European Journal of Cardiovascular Medicine

Varicose veins have always bothered mankind. These have been recognized as a chronic disorder since ancient times as their discussion is documented from the days of Hippocrates 2500 years ago. He observed that ‘it was better not to stand in the case of an ulcer on the leg’ with reference to varicose veins.^[1] The condition affected by man’s upright position and by gravitational forces, is wide spread, involving at least one out of five individuals in the world, hence making this a very common condition. 20% of the population suffers with varicose veins and 2% have skin changes that may precede venous ulceration.^[2] Primary Vericose veins are those that develop as a result of an Inherent weakness in the wall of the vein. They can have a hereditary factor and can often occur in several members of the same family. Whereas Secondary varicose veins are those that develop due to any other cause  other than congenital factors,  such as trauma, DVT, pregnancy etc.

The term varicose is derived from Latin word ‘varicosus’, which means dilated. Varicose veins are not only dilated veins but also tortuous and elongated, but physiologically speaking a varicose vein is one which permits reverse flow through its faulty valves. Vericose veins are referred to as ‘Primary’if they arise without any antecedent cause, probably due to inherent weakness of the vessel wall. Heriditaory factors may also play a role.  Varicose veins, though a common condition, many time remains asymptomatic.^[3] In Indian scenario,  the disease is one of the common surgical problems in low socio-economic class people, which at times compel the patient to change his occupation, which is very disturbing.^[4] Unfortunately most of them seek medical help only after onset of complications and rarely for cosmetic reasons.

 Varicose veins were recognized prehistorically and many inventions were made regarding the diagnosis and treatment of varicose veins by many phlebologists including many bandaging techniques, ligation and stripping of veins. The attention was mainly towards the mechanical effects of the varicosity rather than the basic cause.^[5] It is only in the recent past that considerable knowledge has been gained concerning the anatomy of the venous system of the leg, the physiological mechanism of venous return to the heart against gravity and pathology of the disorder, which has lead to many newer modalities of investigations and treatment. ^[6]

The Doppler ultrasound and duplex imaging has become the mainstay of investigations in the diagnosis of chronic venous insufficiency and varicose veins.^[2] The treatment options for varicose veins include Trendelenburg operation, vein stripping, subfascial ligation of perforators, laser, sclerotherapy, subfascial endoscopic perforator surgery and radio-frequency ablation.^[7] In the recent past, minimally invasive procedures are replacing the more invasive procedures. The search for more effective means of diagnosing and treating the varicose veins and prevention and management of its complications continues.

No significant difference in varicose vein recurrence or recurrent reflux  has been noted between endovenous procedures and surgery and  compared with Radio frequency ablation, surgery seems to be more efficient or equally effective. However complications are less and hospital stay is less following Endovenous thermal ablation compared to surgery^.[8]

Surgical management of primary varicose veins is still the most widely practiced option in the country and in our institute. Our institute predominantly caters to an agrarian population with high incidence of  Primary varicose veins, hence this study is an attempt to understand the clinical profile of the patients from this local population in terms of demographics, presenting complaints, predisposing factors,  findings of investigations, efficacy of surgical management methods and its complications. The data gathered from this study can also be used to propose introduction of other minimal invasive treatment modalities in our institute for management of Primary varicose veins.

This retrospective study was carried out in the Department of Surgery, Mandya Institute of Medical sciences, Mandya ,by collecting the data from records of patients treated between july 2017 to july 2022 (5 years duration).. A total of 104 cases were included based on inclusion & exclusion criteria. Patients with symptomatic primary varicose veins of the lower limbs, confirmed on venous Doppler study and treated at our institute were included. Records of patients aged <18 years, presenting with recurrent varicose veins, with concurrent DVT, secondary varicose veins and those not fit to undergo surgery were excluded.

All the patients had been treated as  inpatients in the surgical ward. Their sociodemographic details, symptoms and examination details were recorded. All patients had undergone  venous Doppler study to confirm clinical diagnosis and to rule out secondary complications like DVT . Cases with complications like ulcers eczema and dermatitis had been initially treated conservatively in order to improve the associated complications and later had undergone operative treatment. Patients who had presented with bilateral varicose veins with symptoms in one leg  had got their symptomatic limb operated on first. No bilateral limb surgeries had been performed. Surgeries had been performed based on the site of incompetence. Postoperative management details,  complications if any, condition on discharge and follow up details were collected  in a standard study proforma. Data was analysed using the SPSS software (Version 22.0; SPSS Inc, Chicago). Descriptive statistics such as mean and standard deviation for continuous variables, frequencies and percentages was calculated for categorical variables.

In our study, Out of the104 patients, 31-50 years age group had the maximum number of 63(60.58%) patients and the mean age of the study population was 44.3% with a range of 23 to 72 years. Patients were predominantly male, 81 (77.9%) in number. Occupations involving prolonged standing and rigorous muscular activity such as farmers and labourers contributed to the major chunk of admissions, together making about 71 ( 60.56%) of 104 patients  as shown in table 1.

Table 1: Patient Demographics

In this series, 47 (45.19%) patients had varicosity in the left lower limb and 31(29.8%) had varicosity in the right lower limb and the remaining 26(25%) had bilateral limb involvement, as shown in table 2.

Table 2: Limb involvement

Table 3: Presentation of symptoms

As in table 3, prominent veins and pain were the commonest presenting complaints in 41 (%) patients. Ankle edema was present in 14 (%) patients. Eczema and pigmentation were the complaint in 10 (11.1%) patients and 17 patients had presented with pain and ulceration of lower limb.

Table 4: Site of Venous incompetence.

