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222 Chapter 23/Ultrasound-Guided Catheter and Foam Therapy for Venous Insuffi ciency
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FIGURE 23.6 The ablation starts at saphenofemoral junction and pro-
ceeds in a distal direction. It is always wise to recheck the catheter position
FIGURE 23.4 Position of the guidewire and radiofrequency catheter is
monitored by ultrasound visualization. (Adapted from Pichot O, Atlas of
Ultrasound Images, Copyright VNUS® Closure.)
at SFJ prior the application of the energy. (Adapted from Pichot O, Atlas
of Ultrasound Images, Copyright VNUS® Closure.)
FIGURE 23.5 Administration of the tumescent anesthesia into the
Saphenous Compartment is monitored by ultrasound. SFJ: Saphenofemoral
Junction; T.A.: Tumescent Anesthesia. (Adapted from Pichot O, Atlas of
Ultrasound Images, Copyright VNUS® Closure.)
the catheter position at SFJ prior the application of the
energy (see Figure 23.6).
22
The ablation starts at saphenofemoral junction and proceeds in a distal direction.16 Successful obliteration is confi rmed by contraction of the saphenous vein to a residual
diameter of <2 mm.16 Patency of the common femoral artery
and vein are confi rmed by ultrasound (see Figure 23.7). A
thrombus may be seen as a hyperechogenic core in the vessel
(see Figure 23.7b).
15,24
Early post treatment duplex scanning should be performed. Evidence of a protruding thrombus from the saphenous vein into the femoral vein should be anticipated (see
Figure 23.8).24 Evidence of a noncompressible GSV with
thickened walls and absence of fl ow on color ultrasound
analysis are signs of successful obliteration (see Figure
9
23.9).
ULTRASOUND MONITORING
DURING SCLEROFOAM
ABLATION OF VARICOSE VEINS
Advent of foam sclerotherapy has added a new tool for
the treatment of chronic venous insuffi ciency. Sclerosant
agents provoke endothelial damage by several mechanisms.25
They change either the surface tension of the plasma membrane (detergents) or the intravascular pH and osmolarity.
The fi nal result is a chemical fi brosis of the treated
25
vessel.
Sclerosing foams (SF) are mixtures of gas with a liquid
solution with surfactant properties. In 1993, Cabrera proposed the use of SF, made of sodium tetradecyl sulfate or
polidocanol in the treatment of varicose veins.26 One of the
intrinsic limits of liquid sclerosants in the treatment of
Ultrasound Monitoring during Sclerofoam Ablation of Varicose Veins 223
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FIGURE 23.7 Duplex examinations (longitudinal views) of the Great Saphenous vein (GSV) at the saphenofemoral
junction (SFJ). A. Pretreatment scan demonstrated an incompetent SFJ after augmentation. B. Intraoperative color duplex
interrogation showed successful occlusion of the GSV with a patent, 3-mm proximal stump (arrow 1) and absence of
fl ow within the treated segment (arrow 2). (Adapted from Puggioni A, Kalra M, Carmo M, Mozes G, Gloviczki P.
Endovenous laser therapy and radiofrequency ablation of the great saphenous vein: Analysis of early effi cacy and
complications, J Vasc Surg. 2005. Sep;42(3): 488–493.)
FIGURE 23.8 Early post treatment duplex scanning should be per-
formed. Evidence of a protruding thrombus from the saphenous vein into
the femoral vein should be looked for. (Adapted from Pichot O, Atlas of
Ultrasound Images, Copyright VNUS® Closure)
varicose veins is dilution by the bloodstream with reduction
of their effi cacy.27 Also, they are rapidly cleared by the
moving bloodstream. Sclerosing foams do not mix with
blood and instead remain in the vessel, continuing to strip
the endothelium.
causes an increased contact time with the intimal surface.
Foam preparation is remarkably simple.27 The Tessari 3-way
stop-cock method is the most commonly used.
