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B
Figure21.5 (A) Administration of the tumescent anesthesia into the
saphenous compartment is monitored by ultrasound. Both the needle
and catheter are visualized in longitudinal view to ensure proper
placement of the solution. (B)In transverse view, tumescent in ltration
within the saphenous compartment is con rmed. e administration of
tumescent solution around the catheter gives an ‘onion skin’ appearance.
e catheter or sheath appear as a hyperechoic line in
16,17
the GSV lumen.
the epigastric vein.
Its placement should be 1cm distal to
18
Administration of the tumescent anesthesia into the
19
saphenous compartment is monitored by ultrasound.
e
vein is seen as “ oating” in an echogenic sea of the anesthetic solution (see Figure21.5). It is always wise to recheck
the catheter position at SFJ prior to tumescent application
at the tip, which may distort the image and the subsequent
27
application of the energy (see Figure21.6).
Also, forceful
tumescent in ltration can advance the catheter forward.
e ablation starts at the SFJ and proceeds in a distal
18
direction.
tion of the saphenous vein to a residual diameter of <2mm.
Successful obliteration is con rmed by contrac-
18
Patency of the common femoral artery and vein are con rmed
by ultrasound (see Figure21.7). Immediately following treatment, a compressible CFV must be documented. Athrom-
16,17
bus may be seen as a hyperechogenic core in the vessel.
Figure21.6 e ablation starts at the SFJ and proceeds in a distal
direction. It is recommended to recheck the catheter position at the SFJ
prior to the application of the energy.
Early post treatment duplex surveillance is mandatory
to evaluate for the presence or absence of DVT and e cacy
of treatment. e presence of a protruding thrombus from
the GSV into the CFV is termed, Post Ablation Super cial
rombus Extension (PASTE) and can occur as a consequence of EVLT or RFA of the GSV (see Figure21.8).
It is visualized within 3–7days at ultrasound follow-up. Its
29
course is typically benign.
Evidence of a noncompressible
GSV with thickened walls and absence of ow on color
ultrasound analysis are signs of successful obliteration (see
10
Figure21.9).
MECHANOCHEMICAL ABLATION
Early results of mechanochemical ablation of the GSV and
30–32
SSV are promising.
e ClariVein catheter utilizes a
combination of mechanical agitation of the vessel endothelia
by a rotating catheter tip and delivery of a sclerosant drug.
As in the thermal ablation techniques, ultrasound guidance
is used for percutaneous access of a sheath, followed by a
Clarivein catheter. e wire is extruded and the distal tip of
the wire is positioned 2cm from the saphenofemoral junction under ultrasound guidance. Catheter wire rotation is
then activated for 2-3 seconds at approximately 3500rpm.
is action induces vasospasm. Since vasospasm occurs and
there is no risk of thermal damage to surrounding structures, mechanochemical ablation does not require tumescent
anesthesia. During rotation of the wire, a liquid sclerosant is
infused simultaneously with catheter pullback. Immediately
following the procedure, ultrasound is used to con rm GSV
occlusion and patency of the common femoral vein using
ultrasound. e same post-treatment protocol for ultrasound
surveillance should be followed as for thermal endovenous
procedures.
16,29
33
178 • PRIMARY SUPERFICIAL VENOUS INSUFFICIENCY
A B
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Figure21.7 Duplex examinations (longitudinal views) of the GSV at the SFJ. (A)Pretreatment scan demonstrated an incompetent SFJ a er
augmentation. (B)Intraoperative color duplex interrogation showed successful occlusion of the GSV with a patent, 3-mm proximal stump (arrow
1)and absence of ow within the treated segment (arrow 2). (Adapted from Reference16).
A B
FIGURE21.8 Early PASTE not well visualized by B-mode imaging (A) but an intraluminal lling defect is apparent (B).
ULTRASOUND MONITORING
DURING SCLEROFOAM
ABLATION OF VARICOSEVEINS
Advent of foam sclerotherapy has added a new tool for the
treatment of CVI. Sclerosant agents provoke endothelial
damage by several mechanisms.
34
surface tension of the plasma membrane (detergents) or the
intravascular pH and osmolarity. e nal result is a chemi-
34
cal brosis of the treated vessel.
Sclerosing foams are mixtures of gas with a liquid solution with surfactant properties. In 1993, Cabrera proposed
the use of sclerosing foam, made of sodium tetradecyl sulfate or polidocanol in the treatment of varicose veins.
