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252 Chapter 27/Principles of Ambulatory Phlebectomy
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phlebectomy is required, we allow three months to elapse;
this allows the infl ammatory response to improve at the
original AP sites.
AVOIDING NONTARGET TISSUES
If the treating physician heeds several important suggestions, complications will rarely be encountered. The venous
surgeon must have a thorough command of neurovascular
anatomy to avoid injury to nontarget tissues such as arteries
and nerves. Knowledge of the course of the common femoral
artery, superfi cial femoral artery, popliteal artery, and anterior and posterior tibial arteries will keep the surgeon from
injuring these structures while probing to exteriorize a varicose vein. It would be very diffi cult, although not impossible, to injure the profunda femoris or peroneal arteries during
AP. As stated earlier, the hook rarely needs to plunge deeper
than 3 mm to contact the target vein.
The saphenous and sural nerves are particularly prone to
injury below the knee because of their proximity to the Great
and Small Saphenous veins. If the saphenous or sural nerves
are displaced by the hook, the patient usually will complain
of shooting pain into the foot. This is a sign for the surgeon
to gently release the structure and replace it in situ. The
femoral, obturator, sciatic, tibial, and peroneal (common,
deep, and superfi cial) nerves are deep and generally not
disturbed in the hands of a competent surgeon. However,
when placing the post-operative compression bandage, the
deep peroneal nerve can be injured if the lateral fi bular
head is not properly padded. Occasionally, hair-sized sensory
cutaneous nerves are encountered and inadvertently extracted
during the course of AP. They are recognized as small
threads and the patient will feel acute sharp pain. The pain
usually dissipates after two to fi ve minutes without treatment. If this occurs in the ankle and foot area, chances are
that the patient will develop postoperative paraesthesias or
areas of dysesthesia that in most cases will be temporary.
14
techniques with either radiofrequency or laser have proven
to be the method of choice for eliminating the GSV from
the circulation.
19,20
Varicosities on the anterior thigh usually result from
Anterior Accessory Saphenous Vein (AASV) incompetence.
These veins usually course over the knee and into the lower
leg. Small Saphenous vein (SSV) refl ux produces varicosities on the posterior calf. When also present on the posterior
thigh, the surgeon must consider a cranial extension of the
SSV, which can be identifi ed with duplex ultrasound
imaging. Cranial extensions may enter the GSV (Giacomini
vein) or enter the femoral vein directly.
In cases where no “feeding source” is found, phlebectomy of the varicosities may be all that is required. Labropoulos21 has shown that varicose veins may result from a
primary vein wall defect and that refl ux may be confi ned to
superfi cial tributaries throughout the lower limb. Without
great and small saphenous trunk incompetence, perforator
and deep-vein incompetence, or proximal obstruction, his
data suggest that refl ux can develop in any vein without an
apparent feeding source. This is often the case when bulging
reticular veins are seen along the course of the lateral leg.
This lateral subdermic complex and its vein of Albanese are
often dilated and bulging in elderly patients. The underlying
source of venous hypertension is usually perigeniculate perforating veins, not easily identifi able with duplex imaging.
AP using an 18-gauge needle stab incision and a small
crochet hook for exteriorization of the vein is an excellent
procedure for this clinical problem. Perforating veins of the
thigh or calf also may become incompetent and be sources
of ambulatory venous hypertension. These can be treated by
a variety of techniques including ligation, subfascial endoscopic perforator surgery (SEPS), and ultrasound-guided
sclerotherapy (UGS).
AP VERSUS POWERED PHLEBECTOMY
TREATMENT OF VARICOSE VEINS
FROM NONSAPHENOUS ORIGINS
Bulging varicose veins on the surface of the skin can
originate from different sources. Identifi cation of these
sources is important because this infl uences the treatment
plan. Varicosities on the medial aspect of the thigh and calf
are usually the result of GSV incompetence. In order to
minimize the chance for recurrence, the GSV must be eliminated from the circulation. This concept has been substantiated in several prospective randomized clinical trials
involving patients who were treated with or without saphenectomy by conventional vein stripping.
rates for limbs without saphenctomy were much higher than
those with saphenectomy. Of course, now thermal ablation
15–18
The recurrence
In a published prospective comparative randomized trial
comparing AP with the new technique of transilluminationpowered phlebectomy (TriVex), there was no difference in
operating time. Although an incision ratio of 7 : 1 favored
TriVex, there was no perceived cosmetic benefi t among the
patient groups. There was a higher number of recurrences
in the TriVex group (21.2%; 7 of 33) compared with the
AP group (6.2%; 2 of 32) at 52 weeks postoperatively.
