Surgery chapters
Venous disorders: varicose veins, DVT and venous ulcers
Venous anatomy of the leg, varicose veins (causes, clinical tests, duplex, ablation and surgery), chronic venous insufficiency and venous ulcers, deep vein thrombosis (risk, Wells score, prevention and treatment) and post-thrombotic syndrome.
In 30 seconds
- Varicose veins are dilated (3 mm or more) tortuous superficial veins from valve failure, most often at the saphenofemoral junction; duplex ultrasound maps reflux and endothermal ablation is the first-line treatment, then foam sclerotherapy, then surgery.
- Venous ulcers sit in the gaiter area above the medial malleolus, are shallow with sloping edges and surrounding pigmentation and lipodermatosclerosis; heal with graduated multilayer compression after checking ABPI (avoid full compression if under 0.8; none if under 0.5).
- DVT follows Virchow's triad; use the Wells score with D-dimer and duplex, treat with LMWH then oral anticoagulant for at least 3 months, and prevent it in every surgical patient.
On this page
Overview
Venous disease of the leg is very common: varicose veins, chronic venous insufficiency with skin changes and ulcers, and deep vein thrombosis (DVT), which can cause fatal pulmonary embolism (PE). DVT prevention is part of every surgical admission.
PGET usually has one MCQ here: clinical tests and investigation of varicose veins, nerve injuries in vein surgery, venous ulcer care or DVT.
Venous anatomy of the lower limb
- Deep veins run with the arteries inside the deep fascia: paired calf veins, popliteal, femoral, common femoral, iliac veins, IVC. The calf muscle pump squeezes blood up through them.
- Superficial veins:
| Vein | Course | Ends | Nerve beside it |
|---|---|---|---|
| Great (long) saphenous vein (GSV) | Starts at the medial end of the dorsal arch, passes in front of the medial malleolus, up the medial leg and thigh | Saphenofemoral junction (SFJ): joins the common femoral vein through the saphenous opening, which lies roughly 2.5 cm inferolateral to the pubic tubercle | Saphenous nerve (below the knee) |
| Small (short) saphenous vein (SSV) | Starts at the lateral end of the arch, passes behind the lateral malleolus, up the back of the calf between the heads of gastrocnemius | Saphenopopliteal junction (SPJ) in the popliteal fossa (variable level) | Sural nerve |
- Tributaries at the SFJ (ligated at surgery): superficial epigastric, superficial circumflex iliac, superficial external pudendal, plus the accessory saphenous veins.
- Perforating veins join superficial to deep veins through the fascia. Normally blood flows from superficial to deep. Medial calf (Cockett) perforators link the posterior arch vein to the posterior tibial veins and matter in ulcers.
- Valves allow only upward and inward flow.
Varicose veins
Definition and causes
- Varicose vein: a dilated, tortuous subcutaneous vein 3 mm or more in diameter. Reticular veins are 1-3 mm; telangiectasia (thread veins) under 1 mm.
- Primary (most): weakness of the vein wall and valve incompetence, mostly at the SFJ. Risk: age, female sex, pregnancy, family history, standing occupations, obesity.
- Secondary: post-thrombotic deep vein damage, pelvic tumours or pregnancy (raised pressure), arteriovenous fistula, Klippel-Trenaunay syndrome (varicosities, port-wine stain, limb overgrowth).
Symptoms and signs
- Visible veins, aching, heaviness and itching, worse at the end of the day and on standing, relieved by elevation; ankle swelling.
- Saphena varix: soft swelling at the SFJ that disappears on lying, has a cough impulse and a thrill, and looks bluish. It can be confused with a femoral hernia.
- Skin changes of chronic venous hypertension: ankle flare (corona phlebectatica), oedema, haemosiderin pigmentation, venous eczema, lipodermatosclerosis (hard, woody, "inverted champagne bottle" leg), atrophie blanche (white scarred patches), then ulcer.
- Complications: bleeding (can be heavy: lie flat, elevate the leg and press), superficial thrombophlebitis (tender red cord), skin changes and ulceration.
