Venous disease can present in various forms, from mild skin changes to frank ulceration (see case study one). There are various pitfalls and myths to watch out for, to avoid the possibility of misdiagnosis.
Often when there is redness and discomfort in the gaiter area, patients are given antibiotics for presumed cellulitis. Skin changes can be severe, making the area hot and tender, so this is a common mistake.1
Such patients should be assessed and if found to have venous disease only (other causes excluded), treated with compression and offered radiofrequency ablation (RFA).
Case study two illustrates a common misdiagnosis, where patients with leg oedema are labelled as having lymphoedema, obesity or 'fluid retention'. A significant proportion of these patients have venous oedema, which is easily treatable.
Patients with skin changes, ulcers or oedema cannot have venous disease if there are no varicose veins to be seen
Absence of varicose veins does not mean there is no venous disease. The only way to be sure is with a duplex scan, which is non-invasive.
Treatment will make no difference for these patients
Many of these patients are markedly improved following ablation of their incompetent veins. The skin is much better and further ulceration is generally prevented. Oedema also improves, especially when the veins are the sole cause.
There is no point referring elderly or unfit patients because they will not be fit for surgery
Treatment with RFA is minimally invasive and often carried out under local anaesthetic in elderly or unfit patients. The procedure takes about 30 minutes and is usually done as a day case.
Patients taking anticoagulants or antiplatelets do not need to stop their medication beforehand.
Elderly patients tend to benefit the most if the treatment prevents ulceration, with huge savings in district nursing time and cost.
Some vascular units prefer laser ablation (endovenous laser treatment, EVLT) but in my opinion, treatment with RFA is gentler and better tolerated.2
Treatment is unsuccessful and prone to recurrences
RFA has a reported 93% success rate over 10 years.3 Results have improved with prior duplex scanning to pinpoint exactly which vein is incompetent before surgery.
Conventional treatment with high tie and stripping of varicose veins has now been largely replaced by endovenous ablation techniques in the past eight to 10 years.
This involves cannulating the incompetent long or short saphenous vein under ultrasound and passing the laser or RF catheter up to the saphenofemoral or saphenopopliteal junction. The vein is surrounded with a weak local anaesthetic, also inserted under ultrasound, and the whole vein is heated or ablated by EVLT or RFA. There is minimal postoperative pain and the patient can be discharged the same day. Results have been excellent so far, with few failures or significant side-effects.
There are a significant number of patients with ulceration, varicose eczema and oedema who at present have undiagnosed venous insufficiency, which is easily treatable with minimal trauma.
Patients who were previously high risk for general anaesthetic should also be referred as they can now be treated under local anaesthetic.
- Mr Loh is a consultant vascular surgeon at Spire Bushey Hospital, Barnet General Hospital, Royal Free Hospital and the Royal National Orthopaedic Hospital, London
1. Quartey-Papafio CM. Importance of distinguishing between cellulitis and varicose eczema of the leg. BMJ 1999; 318(7199): 1672-3.
2. Nordon IM, Hinchliffe RJ, Brar R et al. A prospective double-blind randomized controlled trial of radiofrequency versus laser treatment of the great saphenous vein in patients with varicose veins. Ann Surg 2011; 254(6): 876-81.
3. Taylor DC, Whiteley AM, Fernandez-Hart TJ et al. Ten year results of radiofrequency ablation (Vnus closure) of the great saphenous vein. site2013.atlantacongress.org/userfiles/SITE2013/4/taylor.pdf