Assessment of pain scores showed no difference between
22
groups.
investigators.
These fi ndings have been supported by other
23–27
It is important to point out that all Trivex procedures were
performed in the hospital under general anesthesia, and the
cost of disposable equipment used for the TriVex procedure
was to $314 per patient. Because the trend for venous surgery
is offi ce-based, with local anesthesia, TriVex will likely fall
Offi ce-Based AP with Tumescent Anesthesia 253
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into disfavor in the future if modifi cations for offi ce use are
ignored.
AP VERSUS COMPRESSION
SCLEROTHERAPY
The combination of compression therapy with intravenous injection of a sclerosing agent for the treatment of
varicose veins was introduced in 1953.28 Early studies indicated compression sclerotherapy (Sclero) would be an effi cient addition to varicose vein surgery practiced at that time.
Although ambulatory phlebectomy was “invented” around
the same period,2 this technique required considerable time
to become well-established worldwide. There is one randomized controlled trial on recurrence rates and other complications after Sclero and AP. A total of 98 operations were
randomized to either AP (n = 49) or Sclero (n = 49)
in a total of 82 lateral accessory varicose veins (LAVs). In
this study, polidocanol was used in a 3% solution
(Aethoxysclerol; Kreussler & Co., Wiesbaden, Germany),
which is equivalent to 1.5% sodium tetradecyl sulfate. One
year after Sclero, 12 LAVs had recurred (25%), and only
one postphlebectomy LAV (2.1%). After two years, the
difference in recurrence was even larger because another
six recurrences developed, making a total of 18 recurrences
in the Sclero group (37.5%) and only one recurrence in the
AP group (2.1%). The authors of the study concluded that
AP is the treatment of choice for LAV.
29
AP FOR OTHER AREAS OF THE BODY
Foot
agent near the eye or use it in substantially lower concentrations and volumes. This is due to fear that the solution may
travel to unintended areas of venous circulation such as the
central retinal vein, choroidal vortex veins, or even the cavernous sinus via valveless anastomoses.33 Blindness has
been reported following STS injection into a venous malformation partially located in the orbit.
34
Ambulatory phlebectomy of the periocular vein avoids
the concerns regarding thrombotic phenomena within ocular,
orbital, or cerebral veins possibly associated with periocular
vein sclerotherapy. Weiss35 reported excellent results on 10
patients who underwent removal of periocular reticular blue
veins by AP. A single puncture with an 18-gauge needle
suffi ced in most cases. It is important to attempt to remove
the entire segment, as partial resection may lead to recurrence. The use of postoperative compression for 10 minutes
reduces the incidence of bruising. The puncture sites typically disappear quickly without leaving scars.
Hands
In general, inquiries about hand vein treatment come
from elderly women who fi nd them unsightly. Often, they
have had prior facelift surgery and worry that their hands
need rejuvenation to complement the face. Our initial consultation stresses the importance of hand veins for reasons
of intravenous access, furthermore, removal of these veins
may require central venous access should the patient be
hospitalized in the future. If attempts to dissuade the patient
fail, we recommend AP as the procedure of choice for hand
vein removal. It is performed identical to leg vein treatment,
and closely resembles treating the dorsum of foot because
of the thin skin overlying the area. Results have been
excellent.
In recent years there have been several publications on
the use of AP for the treatment of varicose veins of the foot
and ankle region.
30–32
There are patients who present with
serious phlebologic complaints of varicosities of the foot
and ankle region that can be alleviated through simple treatment. The venous anatomy of the foot with many parallel
veins is complicated; however, safe treatment is possible.
