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
   • Look at legs lying down
   • Inspect gaiter area - venous eczema, lipodermatoscerlosus, ulceration, peripheral oedema
   • Scars indicating previous surgery
   • Stand patient up and look at veins - decide on distribution
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)
   • 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
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. Surgical
   • Sclerotherapy (below knee)
   • 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