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Treatment of Leg Veins
bectomy with 77% of these healing <2 weeks after the
procedure.
Several small comparisons of EVTA using RFA and
HL/S for the GSV have been performed. In the EVOLVes
(Endovenous Radiofrequency Obliteration (Closure)
Versus Ligation and Vein Stripping) sponsor supported
prospective randomized trial, postopertative pain was less
severe, absence from work and return to normal activities
was shorter and physical function was restored faster
after RFA at 4-month follow-up. At two-year follow-up,
recurrent varicose veins were found in 21% of the ligation
and stripping patients and 14% of the RFA patients, but
this difference did not reach significance due the small
treatment populations. However, at 2-years after treatment, the RFA patients had maintained better quality of
life scores when compared to the ligation and stripping
group.
Another small prospective randomized trial by Rautio
demonstrated less pain and more rapid recovery following
GSV RFA when compared with HL/S. Finally, clinical
outcome and patient satisfaction were also better in the
short term but by 6 months these differences were no
longer significant. The conclusion of these small randomized studies of surgery and RFA suggest equivalent
outcomes with shorter recovery periods for the EVTA
patients.
Several small comparison studies have evaluated the
outcomes of laser ablation and surgery. In the first to be
published, 20 patients with bilateral GSV reflux were
treated with conventional HL/S on one leg and HL and
laser in the other and then followed for 3 months. The
patients were not informed on which leg received either
therapy, the choice of which technique was used was
randomized and all patients were treated with either a
spinal or epidural anesthesia. No tumescent anesthetic
was utilized. Early pain was similar for both procedures
although bruising and swelling was worse with surgery. All
patients thought the aesthetic improvement was much
better in both limbs but 70% thought the laser limb benefited the most, 20% the surgical limb and 10% thought
they were equal. APG improvements were equivalent in
both groups.
A non-randomized consecutive treatment comparison
of conventional HL/S with general anesthesia and laser
ablation of the GSV using tumescent anesthesia has been
performed. The authors demonstrated that with the
SF-36 (36-Item Short Form Health survey) at 1 and 6
weeks, the laser treatment patients did not suffer the
decrease in quality of life seen in the surgical group at the
same time. By 12 weeks, both groups had similar improvements in quality of life and in an objective assessment of
the severity of their venous disease. The VCSS improvement was significant compared with the pre-treatment
assessment and similar for both groups of patients.
A randomized comparison of 118 limbs treated with
laser and microphlebectomy and 124 with conventional
HL/S and microphlebectomy compared the QOL of the
post procedure period of both procedures. The study
demonstrated significantly less postoperative morbidity
for the laser procedure using the CIVIQ instrument
(Chronic Venous Insufficiency Questionaire). In addition,
patient satisfaction, analgesia use and the duration of days
before return to work was significantly better for the laser
treated group.
A randomized trial of 68 limbs treated with HL/S and
62 with laser was performed with both groups only being
treated with tumescent anesthesia. The preliminary report
of this ongoing study evaluated the patients up to 6
months after their procedure using a variety of validated
instruments including a visual analogue scale of pain,
VCSS, AVVSS(Aberdeen Varicose Vein Severity Score)
and SF-36. Initial technical successes were equivalent. In
this trial the early bruising and pain favored laser but by
3 months both procedures demonstrated significant
improvements in all indices compared with pretreatment
baselines but no differences were seen between HL/S
and laser.
SUMMARY
In the decade since its introduction, EVTA has become
the primary approach to eliminating saphenous vein reflux,
essentially replacing HL/S for the GSV and HL for the
SSV. The procedure has been validated to result in reliable elimination of saphenous vein reflux . The procedure
is safe, well tolerated and durable. Two different technologies exist but both seem to be reasonably equivalent
in outcome, side effect and complication rates. Both
technologies can be performed in an office setting with
local anesthetic and are associated with a quicker recovery
than HL/S.
