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232 Chapter 25/Inversion Stripping of the Saphenous Vein
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TABLE 25.1 Varicose Veins: Indications for Intervention
General appearance
Aching pain
Leg heaviness
Easy leg fatigue
Superfi cial thrombophlebitis
External bleeding
Ankle hyperpigmentation
Lipodermatosclerosis
Atrophie blanche
Venous ulcer
1
tourniquet. In a study with level 1 evidence, it was shown
that use of a hemostatic cuff tourniquet during varicose vein
surgery reduces perioperative blood loss, operative time,
and postoperative bruising without any obvious drawbacks.22
Villavicencio summarized this advance, saying,11 “This
technique represents a welcome alternative to the bloody,
tedious, and time-consuming traditional varicose vein
surgery of the past. Complex venous surgery for extensive
varicose veins of the extremities can be safely and expeditiously performed under controlled ischemia. It should be
the technique of choice.”
23
Recurrent varicose veins after surgery are acknowledged
to be a major problem for patients and society.
24
Traditionally, it was thought that the most common reason for
varicose recurrence was failure to perform an adequate
saphenofemoral junction dissection (see Figure 25.2), or to
correctly identify the saphenous vein for removal.
25
Duplex
scans have clarifi ed this situation and instead of technical
error, some investigators are convinced that new vessel
growth contributes to recurrent varicose veins.
26
In particular, incomplete superfi cial surgery, at the saphenofemoral
and saphenopopliteal junctions, is a less frequent cause of
recurrent disease, and neovascular reconnection and persistent abnormal venous function are the major contributors to
disease recurrence.
27
FIGURE 25.1 In an early attempt to improve the results of varicose
vein surgery, saphenous stripping, the obturator was drawn from above
downward and then retrieved through the groin incision. Postoperative
appearance was improved but disability from pain, ecchymosis, and hematoma continued.
PREOPERATIVE PREPARATION
Over the years, much space has been given to clinical
examination of the patient with varicose veins. Many
clinical tests have been described. Most carry the names
of now-dead surgeons who were interested in venous
pathophysiology. This august history notwithstanding, the
Trendelenburg test, the Schwartz test, the Perthes test, and
the Mahorner and Ochsner modifi cations of the Trendelenburg test essentially are useless in preoperative evaluation
of patients today.
The clinical evaluation can be improved by using handheld Doppler devices. However, preoperative evaluation
is best performed by means of duplex scanning and a
focused physical examination.
mapping of incompetent superfi cial veins has been pub-
29
lished.
Although many cite cost considerations as a
reason for omitting duplex evaluation, we believe that duplex
scanning for venous insuffi ciency is in fact both simple
and cost effective. Duplex mapping defi nes individual
patient anatomy with considerable precision and provides
valuable information that supplements the physician’s
clinical impression.
Three principal goals must be kept in mind in planning
treatment of varicose veins: 1) the varicosities must be permanently removed and the underlying cause of venous
hypertension treated; 2) the repair must be done in as
28
Our protocol for duplex
Preoperative Preparation 233
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cosmetic a fashion as possible; 3) complications must be
minimized.
Current practice of treating the source of venous hypertension, the saphenous vein alone either by EVLT or VNUS
technology, is inadequate. The patient’s complaint, the varicose veins, must be addressed. This is as important as the
physician’s knowledge that the sources of venous hypertension must be addressed.
To speak of permanent removal of varicosities implies
that all potential causes of recurrence have been considered
and that surgery has been planned so as to address them.
FIGURE 25.2 In the past, a proper groin dissection consisted of laying out each of the named saphenofemoral junc-
tion tributaries and dissecting them back beyond their primary tributaries. Now, this is acknowledged by most to be the
strongest stimulus to neovascularization.
There are four principal causes of recurrence of varicose
veins, of which three can be dealt with at the time of the
primary operation.
