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Chapter
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10
1
2
Role of Surgery in the Treatment of Varicose Veins
4 5
Figure 10.3 Pin-stripping. 1. The great saphenous vein is catheterized from
the groin to the upper third of the lower leg with the pin-stripper. 2-3. The
pin-stripper distal extremity is pushed through the vein wall and the skin.
4-5. A thread is passed through the pin-stripper eyelet. Then the thread is
interlocked with the vein; the tie must be done on the thread and not on
the pin-stripper. 6. Both stripper and invaginated vein are extracted through
the distal incision.
veineuse superficielle. Principes. Techniques. R
Techniques chirurgicales
(Adapted from Perrin M. Chirurgie à ciel ouvert de l’insuffisance
ésultats. EMC (Elsevier Masson SAS, Paris),
– Chirurgie vasculaire, 43-161-B, 2007).
3
A
Figure 10.4 Terminal incompetent valve and high ligation of the
saphenofemoral junction. A, Terminal incompetent valve responsible for
femoro-saphenous reflux. B, Following incorrect high ligation of the
saphenofemoral junction, leaving a stump of the GSV termination the reflux
persists through the terminal valve. The terminal valves of the tributaries
ending in the stump progressively become incompetent, and consequently
the tributaries refluxive.
6
2
Figure 10.5 Cryo stripping. 1. The saphenous trunk is catheterized
downwards with the cryoprobe until the lower limit of the vein to be
stripped. 2-3. While still applying the freezing, the stripper is progressively
pulled out by traction from bottom to top. The GSV remains attached to the
cryoprobe.
superficielle. Principes. Techniques. R
chirurgicales
(Adapted from Perrin M. Chirurgie à ciel ouvert de l’insuffisance veineuse
ésultats. EMC (Elsevier Masson SAS, Paris), Techniques
– Chirurgie vasculaire, 43-161-B, 2007).
B
1
3
conventional stripping, but this procedure has not been confirmed by others to be superior to current techniques.
Surgery with saphenous trunk preservation
This is less invasive than other procedures, including vein
stripping. The most aggressive part of vein stripping is the
trunk excision. Besides, supporters claim that the preserved
saphenous trunk might be used as an arterial substitute either
for coronary surgery or as a bypass in femorocrural obliteration. Unfortunately there are no data on the real need for, or
value of, the saphenous trunk as an arterial substitute after
such surgery. Another argument in favor is the preservation of
venous flow drainage, as ablation of the superficial system
enhances varicose vein recurrence. The different procedures
are depicted in Figure 10.6.
Isolated flush ligation or limited resection
Isolated flush ligation or limited resection of the SFJ and/or
SPJ is termed in Western Europe ‘crossectomie’. This procedure is rarely performed as an isolated procedure since
284
older studies demonstrated very poor outcome after these
procedures.
SFJ and/or SPJ ligation plus incompetent tributary
phlebectomy with or without incompetent
perforator interruption
Suppression of leak points between the DVS and the SVS
combined with reservoir ablation is supposed to restore competence of the saphenous trunk.
15–18
This procedure was promoted during the last two decades but is presently rarely
performed, probably because the myth of compulsory HL has
been discredited on account of its lack of clinical efficacy.
SFJ wrapping or valvuloplasty plus incompetent
tributary phlebectomy with or without
incompetent perforator interruption
The remark made for the previous procedure – that is to say,
on the one hand, the relationship between SFJ incompetence
and the development of VVs, and, on the other hand, the fact
that suppression of the refluxing SFJ is no longer compulsory
– should explain the loss of interest in these techniques.
The Different Surgical Procedures
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CHIVA SFJ wrapping +
Figure 10.6 Schema of the trunk preserving procedures.
phlebectomy +
perforator abblation
SFJ Wrapping
The hemodynamic principle here is that by wrapping the SFJ
using an external stenting technique (instead of the HL
described above), the supposed restoration of competence to
the valve restores valvular function (Fig. 10.7).
19–21
The upholders of this method underlined that the terminal
or subterminal valve has to be assessed carefully by B-flow
ultrasound preoperatively, as only selected valves can benefit
from wrapping. These would be valves that are not irreversibly
damaged and can have their competence restored with a
decrease in their diameter.
Valvuloplasty or Valve Repair
Valvuloplasty is another way to restore either terminal or subterminal valves. Repair is made by using either the assistance
of external valvuloplasty angioscopy
approach.