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CASE STUDIES
• Case 1
A B
Figure 9.7 A 53-year-old white male with symptomatic varicose veins and an incompetent GSV. (A) He underwent endovenous laser ablation
with ambulatory phlebectomy of surface varices, followed by one sclerotherapy session. (B) 6 months after treatment
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• Case 2
A B
Figure 9.8 A 34-year-old white female with very symptomatic varicose veins of the left leg. (A) An EVLT was done to treat an incompetent left
GSV. (B) The GSV was closed on ultrasound at follow-up 6 weeks later. The patient stated that her leg feels much better. The mild residual
varices were subsequently treated with sclerotherapy
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Treatment of Leg Veins
• Case 3
A B
Figure 9.9 A 38-year-old patient with right calf varicose veins
associated with throbbing, aching and leg heaviness despite
compression hose use. DUS demonstrated right SSV reflux filling the
branch varicosities. The patient had a SSV ELA and a
microphlebectomy. The images below were obtained before and one
month after the procedure
• Case 4
A
B
C
CASE 4: A patient with right thigh and calf varicose
veins associated with leg aching and throbbing is found to
have reflux in the GSV beginning at the saphenofemoral
junction and extending to point “A” (Fig. 9.1). The reflux
then spills into a varicose tributary in the thigh only to
return into the GSV at point “B”. The reflux then extends
to point “C” before filling calf varicose veins.
Q: What segment or segments of the GSV would be
required to eliminate the varicose veins and symptoms?
A: EVTA of the GSV in a patient as diagramed ideally
would include ablation of the segment from point “A” to
the SFJ as well as from point C to point “B” to maximize
the hemodynamic, symptomatic and cosmetic benefits
of the procedure as well as to minimize the risk of a
clinical recurrence. If the segment between “A” and “B”
can be traversed with a guidewire this segment can be
treated along with the other two segments with one
venous access and one thermal ablation device. However,
if the segment between “A” and “B” cannot be traversed,
venous accesses near point “C” and point “A” can allow
introduction of a thermal device via each of the two punctures into each segment for 2 segmental ablations.
Q: Is there a rationale to consider treatment of the varicose tributaries from point A to point B and those below
point C along with EVTA of the segment from point A to
Point C or will they return to normal following EVTA.
A: Following EVTA, the varicose tributaries which
result form the saphenous reflux are depressurized.
Figure 9.10 After EVTA of the GSV from the SFJ to point C, the
varicose veins taking origin at point A and draining into point B are at
risk for SVT
However, only the small minority will regress to the point
of being considered normal. The great majority will remain
stretched beyond their elastic limits and will continue to
be segmentally incompetent. They may regress cosmetically after EVTA but are likely to recur in the future.
Failure to eliminate this varicose bed results in persistence of abnormal hemodynamics with consequent persistent negative effects on symptoms, skin changes and
cosmesis. It has been our experience that these low pressure sumps will recruit other pathways of incompetence
and will re-pressurize at some point later leading to late
clinical recurrence of the severity of the original clinical
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state. For this reason elimination of the varicose bed of
veins is recommended following EVTA. This can be done
with microphlebectomy at the time of the EVTA or with
compression sclerotherapy later.
Q: EVTA is performed from point C to the SFJ without
any other adjunctive procedures. The patient returns 1
month after the procedure complaining of pain, tenderness
erythema and palpable lumps over the course of the varicose tributaries from point A to point B. What is the cause?
• Case 5
A: Superficial phlebitis is a complication seen in 5%
of patients after EVTA. It is most likely to occur in
larger diameter tributary varicose veins and in varicose
veins where the inflow and outflow segments to these
veins are ablated (so called “bucket handle veins”).
This complication can be avoided by using microphlebectomy at the same time as the EVTA on the bucket
handle veins and on tributary varies larger the 6-8 mm in
diameter.
@
Femoral V
A
B
Figure 9.11 (A) Axial image: Calipers measure the successfully ablated segment of the GSV approximately 10 cm below the SFJ. The patient
had a RFA procedure 5 years prior with recurrence of her varicose veins, visible in the near field of this image. (B) Axial image: Pulse wave
Doppler ultrasound demonstrating reflux in the proximal GSV with a diameter of 10 mm. This image was taken about 5 cm higher that the
image in about 5 cm below the SFJ. (C) Diagram showing this typical pattern of failure following EVTA with unsuccessful ablation of the vein
just after the deep vein junction but successful ablation lower down the leg. Image (A) is an axial ultrasound image at the level marked with “*”.
