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CHAPTER
39
https://t.me/med1917
Phlebectomy
Mikel Sadek and Lowell S. Kabnick
39.1 INTRODUCTION
The current phlebectomy technique was rst described by
Robert Muller, a dermatology-trained phlebologist from
Neuchâtel, Switzerland, who reinvented and rened the
technique that we know today as ambulatory phlebectomy. Muller’s technique was rst presented in 1967 to the
French Society of Phlebology, and in 1968 to the International Congress of Phlebology, and it was poorly received.
With time and experience, the phlebectomy technique has
become more widely adopted and now represents the standard treatment for reuxing venous tributaries [1–3].
Today, the procedure is performed typically under local
anesthesia in an ambulatory setting. Briey, a small hooklike instrument, together with ne clamps, is employed to
extract the varices using small (~1- to 2-mm) incisions.
At completion of the procedure, a dry sterile compression
dressing or a compression hose is applied to the limb.
This chapter will cover the indications, technique,
peri-procedural care, and possible complications associated with ambulatory phlebectomy. For the reader to best
gain expertise and to visualize technical aspects of the procedure, the authors suggest not only reading this chapter
but also seeking out an expert in the eld of phlebectomy
to observe the procedure.
39.2 DEFINITION OF AMBULATORY
PHLEBECTOMY
The term “ambulatory phlebectomy,” coined by Dr. Muller,
refers to the technique in which varicose veins are extracted
in an outpatient setting under local anesthesia using small
punctures and hooks. Ambulatory phlebectomy, stab avulsion, stab phlebectomy, microphlebectomy, and microextraction are synonymous terms that dene this technique.
The Current Procedural Terminology code book of the
American Medical Association lists three codes for the billing of the procedure: (1) 37765, stab phlebectomy of varicose veins, one extremity, 10–20 stab incisions; (2) 37766,
stab phlebectomy of varicose veins, one extremity, more
than 20 incisions; and (3) 37799, for fewer than 10 incisions [4]. When discussing the procedure with a patient, we
recommended that the terms “ambulatory phlebectomy”
or “microphlebectomy” be used, because they are often
more acceptable to the patient, as compared to “stab avulsion” or “stab phlebectomy.”
39.3 DIAGNOSTIC METHODS AND
INDICATIONS
39.3.1 Diagnostic methods
A complete history and physical examination should be
performed, with attention being paid to the anatomic distribution of concern, the symptom prole, including the
HASTI symptoms (heaviness, achiness, swelling, throbbing and itching), and other patient-reported metrics [5].
A history of supercial phlebitis or varicose vein bleeding
should be obtained. The practitioner should also assess
for a history of venous thromboembolic disease, hypercoagulable states, prior venous procedures, and the use of
antiplatelet or anticoagulant medications. A family history
can also help to inform long-term prognosis. On exam,
the focus should be on the clinical presentation, and this
may be categorized using the CEAP and the venous clinical
severity score (VCSS) classications [6,7]. One should also
pay attention to any evidence of vascular malformations
or other congenital pathologies such as Klippel–Trenaunay
or Parkes–Weber syndromes. An arterial exam/pulse exam
should be performed, and an ankle-brachial index (ABI)
of greater than 0.8 is a reasonable guideline for deeming
that arterial perfusion is adequate. It is worth emphasizing that a normal ABI does not entirely exclude arterial
pathology. A falsely elevated ABI can be seen in diabetic
patients, elderly patients, and patients with renal disease,
due to incompressible calcied vessels.
Regarding imaging studies, a venous duplex ultrasound
should be performed in all cases. It is often benecial to
identify the presence of reuxing venous tributaries, as well
as their source from truncal veins or perforators. As with
reuxing truncal veins, reuxing tributaries are dened
as having a reux time of greater than 500 ms. More
advanced axial imaging (i.e., CT or MR venography) and
direct venography are typically not required unless adjunctive procedures are indicated. At the time of the procedure,
transillumination is very helpful for tracing out the target
DOI: 10.1201/9781003328971-44
395395
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varicose veins or reticular veins and to better visualize
varicose veins associated with overlying telangiectasias.
