Clinical Cases - Superficial Lower Limb

A 40-year-old woman who works as a high school teacher reported to her primary care physician that she varicose veins in both legs. Furthermore, she has pain and edema in both legs that has been getting worse, particularly at the end of a busy day. The pain is relieved when she raises her legs on a desk at home. Support stockings and exercise used to be helpful, but the condition is becoming worse. The physician examined her and excluded deep vein thrombosis. He suggested lower limb venography and surgical management at the hospital.

Questions to consider:

1. Which lower limb veins are most likely to become varicose?

   Superficial veins, e.g. greater and lesser saphenous veins and tributaries .

2. What are the perforating veins?

   Perforating veins are anastomosing channels connecting the superficial veins to the deep veins. Three sets of perforating veins are related to the great saphenous vein: one related to the adductor canal; one related to the calf muscles in the posterior part of the leg; a third one just proximal to the ankle joint. They have valves.

3. Why do varicose veins develop?

   Perforating veins direct blood from the superficial to deep veins. The deep veins are surrounded by muscles and have valves as well. As the muscles contract, they actually pump the blood back toward the heart because of these valves. Valves in the perforating veins prevent backflow to the superficial veins. When the valves in the perforators fail, all of the superficial blood and some of the blood from deep structures is forced into the superficial veins. Because of the hydrostatic pressure and the blood being forced by the muscles into the superficial veins, the valves in the superficial veins then fail and the veins become varicose.

4. What were the predisposing factors to varicosity in this case?

   Prolonged standing.

5. What surgical options are available for treating varicose veins in the legs?

   Injecting sclerosing solutions into the concerned veins; or ligation and stripping.