Last updated: 02/17/2009

Diagnosis

Vein ligation and stripping and ambulatory phlebectomies are considered elective procedures; they are not performed on an emergency basis. The process of diagnosis may begin with the patient's complaints about the appearance...

of the legs or of pain and cramps, as well as with the physician's observations. It is important to note that there is no correlation between the size or number of a patient's varicose veins and the amount of pain that is experienced. Some people have experience considerable discomfort from fairly small varices, while others may have no symptoms from clusters of extremely swollen varicose veins. If the patient mentions pain, burning sensations, or other physical symptoms, the doctor will need to rule out other possible causes, such as nerve root irritation, osteoarthritis, diabetic neuropathy, or problems in the arterial circulation. Relief of pain when the leg is elevated is the most significant diagnostic sign of varicose veins.

After taking the patient's medical history and a family history of venous disorders, the doctor examines the patient from the waist down to note the location of varicose veins and to palpate (touch with gentle pressure) for signs of other venous disorders. Palpation helps the doctor locate both normal and abnormal veins; further, some varicose veins can be detected by touch even though they cannot be seen through the skin. Ideally, the examiner will have a small raised platform for the patient to stand on during the physical examination. The doctor will ask the patient to turn slowly while standing, and will be looking for scars or other signs of trauma, bulges and areas of discoloration in the skin, or other indications of chronic venous insufficiency. While palpating the legs, the doctor will note areas of unusual warmth or soreness, cysts, and edema (swelling of the soft tissues due to fluid retention). Next, the doctor will percuss certain parts of the legs where the larger veins lie closer to the surface. By gently tapping or thumping on the skin over these areas, the doctor can feel if there are any fluid waves in the veins and determine whether further testing for venous insufficiency is required.

The next stage of the diagnostic examination is an evaluation of the valves in the patient's greater saphenous vein. The doctor places a tourniquet around the patient's upper thigh while the patient is lying on the examination table with the leg raised. The patient is then asked to stand on the floor. If the valves in this vein are working properly, the lower superficial veins should not fill up rapidly as long as the tourniquet remains tied. This test is known as Trendelenburg's test. It has, however, been largely replaced by the use of duplex Doppler ultrasound—which maps the location of the varicose veins in the patient's leg and provides information about the condition of the valves in the veins. Most insurance companies now also require a Doppler test before authorizing surgical treatment. The doctor's findings will determine whether the greater saphenous vein will require ligation and stripping or endovenous ablation before smaller varicose veins can be treated.

Some disorders or conditions are contraindications for vascular surgery. They include:

• Cellulitis and other infectious diseases of the skin.
• Severe edema associated with heart or kidney disease. These disorders should be brought under control before a phlebectomy is performed.
• Uncontrolled diabetes.
• Disorders that affect the immune system, including HIV infection.
• Severe heart or lung disorders.

Preparation

Patients preparing for vascular surgery are asked to discontinue aspirin or aspirin-related products for a week before the procedure. They should not eat or drink after midnight on the day of surgery. They should not apply any moisturizers, creams, tanning lotions, or sun-block to the legs on the day of the procedure.

A patient scheduled for an ambulatory phlebectomy should arrive at the surgical center about an hour and a half before the procedure. All clothing must be removed before changing into a hospital gown. The patient is asked to walk up and down in the room or hallway for about 20 minutes to make the veins stand out. The surgeon marks the outlines of the veins with an indelible ink marker on the patient's legs while he or she is standing up. An ultrasound may be done at this point to verify the location and condition of the veins. The patient is then taken into the operating room for surgery.

Although patients are encouraged to walk around for a few minutes after an ambulatory phlebectomy, they should make arrangements for a friend or relative to drive them home from the surgical facility.