessarily always, enlarge and become more extensive with time. The pathophysiology of varicose veins is directly related to the hemodynamic changes that develop when the valves of the major superficial veins become incompetent and fail to function normally. Incompetency generally results from excessive dilatation of a vein and the consequent abnormal separation of valve cusps. Less often, it results from inflammatory destruction of the valve structure by thrombophlebitis. With incompetent saphenous veins, venous hypertension occurs during ambulation; this also disrupts the otherwise normal microcirculation in the capillary bed. When the venous pressure of the leg does not decrease to its normal lower level during walking or exercise, symptoms and complications continued
131
Saphenous vein incompetency, caused by either the abnormal separation or the inflammatory destruction of valve cusps, leads to chronic venous insufficiency and areas of stasis-caused changes.
with the severity of the venous pathophysiology.
Figure 1. "Stasis areaft of leg and ankle. where typical congestive changes develop from chronic venous insufficiency. From u?fgren KA: Stasis ulcer. Mayo Clin Proc40:564-573. /965.
from chronic venous insufficiency eventually develop. The skin and subcutaneous tissues of the lower third of the leg and the ankle suffer from the effects of chronic venous stasis, evidenced clinically in degrees by the appearance of pigmentation, dermatitis, edema, induration, cellulitis, and superficial ulceration. These tissue changes typically occur in the "stasis area" of the lower leg and ankle (figure I) and vary
132
Symptoms Symptoms from varicose veins are usually, although not always, proportional to the size and number of the abnormally dilated vessels. The largest varicosities sometimes cause no complaints; other veins of small caliber may give rise to surprising discomfort. Symptoms due to venous insufficiency or varicose veins are typically relieved with elevation of the legs or with use of proper elastic support. If symptoms are not thus relieved, other causes must be suspected and sought; these might include osteoarthritis of the knee joints, lumbosacral strain, intermittent claudication (always check pedal pulses), flatfeet, "restless legs," or psychosomatic distress. Aching of the legs- This is the most common complaint associated with varicose veins. The discomfort is distributed over the varicose vessels, becomes worse toward evening, and is promptly relieved with rest and elevation of the legs. Relief can also be obtained by wearing elastic bandages or stockings during daytime activities. In women, aching caused by varicosities is accentuated before menstrual periods, when hormonal effects cause additional vasodilatation. Contraceptive medication will produce similar aching in some patients. Fatigue and tired legs- These vague symptoms are frequent conse-
quences of varicose veins and impaired venous flow but may also occur in normal legs because of chronic exhaustion. Relief is usually obtainable with elastic support, rest and elevation of the legs. or surgical removal of malfunctioning varicosities. Swelling of the ankles- This problem is most troublesome in warm weather. Mild swelling causing subjective discomfort is common, but true pitting edema is rare. Severe edema is never caused by uncomplicated varicosities. Cramps of the calf muscles-The chronic venous stasis and increased hydrostatic pressure that accompany large varicose veins sometimes cause cramping of the calf muscles toward the end of the day or during the night, particularly after a person has been standing for long periods. Muscle cramps may also occur in many persons with normal veins. Cramps that develop only during walking or exercise are more likely caused by occlusive arterial disease than by venous insufficiency. Itching or burning-Some patients with varicose veins experience itching or burning, even when no skin lesions are present. Most often neurodermatitis also is present, and locally applied antipruritic lotion in combination with elastic support will usually relieve the symptoms. Cosmetic concern- The unsightly appearance of varicose veins is important to many patients, particularly younger women; spiderbursts and unsightly cutaneous ven-
VOL 65/NO 6/JUNE 1979/POSTGRADUATE MEDICINE
Aching of the legs is the most common complaint with varicose veins. Others are fatigue, swelling, cramps, itching or burning, and unsightly appearance.
