See Table 4.1. Varicose vein disease progression over time is usual, and therefore it is unclear whether development of some “complications or consequences” of varicose vein surgery is true “direct” results of the surgery or actually represents the “natural progression” of the underlying venous disease. Such complications or consequences as new varicose veins/spider veins/pain and discomfort/swelling/skin discoloration/ulceration and even DVT should be considered in this indeterminate category, which may potentially result from surgery. The other listed complications and risks are more clearly associated with surgery. Errors of femoral artery or deep femoral vein stripping, or stenosis of the femoral vein, are very rare and typically result from failure to adequately identify anatomic structures and represent extreme misadventure, perhaps related to inexperience. The incidence of saphenous nerve injury is directly related to stripping of the long saphenous vein below the knee where the nerve is closely applied to the vein. The risk of injury to the saphenous nerve can be effectively reduced, by only stripping of the long saphenous vein above the knee, where the nerve is separated from the vein. Saphenous nerve injury may occur during stab avulsions. Injury to any subcutaneous nerve or neural branch of the lower limb can result from incision and stab avulsion or injection sclerotherapy of varicosities or from ligation of perforators between the superficial and deep venous systems. Infection in the groin wounds is not uncommon and is usually associated with poor wound apposition, devitalization of the wound edges, hematoma formation, lymphocele, or wound separation. The infecting organisms are usually patient-derived endogenous cutaneous organisms such as staphylococci (Staphylococcus aureus) or gram-negative fecally derived organisms, e.g., E. coli, or a mixture of both. Preoperative prophylactic antibiotics should be given to cover both. The decision to prescribe prophylactic antibiotics remains an individual one. Seroma formation is not uncommon and leakage may occur. The relative patient satisfaction and acceptability of the risks can depend on the reason for surgery, whether for cosmetic improvement or for alleviation of venous congestion.

Severe bleeding intraoperatively or postoperatively is very rare, as is the resultant need for blood transfusion. Head-down (Trendelenburg) positioning usually reduces bleeding. Severe bruising may occur in some individuals, especially with impaired coagulation (iatrogenic or otherwise). Injury to the femoral vein (or artery) is rare and should be avoided with careful dissection, identification, and ligation of the saphenous vein at the saphenofemoral junction. Infection usually is avoided by using prophylactic antibiotics, but established infection can typically be treated with antibiotics and wound care. Major infections are rare except in immunocompromised individuals where special care and timing of surgery must be considered. Varicose vein surgery must be a balanced consideration and may need to be averted in these situations. Severe damage to the femoral vein or artery from stripping or direct ligation resulting from mistaken identity for the saphenous vein should be completely avoidable and not occur. Deep venous thrombosis and resultant pulmonary embolism are generally avoidable if adequate prophylaxis is used. Adequate ligation of blood vessels and lymphatics and judicious use of hemostatic diathermy are able to reduce risk of large lymphocele, seroma, and hematoma. Major limb swelling is unusual and avoidable by careful dissection and selective appropriate ligation of correct structures. Very rare severe swelling can result from atypical lymphatic interruption or obstruction from scarring. The use of bandages and graduated stockings often reduces the risk of swelling. Preexisting lymphatic drainage problems should be evaluated prior to varicose vein surgery and the patient adequately informed of the risk of potential worsening of limb swelling and possible permanency of this.