Добавил:
Sekretar
kiopkiopkiop18@yandex.ru
t.me/Prokururor I Вовсе не секретарь, но почту проверяю
Опубликованный материал нарушает ваши авторские права? Сообщите нам.
Вуз:
Предмет:
Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_3656_Библиотеки_им_академика_М_И_Перельмана
.pdf
430 Techniques and results of the modern surgical treatment of the incompetent saphenous vein
https://t.me/med1917
GSV, and can lie anterior or posterior to the GSV as it enters
the common femoral vein. Protection or ligation is required
to prevent unwanted bleeding during an open procedure.
e GSV is doubled in the calf in 25% of the population and in the thigh in about 8%.9 e posterior accessory
GSV is a common tributary which begins posterior to the
medial malleolus, ascending on the posteromedial aspect of
the calf, and joins the GSV distal to the knee. It connects
directly to the deep system via at least three prominent calf
posterior perforating veins, and insuciency in this vein
may be an important component of a patient’s symptoms.
Knowledge that the anterior accessory GSV at the upper
thigh courses deeply (supercial to the muscular fascia, like
the GSV) to a hyperechoic fascia that resembles the GSV
covering can aid the surgeon during anatomic dissection.7 It
is easily identied in that it courses more anteriorly than the
GSV, with a path corresponding to the underlying femoral
artery and veins. is is important since if this vein is insufcient, removal is required to aect a complete operation.
e saphenous nerve lies in close proximity to the GSV
below the knee, and it is separate from it above that location.
In 12% of cases, the nerve is directly next to the vein at the
knee, so even in this location, there can be a risk of injury.
Below the knee, the nerve lies next to the GSV except in
a few patients (two of the 60 dissections preformed).10 Its
method of branching is forked toward the foot, so upward
engagement is more likely than distal, providing some support for distal vein extraction during open operations.
11
e SPJ lies deep in the fascia. In only about 75% of cases,
the small saphenous vein (SSV) actually joins the popliteal
vein; alternatively, it can join the gastrocnemius vein or progress in a more cephalad direction. Although the SPJ may be
absent or rudimentary in about 25% of cases, when present,
it generally joins the popliteal within 4 cm at or above the
knee crease. In about 25% of cases, it is higher in location,
and in about 1%, it is lower.12 A termination in the upper calf
by it either joining the gastrocnemius veins or GSV occurs in
about 1% of cases.13 ere is oen (70%) a thigh extension of
the SSV that has a fascial compartment and follows the posterior femoral cutaneous nerve between the semitendinosis
and biceps femoris muscles. It can terminate in the middle
and upper thigh and equally into deep or supercial veins. It
can connect to the GSV by way of the intersaphenous vein,
formally known as the vein of Giacomini.
12,14
Knowledge
that the SSV runs in the subcutaneous so tissues in the
lower two-thirds of the leg and then dives deep into the fascia is critical when dissecting in this area. Eliminating the
deep dissection in favor of a more supercial to fascia ligation has been advocated, since there are no data to suggest
that ush ligation results in a better outcome.15 is is also
one of the reasons the Society for Vascular Surgery (SVS)/
American Venous Forum (AVF) guidelines committee recommends intra-operative duplex imaging as the safest way
to identify the SSV during an operation.
e ultrasonic relationship of the sural nerve to the SSV
16
has been extensively studied by Ricci and colleagues.
It
lies close to the SSV in the distal leg, with a more distant
relationship in the proximal calf, and is usually lateral to
the vein in the facial compartment. It does not share a perivenous fascia with the vein as occurs in the case of the GSV
and saphenous nerve. e posterior tibial nerve most commonly lies lateral to the SSV (in two-thirds of cases) and
may actually twist around the SSV near the SPJ. e peroneal nerve always lies laterally, but can be in the zone of
17,18
injury.
36.3 INDICATIONS FOR SURGICAL
PROCEDURES
e patient’s symptom(s) determines the need for intervention, not an abnormality found on a diagnostic test.
However, the diagnostic testing provides the conrmation
that venous pathology is present and may be the underlying
cause of the patient’s complaints. Using the CEAP classication to dene in detail your patient’s venous condition
provides a basis for the proper intervention to be chosen.19
To place in perspective the current patient clinical state and
to measure the result of an intervention, the patient’s clinical severity score should be recorded.20 A generic quality of
life measurement tool allows comparison with other disease
states and a general estimate of the ill eect of both the disease state a nd the eect of treatment. e Short Form 36 -Item
Health Survey (SF-16) has been successful in assessing the
global well-being of patients with varicose veins.21 ere are
several disease-specic quality of life scoring systems available, with some more heavily weighed to evaluating earlystage disease (varicose veins), such as the Aberdeen Varicose
Vein Questionnaire, while others are more appropriate for
characterizing patients with more advanced disease, such as
the Charing Cross Venous Ulceration Questionaire.
SVS Venous Clinical Severity Score is a physician-generated
measurement tool which incorporates patient-reported,
physician-observational, and clinical measurements in one
scoring system, and has been recommended as the best estimate of symptom relief by the SVS/AVF guidelines.
surgeon will need to provide the benets to be gained over
what period of time for the risks of surgical intervention.
Ultimately, however, the patient will have to decide whether
the symptom(s) he or she is experiencing is suciently
severe to warrant the risk of open venous surgery.
Pertinent clinical guidelines provide evidence and guidance for the use of these procedures. For the treatment of the
incompetent GSV, the SVS/AVF guidelines committee suggests high ligation and inversion stripping of the saphenous
vein to the level of the knee (grade 2, level of evidence B).
For treatment of SSV incompetence, the recommendation
is high ligation of the vein at the knee crease, about 3–5 cm
distal to the SPJ, with selective invagination stripping of the
incompetent portion of the vein (grade 1, Level of evidence
15
B).
Resolution of supercial reux may aid in venous ulcer
healing (grade 2, level of evidence C), will prevent recurrent
venous ulceration (grade 1, level of evidence B), should be
recommended to prevent recurrence in those with a prior
venous ulceration which has healed, and is reasonable to
22,23
15,20
e
e
36.5 Diagnosis 431
https://t.me/med1917
consider in a patient with skin that is at risk of venous ulceration (grade 2, level of evidence C).24 e presence of deep
or perforator insuciency does not alter these recommendations. Finally, and in contradistinction to current payment structures, the data would support the contention that
compression therapy is not the best primary treatment of
symptomatic varicose veins in patients who are candidates
for saphenous vein ablation (grade 1, level of evidence B).
