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A  CLASSIFICATION  OF   VARICOSE  VEINS

Professor  GEORGE  FEGAN,  M.Ch.,  F.R.C.S.I.

There are many aspects of the disease described as varicose veins, each aspect requiring a different treatment. The need for classification arises because a multiplicity of treatments are available. Confusion as to the best treatment is widespread. This arises from the fact that for many years people have tried to prescribe a single explanation and one form of treatment for the entire group of diseases masquerading under the name of varicose veins.

There is, therefore, a pressing need to classify or group these diseases so that no one treatment will be applied to all, nor should every treatment be applied to one particular group.

There are many pieces of equipment available today for investigating the group of diseases broadly classified as varicose veins. To mention a few - Parks Directional Doppler; the infra-red Scanner; Ascending Phlebology with the use of video-tape and many others of increasing sophistication.

Some of these investigations have a morbidity and even a mortality and are time-consuming and in the end may not properly segregate the patients into their correct groups. I would advocate the taking of a simple history and a physical examination as all that is necessary. Ninety-five per cent of varicose veins can be classified into three broad groups.

Type                                       Varicos Veins                          Symptoms

1                                                        +                                              -

2                                                        +                                              -

3                                                         - (minimal)                            ++ (severe)

Type 1: With varicose veins and without symptoms - this is the young athletic

Person who has impressive varices involving a great number of superficial

Veins and utterly devoid of symptoms.

Type 2: Patients with multiple varices and symptoms, which represents the

Majority of cases.

Type 3: The well-known post-phlebitic limb: aedematous indurated legs with

Bursting pain with or without ulceration or eczema. Varicose veins are

Frequently not a significant feature of this latter group and are sometimes

Completely absent.

This type of patient is often referred for treatment by a doctor who has examined him prior to taking on a new job or for life insurance when the presence of a hernia or varicose veins, despite the fact that they are symptomless, is regarded as a disadvantage. On physical examination, when the patient assumes the erect position, there is a deluge of blood down the long saphenous and marked turbulence can be felt by light palpation over the most proximal varices.

Clinical picture: the start of the trouble is in the teens. There is usually a history of injury to a superficial vein in the calf either at sport or in the ordinary way of life and a painful bruise frequently follows. This superficial thrombosis is often unnoticed and is passed over, but in weeks or months the thrombosed vein will recanalize. Repeated episodes of such sub-clinical thrombosis and recanalization may take place in the same leg and years later varicosity in the superficial veins and symptoms such as muscle cramp are noted. In this type as opposed to Type 1, this is the usual reason for referral to the varicose vein clinic.

The initiating lesion is incompetence of a valve in a perforating vein in the calf or foot. Following this, the superficial veins are subjected to altered pressure patterns during walking and consequently the portion of the vein above the incompetent perforator will, over a considerable period of time, first hypertrophy and subsequently dilate. This dilation spreads upwards from the site of primary incompetence causing the valves in the superficial veins to become incompetent by virtue of the failure of their cusps to approximate. This we have chosen to call secondary valvular incompetence, an incompetence which is reversible in contra-distinction to primary incompetence arising from permanent valve cusp damage.

When ascending dilatation reaches the sapheno-femoral junction or a high perforating vein, the valves at this site become incompetent. When this occurs blood then escapes from the deep system. Downward retrograde flow in the superficial system over the valve cusps is now established. This does not occur while standing or lying down but does occur on assuming the erect position during walking.

A high percentage of the valves of the perforating and deep veins are competent, therefore emptying and hypotension in the superficial system can easily be achieved by the calf muscle pump which has a very considerable reserve pumping capacity.

This hypotension in the lower superficial veins increases the retrograde flow. This high velocity retrograde flow becomes turbulent as it crosses the valve cusps. The turbulence, once established, completely alters the haemodynamics within the vein, subjecting the wall to a totally different stress. The turbulence interferes with the perfusion from without the vein wall from the vasa vasorum in the adventia and media. Also the contracting muscle in the media is subjected to vibration from the turbulence which interferes with its contractility.

Treatment: It should now be obvious that these cases ought to be attacked at the site of commencement of trouble and that one should search for the primary sites of see-saw or retrograde flow that has to be dealt with in the manner most suited to the individual surgeon concerned. Time should be allowed to elapse and assessment should be made of the amount of recovery that is capable of taking place in the superficial system before any surgery is contemplated. We favour compression sclerotherapy as the approach in this group. It allows one to have a second or third chance at localizing and obliterating the sites of retrograde flow and allows one to take advantage of the restoration which occurs naturally after the removal of the abnormal pressure and abnormal flow pattern. It may well be that the dilatation and secondary valvular incompetence has reached a point at which recovery will not take place and on examination of these patients some months after one has obliterated every incompetent perforating vein, one may decide that surgery is necessary. This we have found in only a very small percentage of cases and between three and six months should be allowed before assessment for flush ligation.

This follows widespread deep vein thrombosis. The classic history may be forthcoming and in our practice the commonest is the post-partum. These patients present clinically with no or minimal varices and with tired legs, the tired sensation progressing to a heavy bursting sensation with chronic oedema going on to induration with or without ulceration and eczema.

Some presenting as venous claudication. In these patients the thrombosed deep veins have recanalized but the sum total of the valvular efficiency is impaired to a very great extent and the blood which is being lifted out of the leg by muscular contraction rushes back down. Some of these patients have also a proximal obstruction to cope with in the iliac vein which makes it harder still to eject the blood from the leg. From the history of deep vein thrombosis and the chronic indurated limb one can, in most cases, postulate damage to the valves of the deep veins as well as the perforating veins.

Treatment: Remove the oedema and heal the ulceration as far as possible by (a) night elevation of the limb, (b) various support bandages and elastic stockings, and (c) diuretics. As a result of these, soft spots or weaknesses become apparent, these are continuously transmitting the perforating veins which have become grossly dilated. We find by injecting the veins at these sites, we can enhance the capacity of the pumps to make maximal use of the remaining good and partially damaged valves and eject blood from the limb more efficiently. Also by obliterating these connections, one gets an improved duration of hypotension in the superficial system as a result of which oedema improves considerably and the nutrition of the skin is also markedly improved. By this process of patiently and repeatedly looking for incompetent perforating veins and "knocking them off" together with support and obliterating and advice on the importance of walking and not standing, we can get good results in the vast majority of cases, but we warn this group that we are performing a maintenance job and they will require further observation and possibly treatment for an indefinite period. They will be well advised to have available bandages and elastic stockings for such time as when the leg becomes tired, swollen and painful. One should explain to these patients that it is impossible to put back good new valves into deep veins, and until such time, permanent cure is a pious hope.

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