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292 Chapter 32/Treatment of Small Saphenous Vein Refl ux
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approximately one-quarter of limbs, with fl ow continuing up
2,4
the TE.
The SPJ is within 4 cm above the knee skin crease in
approximately two-thirds of limbs and it is usually higher
than this level in the rest joining the proximal popliteal or
femoral vein,2 although a low junction or termination in the
upper calf to the gastrocnemius veins or GSV has been
described.4 The SPJ is frequently medial or lateral to the
midline.10 Ultrasound has shown that the junction is on the
posterior aspect of the deep vein in just 15%, to the medial
or lateral side in approximately 85%, and even anterior
11
in 1%.
If an operation is to be performed to ligate the SSV fl ush
with the popliteal vein then it is essential to know the junction is present and its exact location.
SURGICAL PATHOLOGY
Superfi cial and Deep Venous Refl ux
Ultrasound shows that the larger proportion of limbs have
superfi cial refl ux with or without deep refl ux and that deep
refl ux alone is uncommon, although the prevalence of deep
refl ux increases with increasing clinical severity (see Table
32.1).3 The prevalence of SSV refl ux increases according to
the presence and extent of deep refl ux.5 Cavezzi and colleagues found that approximately three-quarters of limbs
with SSV refl ux had associated femoral or popliteal refl ux
and that this deep refl ux usually was abolished by SSV
surgery.6 They also found that although most limbs show
refl ux after release of calf compression during ultrasound
scanning, a few show fl ow through the SPJ during calf
compression, particularly where the destination for refl ux is
into the vein of Giacomini.
6
Refl ux in the SSV Territory
Approximately one-third of all limbs with saphenous
refl ux have refl ux in the SSV territory and the proportion of
limbs with SSV refl ux increases with increasing severity of
clinical disease (see Table 32.2).
for refl ux in the SSV territory, and the SPJ is competent in
approximately one-third of limbs with refl ux from other
connections (see Table 32.3).
common along the length of the SSV.
SSV refl ux is a signifi cant risk factor for recurrence of
venous ulceration.5 Ulcers associated with GSV refl ux may
be on any aspect of the leg, but ulceration over the lateral
aspect of the ankle usually is associated with SSV refl ux,
often without associated pigmentation or eczema.
Superfi cial thrombophlebitis of the SSV may have a
higher incidence of associated contiguous or noncontiguous
deep venous thrombosis than for the GSV, occurring in
approximately two-thirds of patients in one ultrasound
13
study.
3,5
There are various sites
2,6
Aneurysmal dilatations are
12
10
FIGURE 32.1 Course and terminations of the SSV and TE at the back
of knee and thigh. VG, vein of Giacomini.
TABLE 32.1 An Ultrasound Study of Proportions of Limbs with Refl ux in the Superfi cial and Deep Veins in Relation to the
Clinical Severity of Venous Disease (Myers and colleagues—unpublished data)
Venous refl ux C2–3 number % C4–6 number % Total number %
Superfi cial alone 1626 89% 65 42% 1691 85%
Superfi cial and deep 172 9% 73 47% 245 12%
Deep alone 29 2% 16 11% 45 3%
Total 1827 154 1981
Refl ux in the TE and Vein of Giacomini
Ultrasound has shown that refl ux in the TE and vein of
Giacomini is far more likely to occur in association with
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TABLE 32.2 An Ultrasound Study of Proportions of Limbs with Refl ux in the GSV or SSV in Relation to the Clinical Severity of
Venous Disease (Myers and colleagues—unpublished data)
Superfi cial refl ux C2–3 number % C4–6 number % Total number %
GSV alone 1255 70% 65 47% 1320 68%
SSV alone 242 13% 31 23% 273 14%
GSV & SSV 301 17% 42 30% 343 18%
Total 1798 138 1936
TABLE 32.3 An Ultrasound Study of the Sources and Destinations of Refl ux into the SSV Territory (Myers et al.3)
Distal destinations
Proximal connections SSV only SSV & VG VG only SSV tributaries Total proximal connections
SPJ only 169 11 5 1 186 (56%)
SPJ & VG 10 — — — 10 (3%)
VG only 54 — — 1 55 (17%)
GSV tributaries 55 — — 2 57 (17%)
Perforators 11 — — — 11 (3%)
Unknown 15 — — — 15 (4%)
Total distal destinations 314 (94%) 11 (4%) 5 (1%) 4 (1%)
TABLE 32.4 An Ultrasound Study of the Frequency of
Association between Refl ux in the TE or Vein of Giacomini
and Refl ux in the GSV or SSV (Georgiev et al.