CEAP clinical classes
| Class | Finding |
|---|---|
| C0 | No visible disease |
| C1 | Thread veins (telangiectasia) or reticular veins |
| C2 | Varicose veins |
| C3 | Venous oedema |
| C4a / C4b | Pigmentation or eczema / lipodermatosclerosis or atrophie blanche |
| C5 | Ulcer that has healed |
| C6 | Ulcer that is still open (active) |
Bedside tests (still asked in exams)
| Test | How | Meaning |
|---|---|---|
| Trendelenburg test | Lie the patient down, raise the leg to empty the veins, press over the SFJ, then stand the patient up | Veins stay empty until pressure is released, then fill rapidly from above = SFJ incompetence. Fill despite pressure = incompetence below (perforators or SPJ) |
| Tourniquet test | Same principle with a tourniquet moved down the leg | Finds the level of the incompetent point |
| Perthes test | Tourniquet below the knee, patient walks or does heel raises | Veins empty = deep veins patent; veins become more prominent and painful = deep vein obstruction |
| Cough impulse | Over the SFJ | Incompetent SFJ or saphena varix |
| Hand-held Doppler | Over junctions | Reflux on calf release |
Exam trap
These clinical tests are now largely replaced by duplex scanning. They are still asked in exams, but in practice duplex comes first.
Investigation
- Duplex ultrasound is the investigation of choice before any intervention. It shows which junctions and trunks have reflux (backward flow for more than about half a second in superficial veins, one second in deep veins), perforators, and whether the deep veins are patent (post-thrombotic disease).
- ABPI if pulses are weak, especially before compression.
Treatment
| Option | Points |
|---|---|
| Conservative | Reassurance, weight loss, exercise, elevation; graduated compression stockings (UK classes: 1 = 14-17, 2 = 18-24, 3 = 25-35 mmHg) ease symptoms but do not cure; check arterial supply first |
| Endothermal ablation (endovenous laser or radiofrequency) first line | Duplex-guided catheter in the incompetent GSV or SSV; heat closes the vein; under tumescent local anaesthesia; day case; quick recovery |
| Ultrasound-guided foam sclerotherapy | Second line; also for tributaries, recurrent veins; sclerosant (sodium tetradecyl sulphate, polidocanol) mixed with air |
| Non-thermal non-tumescent methods | Cyanoacrylate glue, mechanochemical ablation |
| Surgery | If endovenous treatment is unsuitable: high (flush) SFJ ligation, tying all tributaries, with GSV stripping to the knee, plus avulsions (phlebectomies); SPJ ligation for SSV |
- Indications for treatment: symptoms, skin changes, ulcer (healed or active), bleeding, superficial thrombophlebitis.
- Contraindications: DVT or deep vein obstruction, pregnancy, arterial insufficiency, immobility.
Complications of vein surgery
| Complication | Points |
|---|---|
| Wound infection | Commonest complication (groin) |
| Saphenous nerve injury | Numbness of the medial leg and foot; reason to strip the GSV only to the knee, not the ankle |
| Sural nerve injury | In SSV surgery: numbness of the lateral foot |
| Common peroneal nerve injury | In SSV/popliteal fossa surgery: foot drop |
| Bruising, haematoma, lymph leak | Common |
| DVT | Uncommon; give prophylaxis to high-risk patients |
| Femoral vein or artery injury | Rare but serious, at the SFJ |
| Recurrence | Common over years: neovascularisation at the groin, missed incompetent veins |
High-yield
Sural nerve goes with the short saphenous vein; saphenous nerve with the great saphenous vein below the knee.
Chronic venous insufficiency and venous ulcers
Pathophysiology
- Failure of valves (superficial, perforator or deep) or deep vein obstruction stops the calf pump lowering the pressure in the foot veins on walking (ambulatory venous hypertension).
- High pressure leaks fluid, red cells (haemosiderin) and proteins into the tissues, causing inflammation (white cell trapping), fibrosis and skin breakdown.
Clinical features of a venous ulcer
- Site: gaiter area, usually just above the medial malleolus (lateral if SSV disease); rarely on the foot or upper calf.
- Shallow, irregular, with gently sloping edges, a granulating base with slough; moderate pain; often after minor trauma.
- Surrounding skin: pigmentation, eczema, lipodermatosclerosis, atrophie blanche, oedema; varicose veins may or may not be present.
| Feature | Venous ulcer | Arterial ulcer | Neuropathic ulcer |
|---|---|---|---|
| Site | Gaiter area, medial malleolus | Toes, heel, pressure points, shin | Sole, under metatarsal heads, heel |
| Edge and base | Sloping edge, granulating | Punched out, pale base, may show tendon | Punched out, deep, callus rim |
| Pain | Mild-moderate, better with elevation | Severe, worse with elevation | Painless |
| Pulses / skin | Pulses present; pigmentation, LDS | Absent pulses; cold, shiny, hairless | Pulses often present; numb, dry foot |
- Some ulcers are mixed (venous and arterial). Others: rheumatoid, vasculitic, diabetic, malignant, pyoderma gangrenosum.
