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Ochsner modi cations of the Trendelenburg test essentially
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28
are useless in preoperative evaluation of patients today.
e clinical evaluation can be improved by using handheld Doppler devices. However, preoperative evaluation is
best performed by means of duplex scanning and a focused
physical examination. Our protocol for duplex mapping
of incompetent super cial veins has been published.
29
Although many cite cost considerations as a reason for omitting duplex evaluation, we believe that duplex scanning for
venous insu ciency is in fact both simple and cost-e ective.
Duplex mapping de nes individual patient anatomy with
considerable precision and provides valuable information
that supplements the physician’s clinical impression.
ree principal goals must be kept in mind in planning
treatment of varicose veins: (1) the varicosities must be
permanently removed and the underlying cause of venous
hypertension treated; (2) the repair must be done in as
cosmetic a fashion as possible; (3) complications must be
minimized.
Current practice of treating the source of venous hypertension, the saphenous vein alone either by endovenous laser
treatment (EVLT) or VNUS technology, is inadequate. e
patient’s complaint, the varicose veins, must be addressed.
is is as important as the physician’s knowledge that the
sources of venous hypertension must be addressed.
To speak of permanent removal of varicosities implies
that all potential causes of recurrence have been considered
and that surgery has been planned so as to address them.
ere are four principal causes of recurrence of varicose
veins, of which three can be dealt with at the time of the
primary operation.
One cause of recurrent varicosities is failure to perform
the primary operation in a correct fashion. Common errors
include missing a duplicated saphenous vein and mistaking
an anterolateral or accessory saphenous vein for the greater
saphenous vein. Such errors can be eliminated by careful
and thorough groin dissection. Accordingly, failure to do a
proper groin dissection has long been held to be a second
principal cause of recurrent varicose veins. It is now known,
however, that such dissection causes neovascularization in
30
the groin, leading to recurrence of varicose veins.
Athird
cause of recurrent varicosities is failure to remove the GSV
from the circulation. As mentioned earlier, a reason o en
cited for this failure is the desire to preserve the saphenous
vein for subsequent use as an arterial bypass. It is clear,
however, that the preserved saphenous vein continues to
re ux and continues to elongate and dilate its tributaries.
is produces more and larger varicosities. Afourth cause
of recurrent varicosities is persistence of venous hypertension through nonsaphenous sources—chie y, perforating
veins with incompetent valves. Muscular contraction generates enormous pressures that are directed against valves in
perforating veins. Venous hypertension induces a leukocyte
endothelial reaction, which, in turn, incites an in ammatory response that ultimately destroys the venous valves
and weakens the venous wall. 31 e perforating veins most
commonly associated with recurrent varicosities are the mid
thigh perforating vein, the distal thigh perforating vein, the
proximal anteromedial calf perforating vein, and the lateral
thigh perforating vein, which connects the profunda femoris vein to surface varicosities.
Finally, there is a h cause of recurrent varicosities,
which is out of control of the operating surgeon—namely,
the genetic tendency to form varicosities through development of localized or generalized vein wall weakness, localized blowouts of venous walls, or stretched, elongated, and
32
oppy venous valves.
SAPHENOUS SURGERY
For varicose vein surgery to be successful, two tasks must be
accomplished. e rst is ablation of re ux from the deep
to the super cial veins, including the saphenofemoral junction, the saphenopopliteal junction, and mid thigh varices
from the Hunterian perforating vein. Accomplishment of
this task is guided by the careful preoperative duplex mapping of major super cial venous re ux.
e second task is removal or destruction of all varicosities present at the time of the surgical intervention.
Accomplishment of this task is guided by meticulous marking of all varicose vein clusters.
A number of options are available for surgical treatment
of varicose veins. Regardless of the speci c approach taken,
the general technical objectives are the same:(1)ablation
of the hydrostatic forces of axial saphenous vein re ux (see
Figure23.3) and (2)removal of the hydrodynamic forces of
perforator vein out o w.
Ankle-to-groin stripping of the saphenous vein has been
a dominant treatment of varicose veins since the early twen-
33–35
tieth century.
Saphenous Vein
Figure23.3 Inversion stripping of the saphenous vein was an important
step forward in minimizing so tissue trauma while accomplishing
the principal objective of ablating hydrostatic venous hypertension by
removing saphenous re ux. Tearing of the vein during its removal awed
its performance.
One argument against routine stripping
Posterior Arch
Vein
188 • PRIMARY SUPERFICIAL VENOUS INSUFFICIENCY
of the leg (i.e., ankle-to-knee) portion of the saphenous
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vein is the risk of concomitant saphenous nerve injury.
19
Another argument is that whereas the objective of saphenous vein removal is detachment of perforating veins emanating from the saphenous vein, which are seen in the thigh,
the perforating veins in the leg are actually part of the posterior arch vein system rather than the saphenous vein system.
is latter argument notwithstanding, preoperative ultrasonography frequently shows that the leg portion of the
saphenous vein is in fact directly connected to perforating
veins. erefore, removal of the saphenous vein from ankle
to knee should be a consideration in every surgicalcase.
OPERATIVE TECHNIQUE
e surgical approach taken must be individually tailored
to each patient and each limb. Groin-to-knee stripping of
the saphenous vein should be considered in every patient
36
requiring surgical intervention.
In nearly all patients, this
measure is supplemented by removal of the varicose vein
clusters via stab avulsion or some form of sclerotherapy.
Preoperative marking, if correctly performed, will have
documented the extent of varicose vein clusters and identi ed the clinical points where control of varices is required.
