Noninvasive Examination of the Patient Before Sclerotherapy

Prior Treatment

The physician should discuss a patient's prior treatment for venous disease. However, he or she must realize that although proper ligation, with or without stripping of the main saphenous trunks, implies that reflux through the saphenofemoral junction (SFJ) and saphenopopliteal junction (SPJ) has been prevented, this is not always the case. Joshi et al found that reflux in the residual GSV was the most common cause of recurrent varicose veins in 419 legs among 298 patients who underwent ligation of the SFJ and stripping of the GSV. Up to 27% of patients have a duplication of the GSV, indicating that the removal of the GSV may be followed by the development of varicosity in the remaining GSV.

In 20% to 40% of patients, the SSV has a variable termination that is not in the popliteal vein at or above the popliteal fossa. Therefore, the actual SPJ must be correctly located, or it will lead to an apparent rapid recurrence with varicose changes occurring in the remaining segment of the SSV and its tributaries. In a number of patients, a recurrence of varicose veins in the upper thigh may be a result of incomplete ligation and division of the other tributaries arising at the level of the SFJ or of failure to accomplish the ligation flush with the femoral vein. In fact, in a review of 341 extremities that underwent repeat operations for varicose veins, Lofgren et al found that 61% had inadequate ligation. Thus, it is imperative that, even in a patient with a history of ligation, division and stripping, an examination for reflux through the SFJ and SPJ be performed.

The physician should consider responses to and complications due to all treatment modalities (e.g., sclerotherapy, laser). Certain complications, such as ischemic ulceration caused by inadvertent injection into an arteriovenous malformation, can be avoided more easily if a diagnosis is made before treatment. Given the predilection for these to occur in a particular anatomic distribution(s), the physician might avoid treating that area or use greater caution in the previously affected region. A history of prior hyperpigmentation, blushing or poor response to a particular sclerosing agent may support a variety of changes in treatment protocol, such as altering the sclerosant concentration, increasing the strength or duration of compression and paying greater attention to posttreatment thrombectomy.

Complications of Varicose Vein Disease

Complications such as ulceration and hemorrhage should be discussed with the patient, because this provides additional insight into both the severity and the probable locations of abnormality within the venous system. A history of ulceration of the medial aspect of the lower leg should prompt further examination of the GSV trunk, whereas involvement of the lateral aspect of the lower leg suggests an abnormality in the SSV in addition to the deep and perforating vein systems. A history of hemorrhage from telangiectasias in a particular area suggests further examination for underlying incompetent perforators and is an indication to treat all suspicious telangiectasias.

Trendelenburg Test

For the Trendelenburg test, a tourniquet may be placed around the patient's proximal thigh while the patient is standing. The patient then assumes the supine position with the affected leg elevated 45 degrees. The tourniquet is removed, and the time required for the leg veins to empty, which is indicative of the adequacy of venous drainage, is recorded.

When the affected leg is compared with the contralateral leg, the method just described may demonstrate a degree of venous obstructive disease. Another approach is to elevate the leg while the patient is supine and observe the height of the heel in relation to the level of the heart that is required for the prominent veins to collapse ( Fig. 5.2 ). Unfortunately, neither procedure is sufficiently sensitive or accurate or able to differentiate acute from chronic obstruction, which means neither of them is of much assistance in current medical practice. This emphasizes the important role of duplex ultrasound in modern evaluation of the superficial venous system. One study found that pneumatic tourniquets occluded only 27% of saphenous trunks. Several other physical examination maneuvers, described below, can provide information on the competence of the venous valves.

Cough Test

With the cough test, one hand is placed gently, without exerting pressure, over the GSV or SFJ, and the patient is asked to cough or perform a Valsalva maneuver ( Fig. 5.3 ). Simply palpating an impulse over the vein being examined may be indicative of insufficiency of the valve at the SFJ and below to the level of the palpating hand. This test, however, is not applicable to the examination of the SSV and SPJ (see following section). Palpation of a thrill during this maneuver is generally more diagnostic. One study found a low sensitivity of 0.59 and low specificity of 0.67 with this test.

