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Treatment of Leg Veins

more than that before the effects of inaccurate vein treatment will surface. What we can say with certitude is that the appearance of these new techniques induced a sharp decline in stripping operations.

The co-existence of strongly divergent theories and treatments will certainly go on for some time until a clear verdict becomes possible. The scientiﬁc eagerness to follow patients for ten years or more is small when only minor complications are at stake; results may be tampered by health systems favouring or penalizing certain methods and by generous industrial sponsoring. Speaking as a surgeon and a sclerotherapist I cannot fully support the idea of abandoning deﬁnitely the ﬂush ligation of the junction; I have seen too many recurrent varicose veins originating from untreated side-branches exposed to the pressure of an equally untreated incompetent junction. Most actual ultrasonographic devices used in phlebology do not permit a detailled and precise examination of the highly variable reﬂux patterns of the junction; the pertinence of these variants and their long-term effects still remain unclear. New technologies developed to investigate cerebral and cardiac circulation will probably by and by trickle down to phlebology and help to close this gap.

PROS AND CONS OF SURGERY

It is true that the principles of ‘classic’ vein surgery go back to the beginning of the 20 stantial reﬁnements of the last years should not be ignored. Unfortunately non-surgical methods are often compared with the side-effects, complications and long-term results of out-dated operation techniques. On the other hand this unequalled amount of data makes surgery the benchmark for any other method. We have surveys extending for more than thirty years after vein operations. What will be the results of the new techniques after three decades?

Surgical precision cannot be matched by thermal or chemical actions, where incomplete or excessive effects (as propagation of thrombosis into the deep vein system) have to be excluded by routine ultrasound checks. Injection therapy and heat ablation are typically employed in an outpatient setting, whereas larger surgical treatments require the infrastructure of a hospital and therefore tend to be more time consuming and less cost-efﬁcient. However this difference may dwindle when taking in account that one operation can treat both legs, that there is no need for postoperative ultrasound exams and that retreatment for failure or recurrence is uncommon.

Century, yet the sub-

INDICATIONS FOR SURGERY TODAY

• Phlebectomy

The increasing use of laser and radiofrequency to abolish the reﬂux in the saphenous vein suggests that the days of venous surgery are deﬁnitely over. However, few are the cases where the complete treatment consists in the exclu-

sion of the saphenous vein, since this step by itself has only little impact on the varicose side-branches. The logical therapy in a leg already anesthetized is phlebectomy of the remaining varicose veins. In contrast to sclerotherapy no additional session to treatments or controls are necessary, the vein being physically and deﬁnitely removed.

There always will be a place for phlebectomy, be it together with any kind of saphenous treatment, or be it a simple ‘ambulatory phlebectomy’ of isolated varicose veins. Phlebectomy is facilitated when combined with pin stripping. The extraction of the saphenous vein at the distal point of incompetence will also pull out the initial segments of the varicose veins, which permits an easy and complete resection of the entire reﬂux pathway.

• Extended varices

Extended bilateral varicose veins can be approached by any available method, as long as the patient consents in a stepwise procedure requiring several sessions. Tumescent anesthesia, a mandatory requirement for endovenous heat obliterations to reduce the risk of skin burns, is limited in its application. Most heat treatments are applied just on one saphenous system at a time to avoid large volumes of anesthetizing solution reaching critical levels. On the other hand a one-step treatment of patients suffering from extended varices is possible by surgery under regional or general anesthesia; in fact most of these patients visit by themselves a surgeon and not a dermatologist. The recovery is not much changed if one or both legs are operated on. In a 2009 survey (Oesch, in press) on 70 patients, a postoperative loss of work of 8.6 days after bilateral surgery was found and of 7.3 days when one leg was treated.

• Saphenous insufﬁciency below the knee

Due to the vicinity between the saphenous stems and parallel running nerves any treatment of saphenous veins in the lower leg has a higher risk of nervous complications. The more common injuries of the saphenous nerve due to GSV treatments are rather well tolerated, much in contrast to injuries of the sural nerve following therapeutic procedures on the SSV. The latter tend to be painful for a long time and they may occasionally even end in a lawsuit. The critical area for injuries to the sural nerve is the lower part of the calf. Fortunately, often just the upper half of the SSV is incompetent and interventions on the distal part can be avoided.

