When Varicose Veins Reach the Foot: A Case of Recurrent Reflux and a Calf Perforator

Most people picture varicose veins on the calf or behind the knee. It’s far less well known that they can track all the way down into the foot itself, where they become some of the hardest veins in the body to treat safely. Here’s a real case from our clinic, from the first consultation through to an eight-week follow-up.

This patient, a 56-year-old woman, came to us with large, dilated, recurrent varicose veins on both legs, despite open surgical vein surgery under general anaesthetic some 20 years earlier. The veins had come back, and on the right side had progressed further than most: a complex tangle of varicosities extended all the way down into the foot itself. They were a major cosmetic concern, and by the end of the day they ached and throbbed enough to genuinely affect her quality of life.

Varicose veins in the foot are almost always a sign of a problem further up the leg, not a problem that starts in the foot. Superficial leg veins are fed by “perforator” veins — short connecting vessels that pass through the muscle to link the surface veins with the deep venous system. When a perforator becomes incompetent, it allows high-pressure blood to reflux the wrong way, down through the superficial network, all the way to its lowest point: the ankle and foot. Because the skin there is thin, this is often where the disease looks its most dramatic, even though the fault lies higher up.

Not in terms of danger to health — but it is more serious in terms of difficulty to treat well. The foot’s superficial veins sit close to its arterial supply, and the skin covering them is thin and mobile. That proximity is what makes this one of the more technically demanding corners of venous surgery, and it’s why foot varicosities are often left untreated by clinics that don’t have experience working this low down the leg.

A recurrence like this usually announces itself fairly clearly, but it’s worth knowing what to look for after previous vein treatment:

Treating varicose veins at the ankle and foot carries risks that don’t apply higher up the leg. If foam sclerotherapy inadvertently enters an artery instead of a vein, it can cause arterial foot ischaemia and, in severe cases, tissue necrosis. If it travels too far into the deep system at the ankle, it raises the risk of deep vein thrombosis (DVT). This is exactly why cases like this are planned and executed under continuous ultrasound guidance, by someone comfortable reading both the venous and arterial anatomy of the ankle and foot in real time.

Duplex ultrasound scanning did the same two jobs it always does: mapping the structure of the veins, and confirming which way the blood was actually flowing. For a recurrent case like this, the key question is which vessel is now driving the disease, since the original feeding source may already have been dealt with years earlier.

The plan addressed both feeding sources directly, using minimally invasive, keyhole techniques under local anaesthetic throughout. Bilateral endovenous laser ablation (EVLA) of the recurrent GSV was performed via ultrasound-guided Seldinger access with tumescent (1% lidocaine) anaesthesia around the vein before firing the laser, closing the main superficial trunk driving reflux on both sides.

TRLOP of the right calf perforator is a more delicate procedure: the incompetent perforator is accessed directly using an 18-gauge needle under ultrasound guidance, the needle is exchanged for a laser fibre positioned precisely inside the perforating vein, and a short, focused segment of around 1–2cm is ablated at 8.5 watts, carefully staying clear of the adjacent deep vein. TRLOP achieves in a keyhole procedure what open surgery would otherwise need a formal incision and general anaesthetic to attempt, without the difficulty of locating and tying off the vessel by hand.

Foam sclerotherapy (1%) was then used on the residual varicosities on both legs, accessed from above and allowed to reflux down into the diseased foot veins under direct, continuous ultrasound monitoring, watching closely for any sign of the foam tracking too far toward the deep system or straying into arterial territory. No complications were encountered, and the procedure was completed successfully throughout.

Class 2 compression stockings were worn for two weeks after treatment to support healing. Patients receive a post-operative information sheet covering what to expect, a structured telephone consultation with the clinical vein specialist team at one week, and a direct line to the team for anything unexpected in between.

At eight-week follow-up, repeat duplex ultrasound confirmed the right calf perforator was fully occluded, and both the leg and the foot varicosities it had been feeding had resolved. The result was an excellent technical and symptomatic outcome, and the patient was especially pleased that the foot varicosities, her main cosmetic concern from the outset, had resolved along with everything else.

At six months post-op, the patient continues to feel the benefit: durable symptomatic relief, a lasting cosmetic improvement, and, by her own account, a significant boost in confidence. You can see more examples of results like this in our before & after gallery.