The skin of the foot is thin and fi brotic. Further, there is
minimal subcutaneous fat, less protection against trauma of
the skin, and important underlying tissues such as tendons,
tendon sheaths, and joints. There are more small nerve
branches that can be damaged by the hook. As in the popliteal space, there is greater risk of injuring an artery. Moreover, it is possible to grasp and avulse a tendon.
Eyelid
Many ophthalmic plastic surgeons and dermatologic surgeons experienced in sclerotherapy avoid the use of this
OFFICE-BASED AP WITH
TUMESCENT ANESTHESIA
Although there are reports of death and serious complications with tumescent anesthesia, these have largely been
found in the plastic surgery literature.36 Complications are
described when tumescent anesthesia is used in conjunction
with intravenous sedation, and/or general anesthesia.37
Coldiron et al. recently studied State of Florida data over a
four-year period to help clarify actual adverse events occurring in the offi ce setting. There were 77 events reported to
the Florida Agency for Health Care Administration (ACHA)
from March 1, 2000, to March 1, 2004. Liposuction performed under general anesthesia was the most frequent
procedure reported. Five reported deaths and 14 transfer
incidents occurred as a complication of liposuction (with or
without another associated procedure) under general anesthesia or deep sedation. According to the Florida data, there
254 Chapter 27/Principles of Ambulatory Phlebectomy
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Before
After
A
FIGURE 27.4 Before and after photos.
were no problems associated with liposuction using dilute
or tumescent anesthesia.38 Similarly, a malpractice claims
study by Coleman and colleagues study supported the safety
of offi ce-based liposuction performed by dermatologists
using tumescent anesthesia for small-volume fat removal.39
In addition, Housman and colleagues surveyed 261 dermatologic surgeons performing a total of 66,570 liposuction
procedures and found a low rate of serious adverse events
(0.68 per 1000) and no reports of associated deaths.40 All
three studies support the safety of tumescent liposuction
performed by dermatologists in an offi ce setting.
Because the tumescent anesthetic technique for venous
procedures has been adopted from the liposuction community, we feel these data are relevant to subcutaneous venous
surgery using dilute tumescent anesthesia. There have been
no adverse events reported to the Florida ACHA as a result
of varicose vein surgery using tumescent anesthesia.
Advantages of offi ce-based surgery are ease of scheduling for doctor and patient, less paper work (unnecessary
duplication of information and record keeping), no waiting
for other surgeons to fi nish their operations, elimination of
travel time, and cost containment for the health care system.
Furthermore, a staff that performs the same procedures daily
is more streamlined and safe.
B
CONCLUSION
Ambulatory phlebectomy is elegant by its mere simplicity. It is effective and safe with acceptable cosmetic results
(see Figure 27.4). AP is a perfect complement to endovenous thermal ablation of the saphenous veins. With this
combination, patients can expect all varicose veins to vanish
following a one-hour procedure that employed only local
anesthesia, in the comfort of a physician’s offi ce.
References
1. Celsus AC. Medicinae Libri Octo, Patavii. Typis Seminarii Apud
Joannem Manfre, Liber Septimus. 1749. 473–474.
2. Muller R. Traitement des varices par la phlebectomie ambulatoire,
Phlebologie. 1966. 19: 277–279.
3. Goren G, Yellin AE. Surgery for varicose veins: The ambulatory stab
avulsion phlebectomy, Am J Surg. 1991. 162: 166–174.
4. Weiss RA, Goldman MP. Transillumination mapping prior to ambula-
tory phlebectomy, Dermatol Surg. 1998. 24: 447–450.
5. Proebstle TM, Paepcke U, Weisel G, Gass S, Weber L. High ligation
and stripping of the long saphenous vein using the tumescent technique
for local anaesthesia, Dermatol Surg. 1998. 24: 149–153.
6. Klein JA. The tumescent technique for liposuction surgery, Am J
Cosmet Surg. 1987. 4: 263–267.