23–25
22
or a direct surgical
Ambulatory phlebectomy
Muller described this technique in 1956 and published it 10
years later.
patient setting under local anesthesia using small punctures
and hooks, The procedure is described in detail elsewhere,
but it is worth mentioning here that phlebectomy is
performed by using fine-pointed blades, mini-incisions,
and crochet hooks or other specialized phlebectomy hooks
(Fig. 10.8).
Muller used this procedure in isolation or in combination
with trunk stripping to avulse tributary varices, as reported
in 1996.
A powered phlebectomy device, the Trivex system (InaVein
LLC, Lexington, Mass.), was introduced by G. Spitz in1966.
Briefly, the system contains a shaver and a transilluminator
coupled with an irrigator (Fig. 10.9).
26
The method consists of extracting VVs in an out-
30
27–29
High ligation +
phlebectomy +
perforator abblation
Tributary
phlebectomy +
Varices phlebectomy
Varices phlebectomy with conservation of the refluxing saphenous trunk is named in French ‘ablation sélective des varices sous
anesthésie locale’ (ASVAL; selective ablation of varices under
local anesthetic).
31
This process gathers and unifies techniques
of phlebectomy that were previously scattered and insufficiently systematized and is based on the demonstrated fact that
varicose disease most often begins at lower leg level (see above).
According to ASVAL principles, the suppression of varicose
reservoirs (especially extra fascial varicose clusters) can – at
least to a certain extent – improve or restore to normal (centripetal) the reflux in saphenous trunks, thus preserving them.
CHIVA method
CHIVA is the acronym of the French ‘Cure Conservatrice et
Hémodynamique de l’Insuffisance Veineuse en Ambula-
33
toire’.
The pathophysiological basis of CHIVA relates to a
‘hemodynamicocentric model’ of venous insufficiency (VI).
According to CHIVA all the VI symptoms are due to an
obstacle to the flow and/or valvular incompetence which
increases the transmural pressure (TMP). Excessive TMP dilates
the veins (varices) and impairs drainage (edema, lipodermatosclerosis, and ulcer) (Fig. 10.10). The hemodynamic diagnosis consists of checking and, correcting the VI causes in order
to normalize the TMP and, consequently, its clinical symptoms. According to the VI hemodynamic pattern, CHIVA
involves fractioning the hydrostatic pressure, disconnecting
the shunts, and preserving the draining veins in order to cure
all the symptoms of VI at the same time and avoid recurrence.
Open Deviated Shunts Type II (varices + segmental saphenous
trunk reflux) and Closed Shunts Type III (varices + segmental
saphenous trunk reflux + SFJ reflux (SFJR)) are frequent patterns of VI due to superficial valve incompetence. In these
specific cases CHIVA divides the refluxing tributaries at their
32
34
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Chapter
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10
A
Role of Surgery in the Treatment of Varicose Veins
C
Figure 10.7 SFJ wrapping. A, Venocuff II devices. B, Schema of the SFJ wrapping. The Venocuff II is around the terminal valve. In dotted line a the removed
lateral accessory vein. C, Schema of the valve before and after Venocuff application. D, Angioscopic control after Venocuff application.
junction with the saphenous trunk. These divisions result in
trunk reflux suppression and varices ‘remodeling’ to normal
size while the drainage is preserved in order to avoid shortterm side effects and long-term recurrences (in the case of
Shunt III SFJR, redo due to a trunk re-entry) (Figs 10.11–10.14).
Investigations to be Done Before
Before After
D
• Are the symptoms described by the patient connected
• Are there signs that can be used to classify the varicose
• Are the varicose veins primary, secondary or congenital?
• Where are the leaks between the DVS and SVS (junctions
VV Surgery
B
(Courtesy of Dr Lane.)
with his/her varicose veins?
veins into the category of complicated varicose veins
(significant edema, skin changes, hemorrhage, superficial
thrombophlebitis)?
and perforating veins)?
• Which veins are varicose (GSV: trunk, tributaries; SSV:
A thorough physical examination is important; it allows the
clinical class (using the CEAP classification system) to be
identified. Both symptom type and severity must be carefully
recorded.
Systematic DUS prior to surgery for varicose veins is crucial.
From a classification standpoint, DUS is used to complete
CEAP sections E, A and P. In practical terms, it allows creation
of a precise map that will be very useful during surgery
(Fig. 10.15).
This examination is required and is sufficient in clinical
practice for primary and isolated superficial VI (SVI). For
secondary SVI or SVI associated with abnormalities other
than associated perforator incompetence, complementary
tests should be performed depending on the clinical context.
The assessment performed in preparation for surgical treatment of varicose veins should provide answers to the following questions:
286
trunk, tributaries; other non-saphenous veins)?
• What is the DVS status?
