MGM Journal of Medical Sciences

ORIGINAL ARTICLE
Year
: 2019  |  Volume : 6  |  Issue : 4  |  Page : 157--164

Clinicopathological study of varicose veins (descriptive study)


Shantata J Kudchadkar, Shireesha U Chodankar, Francis P Noronha 
 Department of General Surgery, Goa Medical College, Bambolim, Goa, India

Correspondence Address:
Dr. Shantata J Kudchadkar
Department of General Surgery, Goa Medical College, Bambolim, Goa.
India

Abstract

Background: Varicose veins and their associated symptoms/complications constitute the most common chronic vascular disorders, affecting 20% of the adults, leading to surgical treatment. In general, this does not cause major life-threatening illness, yet the morbidity of venous ulceration places a substantial burden on community health care. Aim: The aim of our study was to evaluate various clinical presentations, management, and outcome in 50 patients who presented with varicose veins at tertiary center. Materials and Methods: This study is a descriptive review of clinical data of 50 patients diagnosed and treated for varicose veins at our tertiary center over 2 years. Results: Most commonly affected age-group was 41–60 years. Majority of patients were males, dilated veins being the most common presenting symptom. Increased incidence was observed in left leg (32%) as compared to right (26%). In unilateral leg involvement, great saphenous vein (GSV) was most commonly affected (62.06%), whereas in bilateral leg involvement, 73.8% had perforator incompetence. Patients with advanced disease had both saphenofemoral and perforator incompetence. Majority underwent Trendelenburg’s procedure with stripping of GSV and subfascial perforator ligation. Postoperative complications were minimal, and no patient developed recurrence at subsequent follow-ups. Conclusion: The use of color Doppler is an essential investigation along with clinical examination for effective treatment of varicose veins, to prevent recurrence and reduce morbidity. Operative treatment is the primary procedure in the management with minimal chance of recurrence.



How to cite this article:
Kudchadkar SJ, Chodankar SU, Noronha FP. Clinicopathological study of varicose veins (descriptive study).MGM J Med Sci 2019;6:157-164


How to cite this URL:
Kudchadkar SJ, Chodankar SU, Noronha FP. Clinicopathological study of varicose veins (descriptive study). MGM J Med Sci [serial online] 2019 [cited 2020 Nov 24 ];6:157-164
Available from: http://www.mgmjms.com/text.asp?2019/6/4/157/283462


Full Text



 INTRODUCTION



The term varicose is derived from Latin word meaning “dilated.” Varicosity is the penalty for verticality against gravity.[1] Factors said to be responsible for varicosities are female gender, hereditary, occupations involving prolonged standing, hormonal factors, deep vein phlebitis, and abdominal lump.[2] The definitions of varicose veins vary widely ranging from according to Arnoldi, “clearly visible, dilated, torturous, and possibly prominent subcutaneous veins of lower extremities”; according to Dodd and Cocket, “varicose veins are secondary to loss of valvular efficiency”; and according to the World Health Organization (WHO), “vein with a saccular dilatation, which is often torturous.”[3] This variation in definition has led to wide discrepancies in the incidence reported in literature. They are the response to a dynamic process of strong reversed flow and not just a static distension.[4] Though varicose veins were recognized prehistorically, only in the present century, considerable knowledge has been gained concerning the anatomy of venous system of the leg, the physiological mechanism of venous return to heart against gravity, and pathology of the disorder, which has led to the many newer modalities of treatment.[5]

Venous system of the lower limb is divided into superficial veins (great saphenous vein and short saphenous vein), perforating veins, and deep veins. There are two types of deep veins—intermuscular (anterior tibial, posterior tibial, peroneal, popliteal, and femoral vein) and intramuscular (those from the soleus and gastrocnemius muscles).[6] Normal flow of blood in the veins of the lower limbs is from below upward and from superficial to deep veins through the perforators. Factors, which help in maintaining normal direction of blood flow, are venous (calf) pump, valves in veins, “vis a tergo” (pressure transmitted from the arterial tree) and “vis a fronte” (negative intrathoracic pressure).[7]

