10.1.1 Introduction Nearly every second adult in Europe suffers from ve- nous disorders.

. In only 15% are they considered to be venous diseases threatening the patient. The spectrum ranges from spider telangiectasia to chronic states and acute, potentially lethal, pulmonary embolism generally described as chronic venous in- sufficiency (CVI). In vascular surgery, varicosities of the greater saphe- nous vein in particular are important. In principle, every varicose disorder leading to symp- toms such as oedema and lower leg ulcer should be treated surgically [1, 4, 16, 21]. Duplication of these veins exists in most patients. They drain 90% of the blood in the legs [4, 5, 16, 25]. 10.1.2.3 Perforating Veins 10.1.2 Functional Anatomy and Physiology of the Venous System In the upper and lower leg perforating veins (venae perforantes or communicantes) link the superficial and deep venous systems in a step-like manner. Important perforating veins are the Cocketts (me- dial ankle), Boyds (proximal medial calf) and Dodds group (medial upper leg). Upright body posture demands transportation of blood back to the heart against the force of gravity. To a certain degree, this is accomplished by the suction effect of the heart and the thoracoabdominal pump function of breathing. The tone of the venous system, arteriovenous coupling (transfer of the arterial pulse to a neighbouring vein) and relative venous blood volume (total body blood volume is usually split 80% venous and 20% arterial, with different proportions during exertion) also play an important role. How- ever, the most important mechanism is the calf muscle pump which, in combination with competent venous valves, guarantees blood flow to the heart by muscle contraction. Physiologically, valves of the deep, superficial and per- forating veins open unidirectionally, preventing flow reversal in the venous system and thus protecting the legs from the effects of continuous hydrostatic pressure [10, 14, 16, 18]. 10.1.3 Chronic Venous Insufficiency 10.1.2.1 SuperficialVeins The greater and lesser saphenous veins belong to the superficial venous system [16, 18, 22, 25]. They drain the area between the skin and muscle fas- cia, carrying blood to the deep venous system. Before the greater saphenous vein enters the deep femoral vein numerous small tributaries join the sys- tem. The saphenofemoral junction plays an essential part in the function of the venous system during deep venous thrombosis and in treatment of varicosities. 10.1.2.2 DeepVeins Because the deep veins are located close to the arteries, they are called popliteal and femoral veins. 10.1.3.1 Definition Chronic venous insufficiency (CVI) describes the state of continuous venous hypertension of the lower limb
539540 10.1 Chronic Venous Insufficiency

Fig. 10.1.1ac Different types of varices. a Stem varicosis of greater saphenous vein. b Reticular varices in the area of the popliteal fossa, with pigmentation. c Telangiectasia

due to venous stasis, agenesia of valves, deep venous thrombosis (post-thrombotic syndrome) or progressive primary varicosis. 10.1.3.2 Epidemiology/Aetiology Based on their pathogenesis, varicose veins are di- vided into primary varices, which are more common (95%), and secondary varices, which develop as collat- eral pathways and essentially as a result of deep venous thrombosis [14, 16, 25]. More than 50% of patients with diagnosed post- thrombotic syndrome have no knowledge of previous deep venous thrombosis, for it often remains clinically silent. The most common cause is varicose disease. Varicose veins are dilated, tortuous and superficial veins occurring mainly in the lower limb area. Three types exist (Fig. 10.1.1): dilated saphenous (stem) veins reticular varices (dilated tributaries of saphenous veins) dilated venules (telangiectasia).