Percussion/Schwartz Test

With the percussion/Schwartz test, one hand is placed over the SFJ or SPJ while the other hand is used to tap very lightly on a distal segment of the GSV or SSV ( Fig. 5.4 ). The production of an impulse in this manner implies insufficiency of the valves in the segment between the two hands. Confirmation of valvular insufficiency can be achieved by tapping proximally while palpating distally. This test can also be used to detect whether an enlarged tributary is in direct connection with the GSV or SSV by palpating over the main trunk and tapping lightly on the dilated tributary, or vice versa. The presence of a direct connection results in a palpable impulse being transmitted from the percussing hand to the palpating hand. As might be expected, these tests are far from infallible. In a study of 105 limbs, Chan et al found that these clinical examination techniques correctly identified SFJ incompetence in only 82% of limbs. False negatives were believed to be caused primarily by obesity and previous groin surgery with resultant scarring. However, false positives were the result of variations in venous anatomy, such as a dilated tributary emptying into the common femoral vein (CFV) adjacent to the GSV or the absence of valves in an otherwise normal CFV and external iliac vein (seen in 5–30% of patients) (M. Schadeck, personal communication, September 1989). Researchers in another study found that this test had a low sensitivity of 0.59 and a high spec­ificity of 0.92. A further source of error with the cough and/or percussion test is simply a misinterpretation of the muscle contraction that occurs with coughing as a reflux impulse.

Brodie-Trendelenburg Test

The Brodie-Trendelenburg test traditionally involves the manual obstruction of the proximal end of the GSV (or SSV) while the patient lies supine with the leg elevated, after the vein is stroked in a cephalad direction to empty it of blood. The patient then assumes the standing position, and the leg is observed for 30 seconds ( Fig. 5.5 ). In a ‘nil’ test, the veins fill slowly from below and release of the compression does not result in rapid filling from above, indicating competence of valves in deep and perforating veins and at the SFJ ( Fig. 5.6A ). Rapid filling of the GSV or more distal tributaries that occurs only after release of the compression constitutes a ‘positive’ test, indicating the presence of an insufficient valve at the SFJ ( Fig. 5.6B ). In the ‘double-positive’ test, some distention of the veins occurs within the initial 30 seconds while the compression is maintained, as well as additional filling once the compression is released ( Fig. 5.6C ). This is taken as evidence of incompetent deep and perforating veins as well as reflux through the SFJ. A ‘negative’ test occurs when the veins fill within the initial 30 seconds with no increased filling after the compression is released, implying only deep and perforating valvular insufficiency ( Fig. 5.6D ). The reverse may not be true; that is, filling in longer than 30 seconds does not imply competence of perforating veins. In a study of 901 extremities, Sherman found that 95% had a nil Trendelenburg test, but surgical exploration later showed incompetent perforators in 90% of these patients. Another study showed a high sensitivity of 0.91 with a low specificity of 0.15.

The Brodie-Trendelenburg test thus can be an important method of localizing the most proximal site of reflux in most dilated superficial veins by obstructing the GSV, SSV or whichever vein is suspected of refluxing into a more distal vein. The physician can also place the examining finger over palpable fascial defects in the leg while the patient is supine and then release the obstructions one by one after the patient is standing. This allows the sites of insufficient perforators, or ‘points of control’ (considered so crucial in Fegan's technique of sclerotherapy), to be defined, because the superficial veins distal to the insufficient perforator fill rapidly once the obstructing fingers are removed (see Chapter 9 ).