Symptomatology varies greatly. There are various systems to classify chronic lower extremity venous disease such as clinical, etiological, anatomical, pathophysiological Classification,[8] Venous Disability Score (VDS), and Venous Clinical Severity Score (VCSS). Varicose veins can be classified into primary or idiopathic, secondary or compensatory, and recurrent according to varicose veins working classification. Clinical tests to help in diagnosis and appropriate treatment include Brodie–Trendelenburg test, Tourniquet test, Modified Perthes test, Schwartz test, and Fegan’s method. Majority of patients present with complications, which include hemorrhage, phlebitis, ulceration, skin changes (pigmentation, eczema, and lipodermatosclerosis), calcification of vein, periostitis, and equinus deformity.[9] Morphologically, affected veins are dilated, torturous, elongated, and nodular. Intraluminal thrombosis and valvular deformities are found. Microscopically, there is variable fibromuscular thickening of the vein walls due to alternate dilation and hypertrophy. Degeneration of the medial elastic tissue may occur followed by calcific foci.[10]

Technological progress and evolution in color duplex ultrasound now offer superior diagnostic accuracy in patients with venous disease, which should be the minimum investigation before undertaking any operation as it helps in planning surgery and reducing the incidence of recurrence.[11] Sclerotherapy remains an effective treatment for selected patients presenting with varices in the absence of major truncal incompetence, or in whom long or short saphenous has been treated surgically. Morbidity related with varicose veins can be alleviated by meticulous clinical examination and sound surgical technique followed by closely monitored postoperative management.[12] During surgical treatment, stripping of long saphenous vein is preferable to saphenofemoral ligation alone. The latter course of action allows venous reflux to persist in the trunk of long saphenous vein in over 50% of patients. A better clinical outcome will be achieved, particularly in patients with chronic venous insufficiency, when all sources of venous reflux have been controlled.

For more aesthetic results, surgeries are performed through small-sized incision in patients with varicose veins. Trendelenburg’s operation with subfascial ligation gives good and satisfactory result even in today’s world with access to current novel approaches such as endovenous laser treatment, transilluminated powered phlebectomy, and radio frequency ablation (RFA). Any recurrent or residual varicosities can be detected and managed with routine regular follow-ups.

 MATERIALS AND METHODS



A 2-year study was conducted on “varicose veins in lower limb” in Goa Medical College (GMC), Bambolim, Goa, India, from August 2011 to August 2013.

Source and method of collection of data

A total of 50 patients were studied. The selection of cases was random. Study was performed as per the pro forma drafted. Permission from the ethics committee and consent from patient were obtained before the study. A thorough clinical history with coexisting medical illness was recorded. Detailed examination of the lower limb including the various clinical tests [Figure 1]A and B with systemic examination was performed. Along with routine investigations, all patients underwent duplex ultrasonography (USG) to confirm the diagnosis. On the basis of clinical and Doppler findings, they received either conservative or operative treatment or both. Conservative treatment was given in the form of phlebotropic drugs with compression stockings. Surgical data were documented in detail in patients who received operative treatment. Patients received analgesics, anti-inflammatory agents postoperatively, and were discharged on compression therapy. Follow-up was conducted in outpatient department (OPD) at intervals of 15 days, 1 month, 6 months, and 1 year. At follow-up, operated limb was examined to review scar, occurrence of any complications such as seroma or hematoma formation, neuritis, and any recurrence [Figure 1]C.{Figure 1}

Inclusion criteria

Patients with symptomatic primary varicose veins of lower limb (unilateral and bilateral)

Patients with complicated varicose veins (chronic swelling, ulcer, and skin changes)

Both male and female patients

Exclusion criteria

Patients with deep vein thrombosis

Patients who were pregnancy

Patients with recurrent varicose veins

Patients with secondary varicosities

 RESULTS AND OBSERVATIONS



Results of 50 patients at our center

Age and gender distribution: Our study included patients ranging from 21 to 80 years of age. The most common age-group involved was 41–60 years group. Of 50 patients studied, 30 were males and 20 were females (M:F = 1.5:1) [Table 1].