Image (B) is an axial ultrasound image at the level marked with the “@” in image (C)
C
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Treatment of Leg Veins
CASE 5: A 55 year-old obese male with CEAP 4b
superficial venous insufficiency, large calf varicose veins
and aching. He had an endovenous thermal ablation
(EVTA) of a 16 mm refluxing great saphenous vein and
microphlebectomy 10 months prior with improvement of
symptoms. An ultrasound at 4 weeks following EVTA
documented target vein occlusion. Recently the patient
began to complain of new calf pain and varicose veins.
Duplex ultrasound was performed which demonstrated a
successfully occluded lower thigh and upper calf GSV
with the exam demonstrating a cord in the expected
course of the GSV (Fig. 9.11A). However, beginning at the
SFJ in the upper thigh, a 12 mm diameter refluxing GSV
was identified filling the varicose veins (Fig. 9.11B).
Clinical failures have several possible causes. Inadequate treatment plans are the result of errors in clinical
evaluation or DUS evaluation. They may also be the result
of tactical errors in judgment with regard to deciding on
the need for treatment of segments. These would include
the decision not to treat varicose tributary beds after
EVTA or to avoid treating certain venous segments such
as the below knee GSV or a parallel incompetent anterior
acccessory great saphenous vein.
Progression of insufficency in other veins or in untreated
segments of the treated veins is the most important cause
of clinical failure following any venous treatment. This
progression can occur over a course of years, although
progression following treatment can be seen even in a
matter of months. Other common causes of recurrence
include perforating vein reflux and non-saphenous refluxing pathways.
Anatomical failure of venous thermal ablation is felt to
be a consequence of inadequate vein wall injury and was
the cause of clincial failure in Case 5. In many such situations, target vein occlusion is often seen on follow-up DUS
performed in the first weeks following treatment. However,
since inadequately treated veins are simply thrombosed,
recanalization often occurs underscoring the need to document successful ablation at 9–12 months following treatment. Successfully treated veins will remain occluded and
their diameter will shrink with time, such that by 12
months the veins will either become very small echogenic
cords or become non-visible, as demonstrated in the DUS
image showing the appearance in the lower thigh.
Failure usually involves a several centimeter portion of
vein nearest to the deep junction, whether that is the SFJ
or SPJ (Fig. 9.11C). The most accepted explanation is
inadequate delivery of thermal energy to the vein wall.
For endovenous laser ablation (ELA) of the GSV, Timperman has demonstrated a higher rate of occlusion if
greater than 70–80 J/cm are delivered to the treated vein.
As mentioned in the text of this chapter, others have suggested using higher energy in areas where the vein diameter is larger and less where it is smaller. In our practice
we use more energy proximally and less as we progress
down the leg recognizing that the proximal vein is the
toughest part to close and needs more energy. We usually
use about 140 J/cm at 810 nm for the first 10 cm of the
GSV decreasing to 100 J/cm lower in the thigh and upper
SSV and about 70 J/cm in the calf and lower SSV.
With ELA and CF, emptying the vein lumen of blood
and approximating the vein wall to the thermal device
likely enhances the efficiency of energy transfer to the
vein wall. This is thought to be an important technical goal
when performing thermal ablation. Ultrasound guided
perivenous infiltration of copious volumes of tumescent
anesthetic and the use of Trendelberg position can help
to accomplish this. The proximal vein segment nearest the
junction, especially with the GSV, is the most difficult
portion of the vein to close with thermal ablation. This
may be because it is both larger and less likely to develop
spasm. The use of 4°C anesthetic solution anecdotally may
enhance the likelihood of spasm.
Another feature shown to relate to outcome following
thermal ablation is body mass index (BMI). Timperman
and Merchant showed that failure was more likely in
patients with higher BMI. This is a useful consideration
when discussing outcomes with patients. In contrast, no
correlation between thermal ablation outcome and saphenous vein diameter has been demonstrated in the literature to date. However, making every effort to collapse the
vein lumen should be stressed to maximize success.
DUS is important to identify the mechanism of recurrent symptoms or varicose veins. DUS can distinguish a
treatment failure from other causes of new veins which
include new reflux in another saphenous vein, new or
untreated reflux in a different segment of the treated vein
as well as other non-saphenous sources.
