Clinical Case Study ON Incidence and Management of Varicose Veins

R Sachin Raj, RNM Francis and P Sasikumar^*

^*Correspondence: P Sasikumar, Department of General Surgery, Sree Balaji Medical College & Hospital Affiliated to Bharath Institute of Higher Education and Research, Chennai, Tamil Nadu, India, Email:

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Introduction

The term varicose is derived from latin word varix meaning ‘bent’. Varicose limb which has lost its valvular efficiency and as a product of the resultant venous hypertension in standing position becomes dilated, tortuous, elongated, and thickened. Varicose veins are known from antiquity since Hippocrates and treatment in its length and associated with varicose ulcer. Varicose veins of the lower limb are the most common vascular disorder affecting the human beings [1]. It is almost certainly the price we pay for the erect posture. Nowadays we have various options are available for treating varicose veins. Our renewed interest in the incidence and management of varicose veins has prompted a reappraisal of its basic components and how they are individually affected by biological, mechanical, and physical forces [2,3]. The goal of varicose veins management is safe and easy manipulation of the healing process we are closer to that goal than ever before.

Materials and Methods

This is a prospective clinical study of 100 cases of varicose veins and to assess the management and outcomes, during the period from March 2017 to October 2018 in our Department of General Surgery, Sree Balaji Medical College and Hospital.

All the cases underwent detailed evaluation regarding presenting symptoms, duration, and previous modality of treatment. Clinical examination was made as to which system was involved and to identify which superficial valves and perforators were incompetent. Deep vein patency was assessed. Abdominal and pelvic examinations were made to rule out secondary causes. Cardiovascular and peripheral pulses were assessed to exclude arterial disease.

Routine investigations and selective doppler assessment were done. Documentation was done using a stratified proforma which included demographic data of the patients studied; all the details of investigations carried out and the types of management provided to the patients enrolled in the study.

For all patients, haematological, biochemical, microbiological, and radiological investigations were carried out as enumerated in the proforma using standard procedures.

Inclusion criteria

All cases of varicose veins including Outpatients and inpatients in SBMCH between the period from MARCH 2017–OCTOBER 2018.

Exclusion criteria

All the patients with Varicose veins leaving the hospital before the treatment is complete.

Results

Among the study population, a majority of 26 % constituted between the age group 21–30 years followed by 20% between the age group 31–40 years, 17% between the age group 41- 50 years and less than 20 years, 10 % between the age group 51–60 & above 60 years (Table 1 and Figure 1). The study population was distributed as 62 % of males and 38 % as females (Table 2 and Figure 2).

Figure 1: Age distribution of the patients.

Figure 2: Gender distribution.

Table 1: Age distribution of the patients.

Table 2: Gender distribution.

Most of the people presented with symptoms persists more than 2 years before they seeked the medical attention.12% presented with in six months duration andanother 21% took for about at least 2 yrs. to medical consultation. Those who took 2 -5 yrs. constituted 28%those who took more than 5 yrs. constituted 13%. Time duration for the presentation between 3 months minimum and 20 years maximum (Table 3).

Table 3: Mean duration of presentation.

Manual labourer formed the largest proportion around 16%. Pregnant women and doctors formed 10% each. Those who stood for prolonged periods constitute students, salesmen, security & others which formed 64% (Table 4). Among the total women patients 26% (10 cases) were pregnant women (Table 5).

Table 4: Various occupations of the patients.

Table 5: Ratio of pregnant women among the women patients.

38% of the study population had symptoms related primarily to the dilated varicose veins.25% had discomfort or pain. Symptoms due to skin change and discolouration, ulceration and haemorrhage was presented with 20%, 14% and 3% respectively (Table 6 and Figure 3).

Figure 3: Different symptoms at presentation.

 Table 6: Different symptoms at presentation.

LSS was commonly involved around 49% and short saphenous around 16% while both in left and right constituted 8% and 12% respectively. Left sided lesions constituted 47% and right-sided lesions constituted only 38%. Bilateral made around 15% (Table 7 and Figure 4).

Figure 4: Modalities of segment involvement.

Table 7: Modalities of segment involvement.

Sapheno-femoral incompetence constituted the bulk of the disease339 % of the present study. Sapheno-popletial incompetence & below knee perforator incompetence occurred each in %. Above knee perforator incompetence occurred in 16%. %. Ankle perforators incompetence was least common only in 13%. Lateral perforator incompetence was common in 1% (Table 8 and Figure 5).

