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of varicose veins:from historical background to today’s evi-
https://t.me/med1917
dence, Acta Chir Belg . 2004. 104 :283–289, with permis-
sion from e Royal Belgian Society of Surgeons.
Section III is reprinted in part from Fischer R, Chandler
JG, De Maeseneer MG, etal. e unresolved problem of
recurrent saphenofemoral re ux, J Am Coll Surg . 2002.
195 :80–94, with permission from e American College
of Surgeons.
R E F E R E N C E S
1. Fischer R , Chandler JG , De Maeseneer MG , etal. e unresolved
problem of recurrent saphenofemoral re ux , J Am Coll Surg. 2002 .
195 : 80–94 .
2. De Maeseneer MGR . e role of postoperative neovascularisa-
tion in recurrence of varicose veins:From historical background to
today’s evidence , Acta Chir Bel. 2004 . 104 : 283–289 .
3. von Langenbeck B . Beitrage zur chirurgischen Pathologie der Venen ,
Arch Klin Chir. 1861 . 1 : 47 .
4 . H o m a n s J . e operative treatment of varicose veins and ulcers,
based upon a classi cation of these lesions , Surg Gynecol Obstet.
1916 . 22 : 143–158 .
5. Sheppard M . A procedure for the prevention of recurrent sapheno-
femoral incompetence, ANZ J Surg. 1978 . 48 : 322–326 .
6. Glass GM . Neovascularization in recurrence of the varicose
great saphenous vein following transection , Phlebology. 1987 .
2 : 81–91 .
7. Glass GM . Neovascularization in recurrence of varices of the great
saphenous vein in the groin:Surgical anatomy and morphology , Vasc
Surg. 1989 . 23 : 435–442 .
8. Jones L , Braithwaite BD , Selwyn D , Cooke S , Earnshaw JJ .
Neovascularisation is the principal cause of varicose vein recur-
rence:Results of a randomised trial of stripping the long saphenous
vein , Eur J Vasc Endovasc Surg. 1996 . 12 : 442–445.
9. De Maeseneer MG , Ongena KP , Van den Brande F , Van Schil PE ,
De Hert SG , Eyskens EJ . Duplex ultrasound assessment of neovas-
cularization a er sapheno-femoral or sapheno-popliteal junction
ligation , Phlebology. 1997 . 12 : 64–68 .
10. De Maeseneer MG , Tielliu IF , Van Schil PE , De Hert SG , Eyskens
EJ . Clinical relevance of neovascularisation on duplex ultrasound
in the long term follow up a er varicose vein operation , Phlebology.
1999 . 14 : 118–122 .
11. Nyamekye I , Shephard NA , Davies B , Heather BP , Earnshaw
JJ . Clinicopathological evidence that neovascularisation is a
cause of recurrent varicose veins , Eur J Vasc Endovasc Surg. 1998 .
15 : 412–415 .
12. van Rij AM , Jones GT , Hill GB , Jiang P . Neovascularization and
recurrent varicose veins:More histologic and ultrasound evidence ,
J Vasc Surg. 2004 . 40 : 296–302 .
13. Stücker M , Netz K , Breuckmann F , Altmeyer P , Mumme A .
Histomorphologic classi cation of recurrent saphenofemoral re ux ,
J Vasc Surg. 2004 . 39 : 816–821 .
14. Hollingsworth SJ , Powell GL , Barker SGE , Cooper DG . Primary
varicose veins: Altered transcription of VGFE and its receptors
(KDR, t-1, soluble t-1) with sapheno-femoral junction incompetence ,
15. Lemasle P , Lefebvre-Vilardebo M , Uhl JF , Vin F , Baud J .
Eur J Vasc Endovasc Surg.
Postoperative recurrence of varices:What if inguinal neovascularisation was nothing more than the development of a pre-existing network?, Phlebologie. 2009 . 62 : 42–48 .
16. Chandler JG , Pichot O , Sessa C , Schuller-Petrovic S , Osse FJ ,
B er g a n J J . D e ning the role of extended saphenofemoral junction ligation: A prospective comparative study , J Vasc Surg. 2000 .
32 : 941–953 .
17. Pichot O , Kabnick LS , Creton D , Merchant RF , Schuller-Petrovic
S , Chandler JG . Duplex ultrasound ndings two years a er great
saphenous vein radiofrequency endovenous obliteration , J Vasc Surg.