 Therefore, the pathogenetic centre of CVI is valve dys- function with permanent venous hypertension of sub- cutaneous tissue and skin. Subsequently, typical lesions form. The disease develops in stages over the years with the following factors worsening its course as in a vicious circle: Eczematoid changes of skin and subcutaneous tissue (more than 50% of patients) Recurrent deep venous thrombosis (about 20% of patients) Primary and secondary varicosis. The prevalence of CVI is 15% of the general popula- tion. Females are affected three times as much as men [1, 9, 16, 18, 22, 25]. Based on insufficient perforating veins and valve in- competence of the deep venous system, blood does not flow unidirectionally to the heart, but moves between the deep and superficial venous systems in a pendular way (pendular blood, private circulation). This leads to the so-called crash syndrome: inward and outward flowing blood collides in the perforating veins. Erythrocytes are thus damaged mechanically with subsequent deposit of haemosiderin in the skin (hyperpigmentation) [5, 6, 10, 14]. Lower leg ulcerations and eczematoid dermatitis may develop. Eventually, the chronic volume overload creates rigid- ity of the vein wall. Venous tone can no longer be regulated. 10.1.3.3 Symptoms A typical early symptom of post-thrombotic syn- drome and CVI is a tendency for the lower extremity to swell. Leg ulcer is a leading sign of full extent of the disease [4]. Venous Stasis In the case of primary varicosis, unilateral stasis-oe- dema, generally appearing at the end of the day, may occur prior to the development of varicose veins. Aching heaviness is associated with it. At the early stage of CVI, considering differential diagnostic aspects, other disorders causing oedema (e.g. right ventricular failure, renal dysfunction, local trauma) have to be excluded. Swelling without simultaneous varicosity can be a sign of acute or chronic deep venous thrombosis. On the other hand, acute thrombosis of the iliofemo- ral and calf veins is closely related to pulmonary em- bolism, which is often lethal. Therefore, if suspected, Duplex ultrasonography or ascending venography is needed. This is true as well if other risk factors exist, such as an incidence of thrombosis in the family, coagulation disorder and immobility (e.g. long-distance flights or economy-class syndrome) [1, 14, 21]. Skin Lesions Signs of CVI may be present in the form of hyper- or depigmentation of the skin, eczematoid dermatitis and ulcerations, most common at the medial side of the lower leg, resulting from progressive varicosity or deep venous thrombosis. Long-term venous hypertension with secondary dys- function of the deep venous system is mainly responsi- ble for the severity of skin changes [9, 14, 16, 18, 25]. The typical changes of the skin and veins can be subdi- vided into three stages, often overlapping: Stage I has been referred to as corona phlebectatica paraplantaris (Figs. 10.1.2, 10.1.3) the dilatation of venules at the side aspect of the foot as well as stasis oedema at the end of day, particularly in warm temperatures.
Fig. 10.1.2 Corona phlebectatica as an early symptom of chron- ic venous insufficiency (CVI)
10.1.3 Chronic Venous Insufficiency 541 542 10.1 Chronic Venous Insufficiency

Fig. 10.1.3a,b Dilated veins of the lower leg based on post- thrombotic syndrome and CVI. a Corona phlebectatica, dilated veins and blow-out phenomenon of perforating veins. b Typical Pratt vein as a sign of pretibial venous stasis

Stage II is characterized by stasis eczema. Based on the oedema, the skin tends to allergic reaction (ec- zematoid dermatosis) and hyper- or depigmenta- tion up to the development of atrophie blanche [14, 16, 25]. Florid and healed cutaneous ulceration represent stage III of CVI (Fig. 10.1.4). Diffuse Leg Pain Cramp-like pain may also be a manifestation of CVI, aggravated by prolonged standing and similar to a muscle ache.
Fig. 10.1.4a,b Swelling as a sign of CVI, healed ulceration. Pig- mentation of the skin, atrophie blanche and central ulceration at the stage of progressive CVI

By elevating the legs, the pain can be decreased. This is typical of CVI [1, 9, 14, 16, 18, 21]. External Haemorrhage
Fig. 10.1.5a,b Classification of truncal varicosity as described by Hach. a Different stages stage I: saphenofemoral

incom- petence; stage II: varicosity of greater saphenous vein between groin and upper calf; stage III: varicose veins from saphenofem- oral junction to proximal lower extremity; stage IV: varicosity of entire great saphenous vein. b Distal termination of incompe- tence below knee (stage III)

10.1.3.4 Diagnosis Recommended European Standard Diagnostic Steps of Investigation In all patients with varicosity, the extent of the damage to superficial and deep veins has to be determined. Classification of truncal varicosis of the greater saphenous vein according to Hach depicts the different categories of valve dysfunction (Fig. 10.1.5) [9, 10]. Today, traditional functional tests (Perthes test, Trendelenburg test) are seldom used. In addition to thorough clinical examination, diagnostic modalities such as Doppler ultrasonography (Fig. 10.1.6b), Duplex scanning in particular (Figs. 10.1.6a, The most common location of spontaneous haemor- rhage of varices is the medial aspect of the ankle. External haemorrhage is a frequent indication for var- icose vein treatment [16, 25].
10.1.3 Chronic Venous Insufficiency 543 544 10.1 Chronic Venous Insufficiency