Clinical presentation: Unilateral leg involvement was seen in 58% of patients wherein left lower limb was affected (16) more than the right (13). In 21 patients (42%), both lower limbs were affected. All (100%) had dilated veins, whereas 78% gave history of swelling of lower leg, 54% had pain along the veins, and 54% had cosmetic reasons to seek treatment [Table 1].

Venous system involved and complications: In case of unilateral leg involvement, 62.06% had clinical features and Doppler findings suggestive of GSV involvement with sapheno-femoral junction (SFJ) and perforator incompetence; 27.5% had only perforator incompetence; 6.89% had short saphenous vein (SSV) with perforator incompetence; and only 3.44% had sapheno-popliteal junction (SPJ), SFJ, and perforator incompetence. In case of bilateral leg involvement, 73.8% had clinical features and Doppler findings suggestive of only perforator incompetence, 16.66% had GSV involvement with SFJ and perforator incompetence, whereas SFJ, SPJ with perforator incompetence was present in 9.52% patients. Majority (90%) presented with hyperpigmentation of skin around the medial malleolus, 34% had eczema, and 26% had ulcer over medial aspect of lower leg. Stasis dermatitis was found in 24% patients and 8% had occasional bleeding from the varices [Table 2].

Treatment given: Of 29 patients with unilateral leg involvement, 79.31% were operated and 20.68% were managed only conservatively. Of 21 patients with bilateral leg involvement, in 80.95% patients, one leg was operated and the other leg was given only conservative treatment, whereas in 19.04% patients, both legs were managed conservatively [Table 3].

Conservative treatment: Of 29 cases of unilateral leg involvement, in 75.86% cases, compression therapy with stockings was given, whereas 24.23% cases were managed with both drugs and compression therapy. All 21 patients with bilateral leg involvement were given phlebotropic drugs along with compression therapy. Of these, 4 patients were given only compression therapy, whereas in 17 patients, the more affected leg was operated along with drug and compression therapy and other leg was managed conservatively.

Operative treatment: In case of unilateral leg involvement, of 23 patients, majority (82.6%) underwent Trendelenburg’s procedure with stripping of GSV and subfascial perforator ligation and 17.39% underwent only subfascial perforator ligation. In case of bilateral leg involvement, of 17 patients, majority (52.94%) underwent Trendelenburg’s procedure with stripping of GSV and subfascial perforator ligation, 35.29% underwent only subfascial perforator ligation, whereas 11.76% underwent Trendelenburg’s procedure with saphenopopliteal junction ligation with stripping of GSV and subfascial perforator ligation [Table 4], [Figure 2]A–D.

Postoperative complications: In case of unilateral leg involvement, only 13.04% had neuritis and 8.69% had hematoma and wound infection. In case of bilateral leg involvement, only 23.52% had neuritis, 11.76% developed wound infection and 5.88% had hematoma. Overall, no patient had a recurrence [Table 5].{Table 1}, {Table 2}, {Table 3}, {Table 4}, {Table 5}, {Figure 2}

 DISCUSSION



In this study, a total of 50 patients with varicose veins of lower limb were clinically assessed, investigated, managed accordingly, and followed-up at OPD level in GMC hospital. The analysis of results is as follows:

Age range

{Table 6}

In our study, the age range was from 21 to 80 years. In a study by Malhotra et al.,[13] 677 patients from both north and south India had an age range of 18–65 years. In a study in the West by Wright et al.,[14] it was found that 1338 patients in England had an age range of 20–75 years.

Sex distribution

{Table 7}

In our series, male:female (M:F) was found to be 1.5:1 same as found in Burkitt et al.[17] (India). Widmer,[15] in Switzerland, recorded a ratio of 1:1. Callem[16] in England recorded a ratio of 1:2. Mekky et al.[18] (Egypt and England, 1969) did not record even a single case of male having varicose veins. Leipnitz et al.,[19] in Germany, recorded a ratio of 1:2. The decreased occurrence of disease in females at our setup may be due to hormonal influence or less average height compared to males, which has a direct impact on venous hypertension. Second, males undergo more violent muscular activity compared to females. The Edinburg Vein study,[20] published in 2004, examined 1000 adults in UK and they showed that 50.3% of men and 32.2% of women had a dilated torturous trunk of the long or short saphenous vein and their first-order tributaries.