One of the intrinsic limits of liquid sclerosants in the treatment of varicose veins is dilution by the bloodstream with
36
Figure21.9 Evidence of a noncompressible GSV with thickened walls
and absence of ow on color ultrasound analysis are signs of successful
obliteration. SC:Saphenous compartment.
reduction of their e cacy.
by the moving bloodstream. Sclerosing foams do not mix
with blood and instead remain in the vessel, continuing to
strip the endothelium.
Also, they are rapidly cleared
36
is persistence of the agent in the
ey change either the
35
ULTRASOUNDGUIDED CATHETER AND FOAM THERAPY FOR VENOUS INSUFFICIENCY • 179
vessel causes an increased contact time with the intimal sur-
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36
face. Foam preparation is remarkably simple.
three-way stopcock method is the most commonly used.
e Tessari
36,37
As in electromagnetic ablation, the treatment starts with
clear ultrasound mapping. Varicose veins can be accessed by
the placement of 25-gauge butter y needle, or the GSV or
the SSV can be directly cannulated with an angiocath, an
36,38,39
echogenic Cook needle, or a 25-gauge butter y.
Most descriptions of the technique explain direct
36,40
ultrasound-guided access to the saphenous vein.
In contrast, we achieve a satisfactory and rapid obliteration of the
GSV and SSV by cannulating a peripheral varicosity.
39,41
Although the saphenous vein cannot be cannulated with a
catheter by way of a varicosity because of its angle of connection, there is no such obstacle to the ow offoam.
Foam functions as an e cient ultrasound contrast
medium because of its air content. Its injection can be easily monitored. Its ultrasound appearance is that of a solid
hyperechogenic core with an acoustic shadow projected in
the tissue below (see Figure21.10A).
Foam is introduced into a varix or the saphenous vein
with the patient supine. e leg should be elevated to a 45
degree angle to exsanguinate the vein, decrease the diameter of the vein, which also reduces the amount of scle-
41
rosant needed (see Figure21.10B).
Vasoconstriction and
vasospasm can be induced by intermittent compression of
the vein by the ultrasound transducer and by elevating the
limb. Foam will be seen by ultrasound to ow distally in
the elevated limb. It ows selectively through incompetent
valves and is e ectively blocked by competent valves. ese
maneuvers have the e ect of prolonging the action of the
foamed sclerosant on the intima, improving the e cacy of
the entire treatment.
Ultrasound monitoring during foam sclerotherapy
treatment increases safety as it guides treatment of targeted veins, monitors deep system involvement and helps
to determine the appropriate volume of sclerofoam to be
7
injected.
Ultrasound monitoring of sclerofoam can reduce
the risk of reaching the deep system from the SFJ, SPJ or
via perforating veins. Foam is followed as it is guided to targeted vessels while the femoral, popliteal, and deep veins of
the leg are scanned throughout the entire procedure. Travel
via perforating veins should be avoided. Foam particles
are washed out of deep veins such as the gastrocnemius
or tibial veins by exion-extension maneuvers of the foot.
uick movements of dorsi exion of the foot completely
clear the deep veins. Despite much worry about the problem, major thrombotic events in the femoral and popliteal
veins rarely have been described with use of sclerofoam. In
a study of over 1,200 sclerotherapy sessions, over half of
which involved foam, only a single femoral vein thrombus
42
was encountered.
Other large studies have con rmed the safety and
43
e cacy of foam sclerotherapy.
romboses of the gas-
trocnemius, tibial, and peroneal veins have been reported
only occasionally.
39,44
Intra-arterial injections are uncom-
mon because of monitoring the foam treatment of severe
39,44
CVI.
Ultrasound scanning has con rmed the presence of a tangled network of varicose veins of small caliber, reticular varices, and incompetent perforating veins
under lipodermatosclerotic plaques and under venous
39
ulcers (see Figure 21.11).
Ultrasound monitoring is
used to con rm the fact that these vessels are lled with
foam during the therapeutic maneuvers. Ultrasound guidance is also used in treatment of incompetent perforating
veins by direct cannulation and controlled injection of the
36
sclerosing foam under direct visual control.
More o en
super cial peripheral veins can be directly injected with
obliteration of the inciting perforator and the network of
the incompetentveins.
A
B
Figure21.10 (A) Foam functions as an e cient ultrasound contrast
medium because of its air content. Its injection can be easily monitored.