15,25
ere are certain conditions in which open surgery may
be the preferred method of removing the pathologic saphenous vein, even though less invasive ablation techniques
are available. In some locations, the expense of ablation
technique devices is prohibitive and therefore open surgery
provides a viable option for treatment.
26,27
Catheter-based
therapy is ideal for straight, incompetent veins coursing
within the saphenous canal. e anatomic variations that
pose challenges for endovenous treatment are vein tortuosity
and adherence to the overlying skin, which can be overcome
with an open approach. Although stain resolution aer
endovascular interventions generally occurs spontaneously,
it can persist for more than a year, resulting in cosmetically
unacceptable outcomes in these adherent veins. In such
cases, open surgery provides a potentially better method of
care.28 Patient preference may also be an indication due to
the known long-term track record of open surgery and the
potential for early recurrence aer less invasive procedures.
29
ere may be situations in which recurrence post-ablation is due to saphenofemoral or saphenopopliteal reux
or neovascularization, which will require surgical exploration to treat.30 Furthermore, open surgical intervention may
be needed if arteriovenous stulae develop post-ablation
that are symptomatic. Symptoms are rare but may include
severe limb edema, high-output cardiac failure, and steal
syndrome. Asymptomatic patients may be followed with
duplex ultrasound and may resolve spontaneously.
31
36.4 CONTRAINDICATIONS
e lack of a patent vein being present into which the stripping device can be advanced is a contraindication to the
performance of this procedure. e complete lack of a deep
system capable of draining the lower leg of venous blood is
a contraindication to saphenous vein removal. Although
thought to be indicative of many of those with deep venous
occlusive disease, the reality is that most patients with deep
venous occlusive disease have sucient reserve to allow
saphenous removal when needed in order to treat the signs
and symptoms of supercial disease.
vascular occlusive disease must be taken into account whenever making incisions in the lower extremity, or healing will
be an issue. If concerned with healing based on clinical and
hemodynamic parameters, a more detailed investigation to
eliminate arterial disease as a confounding variable in the
patient’s care is recommended. is is especially concerning in patients with venous ulceration and, in fact, an arterial pulse examination and measurement of ankle–brachial
index is recommended in all of these patients.
32,33
Severe peripheral
24,34
In addition,
associated medical conditions which might place the patient
at higher risk of anesthetic complications (cardiac, pulmonary, and renal), increased bleeding or thrombotic events
(uncorrectable coagulopathy, thrombophilias, cancer, and
immobility), or infection (open wounds and systemic infection) must be appropriately considered and controlled in
order to obtain optimal results. Multiple prior groin explorations is a relative contraindication to open surgery due to
a higher risk of complications which include lymphatic leakage and major vascular injury.35 In a retrospective study of
128 groin re-explorations for recurrent varicose veins, there
was a 40% rate of wound complications.36 Previous groin
infection and radiation-induced scarring are important
considerations when counseling patients about the risks of
surgery. Pregnancy and breast feeding must always be considered as confounding variables, which might inuence the
patient’s decision to proceed with an open procedure.
36.5 DIAGNOSIS
e initial indication that a pathologic saphenous system
exists is based on patient symptoms. ese include pain,
swelling, heaviness, itching, skin discoloration, cramps,
ulcers, and even overt bleeding from supercial veins
which experienced a traumatic insult that can be slight or
more intrusive. e psychological ramications related to
the unsightly appearance of varicose veins or other associated signs such as hyperpigmentation or ulceration aecting self-esteem are important considerations. A detailed
history and physical examination is essential to establishing the diagnosis, noting obvious varicose veins, swelling,
hyperpigmented skin, and present or past ulcers, so that
the CEAP clinical classication can be documented.19 One
should make special note in female patients to rule out vulvar varicosities which are easily missed due to patient and/
or physician reluctance to complete a proper examination.
Physical examination can suggest SFJ or SPJ as well as perforator incompetence, but requires venous duplex imaging
to conrm the clinical impression.
e critical need for venous duplex imaging prior to any
saphenous intervention has become evident due to the variability of ndings noted on the detailed imaging used in the
conduct of certain ablation techniques.
did not always conrm the clinical impression and, in fact,
in some cases, the saphenous proper is not aected when it
was considered the underlying etiology of the clinical ndings.38 e lower extremity venous duplex facilitates procedure planning and appropriate care. It completes much of
the CEAP classication in terms of the etiology, anatomic
distribution, and pathophysiology of the disease that is
present. A detailed description of venous duplex imaging
is contained in a prior chapter of this text and will not be
readd ressed here. e addition of other diagnostic modalities is generally not required, but based on unique patient
conditions might include the need for magnetic resonance
venography, computed tomography venography, venography, or intravenous ultrasonography.
37
Detailed imaging
432 Techniques and results of the modern surgical treatment of the incompetent saphenous vein
https://t.me/med1917
36.6 TECHNIQUES
36.6.1 Anesthesia
Most patients opt for general or regional anesthesia (spinal
or epidural), especially if a bilateral operation is planned.
Others have employed the use of femoral nerve blocks
with supplemental local anesthetic injections or tumescent anesthesia for unilateral procedures, but the manipulation required for the open procedure, especially around
the deep veins in the groin, can be uncomfortable, if not
painful for the patient. One dose of peri-operative antibiotic prophylaxis does decrease the risk of wound infection
and wound-related complications, as demonstrated in a
randomized controlled trial in patients undergoing groin
dissection for the treatment of varicose veins.39 e issue of
peri-operative deep venous thrombosis (DVT) prophylaxis
is best managed by using early and frequent ambulation
in patients who are free of associated risk factors. In those
patients with additional thromboembolic risk factors, such
as thrombophilia, prior history of DVT or thrombophlebitis, and/or obesity, the recommendation is prophylaxis with
low-molecular-weight heparin, low-dose unfractionated
heparin, or fondaparinux.
15
36.6.2 Operative procedure
36.6.2.1 PATIENT POSITIONING
36.6 . 2.1.1 G S V sur g er y
e patient is positioned in the supine position and the
entire leg to umbilicus is prepped and draped in a routine
sterile fashion to expose the entire leg and foot to the umbilicus. e initial dissection to expose the groin anatomy
may be performed with the patient at or slightly elevated.
However, for the actually stripping of the vein from the
body, the patient should be positioned in Trendelenburg to
minimize vein distention and, therefore, blood loss.
