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Annals of the Royal College of Surgeons of England - Volume 41 - October 1967

W. G. FEGAN, M.Ch., F.R.C..S.I.

Consulting Surgeon, Rotunda Hospital, Dublin

Fifteen years ago I was invited to take charge of the varicose vein clinic in the Rotunda Hospital. At that time I did not agree with injection therapy, but as there were no beds available for these patients injection was the only form of treatment possible. As a house surgeon I had injected varicose veins and was well aware of the complications of this form of treatment, of the high recurrence rate and of the fact that some patients were worse after treatment than before. Perhaps because of this I observed the results of my injections critically. I saw that while in some cases extensive, painful thrombophlebitis developed, in others the dilated veins became small and cord-like and were neither tender nor painful. I began to try, therefore, to develop a technique whereby I would produce this second reaction in the majority of cases. This technique, which has now been used for over 15 years, is not followed by a high recurrence rate and certainly does not leave the patient worse than before treatment.

The immediate object of compression sclerotherapy is to produce a permanent fibrous occlusion at the sites of incompetent perforating veins. Its success depends on the facts: (i) that in the vast majority of patients with varicose veins, and in almost all those who have symptoms, incompetent perforating veins are present: (ii) that if these incompetent perforating veins are permanently occluded then the superficial veins, no longer subjected to the strain of an abnormal flow of blood, are capable of regaining their normal tone and diameter.

It is our impression that this condition is primarily an ascending one.

Attention is first directed to the most distal derangements. The proximal veins are then watched for improvement. A surprising degree of resolution often takes place in grossly dilated, tortuous vein in the groin following the restoration of the efficiency of the pumps in the calf. Even large saphena varices often disappear completely without ascending thrombosis within a few weeks of treatment of a perforating vein of the calf.

It should be appreciated that there is usually a large reserve pumping capacity in the lower limb and that considerable damage must be done before the signs and symptoms of venous insufficiency occur. Conversely, it is necessary to restore the pumps completely to normal in order to relieve the symptomatology. In fact, if complete and perfect restoration of the pumps were a sine qua non for successful treatment then a fair number of patients would not be cured by either form of treatment.

In our diagnostic routine the legs are inspected with the patient erect. After standing fir two minute the entire superficial venous complex is carefully mapped out by inspection, palpation and percussion, all three being absolutely essential to produce the full picture. Percussion of a large dilated vein will often reveal veins which may have passed unnoticed. Failure to diagnose these is a potent cause of failure in successful treatment.

The patient now sits down on a couch and lies back with the legs hanging over the edge of the couch. The limb being examined is raised and, with the heel resting on the surgeon's shoulder, the patient is encouraged to relax his muscles. The limb is thoroughly palpated again and in this position feels strikingly different from the limb in the standing patient. The veins are empty, the muscles are relaxed and the whole limb is much softer. Continuous, rapid, finger-tip palpation of the raised leg is necessary until every fascial weakness is located. It is through these orifices that incompetent perforating veins pass. However, decoys are common and a space in the superficial fascia produced by a varix of a superficial vein may give a very similar feeling to a fascial orifice. They can be distinguished by a further test, that is, control of retrograde filling. The most likely sites of retrograde filling can be chosen by considering the relation of the suspected fascial orifices to the marked complex of superficial veins. To this is added our knowledge of the anatomy of the perforating veins and which perforating veins most commonly become incompetent.

As many of the likely sites of retrograde filling as possible are compressed with the tip of the surgeon's fingers and the patient then stands up.

With the compression maintained the limb is watched for filling of the superficial veins. If the vein fills, this is repeated with the finger-tips controlling different sites until the patient can stand without filling of the superficial complex. When this has been achieved we can be satisfied we have included the sites of retrograde filling. The fingers are removed one by one from below upwards. When the finger is withdrawn from an orifice which is transmitting a perforating vein with an incompetent valve the superficial veins fill. There is frequently more than one point of retrograde filling in a limb but rarely more than five.

There are further aids to the location of incompetent perforating veins. The point at which such a vein passes through the deep fascia is often tender and this tenderness is sharply localized. We find that this is perhaps the most important single piece of confirmatory evidence in locating the site of a perforator. In some legs "hot spots" can be detected and these give useful indicationn of the position of incompetent perforators.