• Is there an associated disease that may affect the
therapeutic indication?
• Is surgical treatment the best option?
• If the surgeon has made up his/her mind, have the
anatomical variations been identified?
• What does the patient expect from surgery?
Patient’s Information
The information to be given depends, of course on the technique scheduled, but in all cases the following information
must be provided:
• Advantages and disadvantages of the different surgical
methods must be explained, as well as the postoperative
A B
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Anesthesia and Hospitalization
C
Figure 10.8 Grasping of previously marked varicosities. A, The incision is a 2- to 3-mm stab made with a no. 11 blade. B, After the varicosity is exteriorized,
it is divided and each end is carefully avulsed to remove as much varix as possible. C, With the limb elevated 30 degrees, 2-mm cutaneous incisions can be
made, the varicosity can be brought to the surface by the hook technique, and after division of the vein each end can be avulsed selectively. Placement of
subsequent incisions depends on the length of varicosity excised. D, This photograph, taken 10 days after surgery, shows the location of a distal medial calf
incision through which the great saphenous vein has been stripped from the groin to this level.
D
In addition, a written document is handed over to the
patient (Appendix 10.1).
Anesthesia and Hospitalization
Anesthesia
Regardless of the technique used, surgery may be performed
under local anesthesia (LA). Tumescent anesthesia is strongly
Figure 10.9 Intraoperative view of the transilluminated powered
phlebectomy procedure. Note the subcutaneous transillumination.
course (return to normal activity, convalescence
duration) and possible complications.
• Whether the surgery will be performed on an ambulatory
basis or not.
• How much the patient will be charged.
recommended for all patients. This innovation has revolutionized surgery of varicose veins.
The addition of epinephrine (adrenaline) does decrease
ecchymosis, and Goldman has shown that in appropriate
concentrations, epinephrine is safe when used in a tumescent anesthetic technique during ambulatory phlebectomy. It does reduce the incidence of hematoma and
hyperpigmentation.
37,38
Hospitalization
Surgery for varicose veins is increasingly performed on an
ambulatory basis. Only in elderly patients undergoing
classical surgery or those characterized by a particular social
or pathological context are hospitalized for 24 hours. Hospitalization is therefore determined by the patient’s desires,
local traditions or socioeconomic conditions.
35,36
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Congenital
venous
hypoplasia
Venous
thrombosis
Intra venous pressure IVP
Venous
ablative
treatments
Congenital
valve
absence
Post thrombosis
valve
destruction
Stasis valve
destruction?
N2
Valve incompetence
Open derivated shunt II
Closed shunts I, III, IV, V, VI
Valv musc pump pressure
SHUNT II
N1
N2 N2
N1
Venous obstacle
Dynamic hydrostatic
Pressure fractioning
Residual pressure
Open
vicarious
Role of Surgery in the Treatment of Varicose Veins
shunt
Venous caliber
Varices
Figure 10.10 Hemodynamic CHIVA Model for Venous Insufficiency: varices and trophic changes are symptoms of different causes. CHIVA involves
correcting all the patterns of shunts in order to cure the varices and the trophic disorders at the same time without phlebectomy. EVP external venous
pressure, IVP intravenous pressure, TMP transmural venous pressure.
SHUNT I
SHUNT (1) SHUNT 1 + 1 SHUNT 1 +
N1 N1
N2 N2
IVP - EVP = TMP
Hydrostatic pressure
Drainage
Edema
Skin changes
Ulcer
N1-N2-N1
N1
Figure 10.11 Types of ‘private circulation’ or veno-venous shunts
according to CHIVA nomenclature. Type I shunt with reentry on the
saphenous trunk, and variations. N1 deep vein network; N2 superficial vein
surrounded by the superficial fascia (GSV, SSV, proximal part of the accessory
anterior saphenous vein, Giacomini vein); N3 superficial venous system not
surrounded by the superficial fascia.
(Courtesy of Dr Franceschi.)
Postoperative Care and Convalescence
Drug treatment
After classical surgery minor analgesics may be proposed on
the day of the procedure, which may be supplemented with
anti-inflammatory treatment for 8 days. Tumescent anesthesia
usually provides adequate pain control which lasts for 1 to 2
days. Any patient complaining of pain must be evaluated to
determine the cause. Postoperative antithrombotic prophylaxis with low molecular weight heparin (LMWH) is indicated
in at-risk patients (history of thromboembolic disease, positive family case history, known thrombophilia, etc.). Ambula-
288
N3
N4L
1a
N2-N4L-N2 N2-N3-N2
Figure 10.12 Types of ‘private circulation’ or veno-venous shunts
according to CHIVA nomenclature. Type II shunt without reflux from the
deep circulation, with compartmental regurgitation N2>N4>N2> or
N2>N3>N2. N1 deep vein network; N2 superficial vein surrounded by the
superficial fascia (GSV, SSV, proximal part of the accessory anterior
saphenous vein, Giacomini vein); N3 superficial venous system not
surrounded by the superficial fascia; N4 superficial communicant vein
longitudinal (N4L)
(Courtesy of Dr Franceschi.)