Number with % with
Saphenous refl ux Number TE refl ux TE refl ux
GSV alone 922 6 1%
SSV alone 138 23 17%
GSV & SSV 166 47 28%
Total 1226 76 6%
SSV than GSV refl ux (see Table 32.4).
2
)
1,4
Saphenofemoral or
pelvic vein incompetence can result in proximal to distal
fl ow to the SSV through the TE or vein of Giacomini, and
saphenopopliteal incompetence can result in distal to proximal fl ow through these veins from the SSV to GSV or thigh
tributaries (see Figure 32.2).
1
Gastrocnemius Vein Refl ux
Refl ux into gastrocnemius veins is reasonably common.14
It may be symptomatic, causing aching from calf congestion; this is frequently without evidence of superfi cial varicose veins. Treatment may require fl ush ligation at the
junction with the popliteal vein or excision of the terminal
SSV if the gastrocnemius veins drain to the SSV. However,
recurrence after ligation is common due to failure to ligate
all connections or revascularization.
14
Outward Flow in Perforators
We detected outward fl ow in perforators in the calf in
30% and thigh in 4% in limbs with SSV refl ux and primary
TABLE 32.5 An Ultrasound Study of the Sources and
Destinations for Refl ux through the TE or vein of Giacomini
from Proximal Sources to the SSV or from the Distal SSV to
Proximal Destinations (Georgiev et al.
Destination Number with % with
Source of refl ux of refl ux TE refl ux TE refl ux
GSV SSV 15 20%
Thigh veins SSV 18 24%
Pelvic veins SSV 20 26%
Total distal refl ux 70%
SSV GSV 18 24%
SSV Thigh veins 5 6%
Total proximal refl ux 30%
2
)
varicose veins, and this was not signifi cantly different from
limbs with GSV refl ux.2 There is debate as to whether perforators with valvular incompetence are an avenue for
outward fl ow into superfi cial varicose veins or whether perforators act as safety valves for blood to escape from
diseased superfi cial veins to be removed through normal
functioning deep veins.
Mechanisms for Refl ux
Ultrasound shows that in most limbs, SSV refl ux is associated with one or more intact valves in deep veins above
the SPJ or indeed at the junction itself. There is no large
central pool of blood for refl ux into the SSV. The routine
maneuvers of calf compression or cuff infl ation during ultrasound scanning result in approximately 20 to 30 ml of blood
refl uxing from the deep veins to SSV if the SPJ is incompetent. This equates to the volume in a 5 to 10 cm length of
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FIGURE 32.2 Refl ux through the vein of Giacomini from the GSV territory to the SSV (1) and from the SSV to the
GSV territory (2).
deep vein above and below the junction that acts as the reservoir for fl ow. This is approximately the length expected in
the adjacent deep veins between competent valves.
Ultrasound examination is the standard method to detect
SSV refl ux and advise appropriate treatment. However, it is
probable that the examination bears little relation to the
everyday hemodynamics during standing and walking,
which are poorly understood. Current concepts hold that the
primary abnormality for varicose disease commences in the
saphenous veins and tributaries, with secondary functional
valvular incompetence in many limbs as dilatation reaches
the proximal junctions. Accordingly, it would be naive to
anticipate that simple interruption at the junction would
restore normal venous function. There is undoubtedly a
complex interaction of antegrade and retrograde fl ow through
the SSV and deep veins, and fl ow in either direction through
some calf perforators in the presence of disease. This suggests that destruction of the entire diseased segment of SSV
and TE is required for best results from treatment. This is
not common surgical practice.