Exam trap
An ulcer that fails to heal or has a raised, rolled or everted edge must be biopsied to exclude Marjolin's ulcer (squamous cell carcinoma arising in a chronic ulcer or scar).
Investigation
- ABPI in every patient with a leg ulcer (unless foot pulses are clearly normal), to find arterial disease before compression.
- Duplex ultrasound of the veins; FBC, glucose, swab only if clinically infected; biopsy if atypical.
Treatment
- Compression is the mainstay: multilayer (four-layer) graduated bandaging giving about 35-40 mmHg at the ankle, applied by trained nurses and changed according to exudate.
- ABPI rules:
- 0.8 or above: full compression.
- 0.5-0.8 (mixed disease): reduced (modified) compression under supervision.
- Below 0.5 (or ankle pressure under 60 mmHg): no compression; refer for revascularisation first.
- Simple non-adherent dressings, leg elevation, exercise, treat eczema, antibiotics only for clinical infection (cellulitis); pentoxifylline may help healing.
- Correct superficial reflux (endovenous ablation or surgery) to speed healing and reduce recurrence.
- After healing: lifelong class 2-3 compression stockings; recurrence is common, especially in post-thrombotic legs.
- Large clean ulcers: split-skin (pinch or mesh) grafting after the bed is healthy.
Deep vein thrombosis
Virchow's triad
| Factor | Examples |
|---|---|
| Stasis | Immobility, surgery (especially long operations), long-haul travel, heart failure, paralysis, plaster casts |
| Vessel wall injury | Trauma, hip and knee surgery, previous DVT, IV lines |
| Hypercoagulability | Cancer, pregnancy and the puerperium, oestrogen (combined pill, HRT), dehydration, sepsis, polycythaemia, nephrotic syndrome, IBD, thrombophilia (factor V Leiden, prothrombin mutation, protein C, protein S or antithrombin deficiency, antiphospholipid syndrome) |
- Highest-risk surgery: major orthopaedic surgery (hip and knee replacement, hip fracture) and pelvic or abdominal cancer surgery.
Clinical features
- Calf pain, swelling, warmth, tenderness, pitting oedema, dilated superficial veins, low-grade fever; often silent. PE may be the first sign.
- Homans' sign (calf pain on dorsiflexion) is unreliable and should not be relied on.
- Phlegmasia alba dolens: massive iliofemoral DVT, white swollen painful leg.
- Phlegmasia caerulea dolens: blue, very swollen leg with threatened venous gangrene; urgent thrombolysis or thrombectomy.
- Left leg iliac DVT is commoner because the left common iliac vein is compressed by the right common iliac artery (May-Thurner).
Diagnosis (Wells score)
| Item (1 point each unless stated) |
|---|
| Active cancer (within 6 months) |
| Paralysis, paresis or recent leg plaster cast |
| Bedridden more than 3 days or major surgery within the last 12 weeks |
| Tenderness along the deep vein system |
| Whole leg swollen |
| Calf swelling more than 3 cm compared with the other leg (measured 10 cm below tibial tuberosity) |
| Pitting oedema in the symptomatic leg |
| Collateral superficial (non-varicose) veins |
| Previous DVT |
| Alternative diagnosis at least as likely: minus 2 |
- Score 2 or more: DVT likely → proximal leg duplex ultrasound (within hours; give anticoagulant while waiting if delayed).
- Score under 2: DVT unlikely → D-dimer; if negative, DVT is excluded; if positive, do duplex.
Worked example: Wells score for DVT
Woman on chemotherapy for ovarian cancer (+1), calf 4 cm bigger than the other side (+1), pitting oedema (+1), no likelier alternative (0)
Wells = 1 + 1 + 1 = 3 → DVT likely → proximal leg duplex ultrasound
Exam trap
D-dimer is sensitive but not specific. It is useful only to exclude DVT in low-probability patients; it is raised anyway after surgery, in cancer, infection and pregnancy.
Treatment
- Anticoagulate promptly: LMWH (e.g. enoxaparin) subcutaneously, or a DOAC (rivaroxaban, apixaban). Unfractionated heparin IV in severe renal failure or when quick reversal may be needed.