Examples of transilluminating devices include the Veinlite
(TransLite, Sugar Land, TX) and VeinViewer (Luminetx,
Memphis, TN).
39.3.2 Indications
Indications for ambulatory phlebectomy vary depending
on the skill set of the individual practitioner. Patients of all
ages are candidates for phlebectomy, and this holds true
especially for the octogenarian and the elderly in general,
where venous procedures have been shown to improve
both clinical and patient-reported outcomes [8]. Ambulatory phlebectomy may be medically or cosmetically indicated, and it may be performed as a stand-alone procedure
or in conjunction with another procedure (e.g. endovenous
ablation).
Varicose veins of any size and in any location are candidates for ambulatory phlebectomy. These include the
epifascial supercial accessory great saphenous vein, supercial truncal veins in general, tributaries, and reticular
veins. Also appropriate for ambulatory phlebectomy are
regional venous networks, including accessory saphenous
veins of the thigh, pudendal veins, perineal veins, reticular veins of the lateral subdermic plexus and the popliteal
fossa, hand and foot veins [9, 10]. Dilated veins in other
parts of the body, including the periorbital, abdominal, and
chest areas, as well as medial thigh perforators and small
lateral perforators, may be treated successfully using this
technique [11].
Areas requiring additional attention for ambulatory
phlebectomy are the knee, tibial, and foot areas, where
the veins are tethered by connective tissue, making their
removal somewhat arduous. Other areas of caution are
the peripheral great saphenous vein in the saphenous nerve
distribution and the peripheral small saphenous vein in the
sural nerve distribution. Lateral leg varicosities overlying
the bular head are in the region of the peroneal nerve and
should be approached with caution, and the same applies
to many areas of the hands and feet. Lastly, care should be
taken in the temporal forehead region, given that the tortuous temporal artery is sometimes misconstrued for being
a varicose vein, and a phlebectomy procedure should be
avoided given the potential risks for bleeding or ischemia.
39.4 TREATMENT STRATEGIES
thigh circumex vein; however, many aws were noted in
the study [12]. The two treatment methods are integral to
delivering complete venous care, and the practitioner must
know both procedures.
39.4.1 Delayed versus simultaneous
procedures
There remains debate over whether ambulatory phlebectomy should be performed simultaneously with truncal vein
ablation or if it should be staged. Some insurance carriers,
for example, will require that ablation of the associated
truncal vein be performed rst and that adjunctive phlebectomy be performed in a staged fashion after a prescribed
interval, and this trend has increased steadily over time.
Historically, the complete removal of any varicosities at
the same time as great saphenous vein treatment has been
dogma. In the early twentieth century, Homans and Mayo
published papers stating that the complete removal of varicosities was encouraged to prevent recurrence [13,14]. The
current scientic literature regarding the timing of varicosity treatment after interruption of truncal reux is scant;
however, a review of the literature reveals that simultaneous treatment of varicosities leads to higher patient satisfaction, early gains in quality of life, and a reduced need for
further procedures [15–17]. The nal decision on treatment
strategy should rest with the clinician and the patient, as
both delayed and simultaneous procedure pathways offer
good outcomes [15–17].
39.4.2 Benefits of ambulatory
phlebectomy
Ambulatory phlebectomy is an effective, cosmetic and
cost-efcient way to remove varicose veins. Improvements
in anesthetic technique, namely the use of tumescent anesthesia, have limited the amount of pain both intraoperatively and postoperatively. Patients can return to daily
activities after the procedure. Due to the paucity of reported
complications, the procedure is considered to be safe, but
there are some nuances to be aware of. Post-procedural
bleeding can occur rarely, and appropriate return precautions should be given to the patient. Blistering may occur
at the sites of Steri-Strip application due to shear stress on
the skin resulting from postprocedural edema. Mild pain
and ecchymosis are to be expected, and the patient should
be counseled accordingly [18–20]. Long-term results, even
if presumed excellent, have not been well studied to date.