Its ultrasound appearance is that of a solid hyperechogenic core with an
acoustic shadow projected on the tissuebelow.
(B) Leg elevation to 45 degrees during injection of sclerofoam will help
exsanguinate the vein, decrease the vein diameter which ultimately
reduces the amount of sclerosant needed.
180 • PRIMARY SUPERFICIAL VENOUS INSUFFICIENCY
A
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Proximal
vein
Perforating
vein
B
Network
C
PV
Figure21.11 ( A) ere is a tangled network of varicose veins of small
caliber, reticular varices, and incompetent perforating veins under
lipodermatosclerotic plaques and under venous ulcers. (B)Ultrasound
con rms the network of incompetent vessels beneath the wound bed.
(C)Ultrasound can demonstrate the presence of IPVs relative to the
wound bed. ese incompetent veins are the targets for successful foam
sclerotherapy.
Perforating
vein
Ulcer
Ulcer
Distal
vein
Subcutaneous
layer
Subfascial
layer
DISCUSSION
Compression therapy and surgery have been the cornerstone of CVI treatment for years and they are still useful.
New minimally invasive techniques such as radiofrequency
ablation of saphenous veins, EVLT, and GSV and SSV ablation with sclerofoam of super cial varicose veins have been
demonstrated to be safe, e ective, and more acceptable to
18
the patient.
e contribution of ultrasound in general
and duplex technology in particular has given reliability to
the diagnosis of CVI and has enhanced the development
of these minimally invasive therapies. Intraprocedural and
postprocedural duplex ultrasound monitoring o ers the
best control of the entire procedure with early prevention
of complications (thrombosis of deep veins) and eventual
minimization of failure.
C O N C L U S I O N
Duplex ultrasound is essential in every phase of the CVI
patient care. Experience, critical thinking, uniform testing,
and insight in the pathology are necessary to achieve satisfactory results.
R E F E R E N C E S
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18. Sadick NS . Advances in the treatment of varicose veins:Ambulatory
phlebectomy, foam sclerotherapy, endovascular laser, and radiofrequency closure , Dermatol Clin . 2005 . 23 ( 3 ): 443–455 , vi .
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sural nerve:ultrasound anatomy and rationale for investigation. Eur
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22. Delis KT , Husmann M, Kalodiki E, Wolfe JH, Nicolaides AN. In
situ hemodynamics of perforating veins in chronic venous insu ciency , J Vasc Surg . 2001 . 33 ( 4 ): 773–782 .
23. Labropoulos N , Leon LR Jr. Duplex evaluation of venous insu ciency, Semin Vac Surg. 2005. 18 (1):5 – 9.
24. Caggiati A , Bergan JJ , Gloviczki P , Eklof B , Allegra C , Partsch H .
Nomenclature of the veins of the lower limb: Extensions, re nements, and clinical application , J Vasc Surg . 2005 . 41 ( 4 ): 719–724 .
25. De Maeseneer M, Pichot O, Cavezzi A, Earnshaw J, van Rij A, Lurie
F, Smith PC; Union Internationale de Phlebologie. Duplex ultrasound investigation of the veins of the lower limbs a er treatment
for varicose veins—UIP consensus document. Eur J Vasc Endovasc
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26. Weiss RA . Comparison of endovenous radiofrequency versus
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29. Wright D, Morrison N, Recek C, Passariello F.Post ablation super cial thrombus extension (PASTE) into the common femoral vein as
a consequence of endovenous ablation of the great saphenous vein.
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30. Elias S, Raines JK. Mechanochemical tumescentless endovenous
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MM, de Vries JP. Mechanochemical endovenous ablation of small
saphenous vein insu ciencyusing the ClariVein device: one-year
results of a prospective series. Eur J Vasc Endovasc Surg. 2013.
45(3):299 – 303.
32. van Eekeren RR, Boersma D, Konijn V, de Vries JP, Reijnen MM.
Postoperative pain and early quality of life a er radiofrequency ablation and mechanochemical endovenous ablation of incompetent
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33. Mueller RL, Raines JK. ClariVein mechanochemical ablation:background and procedural details. Vasc Endovascular Surg . 2013.
47 (3):195 – 206.
34. G oldman M . Sclerotherapy:Treatment of varicose and telangiectatic leg veins. In:
Louis, MO : Mosby . pp. 244–279.