References 255
https://t.me/med1917
7. Cohn MS, Seiger E, Goldman S. Ambulatory phlebectomy using the
tumescent technique for local anaesthesia, Dermatol Surg. 1995. 21:
315–318.
8. Klein JA. Tumescent technique for local anaesthesia improves safety
in large-volume liposuction, Plast Reconstr Surg. 1993. 92: 1085–
1098.
9. Keel D, Goldman MP. Tumescent anaesthesia in ambulatory phlebectomy: Addition of epinephrine, Dermatol Surg. 1999. 25: 371–372.
10. Schmid RM, Rosenkranz HS. Antimicrobial activity of local anaesthetics: Lidocaine and procaine, J Infect Dis. 1970. 121: 597.
11. Ricci S. Ambulatory phlebectomy: Principles and evolution of the
method, Dermatol Surg. 1998. 24: 459–464.
12. Olivencia JA. Complications of ambulatory phlebectomy: Review of
1,000 consecutive cases, Dermatol Surg. 1997. 23: 51–54.
13. Gauthier Y. Incidents and complications. In: Dortu J, RaymondMartimbeau P, eds. Ambulatory Phlebectomy/Phlebectomie Ambulatoire. Houston: PRM Editions. 1993. 109–112.
14. Ramelet AA. Complications of ambulatory phlebectomy, Dermatol
Surg. 1997. 23: 947–954.
15. Jones L, Braithwaite BD, Selwyn D, Cooke S, Earnshaw JJ. Neovascularisation is the principal cause of varicose vein recurrence: Results
of a randomized trial of stripping the long saphenous vein, Eur J Vasc
Endovasc Surg. 1996. 12(4): 442–445.
16. 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(4): 634–639.
17. 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(4): 589–592.
18. 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(10): 1455–1458.
19. 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.
20. Merchant RF, Pichot O, Myers KA. Four-year follow-up on endovascular radiofrequency obliteration of great saphenous refl ux, Dermatol
Surg. 2005. 31(2): 129–134.
21. Labropoulos N, Kang SS, Mansour MA, Giannoukas AD, Buckman J,
Baker WH. Primary superfi cial vein refl ux with competent saphenous
trunk, Eur J Vasc Endovasc Surg. 1999. 18(3): 201–206.
22. Aremu MA, Mahendran B, Butcher W, Khan Z, Colgan MP, Moore
DJ et al. Prospective randomized controlled trial: Conventional versus
powered phlebectomy, J Vasc Surg. 2004. 39(1): 88–94.
23. Spitz GA, Braxton JM, Bergan JJ. Outpatient varicose vein surgery
with transilluminated powered phlebectomy, Vasc Surg 2000. 34:
547–555.
24. Arumugasamy M, McGreal G, O’Connor A, Kelly C, Bouchier-Hayes
D, Leahy A. The technique of transilluminated powered phlebectomy:
A novel minimally invasive system for varicose vein surgery, Eur J
Vasc Endovasc Surg. 2002. 23: 180–182.
25. Scavée V, Theys S, Schoevaerdts J-C. Transilluminated powered miniphlebectomy: Early clinical experience, Acta Chir Belg. 2001. 101:
247–249.
26. Cheshire N, Elias SM, Keagy B et al. Powered phlebectomy (TriVex)
in treatment of varicose veins, Ann Vasc Surg. 2002. 16: 488–494.
27. Scavée V, Lesceu O, Theys S, Jamart J, Louagie Y, Schoevaerdts JC.
Hook phlebectomy versus transilluminated powered phlebectomy for
varicose vein surgery: Early results, Eur J Vasc Endovasc Surg. 2003.
25: 473–475.
28. Fegan WG. Continuous compression technique for injecting varicose
veins, Lancet 1963. 20(2): 109–109.
29. De Roos KP, Nieman FH, Neumann HA. Ambulatory phlebectomy
versus compression sclerotherapy: Results of a randomized controlled
trial, Dermatol Surg. 2003. 29(3): 221–226.
30. Olivencia JA. Ambulatory phlebectomy of the foot; review of 75
patients, Dermatol Surg. 1997. 23: 279–280.
