HOME       SELECTED ARTICLES  . . .     FEEDBACK     SEARCH

No standard treatment of varicose veins has yet been accepted. Injection therapy is in disrepute because it has been established that it is followed by recurrences which are frequently worse than the original state.

We have been using the injection technique for over ten years and have found that it is not followed by a high percentage of recurrence and that it certainly does not leave the patients worse than they were prior to treatment.

A great part of our work has been carried out on pregnant women. During pregnancy, varicose veins can produce distressing symptoms. These symptoms are relieved after one or two injections. This, in itself, makes treatment worthwhile, quite apart from the fact that it reduces to zero the incidence of thrombophlebitis in the puerperium.

Symptoms such as cramps in the leg, tiredness, hot throbbing pain, and constant pain in the legs are all relieved, together with the swelling, ulceration and eczema. Over a period of seven years no patient has been admitted from the Varicose Veins Outpatient Department in the Rotunda Hospital for surgical treatment. No patient has, in the last three years, attended for treatment of varicose ulcers, where, formerly, there was an established ulcer clinic.

It has been said that it is pointless treating varicose veins during pregnancy because a high percentage spontaneously recover after delivery. This may be true but, if we consider the fact that five times as many women as men suffer from varicose veins and that 4 out of every 5 women date the commencement of the varicosities from pregnancy, it becomes apparent that, if veins are cared for and controlled during pregnancy, fewer women will suffer from trouble with their veins later in life.

It is, in fact, untrue to say that a high percentage recover spontaneously after delivery; a high percentage improve but very few completely recover and many develop thrombophlebitis. It is to cases in this latter group that great attention should be paid. They appear to improve after the pain of the thrombosis has settled down. Quietly and insidiously, the lumen of the thrombosed vein becomes re-established and, because of the added valvular injury, the pressure of the blood in this re-established vein is higher than before. In six months’ or a year’s time the patients in this group will find that their veins are much worse than before their pregnancy. Should these patients’

legs be examined at regular intervals, these findings would be confirmed.

In order to treat varicose veins successfully, one must spend some time in studying the physiology of the peripheral pump. Briefly, in the calf muscles there is a powerful pump system which is, in many ways, analogous to that of the heart.

The principle of our treatment has been to concentrate rather on restoring the efficiency of the pump than on obliterating apparent superficial varices. In order to do this, one must be able to locate accurately the exact points of emergence of the veins with the incompetent valves because it is through these veins that blood is flowing in the wrong direction and abnormally high pressure is being transmitted. This produces the double disadvantage of high pressure in the superficial veins and reduced output from the peripheral pump.

The introduction of a sclerosant into a vein can be followed by a multiplicity of reactions, varying from a wide-spreading thrombophlebitis to minimal or no reaction.

The ideal method of achieving our aim of permanently blocking the offending leak is to produce a short fibrotic segment of vein, involving the junction area. We have observed that this can be achieved by carrying out the following procedure: (1) Selecting a vein with a good wall. (2) Introducing the sclerosant into this vein after it has been emptied. (3) Maintaining the sclerosant in the segment for 30 seconds. (4) Applying compression immediately to the site of injection, maintaining it until one is quite sure that, when the patient stands erect, the internal pressure of the blood in the adjacent unobliterated vein cannot reopen the segment.

It is important to spend some time examining the legs of each new patient and accurately marking the points where the incompetent derangement begins because one injection, properly placed, can rid the leg of a vast complex of varicose veins. We have found it of great help when attempting to locate the sites of incompetence to consider three factors: firstly, our knowledge of the normal position of the communicating channels, secondly, the pattern of the varicosities and finally, palpation of the fascia of the leg.

If one examines a number of legs with the tips of one’s finger, one will suddenly become aware that there are weaknesses or depressions in the deep fascia. It will be found that these depressions correspond with localized blow-out in the vein and with a known site of a communicating channel between the deep and superficial veins. Digital pressure at one or more of these points will control the filling of the superficial veins. These depressions are the sites of election for injection.

The exact steps in the process of reopening of a thrombosed vein do not appear to have been clearly worked out. From Figs. 1, 2 and 3 one can see the process of reopening which I believe to be the commonest. Fig. 1 shows the slit-like channels developing between the clot and the wall of the vein. Fig. 2 shown this process to have advanced until a third of the circumference of the vein has been involved. Fig. 3 shows the new channel to have become circular instead of slit-like and the central organized clot pushed to one side.

We believe that the process by which the lumen of this vein has become re-established is the result of a combination of three factors: (1) High pressure of the blood in the adjacent veins. (2) The development of slit-like channels between the organizing clot, which is retracting, and the wall of the vein. (3) The lack of external supporting compresson.

We believe that this is the common method by which the lumen of the thrombosed vein becomes re-established and that it can take place very quickly, in fact within a few weeks of the onset of thrombosis. This phenomenon we have observed clinically on many occasions.

But, if the vein is emptied before the sclerosant is introduced and the sclerosant is maintained undiluted in a small segment of the vein for a period of time and followed immediately by uninterrupted compression, then the histological appearance of the vein is very different. This is shown in figs. 4, 5 and 6. Here we note the absence of an organizing blood clot, the considerable endothelial peripheration and the great thickening and fibrosis in the wall of the vein.

We inject all varicose veins without selection. The commonest site of injection has been the Hunterian communicating vein (above the medial condyle of the femur). As far as we know, there have been no ill-effects from this technique or from the solution used (sodium tetradecyl). The danger of spill into the deeper veins is theoretical if the amount is kept small. On six occasions we have observed large sapheno-varices to disappear after injecting the Hunterian communicating vein. This latter observation is important with regard to the evaluation of Trendelenburg’s operation. Three patients with intermittent claudication got relief from their symptoms following treatment for their varicose veins.

People who suffer from deep vein thrombosis during pregnancy or following a fracture and who subsequently develop superficial varices are treated by us. We disregard the history of deep vein thrombosis and consider that these people require to have the leaks from their peripheral pump sealed off., more so than people who have not had deep vein thrombosis. They are suffering from the double embarrassment of diminished output from the pump and continued high pressure in the superficial veins. If the superficial veins are destroyed, there is a definite improvement in their symptoms, although the leg does not completely return to normal.

The extravascular technique which we have used in a large series of cases has been found particularly useful in treating labial varices and the large aneurysmal vascular clusters in the instep of the foot. To avoid the unpleasant reaction following the extravascular technique it is necessary to use only a small amount of the solution, to diffuse it well in the tissues, to keep it well away from the skin and to apply compression with a soft rubber over the site of injection.

It is interesting to note that on many occasions we have been able, from the appearance of the patient’s veins, to suggest to her the possibility of pregnancy before she was aware of it through any other symptoms.

HOME       SELECTED ARTICLES  . . .     FEEDBACK     SEARCH