Greater / Lesser Saphenous Insufficiency The saphenous system of veins consists of the main surface veins of the legs. The two largest surface veins are called the saphenous veins. The long (greater) saphenous vein runs along the inner thigh and leg, from the groin to the ankle. The short (lesser) saphenous vein on the back of the calf drains the calf and foot. The sapheno-femoral junction is where many of the superficial veins come together before joining the major deep vein of the leg at the femoral vein. A one-way valve, which is supposed to direct blood inwards and upwards, controls the flow of blood at this junction helping it to return toward the heart. If this valve fails to function properly, some blood is able to flow back down into the leg, increasing pressure in the superficial veins and their branches. The long saphenous vein is one of the main arteries in the thigh. If a leaking valve forces extra blood into it, often at the junction of the saphenous vein and the femoral vein, it stretches and further valves within it become distorted and begin to leak. Blood is then able to flow further down the leg in the wrong direction, eventually filling and distending more and more branches causing varicose veins to develop in the thigh and calf.

Causes of Greater or Lesser Saphenous Insufficiency

• Inherited tendency either the valves are not properly formed or there are too few of them
• Pregnancy In some women the veins become inflamed during pregnancy, most often due to increased pressure from the uterus on the main veins that drain the legs. Increased levels of progesterone during pregnancy and also for some around the time of menstruation cause the blood vessels to relax. Venous dilation begins in the first trimester of pregnancy due to hormonal changes. Dilation of the vein wall may produce valvular incompetence, or leaking. The impairment or reduction of venous return from the legs increases within months of pregnancy and combined with increased blood volume due to pregnancy and increased weight and size of the uterus, all contribute to swelling in the legs, discomfort in the legs, and formation of varicose veins.

• Tired, heavy, aching sensation in the legs at the end of the day or after standing for a long time
• Swollen ankles because the fluid from the stagnant blood leaks through the walls of the veins into the surrounding tissue
• Itching and scaly skin in the affected areas due to the circulation of blood to parts of the leg is less efficient than it should be
• Bulging, bluish or swollen veins
• Recurrent episodes of varicose veins after sclerotherapy treatments

Diagnosis of Greater or Lesser Saphenous Insufficiency

• Doppler Ultrasound provides a sound analysis of the blood flow at different points along the leg. Blood pressure cuffs are placed around your arms and legs, and then the pressure readings are compared. You may be asked to walk on a treadmill and the blood pressures will be repeated. From these tests, the location and severity of your disease can be determined.
• Duplex Scanning tests provide an image of an artery or vein on a screen. This is very useful for locating blockages in veins and arteries, checking valve functioning as well as measuring the size and its blood flow. . For this test, you will need to lie very still after a cold, wet gel is applied to your leg and the technician will move the probe over the artery or vein being studied.

Treatment of Greater or Lesser Saphenous Insufficiency Saphenous insufficiency treatment depends on the severity and duration of the symptoms, but most often includes compression with external support such as prescription support stockings, sclerotherapy or vein ligation and or stripping.

