Varicose veins: a clinical profile

An “All-Comers” Venous Duplex Scan Policy for Patients with Lower Limb Varicose Veins Attending a One-stop Vascular Clinic: Is It Justified?

Background: Varicose veins represent a common manifestation of chronic venous disease affecting the lower limbs and are associated with considerable morbidity when left untreated. Although often considered benign, complications such as pigmentation, dermatitis, thrombophlebitis, and venous ulceration may significantly impair quality of life. The present study aimed to evaluate the demographic profile, clinical characteristics, and management outcomes of patients presenting with varicose veins at a tertiary care teaching hospital. Materials and Methods: This hospital-based observational study was conducted in the Department of General Surgery at a tertiary care centre over a period of 24 months. A total of 85 patients diagnosed with primary varicose veins were included. Data regarding demographic characteristics, clinical presentation, venous involvement, complications, and surgical management were collected and analysed using descriptive statistics and Chi-square testing. Results: Females constituted the majority of patients (83.5%). The most commonly affected age group was 21–30 years (24.7%). Left lower limb involvement was observed in 49.4% of cases. Farmers represented the predominant occupational group (44.7%). Pigmentation was the most frequent complication (30.6%). Surgical management yielded favourable outcomes, with seroma being the most common postoperative complication (11.8%). Conclusion: Varicose veins predominantly affect young and middle-aged individuals engaged in occupations involving prolonged standing. Early diagnosis and appropriately tailored surgical intervention result in satisfactory clinical outcomes with minimal complications. Preventive public health strategies addressing occupational risk factors are essential to reduce disease burden. Keywords: Varicose veins; Chronic venous disease; CEAP classification; Duplex ultrasonography; Saphenofemoral junction; Surgical management; Occupational risk factors

Dysregulated Apoptosis in Primary Varicose Veins

Summary Background: Neovascularisation (NV) at the saphenofemoral junction (SFJ) is an important cause of recurrent great saphenous varicose veins. Unfortunately up to now no surgical technique at the SFJ could prevent neoreflux completely. We present a new technique at the SFJ with the aim to reduce the rate of neoreflux. Material and Methods: In a prospective study 100 patients (100 SFJ ligations) with extensive crossectomy were included. Extensive crossectomy means: Flush ligation of the SFJ, oversewing the endothelium stump with Prolene®(4 x 0), ligation of the side branches as far away as possible from the SFJ and electrocoagulation of the free endothelium of these side branches. Mean age 47 years (18–65), female/ male 69 %/31 %, ASA-classification I–II (100 %), CEAP-classification C2 59, C3 25, C4 16. All patients could be examined by colour duplex scan after two/three days, three months and one year and 68 patients after two years. Results: Duplex imagines identified neoreflux at the SFJ in two patients (2 %) after one year and in only one patient (1.5 %/ 68 patients) after two years. This female patient was pregnant (31st week) and had recurrent varicose veins with origin mostly from an insufficient Dodd perforator vein. The other patient with reflux at the first examination showed no more reflux after two years. Conclusion: Recurrent reflux in the groin by neovascularisation was strongly reduced by our technique of extensive crossectomy. Up to know no other technique to prevent NV (patch, barrier technique) has shown such favourable results. The technique is easily performed and has no further complication than a simple ligation of the SFJ.

