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414 Chapter 40 Open surgical treatment for superficial truncal incompetence
https://t.me/med1917
Guidelines 40.0 of the American Venous Forum on open surgical treatment of supercial truncal incompetence*
No. Guidelines Grade of
recommendation
40.1 For patients with symptomatic varicose veins and axial reux in the GSV or SSV, we
recommend treatment with HL&S of the saphenous vein if technology or expertise in
1
(strong)
endovenous ablation is not available or if the venous anatomy precludes endovenous
treatment.
40.2 For patients with symptomatic varicose veins and axial reux in the AAGSV or PAGSV,
we suggest treatment with ligation and stripping of the accessory saphenous vein, with
2
(weak)
additional phlebectomy, if needed, if technology or expertise in endovenous ablations is
not available or if the venous anatomy precludes endovenous treatment.
40.3 For patients with symptomatic varicose veins and axial reux in the GSV who place a
high priority on the long-term outcomes of treatment (quality of life and recurrence),
2
(weak)
we suggest treatment with endovenous laser ablation, radiofrequency ablation, or high
ligation and stripping over physician-compounded ultrasound-guided foam sclerotherapy
because of long-term improvement of quality of life and reduced recurrence.
40.4 For patients with symptomatic varicose veins and axial reux in the SSV, we suggest
treatment with EVLA, RFA, or ligation and stripping from the knee to the upper or mid-calf
2
(weak)
over physician-compounded ultrasound-guided foam sclerotherapy because of long-term
improvement of quality of life and reduced recurrence.
40.5 For patients with symptomatic varicose veins and axial reux in the AAGSV or PAGSV
who place a high priority on the long-term outcomes of treatment (quality of life and
2
(weak)
recurrence), we suggest treatment of the reuxing supercial trunk with endovenous laser
ablation, radiofrequency ablation, or high ligation and stripping, with additional phlebectomy, if needed, over physician-compounded ultrasound-guided foam sclerotherapy
because of long-term improvement of quality of life and reduced recurrence.
Quality of
evidence
B
(moderate)
C
(low to very
low)
B (moderate)
C
(low to very
low)
C
(low to very
low)
* Based on recommendations from Reference 13.
REFERENCES
• Randomized controlled trial
* Systematic review or
meta-analysis
Clinical practice guideline or
♦
reporting standards
1. Daseler E, Anson B, Reimann A, Beaton
A. The saphenous venous tributaries and
related structures in relation to the technique of high ligation: Based chiey upon
a study of 550 anatomical dissections. Surg
Gynecol Obstet 1946;82:53–63.
2. Thompson H. The surgical anatomy of
the supercial and perforating veins of
the lower limb. Ann R Coll Surg Engl.
1979;61(3):198–205.
3. Holme J, Holme K, Sorensen L. The
anatomic relationship between the long
saphenous vein and the saphenous nerve.
Relevance for radical varicose vein surgery.
Acta Chir Scand. 1988;154(11–12):631–3.
4. Ramasastry S, Dick G, Futrell J. Anatomy of the saphenous nerve: Relevance
to saphenous vein stripping. Am Surg.
1987;53(5):274–7.
5. Morrison C, Dalsing MC. Signs and symptoms of saphenous nerve injury after greater saphenous vein stripping: Prevalence,
severity, and relevance for modern practice.
J Vasc Surg. Nov 2003;38(5):886–90.
6. Cavezzi A, Labropoulos N, Partsch H,
et al. Duplex ultrasound investigation of
the veins in chronic venous disease of the
lower limbs: UIP consensus document: Part
II: Anatomy. Eur J Vasc Endovasc Surg.
2006;31:288–99.
♦
7. Gloviczki P, Comerato A, Dalsing M, et al.
The care of patients with varicose veins
and associated chronic venous disease: Clinical practice guidelines of the Society for
Vascular Surgery and the American Venous
Forum. J Vasc Surg 2011;53:2S–438S.
8. Pyo Hong K. Midterm Clinical outcomes
after modied high ligation and segmental
stripping of incompetent small saphenous
veins. Korean J Thorac Cardiovasc Surg.
2015;48:398–403.
9. Kerver A, van der Ham AC, Theeuwes H,
et al. The surgical anatomy of the small
saphenous vein and adjacent nerves in
relation to endovenous thermal ablation. J
Vasc Surg. 2012;56:181–8.
10. Schweighofer G, Muhlberger D, Brenner
E. Back to the basics: The anatomy of the
small saphenous vein: Part 1: Fascial and
neural relations, saphenopopliteal junction
and valves. J Vasc Surg. 2010;51(4):982–
89.