One cause of recurrent varicosities is failure to perform
the primary operation in a correct fashion. Common errors
include missing a duplicated saphenous vein and mistaking
an anterolateral or accessory saphenous vein for the greater
saphenous vein. Such errors can be eliminated by careful
and thorough groin dissection. Accordingly, failure to do a
proper groin dissection has long been held to be a second
principal cause of recurrent varicose veins. It is now known,
234 Chapter 25/Inversion Stripping of the Saphenous Vein
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FIGURE 25.3 Inversion stripping of the saphenous vein was an important step forward in minimizing soft tissue
trauma while accomplishing the principal objective of ablating hydrostatic venous hypertension by removing saphenous
refl ux. Tearing of the vein during its removal fl awed its performance.
however, that such dissection causes neovascularization in
the groin, leading to recurrence of varicose veins.30 A third
cause of recurrent varicosities is failure to remove the greater
saphenous vein from the circulation. As mentioned earlier,
reasons often cited for this failure is the desire to preserve
the saphenous vein for subsequent use as an arterial bypass.
It is clear, however, that the preserved saphenous vein continues to refl ux and continues to elongate and dilate its
tributaries. This produces more and larger varicosities. A
fourth cause of recurrent varicosities is persistence of venous
hypertension through nonsaphenous sources—chiefl y, perforating veins with incompetent valves. Muscular contraction generates enormous pressures that are directed against
valves in perforating veins. Venous hypertension induces a
leukocyte endothelial reaction, which, in turn, incites an
infl ammatory response that ultimately destroys the venous
31
valves and weakens the venous wall.
The perforating veins
most commonly associated with recurrent varicosities are
the midthigh perforating vein, the distal thigh perforating
vein, the proximal anteromedial calf perforating vein, and
the lateral thigh perforating vein, which connects the profunda femoris vein to surface varicosities.
Finally, there is a fi fth cause of recurrent varicosities,
which is out of control of the operating surgeon—namely,
the genetic tendency to form varicosities through development of localized or generalized vein wall weakness, localized blowouts of venous walls, or stretched, elongated, and
fl oppy venous valves.
32
SAPHENOUS SURGERY
be accomplished. The fi rst is ablation of refl ux from the deep
to the superfi cial veins, including the saphenofemoral junction, the saphenopopliteal junction, and midthigh varices
from the Hunterian perforating vein. Accomplishment of
this task is guided by the careful preoperative duplex
mapping of major superfi cial venous refl ux.
The second task is removal or destruction of all varicosities present at the time of the surgical intervention.
Accomplishment of this task is guided by meticulous
marking of all varicose vein clusters.
A number of options are available for surgical treatment
of varicose veins. Regardless of the specifi c approach taken,
the general technical objectives are the same: 1) ablation of
the hydrostatic forces of axial saphenous vein refl ux (see
Figure 25.3) and 2) removal of the hydrodynamic forces of
perforator vein outfl ow.
Ankle-to-groin stripping of the saphenous vein has been
a dominant treatment of varicose veins over the past 100
33,34,35
years.
(i.e., ankle-to-knee) portion of the saphenous vein is the risk
of concomitant saphenous nerve injury.
is that whereas the objective of saphenous vein removal is
detachment of perforating veins emanating from the saphenous vein, which are seen in the thigh, the perforating veins
in the leg are actually part of the posterior arch vein system
One argument against routine stripping of the leg
19
Another argument
Operative Technique 235
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rather than the saphenous vein system. This latter argument
notwithstanding, preoperative ultrasonography frequently
shows that the leg portion of the saphenous vein is in fact
directly connected to perforating veins. Therefore, removal
of the saphenous vein from ankle to knee should be a consideration in every surgical case.
OPERATIVE TECHNIQUE
The surgical approach taken must be individually tailored
to each patient and each limb. Groin-to-knee stripping of the
saphenous vein should be considered in every patient requiring surgical intervention.36 In nearly all patients, this measure
is supplemented by removal of the varicose vein clusters via
stab avulsion or some form of sclerotherapy.
Preoperative marking, if correctly performed, will have
documented the extent of varicose vein clusters and identifi ed the clinical points where control of varices is required.
Incisions can then be planned. As a rule, incisions in the
groin and at the ankle should be transverse and should be
placed within skin lines. In the groin, an oblique variation
of the transverse incision may be appropriate. This incision
should be placed high enough to permit identifi cation of the
saphenofemoral junction.
Generally, throughout the leg and the thigh, the best
cosmetic results are obtained with vertical incisions. Transverse incisions are used only in the region of the knee, and
oblique incisions are appropriate over the patella when the
incisions are placed in skin lines.