36.6.2.1.2 SSV surgery
e patient is placed in the prone position for a bilateral
procedure. A prone position is also quite acceptable for a
unilateral procedure, but a semi-lateral position with the
leg to be operated on facing upward on the operative eld
would suce. Flexion of the knee relaxes the tight popliteal fascia for easier exposure. e initial dissection to
expose the venous anatomy may be performed with the
patient at or slightly elevated. However, for the actual
stripping of the vein from the body, the patient should be
positioned in Trendelenburg to minimize vein distention
and blood loss.
36.6.2.2 ELIMINATE PROXIMAL REFLUX:
HIGHLIGATION AND DIVISION
36.6.2.2.1 Saphenofemoral junction
A transverse incision is made in the skin, 1–2 cm below
the inguinal skin crease or somewhat higher in the obese
patient. is approach facilitates easy closure at the completion of the operation via an incision, which is somewhat
self-approximating (Figure 36.1A1, see arrow). e incision
begins just medial to the femoral artery pulse and extends
3–5 cm medial so as to be centered over the saphenous and
common femoral vein junction. Using cephalad and caudal
retraction, the GSV and its branches, as well as the anterior
common femoral vein, are visualized. e major branches of
the GSV are the supercial circumex iliac, supercial epigastric, external pudendal, and, in some cases, the anterior
accessory GSVs. ere is signicant anatomic variability in
how these veins converge near the SFJ, but this makes little
dierence to the ultimate goal of the operation, which is to
ligate and divide each branch well o the trunk and oen
past their second branch points. e posterior accessory
GSV is also ligated and divided if present in the dissection
eld. Occasionally, posterior and anterior thigh circumex
veins join the GSV and are likewise ligated and divided. All
branches are ligated to the secondary branches by tradition,
rather than this being a data-driven approach.
be taken to visualize the supercial external pudendal artery
and either protect it from harm or formally ligate and divide
it in order to prevent undesirable arterial bleeding postoperatively. is artery helps to mark the termination of the
GSV and can lie anterior or posterior to the GSV as it enters
the common femoral vein (Figure 36.1A1 and 36.1A2). If not
accomplished in the prior dissection, the anterior surface of
the common femoral vein is formally visualized so as not to
injure it during GSV ligation and to ensure that the vein to
be stripped is not the common femoral vein. At this stage,
the caudal GSV can be exposed via an overlying transverse
incision centered over the vein (Figure 36.1B1) and situated
just below the knee. rough this incision, the stripping
device can be placed from caudal to cephalad and is seen
to pass into the GSV at the groin incision. Except in obese
patients, the rather rigid stripper can be palpated along the
length of the GSV within the subcutaneous compartment it
occupies. When satised that the anatomy has been correctly
dened and dissected, the GSV is ligated ush on the common femoral vein with a double ligature or oversewn with a
5–0 prolene running suture (Figure 36.1A2) aer securing
it distally to the stripping device with a large silk tie. e
GSV is divided to disconnect it from the deep system prior
to stripping. Alternatively, some surgeons ligate the GSV on
the common femoral vein, transect it, and pass the stripping
device from cephalad to caudal.
15,40
Care must
36.6.2.2.2 Saphenopopliteal junction
A 4–6-cm transverse incision placed directly over the
duplex-marked SPJ allows an incision to be best placed for
later ligation and division of the SSV. e so tissue is dissected in the transverse direction and then the deep fascia
is incised in the longitudinal direction if ush ligation is the
goal (see Figure 36.2A1). In the standard case, the SSV is
subfascial rather than subcutaneous in location. e SSV is
dissected and all tributaries ligated aer clearly dening the
popliteal vein (Figure 36.2A2). e tibial nerves pass near
36.6 Techniques 433
A1 A2 A3
https://t.me/med1917
A1 A2
A
B1 B2
B
C1
C
Figure 36.1 The supine patient’s general anatomy is dem-
onstrated in the long leg drawing. The top insert demonstrates (A1) the proximal great saphenous vein (GSV)
with branches, with particular emphasis on the superficial
external pudendal artery (arrow), which may be located
above or below the insertion of the GSV into the common
femoral vein. Lack of attention to the artery can result in
unwanted bleeding. A2 depicts the ligation and division
of all branches with flush ligation of the GSV on the common femoral vein and a Codman-type stripping device
lying within the vein distally. B1 depicts a small incision
centered over the GSV just below the knee to expose and
control the vein. The saphenous nerve may lie close to the
vein in this area and should be completely dissected away
from the vein. B2 demonstrates the stripping passing
upward to exit the GSV in the groin area (A2); in addition, a second stripper exits the distal vein for removal of
the calf GSV if needed. In this depiction, a small head is
attached to the distal stripper, but often the vein is simply
tied to the small bullet on the end of the stripper. The vein
is divided before stripping is undertaken. If vein removal
was to not include the calf component, the distal vein
would be ligated and divided. C1 is the artist’s depiction
of a small incision centered over the ankle GSV to expose
and control it. Note the close proximity of the saphenous nerve to the vein (arrow); the nerve is dissected and
removed away from the vein as much as possible. C2
shows the distal vein ligated with a proximal stripper in
place and ligated to the vein. Before stripping, the vein is
divided.
C2
A
B1 B2
B
Figure 36.2 This artist’s depiction shows the patient in
a prone position with the general location of the small
saphenous vein (SSV) beginning at the latter malleolus
and terminating near the knee crease (incision proximal).
A1 depicts the saphenopopliteal junction, which lies deep
into the investing fascia rather than in the subcutaneous
tissue in which the SSV lies in the more distal leg. Take
special care to protect the tibial nerves (yellow structures
next to the vein). It should also be understood that the
intersaphenous vein may be a major proximal extension of the SSV. A2 shows the SSV ligated flush with the
popliteal vein and a perforate–invaginate (PIN) stripper
has been placed downward in the open distal SSV. A3 is a
magnified view of the PIN stripper ligated to the SSV via
a “floating knot” and the invagination process has begun.
B1 demonstrates the proximally placed PIN stripper being
forcefully pushed through the vein wall and subcutaneous tissues to indent the skin. An 11 blade or similar small
knife punctures the skin, allowing the distal stripper to
egress. B2 shows the distal PIN stripper exposed, which
will be grasped and pulled downward, invaginating the
vein from the body.
the popliteal vein and both structures must be identied
and protected from harm. Ligation of the SSV ush on the
popliteal vein can be accomplished before or aer placement
of the vein-stripping device via the distal vein. Aer stripper placement, the SSV can be ligated distally on the vein
stripper at the time of ush ligation on the popliteal and the
vein transected (Figure 36.2A2). If retrograde placement
of the stripping device is planned, then ush ligation on
the popliteal vein is performed and subsequently the distal
saphenous vein can be opened for stripper placement.