11. Ricci S, Moro L, Incalzi A. Ultrasound
imaging of the sural nerve: Ultrasound
anatomy and rationale for investigation.
Eur J Vasc Endovasc Surg 2010;39(5):636–
41.
12. Steele R, Coker C, Freed B, Wright B,
Brauer P. Anatomy of the sural nerve
complex: Unaccounted anatomic variations and morphometric data. Annals of
Anatomy. 2021;238:1–10.
♦
13. Gloviczki P, Lawrence P, Wasan S, et al.
The 2022 Society for Vascular Surgery,
American Venous Forum, and American
Vein and Lymphatic Society clinical
practice guidelines for the management
of varicose veins of the lower extremities.
Part 1. Duplex scanning and treatment
of supercial truncal reux. J Vasc Surg
Venous Lymphat Disord. 2023;11:
231–61.
★
14. Farah M, Nayfeh T, Urtecho M, et al. A
systematic review supporting the Society
for Vascular Surgery, the American Venous
Forum, and the American Vein and Lymphatic Society guidelines on the management of varicose veins. J Vasc Surg Venous
Lymphat Disord. 2022;10:1155–71.
15. Raju S, Easterwood L, Fountain T, Fredericks R, Neglen P, Devidas M. Saphenectomy in the presence of chronic venous
obstruction. Surgery. 1998;123:637–44.
★
16. Benfor B, Peden E. A systematic review of
management of supercial venous reux
in the setting of deep venous obstruction.
J Vasc Surg Venous Lymphat Disord.
2022;10:945–54.
♦
17. O’Donnell TF, Jr., Passman MA, Marston
WA, et al. Management of venous leg
ulcers: Clinical practice guidelines of
the Society for Vascular Surgery and the
American Venous Forum. J Vasc Surg.
2014;60(2 Suppl):3S–59S.
18. Critchley G, Handa A, Maw A, Harvey
A, Harvey M, Corbett C. Complications
of varicose vein surgery. Ann R Coll Surg
Engl. 1997;79:105–10.
References 415
https://t.me/med1917
19. Hayden A, Holdsworth J. Complications
following re-exploration of the groin for
recurrent varicose veins. Ann R Coll Surg
Engl. 2001;83(4):272–3.
20. Javier J, Ortiz P. Treatment of chronic
venous insufciency in Latin America.
J Vasc Surg: Venous and Lym Dis.
2020;8:667–75.
21. Eidson 3rd J, Shepherd L, RL B. Aneurysmal dilatation of the great saphenous vein
stump after endovenous laser ablation.
Vasc Surg. 2008;48(4):1037–9.
22. Rudarakanchana N, Berland T, Chasin C,
Sadek M, Kabnick L. Arteriovenous stula
after endovenous ablation for varicose
veins. J Vasc Surg. 2012;55(5):1492–4.
♦23. De Maeseneer M, Kakkos S, Aherne T, et
al. European Society for Vascular Surgery
(ESVS) 2022 clinical practice guidelines on
the management of chronic venous disease
of the lower limbs. Eur J Vasc Endovasc
Surg. 2022;63:184–267.
•24. Mekako A, Chetter I, Coughlin P, J
H, PT M. Randomized clinical trial of
co-amoxiclav versus no antibiotic prophylaxis in varicose vein surgery. Br J Surg
2010;97:29–36.
25. Almeida J. Endovenous thermal ablation
of saphenous reux. In: Almeida JI, ed.
Atlas of Endovascular Venous Surgery,
Second Edition. London: Elsevier Inc.;
2019:184:chap 5.
26. Iafrati M, O’Donnell T. Varicose veins:
Surgical treatment. In: Sidawy A, Perler B,
eds. Rutherford’s Vascular and Endovas-
cular Therapy, Ninth Edition. London:
Elsevier, Inc.; 2019:2020–35:chap 154.
•27. Klem T, Schnater J, Schütte P, Hop W, van
der Ham A, Wittens C. A randomized
trial of cryo stripping versus conventional
stripping of the great saphenous vein. Vasc
Surg. 2009;49(2):403–9.
•28. Disselhoff B, der Kinderen D, Kelder J,
Moll F. Five-year results of a randomized
clinical trial comparing endovenou laser
ablation with cryostripping for great
saphenous varicose veins. Brit Jour Surg.
2011;98:1107–11.