A major cause of discomfort and occasional permanent
skin pigmentation is subcutaneous extravasation of blood
during and after saphenous vein stripping. Such extravasation can be minimized by applying a hemostatic tourniquet
after Esmarch exsanguination of the limb. The pressure in
the hemostatic tourniquet should be between 250 and
300 mm Hg, and the tourniquet should not be in place for
longer than one hour. If a tourniquet is not used, the entire
operation on one limb can be performed with the limb elevated 30º so that the major varicose clusters are higher than
the heart. In addition, hemostatic packing can be placed into
the saphenous vein tunnel.
The practice of identifying and carefully dividing each of
the tributaries to the saphenofemoral junction has been dominant over the past 50 years. The rationale for this practice
has been that it would be inadvisable to leave behind a
network of interanastomosing inguinal tributaries. Accordingly, special efforts have been made to draw each of the
saphenous tributaries into the groin incision so that when
they are placed on traction, their primary and even secondary tributaries can be controlled. The importance of these
efforts has been underscored by descriptions of residual
inguinal networks as an important cause of varicose vein
recurrence.
37
Currently, however, this central practice of
varicose vein surgery is under challenge, on the grounds that
groin dissection can lead to neovascularization and hence to
recurrence of varicosities (see Chapter 26).
Preoperative duplex studies have already demonstrated
incompetent valves in the saphenous system, and a disposable plastic stripper can be introduced from above down-
38
ward; alternatively, a metal stripper can be employed.
Both
of these devices can be used to strip the saphenous vein from
groin to knee via the inversion technique. This approach
should reduce soft tissue trauma in the thigh.
39
In the groin, the stripper is inserted proximally into the
upper end of the divided internal saphenous vein and passed
down the main channel through incompetent valves until it
can be felt lying distally approximately 1 cm medial to the
medial border of the tibia at a point approximately 4 to 6 cm
distal to the level of the tibial tubercle. The saphenous vein
is anatomically constant in this location, just as it is in the
groin and ankle. If the saphenous vein is removed from the
groin to this level, both the midthigh perforating vein, which
usually enters the saphenous vein, and the most distal incompetent perforating veins, which are in the distal third of the
thigh, will be treated. A small incision is made over the
palpable distal end of the stripper. The saphenous vein will
subsequently be divided through this incision, and the stripper and the inverted vein will be delivered through it. In
exposing the saphenous vein at knee level, the superfi cial
fascia must be incised so as to enter the saphenous compartment. If the stripper passes unimpeded to the ankle, it can
be exposed there with an exceedingly small skin incision
placed in a carefully chosen skin line. Passage of the stripper
from above downward to the ankle serves to confi rm the
absence of functioning valves, and stripping of the vein from
above downward is unlikely to cause nerve damage. At the
ankle, the vein should be carefully and cleanly dissected to
free it from surrounding nerve fi bers. If this is not done,
saphenous nerve injury will result, and the patient will experience numbness of the foot below the ankle.
Stripping of the saphenous vein has been shown to
produce profound distal venous hypertension. This occurs
in virtually every operation, even when the limb is elevated.
Therefore, after the stripper is placed, one should consider
performing the stab avulsion portion of the procedure before
the actual stripping maneuver.
Incisions to remove varicose clusters vary according to
the size of the vein, the thickness of the vein wall, and the
degree to which the vein is adhering to the perivenous
tissues. In general, vertical incisions 1 to 3 mm in length are
appropriate, except in areas where skin lines are obviously
horizontal. Successive incisions are spaced as widely as
possible. Varicosities are exteriorized by means of hooks or
forceps. Particularly useful for this purpose are the specially
designed vein hooks known by the names Varady dissector,
Mueller hook, and Oesch hook.
40
These devices effi ciently
detach perforating veins from their tributary varicose
236 Chapter 25/Inversion Stripping of the Saphenous Vein
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FIGURE 25.4 Adding a hemostatic pack to inversion stripping corrected the principal fl aw in inversion stripping, the
tearing of the saphenous vein. The pack acted as an obturator, which insured total vein removal. In most instances, the
pack entered the vein as it was being removed, thus minimizing the soft tissue trauma.
clusters. Dissection of each perforating vein at the fascial
level is not required, and in fact may be cosmetically undesirable. There is no need to ligate or clip the ends of each
vein: the combination of leg elevation, trauma-induced
venospasm, and direct pressure typically ensures adequate
hemostasis. Once exteriorized, the varicosity is divided and
avulsed for as long a length as possible. After avulsion, skin
edges are approximated with tape or with a single absorbable monofi lament suture.
