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Pathophysiology

1. Fibrous tissue invades tunica intima and media of vein and breaks up smooth muscle - preventing maintenance of adequate vascular tone
2. Changes patchh and may not affect adjacent segments of vein

SFJ branches

• Superficial epigastric vein
• Superficial external pudendal vein
• Superficial circumflex iliac vein

Perforators:

1. Ankle: May/Kuster
2. Lower leg: Cockett
3. Gastrocnemius: Boyd
4. Mid thigh: Dodd

Approach

• Expose groin
• Maintain dignity

1. Inspect
   • Stand the patient up and look at the veins - decide on the distribution (LSV, SSV)
   • Inspect gaiter area - venous eczema, lipodermatoscerlosus, ulceration, peripheral oedema
   • Scars indicating previous surgery
2. Palpate
   • Palpate SFJ 2 fingerbreaths below and lateral to pubic tubervle
   • Feel for swelling and palpable thrill of saphena varix (Cruveihier's sign - positive cough impulse)
   • Tap out the vein: put one finger distally, tap proximally for any transmitted impulse which would imply valvular incompetence.
   • Trendelenburg test
     1. Elevate leg and gently empty veins
     2. Palpate SFJ ad get patient to stand whilst maintaining pressure
     3. If veins do not refill - implies SFJ is incompetent
     4. If veins fill, SFJ may be incompetent or competent
   • Tourniquet test
     1. Tourniquet to control junction rather than fingers
   • Use hand-held doppler to identify SFJ reflux: (1) first identify the femoral pulse, then (2) move doppler probe medially ~1cm and (3) compress the gastrocnemius muscle - there should be only one "whoosh" if the SJF is competent.
   • Use hand-held doppler to identify SPJ reflux: (1) identify the popliteal pulse then (2) move doppler laterally (3) compress the calf muscles.
3. Percuss
4. Auscultate

Completion

1. Chevrier's tap test
2. Auscultate vein for bruits (AV fistulae)
3. Examine abdomen for masses / DRE

Indications for pre-operative Duplex ultrasound

1. Previous DVT
2. Ulceration
3. Recurrent varicose veins
4. Difficulty in assessing wether SSV or LSV is incompetent

Treatment options

1. Non-surgical
   • Graded elastic support stockings (grade II compression)
   • Weight loss
   • Exercise
2. Interventional
   • Foam sclerotherapy (below knee)
   • Radiofrequency
3. Surgical 
   • Ligation of SFJ / SPJ + stripping of vein + multiple avulsions
   • Ligation of incompetent perforators
   • Subcutaneous endoscopic perforator surgery

Associated syndromes

• Klippel-Trenaunay-Weber syndrome: triad of (1) varicose veins (2) port wine stain (3) bony or soft tissue hypertrophy of limbs

  

• Parkes-Weber syndrome (1) multiple AV fistulae (2) limb hypertrophy (3) cardiac output failure if severe