27
This persistence of the agent in the vessel
27,28
FIGURE 23.9 Evidence of a noncompressible GSV with thickened walls
and absence of fl ow on color ultrasound analysis are signs of successful
obliteration. (Adapted from Pichot O, Atlas of Ultrasound Images, Copyright VNUS® Closure)
As in electromagnetic ablation, the treatment starts with
clear ultrasound mapping. Varicose veins can be accessed
by the placement of 25 G butterfl y needle, or the Great
Saphenous or the Small Saphenous vein can be directly cannulated with an angiocath, an echogenic Cook® needle, or
27,29,30
a 25 G butterfl y.
Most descriptions of the technique
explain direct ultrasound-guided access to the saphenous
27,31
vein.
In contrast, we achieve a satisfactory and rapid
224 Chapter 23/Ultrasound-Guided Catheter and Foam Therapy for Venous Insuffi ciency
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FIGURE 23.10 Foam functions as an effi cient ultrasound contrast
medium because of its air content. Its injection can be easily monitored. Its
US appearance is that of a solid hyper-echogenic core with an acoustic
shadow projected on the tissue below.
obliteration of the GSV and SSV by cannulating a peripheral
varicosity.30 Although the saphenous vein cannot be cannulated with a catheter by way of a varicosity because of its
angle of connection, there is no such obstacle to the fl ow of
foam.
Foam functions as an effi cient ultrasound contrast medium
because of its air content. Its injection can be easily monitored. Its US appearance is that of a solid hyperechogenic
core with an acoustic shadow projected in the tissue below
(see Figure 23.10).
Foam is introduced into a varix or the saphenous vein
with the patient supine. As the foam reaches the SFJ as
monitored by ultrasound, compression of the SFJ or the SPJ
is effected in order to reduce fl owing of foam into the systemic circulation.
Vasoconstriction and vasospasm can be induced by intermittent compression of the vein by the ultrasound transducer
and by elevating the limb. This minimizes the blood content
of the saphenous vein and its connected varices. Foam will
be seen by ultrasound to fl ow distally in the elevated limb.
It fl ows selectively through incompetent valves and is effectively blocked by competent valves. These maneuvers have
the effect of prolonging the action of the foamed sclerosant
on the intima, improving the effi cacy of the entire treatment.
The femoral, popliteal, and deep veins of the leg are scanned
throughout the entire procedure. Foam particles are washed
out of deep veins such as the gastrocnemius or tibial veins
by fl exion-extension maneuvers of the foot. Quick movements of dorsifl exion of the foot completely clear the
deep veins. Despite much worry about the problem, major
FIGURE 23.11 Ultrasound sonography has confi rmed the presence
of a tangled network of varicose veins of small caliber, reticular varices,
and incompetent perforating veins under lipodermatosclerotic plaques
and under venous ulcers. These are the tagets for successful foam
sclerotherapy.
thrombotic events in the femoral and popliteal veins rarely
have been described with use of sclerofoam. In a study
of over 1,200 sclerotherapy sessions, over half of which
involved foam, only a single femoral vein thrombus was
encountered.
32
Thromboses of the gastrocnemius, tibial, and peroneal
30,33
veins have been reported only occasionally.
Intraarterial
injections are uncommon because of monitoring the foam
treatment of severe CVI.
30,33
Ultrasound sonography has
confi rmed the presence of a tangled network of varicose
veins of small caliber, reticular varices, and incompetent
perforating veins under lipodermatosclerotic plaques and
under venous ulcers (see Figure 23.11).30 Ultrasound monitoring is used to confi rm the fact that these vessels are fi lled
with foam during the therapeutic maneuvers. Ultrasound
guidance is also used in treatment of incompetent perforating veins by direct cannulation and controlled injection of
References 225
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the SF under direct visual control.27 More often superfi cial
peripheral veins can be directly injected with obliteration of
the inciting perforator and the network of the incompetent
veins.