Phlebectomy techniques for varicose clusters have been
markedly refi ned by experienced workers in Europe.
41
Once the stab avulsion portion of the procedure is complete, the previously placed stripper is pulled distally to
remove the saphenous vein. Although plastic disposable
vein strippers and their metallic equivalents were designed
to be used with various-sized olives to remove the saphenous vein, in fact, a more effi cient technique is simply to tie
the vein to the stripper below its tip so that the vessel can
then be inverted into itself and removed distally.
To decrease oozing into the tract created by stripping, a
5 cm roller gauze soaked in a 1% lidocaine-epinephrine solution is attached to the stripper by using the ligature fastening
the saphenous vein to the device (see Figure 25.4). Thus,
inversion stripping is accompanied by hemostatic packing.
The hemostatic pack, which lies within the saphenous vein,
can be pulled into the tract with minimum tissue trauma;
when it is not inverted into the vein itself, it can act as an
obturator to facilitate removal of the saphenous vein without
tearing. As the vein is removed by inversion, the gauze is
left in place for hemostasis while the remainder of the surgical procedure is being completed.
Surgical removal of the saphenous vein on an outpatient
basis still requires two incisions, one in the groin and the
other near the knee. Postoperative compression bandaging
is standard, and most patients experience little downtime.
Some, however, do experience hematomas, pain, and extensive bruising. Varicosities recur in 15% to 30% of patients
42
treated.
EPILOGUE
Study of surgical saphenous stripping has shown that
when undesirable outcomes occur, they become evident
quite early. As noted earlier, it has long been accepted practice to dissect tributary vessels at the saphenofemoral junction very carefully, taking each of the vessels back beyond
the primary and even the secondary tributaries if possible.
In practice, however, such dissection appears to cause neovascularization in the groin. Duplex ultrasound surveillance
supports this fi nding. It has now been amply confi rmed that
neovascularization causes recurrent varicose veins (see
Chapter 26). Clearly, this is a signifi cant disadvantage of
standard surgical treatment of varicosities and the alternative techniques of EVLT and VNUS closure
©
should be
considered in every case.
References
1. Bergan JJ. Surgical management of primary and recurrent varicose
veins. In: Gloviczki P, Yao JST, eds. Handbook of venous disorders.
London: Chapman & Hall. 1996.
References 237
https://t.me/med1917
2. Weiss RA, Feied CF, Weiss MA, eds. Vein diagnosis and treatment—
A comprehensive approach. New York: McGraw-Hill. 2001.
3. Saarinen J, Heikkinen M, Suominen V et al. Clinical disability scores
and refl ux in complicated and uncomplicated primary varicose veins,
Phlebology. 2003. 18: 73–77.
4. Perrin M, Guidicelli H, Rastel D. Surgical techniques used for the
treatment of varicose veins: Survey of practice in France, J Mal Vasc.
2003. 28: 277–286.
5. McMullin GM, Coleridge Smith PD, Scurr JH. Objective assessment
of high ligation without stripping the long saphenous vein, Br J Surg.
1991. 78: 1139–1142.
6. Butler CM, Scurr JH, Coleridge Smith PD. Prospective randomized
trial comparing conventional (Babcock) stripping with inverting stripping of the long saphenous vein, Phlebology. 2002. 17: 59–63.
7. Sarin S, Scurr JH, Coleridge Smith PD. Assessment of stripping the
long saphenous vein in the treatment of primary varicose veins, Br J
Surg. 1992. 79: 889–893.
8. Dwerryhouse S, Davies B, Harradine K, Earnshaw JJ. Stripping the
long saphenous vein reduces the rate of reoperation for recurrent varicose veins: Five-year results of a randomized trial, J Vasc Surg. 1999.
29: 589–592.
9. Jones L, Braithwaite BD, Selwyn D, Cooke S, Earnshaw JJ. Neovascularisation is the principal cause of varicose vein recurrence: Results
of a randomised trial of stripping the long saphenous vein, Eur J Vasc
Endovasc Surg. 1996. 12: 442–445.