Incisions can then be planned. As a rule, incisions in the
groin and at the ankle should be transverse and should be
placed within skin lines. In the groin, an oblique variation
of the transverse incision may be appropriate. is incision
should be placed high enough to permit identi cation of
the saphenofemoral junction.
Generally, throughout the leg and the thigh, the best cosmetic results are obtained with vertical incisions. Transverse
incisions are used only in the region of the knee, and oblique
incisions are appropriate over the patella when the incisions
are placed in skinlines.
A major cause of discomfort and occasional permanent
skin pigmentation is subcutaneous extravasation of blood
during and a er saphenous vein stripping. Such extravasation can be minimized by applying a hemostatic tourniquet
a er Esmarch exsanguination of the limb. e pressure
in the hemostatic tourniquet should be between 250 and
300mm Hg, and the tourniquet should not be in place for
longer than 1 hour. If a tourniquet is not used, the entire
operation on one limb can be performed with the limb
elevated 30 degrees so that the major varicose clusters are
higher than the heart. In addition, hemostatic packing can
be placed into the saphenous vein tunnel.
e practice of identifying and carefully dividing each
of the tributaries to the saphenofemoral junction has been
dominant since the mid-twentieth century. e rationale for
this practice has been that it would be inadvisable to leave
behind a network of interanastomosing inguinal tributaries.
Accordingly, special e orts have been made to draw each
of the saphenous tributaries into the groin incision so that
when they are placed on traction, their primary and even
secondary tributaries can be controlled. e importance of
these e orts has been underscored by descriptions of residual inguinal networks as an important cause of varicose vein
37
recurrence.
Currently, however, this central practice of
varicose vein surgery is under challenge, on the grounds that
groin dissection can lead to neovascularization and hence to
recurrence of varicosities (see Chapter25).
Preoperative duplex studies have already demonstrated
incompetent valves in the saphenous system, and a disposable plastic stripper can be introduced from above downward; alternatively, a metal stripper can be employed.
38
of these devices can be used to strip the saphenous vein from
groin to knee via the inversion technique. is approach
39
should reduce so tissue trauma in the thigh.
In the groin, the stripper is inserted proximally into the
upper end of the divided internal saphenous vein and passed
down the main channel through incompetent valves until
it can be felt lying distally approximately 1cm medial to
the medial border of the tibia at a point approximately 4 to
6cm distal to the level of the tibial tubercle. e saphenous
vein is anatomically constant in this location, just as it is in
the groin and ankle. If the saphenous vein is removed from
the groin to this level, both the mid thigh perforating vein,
which usually enters the saphenous vein, and the most distal
incompetent perforating veins, which are in the distal third
of the thigh, will be treated. Asmall incision is made over
the palpable distal end of the stripper. e saphenous vein
will subsequently be divided through this incision, and the
stripper and the inverted vein will be delivered through it.
In exposing the saphenous vein at knee level, the super cial
fascia must be incised so as to enter the saphenous compartment. If the stripper passes unimpeded to the ankle, it can
be exposed there with an exceedingly small skin incision
placed in a carefully chosen skin line. Passage of the stripper from above downward to the ankle serves to con rm
the absence of functioning valves, and stripping of the vein
from above downward is unlikely to cause nerve damage. At
the ankle, the vein should be carefully and cleanly dissected
to free it from surrounding nerve bers. If this is not done,
saphenous nerve injury will result, and the patient will experience numbness of the foot below theankle.
Stripping of the saphenous vein has been shown to produce profound distal venous hypertension. is occurs in
virtually every operation, even when the limb is elevated.
erefore, a er the stripper is placed, one should consider
performing the stab avulsion portion of the procedure
before the actual stripping maneuver.
Incisions to remove varicose clusters vary according to
the size of the vein, the thickness of the vein wall, and the
degree to which the vein is adhering to the perivenous tissues. In general, vertical incisions 1 to 3mm in length are
appropriate, except in areas where skin lines are obviously
horizontal. Successive incisions are spaced as widely as possible. Varicosities are exteriorized by means of hooks or
Both
INVERSION STRIPPING OF THE SAPHENOUSVEIN • 189
forceps. Particularly useful for this purpose are the specially
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designed vein hooks known by the names Varady dissector,
40
Mueller hook, and Oesch hook.
ese devices e ciently
detach perforating veins from their tributary varicose clusters. Dissection of each perforating vein at the fascial level is
not required, and in fact may be cosmetically undesirable.
ere is no need to ligate or clip the ends of each vein:the
combination of leg elevation, trauma-induced venospasm,
and direct pressure typically ensures adequate hemostasis.
Once exteriorized, the varicosity is divided and avulsed for
as long a length as possible. A er avulsion, skin edges are
approximated with tape or with a single absorbable mono lament suture.
Phlebectomy techniques for varicose clusters have been
41
markedly re ned by experienced workers in Europe.
Once the stab avulsion portion of the procedure is
complete, the previously placed stripper is pulled distally
to remove the saphenous vein. Although plastic disposable
vein strippers and their metallic equivalents were designed
to be used with various sized olives to remove the saphenous
vein, in fact, a more e cient technique is simply to tie the
vein to the stripper below its tip so that the vessel can then
be inverted into itself and removed distally.
To decrease oozing into the tract created by stripping,
a 5-cm roller gauze soaked in a 1% lidocaine-epinephrine
solution is attached to the stripper by using the ligature fastening the saphenous vein to the device (see Figure23.4).
us, inversion stripping is accompanied by hemostatic
packing. e hemostatic pack, which lies within the saphenous vein, can be pulled into the tract with minimum tissue
trauma; when it is not inverted into the vein itself, it can
act as an obturator to facilitate removal of the saphenous
vein without tearing. As the vein is removed by inversion,
the gauze is le in place for hemostasis while the remainder
of the surgical procedure is being completed.