DISCUSSION
Compression therapy and surgery have been the cornerstone of CVI treatment for years and they are still useful.
New minimally invasive techniques such as radiofrequency
ablation of saphenous veins, EVLT, and GSV and SSV ablation with Sclerofoam of superfi cial varicose veins have been
demonstrated to be safe, effective, and more acceptable to
the patient.16 The contribution of ultrasound in general and
duplex technology in particular has given reliability to the
diagnosis of CVI and has enhanced the development of these
minimally invasive therapies. Intraprocedural and postprocedural US duplex ultrasound monitoring offers the best
control of the entire procedure with early prevention of
complications (thrombosis of deep veins) and eventual minimalization of failure.
CONCLUSION
US duplex ultrasound is essential in every phase of the
CVI patient care. Experience, critical thinking, uniform
testing, and insight in the pathology are necessary to achieve
satisfactory results.
References
1. Labropoulos N, Leon LR Jr. Duplex evaluation of venous insuffi -
ciency, Semin Vasc Surg. 2005. 18(1): 5–9.
2. Ballard J, Bergan J, Delange M. Venous imaging for refl ux using
duplex ultrasonography. C. 24, 339–334. In: Aburahma AF, Bergan JJ.
Noninvasive vascular diagnosis, 1e. 2000. London:Springer-Verlag.
3. Depalma RG, Kowallek DL, Barcia TC, Cafferata HT. Target selection
for surgical intervention in severe chronic venous insuffi ciency:
Comparison of duplex scanning and phlebography, J Vasc Surg. 2000.
32(5): 913–920.
4. Yamaki T, Sasaki K, Nozaki M. Preoperative duplex-derived param-
eters and angioscopic evidence of valvular incompetence associated
with superfi cial venous insuffi ciency, J Endovasc Ther. 2002. 9(2):
229–233.
5. Mekenas L, Bergan J. Venous refl ux examination: Technique using
miniaturized ultrasound scanning, J Vasc Tech. 2002. 2(26): 139–
146.
6. Kistner RL, Eklof B, Masuda EM. Diagnosis of chronic venous disease
of the lower extremities: The “CEAP” classifi cation, Mayo Clin Proc.
1996. 71(4): 338–345.
7. Eklof B, Rutherford RB, Bergan JJ, Carpentier PH, Gloviczki P,
Kistner et al. Revision of the CEAP classifi cation for chronic venous
disorders: Consensus statement, J Vasc Surg. 2004. 40(6): 1248–
1252.
8. Lynch TG, Dalsing MC, Ouriel K, Ricotta JJ, Wakefi eld TW. Developments in diagnosis and classifi cation of venous disorders: Non-invasive
diagnosis, Cardiovasc Surg. 1999. 7(2): 160–178.
9. Labropoulos N, Tiongson J, Pryor L, Tassiopoulos AK, Kang SS,
Ashraf Mansour M. Defi nition of venous refl ux in lower-extremity
veins, J Vasc Surg. 2003. 38(4): 793–798.
10. Masuda EM, Kistner RL, Eklof B. Prospective study of duplex
scanning for venous refl ux: Comparison of Valsalva and pneumatic
cuff techniques in the reverse Trendelenburg and standing positions,
J Vasc Surg. 1994. 20(5): 711–720.
11. Markel A, Meissner MH, Manzo RA, Bergelin RO, Strandness DE Jr.
A comparison of the cuff defl ation method with Valsalva’s maneuver
and limb compression in detecting venous valvular refl ux, Arch Surg.
1994. 129(7): 701–705.
12. Delis KT et al. Enhancing venous outfl ow in the lower limb with
intermittent pneumatic compression. A comparative haemodynamic
analysis on the effect of foot vs. calf vs. foot and calf compression,
Eur J Vasc Endovasc Surg. 2000. 19(3): 250–260.
13. Vasdekis SN, Clarke GH, Nicolaides AN. Quantifi cation of venous
refl ux by means of duplex scanning, J Vasc Surg. 1989. 10(6): 670–
677.