10. Winterborn RJ, Foy C, Earnshaw JJ. Causes of varicose vein recurrence: Late results of a randomized controlled trial of stripping the long
saphenous vein, J Vasc Surg. 2004. 40: 634–639.
11. Woodyer AB, Reddy PJ, Dormandy JA. Should we strip the long
saphenous vein? Phlebology. 1986. 1: 221–224.
12. Rutgers PH, Kitslaar PJ. Randomized trial of stripping versus high
ligation combined with sclerotherapy in the treatment of the incompetent greater saphenous vein, Am J Surg. 1994. Oct;168(4):
311–315.
13. Sarin S, Scurr JH, Coleridge Smith PD. Stripping of the long saphenous
vein in the treatment of primary varicose veins, Br J Surg. 1994. 81:
1455–1458.
14. Jakobsen BH. The value of different forms of treatment for varicose
veins, Br J Surg. 1979. 66: 182–184.
15. Neglen P, Einarsson E, Eklof B. The functional long-term value of
different types of treatment for saphenous vein incompetence, J
Cardiovasc Surg (Torino). 1993. 34: 295–301.
16. Munn SR, Morton JB, MacBeth WAAG, McLeish AR. To strip or not
to strip the long saphenous vein? A varicose veins trial, Br J Surg.
1981. 68: 426–428.
17. Negus D. Should incompetent saphenous veins be stripped right down
to the ankle? Phlebologie. 1987. 40: 753–757.
18. Holme JB, Skajaa K, Holme K. Incidence of lesions of the saphenous
nerve after partial or complete stripping of the long saphenous vein,
Acta Chir Scand. 1990. 156: 145–148.
19. Wellwood JM, Cox SJ, Martin A, Cockett FB, Browse NL. Sensory
changes following stripping of the long saphenous vein, J Cardiovasc
Surg. 1975. 16: 123–124.
20. Miyazaki K, Nishibe T, Kudo F, Miyazaki YJ, Nishibe M, Ando M,
Yasuda K. Hemodynamic changes in stripping operation or saphenofemoral ligation of the greater saphenous vein for primary varicose
veins, Ann Vasc Surg. 2004. Jul;18(4): 465–469.
21. Sam RC, Silverman SH, Bradbury AW. Nerve injuries and varicose
vein surgery, Eur J Vasc Endovasc Surg. 2004. 27: 113–120. Review.
22. Sykes TC, Brookes P, Hickey NC. A prospective randomised trial of
tourniquet in varicose vein surgery, Ann R Coll Surg Engl. 2000.
Jul;82(4): 280–282.
23. Villavicencio JL, Gillespie DL, Kreishman P. Controlled ischemia for
complex venous surgery: The technique of choice, J Vasc Surg. 2002.
36: 881–888. J Vasc Surg. 2001. Nov;34(5): 947–951.
24. Stucker M, Netz K, Breuckmann F, Altmeyer P, Mumme A. Histomorphologic classifi cation of recurrent saphenofemoral refl ux, J Vasc
Surg. 2004. 39: 816–821; Discussion 822.
25. Greaney MG, Makin GS. Operation for recurrent saphenofemoral
incompetence using a medial approach to the saphenofemoral junction,
Br J Surg. 1985. 72: 910–911.
26 Glass GM. Neovascularization in recurrence of the varicose great
saphenous vein following transection, Phlebology. 1987. 2: 81–91.
27. van Rij AM, Jiang P, Solomon C, Christie RA, Hill GB. Recurrence
after varicose vein surgery: A prospective long-term clinical study with
duplex ultrasound scanning and air plethysmography, Eur J Vasc
Endovasc Surg. 1998. 15: 412–415.
28. Ballard JL, Bergan JJ, DeLange M. Venous imaging for refl ux using
duplex ultrasonography. Noninvasive vascular diagnosis. AbuRahma
AF, Bergan JJ, eds. 2000. London: Springer-Verlag. 329.
29. Mekenas LV, Bergan JD. Venous refl ux examination: Technique using
miniaturized ultrasound scanning, J Vasc Technol. 2002. 26: 139.