Surgical removal of the saphenous vein on an outpatient
basis still requires two incisions, one in the groin and the
Saphenous
Vein
Posterior Arch
Vein
Figure23.4 Adding a hemostatic pack to inversion stripping corrected
the principal aw in inversion stripping, the tearing of the saphenous
vein. e pack acted as an obturator, which ensured total vein removal.
In most instances, the pack entered the vein as it was being removed,
thus minimizing the so tissue trauma.
other near the knee. Postoperative compression bandaging
is standard, and most patients experience little downtime.
Some, however, do experience hematomas, pain, and extensive bruising. Varicosities recur in 15 to 30% of patients
42
treated.
EPILOGUE
Study of surgical saphenous stripping has shown that when
undesirable outcomes occur, they become evident quite
early. As noted earlier, it has long been accepted practice to
dissect tributary vessels at the saphenofemoral junction very
carefully, taking each of the vessels back beyond the primary
and even the secondary tributaries if possible. In practice,
however, such dissection appears to cause neovascularization in the groin. Duplex ultrasound surveillance supports
this nding. It has now been amply con rmed that neovascularization causes recurrent varicose veins (see Chapter25).
Clearly, this is a signi cant disadvantage of standard surgical
treatment of varicosities and the alternative techniques of
EVLT and RFA should be considered in everycase.
R E F E R E N C E S
1. Bergan JJ . Surgical management of primary and recurrent varicose
veins. In: Gloviczki P , Yao JST , eds. Handbook of venous disorders .
London : Chapman & Hall . 1996 . 394–415 .
2. Weiss RA , Feied CF , Weiss MA , eds. Vein diagnosis and treat-
ment:Acomprehensive approach . NewYork : McGraw-Hill . 2001 .
3. Saarinen J , Heikkinen M , Suominen V, etal. Clinical disability scores
and re ux in complicated and uncomplicated primary varicose veins.
Phlebology . 2003 . 18 : 73–77 .
4. Perrin M , Guidicelli H , Rastel D . Surgical techniques used for the
treatment of varicose veins:Survey of practice in France , J Mal Vasc .
2003 . 28 : 277–286 .
5. 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 .
6. Butler CM , Scurr JH , Coleridge Smith PD . Prospective randomized
trial comparing conventional (Babcock) stripping with inverting
stripping of the long saphenous vein , Phlebology . 2002 . 17 : 59–63 .
7. 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 .
8. Dwerryhouse S , Davies B , Harradine K , Earnshaw JJ . Stripping the
long saphenous vein reduces the rate of reoperation for recurrent varicose veins:Five-year results of a randomized trial, J Vasc Surg . 1999 .
29 : 589–592 .
9. 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 : 442–445 .
10. 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 : 634–639 .
11. Woodyer AB , Reddy PJ , Dormandy JA . Should we strip the long
saphenous vein? Phlebology . 1986 . 1 : 221–224 .
12. Rutgers PH , Kitslaar PJ . Randomized trial of stripping versus high
ligation combined with sclerotherapy in the treatment of the incompetent greater saphenous vein, Am J Surg . 1994 . 168 ( 4 ): 311–315 .
190 • PRIMARY SUPERFICIAL VENOUS INSUFFICIENCY
13. Sarin S , Scurr JH , Coleridge Smith PD . Stripping of the long saphe-
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nous vein in the treatment of primary varicose veins , Br J Surg . 1994 .
81 : 1455–1458 .
14. Jakobsen BH . e value of di erent forms of treatment for varicose
veins , Br J Surg . 1979 . 66 : 182–184 .
15. Neglen P , Einarsson E , Eklof B . e functional long-term value of
di erent types of treatment for saphenous vein incompetence , J
Cardiovasc Surg . 1993 . 34 : 295–301 .
16. Munn SR , Morton JB , MacBeth WAAG , McLeish AR . To strip or
not to strip the long saphenous vein? Avaricose veins trial , Br J Surg .
1981 . 68 : 426–428 .
17. Negus D . Should incompetent saphenous veins be stripped right
down to the ankle?, Phlebologie . 1987 . 40 : 753–757 .
18. Holme JB , Skajaa K , Holme K . Incidence of lesions of the saphenous
nerve a er partial or complete stripping of the long saphenous vein ,
Acta Chir Scand . 1990 . 156 : 145–148 .
19. Wellwood JM , Cox SJ , Martin A , Cockett FB , Browse NL . Sensory
changes following stripping of the long saphenous vein , J Cardiovasc
Surg . 1975 . 16 : 123–124 .
20. Miyazaki K , Nishibe T , Kudo F , et al. Hemodynamic changes
in stripping operation or saphenofemoral ligation of the greater
saphenous vein for primary varicose veins , Ann Vasc Surg . 2004 .
18 ( 4 ): 465–469 .
21. Sam RC , Silverman SH , Bradbury AW . Nerve injuries and varicose vein surgery , Eur J Vasc Endovasc Surg . 2004 . 27 : 113–120 .
Review.
22. Sykes TC , Brookes P , Hickey NC . A prospective randomised trial
of tourniquet in varicose vein surgery , Ann R Coll Surg Engl . 2000 .
82 ( 4 ): 280–282 .
23. Villavicencio JL , Gillespie DL , Kreishman P . Controlled ischemia
for complex venous surgery: e technique of choice , J Vasc Surg .