14. Pichot O et al. Role of duplex imaging in endovenous obliteration
for primary venous insuffi ciency, J Endovasc Ther. 2000. 7(6): 451–
459.
15. Min RJ, Khilnani N, Zimmet SE. Endovenous laser treatment of
saphenous vein refl ux: Long-term results, J Vasc Interv Radiol. 2003.
14(8): 991–996.
16. Sadick NS. Advances in the treatment of varicose veins: Ambulatory
phlebectomy, foam sclerotherapy, endovascular laser, and radiofrequency closure, Dermatol Clin. 2005. 23(3): 443–455, vi.
17. Puggioni A, Kalra M, Carmo M, Mozes G, Gloviczki P. Endovenous
laser therapy and radiofrequency ablation of the great saphenous vein:
Analysis of early effi cacy and complications, J Vasc Surg. 2005. 42(3):
488–493.
18. Caggiati A, Bergan JJ, Gloviczki P, Jantet G, Wendell-Smith CP,
Partsch H. Nomenclature of the veins of the lower limbs: An international interdisciplinary consensus statement, J Vasc Surg. 2002. 36(2):
416–422.
19. Delis KT et al. In situ hemodynamics of perforating veins in chronic
venous insuffi ciency, J Vasc Surg. 2001. 33(4): 773–782.
20. Caggiati A, Bergan JJ, Gloviczki P, Eklof B, Allegra C, Partsch
H. Nomenclature of the veins of the lower limb: extensions, refi nements, and clinical application, J Vasc Surg. 2005. 41(4): 719–
724.
21. Weiss RA. Comparison of endovenous radiofrequency versus 810 nm
diode laser occlusion of large veins in an animal model, Dermatol Surg.
2002. 28(1): 56–61.
22. Weiss RA, Weiss MA. Controlled radiofrequency endovenous occlusion using a unique radiofrequency catheter under duplex guidance to
eliminate saphenous varicose vein refl ux: A 2-year follow-up, Dermatol Surg. 2002. 28(1): 38–42.
23. Morrison N. Saphenous ablation: What are the choices, laser or RF
energy, Semin Vasc Surg. 2005. 18(1): 15–18.
24. Pichot O et al. Duplex ultrasound scan fi ndings two years after great
saphenous vein radiofrequency endovenous obliteration, J Vasc Surg.
2004. 39(1): 189–195.
25. Goldman M. Mechanisms of action of sclerotherapy. Chapter 7,
Sclerotherapy: Treatment of varicose and telangiectatic leg veins, 2e.
1995. St. Louis, Missouri: Mosby. 244–279.
26. Cabrera J. Dr J. Cabrera is the creator of the patented polidocanol
microfoam, Dermatol Surg. 2004. 30(12 Pt 2): 1605; author reply
1606.
27. Coleridge Smith P. Saphenous ablation: Sclerosant or sclerofoam?
Semin Vasc Surg. 2005. 18(1): 19–24.
226 Chapter 23/Ultrasound-Guided Catheter and Foam Therapy for Venous Insuffi ciency
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28. Tessari L, Cavezzi A, Frullini A. Preliminary experience with a new
sclerosing foam in the treatment of varicose veins, Dermatol Surg.
2001. 27(1): 58–60.
29. Cabrera J et al. Ultrasound-guided injection of polidocanol microfoam
in the management of venous leg ulcers, Arch Dermatol. 2004. 140(6):
667–673.
30. Bergan JJ, Pascarella L. Severe chronic venous insuffi ciency: Primary
treatment with sclerofoam, Semin Vasc Surg. 2005. 18(1): 49–56.
31. Guex JJ. Foam sclerotherapy: An overview of use for primary venous
insuffi ciency, Semin Vasc Surg. 2005. 18(1): 25–29.