35. Cabrera J . Dr J . Cabrera is the creator of the patented polidocanol
microfoam , Dermatol Surg . 2004 . 30 ( 12 Pt 2 ): 1605 ; author reply1606.
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sclerosing foam in the treatment of varicose veins , Dermatol Surg .
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38. Cabrera J, Redondo P, Becerra A, etal. Ultrasound-guided injection
of polidocanol microfoam in the management of venous leg ulcers ,
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39. Bergan JJ , Pascarella L . Severe chronic venous insu ciency:Primarytreatment with sclerofoam, Semin Vasc Surg . 2005 .
18 ( 1 ): 49–56 .
40. Guex JJ . Foam sclerotherapy:An overview of use for primary venous
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41. Bunke N, Brown K, Bergan J.Foam sclerotherapy:techniques and
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42. Guex JJ , Allaert FA , Gillet JL , Chleir F . Immediate and midterm
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182 • PRIMARY SUPERFICIAL VENOUS INSUFFICIENCY
22.
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PRINCIPLES OF TREATMENT OF VARICOSEVEINS
Steven E. Zimmet
reatment for venous disease has undergone rapid
innovation. Despite these advances varicose vein
T
treatment is not curative. Super cial venous insuf-
ciency is a chronic disorder that should be viewed more as
1
a medical than a surgical condition.
Nonetheless, it appears
that outcomes can be optimized when certain principles of
treatment are followed. is chapter discusses the development of the principles that are generally acceptedtoday.
A history and physical and a duplex ultrasound examination are prerequisites for adequate treatment of varicose
veins. Treatment of varicose veins, except when addressed by
conservative or pharmacologic measures, should eliminate
sources of venous hypertension. ese can be gravitational,
as with axial vein re ux, or hydrodynamic, due to increased
compartmental pressure during muscular contraction.
erefore, rational treatment depends on the delineation of
sources of re ux between the deep and super cial system
along with the extent of truncal and tributary incompetence. An individualized treatment plan is developed based
on the ndings of the evaluation and on the goals of the
patient. Treatment goals may include cosmetic improvement, relief of venous-related symptoms, management of
venous-related sequelae (such as edema, dermatitis, lipodermatosclerosis, ulceration, thrombophlebitis, and external
bleeding), prevention of complications, and control of the
disease process.
Saphenous vein re ux is the underlying primary
abnormality in the majority of cases of super cial venous
insu ciency. us, approaches to dealing with saphenofemoral junction and saphenous truncal incompetence have
dominated the thinking of phlebologists. Trendelenburg
described saphenofemoral junction ligation alone, without
stripping of the incompetent saphenous vein, in the 1890s.
e advantages of this technique over ligation and stripping
3
are still extolled.
Advocates of this approach have pointed
out that it preserves the saphenous trunk for possible future
4
use as a bypass gra
5
High ligation alone is also less invasive, quicker and
injury.
and avoids the risk of saphenous nerve
simpler to perform, and associated with an easier recovery
compared to vein stripping. Unfortunately, the shortcomings
of ligation alone outweigh its advantages. While it is true
that such treatment routinely “spares” the saphenous trunk,
the use of a diseased saphenous vein as a conduit has been
associated with an increased risk of gra failure.
importantly there is no longer any question that high ligation alone is coupled with persistent re ux in the saphenous
8,9
trunk.
Bergan concluded in 1991 that “duplex scanning
con rms the fact that high ligation alone allows persistence
10
of distal re ux a er surgical intervention.”
ing that varicose recurrence is signi cantly reduced
It is not surpris-
9,11,12
the reoperation rate is 60 to 70% less if the saphenous vein
13,14
is stripped versus ligation alone.
Regarding the clinical
bottom line, more patients were completely satis ed (65%
versus 37%) and were recurrence-free (65% versus 17%)
2
when the great saphenous vein (GSV) had been stripped
compared with saphenofemoral ligation alone (P < 0.05
15
and P < 0.001 respectively).
e authors concluded that
the addition of GSV stripping to saphenofemoral ligation
and multiple avulsions results in a better overall outcome.
While recurrence or residual communication with the junction in the groin was found in 80% of patients a er ligation
alone, 34% of limbs also had mid thigh perforator incom-
16
petence via the unstripped GSV.
As Neglen concluded,
stripping of the GSV of the thigh is essential to minimizing
recurrence due to redevelopment of incompetent communication with the saphenofemoral con uence and due to
17
thigh perforator incompetence.