ules rather than larger varicosities are usually the objects of their concern. Although these tiny vessels are not amenable to surgical treatment, injection therapy by an experienced physician is sometimes helpful in improving the appearance of the legs. Complications
Pigmentation-A harmless complication by itself, pigmentation is an early sign of chronic venous insufficiency. It represents hemosiderin in the extravascular tissues of the skin and subcutaneous layer. Pigmentation over the medial aspect of the ankle and lower leg is often noted with varicose veins of long duration. Removal of incompetent varicose veins will lessen or gradually eliminate the stasis pigmentation. Dermatitis-This condition often develops as a complication of either varicose veins or chronic deep venous insufficiency (postphlebitic leg condition). It typically involves the "stasis area" of the leg (figure 2) and may be of the dry, scaly type or the raw, weeping form. The former is often chronic and accompanied by intense itching in the form of a neurodermatitis that is kept active by repeated scratching. The latter is more acute, with inflammatory redness, edema, and drainage. A generalized sensitivity or "id" reaction on the trunk, arms, or neck, which results in patches of reddish irritated skin, sometimes complicates the problem further; antihistamine or cortisone
medication may be necessary for its control. Bed rest with elevation of the legs is the treatment of choice for the severe forms of dermatitis. This is used in conjunction with moist dressings for the weeping type of dermatitis or bland ointment or cream for the dry, scaly type. In the section of peripheral vein surgery at the Mayo Clinic, we prefer a 0.25% aqueous solution of aluminum subacetate for moist dressings, although a weak boric acid solution or physiologic saline solution can be used instead. Pronounced itching with the dry type of dermatitis may be relieved by use of a cortisone cream or ointment.
Subacute cellulitis-Subacute cellulitis with redness, tenderness, and induration is a fairly common stasis complication of varicose veins and also of chronic deep venous insufficiency. High fever and chills are absent, in contrast to the symptoms of lymphangitis. Stasis cellulitis develops in the lower part of the leg or around the ankle, not higher up in the leg or thigh. Bed rest, elevation of the leg, and application of moist, warm compresses reduce the inflammatory reaction. Antibiotic therapy is seldom necessary except in refractory cases. Any residual induration can be prevented or reduced with adequate elastic support provided by a foam rubber pad over the involved area and a heavy elastic bandage from toes to knee. Ulceration- This condition occasionally complicates varicose veins,
Karl A. Lofgren Dr Lofgren is head of the section of peripheral vein surgery. department of surgery. Mayo Clinic and Mayo Foundation. and associate professor of surgery. Mayo Medical School. Rochester. Minnesota. He is also a fellow of the American College of Surgeons and a diplomate of the American Board of Surgery.
continued
VOL 65/NO 6/JUNE 1979/POSTGRADUATE MEDICINE
133
Complications of varicosities can include pigmentation, dermatitis, subacute cellulitis, ulceration, bleeding, and thrombophlebitis.
Figure 2. Stasis dermatitis. a complication of varicose veins.
usually when superficial abrasion or injury has occurred. Severe ulceration generally accompanies only deep venous insufficiency. Incompetent perforating veins are much more common after deep thrombophlebitis. Small ulcers often heal readily with bed rest, elevation of the leg, and moist dressings. In ambulatory patients, small ulcers can be treated effectively with an Elastoplast boot, which is applied in a manner similar to that for the old, but more cumbersome, Unna boot. The boot is left in place for a week to ten days before
134
being replaced with a new one; this treatment is continued until the ulcers are completely healed. Large ulcers (>3 cm in diameter) may need split-thickness skin grafts to shorten the period of healing. Incompetent perforating veins and varicose veins should be removed. When deep venous insufficiency is the predominant problem, adequate elastic support is necessary for lasting satisfactory control. Bleeding-If not controlled promptly with local pressure and elevation of the leg, bleeding from a small eroding varicosity can be a serious complication. Fatalities among elderly, debilitated patients from spontaneous hemorrhage have been reported in the literature. Such bleeding usually occurs in the ankle or lower leg region. Injection of the offending vessel is often sufficient treatment, although surgical excision is preferable when incompetent large varicosities are also present. Use of elastic support is advisable in all instances. Thrombophlebitis- This common complication of varicose veins may occur spontaneously or after a trivial injury in a prominent varicose tributary, usually on the medial aspect of the leg or lower thigh. Local redness, tenderness, and induration of a varicose vein are characteristically present. Extension of the inflammatory process into the saphenous vein and upward toward the groin is not uncommon. When this occurs, elevation of the leg and ap-
plication of warm compresses are indicated to prevent further spread. In those cases in which the involved area is small and well localized, compression with a foam rubber pad and elastic bandage for one or two weeks may be sufficient to resolve the inflammatory process. Anticoagulant therapy is not necessary unless progressive extension of the thrombophlebitis into the groin appears imminent or deep thrombophlebitis is suspected. Early surgical removal of the thrombosed varicosities and associated faulty saphenous system will often shorten the total time of disability.
Management Both surgical and nonsurgical procedures have been used traditionally in the management of varicose veins. The ideal treatment should be simple, lasting, and without risk to the patient. Before any treatment is undertaken, whether it be surgery, sclerotherapy, or elastic support, the venous problem must be accurately diagnosed. Periodic elevation of the legs and appropriate exercises can be used as supplemental treatment. At times, a combination of surgical and nonsurgical methods is used for effective relief of symptoms.