32. Guex JJ, Allaert FA, Gillet JL, Chleir F. Immediate and midterm
complications of sclerotherapy: Report of a prospective multicenter
registry of 12,173 sclerotherapy sessions, Dermatol Surg. 2005. 31(2):
123–128; discussion 128.
33. Bergan JJ, Weiss RA, Goldman MP. Extensive tissue necrosis following high-concentration sclerotherapy for varicose veins, Dermatol
Surg. 2000. 26(6): 535–541; discussion 541–542.
CHAPTER
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24
Principles of Treatment of Varicose Veins by
Sclerotherapy and Surgery
STEVEN E. ZIMMET
Varicose veins may be of cosmetic concern to patients, and
may cause a variety of symptoms, signs, and sequelae. As
physicians interested in venous disease, we know from daily
practice that venous insuffi ciency signifi cantly impacts our
patients’ quality of life (QoL). There are now data to substantiate our clinical impression
can be improved with intervention in these patients.
Treatment for venous disease has undergone rapid innovation in the last decade. Despite these advances varicose
vein treatment is not curative. Superfi cial venous insuffi ciency is a chronic disorder that should be viewed more like
a medical than surgical condition.8 Nonetheless, it is apparent that outcomes can be optimized when certain principles
of treatment are followed. This chapter will discuss the
development of the principles that are generally accepted
today.
A history, physical, and duplex ultrasound examination
are prerequisites for adequate treatment of varicose veins.
Treatment of varicose veins, except when addressed by conservative or pharmacologic measures, should eliminate
sources of venous hypertension. These can be gravitational,
as with axial vein refl ux, or hydrodynamic, due to increased
compartmental pressure during muscular contraction.
Therefore, rational treatment depends on the delineation of
sources of refl ux between the deep and superfi cial system
along with the extent of truncal and tributary incompetence.
An individualized treatment plan is developed based on the
fi ndings of the evaluation and on the goals of the patient.
Treatment goals may include cosmetic improvement, relief
of venous-related symptoms (such as leg heaviness, fatigue,
pruritus, night cramps, etc.), management of venous-related
sequelae (such as edema, dermatitis, lipodermatosclerosis,
ulceration, thrombophlebitis, and external bleeding), prevention of complications and control of the disease process.
1–5
and to indicate that QoL
3,6,7
9
Treatment risks, benefi ts, and alternatives should be discussed with the patient when determining a treatment plan.
Factors to consider and discuss include:
• Effi cacy of treatment alternatives
• Durability of results
• Cosmetically acceptable results
• Risk of complications
• Ease of recovery
• Cost
Saphenous vein refl ux is the underlying primary abnormality in the majority of cases of superfi cial venous insuffi ciency. Thus, approaches to dealing with saphenofemoral
junction and saphenous truncal incompetence have dominated the thinking of phlebologists. Trendelenburg described
saphenofemoral junction ligation alone, without stripping of
the incompetent saphenous vein, in the 1890s. The advantages of this technique over ligation and stripping are still
extolled today.10 Advocates of this approach have pointed
out that it preserves the saphenous trunk for possible future
use as a bypass graft,
nerve injury.12 High ligation alone is also less invasive,
quicker, and simpler to perform, and associated with an
easier recovery compared to vein stripping. Unfortunately,
the shortcomings of ligation alone outweigh its advantages.
Although it is true that such treatment routinely “spares” the
saphenous trunk,13 the use of a diseased saphenous vein as
a conduit has been associated with an increased risk of graft
failure.14 Most importantly there is no longer any question
that high ligation alone is coupled with persistent refl ux in
the saphenous trunk.
“duplex scanning confi rms the fact that high ligation alone
allows persistence of distal refl ux after surgical intervention.”17 It is not surprising that varicose recurrence is
11
and avoids the risk of saphenous
15,16
Bergan concluded 15 years ago that
The Vein Book
227
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Copyright © 2006, Elsevier Inc.