N3
1b
tory phlebectomy or other mini-invasive techniques (ASVAL,
CHIVA) performed under the same conditions do not require
antithrombotic prophylaxis due to the absence of perioperative muscle atony and immediate mobilization of the patient
at the end of the procedure.
Postoperative elastic compression
Such treatment should be systematically initiated on the day
of the procedure. It has been credited with analgesic effects,
prevents edema and most likely the occurrence of thromboembolic complications that may affect the SVS and DVS.
SHUNT III
1c, d
SHUNT IV
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N3
N1 N1
N1-N2-N3-N1 N1-N2-N4L-N2-N1 N1-N2-N4L-N2-N3-N1 N1-N2-N4T-N2-N1
A
Figure 10.13 Types of ‘private circulation’ or veno-venous shunts
according to CHIVA nomenclature. Type III shunt with re-entry located on
an extrasaphenous perforator, and variations. N1 deep vein network; N2
superficial vein surrounded by the superficial fascia (GSV, SSV, proximal part of
the accessory anterior saphenous vein, Giacomini vein); N3 superficial venous
system not surrounded by the superficial fascia; N4 superficial communicant
vein longitudinal (N4L) or transversal (N4T).
N2 N2
N3
B C D
Incompetent SFJ
Incompetent GSV
Incompetent GSV and Tributary = reservoir
Reentry perforator
N1
N2
N4LN4L
N3
(Courtesy of Dr Franceschi.)
N1
N2
N4T
N2
N2
N3
N1
N1-N3-N2-N3-N1
Figure 10.14 Types of ‘private circulation’ or veno-venous shunts
according to CHIVA nomenclature. Type IV shunt with reflux from the pelvic
circulation. N1 deep vein network; N2 superficial vein surrounded by the
superficial fascia (GSV, SSV, proximal part of the accessory anterior
saphenous vein, Giacomini vein); N3 superficial venous system not
surrounded by the superficial fascia.
Figure 10.15 Surgery preoperative mapping
A, Incompetent SFJ and GSV until half-way down
the thigh (line —— • ——). Below GSV is
competent and a medial-posterior tributary is
refluxing, draining in lower leg reentry
perforators. B, SFJ and GSV competent
(continuous line in blue). Refluxing non-saphenous
veins (dotted line in black). C, SFJ and GSV
proximal part competent (continuous line in blue).
Incompetent femoral canal perforator feeding the
GSV (continuous line in black). D, SFJ and GSV
competent (continuous line in blue). Incompetent
anterior accessory great saphenous vein (dotted
line in black). E, SPJ and proximal SSV
incompetent (continuous line in black) as well as
SSV tributary (dotted line in black). Competent
distal SSV (not mapped). F, Incompetent SSV not
connected with the popliteal vein but with the
GSV.
(Courtesy of Dr Franceschi.)
(Courtesy of Dr Creton.)
Postoperative Care and Convalescence
A
B
C D
E
F
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Role of Surgery in the Treatment of Varicose Veins
290
Depending on the case and customary practice, stockings or
bandages are used. This compression is usually prescribed for
1 to 2 weeks in the absence of skin changes.
For ambulatory phlebectomy and other mini invasive techniques, the duration of elastic compression (with bandages
and then stockings) is usually 1 week. Poorly applied compression may lead to complications.
Recovery and convalescence
Recovery depends on the surgery performed and the level of
patient activity: from 2 weeks for extensive excisional surgery
to a maximum of a few days for so-called conservative surgery.
The norm is rising with movement on the day of the procedure, depending on the procedure performed – with mini
invasive and LA procedure immobility time is shortened. Exercise time is progressively increased during recovery. In principle, surgeons should provide patients with a document
showing all postoperative instructions (Appendix 10.1).
Surgical Complications
39,40
Perioperative complications
Perioperative complications associated with surgery are exceptional when it is performed by a qualified operator. However,
vascular injuries from damage to the principal arterial and
venous trunks or nerves have been reported mainly after conventional surgery, sometimes with dramatic consequences.