With the use of endovenous techniques available today, some recommend treating
the entire incompetent saphenous segment rather than arbi-
18
trarily treating to the knee.
At the other end of the spectrum, stripping of the entire
saphenous from ankle to groin, along with stab avulsion
of varices, has been practiced. is was advocated because
it was assumed that re ux extended to the ankle in most
patients. However, in a duplex study on over 500 legs the
most common pattern was saphenous re ux from the groin
to the knee (43.4%), with re ux reaching the ankle in only
19
e authors concluded that clinically diagnosed GSV
1%.
re ux in the lower leg usually represented tributary varices,
which joined the saphenous vein proximally. ese ndings,
7
Most
and
6
183
along with the high incidence of saphenous neuralgia
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from groin to ankle stripping, explain recommendations
for “short” stripping of the GSV from groin to just below
the knee. Note that such stripping would avoid the risk of
saphenous nerve injury yet would disconnect mid thigh
perforators, which as noted above are a common cause of
recurrence when ligation alone is employed.
It is important to note that recurrence is common even
a er ligation and stripping of the saphenous. Inadequate
surgery of the saphenofemoral junction has been claimed to
20
be an important factor contributing to recurrence.
While
progression of disease is another mechanism that explains
some cases of recurrence, neovascularization around the
junction has been established to be an important cause of
recurrence a er venous surgery.
12,14,21–23
Early reports suggest that endovenous ablation techniques are associated
with a very low incidence of neovascularization. It may be
that by avoiding groin dissection and by preserving venous
drainage in normal junctional tributaries the development
24,25
of neovascularization is largely avoided.
In addition to junctional incompetence, another source
of deep to super cial incompetence is via perforating veins.
Ablation of the GSV doesn’t address lower leg perforator
incompetence directly, as most of these perforators don’t
drain into the GSV itself. Nonetheless, patients with super cial and perforator vein incompetence and with a normal
deep venous system experienced signi cant improvement
in air plethysmograph (APG)–measured hemodynamic
parameters and clinical symptom score a er super cial abla-
26
tive surgery alone.
e authors suggested that treatment of
perforator veins can be reserved for patients with persistent
incompetent perforator vessels, abnormal hemodynamic
parameters, or continued symptoms a er super cial ablative surgery. Another study corroborated these results, but
found that saphenous surgery alone failed to correct perforator re ux when there was coexistent deep venous re ux or
27
if super cial re ux persisted postoperatively.
It should be noted that a few centers advocate newer
conservative surgical approaches that spare the saphenous
vein. External valvuloplasty aims to restore proximal valvular
28,29
competence of the GSV.
e aim of conservative hemodynamic treatment of incompetent varicose veins in ambulatory patients (“Cure Conservatrice et Hemodynamique de
Insu cience Veneuse en Ambulatoire,” CHIVA) is to treat
varicose veins by creating a draining saphenous system by elim-
30
inating re ux points.
Selective ablation of the varicose veins
under local anesthesia (ASVAL), based on a concept that varicose veins evolve in an ascending fashion, seeks to preserve or
31
restore saphenous function by ablation of varices.
ese are
emerging techniques that are practiced by a few groups. eir
reproducibility and long-term success remain a question.
Appropriate treatment of varicose veins begins with an
accurate assessment of the underlying venous pathology
and identi cation of sources of venous hypertension. e
aims of treatment include elimination of the incompetent
connections between the deep and super cial systems as
well as the obliteration of pathways of venous incompetence
and incompetent varicose veins. It is clear that recurrence is
reduced if the incompetent segment of the saphenous trunk
is ablated. Duplex ultrasound examination reveals that the
GSV is o en competent and of much smaller diameter below
a site of saphenous-varicose tributary connection, usually
located in the thigh or proximal lower leg. Ablation of the
entire GSV, from groin to ankle, is almost never required.
It appears that avoiding groin dissection and preserving
normal junctional drainage may prevent the development
of neovascularization, an important cause of recurrence following ligation and stripping. us endovenous treatments,
including endovenous laser, radiofrequency ablation and
foam sclerotherapy, may yield the bene ts of ablation of the
incompetent saphenous trunk while minimizing recurrence
due to neovascularization. Causes of recurrence following
these endovenous treatments appear to be due primarily to
failure to fully ablate incompetent saphenous veins (failure
or recanalization) or due to progression of disease.