As In table 4, based on venous doppler, study out of 104 cases studied, 11 (10.57%) had only saphenofemoral incompetence, 7 (6.54%) had only perforator incompetence and none had isolated saphenopopliteal incompetence. Saphenofemoral incompetence with Saphenopopliteal incompetence & Perforator incompetence  was the commonest combination of incompetence seen accounting for 45 (43.26%) patients.

Table 6: Surgical procedure performed.

The type of surgeries performed and their distribution is shown in the chart above (Table 6). Complications of surgery ( Table 7) were noted in 23 (22.11%) patients, Hematoma  formation (6.54%) was the commonest, followed by wound infection and residual varicosity after surgery (4.8%), seroma (3.84%), and neuropathy of saphenous nerve (1.92%) were also noted during the study.

Table 7: Post Op Complications

In our study, the age distributions of varicose vein show that majority i.e. 60.58% of patients are between the age of 31 to 50 years which correlates well with 58.9% seen in study conducted by Tandon A et al.^[9] The mean age of the study population was 44.3 years, ranging from 23 to 72 years. The majority of patients were male, constituting 77.9% of the total, similar to other studies where male patients (80%) outnumbered the females (20%).^[10]

Among 104 patients studied, 78 patients exhibited a definite history of standing for long duration. 44 of whom were agricultural workers, 19 were labourers and 15 in other occupations which required standing for long duration during their work. This suggests occupation has a definite role as a contributing factor. In Mirji P et al study too, 26 patients in their occupation, involved either prolonged periods of standing or violent muscular efforts.^[11]

In Mulla S et al study among symptomatic patients, pain was seen in 51 (72.85%) of patients and was by far the commonest complaint, followed by edema (20%) and disfigurement (12.85%), 35 (50%) with pigmentation of the limbs, dermatitis (17.14%), ulcer (5.71%) and superficial thrombophlebitis (2.85%)^[10] The most common presenting symptoms  in our study were prominent vein and pain 41 (39.52%), followed by eczema and pigmentation, ankle edema, and ulceration.. None of the patients in our series actually underwent surgery for cosmetic reasons unlike the studies done in the west. In our series, no cases had definite history of deep vein thrombosis and also no case had superficial thrombophlebitis. This finding was in conformity with some authors, who think that superficial thrombophlebitis as a cause of varicose veins is very rare and most probably phlebitic changes occur in the veins which are already varicosed.

In this series, left side involvement was present in 47(45.19%) cases. Higher incidence of varicosity on left side is in accordance with some authors who think that the varicose veins are more common in the left limb probably due to the venous drainage of the left leg, which follows a more tortuous course through the pelvis, with left common iliac vein traversed by the right common iliac artery and also due to presence of loaded sigmoid colon which exerts constant pressure on the vein in the pelvic cavity.^[12] In 31(29.8%) patients right leg was involved and 26(25%)  cases bilateral involvement was present. The present study revealed that long saphenous vein involvement with short saphenous system and perforator incompetence in 45patients (43.26%) was most common. This was somewhat similar to Mulla SA et al where in among 70 patients ,30 (42.85%) patients had the involvement of GSV and communicating system, 6 (8.57%) had involvement of GSV and SSV systems, whereas SSV and CS were affected in 2 (2.85%) patients. 2 (2.85%) had all the three systems involved. ^[10]All patients in our study underwent Doppler ultrasound of both the legs for confirmation of the diagnosis and to rule out presence of deep vein thrombosis which we felt must be done before proceeding with surgical management.

Surgical procedures performed included combinations of Saphenofemoral flush ligation (SFFL), stripping, multiple subfascial ligation (MSFL), and Saphenopopliteal junction ligation (SPJL). According to study done by Mulla SA et al in 2017, among 70 patients,  Trendlenburgs procedure+ stripping+ Stab avulsion+ Perforator ligation was the commonest surgery done in 38.7% pts.^[10]Whereas Saphenofemoral flush ligation with stripping with Saphenopopliteal flush ligation with multiple perforator ligation done in 45( 43.26%) patients is the commonest procedure in our series. This combination of procedures correlates with the commonest pattern of incompetence seen i.e SFJ and SPJ incompetence with multiple perforator incompetence in 45 (43.26%) patients.

The complications of varicose vein surgery are as such very rare, we documented complications in 23 (22.11%) patients. There was no incidence of deep vein thrombosis postoperatively. Out of 104cases, 2 patients complained of sensory impairment in cutaneous nerve distribution of long saphenous nerve. The low incidence of sensory impairment in the present series maybe because of better surgical technique and avoidance of stripping of vein below midcalf where the nerve and vein travel very closely.

In addition to surgery, sclerotherapy, foam therapy, laser endoluminal ablation and radiofrequency endoluminal ablation are the other available treatments for varicose vein. In one meta-analysis of treatment of varicose vein mentioned these treatments appear to be safe with rare side effects. Surgery is the only treatment with long term effectiveness data. The other less invasive treatments are associated with shorter disability and less pain, but only short term effectiveness data. ^[13]

Vericose veins is a disease seen quite frequently in our study population, mainly affecting young men of working age group. Occupations involving prolonged standing and intense manual work tend to be more prone to develop the condition. Majority of them present quite late, only on worsening of symptoms or with onset of complications. Cosmesis is relatively of lesser concern in an agrarian population. Duplex ultrasonography which was the investigation of choice is quite accurate in aiding the surgical planning and further management. The choice of surgical procedure depends on the site of incompetence and should be tailor-made to each case. Surgical procedures do cause complications and hematoma was the commonest. Frequent incidence of varicose veins in our study population definitely warrants introduction of less invasive procedures like endovascular laser ablation to facilitate faster recovery and early return to work for the affected bread winners of their families. Also, there is scope for introduction of awareness programmes facilitating prevention, early detection and avoiding complications.

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