Nonsurgical treatment-Sclerotherapy-This is one approach to managing mild varicose veins. It can be used as cosmetic treatment of minor venules or spiderbursts or as supplemental treatment for smaller, recurrent varicosities sometimes
VOL 65/NO 6/JUNE 1979/POSTGRADUATE MEDICINE
In mild cases, nonsurgical treatment, such as sclerotherapy, elastic support, or elevation of the leg and exercise, is sufficient for relief of varicose vein symptoms.
noted during follow-up examinations after surgical treatment. For spiderbursts, I% sodium tetradecyl sulfate (Sotradecol) made foamy by shaking the half-empty glass syringe is used. A few droplets are injected with a 27-gauge hypodermic needle into the tiny venule, preferably the "central feeder" (figure 3). A pressure pad is applied to the injected site to prevent leakage and to compress the injected vessel for several days. For small varicose tributaries associated with an otherwise normal saphenous vein (so-called reticular varicosities), sclerotherapy is sometimes successful, although recurrences from subsequent recanalization eventually develop in most patients. For large varicose tributaries, surgical excision will produce more long-lasting results. Elastic support-When surgical treatment is not advisable because of medical disorders or a patient's advanced age, elastic support with either elastic bandages or well-fitted elastic stockings can be used for relief of symptoms; it is also prescribed for pregnant patients who have symptomatic varicosities. Elastic bandages or stockings compress dilated superficial varicosities and provide external support for the musculovenous pump mechanism of the leg. Stockings should be of the pressure-gradient type-that is, the compression should be greatest at the ankle and least at the knee. Rarely is elastic support needed
above the knee, although for cosmetic reasons many patients prefer lightweight stockings or support hose that extend over the thigh. Elevation of the legs and exercise-These provide yet another type of nonsurgical treatment. If a patient lies down with the legs elevated 12 to 15 in. above the level of the heart, hydrostatic venous pressure decreases and symptoms of chronic venous insufficiency are alleviated. Exercise such as walking , bicycling, or swimming decreases venous pressure and thereby relieves symptoms by activating the musculovenous pump of the legs and forcing venous blood upward. Active exercise is even more effective when combined with elastic support.
Figure 3. Spiderburst being injected with foamy sclerosing solution.
Surgical treatment-Surgical correction with removal of all malfunctioning superficial veins usually is the treatment of choice in otherwise healthy patients whose incompetent varicosities are causing symptoms and complications, becoming progressively larger, or giving rise to much distress because of the cosmetic defect (figure 4). Generally, satisfactory long-term results can be expected from such surgical treatment, because faulty veins are permanently eliminated. It is important to recognize and to evaluate the respective effectiveness of the various surgical methods that have been used for management of varicose veins. In an early review study, my associates and II noted that high ligation (alone or corn-
Figure 4. Large \aricosities with incompetency of saphenous vein. best managed with complete surgical removal.
continued
VOL 65/NO 6/JUNE 1979/POSTGRADUATE MEDICINE
135
Severe varicoalties require surgical management. Although ligatlon and partial stripping can be effective, the most satisfactory results are generally achieved with complete surgical elimination of faulty veins.
FigureS. Extensive varicosities (incompetency of greater saphenous systems). a. Appearance preoperatively. b. Two weeks postoperatively. c. Fifteen years postoperatively. Figure 5o and h.fi"om l.i!fgren KA: Varicose 1·ein.1". In HaimcJI'ici H (Edilor): Hi/1 &wk Co, 1976, 1'1' 799-H/1. u.~ed hy perminion clf"puhliJher.
bined with injection therapy) provided lasting satisfactory results in fewer than half of the patients treated. Most of these patients required repeated courses of sclerotherapy. Partial stripping (from groin to knee) provides somewhat better long:-term results than does high ligation, but still less satisfactory than the complete stripping operation, which includes surgical re-
138
Va.~cular
Surgc•r.r:
Prinni1le.~ and
moval of all varicose tributaries in addition to the saphenous vein. "Main channel stripping" leaves too many residual varicose tributaries, which then become the source of early recurrences and necessitate additional operations. In general, any procedure less than complete surgical removal of all varicose tributaries as well as of the saphenous vein will invite early recurrence of the
TedmiqueJ. Ne11· )'brk. Mc(iraw-
disorder. During the past 30 years, my colleagues and I have learned from experience that the complete stripping operation gives the best results in cases of incompetent varicose veins. In stripping the great saphenous vein, the surgical steps include saphenofemoralligation flush with the common femoral vein, stripping of the saphenous vein from the dorso-
VOL 65/NO 6/JUNE 1979/POSTGRADUATE MEDICINE
Long-term results of a complete, thorough stripping procedure are usually excellent, and true recurrences are rare.