Lastly, anesthesia, regardless of its mode of delivery, may cause
accidents, but tumescent LA provides fewer complications.
Postoperative complications
Postoperative complications may be cutaneous, vascular, lymphatic, neurological or of a more general nature.
Hematoma
Hematomas are commonly seen following trunk stripping.
They are often worrisome to the patient, who should be notified in advance and reassured that they disappear and have no
lasting consequences. Compression can partially prevent
hematomas and reduce the pain they engender, and the local
application of cold compresses may also be recommended.
Local drainage may be indicated after the blood clots have
resolved (usually 2 weeks post-op).
Local infectious complications
Local infections are rare and usually occur following redo
surgery in the groin. Antibiotic therapy is indicated depending
on the clinical status and culture results.
Lymphatic complications
Occurring early, these lead to lymphatic accumulations and/
or lymphorrhea at the inguinal incision or at any incision
point, owing to injury during surgery to the lymphatic vessels
or nodes. The patient should be referred to the surgeon. The
lymphatic vessels may be damaged during phlebectomy in
certain areas (dorsum of the foot, crest of the tibia). A lymphatic pseudocyst develops and often requires multiple weekly
treatments such as puncture and drainage compression, and
in severe cases, manual lymphatic drainage. In cases of late
onset, the complications lead to lymphedema that may be
treated as such. This lymphedema is very rare and mainly
occurs after redo surgery at the groin.
Neurologic complications
Neurologic complications
stripping, are mainly associated with perioperative injury and,
41–43
are more frequent after trunk
rarely, when elastic compression is applied to patients under
general anesthesia. Lesions to the motor nerves are extremely
rare but may be permanent. In contrast, lesions to superficial
sensory nerves, estimated at between 10% and 40%, lead to
disorders such as anesthesia, paresthesia, dysesthesia and,
more rarely, neuralgia. The patient often only becomes aware
of these neurological disorders a few days after the procedure
and they usually disappear within a few weeks, sometimes
after several months. They are rarely permanent.
Venous thromboembolic complications
Local anesthesia and early mobilization have certainly reduced
the frequency of such complications. Analysis of two prospective series with systematic DUS examination showed that,
after ancillary surgery, DVT and pulmonary embolism were,
respectively, 0.4 to 5.3% and 0.2 to 0%,
that most of the DVTs were distal and asymptomatic. It should,
however, be noted that in the first series the patients (n = 377),
who were treated by HL + saphenous trunk stripping + tributary phlebectomy and/or ligation of the perforating veins,
were operated on under general anesthesia followed by early
mobilization and postoperative compression, but patients
at risk for DVT were not systematically given preventive
anticoagulation. In the second series various open surgery
procedures were performed, but under LA. Although no randomized controlled trials (RCTs) comparing the two modes
of anesthesia are presently available, it appears that venous
thromboembolic complications are more frequent with
general anesthesia.
In practice, on the slightest suspicion, the patient must be
reassured and a venous DUS and/or lung scan urgently
requested to diagnose or exclude possible deep vein thrombosis (DVT) and/or pulmonary embolism.
44,45
demonstrating
Cosmetic complications
Cosmetic complications appear later. Unsightly scars are rare
if the operator respects the accepted rules for cutaneous incisions. Aggravation of pre-existing telangectasias, occurrence of
a neotelangiectatic network (‘matting’) or of pigmentation,
particularly on the medial aspect of the thigh, are not uncommon along the pathway of the stripping. The following cutaneous complications have also been reported along the line of
incision:
• Localized hypertrichosis
• Scleroderma-like dermatitis
• Vitiligo.
These complications may also occur near phlebectomy
incisions.
Redo Surgery
The modality and indication for repeat surgery will be discussed later. Nevertheless it must be underlined that redosurgery, particularly at the SFJ and SPJ, generates a complication
rate higher than primary surgery.
Post Surgical Follow-up
Follow-up, whatever the VV operative treatment undertaken,
is strongly recommended and must be understood both by
patient and physician. One must keep in mind that varices are
a chronic and progressive disease and in most cases surgery
cannot completely cure the patient. Postoperative DUS allows
one to assess the presence of persistent reflux, and treatment
may prevent further recurrence, although no RCT is available
to recommend this practise.
Results from Surgery
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Outcome is difficult to evaluate, owing on the one hand to
the various anatomic and physiologic lesions or disorders, and
on the other hand to symptoms and clinical signs that differ
from one patient to another. These facts help to explain why
there is no universally appropriate classification available
for VVs.
Certain evaluations only take into consideration the investigation results (DUS, plethysmography, etc.) while others
also include evaluation of the symptoms (persistence or disappearance) and/or signs (presence or absence of varicose veins).