Accepted treatment options in phlebology include compression therapy, sclerotherapy, ambulatory phlebectomy,
endovenous thermal ablation, and topical laser. Each treatment modality has its advantages and limitations; however,
there is signicant overlap.
Sclerotherapy is the closest alternative treatment
strategy to ambulatory phlebectomy. At present, there is
still a debate as to which is better and a paucity of evidence-based literature to support the superiority of either
procedure. A single randomized controlled trial by de Roos
et al. demonstrated the superiority of ambulatory phlebectomy over sclerotherapy for the treatment of the anterior
39.4.3 Contraindications
There are a limited number of contraindications to ambulatory phlebectomy. The following conditions should be
considered relative contraindications: infectious dermatitis or cellulitis in surrounding areas, severe arterial insufciency, serious illness, and pregnancy. Although the use
of anticoagulation has traditionally been considered a
contraindication, ambulatory phlebectomy can in fact be
performed safely in patients on anticoagulation, including
with the use of warfarin and direct oral anticoagulants
(DOACs) [21].
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39.4.4 Technique
39.4.4.1 Preoperative preparation
All target veins should be traced while the patient is standing, as
they may be difcult or impossible to identify while recumbent.
Surgical markers include those using gentian violet–colored
solution (e.g., Vismark; Viscot Medical, East Hanover, NJ).
The use of a permanent marker to trace the veins should be
avoided because of the risk of tattooing. After the patient has
been placed in the recumbent position, the vein marks can be
adjusted using a transilluminator or an ultrasound if necessary. Because veins can reposition, this subsequent adjustment
adds to the efcacy and speed of extraction (Figure 39.1) [22].
39.4.4.2 Surgical plan
The timing of ambulatory phlebectomy depends on the
nature and type of other venous procedures being performed,
and it depends on practitioner preference. When ambulatory
phlebectomy is coupled with saphenectomy or endovenous
ablation of a truncal vein, there can be a transient increase
in endoluminal pressure in the caudally distributed veins,
which could result in an increased risk of bleeding. This can
be reduced by placing the patient in the Trendelenburg position. Depending on the physician and patient preferences,
procedures can be staged, treating the truncal vein rst, followed several weeks later by ambulatory phlebectomy. This
method allows the existing truncal varicosities to decrease
in size and number, potentially reducing the extent of subsequent procedures. Both operative strategies have been
shown to be safe and effective [15, 16, 23, 24].
39.4.4.3 Anesthesia
Local anesthesia with or without epinephrine was used historically, but most operators now suggest using tumescent
anesthesia for ambulatory phlebectomy.
39.4.4.4 Tumescent anesthesia
Tumescent function: adjective. Etymology: Latin tumescent-, tumescens, present participle of tumescere to swell
up, inchoative of tumere to swell: somewhat swollen <
tumescent tissue > [25].
J.A. Klein, a dermatologist, was the rst to describe
tumescent anesthesia in 1987 [26]. His method utilized dilute
local anesthesia as a way of creating a eld block. Tumescent anesthesia exploits the principles of pharmacokinetics
to achieve anesthesia of the epidermis, dermis, and subcutaneous tissues. The subcutaneous inltration of a large volume of dilute, buffered lidocaine and epinephrine causes the
targeted tissue to become swollen and rm, or tumescent.
Because the subcutaneous tissue is relatively avascular, a
large volume of diluted epinephrine injected into this area
produces widespread and prolonged vasoconstriction. Vasoconstriction appears to diminish the rate of systemic lidocaine absorption, thus reducing the peak plasma lidocaine
concentration, reducing potential toxicity, and permitting a
much larger dose of lidocaine to be administered [26–29].
