Annals of the Royal College of Surgeons of England (1990) vol.
72, 188-192
Venous disease: investigation and
treatment, fact or fiction?
H J Scott FRCSEd P D Coleridge Smith
Research Fellow Senior Lecturer
G M McMullin FRCSEd J H Scurr
Research Fellow Consultant Surgeon
Department of Surgical Studies, University College and Middlesex School of Medicine,
The Middlesex Hospital, London
Key words: Varicose veins; Venous insufficiency; Clinical competence
This review looks at some clinical and experimental methods
and treatments used in venous disease, and attempts to
dispel some myths which have been associated with it. Over
the last century numerous techniques have been introduced
to aid the understanding of the physiology of normal legs
and the pathophysiology of those with venous disease.
Tourniquet testing along with clinical examination remains
the only method of venous assessment in most hospitals.
Venous ulceration in the past has been associated with deep
vein incompetence, but the newer, non-invasive techniques
of Doppler ultrasound and duplex examination are now
identifying patients with leg ulceration who have superficial
venous insufficiency and therefore a surgically correctable
condition.
Perforating veins and their possible role in the aetiology of
venous ulceration along with invasive and non-invasive meth-
ods for their detection is reviewed. Some of the conservative
compression treatments and dressings available for the
treatment of venous ulceration are discussed. It is concluded
that adherence to sound surgical principles remains the
mainstay of the successful management of patients with
venous disease
Venous disorders are a common problem (1). Varicose
veins are the most common problem seen in district
general hospitals, and are frequently treated without any
investigations, often by relatively junior and inexper-
ienced staff. The recurrence of varicose veins following
both sclerotherapy and surgical treatment is often seen.
Venous disease lacks the urgency inherent in arterial
disease. How many surgeons can really claim a genuine
Correspondence to: Mr J H Scurr FRCS, Department of
Surgical Studies, UCMSM, The Middlesex Hospital, Mortimer
Street, London WIN 8AA
FRCS
FRCS
interest in the management of these patients? Sir
Benjamin Brodie (2) observed in 1846 "I think it very
probable that many among you pass the bedside of such a
patient without thinking it worthy of attention." In a
recent survey of major London teaching hospitals only
two had ulcer clinics attended by a consultant.
Our understanding of the venous system has been
severely hampered by the lack of investigative tools and
over the centuries many myths have developed. These
theories have included the belief that varices were full of
black bile (3); that venous valves were to prevent blood
flowing into the feet and arms (4); that varicose veins
were attributable to a high melancholy temper in men
(5); and that ulcers should be kept open to allow drainage
of evil humours (6). The last century has seen the intro-
duction of numerous techniques allowing a more scien-
tific approach to venous disease, but even these have been
subject to misinterpretation. Many myths remain preva-
lent and this review attempts to dispel some of them.
Before we can truly advance the treatment of venous
disorders, we need to understand the physiology and in
particular the pathophysiology leading to these prob-
lems. Clinical examination, perhaps aided by a tourni-
quet test, is the sole method of investigation in most hos-
pitals (7). These examinations do not give enough infor-
mation to exclude arterial problems; to identify the exact
site of perforating veins, or to distinguish adequately
between superficial and deep venous insufficiency (8,9).
In 1868 Gay (10) and Spender (11), working indepen-
dently, noted that varicose veins occurred without
venous ulcers, and that venous ulcers could occur with-
out varicose veins; though in some cases the two con-
ditions may coexist. It is now often assumed that venous
ulcers in the absence of varicose veins are due to deep
venous insufficiency (DVI) (12). In our own series
(13) about two-thirds of the patients presenting with

symptoms of chronic venous insufficiency, lipodermato-
sclerosis, ulceration and eczema, had superficial venous
insufficiency alone. This finding is supported by other
workers (14,15).
Doppler ultrasound and in particular the newer moda-
lity of duplex (16) (which incorporates B mode ultra-
sound with Doppler) have demonstrated that incompetent
valves with consequent retrograde flow of venous blood
exists in many limbs where varicose veins are not
clinically apparent (17). Duplex has also demonstrated
that in some cases of clinically obvious long saphenous
varicose veins there is a competent saphenofemoral
junction with an incompetent nearby thigh perforator.
The short saphenous system is even more variable (18).
The saphenopopliteal junction may be located anywhere
from the mid-calf to the mid-thigh. This problem is
compounded by two pairs of gastrocnemius veins (19)
into which the short saphenous vein often empties (rather
than into the popliteal vein). Identification of the correct
anatomy is impossible by clinical examination. The
common recurrences following varicose vein surgery,
particularly around the popliteal fossa (20) may well be
attributable to incorrect identification of the vascular
anatomy (21).
Many surgeons rely on tourniquets to determine
whether there is deep or superficial venous insufficiency.