Lastly, pre- and postoperative patient quality of life (QoL) can
be an interesting evaluation tool.
In a comprehensive review including 118 references the
authors’ conclusions were
• relieve symptoms and improve disease-related QoL
• have a role in the secondary prevention of venous
ulcer
• provide a cosmetic improvement, which is almost
certainly operator-dependent
• be associated, as said above, with minor complications
that are relatively common and major neurosensory or
vascular complications that are very rare
• be associated with a definite but variable risk of
recurrence.
Some prospective RCTs, comparing the various surgical
techniques themselves or comparing chemical or thermal
ablation with surgery, are available, but for most there is no
long-term follow-up.
Surgery without preservation of
the saphenous trunk
Conventional surgery
Numerous publications on this technique are available; this
procedure has been used almost exclusively for a century.
Natural Evolution of the Disease Versus Conventional Surgery
A set of 149 patients with uncomplicated but symptomatic
VVs, who had chosen 6 months earlier whether or not to be
treated, were assessed by a questionnaire.
cantly reduced the total number of symptoms reported by the
patients at follow-up (P < 0.02). However, none of the symptoms reported during specific activities were significantly lessened by surgery compared with no treatment.
Conservative Treatment Versus Conventional Surgery
Two RCTs have been conducted, one concerning symptomatic
patients with non-complicated varicose veins, the other one
in patients with venous ulcers. The outcome is displayed in
Table 10.1.
Outcome of conventional surgery in
observational studies
Only two prospective observational studies will be analyzed
here. The patients had been treated at centers highly skilled in
venous surgery, investigated in depth pre- and postoperatively
by USD and there was no patient loss at 5 years follow-up.
In the first one including 93 patients (113 extremities C
the recurrence rate according to the REVAS (recurrent varices
after surgery) definition
were symptomatic (20/28). Nevertheless the clinical score was
an improvement on the preoperative one (P < 0.001). The
main cause of REVAS was neovascularization at the SFJ.
In the second series, which included 92 patients (127
extremities: C
48–52
= 58; C3 = 11; C4 = 34; C5 = 5; C6 = 19); all
2
46
that surgical treatment seems to:
47
Surgery signifi-
55
was 25% (28/113), of which 72%
53,54
2-6
patients were assessed postoperatively to identify incorrect
surgery. The REVAS rate was 47% and mainly related to neovascularization at the SFJ or/and SPJ, but only two ulcers
recurred (2/19 = 10.5%). Clinical recurrence was more likely
in limbs with worse preoperative venous function assessed by
air plethysmography (APG) and reflux present at three or
more sites. After surgery correction to normal venous filling
index was less frequent in limbs with recurrence. Gradual
deterioration in APG measures of reflux was identified in 66%
at 5 years. Unfortunately no correlation was established
between long-term DUS and APG anomalies and patient
satisfaction or symptoms severity.
RCTs on Conventional Surgery Versus Other
Operative Treatment
The results of these trials are shown in Table 10.2
conventional stripping vs HL+ cryostripping), Table 10.3
(HL+S vs radiofrequency ablation (RFA)), Table 10.4
65–68
vs endovenous laser ablation (EVLA)), Table 10.5
(HL+S vs surgery preserving the GSV), and Table 10.6
(HL+S vs foam sclerotherapy).
Classical surgery variants
Saphenous trunk stripping with preservation of
the saphenofemoral confluence +/- incompetent
tributaries phlebectomy +/- incompetent
perforator interruption
A retrospective cohort study of 151 patients (175 lower limbs
C
= 1.5%, C2 = 82.1%, C3 = 6.7%, and C
1
= 9.7%) were
4-6
treated as mentioned above knowing that 68.1% were
symptomatic. The preoperative DSU showed that both
saphenofemoral confluence (SFC) and saphenous trunk were
incompetent. At a mean of 24.4 months postoperatively
(median 27.3 months, range 8 to 34.8), persistent SFC reflux
was observed in only two cases (1.8%) and a SFC neovascularization in one case (0.9%). Recurrence of VVs appeared in
seven cases (6.3%) but in conjunction with SFC reflux in only
one case. Post treatment 83.9% of limbs were converted to
CEAP clinical class 0 to 1 and significant symptom improvement was observed in 91.3% of cases with an esthetic benefit
in 95.5%.
14
There is no RCT comparing this method to other operative
treatments.
Cryostripping
Table 10.2 shows the outcome of the RCTs comparing cryo-
stripping with conventional surgery.