30. Fischer R, Linde N, Duff C et al. Late recurrent saphenofemoral junction refl ux after ligation and stripping of the greater saphenous vein,
J Vasc Surg. 2001. 34: 236.
31. Ono T, Bergan JJ, Schmid-Schönbein GW et al. Monocyte infi ltration
into venous valves, J Vasc Surg. 1998. 27: 158.
32. Thulesius O, Ugaily-Thulesius L, Gjores JE et al. The varicose saphenous vein, functional and ultrastructural studies, with special reference
to smooth muscle, Phlebology. 3: 89, 1.
33. Mayo CH. Treatment of varicose veins, Surg Gynecol Obstet. 1906. 2:
385.
34. Babcock WW. A new operation for extirpation of varicose veins, NY
Med J. 1907. 86: 1553.
35. Keller WL. A new method for extirpating the internal saphenous and
similar veins in varicose conditions: A preliminary report, NY Med J.
1905. 82: 385.
36. Goren G, Yellin AE. Primary varicose veins: Topographic and hemodynamic correlations, J Cardiovasc Surg. 1990. 31: 672.
37. Stonebridge PA, Chalmers N, Beggs I et al. Recurrent varicose veins:
A varicographic analysis leading to a new practical classifi cation, Br J
Surg. 1995. 82: 60.
38. Goren G, Yellin AE. Invaginated axial saphenectomy by a semirigid
stripper: Perforate-invaginate stripping, J Vasc Surg. 1994. 20: 970.
39. Bergan JJ. Saphenous vein stripping by inversion: Current technique,
Surg Rounds. 2000. 118.
40. Bergan JJ. Varicose veins: Hooks, clamps and suction. Application of
new techniques to enhance varicose vein surgery, Semin Vasc Surg.
2002. 15: 21.
41. Ricci S, Georgiev M, Goldman MP. Ambulatory phlebectomy:
A practical guide for treating varicose veins, 2e. 2005. St Louis:
Mosby.
42. Darke SG. The morphology of recurrent varicose veins, Eur J Vasc
Surg. 1992. 6: 512.
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CHAPTER
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26
Neovascularization: An Adverse Response to
Proper Groin Dissection
MARIANNE DE MAESENEER
At the beginning of the twenty-fi rst century, surgical treatment of varicose veins continues to be marred by the development of recurrent varicosities. This has always been a
very disappointing phenomenon for patients and surgeons
alike. Most commonly, recurrent refl ux develops in the area
of the saphenofemoral junction (SFJ), causing recurrent
varicose veins from the thigh downward to the entire leg
(see Figure 26.1).1 Even in clinical centers with a special
focus on minimizing recurrence surgeons do not seem to be
able to avoid such disfi guring and often disabling recurrent
varicose veins.
Some causes of recurrence are obvious: insuffi cient
understanding of venous anatomy and hemodynamics, inadequate preoperative assessment, and incorrect or insuffi cient
surgery (most frequently too superfi cial ligation of the SFJ).
However, recurrence at the SFJ cannot always be explained
by technical inadequacy of the original surgical intervention.
Its development has also been attributed to neovasculariza-
tion in the granulation tissue around the ligated stump.2
Neovascularization is defi ned as new blood vessel formation
(= angiogenesis) occurring in abnormal tissue or in an abnor-
mal position. In some instances the growth of new blood
vessels from the surrounding tissue may be induced by
diffusible chemical factors (angiogenic factors). In the particular context of varicose recurrence after Great Saphenous
vein (GSV) surgery, the term neovascularization describes a
phenomenon of formation of new venous channels between
the saphenous stump on the common femoral vein (CFV)
and the residual GSV or its tributaries (see Figure 26.2).
Neovascularization is a distinctly uncommon fi nding when
the true SFJ has not been divided. However, when the SFJ
has been ligated properly, it is actually a marker of an anatomically correct operation, as well as the best explanation
for SFJ reconnections after such an operation.
Many surgeons only start to recognize the phenomenon
after having to reoperate on patients with recurrent varicose
veins some years after a previous varicose vein operation
“correctly” performed by themselves. The observations
during reexploration of the groin at the level of the
saphenofemoral junction then frequently show neovascularization as the explanation for the recurrence. Despite the
fact that this frustrating phenomenon frequently is encountered by each vascular surgeon, its nature and pathophysiology (hence its prevention) are poorly understood and the
subjects of intensive ongoing research.