434 Techniques and results of the modern surgical treatment of the incompetent saphenous vein
https://t.me/med1917
36.6.2.3 REMOVAL OF THE INCOMPETENT
VEIN:AXIAL STRIPPING
36.6.2.3.1 Great saphenous vein
Attempts to save the GSV using simple high ligation to prevent reux into the incompetent system was fraught with
rapid recurrent pathologic reux and so was abandoned.
Precise duplex imaging demonstrated a generally normal GSV devoid of reux except at branch sites and has
allowed a limited approach to the control of varicose veins.
Unfortunately, primary axial GSV incompetence is generally associated with more advanced disease (C3–C6) and
therefore removal of the pathologic vein is the best approach
for long-term success. Removal of the vein to just below the
knee is acceptable if there is no pre-operative reux present
into the calf and ankle. is limited stripping of the vein
decreases saphenous nerve injury by minimizing the proximity of the two structures during stripping. However, if
the entire vein demonstrates reux on pre-operative duplex
imaging, we would strip the below-knee GSV from the
below-knee incision to the ankle, representing a conscious
eort to dissect the saphenous nerve away from the vein at
both incisions prior to stripping. We have observed minimal clinical consequences as a result of this approach, even
though a careful neurologic examination will demonstrate
some sensory deciency.
Our general approach is to remove all incompetent GSV
above and/or below the knee at the initial operation. If
reux stops at or just below the knee, a 1–2-cm long transverse incision is located a few centimeters below the knee
and centered over the GSV to allow easy exposure (Figure
36.1B1). e vein is dissected from surrounding tissue with
sucient length to allow silk sutures to control bleeding
from the vein proximally and distally to an opening in
the anterior wall. rough the vein opening, the stripping
device is placed cephalad into the vein and the proximal
suture is used to tie the vein onto the stripping device. Vein
stripper devices in general consist of a rather sti and long
wire with or without the ability to attach a “head” of various
sizes to aid in vein removal. e various modications have
been named Codman, Myers, Varady, etc., and are available from a variety of manufacturers. e distal suture is
tied to seal the distal vein and the stripper is passed upward
until it is seen in the groin incision. We like to palpate the
stripper within the subcutaneous saphenous compartment
to provide some tactile impression that it lies in the correct
position. We do this by grasping both ends of the stripping
device and liing upward to tether or bowstring it and allow
improved palpation within the subcutaneous tissue. e
vein in the knee area is divided to allow the vein to ultimately be pulled from the body in a downward direction.
In the groin, the saphenous is ush ligated on the common
femoral vein, the distal vein is ligated to the stripper, and the
vein transected. When using one of the stripping devices
(e.g., the Codman style device), variously sized heads may
be placed on the stripper to aid in complete vein removal,
but we generally choose the smallest available head to minimize the mass of tissue being removed and required to exit
the distal incision. Others perform invagination stripping
with excellent results, as described in more detail below.
If the calf GSV demonstrates signicant reux on preoperative imaging, the GSV at the ankle is exposed via a
1-cm long transverse incision positioned 1 cm anteriorly
and medially to the medial malleolus (Figure 36.1C1). e
subcutaneous tissue is dissected from around the vein to
separate the saphenous vein from the nerve and to allow a
cephalad and caudal silk ligature to be placed around the
vein. e caudal end of the vein is ligated and, with gentle traction on the cephalad suture, the anterior surface of
the vein is opened, through which a stripping device can
be advanced to the calf incision. e vein is ligated to the
stripper at the ankle and the vein transected. Rather than
ligating the saphenous vein at the calf incision, if only proximal stripping was planned, the vein is le open. e stripper is allowed to exit the vein, which is then ligated to it
with a silk tie. We generally do not add a stripper head to
the device in this location since the small obturator located
on the device is generally suciently large to prevent the
vein from pulling o it during invagination and extraction.
e saphenous vein in the calf is divided to allow the vein
to be removed from the body. Rather than stripping the
entire saphenous vein with its accumulated bulk through
the ankle incision, which might tend to drag the saphenous
nerve with it, we have employed this two-incision technique
for complete vein excision.
With the saphenous vein secured to the stripping device
and transected proximally and distally to allow extraction,
the patient is placed in a steep Trendelenburg position. e
proximal vein is extracted rst with gentle pressure held
over the area during and somewhat aer the stripping has
taken place. e distal end of the stripper is grasped rmly
and, with a constant and determined distal pull, the vein
is removed from the body. Aer proximal pressure has
secured acceptable hemostasis, the distal vein in removed
in a similar fashion with external pressure again held to the
point of hemostasis.
A technical modication that allows extraction of the
saphenous from the body without a distal incision involves
the use of a 3.5-mm diameter cryoprobe, which can be placed
from proximal standard saphenous exposure into the distal
vein and stops about 8 cm below the knee. When in place, liquid nitrous oxide is injected into the distal probe to freeze the
probe tip to the veins at −85°C. e vein is then invaginated
on itself by pulling the cryoprobe from distal to proximal,
with the vein now trailing and being pulled from its compartmental bed. e proximal vein was already divided from its
attachment with the common femoral vein to allow removal.
Compression is applied and the proximal wound closed.
41,42
36.6.2.3.2 Small saphenous vein
Extraction of the SSV may follow the same process as
depicted for the GSV. e distal SSV may be exposed via
36.6 Techniques 435
https://t.me/med1917
a transverse incision directed over the vein at the point
of reux termination as determined by pre-operative
duplex imaging and marking. Alternatively, the vein may
be exposed via a transverse incision located between the
Achilles tendon and lateral malleolus at the high ankle.
e sural nerve is not as closely adherent to the SSV as the
saphenous nerve is to the GSV, but it can lie close to the SSV
in the distal third of the leg. e nerve has small accompanying arteries and all must be protected from harm when
dissecting the vein to allow ligation and stripping. Aer
making the incision, the subcutaneous tissue is dissected
to isolate the vein and to allow proximal and distal control with silk ties. e distal vein is ligated and the proximal vein opened to allow advancement of the stripper. e
vein is ligated to the stripper and transected. e stripper
is advanced and exits the vein at the knee vein incision.
e vein is tied to the stripper in this location and, following ligation from the popliteal vein, the vein is transected.