medial aspect of the foot to the groin, meticulous excision and stripping of all varicose tributaries, and individual resection of all incompetent perforating veins. For incompetency of the small saphenous vein, the steps include saphenopoplitealligation, stripping of the saphenous vein from the lateral aspect of the ankle to the popliteal fossa, excision and stripping of all varicose tributaries, and resection of any incompetent perforating veins. 2 The extra operating room time required for the complete stripping operation has been well rewarded by superior long-term results (figure 5). Recurrences after any surgical procedure for varicose veins are generally produced by residual or persistent varicosities not eliminated during the original operation. Thus, most can be prevented if a complete, thorough operation is performed initially. Even after adequate surgical removal, true recurrences from new varicosities may develop in a particularly susceptible patient, but the incidence of this is small. Long-term results have proved to be satisfactory with the complete stripping operation. One thousand consecutive patients operated on for varicose veins at our institution ten or more years ago were followed up in a recent studyJ; all had been operated on by the same two staff surgeons. Letters of inquiry regarding the long-term results of the varicose vein operation were sent to all patients, and an invitation to return for
VOL 65/NO 6/JUNE 1979/POSTGRAOUATE MEDICINE
an examination was extended to each. Of the 656 patients who responded, 86% considered the present condition oftheir legs to be good to excellent. Of the total group, 278 returned for objective examination of their legs, and on the basis of the presence or absence of "recurrent" varicose veins, 85% were considered to have good to excellent results. Summary Varicose veins are the most common peripheral vascular disorder of humans. Although a large proportion of the adult population have dilated superficial veins, only a smaller group-estimated to be approximately 10%-have significant varicosities that cause symptoms, complicationS, or even chronic disability. Although no absolute cure has been discovered, much can be done to control this chronic venous
References 1. Lofgren KA et al: An evaluation of stripping versus ligation for varicose veins. Arch Surg76:310-316,1958 2. Lofgren KA: Varicose veins. In Fairbairn JF 11 et al (Editors): Allen-Barker-Hines Pe-
disorder, to provide relief of symptoms, and to prevent complications. An adequate surgical procedure that completely removes all incompetent varicosities continues to be the most effective method of treatment. Sclerotherapy is useful for small cutaneous venules that are of cosmetic concern only and also for the minor varicosities that sometimes develop after surgical treatment. Elastic support serves a useful therapeutic role for relief of venous symptoms and complications when surgical intervention is not feasible or is contraindicated. Periodic elevation of the legs and suitable leg exercises are additional supportive measures that can relieve venous stasis and improve function of the musculovenous pumping mechanism ofthe calf. Address reprint requests to Karl A. Lofgren, MD, Mayo Clinic, Rochester, MN 55901.
ripheral Vascular Diseases. Ed 4. Philadelphia, WB Saunders Co, 1972, pp 601-622 3. Larson RH et al: Long-term results after vein surgery: Study of I,000 cases after I0 years. Mayo Clin Proc 49:114-117, 1974
139
ISSN: 0032-5481 (Print) 1941-9260 (Online) Journal homepage: http://www.tandfonline.com/loi/ipgm20
Varicose veins Karl A. Lofgren To cite this article: Karl A. Lofgren (1979) Varicose veins, Postgraduate Medicine, 65:6, 131-139, DOI: 10.1080/00325481.1979.11715178 To link to this article: https://doi.org/10.1080/00325481.1979.11715178
Published online: 07 Jul 2016.
Submit your article to this journal
View related articles
Citing articles: 16 View citing articles
Full Terms & Conditions of access and use can be found at http://www.tandfonline.com/action/journalInformation?journalCode=ipgm20
©
1978 Mayo Foundation
Varicose veins Their symptoms, complications, and management
Karl A. Lofgren, MD
Consider What conditions lead to varicose veins? When are nonsurgical approaches warranted? What alternatives to surgery are available? What method of surgical correction produces the best long-term results?