• Vein Stripping (removal) This surgery is normally considered outpatient, or same-day surgery. The varicosities on the lower leg are normally removed by making small incisions over the veins and removing the veins. When sutures are needed, they are placed under the skin with a material that is absorbed. These incisions are then covered with steri-strips, or tape. After the operation, gauze and elastic ACE bandages are applied to the leg. Usually there will be some physical restrictions for 2-4 weeks and rest with leg elevation required at home for several days. A follow-up visit with Dr. King in 2 weeks and at 6 months will be scheduled. Most patients find that within 2-3 months the leg returns fully to normal and the final result of the operation can be assessed. At that point, some sclerotherapy may be desirable to treat the few residual veins for cosmetic purposes.
• Vein Ligation (tied off) The treatment of choice sometimes, is to tie off, or ligate, the saphenous vein at the junction to stop and prevent the distortion of engorged valves and leakage down the entire leg.
• Custom Compression Hose Elastic support stockings may be useful in keeping the symptoms under control, but they will not cure varicose veins. The compression of the stocking functions similar to the muscles in the leg, squeezing the veins so that the blood is pushed upward. This is especially useful for people who must post-pone surgery, such as pregnant or very obese patients who must lose weight before surgery. Custom fit compression stockings should be prescribed by the doctor and carefully fitted for the best results. It is essential that they give plenty of support to the lower leg without squeezing the calf or thigh and the doctors' prescription ensures exact compression distributed in a graduated manner up the leg. Stockings should be put on as soon as you get out of bed and be worn on all day.
  • Compression stockings are most effective when leg swelling is at a low point, such as after elevation or in morning.
  • The compression counters, or balances the increased venous pressure in the legs.
  • The compression reduces venous volume in the legs, increases venous flow.
  • The compression supports superficial veins.
• Sclerotherapy The procedure called sclerotherapy, or injection sclerotherapy, is irritating to the veins and causes the tiny dilated veins to scar and disappear. This procedure treats the veins that are currently visible and does nothing to permanently alter the venous system or prevent new veins from developing in the future. Performed most often in the presence of saphenous insufficiency after vein stripping or ligation to clear the small remaining veins left behind. A chemical solution is injected directly into the veins with a very small needle, irritating and collapsing the lining of the vein. The inner surface of the collapsed vein then grows together and obliterates the vein. This is done in the office, but requires the patient rest and elevate their legs for 48 hours following the procedure. Compression from support hose or elastic bandages (ACE wraps are used for at least several days following treatment.)
  • Sclerotherapy Instructions You will receive specific instructions from Dr. King and his staff, but in general, you will need to plan for someone to drive you home even though anesthesia is not used. This is due to the bulky leg wraps, general temporary discomfort, and occasionally the lingering effects of pain medication. You should wear shorts or bring them to change into for the treatment. Before coming to the office, shave you legs, but do not apply any moisturizers, sunblocks or lotions. You should arrange to be off your feet for 48 hours. Dr. King injects veins on Fridays, and this often makes it easier to arrange to have two days off. Scheduling should be done keeping in mind not only the 48 hours off your feet, but that due to bruising and discoloration, you will not want to wear short skirts, bare legs, or bathing suits for several weeks after the sclerotherapy to allow your legs time to heal. Suntanning should be avoided until all the bruises have cleared to lessen the chance of long-term discoloration. Wearing support hose for the duration of the discoloration is also believed to help reduce the chance of long-term discoloration, increase the success rate of therapy and to help seal in the treatment solution.
  • Appearance Sclerotherapy can enhance the overall appearance and reduce symptoms, but it is unrealistic to believe that every vein will disappear. Often two or more sessions will be necessary to achieve the optimum results. The appearance of the legs will be worse before it improves, with bruising and discoloration common and expected for several weeks following treatment.
  • Touch-ups Most patients find that after a year or rarely, in less than a year, touch-up sessions are required for treatment of new varicose veins. Additionally many find that after a vein stripping and or ligation sclerotherapy is useful to clear the remaining residual veins.
  • Recurrence Wearing support hose reduces risks, but there is no way guarantee that other, formerly healthy veins will not varicose. Following the suggestions for reducing the risk of developing varicose veins will aid in prevention.
  • Discomfort The injections are similar to insect bites. Check with Dr. King if you have a problem tolerating injections, or a low pain threshold. Ibuprofen, such as in the brand name medications Advil or Motrin are usually adequate for pain relief. Treatment sessions last for 15 minutes
  • Risks and Complications Serious medical complications from sclerotherapy are extremely rare when performed by a qualified practitioner. However, complications do occur on occasion. Risks include clots in veins, severe inflammation, and adverse allergic reactions to the sclerosing solution, skin injury that could leave a permanent scar. One common complications is pigmentation irregularities or brownish splotches on the affected area of skin that may take months to fade, or less often more than a year to fade. Another problems that can occur is a "matting" appearance where fine reddish blood vessels appe ar around the treated area, requiring further injections.