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There are many illustrative cases in each of the chapters on treatment, but several clinical situations are common enough to warrant special presentation. In addition, there are some more unusual presentations that are commonly misdiagnosed. These are important for the clinician to recognize and are presented here.


A 29-year-old computer networking consultant who travels extensively presents with varicose veins present since the age of 20 years and painful for the last two years. He noticed the initial onset while playing tennis. Both parents have a history of varicose veins. The presenting veins are situated along the anterior surface of the left thigh and the medial surface of the left lower limb.

EXAM On the left leg, a varicose vein is visible and palpable extending from the upper anterior thigh (not to the groin) down to the knee. Another large varicose vein is seen originating at the medial calf length (mean diameter: 12 mm). Percussion allows a fluid wave to be felt on the thigh portion when the calf portion is tapped repeatedly (Figures 7-1A and 7-1B).

DOPPLER No incompetence is noted at the left saphenofemoral junction (SFJ), even with Valsalva maneuer. Marked incompetence is heard along the entire visible vein, in the region of the great saphenous vein (GSV) at the level of the knee, and in the lower segment of the varicosity in the calf. There is no reflux in the left small saphenous vein (SSV).

FUNCTIONAL TESTS Digital-Photoplethsmography (D-PPG) shows refill time of 19 s.

DUPLEX A Duplex ultrasound examination is ordered with a registered vascular technician knowledgeable in the superficial venous system, but the patient’s insurance plan only pays for a Duplex examination at a specific radiology group. The examination report reads, “No evidence of deep venous thrombosis. Reflux seen in some superficial veins.”

TREATMENT On the basis of the fact that the patient does not desire surgery nor is reflux detected at the SFJ by the general radiologist’s Duplex technician, the patient is treated with 3 percent STS (sodium tetradecyl sulfate) injections of 1 cc at three sites total. At one month, significant reduction of the diameter of the varicosities is noted. A second treatment is performed with 1 percent STS at six sites. A follow-up one month later shows complete resolution.

LONG-TERM FOLLOW-UP The patient returns in 2 years with a slight recurrence in the calf (Figure 7-1C). Duplex examination reveals reflux at the SFJ and along the GSV. Treatment consists of ligation at the SFJ followed by stripping of the thigh portion of the GSV. The calf varicosity is injected 1 month after surgery with 1 percent STS. The patient remains free of disease at five years.

COMMENTARY Reflux in the anterolateral tributary of the GSV extended down the leg to cause reflux in a branch varicosity of the calf. Recurrence at 2 years was due to either new development ...

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