Limb involvement

Unilateral leg involvement was seen in 58% of patients where left was affected more than right. The cause for the increased incidence on left side is not mentioned in any standard textbooks. But it could be attributed to the longer course traversed by the left iliac veins. The exact etiology is yet to be established as the cause lies in the defective wall or valve. Accordingly, two theories have been put forth in the causation of primary varicose veins: weak vein wall theory and faulty valve theory.[21],[10] Irrespective of the cause, the incompetent venous system causes defective venous pump mechanism, which leads to venous hypertension. It is this venous hypertension, which is the main cause of problems associated with varicosities.{Table 8}

Symptomatology and venous system involvement

All 50 patients presented with dilated and torturous veins; 78% gave a history of swelling of lower leg, others had pain along the veins and cosmetic reasons to seek treatment. However, Campbell et al.[22] reported cosmetic symptoms being the most common presentation for varicose veins (90%), followed by aching pain (57%). In our series, in case of unilateral leg involvement, 62.06% had long saphenous vein involvement with junction and perforator incompetence, whereas in case of bilateral leg involvement, 73.8% presented with only perforator incompetence. Delbe and Mocquet,[23] in their study, had found varicosity of long saphenous vein in 98% and only 2% in short saphenous vein. Perforator incompetence was noted in 41 (82%) cases.

Complications

Majority (90%) presented with hyperpigmentation of skin around the medial malleolus, others had eczema, ulcer over medial aspect of lower leg, stasis dermatitis, and only 8% had occasional bleeding from the varices. Two theories have been put forward to explain the mechanism of venous ulceration: Fibrin cuff theory[24] (by Browse and Burnand): oxygen diffusion into cutaneous tissues was restricted by a pericapillary fibrin cuff; and white cell trapping theory[25]: it has been shown that venous hypertension causes leukocyte sequestration in the microcirculation of the leg, and inappropriate activation of leukocyte instigates the series of events, which give rise to the complications associated with venous hypertension. This has been shown in studies by Moyses et al.[26] and Thomas et al.[27] It also suggests that white cell activation releases proteolytic enzymes, superoxide radicals, and chemotactic substances such as interleukin-1 and tumor necrosis factor α.

Investigations

Doppler or duplex scanning is the primary noninvasive method of assessing chronic venous insufficiency in addition to clinical examination. Masuda and Kistner[28] showed that duplex scanning had an overall accuracy of 88%. The purpose of continuous wave Doppler examination is to discern the relationship of existing varicose veins to the saphenous system, to assess the competency of greater and lesser saphenous veins, and to determine if the deep venous system is obstructed.[29] The venous signal is confirmed by forward flow augmentation elicited with distal manual compression. Reverse flow is assessed during Valsalva maneuver and coughing and with sudden release of distal manual compression. Duplex USG is the most useful test for localizing valvular incompetence, it combines B-mode real-time USG with pulsed Doppler USG.[11],[30] It provides information about SFJ, SPJ status, size and status of GSV, SSV, patency and competency of deep veins, site and level of major incompetence, evaluation of perforator incompetence, identification of anatomical abnormalities, and duration and velocity of reflux.[31]

Treatment

Treatment options include reassurance, drugs, compression therapy, sclerotherapy, surgery, and newer approaches[32],[33],[34] (endovenous laser ablation, RFA, foam injection, and endoscopic GSV stripping). Graduated stockings are grouped according to classes (Class I: 18–21mm Hg, Class II: 26–34mm Hg, and so forth), material (cotton and synthetic), length (above knee and below knee), and sizes (small, medium, large, extra large, and custom sized).[33] The exact mechanism by which compression therapy can improve chronic venous insufficiency remains uncertain. An improvement in skin and subcutaneous tissue microcirculatory hemodynamic as well as a direct effect on subcutaneous pressure has been hypothesized as the mechanism of compression therapy.[35] Increases in subcutaneous tissue pressure with elastic compression bandages may counteract transcapillary Starling’s forces, which favor leakage of fluid out of the capillary. In our study, all patients received conservative treatment in the form of compression stockings and phlebotropic drugs preoperatively with the objective of making the limb fit for surgery. Postoperatively, patients were advised to wear elastic crepe bandage or stockings for at least 3–4 months to prevent hematoma formation.