Fig. 10.1.6a,b Ultrasonography for determination of compe- tent and incompetent venous segments. a Duplex scanning with visible reflux into the greater saphenous vein during a Valsalva manoeuvre. b Determination of distal location of insufficiency with Doppler ultrasonography

10.1.7), and, in critical cases, ascending venography can be performed to assess venous dysfunction [5].
DuplexScanning

Because of its reliability, use of Duplex scanning in combination with a functional haemodynamic measurement technique is accepted as the preoperative standard diagnostic procedure. The technique permits anatomical examination as well as assessment of the haemodynamic status of the veins [1, 11, 21].
Ascending Venography

If determination of the patency of venous drainage and differentiation between incompetent and healthy venous segments by Duplex scanning is not sufficient, ascending venography has to be performed. This invasive method may cause complications [9, 10, 21, 25]. Additional Useful Diagnostic Procedures Phlebodynamometry. Peripheral phlebodynamom- etry is a highly sensitive method of assessing venous disorders. It enables statements to be made concern- ing prognosis including those for legal and insur- ance purposes and also the disease progression to be monitored. By using this technique, peripheral venous pressure in the unbandaged and bandaged limb is measured. An indication for surgery on incompetent epifascial veins is given when the measurement curve improves after tight dressing with elastic bandages [5, 14, 16, 18]. Photoplethysmography. Nowadays the invasive method of phlebodynamometry has been virtually superseded by photoplethysmography. Measurement of reflecting light documents the speed of venous refill in the foot [11]. 10.1.3.5 Treatment Conservative Therapy of CVI
External Compression

Indispensable in the therapy of chronic venous insuf- ficiency is external compression of the limb. Nonsurgical treatment is based on sufficient compres- sion to prevent oedema and on acceleration of the venous blood flow by using compression stockings of strength type II. After lower limb ulcerations have healed, type III stockings are necessary. Compression is especially important in the periulcer- ous area, when ulcus cruris is present [22, 25]. Conservative Treatment of Varicose Veins
Sclerotherapy

If the greater and lesser saphenous veins are not affect- ed by a varicose condition, conventional sclerotherapy can be performed. Today, sclerotherapy with its modification by using foam may be an alternative to operative treatment. The method gives better results than the conventional treatment of injection of highly concentrated saline solutions or aethoxysclerol, because under control of Duplex scanning the foam can be applied close to the saphenofemoral or saphenopopliteal junction. This way obliteration of the greater and lesser saphe- nous veins and side branches is possible. It should be pointed out that reflux into the stem veins may cause recurrent varicosity [8, 16, 18].
Application of Drugs

If risk factors for recurrent thrombosis exist, life-long anticoagulation therapy is indicated.

 The application of agents influencing venous tone or reducing oedema (flavonoids, chestnut seed extracts) does not correct the underlying cause [1, 18, 21, 25].
Fig. 10.1.7a,b Examination of popliteal fossa in varicosis of the lesser saphenous vein. a Incompetent lesser saphenous vein with typical varicosis. b Corresponding clinical finding
10.1.3 Chronic Venous Insufficiency 545 546 10.1 Chronic Venous Insufficiency Surgery

If removal of varicose veins is possible, healing of ul- cerations is significantly accelerated. This includes dissection of venae perforantes, nowa- days primarily done endoscopically to avoid trauma- tizing the skin already affected by trophical lesions. If CVI is based on isolated obliteration of the iliac vein, venous by-pass procedures may be indicated. In incompetence of the deep venous system, the meth- od of transposition of valves may be useful to prevent lower limb ulceration [1, 2, 11, 13, 21]. Surgical Treatment of Varicose Veins Removal of varicose veins is one of the most common surgical procedures and can be performed in day-case surgery [1, 3, 6, 20, 21, 2426]. The intention is to completely remove veins with in- competent valves in order to prevent long-term dam- age such as leg ulceration. Depending on the time of the surgery, secondary changes such as swelling, thrombophlebitis or ulcer- ation may regress. In general, skin pigmentation remains.
Indications