DIAGNOSIS
Clinical
Inspection, palpation, and the percussion test may reveal
a dilated SSV or tributaries behind knee in the SSV territory,
but provide no information regarding the SPJ. Tourniquet
tests are of little value for refl ux into the SSV if there are
competent valves in deep veins above the SPJ preventing
deep refl ux, as is very frequently the case. Even if there is
full length deep refl ux, it is diffi cult to be sure that a tourniquet selectively occludes superfi cial veins and not deep
veins. Interpreting results in patients with combined GSV
and SSV refl ux is diffi cult.
Continuous-Wave (CW) Doppler
The handheld CW Doppler probe is considered by many
to be a convenient way to record popliteal vein or SSV
refl ux, but it will provide false-positive results that could
lead to unnecessary popliteal fossa exploration in at least
10%.15 CW Doppler cannot defi ne variations in anatomy and
in particular the information required regarding the SPJ. CW
Doppler is widely used to exclude SSV refl ux because it has
a low false-negative rate, but this seems pointless if the
policy is to perform routine duplex ultrasound scanning.
Duplex Scanning
Many surgeons now routinely request a duplex ultrasound scan prior to treatment for varicose veins.16 Anatomy
needs to be defi ned prior to treating SSV refl ux. However,
results are reliable only if performed by specialist vascular
sonographers or sonologists. A survey from the Vascular
Surgical Society of Great Britain and Ireland17 found that
90% of surgeons obtained duplex scans in all patients with
suspected SSV refl ux. In addition, approximately 60% routinely obtained a further scan to mark the SPJ and SSV
immediately before operation. A British report found that the
preoperative scan did not improve outcome after SSV
surgery, but the recurrence rate was high with or without
preoperative scanning.
18
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Our technique is to examine with the patient standing and
knee slightly fl exed with weight taken on the opposite side
and we prefer to test for refl ux with manual calf compression
and release. The routine scan for the SSV territory is to
examine for pathology including:
• Incompetence at the SPJ
• Refl ux in the popliteal vein proximal and distal to the
SPJ, SSV down its full length, and gastrocnemius veins
• Alternative connections including the TE or vein of
Giacomini, popliteal fossa perforators, GSV tributaries,
intersaphenous veins or pelvic veins traced to the
buttocks or perineum
• Alternative destinations for refl ux including the TE or
vein of Giacomini, or tributaries
• Diameters at the SPJ and along the SSV and TE if there
is refl ux
• The level of the SPJ in relation to the skin crease at
back of knee if there is refl ux
• The position of the SSV in relation to the midline axis
in the popliteal fossa—midline, lateral, or medial if
there is refl ux
Venography and Varicography
A minority of surgeons use this technique prior to operation, either to help diagnose the presence of SSV refl ux or
to defi ne the anatomy as the fi rst step in theatre.
SURGERY FOR SSV REFLUX
Surgery generally is directed toward dividing the saphenopopliteal junction, presupposing that refl ux through the
junction is the cause of varicose veins in the SSV territory.
Anatomical variations for patterns of refl ux determine technique and results of surgery.
Indications
Surgery appears to be the most frequently recommended
treatment for SSV refl ux in most countries,16 but many phlebologists now prefer endovenous techniques. Repeat surgery
for recurrent SSV refl ux to remove the saphenous stump or
other connections is technically demanding and prone to
complications from damage to the popliteal vein or adjacent
nerves, and it is our practice to always recommend endovenous treatment.
Technique
The operation usually is performed under general anesthesia although spinal anesthesia or popliteal nerve and posterior nerve of thigh blocks can be used. Most surgeons
operate with the patient prone and this requires intubation
for general anesthesia. A transverse popliteal fossa incision
is favored by most although an incision for a high SPJ can
be disfi guring.
A survey of members of the Vascular Surgical Society of
17
Great Britain and Ireland
found that most surgeons performed fl ush ligation although few extensively exposed the
popliteal vein unless surgery was for recurrent SSV refl ux.