228 Chapter 24/Principles of Treatment of Varicose Veins by Sclerotherapy and Surgery
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signifi cantly reduced
16,18,19
and the reoperation rate is 60 to
70% less if the saphenous vein is stripped vs. ligation
20,21
alone.
Regarding the clinical bottom line, more patients
were completely satisfi ed (65 versus 37%) and were recurrence-free (65 versus 17%) when the great saphenous vein
(GSV) had been stripped compared with saphenofemoral
ligation alone (P < 0.05 and P < 0.001, respectively).22 The
authors concluded that the addition of GSV stripping to
saphenofemoral ligation and multiple avulsions results in a
better overall outcome. Recurrence or residual communication with the junction in the groin was found in 80% of
patients after ligation alone, and 34% of limbs also had
mid-thigh perforator incompetence via the unstripped GSV.23
As Neglen concluded, stripping of the GSV of the thigh is
essential to minimizing recurrence due to redevelopment
of incompetent communication with the saphenofemoral
confl uence and due to thigh perforator incompetence.
24
Another vein sparing technique is external banding,
which aims to restore proximal valvular competence of the
GSV. A small number of reports suggest this approach may
be effi cacious.
25,26
However, these procedures are not widely
practiced or accepted. Conservative hemodynamic treatment
of incompetent varicose veins in ambulatory patients (Cure
Conservatrice et Hemodynamique de Insuffi cience Veneuse
en Ambulatoire, CHIVA) is another conservative technique
that seeks to normalize venous pressure by ligation of points
of venous refl ux at reentry perforators. It requires a diffi cult
ultrasound mapping of the venous system. Disconnection of
the fl ow to reentry perforators, without high ligation of the
saphenofemoral junction, has been reported to successfully
suppress GSV refl ux.27 A different group found recurrence
of GSV refl ux in 92% at three years.28 These authors concluded that “elimination of refl ux in the GSV after the interruption of insuffi cient collaterals is only temporary.” It’s
revealing that a survey of vascular surgeons in France, where
CHIVA was developed, found this form of venous surgery
to be practiced by only 0.3% of the 280 respondents.
29
At the other end of the spectrum, stripping of the entire
saphenous from ankle to groin, along with stab avulsion of
varices, has been practiced. This was advocated because it
was assumed that refl ux extended to the ankle in most
patients. However, in a duplex study on over 500 legs the
most common pattern was saphenous refl ux from the groin
to the knee (43.4%), with refl ux reaching the ankle in only
30
1%.
The authors concluded that clinically diagnosed GSV
refl ux in the lower leg usually represented tributary varices,
which joined the saphenous vein proximally. These fi ndings,
along with the high incidence of saphenous neuralgia from
groin to ankle stripping, explain recommendations for
“short” stripping of the GSV from groin to just below the
knee. Note that such stripping would avoid the risk of saphenous nerve injury yet would disconnect mid-thigh perforators, which as noted earlier are a common cause of recurrence
when ligation alone is employed.
It is important to note that recurrence is common even
after ligation and stripping of the saphenous. Inadequate
surgery of the saphenofemoral junction has been claimed to
31
be an important factor contributing to recurrence.
Meticulous dissection of the junction, taking each tributary back
beyond each primary and even secondary tributary when
possible, was advocated.32 Whereas progression of disease
is another mechanism that explains some cases of recurrence, neovascularization around the junction has been
established to be an important cause of recurrence after
venous surgery.
21,33
In fact, neovascularization has been
reported as the principal cause of recurrence,19 with neovascular channels of variable size, number, and tortuosity
accounting for the refl ux to recurrent varicosities in the vast
majority of cases.34 Although some have expressed doubt as
to the veracity of true neovascularization, there is clear histological evidence that neovascularization is a cause of
recurrent varicose veins.35 Early reports suggest that endovenous ablation techniques are associated with a very low
incidence of neovascularization. It may be that by avoiding
groin dissection and by preserving venous drainage in
normal junctional tributaries the development of neovascularization is largely avoided.