2004 . 39 : 189–195 .
18. Pittaluga P , Chastanet S , Guex JJ . Great saphenous vein stripping
with preservation of sapheno-femoral con uence: Hemodynamic
and clinical results , J Vasc Surg. 2008 . 47 : 1300–1305 .
19. De Maeseneer MG , Philipsen TE , Vandenbroeck CP , etal. Closure
of the cribriform fascia:An e cient anatomical barrier against postoperative neovascularisation at the saphenofemoral junction? Aprospective study , Eur J Vasc Endovasc Surg. 2007 . 34 : 361–366 .
20. De Maeseneer MG , Vandenbroeck CP , Van Schil PE . Silicone patch
saphenoplasty to prevent repeat recurrence a er surgery to treat
saphenofemoral incompetence:Long-term follow-up study , J Vasc
Surg. 2004 . 40 : 98–105 .
21. van Rij AM , Jones GT , Hill BG , et al. Mechanical inhibition of
angiogenesis at the saphenofemoral junction in the surgical treatment of varicose veins , Circulation. 2008 . 118 : 66–74 .
22. Heim D , Negri M , Schlegel U , De Maeseneer M . Resecting the great
saphenous stump with endothelial inversion decreases neither neovascularisation nor thigh varicosity recurrence , J Vasc Surg. 2008 .
47 : 1028–1032 .
23. Merchant RF , Pichot O , Closure Study Group. Long-term outcomes
of endovenous radiofrequency obliteration of saphenous re ux as
a treatment for super cial venous insu ciency, J Vasc Surg. 2005 .
42 : 502–509 .
24. Ravi R , Traylor EA , Diethrich EB . Endovenous thermal ablation of
super cial venous insu ciency of the lower extremity:Single center
experience with 3000 limbs treated in a 7-year period , J Endovasc
er. 2009 . 16 : 500–505 .
25. De Maeseneer M , Pichot O , Cavezzi A , et al. Duplex ultrasound
investigation of the veins of the lower limbs a er treatment for
varicose veins:UIP consensus document , Eur J Vasc Endovasc Surg.
2011 . 42 : 89–102.
26. De Maeseneer MG , Vandenbroeck CP , Hendriks JM , Lauwers PR ,
Van Schil PE . Accuracy of duplex evaluation one year a er varicose
vein surgery to predict recurrence at the sapheno-femoral junction
a er ve years , Eur J Vasc Endovasc Surg. 2005 . 29 : 308–312 .
2004 . 27 : 259–268 .
198 • PRIMARY SUPERFICIAL VENOUS INSUFFICIENCY
25.
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THE CHANGING IMPORTANCE OF THE
SAPHENOUSVEIN
TREATING VERSUS NONTREATMENT
Paul Pittaluga , S. Chastanet , and T. Locret
INTRODUCTION
e saphenous vein (SV) has been the main target for the
treatment of varices for decades. Indeed, the traditional
physiopathological concept of varicose disease relies on the
descending theory of evolution of the super cial venous
insu ciency (SVI) that describes a development starting
from junctions between the deep venous system and saphenous axes, with the re ux spreading progressively along
the SV to reach the collateral veins on which the varices
develop. us, for numerous decades, the so-called radical
therapeutic principle of varicose disease has the goal of eliminating saphenous axis re ux with surgical treatment combining crossectomy with stripping (CS). e new thermal
or chemical endovenous treatment techniques are based on
the same physiopathological principle and have the same
goal of eliminating SV re ux.
However, the analysis of the long-term results of traditional surgery, the absence of crossectomy when carrying
out endovenous treatments, the recent etiopathogenic studies of SVI, and the clinical studies on the extension of the
super cial venous re ux led to new physiopathological concepts of SVI that question traditional therapeutic designs
focused on the treatment of the SV and the relevance of the
treatment of the SV itself.