There was a degree of caution about the extent of surgery
for only 15% routinely stripped the SSV, and approximately
one-quarter simply ligated the vein and over one-half avulsed
or excised as much as possible within the operation fi eld.
Practice patterns in other countries do not appear to have
been documented.
Each surgeon has a favored technique:
• Flush ligation and division require precise identifi cation
of the point where the SSV joins the deep vein. It is
important not to leave a stump particularly if it includes
a tributary.
• Excision of the terminal SSV within the operation fi eld
is preferred by many to eliminate tributaries near the
junction that could contribute to recurrence. Care must
be taken to identify and ligate important veins such as
the gastrocnemius veins if they join the SSV.
Gastrocnemial vein ligation may be the indication for
surgery.
• Retrograde stripping to mid calf or further may be
performed, now favoring invagination stripping. There is
no evidence as to whether stripping reduces recurrence
rates or increases risk of nerve damage, or whether
invagination reduces the incidence of sural nerve injury.
• Antegrade stripping from the ankle may be performed
and the presence of the stripper in the SSV at the
junction makes it easier to identify the veins. Care must
be taken to avoid damage to the sural nerve during the
distal dissection.
There is little support for routinely ligating perforators at the
same time as SSV surgery. Outward fl ow in perforators is
more frequently associated with superfi cial refl ux alone
rather than with deep refl ux making it unlikely that they are
a “source” for superfi cial tributaries.
Results
The small number of prospective studies published that
used ultrasound for surveillance after SSV surgery show
disturbingly high recurrence rates. Van Rij and colleagues
reported that recurrence rates at three weeks and three years
were 23% and 52%, respectively, after SSV surgery compared to 1% and 25%, respectively, after GSV surgery.
Smith and colleagues studied 37 limbs treated by SSV ligation with excision within the popliteal fossa and showed that
the recurrence rate at 12 months was 38%, due to inadequate
19
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surgery in 27% and neovascularization in 11%.18 Another
British report found an “ideal” outcome in only 39% of 67
limbs at six weeks, with persistent SSV refl ux from tributaries in 20% and an intact patent SPJ in 36%.20 A Dutch study
found that only fi ve of 32 limbs treated by SSV ligation were
completely controlled at three months, with persisting refl ux
into adjacent tributaries in 14 and a patent junction in 13
limbs.21 There is a need for larger prospective objective
studies using ultrasound surveillance for outcome after ligation alone or ligation and stripping.
Sites for recurrence have been defi ned by retrospective
ultrasound studies for recurrent varicose veins after SSV
surgery. Tong and Royle showed an intact SSV to be the
most common fi nding, with varices from the popliteal vein
to residual SSV in the remainder.22 Labropoulos and colleagues showed that the most common pattern after previous
SSV ligation was refl ux into the SSV (75%), whereas the
most common pattern after previous SSV stripping was
refl ux into SSV tributaries (64%).
7
Complications
Many surgeons use deep vein thrombosis prophylaxis
selectively prior to varicose vein surgery, but few use it
routinely.16 However, the risk of deep vein thrombosis after
SSV surgery has not been defi ned.
Nerve injury after venous surgery is the most common
reason for medicolegal claims in vascular surgical practice.23
A survey from the Vascular Surgical Society of Great Britain
and Ireland found that nerve injury is perceived to be more
likely after SSV surgery since two-thirds of surgeons were
more likely to warn of this complication for SSV surgery
compared to GSV surgery.17 However, the incidence of sural
or popliteal nerve injuries after SSV surgery has not been
determined and may be low.24 Damage to the sural nerve
during SSV surgery probably results from straying away
from the vein during dissection.
ENDOVENOUS TREATMENT FOR
SSV REFLUX
Techniques are described in Chapters 29 and 31, and this
chapter will summarize particular features relating to SSV
refl ux in our practice.
Ultrasound-Guided Sclerotherapy
Ultrasound-guided sclerotherapy (UGS) has been used
by our group to treat 175 SSV systems in 144 patients. We
favor foam sclerotherapy using sodium tetradecyl sulphate
diluted with normal saline to a 1.5% concentration and then
foamed in the ratio of two parts sclerosant to three parts air.