VOL 65/NO 6/JUNE 1979/POSTGRADUATE MEDICINE
Varicose veins are a common problem that still presents a major challenge to the physician and the patient. Complete surgical removal of the malfunctioning veins has proved to be the most effective management for significant varicosities, although several nonsurgical methods are available for mild cases or those not suitable for surgery. Since ancient times, varicose veins have been recognized as an important cause of chronic leg symptoms and disabling complications. Many patients afflicted with this common disorder have been discouraged by the need for repeated treatments and by the less-than-satisfactory results. The many modes of treatment still advocated today are a revealing indictment of the refractory nature of varicose veins, and the importance of the problem is underscored by the high incidence of varicosities and their tendency to recur. lt is estimated that approximately I0% of the adult population have significant varicose veins, ie, those causing symptoms or complications of varying degrees. Many more, perhaps 40% to 50% of adults, have minimal and insignificant varicosities or dilated cutaneous venules that are unsightly but of cosmetic concern only. This superficial venous disorder afflicts twice as many women as men, undoubtedly because of the untoward effects of pregnancy on leg veins. A positive family history can be elicited in more than half the patients who have varicosities that need treatment. The term "varicose veins" includes all abnormally dilated super-
ficial veins of the lower extremities, ranging in size from minute spiderbursts of the skin to large protruding vessels in the subcutaneous layer. Whereas the former do not disrupt venous physiology, the latter usually do interfere with normal venous circulation because of valvular insufficiency. Between these extremes are the more numerous but milder varicosities that often, although not necessarily always, enlarge and become more extensive with time. The pathophysiology of varicose veins is directly related to the hemodynamic changes that develop when the valves of the major superficial veins become incompetent and fail to function normally. Incompetency generally results from excessive dilatation of a vein and the consequent abnormal separation of valve cusps. Less often, it results from inflammatory destruction of the valve structure by thrombophlebitis. With incompetent saphenous veins, venous hypertension occurs during ambulation; this also disrupts the otherwise normal microcirculation in the capillary bed. When the venous pressure of the leg does not decrease to its normal lower level during walking or exercise, symptoms and complications continued
131
Saphenous vein incompetency, caused by either the abnormal separation or the inflammatory destruction of valve cusps, leads to chronic venous insufficiency and areas of stasis-caused changes.
with the severity of the venous pathophysiology.
Figure 1. "Stasis areaft of leg and ankle. where typical congestive changes develop from chronic venous insufficiency. From u?fgren KA: Stasis ulcer. Mayo Clin Proc40:564-573. /965.
from chronic venous insufficiency eventually develop. The skin and subcutaneous tissues of the lower third of the leg and the ankle suffer from the effects of chronic venous stasis, evidenced clinically in degrees by the appearance of pigmentation, dermatitis, edema, induration, cellulitis, and superficial ulceration. These tissue changes typically occur in the "stasis area" of the lower leg and ankle (figure I) and vary
132
Symptoms Symptoms from varicose veins are usually, although not always, proportional to the size and number of the abnormally dilated vessels. The largest varicosities sometimes cause no complaints; other veins of small caliber may give rise to surprising discomfort. Symptoms due to venous insufficiency or varicose veins are typically relieved with elevation of the legs or with use of proper elastic support. If symptoms are not thus relieved, other causes must be suspected and sought; these might include osteoarthritis of the knee joints, lumbosacral strain, intermittent claudication (always check pedal pulses), flatfeet, "restless legs," or psychosomatic distress. Aching of the legs- This is the most common complaint associated with varicose veins. The discomfort is distributed over the varicose vessels, becomes worse toward evening, and is promptly relieved with rest and elevation of the legs. Relief can also be obtained by wearing elastic bandages or stockings during daytime activities. In women, aching caused by varicosities is accentuated before menstrual periods, when hormonal effects cause additional vasodilatation. Contraceptive medication will produce similar aching in some patients. Fatigue and tired legs- These vague symptoms are frequent conse-
quences of varicose veins and impaired venous flow but may also occur in normal legs because of chronic exhaustion. Relief is usually obtainable with elastic support, rest and elevation of the legs. or surgical removal of malfunctioning varicosities. Swelling of the ankles- This problem is most troublesome in warm weather. Mild swelling causing subjective discomfort is common, but true pitting edema is rare. Severe edema is never caused by uncomplicated varicosities. Cramps of the calf muscles-The chronic venous stasis and increased hydrostatic pressure that accompany large varicose veins sometimes cause cramping of the calf muscles toward the end of the day or during the night, particularly after a person has been standing for long periods. Muscle cramps may also occur in many persons with normal veins. Cramps that develop only during walking or exercise are more likely caused by occlusive arterial disease than by venous insufficiency. Itching or burning-Some patients with varicose veins experience itching or burning, even when no skin lesions are present. Most often neurodermatitis also is present, and locally applied antipruritic lotion in combination with elastic support will usually relieve the symptoms. Cosmetic concern- The unsightly appearance of varicose veins is important to many patients, particularly younger women; spiderbursts and unsightly cutaneous ven-
VOL 65/NO 6/JUNE 1979/POSTGRADUATE MEDICINE
Aching of the legs is the most common complaint with varicose veins. Others are fatigue, swelling, cramps, itching or burning, and unsightly appearance.