2002 . 36 : 881–888 . J Vasc Surg . 2001 . 34 ( 5 ): 947–951 .
24. Stucker M , Netz K , Breuckmann F , Altmeyer P , Mumme A .
Histomorphologic classi cation of recurrent saphenofemoral re ux ,
J Vasc Surg . 2004 . 39 : 816–821 ; Discussion822.
25. Greaney MG , Makin GS . Operation for recurrent saphenofemoral
incompetence using a medial approach to the saphenofemoral junction , Br J Surg . 1985 . 72 : 910–911 .
26 Glass GM . Neovascularization in recurrence of the varicose great
saphenous vein following transection , Phlebology . 1987 . 2 : 81–91 .
27. van Rij AM , Jiang P , Solomon C , Christie RA , Hill GB . Recurrence
a er varicose vein surgery: A prospective long-term clinical study
with duplex ultrasound scanning and air plethysmography , Eur J
Vasc Endovasc Surg . 1998 . 15 : 412–415 .
28. Ballard JL , Bergan JJ , DeLange M . Venous imaging for re ux
using duplex ultrasonography. In: AbuRahma AF , Bergan JJ , eds.
Noninvasive vascular diagnosis . London : SpringerVerlag . 2000 . 329 .
29. Mekenas LV , Bergan JD . Venous re ux examination:Technique using
miniaturized ultrasound scanning , J Vasc Technol . 2002 . 26 : 139 .
30. Fischer R , Linde N , Du C, etal. Late recurrent saphenofemoral
junction re ux a er ligation and stripping of the greater saphenous
vein , J Vasc Surg . 2001 . 34 : 236 .
31. Ono T , Bergan JJ , Schmid-Schönbein GW, etal. Monocyte in ltration into venous valves, J Vasc Surg . 1998 . 27 : 158 .
32. ulesius O , Ugaily- ulesius L , Gjores JE, etal. e varicose saphenous vein, functional and ultrastructural studies, with special reference to smooth muscle , Phlebology . 3 : 89.
33. Mayo CH . Treatment of varicose veins , Surg Gynecol Obstet . 1906 .
2 : 385 .
34. Babcock WW . A new operation for extirpation of varicose veins , NY
Med J. 1907 . 86 : 1553 .
35. Keller WL . A new method for extirpating the internal saphenous
and similar veins in varicose conditions:Apreliminary report , NY
Med J . 1905 . 82 : 385 .
36. Goren G , Yellin AE . Primary varicose veins:Topographic and hemodynamic correlations , J Cardiovasc Surg . 1990 . 31 : 672 .
37. Stonebridge PA , Chalmers N , Beggs I, et al. Recurrent varicose
veins:Avaricographic analysis leading to a new practical classi cation , Br J Surg . 1995 . 82 : 60 .
38. Goren G , Yellin AE . Invaginated axial saphenectomy by a semirigid
stripper:Perforate-invaginate stripping , J Vasc Surg . 1994 . 20 : 970 .
39. Bergan JJ . Saphenous vein stripping by inversion:Current technique ,
Surg Rounds . 2000 . 118 .
40. Bergan JJ . Varicose veins:Hooks, clamps, and suction:Application
of new techniques to enhance varicose vein surgery , Semin Vasc Surg .
2002 .
15
41. Ricci S , Georgiev M , Goldman MP . Ambulatory phlebectomy:Aprac-
42. Darke SG . e morphology of recurrent varicose veins , Eur J Vasc
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tical guide for treating varicose veins , 2e. St Louis, MO : Mosby . 2005 .
Surg . 1992 . 6 : 512 .
INVERSION STRIPPING OF THE SAPHENOUSVEIN • 191
24.
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NEOVASCULARIZATION
AN ADVERSE RESPONSE TO PROPER GROIN DISSECTION
Marianne De Maeseneer
t the beginning of the twenty- rst century surgical
treatment of varicose veins continues to be marred
A
has always been a very disappointing phenomenon for
patients and surgeons alike. Most commonly recurrent
re ux develops in the area of the saphenofemoral junction (SFJ), connecting with recurrent varicose veins from
the thigh downward to the entire leg (Figure24.1).
in clinical centers with a special focus on minimizing recurrence surgeons do not seem to be able to avoid such dis guring and o en disabling recurrent varicoseveins.
understanding of venous anatomy and hemodynamics,
inadequate preoperative assessment, and incorrect or insuf cient surgery. However recurrence at the SFJ cannot always
be explained by technical inadequacy of the original surgical intervention. Its development has also been attributed
to neovascularization in the granulation tissue around the
ligated stump.
vessel formation (=angiogenesis) occurring in abnormal tissue or in an abnormal position. In some instances the growth
of new blood vessels from the surrounding tissue may be
induced by di usible chemical factors (angiogenic factors).
In the particular context of varicose recurrence a er great
saphenous vein (GSV) surgery, the term “neovascularization” describes a phenomenon of formation of new venous
channels between the saphenous stump on the common
femoral vein (CFV) and the residual GSV or its tributaries
(Figure24.2). Neovascularization is a distinctly uncommon
nding when the true SFJ has not been divided. However,
when the SFJ has been ligated properly, it is actually a marker
of an anatomically correct operation, as well as the best
explanation for SFJ reconnections a er such an operation.
a er having to treat patients with recurrent varicose veins
some years a er a previous varicose vein operation “correctly” performed by themselves. e observations with
duplex ultrasound scanning at the level of the SFJ then
by the development of recurrent varicosities. is
1
Even
Some causes of recurrence are obvious: insu cient
2
Neovascularization is de ned as new blood
Many surgeons only start to recognize the phenomenon
frequently show neovascularization. Despite the fact that
this frustrating phenomenon is frequently encountered, its
nature and pathophysiology (hence its prevention) is poorly
understood and is the subject of ongoing research.
