The upright posture that sets humans apart in how we move brings a distinct challenge to the venous system in our lower limbs. This is perfectly summed up by the saying, “Varicosity is the penalty for verticality against gravity” [1]. The word "varicose" comes from the Latin term "varix" (with the plural being "varices"), which is rooted in "varus," meaning bent or crooked. It refers to those superficial veins where valve failure allows blood to flow backward [2].

Even though Hippocrates recognized them over two thousand years ago, varicose veins continue to be a widespread chronic vascular issue, impacting up to 40% of the general population [3]. Factors like population growth, longer life spans, and lifestyle changes have all contributed to the growing clinical and socioeconomic effects of this condition.

In India, the situation often resembles an iceberg: patients usually only seek medical help when complications arise, rather than for cosmetic reasons. As a result, varicose veins and their consequences can greatly diminish the quality of life for those affected [4]. Understanding the underlying pathophysiology is essential for pinpointing treatment options and creating effective management strategies [5].

Several factors related to hosts and the environment can lead to primary varicose veins[6]. Well-known risk factors include having a family history of the condition, getting older, being female, and experiencing pregnancy. Patients typically come in with one or more of three main issues: noticeable veins that cause limb disfigurement, pain and swelling in the limbs, and complications like thrombophlebitis, eczema, venous ulcers, or bleeding [7] Since the range of the disease can vary from harmless telangiectasias to severe ulceration, treatment needs to be tailored to each individual, often putting the clinician's diagnostic and technical skills to the test.

While bedside clinical tests are still helpful for pinpointing reflux sites, duplex ultrasonography has emerged as the go-to diagnostic tool, offering both anatomical mapping and functional assessment of venous blood flow [8]. There isn't a one-size-fits-all treatment approach. Traditional surgery—like flush ligation of the saphenofemoral junction, with or without stripping—remains a safe and effective option. However, newer methods such as endovenous laser ablation, radio-frequency ablation, ultrasound-guided foam sclerotherapy, and ambulatory phlebectomy are becoming increasingly popular. Before these minimally invasive techniques can be widely adopted, their effectiveness, potential complications, and cost-effectiveness need to be thoroughly assessed against established benchmarks [5].

In light of this context, it's crucial to take a closer look at how regional treatment practices stack up against national and international guidelines, particularly when considering the diverse patient populations and clinical scenarios involved. This hospital-based study, carried out in the Department of Surgery at Assam Medical College & Hospital in Dibrugarh from June 1, 2020, to May 31, 2021, was set up with specific aims and objectives: To analyze the clinical presentation and management of primary varicose veins in the lower limbs. Objectives: To document the clinical features associated with lower-limb varicose veins, To assess the treatment methods used and their short-term outcomes, To identify the range and frequency of complications linked to lower-limb varicose veins.

By connecting clinic-epidemiological data with management practices, this study aims to provide evidence that could improve therapeutic decision-making and ultimately enhance patient care in similar healthcare environments.

Study Design and Setting 

This observational study took place in the Department of General Surgery at Assam Medical College and Hospital in Assam, India. The aim was to assess how primary varicose veins in the lower limbs were managed over a year, specifically from June 1, 2020, to May 31, 2021.

Study Population and Sample Size 

We included all patients admitted with primary varicose veins during the study period, excluding those with secondary varicose veins, deep vein thrombosis, or those under 12 years old. Using a 95% confidence interval and a 15% margin of error, and drawing from previous prevalence data by Kumar et al., we determined that a minimum sample size of 40 patients was necessary.

Ethical Considerations 

The Institutional Ethics Committee (Human) of Assam Medical College and Hospital approved the study. We made sure to obtain written informed consent from all participants before they were enrolled.

Diagnostic Protocol 

We followed a structured approach for diagnosis. This included taking a clinical history and performing a physical examination, which involved inspecting and palpating the lower limbs while the patients stood. We used standardized clinical tests—like Brodie-Trendelenburg, Tourniquet, Perthes’, Schwartz, and Pratt’s—to evaluate the competence of valves and perforators, while also ruling out deep vein thrombosis. We intentionally avoided Homan’s and Moses signs due to the risk of embolism. Additionally, we conducted further systemic examinations and assessed peripheral pulses to eliminate any concerns regarding pelvic or arterial issues.