Injection is made as far distal in the vein as possible control-
ling communications to deep veins at the SPJ or through
large perforators with a fi nger or the ultrasound probe. It is
usual to inject approximately 5 ml of foam to fi ll the SSV
and its tributaries, although larger volumes can be safely
given for very extensive varicosities.
Endovenous Laser Therapy and
Radiofrequency Closure
Endovenous laser therapy has been used by our group for
45 limbs of 40 patients with SSV refl ux using an 810 nm
system. The procedure is performed under local anesthesia
with a 10% xylocaine paste to a strip along the vein for 30
minutes followed by perivenous anesthesia with 0.2% xylocaine with adrenaline injected into the saphenous compartment at intervals along the vein. Perivenous fl uid injection
provides a heat sink and compresses the vein onto the probe
as well as producing anesthesia. The system is set to deliver
14 watts power continuously and the withdrawal rate is 3 to
4 mm per second. Residual tributaries can be treated by UGS
or by ambulatory phlebectomy. We can fi nd no published
reports describing a technique for radiofrequency closure for
SSV refl ux.
Postoperative Management and Surveillance
All limbs are bandaged or compressed with class II stockings for three days and then compressed with stockings
during the day for two weeks. All patients are reviewed with
ultrasound at three to seven days to confi rm occlusion of the
treated veins and to exclude deep vein thrombosis. They are
then followed by ultrasound surveillance at six weeks, semiannually for two years, then annually.
Results
In our series, the primary success rate determined by
ultrasound surveillance after UGS for SSV refl ux was 55%
at two years, but this improved to a secondary success rate
of 77% with repeat UGS as required for clinical recurrence
(see Figure 32.3). Results were signifi cantly worse for
younger patients (see Figure 32.4) and for veins greater than
5 to 6 mm diameter (see Figure 32.5). Dissatisfaction with
the results of surgery has made UGS the preferred treatment
for patients with small diameter refl uxing SSVs or their
tributaries as defi ned by routine ultrasound scanning.
However, worse results with UGS for larger diameter veins
lead us to prefer EVLT, particularly for younger patients.
After EVLT, we had technical failure in one limb and late
recurrence at nine months in another, but all other limbs
remain controlled at one to 30 months (median seven
months). The only complications encountered were transient
sural nerve palsy with full recovery in one limb and asymptomatic minor extension of a tongue of thrombus into the
References 297
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popliteal vein in another. Proebstle and colleagues published
results for EVLT in 41 limbs with SSV refl ux, and found
initial success in 95% and no subsequent recanalization in
any limb determined by ultrasound surveillance at a median
six-month follow-up.25 The single complication reported
was a popliteal vein thrombosis that resolved. These results
persuade us to favor EVLT for SSV refl ux where the vein
has been shown to be straight and of diameter greater than
an arbitrary 5 mm.
There have been no published reports documenting results
after treatment by radiofrequency closure for SSV refl ux. It
is understood that there was an unacceptable risk of transient
sural neuralgia in the early stages and that this has been
FIGURE 32.3 Life table analysis of primary and secondary success rates
from ultrasound surveillance for ultrasound-guided sclerotherapy for the
SSV.
reduced but not eliminated by perivenous anesthesia.
CONCLUSION
The hemodynamics of SSV refl ux are poorly understood.
The concept of a “source” of refl ux from a deep venous pool
does not seem to be valid. Retrograde fl ow into the SSV is
probably simply an expression of the capacity in the dilated
veins. The variable anatomy and refl ux patterns are probably
responsible for the wide variation in treatment techniques
and poor results from surgery. Better techniques need to be
defi ned to improve surgical outcome if it is to remain the
preferred technique for treatment. Otherwise new endovenous techniques will replace surgery as experience grows.
FIGURE 32.4 Life table analysis of primary success rates from ultra-
sound surveillance for ultrasound-guided sclerotherapy for the SSV according to the patients’ ages.