R E F E R E N C E S
1. Guex JJ , Isaacs , MN . Comparison of surgery and ultrasound guided
sclerotherapy for treatment of saphenous varicose veins: Must
the criteria for assessment be the same?, Int Angiol. 2000.
19 ( 4 ): 299–302 .
2. Bergan JJ . Ambulatory surgery of varicose veins. In: Goldman MP ,
B er g a n J J , e d s . Ambulatory treatment of venous disease . St. Louis,
MO:Mosby . 149–154.
3. Cheatle T . e long saphenous vein:To strip or not to strip?, Semin
Vasc Surg. 2005. 18 ( 1 ): 10–14 .
4. Large J . Surgical treatment of saphenous varices, with preservation of the main great saphenous trunk , J Vasc Surg . 1985.
2 ( 6 ): 886–891 .
5. Holme JB , Holme K , Sorensen LS . e anatomic relationship between the long saphenous vein and the saphenous
nerve:Relevance for radical varicose vein surgery , Acta Chir Scand.
1988. 154 ( 11–12 ): 631–633 .
6. Rutherford RB , Sawyer JD , Jones DN . e fate of residual saphenous vein a er partial removal or ligation, J Vasc Surg . 1990.
12 ( 4 ): 422–426 .
7. Panetta TF , Marin ML , Veith FJ , et al. Unsuspected preexisting
saphenous vein disease:An unrecognized cause of vein bypass failure , J Vasc Surg. 1992. 15 ( 1 ): 102–110 .
8. McMullin GM , Coleridge-Smith PD , Scurr JH . Objective assessment of ligation without stripping the long saphenous vein , Br J
Surg. 1991. 78 : 1139–1142 .
9. Sarin S , Scurr JH , Coleridge Smith PD . Assessment of stripping the
long saphenous vein in the treatment of primary varicose veins , Br J
Surg. 1992. 79 : 889–893 .
10. Bergan JJ . Surgical procedures for varicose veins. In: Bergan JJ ,
Yao JST , eds. Venous disorders . Philadelphia: WB Saunders . 1991.
201–216.
11. Munn SR , Morton JB , Macbeth WA , McLeish AR . To strip or not
to strip the long saphenous vein? Avaricose vein trial, Br J Surg.
1981. 68 : 426–481 .
12. Jones L , Braithwaite BD , Selwyn D , Cooke S , Earnshaw JJ .
Neovascularisation is the principal cause of varicose vein recurrence:Results of a randomised trial of stripping the long saphenous
vein , Eur J Vasc Endovasc Surg. 1996. 12 ( 4 ): 442–425 .
184 • PRIMARY SUPERFICIAL VENOUS INSUFFICIENCY
13. Dwerryhouse S , Davies B , Harradine K , Earnshaw JJ . Stripping the
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long saphenous vein reduces the rate of reoperation for recurrent
varicose veins:Five-year results of a randomized trial , J Vasc Surg.
1999. 29 ( 4 ): 589–592 .
14. Winterborn RJ , Foy C , Earnshaw JJ . Causes of varicose vein recurrence:Late results of a randomized controlled trial of stripping the
long saphenous vein , J Vasc Surg. 2004. 40 ( 4 ): 634–639 .
15. Sarin S , Scurr JH , Coleridge Smith PD . Stripping of the long saphenous vein in the treatment of primary varicose veins , Br J Surg. 1994.
81 ( 10 ): 1455–1458 .
16. Corbett CR , Runcie JJ , Lea TM , Jamieson CW . Reasons to strip the
long saphenous vein , Phlebologie. 1988. 41 : 766–769 .
17. Neglen P . Treatment of varicosities of saphenous origin:Comparison
of ligation, selective excision, and sclerotherapy. In: Bergan JJ ,
G o l d m an M P , e d s . Varicose veins and telangiectasias:Diagnosis and
treatment . St. Louis, MO: uality Medical . 1993. 148–165.
18. Min R , Khilnani N . Varicose veins. In: Kandarpa K , ed. Peripheral
vascular interventions . Philadelphia: Lippincott Williams &
Wilkins . 2008. 417–425.
19. Mendoza E . To the topographic anatomy of the vena saphena
magna: Aduplex sonographische study regarding by surgery relevant aspects , Phlebologie. 2001. 30 : 140–144 .
20. Darke SG . Recurrent varicose veins. In: Goldman MP , Bergan JJ , eds.
Ambulatory treatment of venous disease . St. Louis, MO: Mosby . 1996.
163–169.
