Chapter 5: Varicose Veins

This method can be used for the cosmetically unacceptable, isolated varicose vein in the leg, as an alternative to sclerotherapy. A 3/0 polyglycolic acid (Dexon™) suture is simply inserted through the skin to encircle and ligate the vein.

Equipment

You will need:

• 3/0 polyglycolic acid suture

• cutting-edge needle

• needle holder and scissors

• local anaesthetic agent.

Method

1. Infiltrate LA around the site or sites of the vein to be ligated:

   • small veins (up to 5–10 cm), a single suture

   • larger veins, multiple sutures, 5–10 cm apart.

2. Using a cutting-edge needle, pass the suture under the vein (Fig. 5.1a).

3. Bring the suture through the skin and then simply tie it tightly to occlude the vein by constriction (Fig. 5.1b). The treated vein thromboses and atrophies after a short period.

4. Review the patient in 4 weeks and remove the suture.

Precautions

Avoid areas near the dorsalis pedis artery and the common peroneal nerve, or other significant arteries, veins or nerves.

This method can be used to treat the cosmetically unacceptable isolated varicose vein in the leg. It is possible to avulse the vein using local anaesthesia along the length of the varicose vein.

Equipment

You will need:

• local anaesthetic

• no. 15 scalpel blade with scalpel handle

• 6 small Halsted artery forceps (‘mosquitoes’)

• self-adhesive closure strips 1.2 cm (Steri-Strips™), or nylon suture with cutting edge needle

• non-stick gauze dressing with wool and crepe bandage.

Method

1. Infiltrate LA along the length of varicose vein to be avulsed (up to 20 mL of 1% lidocaine can be used):

   • small vein (up to 5–10 cm): a single incision (5–10 mm) along or across the midpoint of the vein

   • larger veins: multiple incisions 5–10 cm apart, depending on the length of the varicose vein avulsed at first incision (Fig. 5.2a).

2. Locate and identify the vein using an artery forceps, ensuring that it is not a nerve. The vein is then divided between two forceps (Fig. 5.2b).

3. Avulse the vein on either side by applying further forceps while pulling on the vein (Fig. 5.2c). Provided the length of the varicose vein has been infiltrated with LA, there should be no pain. Apply pressure for 2 to 3 minutes to stop bleeding once the vein has been avulsed.

4. Achieve skin closure by using either self-adhesive closure strips or suture. The suture can be removed in approximately 10 to 14 days.

5. Apply non-stick gauze dressing to the wound, followed by a wool and crepe bandage. The dressing can be left for 3 days and then removed.

   If multiple avulsions have been carried out, it may be necessary to reapply a crepe bandage for another 2 to 3 days.

6. The patient should be free to do limited walking after the operation, and usually unrestricted walking after 24 hours.

Special precautions

Beware of nerves and arteries, avoiding areas involving the foot and the region of the lateral popliteal nerve where it curves around the neck of the fibula.

When a large varicose vein becomes thrombosed, a tender, raised nodular cord is formed along the line of the vein. There is thrombosis in the superficial vein with no connection to deeper veins.

Clinical features

1. The skin is reddened and the tender nodular cord is palpable (Fig. 5.3a).

2. There is pain.

3. Localised oedema is present.

4. There is no generalised swelling of the limb or the ankle.

Management method

Propagation of thrombus can usually be prevented by uniform pressure over the cord.

1. The whole of the tender cord should be covered by an adhesive pad or a thin strip of foam (Fig. 5.3b) and then a firm crepe bandage applied.

2. The bandage and the pad are left on for 7 to 10 days.

3. Bed rest with leg elevated, if severe, otherwise keep active.

4. Prescribe a non-steroidal anti-inflammatory drug for about 7 days. No anticoagulants are required.

A specialist opinion should be sought for superficial thrombophlebitis above the knee, as this disorder may require ligation at the saphenofemoral junction.

Finally, one must always bear in mind the association between thrombophlebitis and deep-seated carcinoma elsewhere in the body.

Investigations

• Duplex US: accurate for above-knee thrombosis; improving for distal calf (repeat in 1 week if initial test normal).

• Contrast venography, esp. if ultrasound −ve.

• MRI is very accurate.

• D dimer test (consider in certain cases): where probability of DVT is low, a normal D dimer usually excludes diagnosis.

Management

• Prevention (cases at risk)

• Early and frequent mobilisation

• Elastic or graded compression stockings

• Physiotherapy

• Pneumatic compression

• Electrical calf muscle stimulation during surgery

• Surgery: LMW heparin daily or unfractionated heparin 5000 U (SC) bd or tds (LMW heparin for orthopaedic surgery)

• Long flights/sitting: LMWH prior to flying and on arrival

Treatment

• Admit to hospital (usually 5–7 days) if any corrections, but can treat as an outpatient, which is current practice

• Collect blood for APTT, INR and platelet count (check kidney function)

• One-way-stretch elastic bandages (both legs to above knees) or class II graded compression stocking to affected leg, especially if swelling

• IV heparin—Daily SC injection of LMW heparin e.g. enoxaparin

  or

  unfractionated heparin 330 U/kg SC loading then 250 U/kg SC bd

  or

  5000 U heparin statim bolus IV then infusion in IV saline

  or

  Fondaparinux SC according to weight

• Oral anticoagulant (warfarin) for 6 months (monitor with INR)

• Mobilisation upon resolution of pain, tenderness and swelling

Surgery is necessary in extensive and embolising cases.

Advice for this potentially dangerous (because of heavy blood loss) problem is often sought over the telephone. Advise local pressure (not proximal) and elevation. Both a proximal and a distal percutaneous suture (see Fig. 5.1a, b) may be necessary.

The area typically affected by varicose eczema and ulceration is shown in Figure 5.4. The secret of treating ulcers due to chronic venous insufficiency is the proper treatment of the physical factors, especially compression. Removal of fluid from a swollen leg is also mandatory. Debridement of leg ulcers using topical anaesthesia (e.g. EMLA^® cream applied 30 minutes beforehand) is considered to hasten ulcer healing.

Treatment method

1. Clean the ulcer with N saline. If slough, apply Intrasite gel^®. If deep or contaminated, insert cadexomer iodine powder or ointment.

2. Options:

   1. • Cover with Allevyn^® (or similar) dressing

      • Padded dressing e.g. Velband^® (optional)

      • Occlusive paste dressing e.g. Viscopaste™ (7–14 days) from base of toe to just below knee

   2. • Cover with Allevyn^® (or similar)

      • Padded dressing

      • Compression bandage e.g. Eloflex™ to just below knee

   3. • Improvised method:

      • Apply paraffin gauze

      • Pack defect with sponge rubber (Fig. 5.5)

      • Apply compression bandage

3. Consider using a Tubigrip™ stockinette cover.

4. Prescribe diuretics if oedema is present.

5. Insist on as much elevation of the leg as is possible.

Note: Dressings should be changed when they become loose or fall off, or when discharge seeps through. Patients may get ulcers wet and have baths.

Leg ulcers—unorthodox methods

For uncomplicated ulcers, such as non-infected post-traumatic and venous ulcers, various simple preparations have been claimed by many practitioners to promote healing. These include:

• sugar

• sugar and povidone-iodine (Betadine^®) paste

• Intal™ powder.

To facilitate the sliding of a compression stocking over an ulcer on the leg place a plastic shopping bag firmly over the foot and then slide the stocking over this. Once on, the plastic bag is pulled down and out.