Clinical case Symptomatic GSV varicosities with normal saphenous vein

A 49 year old female G3 with long standing history of symptomatic left lower extremity varicose veins presented with cramping, achiness, fatigue and pain around the varicosities. She wears compression stockings. Patient A

History Medical history: Hypertension, COPD, mixed connective tissue disorder, hypothyroidism, fibromyalgia. Social history: Former smoker Family history: Positive for varicose veins Allergies: None Medications: Levothyroxine, Hydroxychloroquine, Lisinopril, albuterol Patient A

Physical examination Both lower limbs were warm and well perfused Distal palpable pulses Prominent left lower limb varicosities (4-6mm) in medial thigh and calf Mild left lower limb edema No skin changes or ulcers Motor and sensory were intact Patient A

Left GSV Proximal Thigh Left SFJ Left GSV Proximal Thigh Patient A SFJ and proximal GSV were normal

GSV in mid-thigh and 6mm varicosities Refluxing varicosities GSV at mid-thigh was normal. Reflux was found in the varicose tributaries.

GSV in distal thigh and calf was normal. Patient A

Left C2,3 EP AS PR VCSS: 6 Clinical Class/Severity SSV and deep veins were normal. The reflux in the varicose tributaries is demonstrated in red color. Patient A

What would be the best treatment option at this point? Evaluate for proximal venous obstruction. Proceed with phlebectomies and/or ultrasound guided sclerotherapy. Proceed with EVLA of the proximal GSV and phlebectomies. Ligation of SFJ and phlebectomies. Patient A

What would be the best treatment option at this point? Evaluate for proximal venous obstruction. Proceed with phlebectomies and/or ultrasound guided sclerotherapy. Proceed with EVLA of the proximal GSV and phlebectomies. Ligation of SFJ and phlebectomies. Patient A

Discussion Highest prevalence of reflux is seen in the saphenous tributaries and particularly those of GSV. It has been shown that reflux affecting only the tributaries without the saphenous trunks occurs in 10% of patients with varicose veins. Most prevalent were the GSV tributaries followed by the SSV and non-saphenous veins. The most common tributaries with reflux were the posterior accessory vein of the calf and the anterior accessory vein of the thigh. CEAP class 2 was the most prevalent in such patients. However, Class 3 and 4 was found in 20% of patients. In Class 3 and 4 patients there was: longer duration of signs and symptoms more refluxing tributaries per limb higher prevalence of both above and below the knee reflux Labropoulos N, et al. EJVES 1999;18:201-6

Discussion Tributary reflux can develop in any vein without an apparent feeding source and in the absence of saphenous trunk or saphenous junction incompetence.  Local vein wall changes are responsible for the development of primary CVD.   It has been shown that reflux can be a local process that can develop in any part of the lower limb veins. Reflux may progress in an ascending, descending, or multicentric manner.  Identification of patterns of reflux is important to direct the correct treatment options. In this case, treatment should only be directed to the tributaries alone, sparing the GSV. Labropoulos N, et al. J Vasc Surg 1997;26:736-42 Labropoulos N, et al. EJVES 1999;18:201-6 Caggiati A, et al. J Vasc Surg 2006;44:1291-5