I. A HISTORICAL PERSPECTIVE
Surgical ligation of the GSV above or below the knee has
been practiced for many centuries, starting with Paulus
of Aegina in 660. However it was not until the nineteenth century that the e ect of ligation on the vein itself
and on the venous hemodynamic situation became better
understood.
In 1861 Langenbeck
happened with a vein a er surgical ligation. He noticed that
a vein had a very important regeneration capacity and that a
new vein channel could be formed a er ligation or extirpation of a piece ofvein:
In one case of very large varix of the great saphena in
a young man Ihad extirpated the enlarged vein in the
length of three inches and ligated the upper and lower
ends. One year later Ifound, in the region of the scar
tissue of the extirpation, a new vein channel of the
thickness of the quill of a crow’s feather, which again
joined the both ends of the fully functioning saphena.
Looking at his detailed description now, one and a
half century later, this could be considered as the rst real
description of formation of new veins a er ligation (which
could possibly lead to recurrence of varicose veins lateron).
roughout the nineteenth century, surgical treatment
of varicosity of the GSV was limited to simple ligation and
transection at a site in the thigh where there were relatively
few tributaries. erefore it was obvious that, if recurrence
occurred, the cause was situated at the site of ligation in the
thigh. In the beginning of the twentieth century Homans
3
described in detail what exactly
4
192
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Figure24.1 Prominent recurrent varicose veins with venous ulcer in
a 32-year-old man who underwent comprehensive SFJ ligation and
stripping of the GSV above the knee 8years earlier.
CFV
introduced SFJ ligation in the groin. He advocated ligation
of all tributaries to the terminal portion of the saphenous
vein to prevent restoration of venous continuity through a
collateral network in the groin. From that time, the theory
of recurrence through preexisting collateral veins gained
ascendancy over the earlier theory of recurrence through
growth of new vessels. Inadequate operation by the previous surgeon was then claimed to be the main cause of
recurrence. Only a minority believed that recurrence could
also occur a er accurately performed SFJ ligation through
formation of new vessels. In explaining the genesis of this
5
phenomenon, Sheppard
hypothesized that, “under the
in uence of the high femoral pressure, the capillaries and
venules in the granulation tissue [of the newly forming scar]
developed into dilated tortuous channels.”
6,7
During the period 1950–1980 Glass
led surgeons to
focus again on recurrence of varicose veins a er surgery
through “regrowth of veins.” He published his clinical and
experimental work concerning this problem, in 1987 mentioning the term “neovascularization” for the rst time.
He also reported on the gross anatomy and histology at
7
the level of the SFJ during reexploration of the groin.
In
the majority of limbs a newly formed vessel or complex of
vessels was found in connection with the former saphenous
stump proximally and with varicose veins on the thigh distally. Macroscopic examination revealed several lumens in
an irregular mass of vein tissue and cords or bands traversing the lumen, which suggested that the vessels were newly
formed and not preexisting. Large lymph nodes were o en
in close proximity to them. e histology con rmed the
macroscopic ndings:an irregular vessel wall with a varying
thickness at di erent points of the circumference, o en with
several lumens. Also typical was the presence of many small
vessels close to the newly formed vessel and in neighboring
lymph nodes. ese studies suggested that neovascularization had played an important role in recurrent saphenofemoral incompetence a er a correctly performed SFJ ligation.
6
Figure24.2 Diagram of neovascularization in the groin a er correct
previous ligation of the great saphenous vein (GSV) and all tributaries
at the SFJ, without stripping the GSV. Anew vein (arrow) is bulging
at the anteromedial side of the CFV and continues downward as a
very tortuous vein, connecting again with the retained GSV trunk. If
the above-knee GSV has been stripped, it may connect with any other
super cialvein.
NEOVASCULARIZATION:AN ADVERSE RESPONSE TO PROPER GROIN RESECTION • 193
GSV
II. NEOVASCULARIZATION:
TODAY’S EVIDENCE
A . S O N O G R A P H I C E V I D E N C E
Duplex scanning can provide the necessary anatomical
and functional information about the nature of recurrence
and has become the investigation of choice in patients
8
with recurrent varicose veins. Jones etal.
found that neovascularization at the SFJ was the commonest cause of
recurrence in 113 legs 2years a er stripping of the GSV.
Typical serpentine tributaries arising from the ligated SFJ
were detected in 52% of limbs. Another duplex-based prospective study revealed some degree of neovascularization
in 14% of 177 limbs already at one year a er ush SFJ or
9
saphenopopliteal junction (SPJ) ligation.
e clinical
Recurrent varicose veins
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n=38
Number
of limbs
No recurrent varicose veins
n=68
Grade 2
n=6 (9%)
Grade 0
n=8 (21%)
Grade 1
n=4 (11%)
Grade 2
n=26 (68%)
Figure24.3 Proportional incidence of di erent degrees of neovascularization according to duplex ultrasound scanning of the groin at long-term
follow-up in limbs with and without recurrent varicose veins. Grade 0:no neovascularization; Grade 1:tiny new vein < 4mm; Grade 2:tortuous
new connecting vein with a diameter ≥ 4mm and with pathological re ux.
relevance of nding neovascularization on postoperative
duplex ultrasound was examined in a long-term follow-up
study at the same institution almost 5years (56months)
10
a er the varicose vein operations.