CRITICAL ANALYSIS
TRADITIONAL CONCEPT OF SVI
AND THERAPEUTIC DESIGNS
Described for the rst time in 1890, the concept of SVI
is based on the existence of points of re ux from the deep
venous network toward the super cial venous network, the
principal vector of this re ux being the SV starting from the
saphenofemoral junction (SFJ) according to the retrograde
extension theory of the re ux.
e saphenous re ux would progress by retrograde valvular decompensation from the ostial valve (OV) to the
malleolar region, furthered by orthostatism. is venous
hyperpressure progressing from the deep venous system
toward the super cial system causes a dilation of the collaterals of the re uxing SV, and in some cases the appearance
of skin damages of chronic venous disease.
is concept justi es the traditional surgical treatment
by CS described at the start of the twentieth century.
goal of the surgical treatment is rigorous elimination of all
the re ux points, from the SFJ and all its a erents to the
re uxing perforating veins (PV), by going through the resection of the SV, of course. is surgical treatment remained
the gold standard for the choice of “radical” therapy of the
SVI up to ourtime.
L O N G T E R M R E S U L T S
OF THE TRADITIONAL
TREATMENTBYCS
As one of the main goals of the treatment of the SVI is to
remove the varices, the presence of varices is an objective
component for evaluation of the e cacy of this treatment.
According to the authors, studies of results of more than
5years report an extremely variable level of clinical varicose
recurrence (6 to 93%), and of the time, the technique of the
procedure, the length of follow-up, and the method of control (Table25.1).
Analysis of the literature regarding the principal factors
for recurrence shows an evolution:the oldest studies mention surgical defects, anatomical error, and tactical error,
while gradually junctional neovascularization appears as a
new nosologic entity
9–12
1,2
3,4
e
5–8
to become the most frequent factor
199
Table25.1 FREQUENCY OF RECURRENCE AFTER TRADITIONAL CROSSECTOMY AND STRIPPING
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OF THE SAPHENOUSVEIN
AUTHOR REFERENCE
NUMBER
Fischer R [9] 2001 125 34 y 48%
Van Rij AM [10] 2003 137 5 y 47.1%
Kostas T [11] 2004 113 5 y 25% Clinical
Winterborn RJ [12] 2004 133 11 y 62% Clinical
for recurrence in publications in the early 2000s.
YEAR OF
PUBLICATION
N FOLLOWUP FREQUENCY OF
13–15
is
evolution could be attributed to the specialization in surgical training, with the enlarged practice of crossectomy, perfectly codi ed for vascular surgeons. us, the number of
residual junctions has decreased, being accompanied by an
increase in the frequency of inguinal neovascularization as
the principal source of postsurgical recurrence.
However, in spite of a standardization of the surgical procedure, the frequency of postsurgical recurrences
has not decreased, only its assumed origin has changed.
Moreover, the proportion of surgical procedures carried out
on recurring varices still represents approximately 20% of
the volume of venous surgery in the literature with the pass
16–19
of time,
even in the early 2000s, with the initial strip-
ping including an enlarged crossectomy.
CONSERVATION OF THE
SFJ AFTER ENDOVENOUS
TREATMENT OR MINIMALLY
INVASIVE SURGERY
RECURRENCE
60%
93%
66%
MEAN OF ASSESSMENT
Clinical
Ultrasound Duplex-scan
Clinical
Ultrasound Duplex-scan
Air plethysmograph
that it was acceptable to preserve a stump of approximately
22–24
2cm upstream of the OV.
e study of the evolution of the untreated SFJ shows
that it is the site of an anterograde ux from the collaterals
toward the deep vein in 88 to 95.7% with a follow-up vary-
25–30
ing from 1 to 5years.
us, an e ective occlusion of the SV endovenously
leads to the disappearance of the junction re ux in the great
majority of cases (Table25.2).
e results obtained a er RF or endovenous laser (EVL)
treatment have led some authors to propose a mini-invasive
surgical approach on the same principle, stripping without
crossectomy (SWC), which associates the achievement of
surgical stripping by invagination under tumescent local
anesthesia, associated with the conservation of the SFJ by
ligature of the great saphenous vein (GSV) at 2cm from its
ostium. At minimum, the results of the SWC con rm those
of the RF or the EVL with abolition of the re ux of the SFJ
in more than 98% of the cases a er stripping of the GSV at
31
2years
and even at 5years. 32
e physical principle of the endovenous techniques is
the delivery of endovenous thermal energy, the purpose of
which is to occlude the SV, ideally leading to the elimination of the treated venous axis by resorption, thus realizing
a real “ablation.”
20–21
So, in principle, the procedure is similar to that of surgical ablation by stripping, with the common purpose of
eliminating the re uxing saphenous axis, based on the same
100-year-old descending theory of evolution of the SVI.
Moreover, the rst protocols of endovenous treatments
o en combined crossectomy to treat the source of the re ux.