Sclerotherapy was not tried in this series because of the paucity and nonavailability of the sclerosant agents and also because of the presence of major incompetence and complications associated with varicose veins. It was described by Chassaignac in 1885.[36],[37] It is a method of obliterating varicose or spider veins by injecting an irritating solution into their lumens. Injection of sclerosant initiates a process, which denudes the endothelium, exposes subendothelial structures (chemical thrombophlebitis), organizes thrombus, and obliterates the lumen by fibrosis. If the thrombus recanalizes, the endothelium regenerates and the treatment fails.[20] Various types of sclerosants can be used, which are either detergent type (sodium tetradecyl sulphate (STS), polidocanol, sodium morrhuate and ethanolamine maleate), osmotic (hypertonic saline) or chemical irritants (poly-iodinated iodine and chromated glycerin).[38] In foam sclerotherapy,[39] foam is made using the Tessari method. The solution used is 1% polidocanol and STS (1%–3%). Not more than 20mL foam should be injected at one sitting to prevent air embolism.

Pharmacological targets of phlebotropic drugs include analgesic, capillary protection effects, effect on venous tone, lymphotropic effects, improvement of red blood cell rheology, pro-fibrinolytic action, and anti-inflammatory action.[40],[41] Indications for surgery include symptomatic varicosity, cosmetic disfigurement, at risk for complications. Absolute contraindication is deep vein thrombosis (DVT).[32] Permanent removal of varicosities, restoring normal venous physiology, ablation of venous hypertension, reduction of stasis, and achievement of best cosmetic result with minimal complications are the goals of surgical management. Ablative procedures comprise Trendelenburg’s procedure, saphenopopliteal flush ligation for main trunk varicosity, whereas for perforators, subfascial ligation of perforators (Modified Linton’s procedure)[42] or subfascial endoscopic perforator ligation[43] is used. In our series, majority underwent Trendelenburg’s procedure with stripping of GSV and subfascial perforator ligation, whereas a few underwent only subfascial perforator ligation. Post-op complications were minimal, the most common being neuritis, few had wound infection and hematoma conservatively managed. We had no recurrence following operative treatment at follow-ups.

Treatment of venous ulcers[44],[45] comprise Bisgaard’s regime, that is, leg elevation, massage of indurated area and entire calf, regular dressing of ulcer, passive and active exercises, and antibiotics.

 CONCLUSION



Varicosity of the lower limb is fairly a common clinical entity. The number of cases reporting to the hospital is much less than the real incidence because in our Indian scenario, a large number of rural populations do not report themselves for asymptomatic veins, it is the complications and not the cosmetic reasons that bring the patient to the doctor. That is the reason why, though common, varicose veins remain as an “iceberg phenomenon.”[13]

A definite relationship exists between occupation involving prolonged standing and the incidence of varicose veins. The outcome depends on a thorough clinical examination and duplex scan by an experienced radiologist. Operative treatment is the primary procedure in the management. Surgical treatment enabled almost every patient to lead a normal life. There is a need for medical insurance for poor people to afford newer modality of treatment. Risk of recurrent varicose veins can be decreased by precise assessment of underlying anatomy.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