Following institution of the Trendelenburg position, the
vein is pulled downward and from the body with external
compression being applied for 2–5 minutes to control any
bleeding. Alternatively, many surgeons will only remove
about 10 cm or less from the proximal incision to prevent nerve injury and with the thought that recurrence is
unlikely in this short vein.
An alternative method of stripping the SSV is depicted
in Figure 36.2. Note that the same method could be used
for stripping the GSV, although a few more incisions are
required to allow visualization of the vein in its entirety.
e method demonstrated is the perforate–invaginate
(PIN) technique of Oesch. e SSV is ligated ush to the
popliteal vein and a stainless steel semi-rigid PIN stripper (30 or 47.5 cm long) is back-loaded and passed retrograde down the vein. Retrograde bleeding is controlled by
a suture encircling the vein with the stripper lying within
it. e stripper is passed down the vein and past any area
of reux, at which point it is forcefully punctured through
the vein and into the subcutaneous tissue, dimpling the
skin. An 11 blade incises the skin via a stab incision, exposing the distal tip (Figure 36.2B1 and 36.2B2). e proximal vein is ligated to the stripper via a “oating knot.” A
silk suture is tied to the stripper, which is pulled a short
distance into the vein, and then the suture encircles the
vein, which is ligated and a long trailing component of the
suture is le in place to allow vein removal if it breaks during stripping (Figure 36.2A3). e patient is placed in the
Trendelenburg position during stripping. Pulling the distal stripper invaginates the vein, which eventually allows
it to be pulled out from the distal incision. It is grasped
and completely avulsed from the leg. Generally, no distal
ligature is applied aer vein transection. If the vein happens to break midway into its removal, the PIN stripper
can be pulled into the vein via the trailing suture and the
vein exposed, ligated to the stripper, and pulled into the
proximal wound for removal. External compression provides hemostasis.
36.6.2.4 ADJUNCTIVE PROCEDURES, TECHNICAL
CONSIDERATIONS, WOUND CLOSURE,
DRESSINGS, AND POST-OPERATIVE CARE
At this point, branch varicosities can be removed via stab
ablation, powered phlebectomy, or by other ablation techniques. In the majority of data that are available for estimating the overall results of open saphenous surgery, the
branch varicosities that are addressed in some manner to
provide complete care at a time when the patient has optimal anesthetic coverage. Incompetent perforator veins may
also be addressed at this time via a variety of techniques.
If clinically indicated, bilateral surgery does not appear
to increase the overall risk of complications in the patient.43
High ligation alone as a treatment of a pathologically
incompetent saphenous vein proved to be unsuccessful
due to recurrent reux and clinically apparent varicosities
within a few years when compared to high ligation and
stripping.44 Dwerryhouse and colleagues reduced the need
for reoperation from 20% with high ligation only to 6% with
high ligation and stripping over 5 years.45 erefore, the
addition of removal of the vein is an integral component of
the open operative approach. Whether less invasive procedures such as the Cure Conservatrice et Hemodynamique
de l’Insusance Veineuse en Ambulatoiere (CHIVA) or
Ablation Selective des Varices sous Anesthesie Locale
(ASVAL) management of varicose veins will be more successful than simple high ligation is currently debatable
and not championed in the United States. e former oen
employs ligation of the proximal saphenous in addition to
ligation, division, and avulsion of incompetent varicose
tributaries while maintaining the saphenous trunk, competent branches, and perforators.
46,47
e latter involves
preservation of the incompetent saphenous and stab phlebectomy of all varicose tributaries.
48
ere has been debate as to whether the saphenous
stump should be oversewn with a running suture versus
simply ligated, and even whether a polytetrauoroethylene
(PTFE) patch should be placed over the ligated saphenous
stump as a means of preventing neovasculogenesis in the
49–52
groin with recurrent reux.
e addition of the PTFE
patch did add a signicant complication risk to the procedure. e method of saphenous ligation likely has little
impact on overall results. Current consensus would favor a
secure closure of the saphenous stump, ligature, or oversewing with a non-absorbable suture, and no additional PTFE
patch placement.
15
e groin and posterior knee incisions used to provide
high ligation can be closed with deep subcutaneous layers of
interrupted 3–O absorbable sutures and a running subcuticular 4–O absorbable suture. e distal incisions used to
expose the vein and allow stripper inversion and removal can
be closed with one or two everting 4–O absorbable sutures.
e incisions are covered with sterile ats and a compression
wrap is applied from the foot to as much thigh circumferentially as possible, with slightly more compression distally
436 Techniques and results of the modern surgical treatment of the incompetent saphenous vein
https://t.me/med1917
and tapering proximally. A sterile at and dressing covers the
groin wound. e patient is instructed to remove the dressing in 48 hours if desired and replace it with similar daily
compression until seen in the clinic in about a week. Postoperative compression bandaging does reduce hematoma
formation aer vein stripping.53 Use of compression stockings past 1 week has not been shown to be benecial with
respect to pain resolution, time to return to work, patient
satisfaction, or wound complication rate.54 e SVS /AVF
guidelines committee recommends post-operative compression for a period of 1 week to reduce hematoma formation,
pain, and swelling (grade 1, level of evidence B).
15
e patient is discha rged on the day of surgery aer recovery from whichever anesthetic method was used. ey are
instructed to resume routine activities which do not involve
heavy liing or water sports. ey can walk as desired rather
than stand or sit for prolonged periods of time and, when
reclining, should have their legs elevated to improve venous
drainage. ey should place a wedge between the boxspring
and mattress to allow leg elevation above the head of about
4 inches when sleeping. A mild pain reliever is provided,
but many patients use only an anti-inammatory with good
eect.55 e patient is to be o work for 1–3 weeks, especially
if they are involved in heavy labor occupations. Showering
is permitted with proper leg wound protection. We generally see the patient in 5–7 days for wound inspection and
examination. If all healing is progressing well, routine daily
activities, including showering and light work duties, can
be started. ere are some data to suggest that high ligation and stripping in addition to stab phlebectomy to treat
branch varicosities do require some time before returning
to normal work activities. In one study, the average return
to work time post-surgery was about 12 days.