36,37
In addition to junctional incompetence, another source of
deep to superfi cial incompetence is via perforating veins.
We’ve already noted the role of thigh perforators in recurrence, primarily when the saphenous trunk is not ablated.
However, ablation of the GSV doesn’t address lower leg
perforator incompetence directly since most of these perforators don’t drain into the GSV itself. Nonetheless, patients
with superfi cial and perforator vein incompetence and with
a normal deep venous system experienced signifi cant
improvement in APG-measured hemodynamic parameters
and clinical symptom score after superfi cial ablative surgery
alone.38 The authors suggested that treatment of perforator
veins can be reserved for patients with persistent incompetent perforator vessels, abnormal hemodynamic parameters
or continued symptoms after superfi cial ablative surgery.
Another study corrobated these results, but found that saphenous surgery alone failed to correct perforator refl ux when
there was coexistent deep venous refl ux or if superfi cial
refl ux persisted postoperatively.
39
The resolution of perforator refl ux following treatment of superfi cial venous disease
is similar to the improvement in deep venous hemodynamics
that has been observed after ablation of superfi cial refl ux,
40,41
and is probably due to a reduction in venous overload.
Currently accepted principles of treatment of varicose
veins serve to maximize outcomes from a hemodynamic and
patient standpoint while minimizing the risk of recurrence.
Appropriate treatment of varicose veins begins with an accurate assessment of the underlying venous pathology and
identifi cation of sources of venous hypertension. The aims
of treatment include elimination of the incompetent connections between the deep and superfi cial systems as well as
Previous Classifi cations of CVD 229
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the obliteration of pathways of venous incompetence and
incompetent varicose veins. It is clear that recurrence is
reduced if the incompetent segment of the saphenous trunk
is ablated. Duplex ultrasound examination reveals that the
GSV is often competent and of much smaller diameter
below a site of saphenous-varicose tributary connection,
usually located in the thigh or proximal lower leg. Ablation
of the entire GSV, from groin to ankle, is almost never
required. It appears that avoiding groin dissection and preserving normal junctional drainage may prevent the development of neovascularization, an important cause of
recurrence following ligation and stripping. Thus endovenous treatments, including endovenous laser, radiofrequency
ablation, and foam sclerotherapy, may yield the benefi ts of
ablation of the incompetent saphenous trunk while minimizing recurrence due to neovascularization. Causes of recurrence following these endovenous treatments appear to be
due primarily to failure to fully ablate incompetent truncal
veins (failure or recanalization) or due to progression of
disease.
There is a pervasive trend in medicine toward minimally
invasive treatments. The approach to venous disease is no
different. Ablating only incompetent venous segments is in
keeping with this approach. The application of the principles
of tumescent anesthesia to venous treatments,42 along with
the development of endovenous treatments, offers the
possibility of treating the vast majority of patients with
superfi cial venous insuffi ciency in-offi ce without general
anesthesia or surgical incisions, while maximizing outcomes
and minimizing recurrence.
Superfi cial venous disease is a chronic disorder. Patient
education regarding preventative measures is appropriate
regardless of which treatments are performed. These measures include regular aerobic exercise and the use of compression stockings.
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7. MacKenzie RK, Paisley A, Lee AJ, Ruckley CV, Bradbury AW. The
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8. Guex JJ, Isaacs, MN. Comparison of surgery and ultrasound guided
sclerotherapy for treatment of saphenous varicose veins: Must the
criteria for assessment be the same? Int Angiol. 2000. 19(4): 299–
302.
9. Bergan JJ. Ambulatory surgery of varicose veins. In: Goldman MP,
Bergan JJ, eds. Ambulatory treatment of venous disease. 1996. St.
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11. Large J. Surgical treatment of saphenous varices, with preservation of
the main great saphenous trunk, J Vasc Surg. 1985. 2(6): 886–891.
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the long saphenous vein and the saphenous nerve. Relevance for radical
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vein after partial removal or ligation, J Vasc Surg. 1990. 12(4): 422–
426.
