The treatment of venous disease has changed dramatically in recent years with the advent of duplex ultrasound evaluation, minimally invasive treatments, and new thrombolytic drugs. For more than 100 years, the treatment of superficial disease had been limited to high ligation and stripping with limited innovation. Attempts at chemical ablation (sclerotherapy) had, historically, been hampered by serious complications and a high rate of recurrence. Deep venous treatment had been largely limited to the use of compression stockings, with occasional attempts to perform venous bypasses, valve reconstruction, or the radical Linton procedure (subfascial ligation of perforator veins), but all of these interventions had high rates of morbidity and low rates of success.
The first big step was the duplex evaluation, which greatly improved the sensitivity and specificity for the diagnosis of deep vein thrombosis (DVT),1 as well as reduced costs. The progress continued with improved diagnosis of superficial reflux and the mapping of incompetent veins. This greatly improved the results of high ligations and stripping and helped considerably with the results of ultrasound-guided sclerotherapy for the chemical ablation of incompetent superficial veins. Newer techniques that use thermal ablation and improved methods of chemical ablation have furthered the improvement.
Deep venous disease treatment has also undergone a renaissance with the use of similar minimally invasive techniques, such as angioplasty, stenting, and intravascular ultrasound (IVUS).
The prevalence of varicose veins in the Western population is greater than 20%, with about 5% of patients having the sequelae of venous edema, skin changes, or ulceration. Approximately 0.5% of patients have active ulceration. The incidence is higher in women than in men.
The superficial system is defined as the portion of veins that lie between the skin and deep fascia that covers the muscles. The main veins of the superficial system are the great saphenous vein (GSV) and the small saphenous vein (SSV) (Figs. 55-1 and 55-2). The GSV starts in the foot, anterior to the medial malleolus, and courses up the medial leg to the saphenofemoral junction in the groin. The GSV runs in the saphenous sheath, which is formed from the deep fascia. In the calf, major tributaries of the GSV are the anterior and posterior arch veins. In the thigh, major tributaries of the GSV are the anterior and posterior accessory saphenous veins. The anterior accessory saphenous vein (AASV) typically joins the GSV at the saphenofemoral junction (SFJ). The SSV starts posterior to the lateral malleolus and runs in the saphenous sheath to the popliteal fossa. The termination point for the SSV is highly variable. It sometimes ends in the popliteal fossa joining the popliteal vein, or through thigh extensions ending in the thigh underneath the gluteus maximus muscle, or it courses medially and joins the GSV, also called the vein of Giacomini.
The deep system includes all the veins beneath the deep fascia (Fig. 55-3). The peroneal, anterior, and posterior tibial veins are usually paired veins that course along the arteries of the same name. The posterior tibial vein joins the peroneal vein to form the tibioperoneal trunk, which joins the anterior tibial vein to form the popliteal vein in the popliteal fossa. This is paired with the popliteal artery. As the popliteal vein courses through the hunterian canal, it becomes the femoral vein (formerly known by the somewhat confusing term of “superficial” femoral vein), which is paired with the superficial femoral artery. This is one of the few times the corresponding vein and artery have different names. The femoral vein joins the profunda femoral vein to form the common femoral vein in the groin. Once the common femoral vein passes under the inguinal ligament, it becomes the external iliac vein, which joins the internal iliac vein to form the common iliac vein. The right and left common iliac veins join to form the inferior vena cava.
Perforating veins connect the superficial and deep systems and penetrate through the deep fascia.2 There are estimated to be over 150 such connections. The important perforators connect along the medial calf and thigh. Some perforating veins connect directly to the GSV and others to the posterior arch vein. There are additional important connections between the pelvic veins and the superficial venous system that sometimes lead to leg vein symptoms. These connections come from the round ligament, obturator, gluteal, and hemorrhoidal veins.
Valves are critical to the healthy functioning of the venous system. Through normal opening and closing of the valves, blood is directed back to the heart. In diseased veins, valves may not close properly, resulting in backward blood flow and pooling.
The presenting complaints from patients with venous disease can range from concerns that are strictly cosmetic, with underlying psychological impact, to many vague symptoms such as pain, aching, tingling, fatigue, and heaviness, to more severe symptoms such as edema, inflammation, and ulceration (Table 55-1). In general, symptoms improve with rest and leg elevation and are worsened by heat and long periods of standing or sitting.
Obtaining a thorough past history of thromboembolic events and thrombophilia as well as family history of the same is important (Table 55-2). Medications, particularly birth control and hormone replacement, can also increase risks of thromboembolic events. Past treatment of venous problems should be elicited.
The physical exam should focus on signs and symptoms of venous insufficiency. The patient should be standing while being carefully examined visually and by palpation for evidence of bulging veins. Any evidence of scars from previous procedures, edema, inflammation, pigmentation, and past or present ulceration should be noted.
Duplex examination has been a major advancement in venous disease, particularly in examination for DVT. The exam can be done with the patient supine. Careful B-mode imaging with visualization of the entire vein and wall-to-wall opposition along the entire deep venous system can rule out the presence of DVT, with a very low false-negative rate. The superficial system can be examined similarly or during the standing portion of the exam.
If imaging of the iliac veins or inferior vena cava (IVC) is to be done, the patient should be instructed to have nothing by mouth (npo) for approximately 8 hours before the exam. Compression is not available, so careful visualization and good color flow are required to make the diagnosis.
The exam to look for reflux should be done with the patient standing. The exam is conducted using a pulsed wave Doppler and 4- to 7-MHz probe. This provides enough pressure to close the valves. The superficial and deep systems are analyzed for spontaneous flow and augmented flow. In the measurement of any retrograde flow, incompetence is defined as retrograde flow greater than 500 milliseconds.
Occasionally, pathologic connections between the pelvic veins and leg veins occur. In particular, round ligament, pudendal, obturator foramen, abdominal wall, sciatic foramen, and gluteal veins can connect to the leg. These can lead to pathology in the leg. Patients may present with varicosities of the vulva or scrotum. In men, testicular varicosities can lead to infertility, and in women, ovarian varicosities can lead to pelvic congestion syndrome. Patients with these symptoms may need pelvic sonography with measurements of the gonadal veins. Veins larger than 5 mm are considered to be abnormal.
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