FIGURE 32.5 Life table analysis of primary success rates from ultra-
sound surveillance for ultrasound-guided sclerotherapy for the SSV according to the vein diameters.
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saphenous vein: From Giacomini’s observations to ultrasound scan
imaging, J Vasc Surg. 2003. 37: 558–563.
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saphenous systems in limbs with primary varicose veins: A study of
1481 limbs by duplex ultrasound scanning, J Phlebology. 2002. 2:
11–17.
3. Myers KA, Ziegenbein RW, Zeng GH, Matthews PG. Duplex ultraso-
nography scanning for chronic venous disease: Patterns of venous
refl ux, J Vasc Surg. 1995. 21: 605–612.
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valvular competence, and clinical signifi cance of the Giacomini vein,
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5. Lin JC, Iafrati MD, O’Donnell TF Jr, Estes JM, Mackey WC. Correla-
tion of duplex ultrasound scanning-derived valve closure time and
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CHAPTER
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33
Classifi cation and Treatment of Recurrent
Varicose Veins
MICHEL PERRIN
INTRODUCTION
Recurrence varices after surgery (REVAS) are a common,
complex, and costly problem both for the patients and the
physicians who treat venous diseases. To deal with this
problem an international consensus meeting was held in
Paris in 1998, which proposed guidelines for the defi nition
and description of REVAS.
In this article 94 references were listed. Since 1998 many
valuable new studies have been published.
1
2–23
DEFINITIONS
According to Browse et al.,24 it is important to distinguish
between residual veins and recurrent veins.
Residual veins are varicose veins that were not treated at the origi-
nal operation, because they were not detected preoperatively, not
found during the operation or were deliberately left untreated.
Recurrent varicose veins are veins which have become varicose
after the initial treatment having been normal at the time of that
treatment.
This defi nition is true from a theoretical point of view but
for the patient any kind of varices after surgery are considered a failure and usually termed recurrence. Consequently
we decided at the REVAS consensus conference to defi ne
REVAS “The presence of varicose vein in a lower limb
previously operated for varices with or without adjuvant
therapies.” This is a clinical defi nition, which includes true
recurrences, residual veins, and varicose veins as a consequence of progress of the disease.
EPIDEMIOLOGY AND SOCIOECONOMIC
CONSEQUENCES
Prevalence and Incidence of REVAS
They are not easy to determine as most studies are retrospective, analyzing patients that were not evaluated preoperatively by duplex scanning (DS), and usually the detailed
operative report is not available. In a 34-year follow-up,12
varicose veins were present in 77% of the lower limb examined and were mostly symptomatic. Fifty-eight percent were
painful, 83% had a tired feeling and edema had reappeared
in 93%.
Two recently published prospective studies are available
with a follow-up of fi ve years.
In both, the patients had preoperative DS and were
treated by high ligation, saphenous trunk stripping, and stab
avulsion.
In the Kostas series from Crete,
were present in eight limbs (8/28, 29%), primarily caused
by neovascularization, new varicose veins as a consequence
of disease progression were seen in seven limbs (7/28, 25%),
residual veins were found in three limbs (3/28, 11%) mainly
due to tactical errors (e.g., failure to strip the GSV), and
complex patterns were identifi ed in 10 limbs (10/28, 36%).
In the limbs with recurrence, 42 sources of venous refl ux
were identifi ed: 19 new sites of venous refl ux were due to
disease progression, 15% of the operated limbs; 13 were
caused by neovascularization, 11.5% of the operated limbs;
six resulted from tactical failures, 5.3% of the operated
limbs; and four were due to technical failures, 3.5% of the
operated limbs. This study showed that recurrence of varicose veins after surgery is common. However, the clinical
16,20
16
true recurrent varices
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condition of most affected limbs remains improved. Progression of the disease and neovascularization are responsible for more than half of the recurrences. Rigorous evaluation
of patients and assiduous surgical technique might reduce
recurrence due to technical and tactical failures.