As mentioned the treatment failures are usually segmental but can involve the entire treated vein segment.
Treatment failures can be retreated with EVTA with successful ablation at the same rate as with untreated veins.
However, practically some of the veins may be difficult
to traverse with a guidewire because of webs and intraluminal thrombus. For this reason, more than one venous
access may be required to treat a previously vein segment.
Waiting a few months for the vein to re-canalize more may
be helpful in some cases. Also, optimizing the technique
on the re-treatment to maximize success includes utilizing
Trendelenberg positioning, copious amounts of cold saline,
external vein compression and aspiration on the sheath
during thermal delivery all to maximize heat transfer to
the vein wall.
FURTHER READING
Almeida JI, Raines JK 2006 Radiofrequency ablation and laser
ablation in the treatment of varicose veins. Annals of Vascular
Surgery 20:547–552
Desmyttere J, Grard C, Wassmer B, Mordon S 2007
Endovenous 980-nm laser treatment of saphenous veins in a
series of 500 patients. Journal of Vascular Surgery 46:1242–
1247
Gibson KD, Ferris BL, Polissar N et al 2007 Endovenous laser
treatment of the short saphenous vein: efficacy and
complications. Journal of Vascular Surgery 45:795–801;
discussion 801–803
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Hingorani AP, Ascher E, Marks N et al 2009 Predictive factors
following radio-frequency stylet ablation of incompetent
perforating veins. Journal of Vascular Surgery 50:844–848
Lurie F, Creton D, Eklof B et al 2003 Prospective randomized
study of enodvenous radiofrequency obliteration (closure
procedure) versus ligation and stripping in a selected patient
population (EVOLVeS Study). Journal of Vascular Surgery
38:207–214
Lurie F, Creton D, Eklof B et al 2005 Prospective randomized
study of enodvenous radiofrequency obliteration (closure) versus
ligation and stripping (EVOLVeS): two-year follow-up.
European Journal of Vascular and Endovascular Surgery
29:67–73
Marston WA, Owens LV, Davies S et al 2006 Endovenous
saphenous ablation corrects the hemodynamic abnormality in
patients with CEAP clinical class 3–6 CVI due to superficial
reflux. Vascular and Endovascular Surgery 40:125–130
Min RJ, Khilnani NM, Zimmett SE 2003 Endovenous laser
treatment of saphenous vein reflux: long-term results. Journal of
Vascular and Interventional Radiology 14:991–996
Myers K, Fris R, Jolley D 2006 Treatment of varicose veins by
endovenous laser therapy: assessment of results by ultrasound
surveillance. Medical Journal of Australia 185:199–202
Perala J, Ratio T, Biancari F et al 2005 Radiofrequency endovenous
obliteration versus stripping of the long saphenous vein in the
management of primary varicose veins: 3-year outcome of a
randomized study. Annals of Vascular Surgery 19:669–672
Proebstle TM, Vago B, Alm J et al 2008 Treatment of the
incompetent great saphenous vein by endovenous
radiofrequency powered segmental thermal ablation: first clinical
experience. Journal of Vascular Surgery 47:151–156
Rasmussen LH, Bjoern L, Lawaetz M et al 2007 Randomized trial
comparing endovenous laser ablation of the great saphenous vein
with high ligation and stripping in patients with varicose veins:
short term results. Journal of Vascular Surgery 46:308–315
Rautio T, Ohinmaa A, Perala J et al 2002 Endovenous obliteration
versus conventional stripping operation in the treatment of
primary varicose veins: a randomized controlled trial with
comparison of the costs. Journal of Vascular Surgery 35:958–
965.