However, the search for less invasiveness, which was the
main motivation of the endovenous principle, led to avoiding the inguinal incision in order to attempt an “endovenous
crossectomy,” in particular with radiofrequency (RF) treat-
21
e existence of a thromboembolic complication
ment.
related to the risk of heating the femoral vein has encouraged the practitioners of endovenous techniques not to
treat the subostial portion of the SFJ. Most authors agreed
VARICOSE RECURRENCE AFTER
THERMAL ENDOVENOUS
TREATMENT
e series a er endovenous treatment unreliably report the
frequency of clinical varicose recurrence, in particular a er
EVL treatment where this data is o en not mentioned, the
principal result criterion being the closure of theSV.
On the other hand, the frequency of recurrences according to the PREVAIT de nition (presence of clinical varices
on a lower limb [LL] that has already been treated, whatever
33
the mean of treatment)
is reported in the series with treatment by RF, with gures that vary between 22 and 30% at
3 and 5years, while the persistence of saphenous re ux var-
27,28,30
ies between 12 and 15% for these same series,
meaning
that the majority of clinical recurrences appear while the
GSV is occluded and while it no longer presents re ux.
We had reported the same observation in a surgical
series in which out of 203 LL operated on for poststripping
200 • PRIMARY SUPERFICIAL VENOUS INSUFFICIENCY
Table25.2 ABSENCE OF REFLUX OF THE SFJ AFTER SAPHENOUS ABLATION BY RF
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OR EVL TREATMENT ORBYSWC
AUTHOR REFERENCE
NUMBER
Pichot [26] 2004 104 2 y RF 95.2 %
Merchant [27] 2005 406 5 y RF 83.8 %
Nicolini [28] 2005 68 3 y RF 88 %
Min RJ [25] 2003 121 2 y EVL 93.4 %
Proebstle T [29] 2006 188 1 y EVL 95.7%
Casoni [32] 2008 62 5 y SWC 98.4%
Pittaluga [31] 2008 195 2 y SWC 98.2%
(From Reference32)
YEAR OF
PUBLICATION
recurrence, the source of re ux was a neojunction in less
than 40% of the cases, while the great majority of clinical
recurrences were independent of the saphenous axis that
34
had been stripped.
REVERSIBILITY OF THE
REFLUX OF THE GSV AFTER
PHLEBECTOMIES
N FOLLOWUP TECHNIQUE ABSENCE
•
Morphological studies:decrease in the elastin/collagen
50,51
ratio
•
Biochemical studies:decrease in proteolytic activity,
parietal hypoxia
or increase in the connective tissue in the media 52
53,54
REFLUX JSF
us, Labropopulos et al. con rm that “the parietal
venous modi cations may appear in any venous segment,
55
whatever its localization and quality of its valves.”
Some authors have reported that simple phlebectomies
could modify the hemodynamics and the diameter of the
35–41
saphenous vein.
We reported our experiment with
this approach through the ASVAL method (ambulatory
selective varices ablation under local anesthesia) with
short-term abolition of the saphenous re ux in 70% of
42
the cases,
a result that remains stable with a frequency of
freedom from varicose recurrence of 91.5% and 88.5% at
43,44
3 and 4years respectively,
frequency of freedom for recurrence a er surgical
equivalent to or less than the
45,46
or
endovenous ablation treatment of the GSV with the same
27,28,30
follow-up.
ETIOLOGY AND PATHOGENY OF
ESSENTIAL VARICES
e descending theory relies on an insu ciency of the terminal valves of the SV or valves of femoral perforating veins
as the origin of the insu ciency of the SV upstream of its
2,47
secondary dilation.
is theory has been predominant for a long time, but it
is currently questioned by partisans of the “parietal hypothesis” with well-supported arguments. Indeed, numerous
publications bring to fore the importance of parietal modi cations in the etiology of the varices:
•
Functional studies:presence of venous dilations under
continent valves
48,49
TYPOLOGY AND EXTENSION
OF THE SUPERFICIAL
VENOUSREFLUX
Faced with re ux of the SV, it has been established that the
ostial valve was o en continent. e frequency of an isolated subostial or truncular re ux is estimated to be around
56,57
50% in the literature.
e incontinence of the ostial
valve is thus not necessary for the development of distal
SVI. Moreover, it is thought that the SVI is associated with
57,58
a deep venous re ux in only 2 to 10% of cases.