Selective abolishment of this short upper segment by pin stripping is safe and easy. The SPJ is ligated, a pinstripper is introduced and the incompetent segment is selectively removed in a quick and safe way. The procedure is almost painless, lesions of the sural nerve occur in well below 1%. A simple local anesthesia is sufﬁcient for stripping and phlebectomy; it is possible to operate both legs in one session.

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• Short proximal reﬂux

In this situation, only a short part of the saphenous vein needs to be inactivated, e.g. from groin to mid-thigh (about 20% of GSV incompetence) or from the poplitea to midcalf (about 40% of SSV incompetence). Pin stripping with retrograde insertion of a stripper at the junction permits to spare the intact distal segments. Open preparation of the distal point of incompetence is avoided when using the pin stripping method; which in voluminous thighs is a great beneﬁt for the patient as well for the surgeon.

• Complex anatomical patterns

Many varices of the thigh are perfused both by the anterolateral vein and the GSV itself; to obtain durable longterm results the two reﬂux systems should be eliminated. These veins are separated by just a small amount of tissue which would be damaged by aggressive therapies, stripping by invagination is well tolerated. The open resection of the junction often shows an aneurysmatic thin-walled dilatation of the anterolateral tributary and permits the retrograde pin stripping of both veins. This ‘doublestripping’ also reveals the various distal varicose connections between the two reﬂux systems.

Ultrasound investigations have shown a formerly unknown variety of complex pathophysiological patterns. The reﬂux is often not conﬁned to the intrafascial GSV; it may switch into large epifascial tributaries and even return distally into the stem. Obliteration of complex reﬂux pathways without touching the intact segments by endovenous procedures or sclerotherapy is difﬁcult or simply impossible. With the pin-stripper the reﬂux pathway can be eliminated selectively from proximal to distal by re-introducing the probe at the points where the ﬂow is deviated.

• Special localizations

Perforators in critical areas such as the knee joint cannot be treated safely by thermal procedures. Ultrasoundguided sclerotherapy is often followed by long-lasting clots. Surgery in local anesthesia is well tolerated and usually performed in one session; neurological or other complications are scarce.

Varicose veins originating from the deep-lying and relatively thin Giacomini vein are a therapeutic challenge. Open surgery through a small transverse popliteal incision allows the clear identiﬁcation of the SSV and the Giacomini vein and an exact closure and resection of the involved vessels. The Giacomini vein is the removed by pin stripping from the popliteal junction to the GSV. Care has to be taken to avoid the introduction of the probe into the deep venous system.

• Limited ﬁnancial resources

Endovenous laser and radiofrequency treatment are hightech procedures. Generators as well as the single-use probes are expensive; an accurate Duplex ultrasound

equipment is the prerequisite for any endovenous treatment including foam sclerotherapy. Scarce ﬁnancial resources limit the wide application of these techniques. Vein surgery can be realized at any place with a few inexpensive and reusable instruments.

CONCLUSION

Surgery still has its place in the treatment of venous disease. The propagators of new technologies often overemphasize the negative aspects of stripping by overseeing recent advances in surgery, as selective stripping, invagination stripping and hook phlebectomy. This approach has low rates of thrombosis, few sensory losses and an uncomplicated recovery with a good cosmetic result. It compares very favorably with any of the other therapies, especially in patients with severe venous problems. Postoperative pain is not a real issue: in my experience three in four patients do not need any painkillers after the ﬁrst postoperative day.

Nevertheless, GSV stripping has two disadvantages: unpleasant bruising of the thigh and varicose recurrence in the groin. Bruising can be reduced by immediate local compression of torn tributaries and by rinsing the stripping tunnel or inﬁltrating the tissues with epinephrine solutions. Inguinal recurrence has been drastically reduced in my patients by an inverting vascular suture of the femoral stump and with the closure of the fascia cribrosa.

Most complications of radiofrequency and laser ablation were minor problems, such as skin burns, sensory loss and indurations, but there still are alarming reports on DVT involving the femoral vein. Increasing experience seems to reduce the overall complication rate to the level of surgery. However a minimal risk of proximal DVT is apparently inherent to thermal occlusions, whereas this complication is extremely uncommon after vein surgery. Precise placement of the probe below the junction and a correct temperature adjustment is probably the clue to reduce DVT without compromising good long-term results. Sound practical knowledge of ultrasound techniques is mandatory.