Figure 5: Different pathology of varicose veins.

Table 8: Different pathology of varicose veins.

Trendlenburg and stripping with stab avulsion constitutes 33%, trendlenburg and stripping with constitutes 15% whereas trendlenburg with stripping and SSG is done in 20%. Subfascial ligation procedure is done in 9%. Foam sclerotherapy and compression therapy is done in 15% and 18% respectively (Table 9 and Figure 6).

Figure 6: Different modality of treatment.

Table 9: Different modality of treatment.

Among the total cases 23 % had hyperpigmentation, 20 % had eczema, 31 % had Lipodermatosclerosis, 19 % had venous ulcer and 7 & had haemorrhage (Table 10 and Figure 7). Among the 100 cases, 41 patients had complications out of which 34 % had seroma and 66%had recurrence (Table 11 and Figure 8).

Figure 7: Patients with complications of varicose vein.

Figure 8: Post-operative complications.

Table 10: Patients with complications of varicose vein.

Table 11: Post-operative complications.

33 % of the people stayed mean duration 5 -10 days in hospital. 28% people stayed for the duration about 11-15 days. 20% people sxdtayed for the duration about 16-20 days in the hospital and 19 people stayed for less than 5 days in the hospital. Minimum 4 days maximum 19 days is duration of hospital stay for the patient (Table 12 and Figure 9).

Figure 9: Duration of hospital stay

Table 12: Duration of hospital stay.

Discussion

This study was conducted among 100 patients with varicose veins of Sree Balaji Medical College and Hospital between March 2017 and October 2018 for a period of 18 months. According to Evans CJ, FowkesFGR, Male and female ratio constitutes for about 1:2, Males constitute 62 % of our study and females 38 %. Male:female ratio 1.6:17.The age group which affects predominately economically productive people between 20 to 40 yrs. Mean age of presentation is around 2 years. 12 patients less than six months and longest duration are more than 10 years. Varicose vein being a benign disorder hence people do not seek medical attention early except for haemorrhagic varicose veins. Manual worker constitutes 16% of our study. Occupations like manual labourer, salesman, farmers, security guards constitute around 50%. 38% of the people seek medical attention due to varicosities and one fourth of patient complaints discomfort or pain. Ulceration and haemorrhage were about 14 % and 3 %respectively, In my study Left sided lesions were more common than right side. Varicosities is the most common presenting symptom. Long saphenous segment is more common than short saphenous segment. Both systems were involved in 15% of people.Sapheno-femoral incompetence is the most observed pathology. Of the perforators below knee perforator is commonly involved and lateral perforator least. Trendlenburg procedure with stripping and stab avulsion with subfacial ligation of perforation was most done.

SSG combined with the above procedure was done in 10% of the patients. Lipodermatosclerosis was the common complication. Hyperpigmentation was seen in 23 % of patients. 19 % of the patients presented with venous ulcers. Eczema was seen in 10 % of patients and 5% of the patients presented with haemorrhage. Meanhospital stay was 11 days. Minimum stay in the hospital was 4 days and the maximum was 19 days [4-35].

Conclusion

In my study Varicose veins was relatively common among the youth and middle age groups. Risk factors for the development of varicose veins were prolonged standing and multiparity. Clinical presentations ranged from mild to severe varicosities, with ulcer and Lipodermatosclerosis being the most severe forms. At present, Duplex ultrasound scanning is the most reliable investigative tool in making diagnosis of varicose veins in terms of valve incompetence along GSV and SSV, deep vein thrombosis and perforator incompetence. Treatment includes conservative management, sclerotherapy, and surgery. Conservative management was advised in patients who are pregnant and patients with contra indications for surgery. These patients were advised to wear compression stockings. Sclerotherapy was advised in patients with reticular veins. Surgical procedure includes Trendlenburg procedure, stripping of the vein and sub facial ligation of the perforators. Surgical intervention has been revolutionized by the development of endovenous techniques like radiofrequency abalation, laserabalation, foam sclerotherapy and sub facial endoscopic perforator surgery.

Funding

No funding sources.

Ethical Approval

The study was approved by the Institutional Ethics Committee.

Conflict of Interest

The authors declare no conflict of interest.

Acknowledgements

The encouragement and support from Bharath University, Chennai is gratefully acknowledged. For provided the laboratory facilities to carry out the research work.

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