According to Klein,
In fact tumescent technique permits safe lidocaine
dosage of at least 35 mg/kg of body weight and
provides effective local anesthesia for as long as ten
hours. The widely accepted 5–7 mg/kg safe maximum
dose for lidocaine with epinephrine when administered subcutaneously has never been substantiated by
a published scientic study. [29]
39
39.1 The circle and dotted line tracing the vein were drawn
with the patient in an erect position (blue arrows). The straight
line was drawn with the patient in a recumbent position (red
arrows).
Klein and others observed that the pharmacokinetics of
dilute lidocaine with epinephrine are different from those
of 1%–2% lidocaine. With undiluted lidocaine, a measurable plasma level appears in 15 minutes and peaks soon
after; lidocaine is metabolized in a few hours. Absorption
of the tumescent solution is slower, causing peak plasma
levels to occur many hours later, and thus the anesthetic
effect is longer. Patients receiving large volumes can have
plasma levels that peak in 4–14 hours and linger for longer
than 24 hours [29].
39.4.5 Procedure for administering
tumescent anesthesia
In 1995, Cohn and coworkers reported using the tumescent technique for local anesthesia while performing
ambulatory phlebectomy [30]. Three years later, Smith
and Goldman reported the use of tumescent anesthesia for
ambulatory phlebectomy [31].
The inltration of dilute anesthesia in a perivascular position—epidermal and dermal—serves several purposes: (1) the anesthetic effect is long-lasting and sensation
returns slowly; (2) with the use of longer needles and dilute
solution, fewer needle punctures are needed and less pain
upon administration is observed; (3) the tumescent technique causes more compression of the surrounding tissues,
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leading to less hematoma and ecchymosis; (4) hydro-dissection occurs around the vein, facilitating the removal;
and (5) reduction of infection, usually limited to the incision site, is a result of the bacteriostatic and bactericidal
properties of lidocaine [32].
The methods of delivering and mixing ingredients of
tumescent anesthesia vary between operators. A typical
solution is as follows: 445 mL of 0.9% saline, 50 mL of
1% lidocaine with 1:100,000 epinephrine, and 5 mL of
8.4% sodium bicarbonate.
Presently, most operators use a regular syringe, a
self-lling syringe, or a peristaltic pump to deliver tumescent anesthesia. The last two methods facilitate the delivery
of higher volumes of tumescent anesthesia. Microcannulas,
22G/25G 7 cm hypodermic, or spinal needles are used for
the delivery of the solution.
39.4.6 Procedural equipment
Incisions or punctures can be made with various instruments, including hypodermic needles and surgical blades.
The most common instruments are 18G needles, number
11 blades, and standard 15-degree ophthalmologic blades
(I-KNIFE II Alcon, Fort Worth, TX). After the phlebectomy
is completed, 12 × 33-mm adhesive microporous surgical
tapes (Steri-Strips 3M, Oakdale, MN) are placed to close
the punctures. Occasionally, one may close the surgical
sites with interrupted 6-0 or 5-0 nylon sutures when there
is signicant bleeding, and sometimes this is benecial at
the joints where surgical tape may not adhere as well. If
sutures are used, it is important to plan for expeditious
suture removal within approximately 1 week in order to
ensure the best cosmetic result.
Several different hooks are available for use, varying
in size, shape, and sharpness. Commonly used hooks are
the Muller, Oesch, Tretbar, Ramelet, Verady, Dortu-Martimbeau, and Kabnick hooks [33]. One particular phlebectomy instrument is not superior to another. It is important
for the clinician to be comfortable with a particular set of
hooks, making the selection after trying the gamut.
The clamps used for vein extraction should have a ne
tip so that they can grip close to the skin. A serrated face is
helpful in maintaining rm traction without slippage. The
operator should have at least three ne hemostat clamps
available, but ve or more is preferable (Figure 39.2).