The epidemiology of vein diseases has changed within the last decades. More patients present with mild forms of varices, probably due to increased awareness and to enhanced diagnostic possibilities. The label of ‘saphenous incompetence’ is distributed on a much larger scale than in the pre-Duplex times, when smaller reﬂuxes remained unrecognized. Consequently less invasive therapeutic concepts for the simpler forms of varicose veins have been developed. It is not yet clear if these are equally suited for more complex situations and if all of them will stand the test of time.

CASE STUDIES

• Case study 1

A 61-year-old patient who has had varicose veins since the age of 30. He had disturbing itching for 2 years. There

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Treatment of Leg Veins

A B C

Figure 11.1 (A-D) Before operation’ (E-G) 9 weeks post-operation

F GE

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was an insufﬁciency of both GSV with large dilatation of

18 mm in the right groin. CEAP classiﬁcation: C3s Ep

9 × As Pr. Comorbidities: Oral anticoagulation for recurrent atrial ﬁbrillation, BMI 32.3 kg/m2. Extensive surgery is feasible in the presence of comorbidities. The patient was operated on: Right leg : ﬂush ligation, resection of aneurysmatic dilatation and pin stripping to the knee, phle-

• Case study 2

A 70-year-old patient had ambulatory phlebectomy of the vein performed under local anesthesia. Previous history: large and very superﬁcial varicose vein within the right GSV had been stripped 5 years previously (at age 65

bectomy. Left leg: ﬂush ligation, pin stripping of the anterlo-lateral branch to mid-thigh and short resection of the main stem, phlebectomy. Spinal anesthesia, temporary stop of anticoagulation and bridging with LMWH. Discharge after 24 hrs. No pain medication required after discharge. Normal recovery. (A–C) Before operation. (D–H) 9 weeks post-operation.

years), without inguinal recurrence. Repair of the anterior cruciate ligament had been carried out 10 years previously (at age 60 years). Hip prosthesis 4 years previously (at age

66). No pain medication required. No additional sclerotherapy required.

A B

Figure 11.2 (A) Before operation; (B) 3 weeks post operation

• Case study 3

A 60-year-old patient had stripping of both SSVs and of the right GSV under spinal anesthesia. Previous history: GSV stripping of left leg 19 years previously (at age 41 years). There were new bilateral symptomatic varicose veins after 10 years (at age 51 years). No recurrence of

operated left GSV, insufﬁciency of both SSVs with dilatation of 6 mm and of the right GSV with a thin-walled dilatation below the junction of 10 mm. (A–C) Before operation; (D–F) 1 day post-operation. Efﬁcient compression avoids bruising. Paracetamol tablets were taken for two days.

Index

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Ablation

chemical 45, 46f endovenous 63 radiofrequency 62, 62f

thermal see Thermal ablation ACE® wraps 165 Alexandrite laser, long-pulsed 55–56, 56t, 97t, 101t–103t,

107f Alignment sign 38–39, 44–47 Allergic reactions

compression dressings 82–83

sclerosants 77f Ambulatory phlebectomy see Phlebectomy American College of Phlebology 33 American College of Radiology 33 American College of Surgeons 33 American Registry of Diagnostic Medical Sonographers

33 Anatomy 1–3 Anesthesia, tumescent

phlebectomy 116–117, 117b, 117f

thermal ablation 127, 127f, 132 Angiogenesis 85 Angle sign 39f Apoptosis 85 Arteriovenous ﬁstula 135 Asclera 78t Atherosclerotic plaque 36f

Bejar’s plexus 5–6 Blisters, post-laser therapy 106f Boyd’s perforators 2t, 17–18, 19f Bucket handle veins 139

Cabrera, Juan 57–58 Calf

compartments 12f

quadrants 17b Cardiovascular Credentialing International 33 Charting 30

classiﬁcation and quantiﬁcation 30

preliminary assessment 30 Chemical ablation 45, 46f Chemical sclerosants 81–82

glycerin 53t, 81–82

see also Sclerosants Chromated glycerin 81–82 CircAid® 167–168

Circumﬂex veins

anterior 5t

posterior 5t ClosureFast® 128–130 Coban™ 2 Layer Compression System 165 Cockett’s perforators 2t, 4t, 16f, 17 Codman stripper wire 147–149, 148f–150f Collagen 7–8 Color ﬂow 32, 32f Compression 49, 82–83, 163–170, 164f