In 68% of limbs with
clinically obvious recurrent varicose veins, neovascularization (with new veins greater than 4mm in diameter, pathological re ux, and connected to recurrent varicose veins)
was present at the site of the saphenous ligation on duplex
examination, whereas in limbs without recurrent varicose
veins this degree of neovascularization was only seen in 9%
of cases (Figure24.3).
Grade 1
n=12 (18%)
Grade 0
n=50 (73%)
as well as lack of intramural nerves on immunohistologically S100-stained sections. e authors drew the attention
to the fact that a negative demonstration of a focal structure, such as a mural nerve seen on S100-stained sections,
is never entirely convincing and that a more useful tool for
the diagnosis of neovascularization was not yet available. In
spite of this warning, the ndings of his study were cited
in many instances as the nal histological description of
neovascularization.
e causality of recurrence was further investigated by
12
van Rij etal.
by correlating ndings from duplex ultra-
sound scans before reoperation with histological ndings in
B . H I S T O P A T H O L O G I C A L E V I D E N C E
Nyamekye etal. 11 provided further evidence that neovascularization was one of the causes of recurrence. Histological
examination of the venous tissue blocks, excised during groin reexplorations, showed neovascularization in
twenty-seven of twenty-eight blocks, characterized by vein
tortuosity, small size, and mural asymmetry (Figure24.4),
specimens taken from the groin at operation and resin casts
made from some of the excised tissue blocks (Figure24.5).
Neovascular channels of variable size, number, and tortuosity accounted for the ultrasound appearances in the vast
majority of examined specimens. ese new vessels connected to the CFV at the site of the previous SFJ. At histological examination such neovascular channels were lined
by a simple squamous endothelium overlying a medial layer
consisting of two to ve layers of vascular smooth muscle.
ey lacked elastic bers and had no distinct intimal medial
boundary and no distinct adventitia. In both studies
the de nition of neovascular vessels was mainly based on
negative criteria: no intramural nerves, no three-layered
wall structure, and lack of lumen regularity. Stücker etal.
added a positive criterion that scar tissue must always surround a newly formed vein (Figure24.4).
11,12
13
Figure24.4 Histological section of an excised tissue block in the groin
showing tortuous newly formed veins within the scar tissue (Masson’s
trichrome stain, original magni cation40×).
III. RESEARCH ON THE
PATHOPHYSIOLOGY OF
SAPHENOFEMORAL RECURRENCE AND
THE ROLE OF NEOVASCULARIZATION
e ultimate answer to the question:“is neovascularization
at the ligated SFJ really important?” still has to be given.
As animals do not su er from varicose veins an animal
194 • PRIMARY SUPERFICIAL VENOUS INSUFFICIENCY
A
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Distal
Proximal
B
Proximal
Figure24.5 Vascular casts of recurrent re uxing SFJ specimens, showing
the connecting network of vessels. In both specimens there are abundant
tortuous vessels. Casts injected from the SFJ show resin present in
the connecting network of vessels. Notice the variation in size of the
abundant tortuous vessels in both specimens. (A) ough several
channels are larger, there are more than 100 channels running in a similar
proximal distal direction. (B) ree large-diameter channels dominate
the cast; however, there are also small channels present in continuity.
Note the injecting cannula (distal). Scale bars:A, 5mm; B,10mm.
Reprinted from AM van Rij, GT Jones, GB Hill, P Jiang. Neovascularization and recurrent varicose
veins:More histologic and ultrasound evidence. J Vasc Surg 2004. 40:296–302, with permission from e
Society for Vascular Surgery.
Distal
experiment is hardly possible to prove the existence of
neovascularization. erefore it can only be proved in an
indirect way. Observations made in patients prospectively
studied a er varicose vein operations with duplex scan are
very useful. Moreover in patients operated on because of
recurrent varicose veins preoperative duplex ndings can
be compared with visual inspection at the previous ligation
site during reexploration and histological examination of
the excised tissue blocks from the scar tissue in the groin.
Although ndings from such studies may be suggestive for
neovascularization, none of them is conclusive. is means
that further observational studies will not de nitely answer
this question.
More fundamental research should focus on the potential pathophysiological mechanisms that could explain how
new veins can develop a er correct SFJ ligation:angiogenic
stimulation in the free endothelium of the ligated stump,
15
transnodal lymphovenous connection,
dilation of small
14
adventitial vessels in the vasa vasorum of the femoral vein,
or disturbed venous drainage of the ligated tributaries of
the SFJ. All of these occur on a background of the normal
wound-healing process, in which angiogenesis is an important component, potentially giving rise to a more generalized, eld-related neovascularization in thegroin.
A . A N G I O G E N I C S T I M U L A T I O N I N
THE FREE ENDOTHELIUM OF THE
SAPHENOUSSTUMP
A er surgical ligation and transection of the GSV, angiogenic stimulation in the free endothelium of the ligated
stump has been claimed to be one of the most important
triggers for the onset of the neovascularization process.
Such stump-related neovascularization might originate
from hypoxia-induced activation of endothelial cells distal
to the stump ligature, which could be mediated by growth
14
factors.
Another cause of stump-related neovascularization could be in ammation related to ligature, particularly
those of absorbable material, or to the results of dissection
in the immediatearea.