Theivacumar NS, Beale RJ, Mavor AI, Gough MJ 2007 Initial
experience in endovenous laser ablation (EVLA) of varicose
veins due to small saphenous vein reflux. European Journal of
Vascular and Endovascular Surgery 33:614–618
Timperman PE, Sichlau M, Ryu RK 2004 Greater energy delivery
improves treatment success of endovenous laser treatment of
incompetent saphenous veins. Journal of Vascular and
Interventional Radiology 10:1061–1063
Timperman PE 2005 Prospective evaluation of higher energy great
saphenous vein endovenous laser treatment. Journal of Vascular
and Interventional Radiology 16:791–794
Timperman PE 2007 Endovenous laser treaetment of incompetent
below-knee great saphenous vein. Journal of Vascular and
Interventional Radiology 18:1495–1499
Vuylsteke M, van den Bussche D, Audenaert EA, Lissens P 2006
Endovenous obliteration for the treatment of primary varicose
veins. Phlebology 21:80–87
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Venous Stripping and
Subfacial Endoscopic
Perforator Surgery (SEPS)
Joseph R. Schneider, Joseph A. Caprini
INTRODUCTION
Surgery remains a mainstay of treatment for lower extremity varicosities. Surgery may be as minimal as a local
phlebectomy, as discussed in Chapter 8, or as invasive as
subfascial endoscopic perforator surgery or stripping of
great and small saphenous veins combined with phlebectomy. Surgery must be tailored to the patient’s problem.
The role of noninvasive testing prior to embarking on
surgical correction cannot be overemphasized. This
chapter will provide a brief explanation of the major ablative surgical options that may be appropriate in the treatment of patients with lower extremity venous disease.
STRIPPING OF GREAT AND SMALL
SAPHENOUS VEINS
• Basic concepts, indications and
patient selection
Most symptoms in chronic venous disease are due to
reflux. For the vast majority of patients treated by experienced clinicians, duplex scanning has replaced all other
forms of venous testing, including qualitative assessment
of reflux. Patients are tested in the standing position on
the upper step of a two-step platform by asking them to
stand normally but relaxed and with most of their weight
on the leg opposite the leg being interrogated.
The great saphenous vein (GSV) is imaged with the
patient facing the technologist and the study leg slightly
forward and externally rotated. The vein is examined for
dilation, compressibility, and echogenicity in the transverse orientation. The longitudinal view is also assessed,
and thickness of the vein wall, valvular changes or any
echogenicity are documented (Figs 10.1–10.5). The operator tests for reflux in the axial vein and perforating veins
using color flow, and also uses the pulsed Doppler with
the probe in longitudinal orientation to test for reflux in
the saphenofemoral junction, the common femoral vein
above and below the saphenofemoral junction, and the
proximal GSV. The Valsalva maneuver is appropriate for
provoking reflux in the groin, but may not provoke reflux
inferior to the groin if there is a competent valve in the
groin area. Therefore, compression of the leg above and
below the segment being interrogated is used to detect
evidence of reflux in the target segment. For example,
saphenofemoral and proximal great saphenous reflux may
be masked during the Valsalva maneuver by the presence
of a competent valve in the proximal common femoral
vein. The author tests for this by squeezing the upper
thigh between two hands (lateral and medial) while interrogating the proximal GSV with pulsed Doppler and
looking for ‘to and fro’ flow. The Valsalva maneuver may
also fail to demonstrate reflux in the more inferior segment
of the GSV and the practitioner must depend on proximal
and distal compression maneuvers to elicit reflux when it
is significantly inferior to the saphenofemoral junction.
The small saphenous vein (SSV) is examined for dilation and reflux with the patient standing and facing away
from the technologist and the popliteal vein is imaged
from this approach as well. Examination of the SSV is
started at the ankle posterior to the lateral malleolus. The
course of the vein is traced proximally where it very
quickly drifts to the midline of the calf and can clearly be
identified within its superficial fascial compartment.
Branches and connections are usually seen in the mid-calf
and the operator eventually traces these branches but not
until the entire course of the SSV is studied.
The examination is done in the transverse view until
the whole course of the vein is mapped. Often the vein
will extend proximally past the popliteal fossa and sometimes eventually connects to the GSV in the upper medial
thigh or groin as the so-called vein of Giacomini. The SSV
is also interrogated in the longitudinal view near the popliteal fossa to document the saphenopopliteal junction.