Investigations

The routine investigations included a variety of tests such as hematological, biochemical, and serological assessments, along with chest X-rays and ECGs. For checking vascular health, we typically used non-invasive methods like Doppler and duplex ultrasound, considering a reflux time over 500 milliseconds to be a sign of pathology. More invasive procedures, like phlebography and MR venography, were reserved for particularly complex cases.

Management Strategy

We tailored the management approach based on clinical findings and the results of investigations. For early-stage disease, non-surgical candidates, and those with secondary varicosities, we opted for conservative treatment. This involved strategies like elevating the limbs, compression therapy, managing weight, and encouraging exercise. Venous ulcers were addressed with compression bandaging or the Bisgaard regimen. We also used pharmacotherapy with a micronized purified flavonoid fraction to improve microvascular function.

Surgical and Minimally Invasive Interventions

When it came to surgical treatment, we employed traditional techniques such as saphenofemoral flush ligation, stripping of the great saphenous vein, and saphenopopliteal ligation guided by duplex ultrasound, along with perforator ligation. We adhered to standard preoperative and intraoperative protocols, which included administering prophylactic antibiotics and heparin, as well as using tumescent anesthesia. For tributaries under 4 mm, we performed sclerotherapy using sodium tetradecyl sulfate or ultrasound-guided foam sclerotherapy with polidocanol-air foam.

Demographic and Clinical Characteristics 

This study looked at 40 patients suffering from primary varicose veins, all treated between June 2020 and May 2021. The average age of the participants was 40.7 years (with a standard deviation of 14.8), and the most common age group affected was between 31 and 40 years, making up 30% of the cases. There was a noticeable male predominance, with 80% of the patients being male and 20% female, giving a ratio of 4:1. Most patients had unilateral involvement (90%), with the right limbs being the most frequently affected at 47.5%. A family history of the condition was noted in 22.5% of the cases, and 32.5% had occupational risk factors, such as prolonged standing. The most common symptoms reported were dilated veins (30%), leg pain (20%), and venous ulcers (17.5%) ( Table 1, Figure 1).

Diagnostic Findings 

Duplex ultrasound revealed incompetence mainly in the long saphenous system (57.5%), while 25% showed involvement of both the long and short saphenous veins. Perforator incompetence was most frequently found above the ankle (55%). In 60% of patients, there was a combination of superficial and perforator incompetence, whereas isolated perforator incompetence was observed in 15%. Clinical examinations were able to detect saphenofemoral junction (SFJ) incompetence with an accuracy of 82%, but were less effective for saphenopopliteal junction (SPJ) incompetence (42%) and perforator incompetence (50%).

Treatment and Outcomes 

Surgical treatments included saphenofemoral junction ligation (SFJL) along with great saphenous vein stripping (STR) and perforator ligation (PL) in 42.5% of the patients. Complications arose in 32.5% of cases, with the most common being delayed ulcer healing (38.4%), seroma (23.1%), and infection (15.4%). Recurrence of symptoms was noted in 10% of the cases, which was significantly linked to SFJL performed without stripping (p=0.002). The mean hospital stay was 12.72 days (SD: 3.8), with no significant difference between procedures involving stripping versus non-stripping (p=0.813).

Table 1: Demographic and Symptom Profile

Table 2: Treatment Outcomes

Figure 1: Symptom distribution (dilated veins, pain, ulcers dominant).

Figure 2: Sites of incompetence (combined SFJ+perforator most frequent).

Figure 3: Surgical procedures (SFJL+STR+PL most common).

Figure 4: Complication types (delayed healing prevalent).

Figure 5: Recurrence by procedure (highest after SFJL without stripping).