31. Muller R. Traitement des varices du pied par la phlebectomie ambu-
latoire, Phlebologie. 1990. 43: 317–318.
32. Constancias-Dortu I. Indications therapeutiques de la phlebectomie
ambulatoire, Phlebologie. 1987. 40: 853–858.
33. Fante RG, Goldman MP. Removal of periocular veins by sclerotherapy, Ophthalmology. 2001. 108: 433–434.
34. Siniluoto TM, Svendsen PA, Wikholm GM, Fogdestam I, Edstrom S.
Percutaneous sclerotherapy of venous malformations of the head and
neck using sodium tetradecyl sulphate (sotradecol), Scand J Plast
Reconstr Surg Hand Surg. 1997. 31: 145–150.
35. Weiss RA, Ramelet AA. Removal of blue periocular lower eyelid veins
by ambulatory phlebectomy, Dermatol Surg. 2002. 28(1): 43–45.
36. Rao RB, Ely SF, Hoffman RS. Deaths related to liposuction, N Engl
J Med. 1999. 340: 1471–1475.
37. Hanke CW, Bernstein G, Bullock S. Safety of tumescent liposuction
in 15,336 patients, Dermatol Surg. 1995. 21: 459–462.
38. Coldiron B, Fisher AH, Adelman E, Yelverton CB, Balkrishnan R,
Feldman MA, Feldman SR. Adverse event reporting: lessons learned
from 4 years of Florida offi ce data, Dermatol Surg. 2005. 31(9): 1079–
1093.
39. Coleman W, Hanke C, Lillis P et al. Does the location of the surgery
or the specialty of the physician affect malpractice claims in liposuction? Dermatol Surg. 1999. 25: 343–347.
40. Housman TS, Lawrence N, Mellen BG et al. The safety of liposuction:
Results of a national survey, Dermatol Surg. 2002. 28: 971–978.
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CHAPTER
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28
Powered Phlebectomy in Surgery of
Varicose Veins
STEVE ELIAS
PREMISE
The generic name of the TriVex technique is transilluminated powered phlebectomy (TIPP). TriVex is a mechanical
method used to remove tributary varicose veins that normally would be excised with the traditional techniques
of stab avulsion and hook phlebectomy. The indications
for TriVex are the same as for the use of traditional
procedures.
INSTRUMENTATION
The TriVex system consists of a transilluminator/irrigator (see Figure 28.1) and a powered resector (see Figure
28.2). The transilluminator/irrigator is placed subcutaneously to provide for visualization of the varicose veins and
instillation of the tumescent fl uid (see Figure 28.3). Utilizing
the powered resector with its rotating blade on suction mode,
the varicosities are removed (see Figure 28.4). TriVex has
been described as “liposuction of the veins.” The resector is
a modifi cation of an arthroscopic shaver. The complete upto-date step-by-step technique will be described later, in a
subsequent section of this chapter.
The advantages of the TriVex technique compared to
traditional open surgery are speed, effi ciency, decreased
number of incisions, and more complete removal due to
direct visualization of the target veins. Fewer residual and
recurrent varicosities are also a theoretical possibility, again,
due to a more complete removal of the primary targets.
These are presumptive advantages and, in fact, most have
been realized.
THE BEGINNING
The TriVex system was developed in 1996 by Greg Spitz,
MD, a surgeon from Aurora, Illinois. He was looking for a
faster, more effi cient way to remove varicose veins. It was
a Friday afternoon and Greg was on his third or fourth
extensive bilateral vein case. He asked the scrub nurse if
there was anything available to more quickly excise the
varicose veins. Together they decided to try a small
arthroscopic shaver used to treat carpal tunnel syndrome.
This seemed to work. Later on, specifi c instrumentation to
allow visualization and transillumination with a modifi ed
cystoscope was developed.
After a series of modifi cations and the addition of tumescent anesthesia for hydrodissection, the essential components of the system were in place. Eventually, these included
a transilluminator/irrigator, which is similar to the present
device, and a resector, which was still a modifi ed arthroscopic
shaver with a 4.5 mm blade.