Varicose veins represent a frequent vascular disorder leading to chronic venous insufficiency, with accurate localization of incompetent saphenofemoral junction (SFJ) and perforators being essential for surgical planning and prevention of recurrence. While bedside clinical tests have traditionally been used, Doppler ultrasonography is increasingly considered more reliable. This study was undertaken to compare the diagnostic accuracy of clinical evaluation and Doppler ultrasound in identifying incompetent SFJ and perforators, using intraope-rative findings as the reference. A prospective comparative study was carried out on 100 patients with symptomatic primary varicose veins between June 2022 and May 2024 at a tertiary care hospital. Each patient underwent detailed clinical examination using standard tests followed by Doppler ultrasound assessment. All cases subsequently proceeded to surgery, where intraoperative findings served as the gold standard. Diagnostic performance was assessed by calculating sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV). For SFJ incompetence, both clinical assessment and Doppler ultrasound achieved 100% sensitivity, specificity, PPV, and NPV when compared with operative findings. In contrast, for perforator incompetence, Doppler demonstrated higher diagnostic accuracy (sensitivity 97.4%, specificity 50%, PPV 97.4%, NPV 50%) compared with clinical examination (sensitivity 95.1%, specificity 50%, PPV 93.6%, NPV 57.1%). Clinical examination remains dependable for identifying SFJ incompetence; however, Doppler ultrasound provides greater accuracy in detecting perforator incompetence. Incorporating Doppler routinely in preoperative evaluation can improve localization of incompe-tent veins, optimize surgical outcomes, and reduce recurrence rates in varicose vein management.

A 42 years old male was diagnosed with varicose vein with perforator incompetence and ulcerative gangrene in left leg leading to bleeding, puss, severe pain, numbness and frequent infections. He was not able to walk and perform his day to day activities because of this situation. He had a history of varicose vein since 2010 and was operated 3 times for the same between 2010 to 2019. In 2022, he was again suggested to go for surgery as the situation was worsened. He came in contact with Yoga Prana Vidya (YPV) healer and decided to go for Yoga Prana Vidya (YPV) healing. This paper presents the case of Varicose Vein with perforator incompetence and ulcerative gangrene treated successfully using Yoga Prana Vidya healing protocol. Methods: This is the case study method with detailed analysis of medical records and photos of affected leg of patient’s health condition pre and post Yoga Prana Vidya (YPV) healing treatment applied as alternative medicine. This is the case of a 42 years old male diagnosed with varicose vein with perforator incompetence and ulcerative gangrene in left leg in May 2022. The initial symptoms were bleeding, puss, severe pain, numbness and frequent infection in left leg. The pain was so severe that he was not able to walk properly or perform his day to day activities. He was on heavy antibiotics and painkillers prescribed by doctor earlier. Doctor suggested to go for surgery for varicose vein. Results: Analysis of the patient’s health condition, photos of his leg and medical case documents pre and post treatment shows that he got cured with Yoga Prana Vidya (YPV) healing method for Varicose Vein with Perforator Incompetence and ulcerative gangrene. Conclusion: This case study documents the evidence on the effective use of Yoga Prana Vidya (YPV) in treating Varicose vein with perforator incompetence and ulcerative gangrene. There is ample scope to conduct further research on the application of YPV as alternatively effective and low cost medicine for various medical conditions.

The relationship between increased body mass index and primary venous disease severity and concomitant deep primary venous reflux.

Objective To establish an effect of isolated phlebectomy in patients with incompetent great saphenous vein (Ambulatory Selective Varices Ablation under Local anesthesia (ASVAL) procedure) on the reflux and diameter of the trunk and to assess recurrence rate of varicose veins at one year. Material and methods We conducted a prospective study on patients with primary varicose veins and with C2 or C2,3 or C2,3,4 or C2,4 classes of chronic venous disease and great saphenous vein incompetence. The study included 67 patients (51 women and 16 men; 75 limbs in total). Age varied from 17 to 71 years; mean age was 46.8 years (SD 13.9). We recorded the presence or absence of reflux in the great saphenous vein with duplex ultrasound before and after surgery. The recurrence of varicose veins was evaluated at 12 months. All the patients underwent isolated phlebectomy with preservation of incompetent great saphenous vein (ASVAL procedure) under local anesthesia. Results At one year after removing of tributaries of the incompetent trunk, 66% of them were competent. Reflux persisted in 17% of great saphenous veins with reflux above mid-thigh and in 61% of trunks with reflux extended below the mid-thigh (p = 0.0004). The diameter of all the veins decreased significantly no matter reflux disappeared or not. Varicose veins reoccurred in 13.5% cases. In 6.5% of limbs with a reflux above the mid-thigh, the recurrence was registered at one year, while in the limbs with the reflux below the mid-thigh at a baseline, the recurrence rate was 25% (p = 0.036). Conclusion Isolated phlebectomy with a preservation of incompetent great saphenous vein leads to disappearance of reflux in a majority of cases and to significant decrease of vein diameter in all the cases. ASVAL procedure could be considered as a less aggressive and less expensive approach in selected cases. Clear indications for isolated phlebectomy need to be established.