29. Matei S, Matei M, Anghel F, Murariu M.
Cryostripping—A safe and efcient alter-
native procedure in chronic venous disease
treatment. J Clin Med. 2022;11:5028–38.
DOI:10.3390/jcm11175028
30. Shamiyeh A, Schrenk P, Wayand W.
Prospective trial comparing bilateral and
unilateral varicose vein surgery. Arch Surg.
2003;387:402–5.
•31. Dwerryhouse S, Davies B, Harradine K,
Earnshaw J. Stripping the long saphenous vein reduces the rate of reoperation
for recurrent varicose veins: Five-year
results of a randomized trial. J Vasc Surg.
1999;29:589–2.
•32. Gonzalez Canas E, Lopez S, Vilagut R, et
al. A randomized controlled noninferiority trial comparing radiofrequency with
stripping and conservative hemodynamic
cure for venous insufciency technique for
insufciency of the great saphenous vein. J
Vasc Surg: Venous Lym Dis. 2021;9:101–
12.
•33. Biswas S, Clark A, Shields D. Randomised
clinical trial of the duration of compression therapy after varicose vein surgery.
Eur J Vasc Endovasc Surg 2007;33:631–7.
34. Aromaa U, Asp K. A comparison of
naproxen, indomethacin, and acetylsalicyclic acid in pain after varicose vein surgery.
J Int Med Res 1978;6:152–6.
•35. Lurie F, Creton D, Eklof B, et al. Prospective Randomised Study of Endovenous
Radiofrequency Obliteration (Closure)
Versus Ligation and Vein Stripping
(EVOLVeS): Two-year followup. Eur J Vasc
Endovasc Surg. 2005;29:67–73.
★36. Whing J, Nandhra S, Nesbitt C, Stansby
G. Interventions for great saphenous
vein incompetence (Review). Cochrane
Database Syst Rev 2021;8;Art No:
CD005624. DOI:10.1002/14651858.
CD005624.pub4.
•37. Cañas E, López S, Vilagut R, et al. A
randomized controlled noninferiority trial
comparing radiofrequency with stripping
and conservative hemodynamic cure for
venous insufciency technique for insufciency of the great saphenous vein. J Vasc
Surg: Venous Lym Dis. 2021;9:101–12.
•38. Liao C, Song S, Li T, Zhang Y, Zhang W.
Randomized clinical trial of radiofrequen-
cy-induced thermotherapy combined with
transilluminated powered phlebectomy
versus high ligation and stripping for the
treatment of lower limb varicose veins. J
Vasc Surg: Venous Lym Dis. 2021;9:95–
100.
•39. Venermo M, Saarinen J, Eskelinen E, et
al. Randomized clinical trial comparing
surgery, endovenous laser ablation and
ultrasound-guided foam sclerotherapy for
the treatment of great saphenous varicose
veins. BJS. 2016;103:1438–44.
40. Kusagawa H, Ozu Y, Inoue K, Komada T,
Katayama Y. Clinical results 5 years after
great saphenous vein stripping. Ann Vasc
Dis 2021;14(2):112–7.
41. Kushwaha J, Gupta A, Yadav P, Sonkar
A. A Comparative study to evaluate early
postoperative complications and shortterm quality of life assessment between
stripping and endovenous laser therapy in
the treatment of chronic venous insufciency patients: A Study From North
India. Indian J Public Health Res Dev
2020;11:134–40.
•42. El-Kaffas K, El-Kashef O, Eibaz W. Great
saphenous vein radiofrequency ablation
versus standard stripping in the management of primary varicose veins—A
randomized clinical trial. Angiology.
2011;62(1):49–54.
43. Rudstrom H, Bjorck M, Bergqvist D.
Iatrogenic vascular injuries in varicose vein
surgery: A systematic review. World J Surg.
2007;31:228–33.
•44. Eggen C, Alozai T, Pronk P, et al.
Ten-year follow-up of a randomized
controlled trial comparing saphenofemoral ligation and stripping of the great
saphenous vein with endovenous laser
ablation (980 nm) using local tumescent
anesthesia. J Vasc Surg: Venous Lym Dis.
2022;10:646–53.
•45. Gohel M, Barwell J, Taylor M, Chant T,
Foy C, Earnshaw J. Long term results
of compression therapy alone versus
compression plus surgery in chronic
venous ulceration (ESCHAR): Randomized controlled trial. Br Med J
2007;335:83–9.