Spitz’s original experience was reported fi ve years ago.1
His original description of the technique is very similar to
the present-day method with some modifi cations. “The
TriVex System” combination tumescent anesthesia delivery
system and illuminator were used to select sites for the local
anesthesia. Transillumination was obtained with light from
a 45-degree illuminator specifi cally designed for this
purpose. Varicose clusters were extracted by use of a modifi cation of Smith and Nephew EP-1 endoscopic powered
tissue dissector. Then, as now, this device is a rotating,
tubular inner blade encased in a protective stationary outer
sheath. The working opening is placed adjacent to the varicosities, which are then aspirated, morcellated, and removed
The Vein Book
257
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258 Chapter 28/Powered Phlebectomy in Surgery of Varicose Veins
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FIGURE 28.1 Original transilluminator/irrigator.
FIGURE 28.3 Instillation tumescent fl uid.
FIGURE 28.4 Resection varicosities.
FIGURE 28.2 Original powered resector.
by irrigation suction. Control of vein removal is through a
handpiece that directs the vein fragments into a container
connected to hospital wall suction.
1
As reported, the initial results were encouraging. The
operation appeared faster (41 vs. 75 minutes) and required
fewer incisions (5.6 vs. 17). Cellulitis, hematoma, signifi cant bruising, and swelling were recorded as complications.
However, cosmetic scores appeared acceptable.
The discussion following the initial presentation commented, “Despite knowing that change is constant, who
would have thought that change would occur in routine
varicose vein surgery. Yet change has occurred. This presentation by Spitz demonstrates ingenuity and imagination
in pursuing development of a dedicated tool for better
removal of venous varicosities.” TriVex was now ready for
a larger clinical trial.
Initial Clinical Trial and Technique 259
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FIGURE 28.6 Transillumination intra op.
Trendelenburg position. An initial 3 mm incision was made
FIGURE 28.5 Pre-op marking.
INITIAL CLINICAL TRIAL
AND TECHNIQUE
The initial clinical trial consisted of centers in the United
States (4) and Europe (4), in which we participated.2 Prior
to instituting the trial, Spitz visited each site or the participants visited him to gain hands-on proctored experience.
This, of course, insured relative consistency of methodology. There were variations developed on the original theme
especially regarding irrigation pressure devices.
The technique ultimately used in the trial was very similar
to that described in Spitz’s original presentation. For purposes of understanding, the original technique and technology are described next, because these have implications
regarding the subsequent modifi cations. The technique
being described is the original method and not the present
modifi cation.
Initial patient evaluation is exactly as is traditional in
varicose vein surgery. Full duplex imaging is obtained and
all abnormal vein segments are identifi ed and marked. The
markings are placed around the veins and not directly on the
varices themselves (see Figure 28.5). The reason for not
placing markings directly over the veins is that these may
be misinterpreted under transillumination as residual unresected veins. Saphenous incompetence is managed by surgeon’s choice, laser (EVLT), radiofrequency (VNUS), or by
traditional stripping.
The operation was done using general, spinal, or laryngeal mask airway anesthesia with the patient positioned in
just outside the marked area of varicosities. The transilluminator/irrigator was placed subcutaneously and distal to the
level of the veins The room lights were dimmed for better
transillumination (see Figure 28.6).
The fi rst stage of tumescence was infused using a mixture of 40 cc of 2% xylocaine and 1 cc epinephrine in a liter
of saline. This is infused using a pressure bag, high pressure
blood transfuser, or a peristaltic pump as that used for
liposuction.
As will be discussed later, infusion techniques became a
signifi cant variable.
The tumescent fl uid hydrodissects the veins, partially
exsanguinates the veins, and allows better diffusion of light
in the subcutaneous tissue.
After the fi rst stage of tumescence, the veins are ready
for resection. A second 3 mm incision is made, preferably
180º from the fi rst incision. The resector is passed subcutaneously immediately beneath the veins in a more superfi cial
plane than the illuminator (see Figure 28.7). The resector
targets the veins and these are suctioned into the rotating
blade, morcellated, and removed (see Figure 28.4).