References

1Shenoy KR. Varicose veins, deep vein thrombosis. In: Manipal Manual of Surgery. 3rd ed. New Delhi, India: CBS Publishers and Distributors; 2010. p. 103-16.
2Scurr JH. Venous disorders. In: Russell RCG, Williams NS, Bulstrode CJK (eds). Bailey and Love’s Short Practice of Surgery. 24th ed. London, UK: Edward Arnold (Publishers) Ltd; 2004. p. 954-973.
3McGregor AL, Decker GAG, Du Plessis DJ. Lee McGregor's synopsis of surgical anatomy. 12th edn, Bristol: Wright; 1986.p. 258-263.
4Tibbs DJ, Scurr JH. Venous disorders, vascular malformations and chronic ulcerations in the lower limbs. In: Peter JM, William CW, editors. Oxford Textbook of Surgery. Volume 1. 2nd ed. Oxford, UK: Oxford University Press; 2000. p. 995-1000.
5William AM, George JJ. Varicose veins and superficial thrombophlebitis. In: Richard HD, James STY, David CB (eds). Current Diagnosis and Treatment in Vascular Surgery. 1st ed. Connecticut: Appleton and Lange, McGraw Hill Medical Publisher; 1995. p. 351-364.
6Williams PL, Dyson M. Gray’s Anatomy. 37th ed. Edinburgh, Scotland: ELBS with Churchill Livingstone; 1993. p. 812-4.
7George JJ. Management of venous disorders. In: Rutherford RB (ed). Vascular Surgery. 2 vols, 4th edn. Philadelphia: WB Sounders Company; 1994. p. 1671-1862.
8Eklöf B, Rutherford RB, Bergan JJ, Carpentier PH, Gloviczki P, Kistner RL, et al Revision of the CEAP classification for chronic venous disorders: consensus statement. J Vasc Surg. 2004;40:1248-1252.
9Das S. Examination of varicose veins. In: A Manual on Clinical Surgery. 4th ed. Kolkata: SB Publications; 1998. p. 73-79.
10Vinay K, Cotran RS, Robbins SL. Veins and lymphatics. In: Basic Pathology. 7th ed. Amsterdam, Netherlands: Elsevier; 2000. p. 353-354.
11Dur AHM, Mackay AJC. Duplex assessment of clinically diagnosed chronic venous insufficiency. Br. J. Surg June 1992;79 (Suppl): 155-161.
12Dodd H, Cocket FB. The Pathology and Surgery of the Veins of the Lower Limb. 2nd ed. Edinburg, Scotland: Churchill Livingstone; 1976.
13Malhotra SL. An epidemiological study of varicose veins in Indian Railroad workers from south and north of India, with special reference to the causation and prevention of varicose veins. Int J Epidemiol 1972;1:177-83.
14Wright DDI, Franks PJ, Moffatt K. The prevalence of venous disease in a West London population. In: Davy A, Stemmer R (eds). Phlebology’ 89. London: Libbey Eurotext; 1989. p. 176-178.
15Widmer LK, editor. Peripheral Venous Disorders Prevalence and Socio-medical Importance. Bern, Switzerland: Hans Huber; 1978. p. 1-90.
16Callem MJ. Epidemiology of varicose veins. Br J Surg 1994;81:167-73.
17Burkitt DP, Jansen HK, Mategaonker DW, Phillips C, Phuntsog YP, Sukhnandan R. Letter: Varicose veins in India. Lancet 1975;2:765.
18Mekky S, Schilling RS, Walford J. Varicose veins in women cotton workers. An epidemiological study in England and Egypt. Br Med J. 19697;2:591-595.
19Leipnitz G, Kiesewetter P, Waldhausen F, Jung F, Witt R, Wenzel E. Prevalence of venous disease in the population: first results from a prospective study carried out in Greater Aachen. In: Davy A, Stemmer R (eds). Phlebologie’89. Paris: John Libbey Eurotext Limited; 1989. p. 169-171.
20Wesley SM. Varicose veins: Post-phlebitic syndrome and chronic venous insufficiency, Vascular Surgery: A Comprehensive Review, 2nd ed. Philadelphia: W.B. Saunders; 2012. p. 1093-1117.
21Anderson W. Boyd's Pathology for the Surgeon. 8th edn. Philadelphia: W. B. Saunders Company; 1967. 842 p.