40
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CHAPTER
41
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Saphenous-preserving
surgical interventions
CHIVA and ASVAL
Tristan R. A. Lane, Sarah Onida, and Alun H. Davies
41.1 INTRODUCTION
The treatment of supercial venous reux has predominantly focused on obliteration of the incompetent vein by
various methods and thus removing it from the venous
tree. This includes open surgery, endovenous ablation, and
sclerotherapy, all targeted at removing reuxing veins (1).
However, there is some evidence that this ablative approach
may not always be the most appropriate method hemodynamically of improving the venous drainage of the leg.
Such techniques depended on the rst revolution in
varicose vein treatment—the development of color duplex
ultrasound allowing careful assessment of the venous tree,
which has revolutionized our understanding of the patterns of disease (2). With careful venous mapping, our
understanding of the development of varicose veins has
progressed with competing theories—the ascending and
descending theories (3). This new mapping system allowed
optimization of open surgery with multiple different
approaches to groin and strip tract recurrence (4) and local
anesthetic surgical techniques (5), allowing even open surgery into outpatient clinic-based settings.
Saphenous-sparing techniques were developed in this
era, but with the rise of endovenous techniques and numerous new devices, there has been a denite preponderance of
literature reviewing optimal methods for ablation and how
such techniques may be optimized to reduce the rates of
recurrence and improve the quality-of-life (QoL) benets
after intervention. These techniques offer simple and reproducible “workhorse” treatments that improve the QoL outcomes for many (6). This may have dissuaded many from
persevering with more complex open methods, though
reimbursement issues have prevented many regions of the
world from utilizing the endovenous approaches fully.
Standard open surgical techniques remain a robust
and equally effective approach to reuxing vein removal;
however, different pathways for simple procedures such
as ligation and avulsion offer the opportunity for bespoke
adjustment of the venous treatment process. Saphenous-sparing techniques advocate that bespoke service
and are principally divided into CHIVA (ambulatory conservative hemodynamic cure for venous insufciency) and
ASVAL (ambulatory selective variceal ablation under local
anesthetic), and both have originated in France.
41.2 CURE CONSERVATRICE ET
HÉMODYNAMIQUE DE
L’INSUFFISANCE VEINEUSE EN
AMBULATOIRE (CHIVA)
Introduced by Claude Franceschi in 1988, this is a
method of interrupting “shunts” of reux that lead to
venous hypertension (7). The name CHIVA is an acronym for cure conservatrice et hémodynamique de l’insuf-
sance veineuse en ambulatoire in French: ambulatory
conservative hemodynamic cure for venous insufciency
in English.
The method polarizes clinicians, and this is likely due
to the very steep learning curve (8). It requires careful and
methodical mapping of the ow of blood in the leg, utilizing modied Trendelenburg tests to assess the outcomes
of obstructing these patterns of ow. This clinical test is
notoriously difcult to reproduce (9), and the hemodynamic venous mapping may not be suitable for all patients.
The nal stumbling block for the interested clinician is the
nomenclature of “shunts,” which conjures up the world
of complex cardiovascular disease and does not engender
enthusiasm in the majority of vascular surgeons who may
not be phlebologically inclined. The most common shunt is
not “CHIVA 1” (30% have CHIVA 1, 60% have CHIVA 3,
and CHIVA 2 is therefore rare), and the classication criteria can be difcult to follow without diagrammatic representation. Fortunately, many publications have tried to
produce high-quality diagrams to support this, such as (5),
and indeed Zamboni and Franceschi’s book on the matter (10) provides detailed explanation. However, detail can
confuse and obscure the principles. The various “shunts”
described are essentially either closed-loop recirculation
of venous blood or escape points into tributaries that then
drain into perforators.
CHIVA pictograms are in Figure 4.1–4.5.
DOI: 10.1201/9781003328971-46
417417
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41.1 CHIVA shunt 1 pictogram.
41.2 CHIVA shunt 2 pictogram.
41.3 CHIVA shunt 3 pictogram.
41.4 CHIVA shunt 4 pictogram.
41.3 Ablation Sélective des Varices sous Anesthésie Locale (ASVAL) 419
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41
41.5 CHIVA shunt N3 pictogram.
In essence the careful ligation of “shunts” ascribes to the
descending theory of venous disease and offers minimally
invasive procedures, but these are by necessity surgical
operations with small incisions, venous ligation, and disruption. Mainly performed under local anesthetic as an
ambulatory procedure, they are usually well tolerated by
patients, though outcomes in the literature are sparse.
The principles are clear—preserve as much vein as
possible and allow drainage to the deep veins by existing pathways. If problems persist, then further disconnections can be performed. However, although the
principles are clear, the procedures require diligent and
repeated mapping of the venous tree before and after
intervention.