A HISTORICAL PERSPECTIVE
Surgical ligation of the GSV above or below the knee has
been practiced for many centuries, starting with Paulus
of Aegina in 660 a.d. However it was not until the nineteenth century before the effect of ligation on the vein itself
and on the venous hemodynamic situation became better
understood.
In 1861, Langenbeck
happened with a vein after surgical ligation. He noticed that
a vein had a very important regeneration capacity and that
a new vein channel could be formed after ligation or extirpation of a piece of vein:
In one case of very large varix of the great saphena in a young man
I had extirpated the enlarged vein in the length of three inches and
ligated the upper and lower ends. One year later I found, in the
region of the scar tissue of the extirpation, a new vein channel of
the thickness of the quill of a crow’s feather, which again joined
the both ends of the fully functioning saphena.
Looking at his detailed description now, one and a half
centuries later, this could be considered as the fi rst real
3
described in detail what exactly
The Vein Book
239
All rights of reproduction in any form reserved.
Copyright © 2006, Elsevier Inc.
240 Chapter 26/Neovascularization: An Adverse Response to Proper Groin Dissection
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CFV
FIGURE 26.1 Prominent recurrent varicose veins with venous ulcer in
a 32-year-old man who underwent comprehensive saphenofemoral junction
ligation and stripping of the great saphenous vein above the knee 8 years
earlier.
description of formation of new veins after ligation (which
could possibly lead to recurrence of varicose veins later
on).
Throughout the nineteenth century, surgical treatment of
varicosity of the GSV was limited to simple ligation and
transection at a site in the thigh where there were relatively
few tributaries. Therefore it was obvious that, if recurrence
occurred, the cause was situated at the site of ligation in the
thigh. In the beginning of the twentieth century, Homans
4
introduced saphenofemoral junction ligation in the groin. He
advocated ligation of all tributaries to the terminal portion
of the saphenous vein to prevent restoration of venous continuity through a collateral network in the groin. From that
time, the theory of recurrence through preexisting collateral
veins gained ascendancy over the earlier theory of recurrence through growth of new vessels. Ever since, inadequate
operation by the previous surgeon was claimed to be the
main cause of recurrence. Only a minority believed that
recurrence also could occur after accurately performed
saphenofemoral ligation through formation of new vessels.
In explaining the genesis of this phenomenon, Sheppard
5
GSV
FIGURE 26.2 Diagram of neovascularization in the groin after correct
previous ligation of the Great Saphenous vein (GSV) and all tributaries
at the saphenofemoral junction, without stripping the GSV. A new vein
(arrow) is bulging at the anteromedial side of the common femoral vein
(CFV) and continues downward as a very tortuous vein, connecting again
with the retained GSV trunk. If the above knee GSV has been stripped, it
may connect with any other superfi cial vein remnant.
hypothesized that, “under the infl uence of the high femoral
pressure, the capillaries and venules in the granulation tissue
(of the newly forming scar) developed into dilated tortuous
channels.”
Starnes et al.
of varicose veins, which could occur even after skillful high
ligation. He was convinced that ascribing all thigh recurrences to a missed venous branch at the time of high ligation
of the saphenofemoral junction was too simple an explanation. In four out of six cases with clinical recurrence varicography demonstrated the presence of a new, tortuous
segment of vein at the site of the previous operation. The
proximal and distal cut ends of the GSV or one of its
branches had been rejoined by new vessels, described as “a
zigzag of recurrent vein joining the remnant of the GSV with
the femoral vein.”
6
described a radiological type of recurrence
Neovascularization: Today’s Evidence 241
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During the period 1950 to 1980, Glass
7–9
led surgeons to
focus again on recurrence of varicose veins after surgery
through “regrowth of veins.” He published his clinical and
experimental work concerning this problem, in 1987 mentioning the term neovascularization for the fi rst time.7 In this
study, a series of patients with venous ulceration due to GSV
insuffi ciency were treated in stages. First, a transection of
the GSV was performed in the lower part of the thigh and
all side branches at that site were ligated. In a second stage,
individually timed for each patient by healing of the ulcer,
the SFJ was ligated in combination with stripping of the
GSV. During the same operation the ends of the vein at the
site of the original transection in the lower thigh were
excised together with the tissue intervening between them.