There is differentiation between carriers of asymptom- atic varices and patients actually suffering from vari- cose disease. The first group has no subjective complaints except for occasional heaviness of the legs (relative indication for surgery). The other develops complications up to chronic venous insufficiency (absolute indication for surgical treatment). In primary varicosity, surgical therapy is indicated for saphenous, perforating and branch vein varicosis [16, 18, 21]. The decision on surgical treatment of secondary vari- cosities has to be made carefully! Sufficient blood flow from the lower extremities to the heart has to be en- sured after surgery. Preoperative use of highcompres- sion bandages over a period of several weeks simulates removal of varices. If the patients experience improve- ment of symptoms, surgical intervention is justified [16, 18, 25]. Surgical treatment is indicated according to the sever- ity and pathophysiological significance of the varicosity.
Contraindications

Absolute contraindications are the incidence of pe- ripheral arterial occlusive disease and angiodysplasia, particularly arteriovenous fistulas as in Parkes-Weber syndrome. Systemic connective tissue disorders (e.g. Marfans syndrome), dysfunction of venous flow (e.g. post- thrombotic syndrome, agenesia of valves) and pro- gressive degenerative joint disease are relative contra- indications [16].
Risks and Complications of Surgery

Trauma of the femoral and popliteal artery and vein is a rare complication. More commonly, lesions of lymphatic vessels occur. The saphenous nerve in the calf area and sural nerve (medial ankle), which are close to the saphenous veins, can also be injured [3, 16, 18]. Generally, resulting postoperative sensory dysfunction disappears, only occasionally appearing as permanent paraesthesia. Infection is a rare but serious complication often based on haematomas, which are an ideal prerequisite for colonization of microorganisms. In principle, surgeons should only perform techniques whose complications they are able to manage.
Preparation for Operation

Different opinions exist about general thrombosis pro- phylaxis with heparin in varicose surgery. Peri-operative application in high-risk patients reduc- es the incidence of deep venous thrombosis. Patients under permanent anticoagulation therapy take heparin instead [21]. Meticulous marking of the varicose veins with indel- ible ink precedes surgical procedure.

Surgical Techniques High Ligation and Stripping

The high ligation and stripping procedure as described by Babcock may be performed in truncal varicosis of the greater saphenous vein (saphenus = hidden) with

or without perforating varices. The entire incompetent vein is extracted by intraluminal stripper from groin to ankle. Healthy segments of the saphenous vein are preserved [21, 25]. With regards to future arterial by-pass surgery, the saphenous veins play a major role as physiological vascular grafts. Analogously, this procedure is performed for varicosity of the lesser saphenous vein with incision at the lat- eral aspect of the ankle and the popliteal fossa. Prior to operation, identification of the exact termination of the lesser saphenous vein with the help of Duplex scanning is advisable. Active preparation of the sural nerve is necessary in order to protect it from injury [9].
Dissection of Perforating Veins

By using the method of endoscopic dissection, an en- doscope is inserted in the area of healthy skin (Fig. 10.1.8). In this way, further damage to existing trophical le- sions of the skin can be avoided. Perforating veins are interrupted by clipping or coagu- lation under visual control. If no pathological skin conditions exist, open prepara- tion with ligation of the incompetent perforating vein (blow out phenomenon) can be done [11, 21].
Fig. 10.1.8a,b Endoscopical ligation of perforating veins. a En- doscope inserted subfascially. b Vena perforans, which will be interrupted

Removal of Local Varices

Larger varicosites of the side branches are extirpated locally by stab avulsion through incisions, which may lead to scars. When using a phlebextractor, a modified hook in- strument, only small punctual incisions are required, which do not need to be sutured, thus optimizing cos- metic results [4, 8, 11, 21]. Postoperative Procedure After applying the wound dressing, the leg has to be bandaged elastically with sufficient compression from the basal toe joints up to the groin. In order to avoid pressure damage, the bandaged leg has to be observed during the day of surgery. In some cases wound drainage is necessary, because the above-mentioned surgical techniques can cause extensive haematomas. Certainly, haematomas should not be mistaken for haemorrhage demanding instant revision [16, 18]. Postoperative Results Excellent cosmetic and functional results of 95% have been reported using a combination of surgical treatment and postoperative sclerotherapy [3, 20, 26].
10.1.3 Chronic Venous Insufficiency 547 548 10.1 Chronic Venous Insufficiency Recurrent Varicosity