CHIVA treatment pictograms are shown in Figures 4.6
and 4.7.
The evidence for CHIVA has been assessed by a
Cochrane review in 2015 and updated in 2021 (11, 12);
however, these reviews are limited by the quality of the
data presented—only ve randomized studies have been
performed, with the quality of these being suboptimal due
to low numbers or difculties with bias. Only two studies have assessed CHIVA against endovenous ablation:
41.6 CHIVA shunt 1 treatment.
Gonzalez Canas et al. (13) and Wang et al. (14), though the
Wang et al. study has some signicant questions regarding
many of the steps reported. In these two studies, no difference in primary outcome was seen between endovenous
ablation and CHIVA.
To really assess the outcomes of CHIVA, an appropriately powered randomized prospective study with
long-term outcomes (5 years plus) is required, equivalent to the CLASS or Rasmussen studies on other techniques (6, 15).
The lack of clear superiority of the technique when
added to the sheer complexity of the venous mapping and
the meticulous planning required to achieve reasonable
outcomes is the probable reason why take-up has been so
limited across the world.
41.3 ABLATION SÉLECTIVE DES
VARICES SOUS ANESTHÉSIE
LOCALE (ASVAL)
Ambulatory selective variceal ablation under local anesthesia (ASVAL) is the selective removal of varicosities
using ambulatory phlebectomy without treatment of
truncal veins (16). This approach is similar to but crucially different from the CHIVA method in that it works
to remove the incompetent venous reservoir, aiming to
420 Chapter 41 Saphenous-preserving surgical interventions
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41.7 CHIVA shunt 3 treatment.
thereby improve the relative outow of the leg. A recent
systematic review found that although the evidence was
weak, there were early data to support the use of ASVAL
as a valid component of the armory of the vascular surgeon or phlebologist (17).
A recent development has been the publication of the
SAPTAP randomized controlled trial (18), which reported
1-year outcomes in 2022. This study recruited 464 patients
to compare truncal thermal ablation with concomitant
phlebectomy (TAP) with “single” ambulatory phlebectomy
(SAP)—though this was actually multiple phlebectomy
points as many surgeons normally practice. The study
reported similar outcomes at 1 year between groups,
though 25% of patients in the SAP group required further
procedures between 9 months and 1 year (almost all truncal ablation). Although very few cases had residual saphenofemoral junction reux at 1 year follow-up in either
group, the presence of 42% with GSV reux (or, in fact,
60% if those having truncal treatment after 9 months are
counted) does raise concerns of signicantly higher recurrence rates after this time. Hopefully these patients can be
followed up for longer and a denitive answer on longterm outcomes can be made.
ASVAL pictograms are shown in Figures 41.8 and
41.9.
A further technique of high ligation (crossectomy) and
multiple stab avulsions was described by Fligelstone et al.
41.8 Pictogram describing ASVAL venous tree preoperatively.
in 1993 (19, 20), which marries more classical techniques.
However, this has not been practiced widely, potentially
due to the nding of persistent reux in the great saphenous vein and the dominance of descending venous reux
theory in this era (21).
Previous work by Pittaluga et al. suggests reasonable
long-term outcomes in the context of single-specialist-center
retrospective data—at 10 years, 64% freedom from GSV
reux, with 23% requiring further treatment (22). However, improvement in symptoms was found in 70%. This
suggests that isolated phlebectomy treatment can provide
a reasonable solution; however, these data are limited by
the size and nature of the study, and the SAPTAP RCT is
limited by duration of follow-up.
41.4 THE BENEFITS OF A
SAPHENOUS-SPARING
APPROACH
Proponents describe three main benets:
1. Minimally invasive and minimally destructive
2. Preservation of the saphenous trunk as a venous conduit
for bypass
3. Can allow optimal leg drainage—reux may not be “bad”
41.9 Pictogram describing venous tree after ASVAL procedure.
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41.5 DIFFICULTIES WITH A
SAPHENOUS-SPARING APPROACH
Critics answer these as follows:
1. Long-term recurrence rates are poorly researched.
2. Varicose veins are not suitable for bypass conduits
unless they have reverted to normal veins after removal
of reux—there is no evidence that this occurs, and
indeed many saphenous-sparing techniques do not
remove reux.
3. “Optimal” leg drainage is controversial, and outside of
specialized centers, outcomes are poor.