Most of the veins are removed with the fi rst pass. The
operator should not go back and forth over a resected area,
as more bruising will occur. The skin lying over the area of
resection is kept taut to minimize skin trauma and stabilize
the veins that are being resected (see Figure 28.8). To treat
other areas, the resector is removed and redirected. Shearing
through tissue is therefore minimized. To reach more distant
areas the resector and irrigator/illuminator ports may be
reversed or inserted through other incisions.
After resection, a second stage tumescence is infused.
This has a two-fold goal: irrigation and removal of any
residual blood and creation of subcutaneous pressure to
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incisions required were three. Most patients were happy
with the results. Complications did occur: hematoma, subcutaneous scarring, bruising, and hyperpigmentation were
the most notable.
CLINICAL TRIAL AND
TECHNIQUE DISCUSSION
Every procedure has a learning curve. Changes were
made to address the technique and technology issues that
were identifi ed in the initial experience. These led to a better
procedure, thus giving the present excellent results.
We entered the maximum number of cases (20) that could
be entered into the trial and patients operated upon later in
FIGURE 28.7 Level of resector.
FIGURE 28.8 Resection with skin tension.
the series did better than those treated earlier. Overresecting
and shearing through tissue caused some of the subcutaneous scarring and bruising. In the beginning it was not appreciated by most of us that veins were removed with the fi rst
pass of the resector. This lead to overresecting. After a vein
segment is resected blood fi lls that resected channel from
either end of the resected vein. This can appear as an
unresected vein and the operator may re-resect the area
leading to excessive subcutaneous trauma. The resection
vein site does appear different from an unresected vein. It
appears as if a vein has been smudged and has a less defi ned
outline.
Hematoma and hyperpigmentation are caused by residual
trapped blood. The initial technique called for closing incisions with steri-strips or suture to keep the second stage
tumescence in the subcutaneous tissue to help tamponade
bleeding from the ends of the resected veins. This of course,
did not enhance drainage of any residual blood.
tamponade the ends of resected veins. Enough fl uid is
infused to create a peau d’orange effect on the skin. The
incisions are closed with steri-strips and overwrapped with
an absorbent compression dressing.
Postoperatively, the leg is redressed on the second or
third day, and compression stockings are prescribed for two
to three weeks.
Initial visual results are usually good. Bag Balm, an ointment with hydroquinilone, is used with massage to help
minimize scarring and hasten subcutaneous healing.
This was the technique and technology for the initial
trial. This was also the technique that was taught and used
during the initial three years of TriVex use. Results of the
clinical trial were good. The procedure was relatively quick:
14 minutes for phlebectomy and 45 minutes for phlebectomy and saphenous excision. The median number of
CLINICAL TRIAL TECHNOLOGY ISSUES
As mentioned previously, the irrigator/illuminator was
used with various pressure infusion devices. This did not
allow standard instillation of fl uid for tumescence or for
evacuation of blood post resection. Various trial centers
were able to be highly effective, whereas others could
not attain signifi cant fl ow rates. This lead to residual
hematomas.
Blade speeds of 800–1000 rpms were used. In general
4.5 mm (smaller) blades were used. Both of these factors did
not allow suction to be applied adequately to the veins to be
resected due to the small blade aperture. Some residual segments were left and areas needed multiple passes to resect
veins. This enhanced subcutaneous scarring.
The counterintuitive notion of slow blade speeds and
larger blades being less traumatic did not surface until later
in the experience.
Results 261
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SUMMARY OF INITIAL TRIAL
Despite some of the shortcomings identifi ed earlier, most
patients and surgeons participating in the trial were quite
happy. The procedure was faster, required less incisions, and
was more enjoyable and less tedious than traditional procedures. Cosmetic scores and patient satisfaction scores were
acceptable.
EARLY RESULTS AND EXPERIENCE
After the initial clinical trial, training of other physicians
began. This consisted of a variety of methods. Didactic
presentations were held throughout the country. Training
also involved observing cases, hands-on experience, as well
as proctoring of initial cases. Many surgeons began to utilize
the technique; the appeal being a faster, more complete vein
removal with fewer incisions.