The appearance of recurrent varices based on incom- plete removal of the greater saphenous vein is rare. However, development of varicosities in the area of healthy side branches after a period of years is common. In this case, once again therapeutic methods have to be taken into consideration and surgical intervention is carried out if indicated [1, 3, 6, 9, 11, 12, 20, 21, 25]. Complications Manifestations of injury to the femoral and popliteal artery or vein, deep venous thrombosis and pulmo- nary embolism are considered serious complications. With meticulous surgery technique and proper peri- operative management they rarely occur. Lethality of varicose surgery is 0.02% [3]. Minor complications include lesion of local sensory nerves in 810% (mainly the saphenous nerve, often reversible), lymphatic fistulas in the groin in 5% and impaired wound healing. Alternative Treatment of Varicose Veins Modern therapeutic methods compete with conven- tional stripping operations [e.g. endovenous ablation using radiofrequency or laser, transluminal phlebec- tomy (TriVex), CHIVA (cure conservatrice et hemodynamique de linsuffisance veineuse en ambulatoire)] and reconstructive techniques such as banding (external valvuloplasty). These methods are the subject of controversial discussion [11, 15, 17, 21]. Surgical Treatment of Venous Thrombosis The operative therapy of deep venous thrombosis re- quires special indication. However, in a number of cases it reduces the risk of developing post-thrombotic changes [16, 18].
Rare Operations for CVI By-pass in Unilateral Occlusion of the Iliac Vein

Today, the procedure described by Palma is the only operation which may be carried out in the case of se- vere post-thrombotic syndrome or unilateral occlu- sion of the common iliac vein (Fig. 10.1.9). Criteria for indication are pressure measurements in the iliac vein that are three times higher during

exer- cise than while resting. A prerequisite is patency of the deep venous system of the lower and upper leg. The by-pass consists of autologous vein or alloplastic material [4, 16, 18, 23]. The technique of the Palma procedure is to transfer the greater saphenous vein of the healthy side through a suprapubic subcutaneous tunnel to the contralateral, occluded side. An end-to-side anastomosis with the
Fig. 10.1.9a,b a Post-thrombotic syndrome with CVI and decompensated venous stasis: extensive oedema, skin pigmentation and florid ulcer. b Radiograph of patient after by-pass operation according to Palma without significant improvement

femoral or iliac vein is performed. Simultaneously, distal to the anastomosis, a temporary arteriovenous fistula is made. It remains for 36 months, preventing recurrent thrombosis, particularly when the calibre of the vein is small [16]. If the cause of CVI is post-thrombotic syndrome, an adequate form of therapy has to be chosen. In some cases surgical therapy is required. It is difficult to treat CVI when severe damage of tissue or ulceration has already developed. Reconstruction and Transposition of Valves References Kistner [13] suggested direct reconstruction of insuf- ficient deep veins to re-establish patency of the deep venous system. As an alternative, transposition of healthy venous seg- ments (mainly axillary vein) is described. Transposition of leg veins from the side not affected by thrombosis is not considered favourable, because lesion to the healthy side might occur. Likewise, by-pass procedures with normal epifascial veins as described by May [16] have not proven to be useful. The operation consists of by-passing an occluded su- perficial femoral vein by using the greater saphenous vein. Nature takes advantage of this physiological collateral pathway. Elevated pressure in the deep venous system leads to reversal of flow in the perforating veins.
Surgical Treatment of Leg Ulcers

Prior to venous reconstruction, arterial lesions have to be treated if the arterial system is affected at the same time (combined ulcer) [14, 16, 21]. After proper elimination of venous stasis, adequate additional treatment of the ulceration must follow. Debridement of the ulcer with subsequent skin graftlesions (as in dermatoliposclerosis) caused by permanent venous hypertension. If deep subdermal layers are already indurated and degenerated, generous excision and closure of the wound by applying skin graft is the method of choice. Medial or lateral paratibial fasciotomy may reduce pressure in the different compartments and support the healing process [11]. 10.1.3.6 Conclusion CVI can be avoided if varicose veins are treated in time.
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