41.6 Discussion 421
though this remains controversial. The techniques are safe
and well-tolerated, with excellent results in skilled hands,
though whether this is translatable to all centers and all clinicians is currently undecided. Additionally, whether these
techniques are superior to other techniques has not been
proved, though, as with many areas of venous treatment,
equivalence is apparent.
Cost assessments may be of benet—as the QoL metrics
seen in many studies remain the same between treatment
options, the cost of the procedure becomes key. This is
primarily dependent on consumables and theater time.
Whereas endovenous ablation and foam sclerotherapy
procedures only need a “clean” room, open ligation and
phlebectomies have a higher infection risk and so require a
procedure room with theater-grade ventilation. This comes
at a cost, which makes the comparisons quite difcult and
location dependent.
Evidence of benet of saphenous trunk preservation
for bypass is severely limited, and until a signicant study
shows that varicose veins are noninferior in terms of
patency and safety, cardiovascular and vascular bypasses
will continue to eschew their use. Indeed currently, not only
are varicosed conduits associated with aneurysmal complications, but their long-term patency is reduced in previous
studies (23–26). No study has yet shown a return to normal histological structure with removal of reux. Indeed,
it would be difcult to convince most arterial surgeons
that continuing reux in an incompetent vein produces a
good-quality and robust conduit—this would require good
basic science and clinical data.
Until the publication of the SAPTAP study, saphenoussparing techniques were limited by small-scale studies. The
SAPTAP study allows a more careful assessment; however,
the long-term outcomes remain lacking. Hopefully with
longer follow-up, this study may clearly show the outcomes of saphenous-sparing techniques.
Currently, these techniques remain an option mainly
for enthusiasts, who, like practitioners of foam sclerotherapy, are willing to accept that these procedures may lead to
greater recurrence rates in the medium to long term after
surgery.
Most important is the application of a good technique
with diligent preoperative assessment and counseling to
achieve satisfactory results that match patient expectations.
41
41.6 DISCUSSION
Saphenous-sparing approaches offer an alternative technique, allowing for preservation of the truncal vein. This
may allow for utilization of truncal veins as a conduit,
Guidelines 41.0 of the American Venous Forum on saphenous-preserving surgical interventions*
No. Guideline Grade of
41.1 For patients with the early stages of symptomatic varicose veins, we suggest preserving
the GSV using the ASVAL technique, if performed by a physician who is familiar with it.2(weak)
41.2 For patients with symptomatic varicose veins, we suggest preserving the GSV using the
CHIVA technique, if performed by physician who is familiar with it.
* Based on recommendations from Reference 27.
recommendation
2
(weak)
Quality of
evidence
B
(moderate)
B
(moderate)
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REFERENCES
★ Systematic review
♦ Guidelines
1. Whiteley MS, Shiangoli I, Dos Santos
SJ, Dabbs EB, Fernandez-Hart TJ,
Holdstock JM. Fifteen year results of
radiofrequency ablation, using VNUS
closure, for the abolition of truncal
venous reux in patients with varicose veins. Eur J Vasc Endovasc Surg.
2017;54:357–362.
2. Qureshi MI, Gohel M, Wing L et al. A
study to evaluate patterns of supercial
venous reux in patients with primary
chronic venous disease. Phlebology.
2015;30:455–461.
3. Qureshi MI, MacDonald A, Wing L et al.
Neither ascending nor descending theory
can fully explain the pattern of venous
reux in patients with primary chronic
venous disease. J Vasc Surg. 2010;51:
791–792.
4. Gianesini S, Menegatti E, Malagoni AM,
Occhionorelli S, Zamboni P. Mini-invasive high-tie by clip apposition versus
crossectomy by ligature: Long-term
outcomes and review of the available
therapeutic options. Phlebology J Venous
Dis. 2017;32:249–255.
5. Mowatt-Larssen E, Shortell CK. Treatment
of primary varicose veins has changed with
the introduction of new techniques. Semin
Vasc Surg. 2012;25:18–24.
6. Brittenden J, Cooper D, Dimitrova M, et
al. Five-Year Outcomes of a Randomized
Trial of Treatments for Varicose Veins. N
Engl J Med. 2019;381:912–922.
7. Franceschi C. Ambulatory and hemodynamic treatment of venous insufciency
(CHIVA cure). J Mal Vasc. 1992;17:
291–300.
8. Milone M, Salvatore G, Maietta P, Sosa
Fernandez LM, Milone F. Recurrent varicose veins of the lower limbs after surgery.
Role of surgical technique (stripping vs.
CHIVA) and surgeon’s experience. G Chir.