ules rather than larger varicosities are usually the objects of their concern. Although these tiny vessels are not amenable to surgical treatment, injection therapy by an experienced physician is sometimes helpful in improving the appearance of the legs. Complications
Pigmentation-A harmless complication by itself, pigmentation is an early sign of chronic venous insufficiency. It represents hemosiderin in the extravascular tissues of the skin and subcutaneous layer. Pigmentation over the medial aspect of the ankle and lower leg is often noted with varicose veins of long duration. Removal of incompetent varicose veins will lessen or gradually eliminate the stasis pigmentation. Dermatitis-This condition often develops as a complication of either varicose veins or chronic deep venous insufficiency (postphlebitic leg condition). It typically involves the "stasis area" of the leg (figure 2) and may be of the dry, scaly type or the raw, weeping form. The former is often chronic and accompanied by intense itching in the form of a neurodermatitis that is kept active by repeated scratching. The latter is more acute, with inflammatory redness, edema, and drainage. A generalized sensitivity or "id" reaction on the trunk, arms, or neck, which results in patches of reddish irritated skin, sometimes complicates the problem further; antihistamine or cortisone
medication may be necessary for its control. Bed rest with elevation of the legs is the treatment of choice for the severe forms of dermatitis. This is used in conjunction with moist dressings for the weeping type of dermatitis or bland ointment or cream for the dry, scaly type. In the section of peripheral vein surgery at the Mayo Clinic, we prefer a 0.25% aqueous solution of aluminum subacetate for moist dressings, although a weak boric acid solution or physiologic saline solution can be used instead. Pronounced itching with the dry type of dermatitis may be relieved by use of a cortisone cream or ointment.
Subacute cellulitis-Subacute cellulitis with redness, tenderness, and induration is a fairly common stasis complication of varicose veins and also of chronic deep venous insufficiency. High fever and chills are absent, in contrast to the symptoms of lymphangitis. Stasis cellulitis develops in the lower part of the leg or around the ankle, not higher up in the leg or thigh. Bed rest, elevation of the leg, and application of moist, warm compresses reduce the inflammatory reaction. Antibiotic therapy is seldom necessary except in refractory cases. Any residual induration can be prevented or reduced with adequate elastic support provided by a foam rubber pad over the involved area and a heavy elastic bandage from toes to knee. Ulceration- This condition occasionally complicates varicose veins,
Karl A. Lofgren Dr Lofgren is head of the section of peripheral vein surgery. department of surgery. Mayo Clinic and Mayo Foundation. and associate professor of surgery. Mayo Medical School. Rochester. Minnesota. He is also a fellow of the American College of Surgeons and a diplomate of the American Board of Surgery.
continued
VOL 65/NO 6/JUNE 1979/POSTGRADUATE MEDICINE
133
Complications of varicosities can include pigmentation, dermatitis, subacute cellulitis, ulceration, bleeding, and thrombophlebitis.
Figure 2. Stasis dermatitis. a complication of varicose veins.