Presidential address: Venous disorders—Reflections of the past three decades

The aim of this study was to compare the recurrence rate and hemodynamic effect retrospectively among various technical approaches for ligations of the great saphenous vein in the treatment of primary varicose veins. 455 limbs with primary uncomplicated great saphenous varicose veins, which underwent ligations of the great saphenous vein followed by sclerotherapy, were classified into 5 groups according to different ligation techniques. The recurrence rate and hemodynamic effect, evaluated by the photoplethysmographic technique, were compared among the 5 groups at one year intervals up to 5 years. The 3-ligation technique, in which the great saphenous vein was resected at the groin, thigh, and calf, showed a significantly lower recurrence rate at the 5-year follow-up. The recurrence rates were 27.7, 62.0, 58.5, and 91.9% in the 3-ligation group, 2-ligation group at the groin and thigh, 2-ligation group at the thigh and calf, and 1-ligation group at the thigh, respectively. A lower hemodynamic improvement was observed in the latter two groups. A significantly higher recurrence rate was shown even in the 3-ligation group, when all tributaries were not dissected at the sapheno-femoral junction (50.2 vs. 27.7%, p<0.01). The 3-ligation technique followed by sclerotherapy, which includes the resection of the great saphenous vein for as long as possible, and dissection of all tributaries at the groin, thigh, and calf, is one of the important choices of minimum invasive treatments for varicose veins, although this technique is not a fully alternative procedure to the stripping operation.

Ten-Year Outcomes of Treatment of Varicose Veins by Ambulatory Selective Ablation of Varices Under Local Anesthesia (ASVAL)

Background: The goal of this prospective cohort study was to study the different determinants impacting primary varicose vein recurrence rates and patterns after endo venous laser ablation (EVLA) for primary lower limb varicose veins.Patients and Methods: 127 symptomatic patients (127 limbs) with great saphenous vein reflux (>0.5 seconds), GSV diameter> 3mm and pre-operative incompetent perforators were followed up within two years for recurrence after EVLA.Outcomes: Recurrence was defined clinically by venous clinical severity score (VCSS) and CEAP classification and radiologically by patterns of reflux on duplex ultrasound examination. Assessment was done at 1, 6, 12 and 24 months after the procedure. Results: Two-year life table analysis showed varicose vein recurrence in 9 (7.1%) of limbs. Varicose vein recurrence was mostly seen owed to due to BMI more than 30.5 kg/m2 in 77.8 % (p <0.001, 95% CI 1.105 to 1.590) of recurrence patients, refluxing anterior accessory saphenous vein in 77.8% of patients (p <0.001, 95% CI 3.2 to 1669.1) and postoperative incompetent perforators in 77.8% of patients (p <0.001, 95% CI 2.7 to 69.3). Age, gender and pre-operative GSV diameter ≥ 5.5 mm were statistically insignificant in determination of recurrence. Conclusion: BMI, refluxing anterior accessory saphenous vein and postoperative incompetent perforators are the most importantdeterminants of recurrence after EVLA with a statistically significant impact in comparison with age, gender and preoperative dilated GSV diameter ≥5.5 mm.

Neovascularisation is the principal cause of varicose vein recurrence: Results of a randomised trial of stripping the long saphenous vein

Prevalence of Varicose Veins and Venous Anatomy in Patients Without Truncal Saphenous Reflux

Recurrence types 3 years after endovenous thermal ablation in insufficient saphenofemoral junctions