- Then warfarin (INR 2-3) or a DOAC for at least 3 months (provoked DVT); longer for unprovoked or recurrent DVT; LMWH is preferred in active cancer (and in pregnancy).
- IVC filter only when anticoagulation is contraindicated (e.g. recent bleeding or surgery) or fails.
- Catheter-directed thrombolysis for selected massive iliofemoral DVT or phlegmasia.
- Early walking with compression for comfort.
- Heparin-induced thrombocytopenia (HIT): platelet fall about 5-10 days after starting heparin with new clots; stop all heparin, use fondaparinux or a direct thrombin inhibitor.
Complications
- Pulmonary embolism: sudden breathlessness, pleuritic pain, tachycardia, hypoxia, collapse; CT pulmonary angiography.
- Post-thrombotic syndrome: chronic swelling, pain, skin changes and ulcer from damaged deep valves or obstruction; affects many patients within 5 years of a DVT. Prevented partly by good anticoagulation and compression.
- Recurrent DVT.
Prevention (thromboprophylaxis)
- Assess VTE and bleeding risk on admission for every surgical patient.
- Mechanical: early mobilisation, hydration, graduated compression stockings (not in arterial disease), intermittent pneumatic compression.
- Pharmacological: LMWH once daily (no monitoring), fondaparinux, DOACs after hip and knee replacement; continue for extended periods (about 4 weeks) after major cancer surgery of the abdomen or pelvis and after hip surgery.
- Stop the combined pill or HRT about 4 weeks before major elective surgery.
Superficial thrombophlebitis
- Tender, red, hard cord along a superficial vein; usually in varicose veins or at an IV cannula site.
- NSAIDs, warm compresses, compression. Duplex if near the SFJ (risk of extension into the deep veins: anticoagulate). Migratory thrombophlebitis suggests malignancy (Trousseau sign) or Buerger's disease.
Upper limb DVT
- From central venous lines, or effort thrombosis (Paget-Schroetter syndrome) in the subclavian vein in young people after strenuous arm use, often with a thoracic outlet compression.
Exam focus
Expect: duplex as the investigation of choice for varicose veins, interpretation of the Trendelenburg and Perthes tests, saphena varix versus femoral hernia, endothermal ablation as first-line treatment, sural and saphenous nerve injuries, the gaiter-area venous ulcer with lipodermatosclerosis, venous versus arterial ulcer, ABPI before compression (0.8 and 0.5 cut-offs), four-layer bandaging, Marjolin's ulcer, Virchow's triad and highest-risk operations, Wells score with D-dimer and duplex, LMWH followed by at least 3 months of oral anticoagulation, IVC filter indications, post-thrombotic syndrome and thromboprophylaxis.
Quick revision
- Varicose vein = superficial vein 3 mm or more; SFJ commonest incompetent site.
- Duplex before any treatment; endothermal ablation first line.
- Trendelenburg: veins fill fast on release = SFJ incompetence.
- Sural nerve with SSV; saphenous nerve with GSV below knee.
- Venous ulcer: medial gaiter, sloping edge, pigmentation; four-layer compression.
- ABPI under 0.8: reduced compression; under 0.5: no compression, revascularise.
- Non-healing ulcer with raised edge: biopsy for Marjolin's.
- Wells 2 or more: duplex; under 2: D-dimer first.
- DVT: LMWH or DOAC, then at least 3 months; IVC filter if anticoagulation impossible.
Written by The House Job from standard references (Bailey & Love).
FAQ
What is the investigation of choice for varicose veins?
Duplex ultrasound, which shows exactly which junctions, trunks and perforators have reflux and confirms the deep veins are open before treatment.
Which nerve is at risk during short saphenous vein surgery?
The sural nerve, which runs with the small saphenous vein in the calf; injury causes numbness along the outer side of the foot.
Why is ABPI measured before bandaging a leg ulcer?
Strong compression on a leg with poor arterial supply can cause pressure necrosis or gangrene, so arterial disease must be ruled out first.
How long is a provoked DVT treated?
Usually for at least 3 months with LMWH followed by warfarin or a DOAC; unprovoked or recurrent clots and active cancer need longer.
When is an IVC filter used?
When a patient with DVT or PE cannot be anticoagulated, for example because of active bleeding or very recent surgery, or when clots recur despite proper anticoagulation.