39.4.7 Procedure
After the anesthetic has been injected into the perivenous
tissues, an incision/puncture (~1–2 mm) is made near the
vein (Figure 39.3). Most are oriented vertically, except
around the knee, where they should be oriented along
the tension lines (Langer lines). A blunt-tip spatula may
be inserted into the incision to dissect the dermal fascia,
although this is not mandatory (Figure 39.4). It does, however, facilitate a hook to be inserted without interference
from surrounding tissues and without enlarging the incision. Once the hook has been inserted, the vein is grasped
blindly and extracted through the incision (Figure 39.5a).
If the vein is not extracted, the hook is maneuvered with
nesse at different angles, repositioning the instrument
through the incision until the vein
should be aware that when attempting different angles at
39.3 Incision.
is captured. The operator
39.2 A typical surgical tray for phlebectomy.
39.4 Kabnick phlebectomy instrument with the spatula end
used as a dissector.
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39
39.5 (a) Hook delivering the target vein above the skin surface. (b) Delivering a loop of vein and clamping proximally and distally.
(c) Transection of the vein loop. (d) Gentle traction on the clamp. (e) Optional vein ligation.
approaching the vein, he or she should execute the motion
while paying attention to the depth. When just the perivascular connective tissue is hooked, that tissue is clamped
with a hemostat and kept in traction while the hooking
maneuver is repeated until a venous loop is exteriorized.
The vein is then grasped between clamps and transected
with ne scissors (Figure 39.5b and c). Using gentle traction on the hemostat in a “windshield wiper movement,”
one end of the varix is teased out of the puncture site. Successive hemostats are applied to the varix as it is extracted
from its position, keeping in mind that the vein will eventually tear (Figure 39.5d). Very long segments can often be
removed through a single puncture site. Once a segment
has been extracted, the operator moves along the vein by a
roughly equivalent distance to
makes another incision, and the process is repeated. Any
redundant perivascular tissue exposed out of the puncture
site should be trimmed at the skin level. If a small nerve
ber is exteriorized, it is likely that the patient will experience an immediate sharp pain and burning sensation. If
the nerve ber has not been transected, the operator should
reintroduce the nerve ber into the incision and move on
to another area to access the vein segment. After the procedure, some patients may develop areas of hypoesthesia that
in most cases will resolve [18].
The operator is encouraged to remove all parts of the
varix without leaving isolated segments behind to reduce
a possible inammatory response from thrombosis of the
the segment extracted and
retained segment. Nevertheless, if most of the segment
is removed, the patient should have an excellent result,
and residual segments will brose and regress over time.
There is rarely need to ligate a vessel except when a perforator, peripheral foot vessel, hand vessel, or large varix
(>1 cm) is exposed (Figure 39.5e). Sometimes ligation
may also be performed at the central and most peripheral aspects of the phlebectomy procedure in order to
reduce ecchymosis. Ligation of vessels may improve the
early cosmetic result due to less bruising and subsequent
staining.
the vein, often with an orientation that is perpendicular
to the skin, and can be associated with a deep pulling
sensation.
rous surgical tape or closed with sutures as needed, and are
subsequently wrapped with a soft gauze roll and stretch
bandages (Figure 39.6a–d).
Perforating veins are recognized as branches in
The puncture sites are covered with adhesive micropo-
39.4.8 Discharge recommendations
After ambulating and once vital signs are stable, the patient
can be safely discharged from the facility. Discharge and
follow-up recommendations to patient are as follows:
1. On the day of surgery, walk ad libitum.
2. Take acetaminophen or ibuprofen as needed for discomfort.
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39.6 (a) Placement of adhesive strips over vein extraction sites. (b) Sterile gauze placement. (c) Gauze wrap. (d) Stretch bandage
placement.
3. Wear the compression wraps continuously for 24 hours.
After 24 hours, remove all of the dressing materials
except the adhesive microporous surgical tape. The
adhesive surgical tape should be left in place for 10–14
days.
4. Once the dressing is removed, apply the compression
stocking(s) (class 2, 30–39 mmHg) for a minimum of 1
week during waking hours. The data for this have varied, with some studies showing benet to wearing compression, and others failing to show benet [17, 34].