With this technique, described well in many papers, the practitioner first marks on the leg the sites of all dilated varicosities. The patient then assumes the supine position with the leg elevated to approximately 60 degrees to empty the veins. After at least 20 seconds, or when the distended veins are flattened, the leg is gently and rapidly palpated to detect any defects in the fascia. With experience, these can be detected easily as locations that allow the entrance of the examining finger without the use of any pressure. Fascial defects can be caused by many abnormalities other than perforating veins; thus, the practitioner continues the examination by compressing the individual fascial defects with his or her fingers and then having the patient stand. The fingers are then released one by one, starting with the most distal defect, and rapid filling of more distal varicosities is noted ( Fig. 5.7 ). Those defects that cause distal filling when released are assumed to correspond to sites of IPVs. In the presence of a dilated GSV or SSV, these points of reflux first must be controlled with either digital compression or a tourniquet to evaluate the lower volume reflux through the perforators. For the evaluation to be helpful, compression of the defects must first cause sustained flattening of the varicosities when the patient initially stands. If the veins fill before any of the fingers are released, the test must be restarted and other sites compressed until the sites responsible for the reflux are located. This examination is associated with 50% to 70% accuracy compared with findings at surgical exploration. Repeated examination at different times and improvement of edema allow the detection of increased numbers of perforators.

Bracey Variation

A clever variation of the Brodie-Trendelenburg technique was proposed by Bracey in 1958 ( Fig. 5.8 ). He used a flat, 3.8-cm-wide rubber tourniquet and two rubber rings covered with latex, with inside diameters of 7 cm and 8.2 cm. The smaller ring is used between the ankle and knee and may also be used for the thigh if the patient is thin. If not, the larger ring is used for the thigh. With the patient standing, the small ring is rolled over the foot to just above the ankle, and the rubber tourniquet is then placed below the ring to obstruct any upward flow of blood through the superficial veins. The small ring is then slowly rolled upward, emptying the superficial veins as it moves. As soon as it passes an IPV, the blood enters the superficial vein that connects with it, causing a dilation of the vein. The exit site of the perforating vein may then be marked. This reflux of blood can be accentuated by asking the patient to repetitively dorsiflex the foot. When the ring reaches the knee, the tourniquet is moved up to the knee, just below the ring. Either the smaller or larger ring is then used similarly to examine the thigh.

Perthes Test

The Perthes test has several uses, including distinguishing between venous valvular insufficiency in the deep, perforator and superficial systems and screening for DVT ( Table 5.2 ). To localize the site of valvular disease, the physician places a tourniquet around the proximal thigh with the patient standing. When the patient ambulates, a decrease in the distention of varicose veins suggests a primary process without underlying deep venous disease because the calf muscle pump effectively removes blood from the leg and empties the varicose veins. Secondary varicose veins do not change caliber (if there is patency of the deep venous system) because of the inability to empty blood out of the veins as a result of impairment of the calf muscle pump. In the setting of a concurrent DVT, these veins may increase in size. If there is significant chronic or acute obstructive disease in the iliofemoral segment, the patient may note pain (venous claudication) as a result of the obstruction to outflow through both the deep and superficial systems. Information regarding the presence of deep venous valvular insufficiency and thrombosis is important to note to aid in patient selection. This avoids causing catastrophic complications, such as pulmonary embolism resulting from an undiagnosed and worsened DVT or venous claudication caused by further impairment of venous return. Indeed, these two complications are serious enough to warrant the use of a much more sensitive and accurate method; therefore, the Perthes test is now of more historical than actual clinical importance.

To test for perforator valvular defects, the physician may embellish the traditional Perthes test by placing a tourniquet around the calf just below the popliteal fossa. If the dilated superficial veins in the calf and ankle become less prominent as the patient ambulates, this implies that the blood is being drawn into the deep system through competent perforating veins. However, if the veins become increasingly dilated, the perforating veins must be incompetent. A more involved test, the Mahorner-Ochsner comparative tourniquet test, similarly localizes the site(s) of reflux by observing the leg while the patient walks with the tourniquet placed at various levels on the leg (upper, middle and lower thigh) ( Fig. 5.9 ).