As more surgeons became involved, a number of technical and technological issues began to surface. From a
technology perspective there was not standardization of
irrigation and tumescent infusion. A variety of devices were
used, including pressure bags, gravity, blood infusers,
laparoscopic irrigators, and peristaltic pumps. These all
delivered varying rates and pressures of infusion. The dictum
was to use the highest pressure available, but that varied
from institution to institution. This led to signifi cant residual
subcutaneous blood and, at times, hematomas requiring
drainage.
Another technological issue was blade size. Most surgeons utilized the smaller original blade at 1000 rpm. This
led to excessive mechanical trauma and less effi ciency in
suctioning veins into the blade. From a technique viewpoint,
some surgeons did not appreciate the damage that a patient
could incur if one was rough and swept through the subcutaneous tissue when one was resecting. The concept of “targeted gentle” resection was not always adhered to. Many
surgeons continued the pulling and tugging required during
traditional techniques.
The instillation of second stage tumescence after vein
resection and the closure of incision sites led to trapped
blood and fl uid, not allowing adequate drainage. The original thinking was that the pressure of tumescence would
tamponade the ends of resected veins, and minimize bleeding. What did occur in some cases was prolonged subcutaneous edema from the tumescence. Most edema did resolve
over a period of time.
Despite some of these issues, many surgeons gained
signifi cant experience and results continued to improve.
Groups then began reporting results with very consistent
fi ndings.
RESULTS
The original reported results of Spitz et al. continued to
be obtained by other investigators. At the core were consistent fi ndings: shorter procedure, decreased number of incisions, similar patient satisfaction, and similar complication
rates, when compared to traditional methods.
results with experience was expected and was echoed by a
number of investigators.
5,6
The resection of extensive varicosities was an area in which TriVex was found to be signifi cantly faster than traditional procedures.
time varied between investigators but most were within the
range of 12 to 30 minutes for the TriVex part of the proce-
2,3,7
dure.
This difference became more important and
achieved greater statistical signifi cance as the extent of
resected varicosities increased.
The initial multicenter safety and effi cacy trial had an
average phlebectomy time of 14 minutes and the median
2
number of incisions as 3.
All other reports showed a signifi cant decrease in incisions ranging from 3.6 reported by
Arumugasamy to 4.0 (compared to 18.9) attained by RayChaudhuri et al. in a prospective trial. In the only prospective randomized trial Aremu et al. found a signifi cant
difference between traditional (29) and TriVex (5) incisions
(p < .0001). What is also clear and consistent is the conclusion that post-op pain scores, patient satisfaction, patient
cosmetic scores, and complication rates are essentially the
same as traditional methods. Ray-Chaudhuri et al. compared
post-operative pain scores with the results after 14 days
being 2.6 (traditional) and 1.9 (TriVex) (NS). Mean cosmetic scores were also similar 6.9 (traditional) and 5.9
(TriVex) (NS).3 Scavee, after gaining experience, reported
midterm clinical experience.8 The mean pain score at six
weeks was 0 (no pain) for TriVex. Patient satisfaction and
patient cosmetic scores showed no signifi cant differences in
the two randomized trials.
3,4
This was fi rst pointed out in
Spitz’s original report. Complications do occur and have
been reported. The rates appear to be similar to conventional
procedures. Arumugasamy et al. reported that, “bruising was
seen in nearly all patients at 1 week and this settled between
6–12 weeks later.”
7
Mackay9 reported a 66% incidence of perceived complications, including bruising, within the fi rst two weeks
following conventional surgery. Aremu et al. in a prospective randomized trial found no difference with regard to
bruising, cellulitis, or numbness between techniques. Nerve
injury was 3% at one year.
4
The learning curve has been discussed by a number of
investigators. It is no surprise that earlier cases resulted in
poorer results and experience improved results. Scavee in
his midterm trial results states “our initial clinical experience
was associated with a high rate of hematoma formation,
especially in the calf region, resulting from our learning
3–5
Improved
3,4
Operative
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