In the van Rij series20 from New Zealand, 127 limbs
(C2–C6) were evaluated postoperatively by clinical exam,
DS, and air plethysmography (APG). Clinical varices recurrence was progressive from three months onward (13.7%)
to fi ve years (51.7%). Corresponding to clinical changes
there was a progressive deterioration in venous function
measured by APG and recurrence of refl ux evaluated by
DS.
The longest prospective study22 gives a REVAS rate of
62% at 11 years and there was no statistical difference
between the HL-only and the HL+GSV trunk stripping+
phlebectomies, but the patients were assessed preoperatively
by handheld Doppler.
A prospective study concerning recurrence after radiofrequency procedure has been reported.
At four-year follow-up recurrence is estimated at 21%.
25
Socioeconomic Consequences
There are no available published socioeconomic data
on REVAS. The incidence is variable according to the different National Health Service reimbursement rates. When
redo surgery is performed its cost is higher than fi rst time
surgery because of the number of peri- and postoperative
complications.
Previous Treatment
The date of previous surgical treatment(s) for varicose
veins, the age of the patient at the time of surgery, the name
of the surgeon and the place of the operation in order to
retrieve the operative record, postoperative surgical complication, date of the onset of recurrence, and reappearance of
symptoms have to be documented, as does other treatment
received after initial surgery (e.g., phlebotonic drugs, sclerotherapy, use of compression stockings, and leg elevation).
Physical Examination
Presence and intensity of the various vein-related symptoms have to be noted: pain, throbbing, heaviness, itching,
feeling of swelling, night cramps, heat or burning sensations, or restless legs.
Inspection and palpation allow fi lling in the C of the
CEAP classifi cation, but it must be kept in mind that some
signs such as corona phlebectatic are not described in the
CEAP. Edema should be quantifi ed.
The presence of scars on the lower limb must be noted,
especially at the groin or popliteal fossa. Neurological
abnormalities and particularly numbness have to be documented. Effi ciency of the calf pump has to be assessed,
particularly degree of ankle motion. Arterial pulses should
be checked and ankle brachial index calculated.
A general examination including abdominal palpation
should be performed, and possible obesity can be identifi ed
by BMI calculation.
Investigation
DIAGNOSIS
Modes of Presentation
Patients who have previous surgical treatment may consult their physicians for various reasons: unsightly recurrent
varicose veins or related emotional problems, which are
especially common in female patients; discomfort (in other
words venous-related symptoms); appearance of cutaneous
or subcutaneous changes; concerns about the health risk
related to their veins; or limitation of activity. Also, REVAS
may be found at routine follow-up.
Medical History
Family and Personal History
Family history of varicose veins and personal history
including pregnancies, hormone therapy, superfi cial thrombophlebitis, deep vein thrombosis, and so on should be
recorded.
Many investigations have been used in the past to assess
REVAS. At the moment there is a large consensus for recommending DS in all cases. This investigation provides
anatomical and hemodynamic data including
• The topographical sites of REVAS that can be mapped
• The possible sources of refl ux from the deep venous
system to the superfi cial
• The intensity or degree of refl ux
• The nature of sources keeping in mind that causes have
to be classifi ed differently if recurrence occurs in a site
previously operated or not.
In addition DS gives information on perforator and deep
venous systems that must be assessed in patients with
REVAS.
One problem remains: a standardized DS investigation
protocol is not universally used by the different investigators. A written investigation protocol consensus has to be
tailored when dealing with REVAS. In very few cases
venography, including descending venogram and threedimension imaging, may give complementary valuable
information.
26
Classifi cation 301
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Other investigations such as APG and AVP may be
useful for research studies but not for daily practice.
Quality of Life Questionnaires
To determine whether REVAS affect patients’ quality
of life, the health-related quality of life (HRQL) score
of patients can been used in different ways for clinical
studies. Beresford2 compared patients presenting with
REVAS versus patients with untreated varicose veins. No
survey has compared operated patients with or without
REVAS.