21. Kostas T , Ioannou CV , Touloupakis E , et al. Recurrent varicose
veins a er surgery: A new appraisal of a common and complex
problem in vascular surgery , Eur J Vasc Endovasc Surg. 2004.
27 ( 3 ): 275–282 .
22. van Rij AM , Jones GT , Hill GB , Jiang P . Neovascularization and
recurrent varicose veins:More histologic and ultrasound evidence ,
J Vasc Surg. 2004. 40 ( 2 ): 296–302 .
23. Nyamekye I , Shephard NA , Davies B , Heather BP , Earnshaw JJ .
Clinicopathological evidence that neovascularization is a cause of
recurrent varicose veins , Eur J Vasc Endovasc Surg. 1998. 15 : 412–415 .
24. Min RJ , Khilnani N , Zimmet SE . Endovenous laser treatment of
saphenous vein re ux:Long-term results, J Vasc Interv Radiol. 2003.
14 ( 8 ): 991–996 .
25. Bergan JJ , Rattner Z . Endovenous therapy: 2005 , Acta Chir Bel.
2005. 105 ( 1 ): 12–15 .
26. Mendes RR , Marston WA , Farber MA , Keagy BA . Treatment
of super cial and perforator venous incompetence without deep
venous insu ciency:Is routine perforator ligation necessary?, J Vasc
Surg. 2004. 38 ( 5 ): 891–895 .
27. Stuart WP , Adam DJ , Allan PL , Ruckley CV , Bradbury AW .
Saphenous surgery does not correct perforator incompetence in the
presence of deep venous re ux , J Vasc Surg. 1998. 28 ( 5 ): 834–838 .
28. Lane RJ , Graiche JA , Coroneos JC , Cuzzilla ML . Long-term comparison of external valvular stenting and stripping of varicose veins ,
ANZ J Surg. 2003. 73 ( 8 ): 605–609 .
29. Kim IH , Joh JH , Kim DI . Venous hemodynamic changes in the surgical treatment of primary varicose vein of the lower limbs , Yonsei
Med J. 2004. 45 ( 4 ): 577–583 .
30. Carandina S , Mari C , De Palma M , etal. Varicose vein stripping vs
haemodynamic correction (Chiva):A long term randomized trial ,
Eur J Vasc Endovasc Surg. 2008. 35 : 230–237 .
31. Pittaluga P , Chastane S , Rea B , Barbe R . Classi cation of saphenous
re uxes:Implications for treatment , Phlebology. 2008. 23 ( 1 ): 2–9 .
PRINCIPLES OF TREATMENT OF VARICOSE VEINS • 185
23.
https://t.me/med1917
INVERSION STRIPPING OF THE SAPHENOUSVEIN
J o h n J . B e r g a n
ne of the cornerstones of surgery for varicose veins
is removal of the great saphenous vein (GSV ) from
O
the circulation. is can be done using minimally
invasive techniques described elsewhere in this volume,
but speci c indications for performing saphenous surgery
remain. ese are largely institutional and geographic but
they justify the following exposition.
Indications for intervention in primary venous insu ciency are listed in Table23.1. O en, the appearance of telangiectatic blemishes or protuberant varicosities stimulates
consultation. Ultimately, this may be the only indication for
1
intervention.
Characteristic symptoms include aching, pain, easy
leg fatigue, and leg heaviness, all relieved by leg elevation,
2
and worsened on the rst day of a menstrual period. Other
indications for intervention for venous varicosities include
super cial thrombophlebitis in varicose clusters, external
bleeding from high-pressure venous blebs, or advanced
changes of chronic venous insu ciency such as severe
ankle hyperpigmentation, subcutaneous lipodermatosclerosis, atrophie blanche, or frank ulceration. Symptoms are
frequent throughout the CEAP (clinical, etiological, anatomic, pathophysiologic) classes 1 through 6.Clinical dis-
3
ability scores parallel the clinical classi cation.
Objectives of treatment should be ablation of the
hydrostatic forces of axial re ux and removal of the e ects
of hydrodynamic forces of perforator vein re ux. e latter
can be accomplished by removal of the saphenous vein in
the thigh and the varicose veins without speci c perforating vein interruption. In France, the two most performed
procedures in the early 2000s were, respectively, high
ligation + saphenous trunk stripping + tributary stab avulsion (71.9%) and high ligation + saphenous trunk stripping
(17.3%). Isolated phlebectomy was done in 5.6%, high ligation + tributary stab avulsion + saphenous trunk preserva-
4
tion 2.8%, isolated high ligation2.2%.