usually when superficial abrasion or injury has occurred. Severe ulceration generally accompanies only deep venous insufficiency. Incompetent perforating veins are much more common after deep thrombophlebitis. Small ulcers often heal readily with bed rest, elevation of the leg, and moist dressings. In ambulatory patients, small ulcers can be treated effectively with an Elastoplast boot, which is applied in a manner similar to that for the old, but more cumbersome, Unna boot. The boot is left in place for a week to ten days before
134
being replaced with a new one; this treatment is continued until the ulcers are completely healed. Large ulcers (>3 cm in diameter) may need split-thickness skin grafts to shorten the period of healing. Incompetent perforating veins and varicose veins should be removed. When deep venous insufficiency is the predominant problem, adequate elastic support is necessary for lasting satisfactory control. Bleeding-If not controlled promptly with local pressure and elevation of the leg, bleeding from a small eroding varicosity can be a serious complication. Fatalities among elderly, debilitated patients from spontaneous hemorrhage have been reported in the literature. Such bleeding usually occurs in the ankle or lower leg region. Injection of the offending vessel is often sufficient treatment, although surgical excision is preferable when incompetent large varicosities are also present. Use of elastic support is advisable in all instances. Thrombophlebitis- This common complication of varicose veins may occur spontaneously or after a trivial injury in a prominent varicose tributary, usually on the medial aspect of the leg or lower thigh. Local redness, tenderness, and induration of a varicose vein are characteristically present. Extension of the inflammatory process into the saphenous vein and upward toward the groin is not uncommon. When this occurs, elevation of the leg and ap-
plication of warm compresses are indicated to prevent further spread. In those cases in which the involved area is small and well localized, compression with a foam rubber pad and elastic bandage for one or two weeks may be sufficient to resolve the inflammatory process. Anticoagulant therapy is not necessary unless progressive extension of the thrombophlebitis into the groin appears imminent or deep thrombophlebitis is suspected. Early surgical removal of the thrombosed varicosities and associated faulty saphenous system will often shorten the total time of disability.
Management Both surgical and nonsurgical procedures have been used traditionally in the management of varicose veins. The ideal treatment should be simple, lasting, and without risk to the patient. Before any treatment is undertaken, whether it be surgery, sclerotherapy, or elastic support, the venous problem must be accurately diagnosed. Periodic elevation of the legs and appropriate exercises can be used as supplemental treatment. At times, a combination of surgical and nonsurgical methods is used for effective relief of symptoms.
Nonsurgical treatment-Sclerotherapy-This is one approach to managing mild varicose veins. It can be used as cosmetic treatment of minor venules or spiderbursts or as supplemental treatment for smaller, recurrent varicosities sometimes
VOL 65/NO 6/JUNE 1979/POSTGRADUATE MEDICINE
In mild cases, nonsurgical treatment, such as sclerotherapy, elastic support, or elevation of the leg and exercise, is sufficient for relief of varicose vein symptoms.
noted during follow-up examinations after surgical treatment. For spiderbursts, I% sodium tetradecyl sulfate (Sotradecol) made foamy by shaking the half-empty glass syringe is used. A few droplets are injected with a 27-gauge hypodermic needle into the tiny venule, preferably the "central feeder" (figure 3). A pressure pad is applied to the injected site to prevent leakage and to compress the injected vessel for several days. For small varicose tributaries associated with an otherwise normal saphenous vein (so-called reticular varicosities), sclerotherapy is sometimes successful, although recurrences from subsequent recanalization eventually develop in most patients. For large varicose tributaries, surgical excision will produce more long-lasting results. Elastic support-When surgical treatment is not advisable because of medical disorders or a patient's advanced age, elastic support with either elastic bandages or well-fitted elastic stockings can be used for relief of symptoms; it is also prescribed for pregnant patients who have symptomatic varicosities. Elastic bandages or stockings compress dilated superficial varicosities and provide external support for the musculovenous pump mechanism of the leg. Stockings should be of the pressure-gradient type-that is, the compression should be greatest at the ankle and least at the knee. Rarely is elastic support needed
above the knee, although for cosmetic reasons many patients prefer lightweight stockings or support hose that extend over the thigh. Elevation of the legs and exercise-These provide yet another type of nonsurgical treatment. If a patient lies down with the legs elevated 12 to 15 in. above the level of the heart, hydrostatic venous pressure decreases and symptoms of chronic venous insufficiency are alleviated. Exercise such as walking , bicycling, or swimming decreases venous pressure and thereby relieves symptoms by activating the musculovenous pump of the legs and forcing venous blood upward. Active exercise is even more effective when combined with elastic support.
Figure 3. Spiderburst being injected with foamy sclerosing solution.
Surgical treatment-Surgical correction with removal of all malfunctioning superficial veins usually is the treatment of choice in otherwise healthy patients whose incompetent varicosities are causing symptoms and complications, becoming progressively larger, or giving rise to much distress because of the cosmetic defect (figure 4). Generally, satisfactory long-term results can be expected from such surgical treatment, because faulty veins are permanently eliminated. It is important to recognize and to evaluate the respective effectiveness of the various surgical methods that have been used for management of varicose veins. In an early review study, my associates and II noted that high ligation (alone or corn-
Figure 4. Large \aricosities with incompetency of saphenous vein. best managed with complete surgical removal.
continued
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Severe varicoalties require surgical management. Although ligatlon and partial stripping can be effective, the most satisfactory results are generally achieved with complete surgical elimination of faulty veins.