56
36.7 COMPLICATIONS
e risk of wound infections ranges from 1.5% to 16%.57 In
a retrospective study of 714 varicose vein surgeries in an
outpatient setting spanning over 9 years, spinal anesthesia
was found to be a signicant risk factor for wound infection, with an odds ratio of 6.5. However, the discussion centered around the possibility that cigarette smoking was the
actual risk factor, since spinal anesthesia was administered
preferentially to this population. ey had an overall incidence of 1.5%.
treated in 599 patients reported a wound complication rate
of 4%. Lymphatic complications occurred in 1.3% and all
of the leaks were in patients undergoing groin re-explorations for recurrence. Two of the patients had lymphatic leak
from phlebectomy sites. One patient had lymphedema.35 A
randomized controlled trial comparing prophylactic antibiotic use versus no antibiotics in high ligation and stripping
with phlebectomies used an in-depth daily evaluation of the
groin wound as assessed by a weighted scoring system composed of seven parameters. Based on a score that denes a
wound infection, 9.9% in the treatment group and 18.2%
in the control group experienced a wound infection. Two
58
Another study which included 973 limbs
patients in the control group required incision and drainage
of a wound abscess, and none require such an approach in
39
the treatment group.
is study found two factors which
increased the risk of a groin wound infection: obesity and
current smoking.
Supercial nerves are at risk of injury due to their proximity to the veins being removed. e direction of stripping
does aect nerve avulsion, as demonstrated by Ramasastry
and colleagues, with much less risk if the direction of stripping is downward, since the branch points of the nerves are
less likely to be engaged.11 In fact, when stripping the entire
saphenous vein downward, one investigator noted no objective nerve injury in 14 patients, while another demonstrated
objective ndings in upward stripping for an overall rate of
injury of about 39%.
11,59,60
Stripping the vein only to the knee
may eliminate this risk, but in 12% of cases, the nerve is on
the vein at the knee.10 Stripping to the knee is still associated with about a 7%–10% incidence of clinical saphenous
nerve injury, so this approach does not eliminate the issue
entirely.
35,60
Unfortunately, if you leave the below-knee vein
in place, reux and recurrent var icosities are risks which were
noted in 4% of cases in one of the largest long-term follow-up
studies available.45 In fact, 29% of the patients in this study
had duplex-conrmed reux in the retained distal saphenous vein on follow-up, and the authors expressed a concern
that this pathology may eventually be expressed as recurrent
varicosities. In our own study, we preformed removal of all
incompetent veins at the rst operation, but via two separate
incisions (an intervening knee incision). We observed a very
small area of saphenous decit in 58% of our cases (median
50 cm2) around the medial malleolus or medial knee. A total
of 54% of our patients with documented decits did not recognize a problem, while four out of 26 still had symptoms,
with only one noting moderate discomfort. None of our
patients required recurrent surgery, although 29% had isolated cluster varicose veins.61 No matter which approach is
taken to remove the incompetent saphenous vein, the tradeo will be nerve injury risk versus recurrence in the retained
saphenous vein. Common peroneal nerve injury occurred in
5%–7% of patients undergoing SSV ligation and stripping,
with a sural nerve injury rate of 2%–4%.
15,62
Injury to the femoral vein or artery is fortunately very
rare (0.0017%−0.3%), but can be devastating, oen because
the problem is not promptly recognized and treated.63 In one
systemic review, 87 major vascular injuries were found, with
about half being arterial in nature. In ve cases, stripping
of the femoral or popliteal vein occurred, and in 17 cases,
stripping of the femoral artery was reported. Adherence
to technique detail is apparent when considering that the
stripper was inadvertently advanced into the deep artery or
vein in these cases. Amputation can be the ultimate result if
vascular repair is delayed or unsuccessful. Hagmuller from
Germany reported an incidence of 0.02% of arterial injury
64
and 1% of venous injury.
Critchley etal. reported one femoral vein injury among 599 patients in whom groin exploration was undertaken for the third time. ey highlighted
the risk of reoperation in a scarred groin.
35
36.9 Conclusions 437
https://t.me/med1917
romboembolic complications including DVT or pulmonary embolism (PE) are rare, but can be serious in nature.
Clinically apparent DVT and PE have been reported in series
with maximal rates of about 0.5% and 0.17%, respectively.35
In a more detailed prospective duplex study of 377 patients
imaged before and at 2–4 weeks and 6–12 months postsurgery, acute DVT was detected in 20 patients (5.3%), with
only eight being symptomatic (2.1%), and no clinical PE was
observed.65 Eighteen of the 20 cases were conned to the calf
veins, wit h half completely resolved without reux at 1 year. In
a study comparing complications when stratied to younger
or older than 65 years of age, there were no signicant differences, but thromboembolism was seen only in the older
group at a rate of 0.5%.66 Protocols involving the use of graduated compression stockings for 6 weeks post-operatively with
recommendations for early mobilization have been shown to
decrease complications of venous thromboembolism from
0.7% to 0.2%. e PE rate decreased from 0.2% to 0% in this
st udy.67 When considering all of the available data, routine
pre-operative prophylactic anticoagulation is not supported
by Critchley et al. or the SVS/AVF guidelines committee
members. e rate is low and generally not clinically signicant when patients use compression and are allowed to
ambulate early.
15,35
Based on their study ndings, Critchley
etal. started administering 40 mg of enoxaparin 1 day prior
to surgery and continued this for 1 week post-operatively for
patients with a history of venous thromboembolism.
reality should be made clear to the patient prior to intervention in order to ensure a realistic expectations of outcomes.
For more advanced disease in which venous ulcer healing and prevention of recurrence are the markers of success,
supercial vein surgery prevents recurrence. e ESCHAR
trial randomized 500 patients with leg ulcers and isolated
supercial or mixed supercial/deep reux to compression
only verses compression with high ligation, division, and
saphenous stripping.
77, 78
e rate of healing was the same
at 4 months (65%), but at 12 months, the rate of ulcer recurrence was 28% in comparison to 12% when surgery was
included in the patients’ treatment (P < 0.0001), and the difference in ulcer recurrence was maintained at 4 years.
When compared to the less invasive techniques of radiofrequency or laser ablation that are now available to treat major
saphenous reux, early results (quality of life scores, associated pain, and recovery) favor the less invasive techniques;
however, at 2 years, the clinical and hemodynamic results are
56,79–82
similar.
Sclerotherapy, and even foam sclerotherapy,
was less eective than surgery at eradicating major reux.83
A very recent large meta-analysis supported by the SVS and
the AVF reviewed current data regarding these modalities
for the treatment of saphenous incompetence. e analysis
found surgery to be associated with a non-statistically signicant reduction in varicose vein recurrence when compared
to the other modalities, but with less early disability and pain
associated with the less invasive techniques.