5. May shower after 2 days. There is to be no tub bathing or swimming until the adhesive surgical tapes are
removed.
6. There is to be no lower body or heavy aerobic exercise
for 1 week. Return to activities of daily living as usual.
7. Follow-up is to take place in 2 weeks, 3 months, and 1
year.
phlebectomies [37]. The second was a literature review
by Ramelet in 1997 [18]. He reported the complication
rates of several different authors. The rates of complications vary widely, with skin blistering being the highest,
ranging from 1.3% (1997 Olivencia report) to 20% (1980
Gillet report) [38]. Telangiectatic matting has varied in the
different studies from 1.5% to 9.5% in Trauchessec and
Vergereau’s report [39]. Some authors have reported telangiectatic matting to be as high as 2.4%. However, if we
look at current reports, the common complications appear
to change in frequency. Regardless, the most common complications are development of telangiectasias, 2%; blistering, 0.5%; and hyperpigmentation (limited), 0.01%. The
most common technical failure is a missed varix, occurring
in 0.3% of cases.
39.5 TRANSILLUMINATED POWERED
39.4.8.1 Complications
Complications arising from ambulatory phlebectomy are
quite rare, but can occur, as listed in Table 39.1 [19, 20,
35, 36]. There have been two large retrospective studies
looking at the complications of phlebectomy. The rst
was a multicenter French study that reviewed 36,000
The proprietary name for the transilluminated powered
phlebectomy (TIPP) device is the TriVex System (LeMaitre Vascular, Inc., Burlington, MA). The development of
this device began in 1966, when Greg Spitz, a surgeon,
PHLEBECTOMY
(a)
(b
)
(a
(b)
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39.7 (a) Transillumination and instillation of tumescent anes-
thesia. (b) Removing vein placement of the TriVex resector and
illuminator.
took an arthroscopic shaver and applied it for the removal
of varicose veins. Through many derivations, including
transillumination and a delivery method for tumescent
anesthesia, the present system was complete. The system
contains a modied arthroscopic shaver and a transilluminator coupled with an irrigator that delivers tumescent
anesthesia. The concept was developed to decrease the
time for ambulatory phlebectomy. Although there have
been many modications, the procedure remains virtually
the same. Varicose clusters are transilluminated, anesthetized, morcellated, and aspirated (Figure 39.7a and b).
39.6 Conclusion 401
complications can be reduced by dissecting carefully
along and parallel to the varicose vein, avoiding lateral
movements, and using a lower oscillation frequency and a
pulsing technique to allow for proper aspiration [41, 44].
Other encountered complications after TIPP are skin perforation, nerve injury, deep vein thrombosis, incomplete
vein resection, hypertrophic scarring, permanent skin discoloration, and wound infection [45].
Traditionally, TIPP has been performed in an operating room under general or regional anesthesia with sedation; however, in 2011 Spitz reported his experience with a
series of 36 patients treated with TIPP in the ofce setting
with good clinical outcomes [46].
Although TIPP is presently utilized, compared with
hook microphlebectomy, TIPP has not been proven to be
simpler, more cost-effective, less insulting to tissue, or better cosmetically.
39.6 CONCLUSION
Ambulatory phlebectomy has been adopted as the standard procedure and denitive treatment for the removal
of varicose veins. This simple procedure has added a
highly acceptable aesthetic results to the medical indication. Preoperative mapping with transillumination
accurately identies the location of varicosities. Local or
tumescent anesthesia is recommended when performing
ambulatory phlebectomy. The above-described procedure,
including—1- to 2-mm incisions, hook technique, and
compression—results in minimal recovery times and few
complications (Figure 39.8 a and b). Ambulatory phlebectomy can be staged or performed concurrently with truncal ablation. TIPP has been effective in multiple studies in
treating varicose veins. Phlebectomy has been superior to
sclerotherapy for varicose veins.