B. TRANSNODAL LYMPHOVENOUS
CONNECTION
Lemasle etal. 15 have focused on the important role of the
lymph nodes in the neighborhood of the ligated saphenous stump. eir hypothesis is that neovascularization is
essentially the development of preexisting venous vessels in
the inguinal lymph nodes. is physiological venous network is normally thin and competent. Due to the action of
angiogenic factors it could become larger and incompetent.
is could correspond with the tiny re uxing veins passing
through the surrounding lymph nodes, o en seen at postoperative duplex examination of the groin. In exceptional
cases such lymph node vein networks can also be seen without any previous operation. Further study of the lymph
nodes by means of high-de nition ultrasound before and
a er surgery at the SFJ may help to clarify the role of lymph
nodes and lymphovenous connections. In previous studies
histological examination mainly focused on excised tissue
blocks from the scar tissue in the groin at reoperation.
To improve our understanding of the histological alterations in recurrent varicosis, it might be interesting to investigate primary and recurrent varicose veins, normal vessels
of the saphenofemoral area, lymph nodes, and lymph vessels
of this area and compare these ndings with those at other
localizations.
C . D I L A T I O N O F S M A L L A D V E N T I T I A L
VESSELS IN THE VASA VASORUM
eoretically, dilation of small adventitial vessels in the
vasa vasorum of the femoral vein could be responsible for
new connections between the deep and super cial venous
system. It is known that the very tiny veins of the vein wall
are draining their blood directly into the lumen of the vein.
Venous endoscopy of the femoral vein, done to assess valve
function, has occasionally shown extremely small medial
or lateral ori ces near the entrance of the GSV. ese have
been thought to be the openings of tiny tributaries that are
7,11–13
NEOVASCULARIZATION:AN ADVERSE RESPONSE TO PROPER GROIN RESECTION • 195
too small to show on phlebography or duplex sonography.
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e observers, for this reason, cannot be certain that these
are not just vasa vasorum serving the vein wall and having
no external connections, but they have postulated that these
tiny ori ces might enlarge, to become conduits of blood
re uxing to the super cialveins.
D . D I S T U R B E D V E N O U S D R A I N A G E O F
LIGATED TRIBUTARIES
Disturbed venous drainage of the ligated tributaries of the
SFJ has also been cited as a potential pathophysiological
mechanism to explain recurrence in the groin. Chandler
16
have suggested that neovascularization might be
et al.
driven not only by angiogenic stimuli inherent to the
wound-healing process but also by localized venous hypertension, or “frustrated venous drainage” secondary to ligation of tributaries. is tributary ligation might interfere
with normal venous drainage of the super cial tissues of
the lower abdomen and pudendum. e presence of neovascular cross-groin collaterals (small veins passing from
the anterior abdominal wall, across the groin, toward the
thigh) in some cases at postoperative duplex examination
or reoperation could be an illustration of this hypothesis.
Moreover, the idea that localized venous hypertension
might be a trigger for neovascularization is supported by
the ndings a er endovenous treatment techniques, consisting in ablation of the saphenous vein by radiofrequency
or laser energy without a groin incision. ese procedures
were not associated with neovascularization in the groin
17
according to duplex scan follow-up.
Comparable ndings were reported in a retrospective study by Pittaluga
etal. 2years a er limited surgery in the groin in addition
18
to stripping of the re uxing trunks.
Ligation of the GSV
at a distance from the SFJ, preserving the proximal (nonre uxing) tributaries of the GSV resulted in a very low
rate of neovascularization (only 1.8 %), far lower than a er
classic SFJ ligation. Opposite to the situation of “frustrated
venous drainage” following ligation of tributaries in the
groin, leaving open these tributaries could reduce the stimulus to neovascularization as the normal venous drainage
of the lower abdominal and pudendal tissues is preserved.
Further prospective studies will be needed to elucidate this
pathophysiologicalissue.
E . M O R E T R I G G E R S I N V O L V E D I N
DEVELOPMENT OF EARLY AND LATE
RECURRENCE
Probably neovascularization at the SFJ as such is not the
unique cause for the development of recurrent varicose
veins a er SFJ ligation surgery. Something has to happen
in the periphery as well, where a re uxing vein will try to
make a “joint venture” with the neovascular veins at the
SFJ and vice versa, by sending out some—not yet clearly
understood—chemotactic signs, which will nally result
in reconnection between peripheral veins and neovascular
veins. erefore recurrence can appear early a er the opera-
tion (sometimes already within the 1st year) if residual
varicose veins or a re uxing GSV or anterior accessory saphenous trunk have been le in place:reconnection between
these pathologic veins and neovascular veins could be quite
evident in such situation. Recurrence developing late (sev-
eral years) a er the operation is more o en primarily due
to progression of the varicose disease. Neovascularization
at the previous SFJ site can play a secondary role in these
cases. A er a few years new varicose veins develop little by
little and these can connect with neovascular veins in the
groin, which in the long term can become larger and re uxing. is leads to the typical clinical picture of thigh or
whole-leg varicose vein recurrence several years a er GSV
surgery (Figure24.1).
F . C O N S T I T U T I O N A L R I S K F A C T O R S
In addition to all the abovementioned pathophysiological mechanisms, constitutional risk factors, which could
potentially enhance the tendency to recurrence, should also
be further examined. e importance of risk factors such
as female gender, le -sided disease, associated deep vein
incompetence, severe chronic venous disease (C4–C6 of
the CEAP classi cation), obesity, and subsequent pregnancies a er surgery, which have all been claimed to promote
recurrence, should be prospectively studied.
I V . E F F O R T S T O M I T I G A T E
NEOVASCULARIZATIONRELATED
RECURRENTREFLUX
A . B A R R I E R T E C H N I Q U E S T O C O N T A I N
NEOVASCULA RIZATION
Containment involves constructing an anatomical barrier
or inserting a prosthetic barrier between the ligated SFJ
stump and the surrounding super cial veins in the groin.