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et al. Unsuspected preexisting saphenous vein disease: An unrecognized cause of vein bypass failure, J Vasc Surg. 1992. 15(1): 102–
110.
15. McMullin GM, Coleridge Smith PD, Scurr JH. Objective assessment
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vein in the treatment of primary varicose veins, Br J Surg. 1994.
81(10): 1455–1458.
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CHAPTER
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25
Inversion Stripping of the Saphenous Vein
JOHN BERGAN
One of the cornerstones of surgery for varicose veins is
removal of the Great Saphenous vein (GSV) from the circulation. This can be done using minimally invasive techniques described elsewhere in this volume, but specifi c
indications for performing saphenous surgery remain. These
are largely institutional and geographic but they justify the
following exposition.
Indications for intervention in primary venous insuffi ciency are listed in Table 25.1. Often, it is the appearance
of telangiectatic blemishes or protuberant varicosities that
stimulates consultation. Ultimately, this may be the only
indication for intervention.
1
Characteristic symptoms include aching, pain, easy leg
fatigue, and leg heaviness, all relieved by leg elevation,2
and worsened on the fi rst day of a menstrual peritod.
Other indications for intervention for venous varicosities
include superfi cial thrombophlebitis in varicose clusters,
external bleeding from high-pressure venous blebs, or
advanced changes of chronic venous insuffi ciency such
as severe ankle hyperpigmentation, subcutaneous lipodermatosclerosis, atrophie blanche, or frank ulceration.
Symptoms are frequent throughout the CEAP Classes 1
through 6. Clinical Disability Scores parallel the clinical
classifi cation.
3
Objectives of treatment should be ablation of the hydrostatic forces of axial refl ux and removal of the effects of
hydrodynamic forces of perforator vein refl ux. The latter can
be accomplished by removal of the saphenous vein in the
thigh and the varicose veins without specifi c perforating
vein interruption. In France, the two most performed procedures recently were, respectively, high ligation + saphenous
trunk stripping + tributary stab avulsion (71.9%) and high
ligation + saphenous trunk stripping (17.3%). Isolated phlebectomy was done in 5.6%, high ligation + tributary stab
avulsion + saphenous trunk preservation 2.8%, isolated high
ligation 2.2%.
4
Ligation of the saphenous vein at the saphenofemoral
junction has been practiced widely in the belief that this
would control gravitational refl ux while preserving the vein
for subsequent arterial bypass.5 It is true that the saphenous
vein is largely preserved after proximal ligation. Unfortunately, refl ux continues and hydrodynamic forces are not
controlled. Less refl ux persists when the long saphenous
vein has been stripped.6 There is a better functional outcome
after stripping and fewer junctional recurrences.7 Randomized trials show effi cacy of stripping compared to simple
proximal ligation.
8–11
Earlier comparisons of saphenous ligation versus stripping were fl awed by today’s standards. Subjective evaluation was the only means of measuring outcome for a time.12
Duplex scanning came into use, verifying that stripping was
superior to proximal ligation; this fact was supported by
PPG.13 Despite those facts, it was acknowledged that the
period of disability after stripping was greater than that after
14
simple ligation.
In attempts to decrease disability and
improve effi cacy, high tie was added to saphenous vein
sclerotherapy, but foot volumetry showed that radical
surgery, including stripping produced superior results.
15
Ultimately, attention became focused on saphenous nerve
injury associated with ankle to groin stripping.16 It was concluded that nerve injury was reduced by groin to ankle
stripping (see Figure 25.1).
18,19
Preservation of calf veins by
stripping to the knee was shown to reduce nerve injury and
did not adversely affect early venous hemodynamic improve-
20
ment.
This fact is contraintuitive, and the subject deserves
further study.
21
Attempts to reduce nerve injury and simultaneously
clean up varicose vein surgery led to use of the hemostatic
The Vein Book
231
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