39
39.5.1 Study results
Studies of the TriVex System describe several modications of the procedure to improve patient outcomes.
Investigators have often compared manual phlebectomy
with TIPP. Most authors indicate that the number of incisions is fewer with TIPP and the operating time is faster.
Ray-Chaudhuri et al. compared postoperative pain scores,
with the results after 14 days being 2.6 (manual) and 1.9
(TIPP), a difference that was not statistically signicant
[40]. Cosmetic effect was also equal. In two randomized
trials Aremu et al. and Scavée et al. demonstrated no difference in patient cosmetic scores or satisfaction [41, 42].
These conclusions were recognized by Spitz and coworkers in their original reported ndings [43]. In addition,
the authors agree that TIPP has a signicant learning
curve. The learning curve is associated with a higher number of missed veins along with an increased incidence of
hematoma and other adverse events. These postoperative
)
39.8 (a) Preoperative photograph of varicose veins. (b) Postop-
erative view 12 weeks after phlebectomy.
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TABLE 39.1 Potential complications of ambulatory phlebectomy*
Complication type Complication
Anesthetic complications Allergic reaction (e.g., to preservative or lidocaine), technique related (e.g., placement of
injection)
Skin complications Blister, dimpling, hypo- or hyper-pigmentation (incision), induration, infection, pigmenta-
tion, transitory or permanent
Complications of compression bandage Blisters, contact dermatitis, ischemia, skin necrosis, swelling
Vascular complications Bleeding or seroma, deep vein thrombosis, matting, pulmonary embolism, supercial
thrombosis, telangiectasias
Lymphatic complications Lymphocele, lymphorrhea, persistent edema
Neurological complications Dysesthesia (temporary or permanent), nerve damage: saphenous, sural, peroneal
nerves, etc., temporary hypoesthesia, traumatic neuroma
* This list is compiled from the experience of several physicians: Mikel Sadek, Lowell Kabnick, J se Olivencia, Robert Muller, Stefano Ricci, and Michael
Ombrellino.
Guidelines and Consensus Statement 39.0 of the American Venous Forum on phlebectomy*
Guidelines Grade of
recommendation
39.1 For treatment of symptomatic varicose tributaries, we recommend ambulatory phlebec-
tomy or ultrasound-guided sclerotherapy using physician-compounded foam (PCF) or
1
(strong)
polidocanol endovenous microfoam (PEM).
39.2 For treatment of symptomatic varicose tributaries, we suggest transilluminated powered
phlebectomy as an alternative treatment for patients with clusters of varicosities by a
2
(weak)
physician who is trained in the procedure.
Consensus Statement
39.3 For patients with symptomatic varicose tributaries, treatment of the tributaries should be performed even if the supercial trunks
are competent.
Quality of
evidence
B
(moderate)
C
(low to very
low)
* Based on recommendations of Reference 48.
REFERENCES
★ Systematic review
♦ Guidelines
1. Muller R. History of ambulatory phlebectomy. In: Ricci S., Georgiev M., Goldman
M.P., eds. Ambulatory Phlebectomy, 2nd
Ed. Boca Raton, FL: Taylor & Francis
Group, 2005, xxxiii–xl.
2. Muller R. Treatment of varicose veins
by ambulatory phlebectomy (in French).
Phlebologie. 1966;19:277–279.
3. Muller R. Clarication on ambulatory phlebectomy according to Muller.
(A.P.M.) (in French). Phlebologie.
1996;49:335–344.
4. Gordy T, et al. Current Procedural Ter-
minology 2023. Chicago, IL: American
Medical Association; 2023, 175.
5. Guex JJ. Importance of patient-reported
outcomes in chronic venous disorders.
Phlebology. 2012 Mar;27(Suppl. 1):136–
138. DOI: 10.1258/phleb.2012.012s20.
PMID: 22312080
6. Lurie F, Passman M, Meisner M, Dalsing
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