Ligation of the saphenous vein at the saphenofemoral junction has been practiced widely in the belief that
this would control gravitational re ux while preserving
5
the vein for subsequent arterial bypass.
It is true that the
saphenous vein is largely preserved a er proximal ligation.
Unfortunately, re ux continues and hydrodynamic forces
are not controlled. Less re ux persists when the long saphe-
6
nous vein has been stripped.
ere is a better functional
outcome a er stripping and fewer junctional recurrences.
Randomized trials show e cacy of stripping compared to
8–11
simple proximal ligation.
Earlier comparisons of saphenous ligation versus stripping were awed by today’s standards. Subjective evaluation was the only means of measuring outcome for a time.
Duplex scanning came into use, verifying that stripping was
superior to proximal ligation; this fact was supported by
13
photoplethysmography (PPG).
acknowledged that the period of disability a er stripping
was greater than that a er simple ligation.
Despite those facts, it was
14
In attempts to
decrease disability and improve e cacy, high tie was added
to saphenous vein sclerotherapy, but foot volumetry showed
that radical surgery, including stripping, produced superior
15
results.
Ultimately, attention became focused on saphenous
nerve injury associated with ankle-to-groin stripping.
It was concluded that nerve injury was reduced by groin-
18,19
to-ankle stripping (see Figure23.1).
Preservation of calf
veins by stripping to the knee was shown to reduce nerve
injury and did not adversely a ect early venous hemody-
20
namic improvement.
subject deserves further study.
Table23.1 VARICOSE VEINS:INDICATIONS FOR
INTERVENTION
General appearance
Aching pain
Leg heaviness
Easy leg fatigue
Super cial thrombophlebitis
External bleeding
Ankle hyperpigmentation
Lipodermatosclerosis
Atrophie blanche
Venous ulcer
is fact is contraintuitive, and the
21
1
16,17
7
12
186
Recurrent varicose veins a er surgery are acknowl-
https://t.me/med1917
edged to be a major problem for patients and society.
24
Traditionally, it was thought that the most common reason
for varicose recurrence was failure to perform an adequate
saphenofemoral junction dissection (see Figure23.2), or to
25
correctly identify the saphenous vein for removal.
Duplex
scans have clari ed this situation and, instead of technical error, some investigators are convinced that new vessel
26
growth contributes to recurrent varicose veins.
In particular, incomplete super cial surgery, at the saphenofemoral
and saphenopopliteal junctions, is a less frequent cause of
recurrent disease, and neovascular reconnection and persistent abnormal venous function are the major contributors
27
to disease recurrence.
PREOPERATIVE PREPARATION
Over the years, much space has been given to clinical examination of the patient with varicose veins. Many clinical tests
have been described. Most carry the names of now-dead surgeons who were interested in venous pathophysiology. is
august history notwithstanding, the Trendelenburg test,
the Schwartz test, the Perthes test, and the Mahorner and
Figure23.1 In an early attempt to improve the results of varicose vein
surgery, saphenous stripping, the obturator was drawn from above
downward and then retrieved through the groin incision. Postoperative
appearance was improved but disability from pain, ecchymosis, and
hematoma continued.
Attempts to reduce nerve injury and simultaneously
clean up varicose vein surgery led to use of the hemostatic
tourniquet. In a study with level 1 evidence, it was shown
that use of a hemostatic cu tourniquet during varicose
vein surgery reduces perioperative blood loss, operative
time, and postoperative bruising without any obvious draw-
22
backs.
Villavicencio summarized this advance, saying,
“ is technique represents a welcome alternative to the
bloody, tedious, and time-consuming traditional varicose
vein surgery of the past. Complex venous surgery for extensive varicose veins of the extremities can be safely and expeditiously performed under controlled ischemia. It should be
23
the technique of choice.”
Circumex
Iliac
vein
Anterolateral
vein
Figure23.2 In the past, a proper groin dissection consisted of laying out
each of the named saphenofemoral junction tributaries and dissecting
them back beyond their primary tributaries. Now, this is acknowledged
by most to be the strongest stimulus to neovascularization.
Supercial
Epigastric vein
Supercial
External
Pudendal vein
Posteromedial
vein
INVERSION STRIPPING OF THE SAPHENOUSVEIN • 187
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