2011;32:460–463.
9. Kim J, Richards S, Kent PJ. Clinical examination of varicose veins–a
validation study. Ann R Coll Surg Engl.
2000;82:171–175.
10. Zamboni P, Franceschi C. Principles of
Venous Hemodynamics. Nova Science
Publishers; 2009:198.
★
11. Bellmunt-Montoya S, Escribano JM,
Dilme J, Martinez-Zapata MJ. CHIVA
method for the treatment of chronic
venous insufciency. Cochrane Database
Syst Rev. 2015;2015:CD009648.
★
12. Bellmunt-Montoya S, Escribano JM,
Pantoja Bustillos PE, Tello-Díaz C,
Martinez-Zapata MJ. CHIVA method for
the treatment of chronic venous insufciency. Cochrane Database Syst Rev.
2021;9:CD009648.
13. González Cañas E, Florit López S,
Vilagut RV, et al. A randomized
controlled noninferiority trial comparing radiofrequency with stripping
and conservative hemodynamic cure
for venous insufciency technique for
insufciency of the great saphenous vein.
J Vasc Surg Venous Lymphat Disord.
2021;9:101–112.
14. Wang H, Chen Q, Fei Z, Zheng E, Yang
Z, Huang X. Hemodynamic classication
and CHIVA treatment of varicose veins in
lower extremities (VVLE). International J
Clin Exp Med. 2016;9:2465–2471.
15. Lawaetz M, Serup J, Lawaetz B et al.
Comparison of endovenous ablation
techniques, foam sclerotherapy and
surgical stripping for great saphenous
varicose veins. Extended 5-year
follow-up of a RCT. Int Angiol.
2017;36:281–288.
16. Pittaluga P, Chastanet S, Locret T, Barbe
R. The effect of isolated phlebectomy
on reux and diameter of the great
saphenous vein: A prospective study.
Eur J Vasc Endovasc Surg. 2010;40:
122–128.
★
17. Richards T, Anwar M, Beshr M,
Davies AH, Onida S. Systematic review
of ambulatory selective variceal ablation
under local anesthetic technique for the
treatment of symptomatic varicose veins.
J Vasc Surg Venous Lymphat Disord.
2021;9:525–535.
18. Scheerders ERY, van der Velden SK, Goossens LMA et al. A randomized clinical
trial of isolated ambulatory phlebectomy
versus saphenous thermal ablation with
concomitant phlebectomy (SAPTAP Trial).
Br J Surg. 2022;znac388.
19. Fligelstone LJ, Salaman RA, Oshodi
TO et al. Flush saphenofemoral ligation
and multiple stab phlebectomy preserve a
useful greater saphenous vein four years
after surgery. J Vasc Surg. 1995;22:
588–592.
20. Fligelstone L, Carolan G, Pugh N, Shandall A, Lane I. An assessment of the long
saphenous vein for potential use as a vascular conduit after varicose vein surgery. J
Vasc Surg. 1993;18:836–840.
21. McMullin GM, Coleridge Smith PD, Scurr
JH. Objective assessment of high ligation
without stripping the long saphenous
vein. Br J Surg. 1991;78:1139–1142.
22. Chastanet S, Pittaluga P. Ten-year
outcomes of treatment of varicose veins
by ambulatory selective ablation of varices
under local anesthesia (ASVAL). J Vasc
Surg Venous Lymp Disord. 2018;6:289.
23. Ortega MA, Fraile-Martínez O,
García-Montero C et al. Tissue
remodelling and increased DNA damage
in patients with incompetent valves in
chronic venous insufciency. J Cell Mol
Med. 2021;25:7878–7889.
24. Perek B, Malinska A, Stefaniak S, et
al. Predictive factors of late venous
aortocoronary graft failure: Ultrastructural studies. PLoS One. 2013;8:e70628.
25. Wilson YG. Vein quality in infrainguinal
revascularisation: Assessment by angioscopy and histology. Ann R Coll Surg Engl.
1998;80:3–15.
26. Davies AH. Vein factors that affect the
outcome of femorodistal bypass. Ann R
Coll Surg Engl. 1995;77:63–66.
♦
27. Gloviczki P, Lawrence PF, Meissner MH, et
al. The 2023 Society for Vascular Surgery,
American Venous Forum, and American
Vein and Lymphatic Society Clinical
practice guidelines for the management of
varicose veins of the lower extremities. Part
II. Endorsed by the Society of Interventional Radiology, the Society for Vascular
Medicine and the International Union of
Angiology. J Vasc Surg Venous Lymphat
Disord. 2024;12:101670.