84
36.8 RESULTS
Saphenous high ligation and stripping of the vein has been
the gold standard for the treatment of saphenous incompetence for over a century, with only minor modications
over the decades. A randomized clinical trial has demonstrated that high ligation and stripping of the saphenous
vein results in improved quality of life, cosmetic result, and
relief of symptoms over that observed when using conservative management with compression garments only for the
treatment of uncomplicated varicose veins.25 A signicant
improvement in quality of life measurements was further
conrmed by a randomized controlled trial report comparing open surgery to radiofrequency ablation.
Recurrent varicose veins represent a failure of treatment
to the patient and to the physician, especially when all has
been done to eradicate the pathologic process at the rst
operation. Alternatively, they may reect the chronicity of
the disease process, but more likely they reect some component of each. ere are long-term data available regarding recurrence, which appears to be a progressive process.
Clinical series with 2-, 5-, and >10-year follow-up data
are available and note recurrent varicose veins at rates of
7%–37% at the 2-year follow-up, but up to approximately
50% and even 62% at 5 and 11 years, respectively.
e specic rates reported are subject to the rigors of patient
inspection and the denition of recurrence, but these results
do highlight the progressive nature of the disease even aer
an aggressive and extensive approach to intervention. is
39
40,45,68–76
36.9 CONCLUSIONS
e clinical consequences of saphenous vein incompetence
is associated with signicant medical consequences demonstrated as a negative impact on patient quality of life, ability
to work, and costs of medical care. Venous duplex imaging
is required to determine the etiology, anatomic distribution,
and pathophysiology of the reux that is present. e rapid
rise of less invasive means to ablate the saphenous system
and therefore eliminate reux has relegated open surgery
to a niche procedure in locales with nances insucient
to provide less invasive options. However, there are situations in which the cost of care, patient preference, and/or
anatomic considerations reconrm the open operation as
a useful technique for the care of patients with saphenous
insuciency. Saphenous ablation—whatever form is taken
to accomplish it—does provide patient relief that is better
than compression alone and is proven to aid in the care
of patients with advanced disease, especially those with
venous ulceration. Knowledge of the anatomic variability of
the lower leg supercial venous system is required for optimal open surgical results. e results of open saphenous
surgery are quite comparable and, in some cases, superior
to less invasive procedures in terms of long-term benet, but
such surgery is less well tolerated by patients and has higher
morbidity in the short term. Current guidelines on surgical treatment of the incompetent varicose veins are listed
below. Further guidelines on saphenous ablation in patients
with venous ulcers are listed in Chapter 52.
438 Techniques and results of the modern surgical treatment of the incompetent saphenous vein
https://t.me/med1917
Guidelines 4.8.0 of the American Venous Forum on the surgical treatment of the incompetent saphenous vein
Grade of
recommendation
(1: strong;
No. Guideline
4.8.1 For treatment of the incompetent saphenous vein in
2:weak)
1 B
association with symptomatic varicose veins, we recommend
saphenous vein ablation over compression therapy for
appropriate candidates.
4.8.2 For treatment of the incompetent great saphenous vein in
2 B
association with symptomatic varicose veins, we suggest
high ligation and inversion stripping of the saphenous vein
to the level of the knee.
4.8.3 For the treatment of the incompetent small saphenous vein
2 B
associated with symptomatic various veins, we suggest high
ligation at the knee crease 3–5 cm distal to the
saphenopopliteal junction and selective stripping of the vein.
4.8.4 To decrease the risk of infection during open saphenous
1 B
surgery, we recommend prophylactic systemic antibiotics.
4.8.5 To reduce swelling, hematoma formation, and pain, we
1 B
recommend post-operative compression for a period of
1week.
Note: For guidelines on saphenous and perforator ablation in the setting of venous ulcers, see Chapter 52.
Grade of evidence
(A:high quality;
B:moderate quality;
C:low or very low quality)
REFERENCES
●
= Key primary paper
★
= Major review article
◆
= Formal publication of a management guideline
1. Kistner RL and Eklöf B. Classification and etiology of chronic venous disease. In: Gloviczki P, ed.
Handbook of Venous Disorders: Guidelines of the
American Venous Forum, 3rd Ed. London: Hodder
Arnold, 2009, 37–46.
2. Kaplan RM, Criqui MH, Denenberg JO, Bergan J,
Fronek A. Quality of life in patients with chronic
venous disease: San Diego population study. J Vasc
Surg 2003;37:1047–53.
★
3. Coleridge-Smith P, Labropoulos N, Partsch H etal.
Duplex ultrasound investigation of the veins in
chronic venous disease of the lower limbs: UIP consensus document: Part I. Basic principles. Eur J Vasc
Endovasc Surg 2006;31:83–92.
4. McLafferty RB, Passman MA, Caprini JA etal.
Increasing awareness about venous disease: The
American Venous Forum expands the national
venousscreening program. J Vasc Surg 2008;48:394–9.
5. Korn P, Patel ST, Heller JA etal. Why insurers should
reimburse for compression stockings in patients with
chronic venous stasis. J Vasc Surg 2002;35:950–7.
6. Smith JJ, Garratt AM, Guest M, Greenhalgh RM, and
Davies AH. Evaluating and improving health-related
quality of life in patients with varicose veins. J Vasc
Surg 1999;30:710–9.
●
7. Caggiati A, Bergan JJ, Gloviczki P etal.
Nomenclature of the veins of the lower limb:
Extensions, refinements, and clinical application.
JVasc Surg 2005;41:719 –24.
●
8. Daseler EH, Anson BJ, Reimann AF, and Beaton
AE.The saphenous venous tributaries and
relatedstructures in relation to the technique of
highligation: Based chiefly upon a study of 550
anatomical dissections. Surg Gynecol Obstet
1946;82:53 – 63.
●
9. Thompson H. The surgical anatomy of the superficial
and perforating veins of the lower limb. Ann R Coll
Surg Engl 1979;61(3):198–205.
10. Holme JB, Holme K, and Sorensen LS. The anatomic
relationship between the long saphenous vein and
the saphenous nerve. Relevance for radical varicose
vein surgery. Acta Chir Scand 1988;154(11–12):631–3.
11. Ramasastry SS, Dick GO, and Futrell JW. Anatomy of
the saphenous nerve: Relevance to saphenous vein
stripping. Am Surg 1987;53(5):274–7.
★
12. Cavezzi A, Labropoulos N, Partsch H etal. Duplex
ultrasound investigation of the veins in chronic
venous disease of the lower limbs: UIP consensus
document: Part II: Anatomy. Eur J Vasc Endovasc
Surg 2 0 06;31:288 –99.