More and more publications mention a progres-
sion of the super cial venous re ux from the suprafascial
55,56,58,59
veins.
Some authors also con rm that these observa-
tions contradict the assumption that the re ux is developed
60–62
from the saphenous junction retrogradely.
In a retrospective study based on 2,275 echo-Doppler
mappings, we had noted that there was a positive correlation between the patient’s age, the clinical stage of the SVI,
and the extent of the super cial venous re ux, and these
observations speak in favor of an anterograde or multifocal
development of the super cial venous insu ciency, prob-
63
ably from the suprafascial venous network
(Figure25.1).
In 2010, Labropoulos et al. provided additional evidence that the frequency of varicosities is lower in the
saphenous trunk than in the tributaries or accessory veins.
ey also established a correlation between the CEAP classi cation and the extent of the re ux and the saphenous
64
trunk diameter.
THE CHANGING IMPORTANCE OF THE SAPHENOUS VEIN • 201
A
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Age
63 yrs
55 yrs
50 yrs
43 yrs
Isolated VV Saph. reux +
junct. compet.
Saph. reux +
junct. incomp.
Whole saph.
reux
All dierences are
signicant (p<0.05)
B
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
Figure25.1 Correlation of the venous re ux progression with age (A)and signs and symptoms (B)according to a retrospective study on 2,275
echo-Doppler mappings (From Reference63).
Isolated VV Saph. reux +
QUESTIONS ABOUT THE
IMPORTANCE OFTHESV
Freq. of symptoms Freq. of C4–C6
61.1%
3.1%
junct. compet.
66.5%
7.6%
9.8%
Saph. reux +
junct. incomp.
•
How does one interpret the clinical observations that
87.3%
73.2%
16.6%
Whole saph.
reux
All dierences are
signicant (p<0.05)
report the frequent existence of a suprafascial SVI in the
absence of re ux of theGSV?
e analysis of the above studies raises several questions:
•
Why does the frequency of varicose recurrences remain
as high in spite of carrying out a “radical” treatment
with CS of the GSV that has been perfectly codi ed for
several decades?
•
How does one explain the abolition of the re ux of the
SFJ in spite of the absence of crossectomy a er removal
of the GSV by RF or EVL treatment or bySWC?
•
How can truncular re ux of the GSV be abolished a er
DESCENDING THEORY AND THE
It is not possible to answer these questions without questioning in depth the principle of the descending theory
starting from junctions and saphenous axes. Indeed, the traditional descending theory does not enable any of the previous questions to be answered.
QUESTIONING THE
TREATMENT OFTHESV
simple phlebectomies?
•
Why did more than half of the clinical recurrences
observed in the medium term a er treatment with RF
appear while the GSV was occluded and no longer
presented re ux?
•
What is the physiopathological incidence in studies
on the etiopathogeny of the essential varices that favor
a parietal, not valvular, hypothesis of the origin of the
disease?
e initial notion of a surgical defect (absence of resection
of the SFJ) as the predominant explanation for the recurrence of the retrograde pathway occurring a er CS, has
regressed because of the extensive practice of crossectomy.
e concept of inguinal neovascularization has become
the predominant explanation of recurrence a er CS. is
ON THE FREQUENCY OF
RECURRENCES AFTERCS
202 • PRIMARY SUPERFICIAL VENOUS INSUFFICIENCY
neovascularization may be considered as a healing of the
https://t.me/med1917
crossectomy zone, and some authors question its role as a
65
recurrence factor,
particularly as Perrin etal. 66 report that
there is only a single “source” of re ux during a poststripping recurrence in less than 10% of cases. e ablation of
the saphenous axis to treat the origin of the SVI, in keeping
with the descending theory, thus has very serious limits.
hypothesis seriously contradicts the descending theory based
on the successive rupture of the junctional or saphenous
valves leading to “the ooding” of suprafascial collaterals.