There is no standard method of application or indeed no
standard tourniquet which can be applied. Some large
superficial veins are not compressed by tourniquets, and
conversely in some patients, the deep veins along with
the superficial system are compressed. The results of a
tourniquet test can at best be a guide, and cannot be
relied upon. Despite this, surgical treatment is planned
on these results.
The role of perforating veins in the development of
venous ulceration remains a subject of controversy. Their
existence is undisputable and has been well documented.
Cadaveric dissections (22,23) combined with in vivo
studies (24), have led to the description of many epony-
mous perforating veins (25). The pathophysiology of
these veins remains uncertain. The 'blow-out theory'
attributes the skin changes of venous disease to the
transmission of high pressure through incompetent per-
forating veins (26,27). There are those who believe that
no venous ulcer exists without these veins (28,29).
However, other workers have disputed this and in a
number of cases ulceration has been shown to be solely
due to long saphenous insufficiency (30,31).
Incompetent perforating veins have also been des-
cribed as irrelevant (32). Bjordal (33) demonstrated that
the main cause of raised venous pressure in patients with
venous insufficiency was due to reflux of blood within the
major venous channels. He demonstrated that the incom-
petent perforating veins contribute little to this pressure.
Nonetheless, incompetent perforating veins have con-
tinued to be considered important and numerous tech-
niques (34), operations (35,23) incisions and approaches
(28,36), and instruments (37) have been described to
divide them. All these procedures have been associated
with complications including haemorrhage, skin necrosis
Venous disease 189
and infection. Many published series (38-41) report
widely differing results with ulcer cure rates varying
from 40% (42) to 90% (43). Poor results have been
attributed to missing incompetent perforating veins at
surgery and the exact location of these veins remains a
problem. A variety of techniques have been described to
identify their position. These include fluorescein injec-
tion (44), thermography (45), infra-red photography
(46), Doppler ultrasound (47) and phlebography (48,49).
The only investigation found to show significant im-
provement over clinical examination was phlebography
(50,51).
At surgery, many more veins are seen than are ever
identified preoperatively and there is still no accurate
method for locating incompetent perforating veins.
Colour duplex may alter this.
Venography is still considered the 'gold standard' for
venous assessment, though poor patient acceptibility and
a significant morbidity (52) limit its use. It is time
consuming and operator dependent. In radiological
departments where venograms are an occasional pro-
cedure performed by staff in training, results can be
unsatisfactory and films difficult to interpret.
Tourniquets used for identification of perforators also
pose problems of interpretation. An ineffective tourni-
quet will lead to filling of the superficial rather than the
deep veins. Cinevenography (53,54) overcomes some of
these problems, but is only used in a few specialised
centres.
Duplex scanning has shown that short segments of
reflux exist within an otherwise normal venous system
(55). Reflux within the common femoral vein can coexist
with a competent popliteal vein. Venography is unable to
identify these abnormal segments. The significance of
regional reflux has yet to be fully elucidated.
Ascending venography identifies post-phlebitic
damage, but not primary valve failure, a condition now
recognised as a cause of DVI (56). In this syndrome the
deep veins and valves look normal on ascending veno-
graphy (57) and changes are only seen on descending
venography. Descending venography will show floppy
valves and reversed flow (58). The interpretation of
descending venograms is difficult, as some 'clinically
normal' limbs show reflux to below the knees (59,60).
Venography has also been used for the definitive diagno-
sis of deep vein thrombosis (DVT) (61,62). Lensing et al.
(63) using duplex have shown 100% sensitivity and 99%
specificity for the detection of vein thrombosis in the
common femoral vein and the popliteal veins. Detection
of venous thrombosis in the calf and iliac veins is more
difficult.
Continuous-wave Doppler using a simple 5 MHz
hand-held pencil probe, can be used to detect deep vein
patency, vessel occlusion and flow direction at the
bedside (64). Occlusion of major vessels such as the iliac,
femoral and popliteal veins (which have few collaterals)
can be diagnosed with this method to an accuracy of
90%. The sensitivity is 95% and the specificity is 90%
(65). Eklof stated that every surgeon treating varicose
veins should have a continuous-wave Doppler in his
190 H J Scott et al.
pocket (66). However, problems exist with this investi-
gation and its reliability has been challenged by many
authors (67-69). The major drawback of this procedure
is that the vessel being insonated cannot be identified,
making interpretation of the Doppler recording in
regions with a complex anatomical arrangement difficult.
When used in conjunction with tourniquets the problems
are compounded.