13. Delis KT, Knaggs AL, and Khodabakhsh P. Prevalence,
anatomic patterns, valvular competence, and clinical significance of the Giacomini vein. J Vasc Surg
2004;40:1174–83.
14. Georgiev M, Myers KA, and Belcaro G. The thigh
extension of the lesser saphenous vein: From
References 439
https://t.me/med1917
Giacomini’s observation to ultrasound scan imaging.
J Vasc Surg 2003:37:558–63.
◆
15. Gloviczki P, Comerato AJ, Dalsing MC etal. The
care of patients with varicose veins and associated
chronic venous disease: Clinical practice guidelines
of the Society for Vascular Surgery and the American
Venous Forum. J Vasc Surg 2011;53:2S–438S.
16. Ricci S, Moro L, and Antonelli Incalzi R. Ultrasound
imaging of the sural nerve: Ultrasound anatomy and
rationale for investigation. Eur J Vasc Endovasc Surg
2010;39(5):636–41.
17. Schweighofer G, Muhlberger D, and Brenner
E. Back to the basics: The anatomy of the small
saphenous vein: Part 1: Fascial and neural relations,
saphenopopliteal junction and valves. J Vasc Surg
2010;51(4):982–9.
18. Tuveri B, Borsezio V, Argiolas R, Medas F, and Tuveri
A. Ultrasonographic venous anatomy at the popliteal
fossa in relation to tibial nerve course in normal and
varicose limbs. Chir Ital 200 9 ; 61:171–7.
★
19. Eklöf B, Rutherford RB, Bergan JJ etal. Revision
of the CEAP classification for chronic venous
disorders:Consensus statement. J Vasc Surg
2004;40:1248–52.
◆
20. Vasquez MA, Rabe E, McLafferty RB etal. Revision
ofthe venous clinical severity score: Venous
outcomes consensus statement: Special communicationof the American Venous Forum Ad
Hoc Outcomes Working Group. J Vasc Surg
2010;52:1387–96.
21. Baker DM, Turnbull NB, Pearson JC, and Makin GS.
How successful is varicose vein surgery? A patient
outcome study following varicose vein surgery using
the SF-36 Health Assessment Questionnaire. Eur J
Vasc Endovasc Surg 1995;9:299–304.
22. Garratt AM, Macdonald LM, Ruta DA etal. Towards
measurement of outcome for patients with varicose
veins. Qual Health Care 1993;2:5–10.
23. Smith JJ, Guest MG, Greenhalgh RM, and
DaviesAH. Measuring the quality of life in
patientswith venous ulcers. J Vasc Surg
2000;31:642–9.
◆
24. O’Donnell TF, Passman MA, Marston WA etal.
Clinical practice guidelines of the Society for
Vascular Surgery (SVS) and the American Venous
Forum (AVF): Management of venous leg ulcers.
JVasc Surg 2014;60(Suppl.):3S–59S.
●
25. Michaels JA, Campbell WB, Brazier JE etal.
Randomized clinical trial, observational study and
assessment of cost-effectiveness of the treatment
of varicose veins. (REACTIV Trial). Health Technol
Assess 20 06;10:1–196.
★
26. Carroll C, Hummel S, Leaviss J etal. Clinical effectiveness and cost-effectiveness of minimally invasive
techniques to manage varicose veins: A systematic
review and economic evaluation. Health Technol
Assess 2013;17(48)1–141.
27. Perkins JM. Standard varicose vein surgery.
Phlebology 2009;24(Suppl. 1):34–4.
28. Almeida JI and Boatright C. Candidacy for endogenous ablation. Endovascular Today, March 2012.
29. Proebstle TM, Gül D, Lehr HA, and Kargl A, and
Knop J. Infrequent early recanalization of greater
saphenous vein after endovenous laser treatment.
JVasc Surg 2003;38(3):511–6.
30. Eidson JL 3rd, Shepherd LG, and Bush RL.
Aneurysmal dilatation of the great saphenous vein
stump after endovenous laser ablation. Vasc Surg
2008;48(4):1037–9.
31. Rudarakanchana N, Berland TL, Chasin C, SadekM,
and Kabnick LS. Arteriovenous fistula after endovenous ablation for varicose veins. J Vasc Surg
2012;55(5):1492–4.
●
32. Raju S, Eastwood L, Fountain T etal. Saphenectomy
in the presence of chronic venous obstruction.
Surgery 1998;123 (6):6 37– 4 4.
33. Padberg FT, Pappas PJ, Araki CT, Back TL, and
Hobson RW 2nd. Hemodynamic and clinical
improvement after superficial vein ablation in primary combined venous insufficiency with ulceration.
J Vasc Surg 1996;24(5):711–8.
34. Georgopoulos S, Kouvelos GN, Koutsoumpelis A
etal. The effect of revascularization procedures on
healing of mixed arterial and venous leg ulcers. Int
Angiol 2013;32:368–74.
35. Critchley G, Handa A, Maw A, Harvey A,
Harvey MR, and Corbett CR. Complications
of varicose vein surgery. Ann R Coll Surg Engl
1997;79:105 –10.
36. Hayden A and Holdsworth J. Complications following re-exploration of the groin for recurrent varicose
veins. Ann R Coll Surg Engl 2001 Jul;83(4):272–3.
●
37. Zamboni P, Cisno C, Marchetti F etal. Minimally
invasive surgical management of primary venous
ulcers vs. compression treatment: A randomized clinical trial. Eur J Vasc Endovasc Surg
2003;25:313–8.
38. Criado E, Lujan S, Izquierdo L etal. Conservative
hemodynamic surgery for varicose veins. Semin Vasc
Surg 2002;15(1):27–33.
39. Mekako AI, Chetter IC, Coughlin PA, Hatfield J, and
McCollum PT. Randomized clinical trial of co-amoxiclav versus no antibiotic prophylaxis in varicose vein
surgery. Br J Surg 2010;97:29–36.
●
40. Rasmussen LH, Bjoern L, Lawaetz M etal.
Randomised clinical trial comparing endovenous
laser ablation with stripping of the great saphenous
vein: Clinical outcome and recurrence after 2 years.
Eur J Vasc Endovasc Surg 2010;39:630 –5.
●
41. Menyhei G, Gyevnar Z, Arato E, Kelemen O, and
Kollar L. Conventional stripping versus cryostripping:
A prospective randomised trial to compare improvement in quality of life and complications. Eur J Vasc
Endovasc Surg 2008;35:218–23.
Соседние файлы в папке Библиотека им академика М.И. Перельмана