The excised specimen was examined by injecting normal
physiologic solution into the distal segment. Continuity
between the proximal and distal cut end had been reestablished through small vessels after 40 weeks and through
larger dilated vessels after 64 weeks. The histological examination showed organization of the blood clot starting soon
after the operation, with blood vessels moving in from the
surrounding tissue. At six weeks, there was recanalization
of the thrombus occluding the vein and vessels started to
grow from the transected vein end. At 18 weeks it could be
observed that new vessels between the cut ends were
arranged in a parallel formation. At 40 weeks, continuity
of the vein had been completely restored through small
vessels, which were continuous with the transected vein
ends. The new vessels were very thin-walled with muscular
tissue. At the site of the previously closed vein end it seemed
to be reopened, establishing a new connection with the
surrounding tissue. He hypothesized that one of the important triggers for restoration of continuity was a large
pressure difference in a vein proximal and distal to the site
of transection.
He also studied the gross anatomy and histology at the
level of the SFJ during reexploration of the groin.
8,9
In the
majority of limbs a newly formed vessel or complex of
vessels was found in connection with the former saphenous
stump proximally and with varicose veins on the thigh distally. Macroscopic examination revealed several lumens in
an irregular mass of vein tissue and cords or bands traversing the lumen, which suggested that the vessels were newly
formed and not preexisting. Large lymph nodes were often
in close proximity to them. The histology confi rmed the
macroscopic fi ndings: an irregular vessel wall with a varying
thickness at different points of the circumference, often with
several lumens. Also typical was the presence of many small
vessels close to the newly formed vessel and in neighboring
lymph nodes. These studies clearly indicated that neovascularization had played an important role in recurrent saphenofemoral incompetence after a correctly performed SFJ
ligation.
NEOVASCULARIZATION:
TODAY’S EVIDENCE
Sonographic Evidence
Duplex scanning can provide the necessary anatomical
and functional information about the nature of recurrence
and has become the investigation of choice in patients with
recurrent varicose veins. Jones et al.10 found that neovascularization at the SFJ was the most common cause of recurrence in 113 legs two years after stripping of the GSV.
Typical serpentine tributaries arising from the ligated SFJ
were detected in 52% of limbs. Another duplex-based prospective study revealed some degree of neovascularization
in 14% of 177 limbs already at one year after fl ush saphenofemoral or saphenopopliteal junction ligation.11 The clinical relevance of fi nding neovascularization on postoperative
duplex ultrasound was examined in a long-term follow-up
study at the same institution almost fi ve years (56 months)
12
after the varicose vein operations.
In 68% of limbs with
clinically obvious recurrent varicose veins, neovascularization (with new veins of >4 mm diameter, pathological refl ux,
and connected to recurrent varicose veins) was present at
the site of the saphenous ligation on duplex examination,
whereas in limbs without recurrent varicose veins this degree
of neovascularization was seen in only 9% of cases (see
Figure 26.3). A reintervention was proposed to all patients
with disabling recurrent varicose veins and obvious neovascularization on duplex examination. Fifteen reinterventions
were performed. In all 15 reinterventions, newly formed
vessels were present exactly at the site of the previous saphenous ligation, which confi rmed the duplex fi ndings in all of
them. Histological examination of the excised tissue in
some of the reoperated cases illustrated the presence of
typical tortuous veins (see Figure 26.4). These fi ndings
demonstrate the clinical relevance of duplex-detectable
neovascularization in the long-term follow-up after varicose
vein operations.
Histopathological Evidence
Nyamekye et al.13 provided further evidence that neovascularization was the cause of recurrence. Histological examination of the venous tissue blocks, excised during groin
reexplorations, showed neovascularization in 27 of 28
blocks, characterized by vein tortuosity, small size, and
mural asymmetry and lack of intramural nerves on immunohistologically S100 stained sections. The authors drew
attention to the fact that a negative demonstration of a focal
structure, such as a mural nerve seen on S100 stained sections, is never entirely convincing and that a more useful
tool for the diagnosis of neovascularization was not yet
available. In spite of this warning, the fi ndings of his study
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