56,57
Surgery with saphenous trunk preservation
Isolated flush ligation or limited resection of
the SFJ and/or SPJ
Various observational studies as well as RCTs have demonstrated that this procedure results in a poor outcome in the
long term.
SFJ and/or SPJ ligation plus incompetent tributaries
phlebectomy with or without incompetent
perforator interruption
In addition to observational studies, two RCTs are available
)
that include patients presenting with SFC and saphenous
trunk incompetence (see Table 10.5).
whether this procedure provides better results than the ASVAL
method (see below).
Apart from in one study,
16
the quality of the preserved
saphenous trunk to be used as an arterial substitute has never
been assessed in depth.
16,17,69
It is not clear
56,57
(HL+
(HL+S
16,17,69–71
58–64
72–74
Results from Surgery
291
Chapter
https://t.me/med1917
10
Table 10.1 Conservative treatment versus conventional surgery
Type of Procedure Article Conclusion
Uncomplicated symptomatic
VVs
HL+S
versus
conservative treatment
Role of Surgery in the Treatment of Varicose Veins
Venous ulcer
HL+S and compression
versus
compression
F-U, follow-up; HL, high ligation; NHS, National Health Service; QoL, quality of life; S, saphenous stripping.
Michaels JA, et al. Randomized clinical trial
comparing surgery with conservative treatment
for uncomplicated varicose veins. Br J Surg
2006;93:175
Ratcliffe J et al. Cost effectiveness analysis of
surgery versus conservative treatment for
uncomplicated varicose veins in a randomized
control trial. Br J Surg 2006;93:182
Barwell JR, Davies CE, Deacon J Harvey K, et al.
Comparison of surgery and compression with
compression alone in chronic venous ulceration
(ESCHAR study): randomized control trial. Lancet
2004;363:1854
Guest M, Smith JJ, Tripuraneni G, Howard A,
Madden P, Greenhalgh RM, Davies AH.
Randomized clinical trial of varicose vein surgery
with compression versus compression alone for
the treatment of venous ulceration. Phlebology
2003;18:130-6;363 Ulcer
Gohel MS, Barwell JR, Earnshaw JJ, et al.
Randomized clinical trial of compression +
surgery versus compression alone in chronic
venous ulceration. (ESCHAR study)haemodynamic and anatomic changes. Br J
Surg 2005;92:291
Gohel MS, Barwell JR,Taylor M, et al. Long term
results of compression therapy alone versus
compression plus surgery in chronic venous
ulceration (ESCHAR): randomized controlled trial.
BMJ 2007;335:83
246 patients
Uncomplicated symptomatic VVs (C
Conservative treatment (lifestyle advice) versus HL+S
F-U 2 years
After surgery
Health-related QoL better
Symptoms improvement (pain and edema feeling)
Cosmetic improvement
246 patients
Uncomplicated VVs (C
Conservative treatment (lifestyle advice) versus HL+S
F-U 2 years
After surgery
Modest health benefit for relatively little NHS cost (United Kingdom)
500 extremities
HL+S and compression versus compression
Venous ulcer healing (C
F-U 24 weeks
No difference between the 2 groups
Ulcer recurrence prevention
F-U 1 year
Less ulcer recurrence in the surgical group.
P < 0.0001
76 patients
Ulcer healing
F-U 26 weeks
Compression (n = 39) versus HL+S and compression (n = 37).
Surgery gives no additional benefit to compression therapy from the
point of view of healing rate and quality of life generic questionnaire
(SF 36) and disease specific questionnaire (CXVUQ)
Venous ulcer
Compression (n = 112) versus HL+S+ compression (n = 102)
F-U 1 year
Saphenous surgery abolished deep reflux in 10 of 22 legs with
segmental reflux and 3 of 17 with axial reflux. P = 0.175
A significant hemodynamic benefit was obtained despite co-existent
deep reflux; residual saphenous reflux was common
Venous ulcer recurrence
(500 legs)
HL+S and compression versus compression
At 4-years F-U
– In patients with isolated superficial reflux surgery + compression is
better than compression P < 0.01
– In patients with superficial reflux combined with segmental deep
reflux surgery is better than compression P = 0.04
– In patients with superficial reflux combined with axial deep reflux
no difference between the 2 groups P = ns
At 3-years F-U the surgical group experienced a greater proportion
of ulcer free-time P = 0.007
S)
2
)
6
S)
2
SFJ wrapping or valvuloplasty plus incompetent
tributaries phlebectomy with or without
incompetent perforator interruption
Some observational studies have been reported claiming
both good clinical and hemodynamic results for this proce-
21,22
dure.