CLASSIFICATION
Many classifi cations have been developed concerning
REVAS,
main goals was to identify if redo surgery, particularly at the
previous saphenofemoral and saphenopopliteal junctions,
must be part of the REVAS treatment. As will be shown
later, indications have changed and this point is less important than it was previously. At the consensus meeting1 we
decided to use both the previously reported CEAP classifi cation28 and a specifi c classifi cation named the REVAS classifi cation. This new classifi cation was intended to serve
everyday clinical practice as well as in research studies into
epidemiology, clinical status, and treatment of recurrent
varicose veins. A survey was undertaken in order to test its
intraobserver and interobserver reproducibility.29 The conclusion of this study was that intraobserver reproducibility
is quite satisfactory, and making slight changes in the
answers to one question might increase interobserver reproducibility. However, the fact that interobserver reproducibility was less than intraobserver reproducibility refl ects
conditions of real life, and especially interobserver differences. Such interobserver differences may arise from
interobserver technical differences, but this fi nding emphasizes the need for validating a duplex scanning protocol and
standardizing duplex scan reports.
items: T is for topographic sites of REVAS; S for sources of
refl ux; R for degree of refl ux; N for nature of sources (Nss
for same site of previous surgery, and Nds for different
sites); P for contribution from a persistent incompetent
saphenous trunk; and F for possible contributory factors (Fg
for general and Fs for specifi c factors).
T is for topographic sites of REVAS. Recurrent varices
24,27
but they have not been widely used. One of their
The REVAS classifi cation (see Table 33.1) includes six
should be localized at fi ve sites: g is for groin, t for thigh,
p for popliteal fossa, l for lower leg including ankle
and foot, and o for other. Since that more than one terri-
tory may be involved in the same limb, topography
gives a degree of quantifi cation as to the extent of the
recurrences.
S is for sources of refl ux. It is considered important to iden-
tify the sources of refl ux from the deep system when it
is present. 0 is for no identifi ed source of refl ux, 1 for
pelvic or abdominal, 2 for saphenofemoral junction, 3
for thigh perforators, 4 for saphenopopliteal junction, 5
for a popliteal perforator, 6 for gastrocnemius veins, and
7 for lower leg perforators. Several sources of refl ux
should be identifi ed.
R is for degree of refl ux. Although it is recognized that there
are limitations for quantifying the degree of refl ux according to parameters (duration, volume, mean peak velocity), it has not been proven that additional present refl ux
is valuable. However, the clinician should estimate the
clinical signifi cance of refl ux. This estimate should be
based on DS information and how the degree of refl ux
relates to the overall clinical situation.
R+ is for clinical signifi cance probable, R− is for clini-
cal signifi cance unlikely, R? for clinical signifi cance
uncertain.
It is worthy of note that in the international survey
interobserver R reproducibility was moderate but the
intra observer R was reliable.
29
N is for nature of sources. This letter classifi es the source as
to whether or not it is the site of previous surgery and
describes the cause of the recurrence.
Ss is for the same site that means the recurrence occurred in
a territory where the previously superfi cial veins were
operated on, and one of the fi ve items may be chosen for
NSs: 1 technical failures (see Figure 33.1), 2 tactical
failures, 3 neovascularization (see Figure 33.2), 4 uncertain or unknown, 5 mixed.
Ds is for different (new) site. In other words when varices
are present in a territory not previously operated, one of
the three items may be selected for NDs: 1 persistent
(known to have been present at the time of the previous
surgery and not treated), 2 new (known to have been
absent at the time of previous surgery), 3 uncertain or not
known (insuffi cient information on the preoperative
status before the previous surgery). As it might be foreseen in a retrospective study using REVAS classifi cation,
two-thirds of the patients were classifi ed uncertain or not
known and both the intraobserver and interobserver
reproducibility was moderate.
29
A precise answer to N in the REVAS classifi cation should
be anticipated in a prospective study, and, if used by
dedicated physicians looking at their own patients before
and after treatment, it might work very well.
C is for contribution from persistent incompetent saphenous
trunks: GSV AK (above knee), GSV BK (below knee),
SSV; O other, N neither.
F is for possible contributory factors that should be gathered
and reported in the REVAS fi le: gF (general factors):
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