From Nonsaphenous Origins

Bulging varicose veins on the surface of the skin can originate from different sources. Identification of these sources is important because this influences the treatment plan. Varicosities on the medial aspect of the thigh and calf are usually the result of GSV incompetence. In order to minimize the chance for recurrence, the GSV must be eliminated from the circulation. This concept has been substantiated in several prospective randomized clinical trials involving patients who were treated with or without saphe-nectomy by conventional vein stripping.1518 The recurrence rates for limbs without saphenctomy were much higher than those with saphenectomy. Of course, now thermal ablation techniques with either radiofrequency or laser have proven to be the method of choice for eliminating the GSV from the circulation.19,20

Varicosities on the anterior thigh usually result from Anterior Accessory Saphenous Vein (AASV) incompetence. These veins usually course over the knee and into the lower leg. Small Saphenous vein (SSV) reflux produces varicosities on the posterior calf. When also present on the posterior thigh, the surgeon must consider a cranial extension of the SSV, which can be identified with duplex ultrasound imaging. Cranial extensions may enter the GSV (Giacomini vein) or enter the femoral vein directly.

In cases where no "feeding source" is found, phlebectomy of the varicosities may be all that is required. Labro-poulos21 has shown that varicose veins may result from a primary vein wall defect and that reflux may be confined to superficial tributaries throughout the lower limb. Without great and small saphenous trunk incompetence, perforator and deep-vein incompetence, or proximal obstruction, his data suggest that reflux can develop in any vein without an apparent feeding source. This is often the case when bulging reticular veins are seen along the course of the lateral leg. This lateral subdermic complex and its vein of Albanese are often dilated and bulging in elderly patients. The underlying source of venous hypertension is usually perigeniculate perforating veins, not easily identifiable with duplex imaging. AP using an 18-gauge needle stab incision and a small crochet hook for exteriorization of the vein is an excellent procedure for this clinical problem. Perforating veins of the thigh or calf also may become incompetent and be sources of ambulatory venous hypertension. These can be treated by a variety of techniques including ligation, subfascial endoscopic perforator surgery (SEPS), and ultrasound-guided sclerotherapy (UGS).

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