FigureS. Extensive varicosities (incompetency of greater saphenous systems). a. Appearance preoperatively. b. Two weeks postoperatively. c. Fifteen years postoperatively. Figure 5o and h.fi"om l.i!fgren KA: Varicose 1·ein.1". In HaimcJI'ici H (Edilor): Hi/1 &wk Co, 1976, 1'1' 799-H/1. u.~ed hy perminion clf"puhliJher.
bined with injection therapy) provided lasting satisfactory results in fewer than half of the patients treated. Most of these patients required repeated courses of sclerotherapy. Partial stripping (from groin to knee) provides somewhat better long:-term results than does high ligation, but still less satisfactory than the complete stripping operation, which includes surgical re-
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Va.~cular
Surgc•r.r:
Prinni1le.~ and
moval of all varicose tributaries in addition to the saphenous vein. "Main channel stripping" leaves too many residual varicose tributaries, which then become the source of early recurrences and necessitate additional operations. In general, any procedure less than complete surgical removal of all varicose tributaries as well as of the saphenous vein will invite early recurrence of the
TedmiqueJ. Ne11· )'brk. Mc(iraw-
disorder. During the past 30 years, my colleagues and I have learned from experience that the complete stripping operation gives the best results in cases of incompetent varicose veins. In stripping the great saphenous vein, the surgical steps include saphenofemoralligation flush with the common femoral vein, stripping of the saphenous vein from the dorso-
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Long-term results of a complete, thorough stripping procedure are usually excellent, and true recurrences are rare.
medial aspect of the foot to the groin, meticulous excision and stripping of all varicose tributaries, and individual resection of all incompetent perforating veins. For incompetency of the small saphenous vein, the steps include saphenopoplitealligation, stripping of the saphenous vein from the lateral aspect of the ankle to the popliteal fossa, excision and stripping of all varicose tributaries, and resection of any incompetent perforating veins. 2 The extra operating room time required for the complete stripping operation has been well rewarded by superior long-term results (figure 5). Recurrences after any surgical procedure for varicose veins are generally produced by residual or persistent varicosities not eliminated during the original operation. Thus, most can be prevented if a complete, thorough operation is performed initially. Even after adequate surgical removal, true recurrences from new varicosities may develop in a particularly susceptible patient, but the incidence of this is small. Long-term results have proved to be satisfactory with the complete stripping operation. One thousand consecutive patients operated on for varicose veins at our institution ten or more years ago were followed up in a recent studyJ; all had been operated on by the same two staff surgeons. Letters of inquiry regarding the long-term results of the varicose vein operation were sent to all patients, and an invitation to return for
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an examination was extended to each. Of the 656 patients who responded, 86% considered the present condition oftheir legs to be good to excellent. Of the total group, 278 returned for objective examination of their legs, and on the basis of the presence or absence of "recurrent" varicose veins, 85% were considered to have good to excellent results. Summary Varicose veins are the most common peripheral vascular disorder of humans. Although a large proportion of the adult population have dilated superficial veins, only a smaller group-estimated to be approximately 10%-have significant varicosities that cause symptoms, complicationS, or even chronic disability. Although no absolute cure has been discovered, much can be done to control this chronic venous
References 1. Lofgren KA et al: An evaluation of stripping versus ligation for varicose veins. Arch Surg76:310-316,1958 2. Lofgren KA: Varicose veins. In Fairbairn JF 11 et al (Editors): Allen-Barker-Hines Pe-
disorder, to provide relief of symptoms, and to prevent complications. An adequate surgical procedure that completely removes all incompetent varicosities continues to be the most effective method of treatment. Sclerotherapy is useful for small cutaneous venules that are of cosmetic concern only and also for the minor varicosities that sometimes develop after surgical treatment. Elastic support serves a useful therapeutic role for relief of venous symptoms and complications when surgical intervention is not feasible or is contraindicated. Periodic elevation of the legs and suitable leg exercises are additional supportive measures that can relieve venous stasis and improve function of the musculovenous pumping mechanism ofthe calf. Address reprint requests to Karl A. Lofgren, MD, Mayo Clinic, Rochester, MN 55901.
ripheral Vascular Diseases. Ed 4. Philadelphia, WB Saunders Co, 1972, pp 601-622 3. Larson RH et al: Long-term results after vein surgery: Study of I,000 cases after I0 years. Mayo Clin Proc 49:114-117, 1974
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