A 35-year-old woman, mother of three, presented with a progressive increase in the size of the vein on the inside of her thigh during her pregnancies. She described aching, fatigue, and heaviness as the day wore on and experienced some relief with elevation. She initially related some relief with prescription stockings but steady worsening over the last year. She found it difficult to stand at work or during regular chores at home. Both her parents had intervention for varicose veins.

Her physical examination showed a very large great saphenous vein (GSV) from the mid calf to the groin with some tenderness along the course of the vein without any palpable thrombus. No ulceration or pigmentation was noted at the ankle. Her duplex venous ultrasound examination showed no deep or superficial venous thrombosis but a large-diameter GSV and significant reflux (retrograde flow during a Valsalva maneuver) down to the mid-calf (Figure 65-1).

After discussing various options she elected for ablation of her GSV with a laser (Figure 65-2).

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  The prevalence of varicose veins in the Western population is about 20%.¹

  
  
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  The bicuspid venous valves are crucial in promoting unidirectional flow caudal to proximal, with the most important saphenous valve being close to the saphenofemoral junction.

  
  
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  Most varicose veins probably have a multifactorial etiology, although an intrinsic structural weakness is a likely cause.

  
  
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  Varicose veins can also occur following deep venous thrombosis or on a congenital basis.

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  Common symptoms of varicose veins include pain, heaviness, aching, burning, fatigue, throbbing, itchiness, and occasionally restless legs syndrome.

  
  
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  Physical examination should mainly focus on the extremity involved with the patient standing as well as supine. The location, size, and general distribution of the varicose veins are noted and preferably marked on a diagram.

  
  
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  Palpation as well as auscultation is also recommended to detect pulsatility, thrills, bruits, or any tenderness.

  
  
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  Signs of chronic disease such as ulceration, skin changes, pigmentation, eczema, temperature changes, and edema should be noted.

  
  
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  A record of palpable pulses is made.

  
  
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  The traditional named tests such as Trendelenburg test or Perthes test are now rarely performed, and their utility today is questionable.

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  Duplex venous scanning is performed to identify reflux or retrograde flow in the GSV, and to document the vein size and extent of the reflux.

  
  
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  Normally, Doppler evaluation of the GSV during a Valsalva maneuver results in little retrograde flow through the first valve in a caudal direction. However, in patients with varicose veins due to saphenous vein incompetence, retrograde reflux is easily detected. Any reflux lasting longer than 0.5 ms and ideally greater than 1 ms is said to be diagnostic of valvular incompetence. In addition, measurement of the vein diameter and extent of the reflux is also important. A very large-sized saphenous vein, certainly greater than 20 mm in diameter, may lead to a high failure rate with ablation, although recent developments in technology may allow larger veins to be ablated.

  
  
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  Venography or other imaging studies are generally not necessary.

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  Since most ablation procedures are performed either under local anesthesia or with light sedation, routine laboratory tests are not needed.

  
  
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  If regional or general anesthesia is necessary for specific reasons, then hospital or ambulatory care policies will dictate tests such as a complete blood cell count or electrolyte panel.