In particularly difficult cases additional help may be obtained from cine-phelbography and stereoscopic ascending phlebogrtams. This is not a routine procedure in our clinic, both techniques being difficult and time consuming.

The method of examining described here is sometimes made impossible because of oedema of the lower limb. In these cases an elastic bandage and elastic stocking are applied from the roots of the toes to above the highest point of swelling. The patient is advised to go to bed for 24 hours, raising the foot of the bed and using a pedalling machine in the elevated bed. Examination after this routine makes the diagnosis much more simple.

Having decided upon the advisability of injection and selected the exact points at which the injections should be placed, the patient sits upright on a couch with the leg horizontal. The pressure of blood within the veins in this position is sufficient to make venipuncture possible but low enough to obviate the daamger of bleed back along the needle track. It is quite unnecessary for the patient to stand upright or for a tourniquet to be applied.

The most distal incompetent perforating vein should be injected first, followed by the next most distal and so on until all the selected sites have been injected. The direction of progression is chosen so as to allow complete emptying of the veins for each injection.

A 2 ml. all-glass syringe containing 1 c.c. of sodium tetradecyl and fitted with a 20 gauge disposable needle is used for injection. In our opinion the use of an all-glass syringe is preferable to a disposable syringe because it allows earlier detection of extravascular injection. Venipuncture opposite an incompetent perforating vein is performed in the usual manner, following which the leg is elevated and the patient lies back. The segment of vein to be injected is isolated by the fingers of the left hand and injection is maed gently over a 15-second interval.

The solution is a detergent which acts not on the blood but on the vein wall, producing a wettable sticky surface. The interaction of the solution with the intima is very rapid, and from examination of the clinical end results would appear to remain strictly isolated to the interdigital gap. The object of restricting the segment of vein treated is to avoid the involvement of good functioning valves. However, at least 2 inches of vein should be obliterated in order to withstand the forces attempting to re-open the vein.

Immediately following injection, compression is applied. The object of immediate compression is to reduce to a minimum the development of the core of thrombus in the segment of vein which is being rendered sticky by exposure to the detergent. The smaller the core the more rapid and complete its organization, thereby reducing to a minimum the incidence of recanalization.

Bandaging is the most important part of the technique.  This cannot be stressed too much. Our best results are the results of the best bandaging. This part of the technique should be carried out by the surgeon himself or should only be delegated to someone who is known to be as competent. The bandages used are stiff cottonn crepe 3 inches wide. A bevelled sorbo rubber pad is placed directly over the site of venipuncture and bandaged into this position to give a relatively greater pressure over this area as distinct from the pressure applied over the leg as a whole. Both hands are used in bandaging, the right holding the bandage and wrapping it round the limb, while the left hand palpated the limb assessing the firmness and tension of the bandage. The limb should have a firm even contour when bandaging is completed. To avoid ascending phlebitis in the long saphenous vein a rubber pad should project above the bandage over it. A full length two-way stretch elastic stocking is fitted over the completely injected and bandaged leg and held in place by a belt suspended from the waist. It is wise to make the patient walk twice around an average room between the application of the bandages and the fitting of the stocking. The application of the stocking holds the bandages in position, especially in bed at night when bandages are inclined to loosen or roll into cords. The stocking, therefore, must be worn throughout the 24 hours.

Important though the surgeon's technique may be in this treatment for the attainment of good results, we believe the patient's contribution is even more important. The patient should be indoctrinated as to the importance of walking or even running and playing games at all times, but especially immediately after treatment. This we find easy to explain to the patient, but we have the greatest difficulty in making our patients understand the great harm which standing does. They are repeatedly advised not to stand but persist in doing so. To achieve good results the technique of bandaging is the surgeon's major contribution, but the patient who walks well and does not stand makes an even more important contribution to the success of his own treatment.

After a week, the patient is re-examined and any remaining leaks are dealt with in an identical manner. However, one should attempt to obliterate every incompetent perforator at the first visit, this yielding the best results.

All patients should be followed up for at least five years. This treatment should only be carried out in an Out-Patients Clinic specially devoted to it, as the occasional injector does not get such good results.

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