Again, it is not known whether this procedure produces better results than ASVAL nor whether the quality of the
preserved saphenous trunk is suitable for use as an arterial
substitute.
292
Ambulatory phlebectomy
The results from Muller’s technique of ambulatory phlebectomy are difficult to assess as it is used either as an isolated
procedure or in combination with any kind of trunk ablation,
including the different stripping modalities.
Hook phlebectomy or powered phlebectomy
According to the RCTs there is no evident benefit in using
powered phlebectomy (Tables 10.6 and 10.7).
75–77
Table 10.2 RCTs of HL+ conventional stripping versus HL+ cryostripping
https://t.me/med1917
Type of Procedure Article Conclusion
HL + S (conventional)
versus
HL + cryostripping
F-U, follow-up; HL, high ligation; S, saphenous stripping.
Table 10.3 RCTs (except Kianifard article) HL+S versus RFA
Menyhei G et al. Conventional stripping versus
cryostripping: a prospective randomised trial to
compare improvement in quality of life and
complications. Eur J Vasc Endovasc Surg
2008;35:218
Taco MAL et al. A randomized trial of cryostripping versus conventional stripping of the
great saphenous vein. J Vasc Surg 2009;49:403
HL + S (n = 80) versus HL+ cryostripping (n = 79)
F-U 6 months
No difference in terms of postoperative pain and outcome
Less bruising with cryostripping P = 0.01
HL + S (n = 245) versus HL+ cryostripping (n = 249)
F-U 6 months
Cryostripping has no benefits over conventional stripping.
Type of Procedure Article Conclusion
Results from Surgery
HL+S
versus
RFA
F-U, follow-up; GSV, great saphenous vein; HL, high ligation; QoL, quality of life; RFA, radiofrequency ablation; S, saphenous stripping.
Hinchliffe RJ, et al. A prospective randomised
controlled trial of VNUS Closure versus surgery
for the treatment of recurrent long saphenous
varicose veins. Eur J Vasc Endovasc Surg
2006;31:212
Kianifard B, et al. Radiofrequency ablation
(VNUS Closure) does not cause neovascularisation at the groin at one year: results
of a case controlled study. Surgeon 2006;4:71
Lurie F et al. Prospective randomized study of
endovenous radiofrequency obliteration
(Closure procedure) versus ligation and
stripping in a selected patient population
(EVOLVES Study). J Vasc Surg 2003;38:207
Lurie F et al. Prospective randomized study of
65 endovenous radiofrequency obliteration
(Closure) versus ligation and vein stripping
(EVOLVeS) Two-year follow-up. Eur J Vasc
Endovasc Surg 2005;29:67
Rautio T, et al. Endovenous obliteration versus
conventional stripping operating in the
treatment of primary varicose veins: a
randomized controlled trial with comparison of
the costs. J Vasc Surg 2002;35:958
Perala J et al. Radiofrequency endovenous
obliteration versus stripping of the long
saphenous vein in the management of primary
varicose veins: 3-year outcome of a
randomized study. Ann Vasc Surg 2005;19:1
Subramonia S, Lees T. Radiofrequency ablation
vs conventional surgery for varicose veins-a
comparison of treatment costs in a randomized
trials. Eur J Vasc Endovasc Surg 2009;39:104
16 patients presenting REVAS with persistent GSV trunk RF
VNUS Closure bipolar catheter versus redo-groin surgery + S.
F-U 10 days
With RF
Procedure shorter P = 0.02
Less post-operative pain. P = 0.02
Less bruising P = 0.03
55 patients treated by VNUS closure bipolar catheter versus HL+S
(control group)
F-U 1 year
Absence of neovascularization after RFA
11% after conventional surgery P = 0.028
86 patients
VNUS Closure bipolar catheter versus HL+S
F-U 4 months
With RFA
Return to normal activity shorter P = 0.02
Return to work shorter P = 0.05
Better health-related QoL
65 patients
VNUS Closure bipolar catheter versus HL+S
F-U 2 years
With RFA
Clinical and DUS results at least equal to those after HL+S
Better health-related QoL
VNUS Closure bipolar catheter (n = 15) versus HL+S (n = 13)
F-U 2 months
Less post-operative pain P = 0.017–0.036
Shorter convalescence. P < 0.001
Cost-saving for society in employed patients
VNUS Closure bipolar catheter (n = 15) versus HL+S (n = 13)
F-U 3 years
No difference in terms of clinical result
VNUS closure bipolar catheter versus HL (n = 47) vs HL+S (n = 41)
RFA was more expensive but return to work was earlier P = 0.006
293
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