This is a critical step since the SSV may empty into a
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Figure 10.1 Linear array duplex probe in longitudinal orientation
about to be applied to upper anteromedial left thigh/groin to
interrogate the underlying femoral vein and saphenofemoral junction
with color flow and pulsed Doppler
Figure 10.2 Duplex scan image and Doppler spectrum from
interrogation of the saphenofemoral junction with pulsed Doppler
using the probe position as in Figure 10.1. The patient’s head
(superior) is left and foot (inferior) is to the right on the image in the
upper portion of the frame. The lower portion of the frame is the
Doppler blood flow signal over time coursing from left to right. Flow
demonstrated above the 0 line on the spectrum represents reflux
during the Valsalva maneuver. In this case, there is gross reflux with
‘aliasing’ of the Doppler spectrum beginning with Valsalva at the first
large time tick mark in the lower left part of the figure and lasting
longer than 2 seconds
gastrocnemius branch, which then enters the popliteal
fossa. If this is not well understood and observed by
the surgeon, important errors can occur and precipitate
damage and/or thrombosis of the deep venous system
at the time of ablative treatments. The small diameter
of the SSV may make it difficult to interrogate with
pulsed Doppler or color flow in longitudinal orientation
and occasionally this must be performed in transverse
orientation.
Careful documentation is required of reflux, valve
anatomy and any vessel defects in the common femoral
Figure 10.3 Transverse image of the GSV in the mid-medial thigh.
The vein is the relatively echolucent (dark) oval in the upper center
portion of the frame. The vein is patent and dilated (17.5 mm)
Figure 10.4 Linear array duplex probe in longitudinal orientation
applied to the left popliteal region (posterior) to interrogate the
underlying popliteal vein and saphenopopliteal junction with color flow
and pulsed Doppler
and popliteal veins, with the operator specifically looking
for evidence of previously unsuspected deep venous
abnormalities, which if present dictate a conventional
supine duplex scan of the entire deep venous system.
Evidence of significant chronic abnormalities in the
deep vein system would not necessarily preclude any
planned ablation of the superficial veins but further
consideration and discussion with the patient may be
necessary.
Figure 10.5 Duplex scan image and Doppler spectrum from
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interrogation of the popliteal vein just superior to the saphenopopliteal
junction with pulsed Doppler using the probe position as in Figure
10.4. The patient’s head (superior) is left and foot (inferior) is to the
right. In this case, there is prograde flow with compression of the calf
(Doppler detected flow below the 0 line and ‘aliasing’ above the 0 line
just after the first large time tick mark in the lower left portion of the
frame) and no reflux is demonstrated (no sustained significant flow
above the 0 line) with release of calf compression
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Venous Stripping and Subfacial Endoscopic Perforator Surgery (SEPS)
Common femoral vein
Saphenofemoral junction
Posteromedial vein
Anterolateral vein
Great saphenous vein
Correction of superficial venous insufficiency in the
presence of deep venous insufficiency may improve the
patient’s clinical degree of disability but does not obviate
the necessity of wearing appropriate heavy compression
stockings. This must be carefully explained to the patient
since many patients assume that surgery will render the
wearing of these hose unnecessary. Stockings are the best
treatment and prophylaxis for deep venous insufficiency,
and long-term compliance is the key to success, especially
postoperatively.
Being physically present to conduct the exam with the
technologist is important to the surgeon’s understanding
of the patient’s pathophysiology and to the eventual
success of any contemplated operation. Readers interested
in a more detailed description of diagnostic standards may
wish to consult Mattos and Sumner or Nicolaides.
• Stripping procedures
The first description of ‘stripping’ of the GSV is generally
credited to Babcock. This operation is most commonly
considered for patients with primary varicose veins,
usually clusters of varicose branches of the GSV adjacent
to (and probably communicating with) the various named
perforating veins connecting the deep and superficial veins
of the medial leg. The strategy of this approach is to ablate
the major axial conduit through which venous hypertension is transmitted from the level of the right atrium to
the superficial veins of the leg in patients with venous
valvular incompetence. Furthermore, ablation of the axial
vein theoretically leads to thrombotic occlusion of any
perforating veins that communicate directly with the
GSV. However, the effectiveness of stripping for perfora-
Boyd’s perforator
Posterior Arch vein
Cockett’s perforators
Figure 10.6 The important perforating veins below the knee
communicate with the posterior arch vein (Leonardo), not the axial
GSV
tor ablation is less certain, especially below the knee,
where the major axially directed vein that connects
with the Cockett perforating veins is the posterior arch
(Leonardo) vein, which is not ablated by a conventional
stripping operation (Fig. 10.6).