CHAPTER
42
https://t.me/med1917
Radiofrequency treatment of the
incompetent saphenous vein
Alan M. Dietzek and Emilia Krol
42.1 INTRODUCTION
Chronic venous disease (CVD) is one of the most common
vascular diseases to affect a patient’s health and quality of
life (QoL). It is estimated that the prevalence of varicose
veins is as high as 23%–88%
Americans are affected by chronic venous insufciency
2
The symptoms and signs of this disease are varied
(CVI).
and range from mild to disabling. They include varicose
veins, leg swelling, skin discoloration, thickening of the
skin, and, in the most advanced cases, ulceration. Consequently, CVD and its more severe form, CVI, have resulted
in U.S. annual health care expenditures in the billions of
dollars.
the most frequent causes of primary CVD. Prior to endovenous ablation, surgical stripping of the GSV was the
accepted standard for the management of symptomatic
supercial venous disease. This intervention was associated with signicant morbidity, postoperative pain, and
prolonged recovery times. Radiofrequency ablation (RFA)
for treatment of the incompetent saphenous vein was rst
introduced in Europe in 1998 and approved for use in
the United States by the Food and Drug Administration
(FDA) in 1999. RFA is a minimally invasive alternative to
saphenous vein ligation and stripping. Since its introduction, the procedure has become increasingly popular as it
offers equal efcacy, decreased morbidity, a milder recovery
course, and greater patient satisfaction when compared to
saphenous vein stripping.
saphenofemoral junction (SFJ), varicose vein recurrence
affects 15%–30% of patients. The primary cause is neovascularization.
neovascularization frequency is greatly reduced.
et al. performed detailed ultrasonographic analysis of the
GSV in patients receiving RFA over a 2-year period. The
most common observation at the SFJ was a short patent
stump conducting antegrade tributary ow through the
SFJ with an obliterated GSV trunk.
believed to serve as a conduit to preserve the normal physiologic ow from one or more patent tributaries such as
those draining blood from abdominal and pudendal areas.
Following RFA of the GSV, it has become clear that reux
at the SFJ can be eliminated without groin dissection or
3
Reux in the great saphenous vein (GSV) is one of
Following stripping and ligation of the GSV at the
4
Following endovenous ablation via RFA, the
1
and that over 25 million
5,6
Pichot
6
This patent stump is
ligation of second- and third-order tributary branches.
Preservation of such physiologic ow has been an advantage of endovenous procedures over traditional vein stripping, as it causes less hemodynamic disturbance, which is
thought to be one of the factors responsible for stimulating
postsurgical neovascularization.
Over the course of the past 20 years, several randomized trials have compared endovenous RFA with surgical
stripping or endovenous laser therapy (EVLT) of the saphenous vein. All have demonstrated RFA to have equal or
better outcomes and will be reviewed in greater detail later
in this chapter.
RFA device available in the United States and approved by
the FDA for use in supercial veins, albeit with modications and different manufacturers over time (Closure and
ClosurePlus [CP], VNUS Medical Technologies, San Jose,
CA; ClosureFast [CLF], Venet Covidien, Manseld, MA;
and currently ClosureFast RFA System, Medtronic, Minneapolis, MN). As of this writing, this is the most widely used
RF device. As such, the majority of studies reviewed in this
chapter were performed with this catheter.
Other approved devices include the Olympus Celon
RFiTT (Celon AG, Medical Instruments, Teltow, Germany)
pending FDA approval and VenClose (Venclose, Inc.,
San Jose, CA) which was approved in 2021. They will be
described at the end of the chapter.
7–18
Until recently, there has been only one
42.2 THE CLOSURE SYSTEM AND RFA
PROCEDURE
42.2.1 Mechanism of action
The rst-generation RFA catheters (CP) utilized bipolar
electrodes at the tip of the catheter to apply to the vein wall
an alternating electrical current at a frequency of 200–1200
kHz (Figure 42.1). The vein wall acted as a conductor with
a known resistance, thus converting radiofrequency (RF)
energy into thermal energy, resulting in heating of the vein
wall. This caused denaturation of the collagen in the vein
wall with resultant contraction of the vessel and obliteration of the vessel lumen. To transfer electrical current, there
had to be good apposition of the catheter electrodes to the
intraluminal vein wall.
catheter was withdrawn slowly (2–3 cm/minute) to ensure
19
With the RF energy activated, the
DOI: 10.1201/9781003328971-47
423423
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