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A case of intermittent exophthalmos due to orbital venous veins in which there were associated varicose veins of the legs is described. Of note was the preservation of vision despite the long history (28 years) of the disturbance.
Varicosities may be due to congenital weakness of the vein walls or valves, or may be secondary to deep thrombophlebitis. The latter leads to loss of valve competency in the communicating veins and transmission of relatively high pressures to the superficial system. Edema, thrombophlebitis and stasis dermatitis are common side effects. Adequate surgical therapy is successful in 90% of cases. Sclerosing agents are of limited use.
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Venous valves do not play a role in pathogenesis of primary varicose veins. Their number remains constant during life time. In varicose veins their insufficiency is secondary. Intimal fibrosis is no prerequisite for the development of varicose veins. It is a frequent finding in non-varicose veins of all age groups. Fibrosis of media and adventitia is no early morphological alteration in varicose veins. Fibrotic replacement of smooth muscles represents a late stage of varicosis. Degenerative lesions of deep leg veins are rare even at old age. The deep veins are not influenced by sclerotic lesions of the adjacent arteries. Preexisting intimal fibrosis in autogenous graft veins may be one of several factors which induce an overshooting intimal proliferation. Degenerative alterations (fibrotic lesions of the wall layers, insufficiency of the valves) are secondary phenomena in pathogenesis of varicose veins which follow a functional deficiency of the smooth musculature.
The varicose tendency cannot be cured but it can be controlled. Injection compression sclerotherapy, if performed competently on selected patients, is an effective treatment. It is a relatively simple, economical, safe, and ambulatory form of therapy which has a major place in the management of varicose veins. The technique for injection is subject to considerable variation, but the necessity for post injection compression of the veins is absolute. Post injection compression reduces the potential for recurrence by preventing return of the blood to the vein after injection and maintaining contact of the intimal surfaces so that bonding can occur, thus converting the vein from a tube to a solid fibrotic cord. Injection compression sclerotherapy is the best treatment of selected varicosities.
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374 varicose extremities in 238 patients were examined. In 344 (92%) out of 374 extremities valvular incompetence and dilatation of the basal trunk of the great saphenous vein over its length were found. In 212 (56.7%) extremities dilatation of the first median anastomosis between the great and small saphenous veins was found. The upper medial inflow in the leg gets injuried in 36.1% of cases, and the superficial tibial vein in 28%. Lateral varicosity occurred in 0.5% of cases. Injuries to the lateral branches without dilatation of basal trunk constituted 5.6%. There were no cases of dilatation of femoro-popliteal vein.
INDICATION: varicose veins of the long saphenous vein and short saphenous vein. CONTRAINDICATION: locally developed varicose veins and all forms of edema. When there is doubt, venography and tracing of the lymphatic vessels should be performed. Preservation of the lymphatic channels: incision in the groin higher than usual. Note the seven variations of the junction of the short saphenous vein. In case of damaged deep veins, operative treatment only if venous pressure curve shows improvement after compression of the superficial varicose veins.
The authors studied venous pressure in the posterior tibial vein and the internal saphenous vein in primary varicose veins and after saphenous ligation with stripping. It is saphenous reflux which is the cause of all the disorders and which it is necessary to suppress by a perfect saphenous arch ligation. He has done this successfully in 358 cases.
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The activity of lactate dehydrogenase and fractions of this enzyme has been estimated in human large saphenous veins. Typical varicosities were compared in composition with normal veins from the same patients. The total LDH activity was significantly decreased in typical varicosities. Varicose veins further differed from macroscopically normal veins by a lower content of aerobic fractions of LDH and a higher content of anaerobic fractions. These results suggest that there is a disturbance in metabolism of the smooth muscle of the venous wall in varicosities which would make the diseased wall more dependent on anaerobic glycolysis than normal tissue.
Pressures in the superficial leg veins of 24 patients with varicose veins and 6 normal controls were studied. In the controls there was no rise in pressure in the veins on increasing the intra-abdominal pressure, but in the patients with varicose veins pressure rose significantly. Squatting was no better than sitting in preventing transmission of intra-abdominal pressure to the leg veins. It was concluded that the difference in the positions adopted for defaecation is not the cause of the wide variation in the geographical distribution of varicose veins.
In the treatment of varicose veins and their complications most European phlebologists use today, unlike the past, surgery, sclerotherapy and compression without any preconceived preference, guided solely by the indications of choice of each method. Within this framework, it is generally admitted that surgery is by far the best treatment for incompetent saphenous terminations, main saphenous trunks and insufficient bulky perforating veins. Sclerotherapy, on the other hand, is given the task of eliminating the varicose tributaries of the removed saphenous conduits, as well for treating reticular non-saphenous varices, dermal varicosities and recurrent varicose veins after correct operations. As far compression treatment, it requires today respect for "posology" that is expressed in terms of mmHg of pressures to be exerted at different levels of the extremity; depending on venous and skin changes, semi-stiff sticky bandages or various types of elastic stockings will be chosen. Often two or more of the methods listed are used during the same treatment or in successive stages.
A prime requisite of successful varicose vein surgery is a detailed clinical examination. This reveals a new test for short saphenous incompetence and shows that 14 per cent of varices stem from a saphenopopliteal reflux. The intimate details of juxtafemoral and juxtapopliteal ligation are emphasized and the common causes of failure pointed out. The technique of 'scarless' varicose vein surgery is described. A 6-10-year follow-up of some 2000 patients reveals an overall recurrence rate of 7 per cent.
Many clinical types can be distinguished among the post-phlebitis varicose veins : Substitution varicose veins : pre and supra pubic varicose veins that should be left intact-superficial post-phlebitis venous insufficiency which is characterized by a saphenous insufficiency that is not significantly different as a whole in its physiopathology from the essential saphenous insufficiency, and requires therefore the same forms of therapy. Superficial venous insufficiency combined with an insufficiency of communicating veins of the leg are quite frequent in post-phlebitis situations and can necessitate a special procedure on the insufficient communicating veins. Finally an isolated insufficiency of the communicating veins.
A glycoprotein fraction was isolated from varicose veins by a successive extraction procedure. Antibodies to this fraction were shown to exist in the serum of persons suffering from varicose veins. The pathology of this illness is discussed in relation to the autoimmune reaction, and the basis for a method for the early diagnosis of varicose veins is proposed.
Three categories (none, mild, and moderate) of varicose veins are studied, and the independent variables studied are race, age, sex, height, weight. Quetelet index and parity. In Maoris the age standarised prevalence rates of varicose veins are 36.3 percent in males and 47.4 percent in females. In Pakehas the rates are 21.6 percent in males and 40.4 percent in females. In both sexes Maoris have a significantly higher prevalence of the more severe category of varicose veins. All variables studied were associated with the prevalence of varicose veins although the relationships vary by race and sex. In the univariate analyses the only variable that distinguished the three categories of varicose veins was parity in Maori females. In the multivariate analyses only in Maori males was a significant discrimination between the three groups of varicose veins achieved although "suggestive" discriminations were also achieved for females of both races.