Bandaging for varicose veins has been a mode of
treatment since the time of Hippocrates (70). Bringing
patients into hospital, elevating the leg and cleaning the
ulcer results in rapid healing. Compression is thought to
be important in healing ulcers in ambulant patients, but
how much, for how long, and how this compression
should be applied, is not known. There have been many
successful studies demonstrating improved ulcer healing
using a particular technique, a particular bandage or a
particular dressing. Until it is known what pathophysio-
logical changes we are attempting to modify, and we have
a method of monitoring these changes, we are unlikely to
be able to design more effective regimens.
The first stockings and laced bandages were used by
Richard Wiseman in 1676 to repress humours impacted
in the leg (71). The application of effective graduated
compression has been the single most important factor in
the successful control of venous disorders. Elastic stock-
ings have been shown to give effective graduated com-
pression (72-74), and have been shown to be more
effective than bandages (75-77). Their use has been
advocated for varicose veins, oedema, venous ulceration
and following surgery or sclerotherapy (78). They are
more acceptable than bandages, both cosmetically and
for reasons of comfort and ease of use. Unfortunately,
there are a number of patients who are unable to cope
with them. The Textile and Clothing Standards
Committee (which included medical personnel) prepared
the British Standard BS6612: 1985 in 1985 (79). This led
to the revision of the Drug Tariff allowing National
Health Service prescriptions of stockings on FP10s.
Nevertheless there are still venous clinics operating
where stockings are not provided.
In an attempt to heal ulcers many creams, pastes and
dressing materials have been described. More than 100
different products have been advanced, many claiming
magical cures for venous ulceration. Whilst the possibility
of modifying wound healing remains, with the use of
growth factors, our current generation of products rely
on modifying the wound environment. Reducing infec-
tion is clearly important, and the application of paste
bandages producing an environment similar to the septic
tank aims to hold bacterial contamination at levels in
which wound healing can take place. Hydrocolloid dress-
ings have been advocated in producing a moist environ-
ment. Other dressings claim active properties promoting
wound healing. Whatever the advantages or disadvan-
tages of these dressings, adequate debridement, regular
cleansing and good compression must remain the hall-
mark of proper treatment.
This paper questions our approach to patients with
venous disorders. It remains essential to correctly
identify and treat those patients with a surgically treat-
able condition and to apply sound surgical principles to
the management of patients with venous disorders.
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Book review
Complications of Plastic Surgery by A McG Morris,
J H Stevenson, A C H Watson. 442 pp, illustrated.
Bailliere Tindall, London 1989. £52.50. ISBN 0 7020 1360 9
Plastic surgery is a technical rather than a diagnostic specialty.
Its fascination lies in the restoration of function and the
correction of deformity using a wide variety of techniques
which the surgeon tailors to each patient's needs and which
require skill, judgement, and experience in their selection.
There is a temptation among those not trained in the specialty
to read about the techniques, seemingly of apparent simplicity,
and to be beguiled into applying them without thought or
knowledge of the complications that can ensue. The results of
such ignorant meddling can be disastrous for the patient and a
source of great difficulty to the plastic surgeon, who is then
called in to solve an avoidable problem.
This little volume should be required reading for all sur-
geons, as it highlights the difficulties and dangers in a concise
way, aided by useful photographs and clear diagrams. As can
happen with multi-author books, it is uneven and there is
sometimes a lack of emphasis on which complications are of
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logical study of elastic compression stockings in venous
disorders of the leg. BrJ Surg 1980;67:569-72.
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sion bandages. Phkebology 1988;3:55-61.
76 Coleridge Smith PD, Scurr JH. Optimum methods of limb
compression following varicose vein surgery. Phkebology
1987;2: 165-72.
77 Wright DDI, Munro C, McCollum CN. How good are
elastic bandages? Phlebologie 1988;41:794-5.
78 Scurr JH, Coleridge Smith PD, Cutting P. Varicose veins:
optimum compression following sclerotherapy. Ann R Coll
Surg Engl 1985;67:109-11.
79 British Standards Institution. BS6612:1985. British Stan-
dard Specification for Graduated Compression Hosiry, 1985.
Received 19 October 1989
special note as opposed to those which are not. To exclude any
specific mention of the problem of the burned hand, a common
enough condition, but to include Marjolin's ulcer which is rare,
is a case in point. It is insufficiently emphasised that exposure
of the cornea demands early, even emergency, grafting if the
eyelid is to provide corneal cover and to even hint to the
inexperienced surgeon that to perform multiple z-plasties, to
supposedly improve the appearance of scarring, will help to
perpetuate folly and encourage complications which the book
seeks to warn against.
Future editions will undoubtedly be modified and a chapter
on the medico-legal aspects of patient counselling and care in a
specialty which is increasingly assailed by potentially litigious
and dissatisfied patients should be included. Finally, it is to be
hoped that future editions will have the text squarely placed on
the page and not askew as it is in the reviewer's copy.
J P BENNETT
Consultant Plastic Surgeon
Queen Victoria Hospital
East Grinstead