22Campbell WB, Halim AS, Aertssen A, Ridler BM, Thompson JF, Niblett PG. The place of duplex scanning for varicose veins and common venous problems. Ann R Coll Surg Engl 1996;78:490-3.
23Delbe, Mocquet. Varicose veins and deep vein thrombosis: Epidemiology and suggested aetiology. Br Med J 2005;2:556.
24Browse NL, Burnand KG. The cause of venous ulceration. Lancet 1982;2:243-5.
25Bradbury AW, Murie JA, Ruckley CV. Role of the leucocyte in the pathogenesis of vascular disease. Br J Surg 1993;80:1503-12.
26Moyses C, Cederholm-Williams SA, Michel CC. Haemoconcentration and accumulation of white cells in the feet during venous stasis. Int J Microcirc Clin Exp 1987;5:311-20.
27Thomas PRS, Nash GB, Dormandy JA: White cell accumulation in the dependent legs of patients with venous hypertension: A possible mechanism for trophic changes in the skin. Br Med J 1988;296:1693-5.
28Masuda EM, Kistner RL. Prospective comparison of duplex scanning and descending venography in assessment of venous insufficiency. Am J Surg 1992;164:254-9.
29Chisholm CA, Royle JP. The use of directional Doppler ultrasound in the assessment of sapheno-femoral incompetence. Aust N Z J Surg 1983;53:399-402.
30Margaret F, Brendan M. Farquharson’s Textbook of Operative General Surgery. 9th edn. London: Edward Arnold Publications, Taylor & Francis Ltd; 2005. 81-86.
31Hach W, Hach-Wunderle V. Phlebography and Sonography of the Veins. Heidelberg, Germany: Springer; 1997.
32Puggioni A, Kalra M, Carmo M, Mozes G, Gloviczki P. Endovenous laser therapy and radiofrequency ablation of the great saphenous vein: Analysis of early efficacy and complications. J Vasc Surg 2005;42:488-93.
33Mathew JM, Ian JF. VNUS closure FASTTM. In: Greenhalgh RM, editor. Vascular and Endovascular Consensus Update, Charing Cross 30th Symposium; 2008. p. 576-9.
34Colin J, Irving T. Recent Advances in Surgery. 29th edn. London: Taylor & Francis Ltd, Royal Society of Medicine Press Ltd; 2006, 190-193.
35Jonathan DB, Peter AG. Vascular and endovascular Surgery. 2nd edn. Philadelphia: Mosby Ltd, Elsevier; 2009. p. 502-506.
36Nehler MR, Porter JM: The lower extremity venous system. Part II: The pathophysiology of chronic venous insufficiency. Perspect Vasc Surg 1992;5:81.
37Goldman MP. Sclerotherapy, Treatment of Varicose and Telangiectactic Leg Veins. 2nd ed. St Louis, MO: Mosby; 1995.
38Jonathan DB, Peter AG. Vascular and endovascular Surgery. 2nd ed. Philadelphia: Mosby Ltd, Elsevier; 2009. p. 495.
39Fegan G. Varicose Veins, Compression Sclerotherapy. Springfield, IL: Charles C Thomas; 1967.
40Michel P, George G. Pharmacological treatment of chronic venous disorders. Phlebolymphology 2007;14:23-30.
41Daniel C, Chetter L. Endovenous laser ablation in the management of varicose veins. In: Greenhalgh RM, editor. Vascular and Endovascular Consensus Update, Charing Cross 30th Symposium 2008. p. 581-3.
42Scott-Conner EH, Dawson DL. Ligation, striping and harvesting of the saphenous vein Operative Anatomy. 2nd edn. Philadelphia; Lippincott Williams & Wilkins; 2002. p. 655-662.
43Rajagopalan S, Mukherjee D, Mohler ER. Manual of Vascular Diseases. Philadelphia: Lippincott Williams & Wilkins, 2005, 276.
44Homans J. The etiology and treatment of varicose ulcer of the leg. Surg Gynecol Obstet 1917;24:300-11.
45Brunicardi FC. Venous and lymphatic disease. In: Schwartz’s Principles of Surgery. 9th ed. New York, NY: McGraw Hill Education; 2010. p. 793-795.