Various barrier techniques have been studied in primary
as well as in recurrent varicose veins, with di erent rates
of success. In primary GSV surgery, closing the opening
in the cribriform fascia suppressed postoperative neovas-
19
cularization at the SFJ a er 1year.
In repeat surgery at
the SFJ, implantation of a patch at the level of the religated
saphenous stump signi cantly improved the clinical and
20
duplex scan results, a er a follow-up period of 5years.
In a
recently published well-conducted randomized controlled
trial van Rij etal. demonstrated that use of a polytetra uoroethylene (PTFE) patch is an e ective mechanical suppressant of neovascularization at the SFJ and can safely be
used as a strategy to improve long-term outcome of vari-
21
cose vein surgery.
196 • PRIMARY SUPERFICIAL VENOUS INSUFFICIENCY
B. AVOIDING ENDOTHELIAL
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EXPOSURE AT THE GSVSTUMP
Isolating the stump endothelium from the wound milieu, by
oversewing the “mouth” of the ligated SFJ with a running
polypropylene suture, or destroying the stump endothelium
with chemical or heat cauterization have been described, all
without conclusive results. Amore radical approach, consisting in complete resection of the GSV stump and inversion suturing of the common femoral vein venotomy, instead
of ush ligation at the level of the SFJ, did not appear to
decrease neovascularization and related thigh varicose vein
22
recurrence 2years a er GSV stripping.
C. ABANDONING SFJ LIGATION
Finally, what about comprehensive SFJ ligation , previ-
ously considered the “sacred cow”? Although we have been
taught for many decades that an accurate groin dissection
with detachment of all tributaries is the ideal method to
prevent recurrence from the groin, in fact, the reverse
could be true. It has to be acknowledged that the importance of ligating all tributaries of the GSV in the groin is
16
assumed rather than proved. Chandler etal.
attempted
to de ne the role of extended SFJ ligation in one of the
rst studies on endovenous radiofrequency ablation.
ey compared the results of endovenous ablation with
or without SFJ ligation and found no di erence between
the treatment options. It is now widely accepted that endovenous ablation can be safely performed without SFJ ligation with good long-term results and without inducing
neovascularization at the SFJ. e same seemed to be true
with an alternative surgical technique consisting of more
distal ligation of the GSV with preservation of the proxi-
18
mal tributaries at the SFJ.
erefore the old axiom that
SFJ ligation with ligation of all tributaries is an essential
component of the treatment of GSV insu ciency should
de nitely be questioned.
D . E N D O V E N O U S T R E A T M E N T M E T H O D S
As mentioned previously, endovenous treatment does not
seem to be associated with neovascularization in the groin
and has now become the method of choice for treatment of
primary varicose veins in many centers around the world.
e results of GSV radiofrequency ablation a er up to
5 years are promising, and duplex ultrasound ndings
con rm the absence of neovascular veins in the groin.
17,23
Endovenous laser treatment is a comparable technique
developed to treat saphenous vein incompetence with very
24
satisfying long-term results.
Ultrasound-guided foam
sclerotherapy was introduced as a third alternative treatment method. e increased e cacy of foam, in comparison
with classic sclerotherapy with liquid sclerosants, enabled
treatment of varicose veins with larger diameter as well as
main super cial trunks. Encouraging results have also been
obtained in patients with recurrent varicoseveins.
E . I M P O R T A N C E O F F O L L O W U P A F T E R
TREATMENT
Whatever technique has been used, serial duplex examina-
25
tions remain the cornerstone of follow-up.
Early evaluation, 1 to 2months a er the procedure, is useful for initial
quality control of the intervention. Further evaluations (at
1, 3, and 5years) may help to understand and de ne the
process and causes of recurrence. It has been shown that
color duplex scan of the SFJ 1year a er GSV surgery has a
high sensitivity and speci city. It accurately predicts which
patients are more likely to have a good outcome 5years a er
26
surgery.
C O N C L U S I O N
A er proper groin dissection, neovascularization is both
a marker of thoroughly performed SFJ tributary ligation
and a pathway for super cial to deep reconnections. It is
remarkably focused on the site of the former SFJ and it
appears to arise because of stimuli that are related to healing of the surgical wound as well as to the continued (or
renewed) presence of diseased super cial veins. It can be
suppressed by barrier techniques but not completely eliminated. In the long term, progression of the varicose disease
plays a major role in recurrence, and neovascularization
takes only a secondary role. When new varicose veins
develop in the thigh, they may connect with neovascular
veins in the groin, and re ux from the SFJ may become
obviousagain.
Duplex scanning has rationalized the management
of lower extremity venous disease. orough preoperative assessment with duplex ultrasound now leads to a
well-established surgical or endovenous approach, guided
by the venous anatomy of each individual patient. Duplex
scanning also o ers a unique opportunity to compare the
posttreatment events of these two approaches with early
25
and serial posttreatment scanning.
In this process, the
physician will have an opportunity to assess his or her own
technique and to uncover variables that might be associated
with relative stability or progression to clinically relevant
reconnections and new varicosities. e ultimate truth will
come from knowledge of cell signaling and other molecular
events that would require repeated tissue sampling, timed
in accord with the evolving duplex anatomy.
ACKNOWLEDGMENTS
Section Iis reprinted in part from De Maeseneer MGR.
e role of postoperative neovascularisation in recurrence
NEOVASCULARIZATION:AN ADVERSE RESPONSE TO PROPER GROIN RESECTION • 197
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