This study, conducted in a hospital setting with 40 patients suffering from primary varicose veins, aligns well with known epidemiological trends while also shedding light on some region-specific details. Notably, the highest occurrence was found in the 31–40 age group (30%), which mirrors global findings from researchers like Campbell et al. [9] and Kumar et al. [10], highlighting how venous hypertension tends to progress during active adulthood. Interestingly, there was a significant male predominance (80%, M:F 4:1), which stands in contrast to Western studies—like the one in San Diego, where 64% of cases were female. This difference likely arises from socioeconomic factors affecting our group, where long hours of standing in manual jobs (32.5%) and a tendency to delay seeking medical help lessen the cosmetic concerns that often lead women to seek treatment earlier.

When it comes to symptoms, dilated veins (30%) and leg pain (20%) were the most common complaints, which is quite different from Campbell et al.'s [9] findings that showed 90% of patients were concerned about cosmetic issues. This suggests that socioeconomic factors might influence how patients report their symptoms, with many coming in later due to functional problems rather than early cosmetic worries. The presence of venous ulcers at the time of presentation (17.5%) further highlights that our population is often dealing with more advanced stages of the disease. Anatomically, involvement of the long saphenous vein (57.5%) was the most common, aligning with Samane et al.'s findings (85%), while the combination of superficial and perforator incompetence (60%) echoed the work of Tenginkai et al. and Labropoulos et al. [14], pointing to the complex hemodynamics at play.

From a diagnostic perspective, clinical examinations reliably identified SFJ incompetence (82% vs. Duplex), supporting Wills et al. 's [11] conclusions. However, the sensitivity for detecting SPJ (42%) and perforators (50%) dropped significantly, reinforcing the idea that Duplex imaging is essential for thorough mapping—something that's crucial for effective surgical planning.

The treatment outcomes provided some eye-opening insights: The absence of stripping during SFJL significantly increased the risk of recurrence, jumping to 75% compared to just 6% when stripping was performed (p=0.002). This aligns with findings from Sarin et al. [12], which noted a 45% recurrence rate without stripping. It highlights how crucial neovascularization and tributary reconnection are as failure mechanisms when stripping isn't done. The most common complications were delayed healing (38.4%) and seroma (23.1%), which is consistent with what Rasmussen et al. [15] reported. The lack of DVT/PE cases indicates that strict prophylaxis measures were in place. Surgery combined with compression led to an impressive 86% resolution rate for ulcers, echoing the results from Barwell et al. [13] However, the 14% recurrence rate suggests that long-term monitoring is necessary.

The average hospital stay was 12.7 days, and there was no increase in length of stay related to stripping, which underscores the safety of the procedure. Economic limitations meant that more advanced interventions, like endothermal ablation, were not pursued, leading to a preference for traditional surgery with compression support.

In summary, this study places varicose vein management within a context that considers available resources. The essential role of stripping in preventing recurrence and the diagnostic superiority of Duplex imaging are clear. Moving forward, it’s important to focus on early intervention and improving access to advanced treatment options in similar settings.

This hospital-based study involving 40 patients with primary varicose veins sheds light on important demographic, diagnostic, and management aspects of the condition. It primarily affects active individuals between the ages of 31 and 40 (30%), with a notable male majority (80%, M:F ratio of 4:1) and a tendency for the right limb to be more affected (47.5%). The main symptoms reported were dilated veins (30%) and pain (20%), often accompanied by significant hemodynamic issues, including combined valvular incompetence (60%) and perforator dysfunction (55% above the ankle). While clinical examinations effectively identified saphenofemoral incompetence (82%), duplex ultrasonography was crucial for thorough mapping—especially for the saphenopopliteal junction (only 42% detected clinically) and perforator sites—helping to guide precise surgical planning. Surgical procedures, particularly saphenofemoral flush ligation combined with great saphenous vein stripping up to the knee, led to a significant drop in recurrence rates (6% compared to 75% without stripping; p<0.05) without extending hospital stays (average of 12.7 days) or increasing complications. These results highlight the importance of careful preoperative duplex assessments and selective stripping in improving outcomes, underscoring their vital role in resource-conscious environments to reduce recurrence and enhance patients' quality of life.

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