Some surgeons use thresholds of ≥
6 mm in diameter
with reflux of at least 0.5 seconds in duration when considering ablation or removal of the axial GSV. However,
the ideal patient for classic stripping of the GSV will have:
(1) a dilated GSV (≥
8 mm in diameter adjacent to the
saphenofemoral junction) with saphenofemoral or proximal great saphenous reflux lasting at least 1.5 seconds;
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(2) clusters of varicose branches in the calf and/or thigh;
(3) absence of significant perforating vein reflux; and (4)
no evidence of significant changes of deep vein thrombosis
(DVT). Removal may still be indicated in certain patients
with distal communicating branches off a normal-caliber
GSV with reflux, or with dilatation of the GSV without
observable reflux. In practice, most patients with symptomatic varicose veins disease have areas of the GSV much
larger than 8 mm in diameter and reflux lasting much
longer than 1.5 seconds. The location of the lowest connecting perforator, which is often in the distal thigh or very
proximal calf, is marked during the duplex examination
since removal of the vein below this level is unnecessary
and increases the chance of saphenous nerve injury (Fig.
10.7). In practice, it is rarely necessary to remove the GSV
below the upper calf as is discussed in more detail below.
Small saphenous vein (SSV) stripping is performed less
often and when it is performed, it may be limited to a
Figure 10.7 The saphenous nerve is adjacent to the GSV and at
most risk of injury from the upper calf to the ankle
segment and not the entire SSV. The superior termination
of the SSV is variable (Fig. 10.8) and must be clearly
delineated at the time of any diagnostic imaging study to
provide sufficient information on which therapeutic decisions may be based. It may be useful to re-image the
patient just before surgery and to mark the location of the
SSV and its termination at and above the knee to allow
accurate placement of incisions. This may even be performed in the operating room with the patient prone on
the operating table. SSV segments at least 4 mm in diameter with demonstrable reflux can be considered for stripping. It is rarely necessary to remove the distal third of
this vein, and normally the vein can be removed to the
proximal or mid-calf just below the last major communicating varicosity identified during the duplex examination.
• Technique
Subarachnoid block (spinal) or general anesthesia is used
when classic stripping operations are performed. In the
majority of patients, the GSV may be removed using two
small incisions. One incision in the groin crease just medial
to the femoral pulse usually allows easy exposure of the
proximal GSV and saphenofemoral junction (Fig. 10.9).
The incision should be large enough to provide adequate
exposure to allow a complete and safe procedure, particularly in obese patients, but is usually 3 cm or less in length.
The incision should not be made inferior to the groin crease
since an inappropriately inferior incision would make
control of branches other than the GSV more difficult.
It is appropriate to obtain control of the GSV near the
saphenofemoral junction, but to not ligate the vein at this
point for reasons that will become apparent later. First,
the operator may attempt to identify all other branches,
most often including the anterolateral saphenous, external
pudendal, superficial epigastric, and circumflex iliac
branches (Fig. 10.10). Each of these latter branches is then
divided and attempts made to ligate each of their primary
branches as well to reduce the risk of persistent or recurrent communication between the deep and superficial
venous systems in the groin. The posteromedial aspect of
the common femoral vein is inspected, with frequent
attendant identification and ligation of a small (2–4 mm)
branch in this area that might contribute to recurrences.
At the completion of this portion of the operation, the
axial GSV is the only remaining unligated branch at the
saphenofemoral junction.
The authors have noted that it was necessary to remove
only part of the GSV in a majority of more than 1500
patients. In many such cases, the vein may be removed
from upper calf to groin using a second incision placed
medially just inferior to the knee instead of at the medial
malleolus. Use of the retrograde pin stripping technique
as described by Oesch (see Chapter 11) may allow even
more limited surgical trauma to the patient, but still allow
adequate removal of abnormal axial GSV (Fig. 10.11). The
key is appropriate preoperative documentation by duplex
scan of the venous anatomy. In many patients, dilatation,
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