active and passive 49, 50f

allergic reactions to 82–83

indications 50b

patient selection 164–165

physiology and anatomy 163–164, 164f

types of 165–167

vascular compromise 82 Compression bandages 49–51

application of 51f

indications 164t–165t

manufacturers 50t

types of 165t

long-stretch 49–50 multilayer 50–51 short-stretch 49

Compression stockings 51–52, 83, 165–167

advantages/disadvantages 168

application aids 167, 167f, 169

classes of 51t, 166t

contraindications 167–168, 167b, 168f

costs of 168

ﬂat weave 166

instructions for patients 169–170

manufacturers 50t

post-sclerotherapy 167

prescription of 166–167, 166f

removal devices 170f

troubleshooting 169 Comprilan® 165 Corona phlebectasia 19–20, 20f Costs

of compression garments 168

of surgery 159

Deep vein thrombosis 24, 36f, 125

post-thermal ablation 134 Deep venous system 35–38 Deoxyhemoglobin, absorption spectrum 100f

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Index

Detergents 66–68, 76–80

in vitro studies 80, 81f polidocanol see Polidocanol sotradecol sulfate 77

see also Sclerosants Diagnosis, ultrasound 33–44 Diode lasers 56, 101t Dodd’s perforators 2t, 12–13

incompetence 113f Doppler, Johann Christian 28 Doppler ultrasound 31–32

auscultation 25, 27

examination 28, 29f Doppler-guided sclerotherapy 59–60, 60f

indications 60, 60t Duplex ultrasound 11–12, 24, 31–34, 125

diagnostic 34, 144f

foam sclerotherapy 99–100

Echo-guided phlebectomy 122–123 Elastin 7–8 Endovenous thermal ablation see Thermal ablation Equipment

examination 24–25

laser therapy 101–103, 101t–103t

phlebectomy 114–116, 115f–116f

thermal ablation 126–127, 126b

ultrasound 31–33 Examination platform 25, 40f Examination table 25

Farrow Wrap™ 167–168, 168f Fascial gaps 86 Federative International Committee for Anatomical

Nomenclature (FICAT) 1

Femoral arteries

common 35f

superﬁcial 37f Femoral veins 2t

common 2t, 35f, 37f–38f

duplicated 37f Foam sclerotherapy 45, 57–59, 58f, 66–68

advantages of 58

disadvantages of 66–67

duplex imaging 99–100

experience with 100 Foot, dorsal venous arch 5t

Gastrocnemius veins 2t Giacomini’s vein see Intersaphenous vein Glycerin 53t, 81–82

chromated 81–82 Great saphenous vein 1–2, 2t, 3f, 5t, 11, 38–39, 62f

anatomy 129f

anterior accessory 5t

infragenicular 148f

major branches 13f

posterior accessory 5t

reﬂux 15f, 18f, 20f

stripping 148f, 151–152

telangiectasias 26f terminal valve reﬂux 41f valvular leaﬂets 40f varicose 14f see also Saphenous veins; Small saphenous vein

Hemoglobin, absorption spectrum 100f Hemosiderotic hyperpigmentation 83

clinical subtypes 83 Hierarchy of drainage 34 Historical aspects 157–162 History, clinical 23

general 23

symptoms 24, 24b

vascular disease 23–24 Homans, John 6 Hunterian perforators 2t, 12–13 Hyperpigmentation 84

evacuation of thrombi 85f

hemosiderotic 83

post-laser therapy 106f Hypopigmentation, post-laser therapy 106f

Inspection 26 Intense pulsed light 56, 101t–103t

patient selection 56

see also Laser therapy International Federation of Anatomical Associations

(IFAA) 1 International Union of Phlebology (IUP) 1 Intersaphenous veins 2t, 3, 4t–5t, 11, 16f, 39 Intersocietal Commission for the Accreditation of Vascular

Laboratories 35

Jobst-Elvarex® stockings 166 Jobst® ActiveWear® sock 166 Jobst® Stocking Donner 167f

Labropoulos, Nicos 34–35 Laser therapy 54–56, 95–109

beneﬁts 95–97 choice of treatment 96b equipment 101–103, 101t–103t guidelines 97f laser selection 54–56 major determinants 99–100, 100b, 100f, 100t parameter selection 54, 54f–55f patients 101, 101b

interviews 100

selection 56, 95 problem to be treated 95, 96f results 98f side effects and complications 105, 105b, 106f thermal ablation 126b treatment algorithm 103–105, 104f treatment approach 97–99, 99f troubleshooting 105, 105b