ON THE EXISTENCE OF PRIMITIVE
VARICES IN THE ABSENCE OF REFLUX
OF THE SFJ, EVEN OF THEGSV
ON THE REVERSIBILITY OF
AREFLUX OF THE SFJ AFTER RF OR
EVL TREATMENTORSWC
e absence of treatment of an SFJ that presents an ostial
re ux should logically lead to the persistence of the junction
re ux or at the very least to its reappearance in the medium
or long term in the logic of the descending theory. However,
the studies of the results of RF treatment at 5years show that
the absence of re ux at the level of the untreated SFJ is main-
27,30
tained when the GSV is occluded.
e results reported
a er SWC are similar, with an absence of re ux at the level
31,32
of the SFJ in 98.2% at 2 years
and 98.4% at 5 years.
us, the treatment of ostial re ux, a key component of the
descending theory for which the irreducible corollary is the
enlarged crossectomy, is solidly brought back into question.
ON THE ABOLITION OF AREFLUX
OF THE GSV AFTER PHLEBECTOMIES
And yet, the descending theory of evolution following
successive valvular lesions cannot explain this observed
phenomenon, because a single functional valvular incom-
39–44
petence can explain a reversibility of the re ux.
ON THE PROBLEM OF CLINICAL
VARICOSE RECURRENCES AFTER
ENDOVENOUS TREATMENT
If the endovenous techniques have shown their e ectiveness
for obliteration of the GSV and the elimination of the re ux
of the SFJ, that has not resolved the frequency of clinical
varicose recurrences that remain at about 30% at 5years,
45,46
close to the gures obtained a er CS.
erefore, the
27,30
elimination of the saphenous re ux endovenously or by
stripping, even if it is a complete success, does not enable
varicose recurrence to be avoided.
A certain number of clinical studies show that in the presence
of varices not only is the SFJ competent in more than 50%
56,57
of cases
or totally competent SV.
but what is more, there is frequently a partially
58,59,63
Moreover, the studies that are
involved with progression of re ux certainly recognize the
involvement of the SV in the development of the SVI but
without assigning any responsibility to the SV forit.
58–64
NEW HEMODYNAMIC CONCEPT
CALLING INTO QUESTION THE
IMPORTANCE OFTHESV
is in-depth questioning of the descending theory leads
to a very di erent hypothesis:that of ascending theory of
evolution of the SVI from the suprafascial venous network,
ascendingly or multifocally toward the SV. e extension of
the SVI on the super cial venous network is done centripetally:the evolution begins on the suprafascial tributaries at
the bottom, where the hydrostatic pressure is higher, causing the dilatation of the vein wall. is evolution initially
remains within the suprafascial plane, creating a dilated and
re uxing venous network and progressing following the
decreasing hydrostatic pressure gradient. In addition, this
re uxing network, when becomes su ciently important,
creates a “varicose reservoir” (VR) with a lling e ect in
the intrafascial saphenous axis, causing functional incompetence of the saphenous valves, then a dilatation of the
SV, evolving anterogradely up to the SFJ also following the
61,62
decreasing hydrostatic pressure gradient.
e concept of the ascending theory makes it possible
to outline answers to the questions mentioned previously:
ON THE FREQUENCY OF
RECURRENCES AFTERCS
O N T H E P R O G R E S S I V E
ABANDONMENT OF THE VALVULAR
HYPOTHESIS TO THE BENEFIT OF
THE PARIETAL HYPOTHESIS
e descending theory is based on an insu ciency of the
terminal valves of the SV or valves of the femoral perforating veins as being at the origin of the insu ciency of the
SV by retrograde pathway. is theory is currently questioned by numerous studies
parietal modi cations prior to valvular lesions. e parietal
Treatment as speci c as CS cannot eradicate varicose recurrence, which would be more or less irreducible because of
the natural evolution of the disease starting from the collateral veins themselves.
ON THE REVERSIBILITY OF
AREFLUX OF THE SFJ AFTER RF OR
EVL TREATMENT ORBYSWC
48–54
that show the existence of
Since re ux of the SFJ is a consequence of the re ux upstream,
it can be understood that abolition of the re ux of the GSV
THE CHANGING IMPORTANCE OF THE SAPHENOUS VEIN • 203
by RF or EVL treatment or by SWC could restore an antero-
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grade ow with it by virtue of the anastomosis of the collaterals of the SFJ that have an anterograde ow. e enlarged
crossectomy, removing an important physiological drainage
pathway of the inguinal region could even be deleterious, as
the very low rate of neovascularization appears to demon-
26–28, 31
strate a er preservation of the SFJ (0 to 1.7%)
trast to the surgical series with crossectomy (20 to 52%).
ON THE ABOLITION OF A
REFLUX OF THE GSV AFTER
PHLEBECTOMIES
in con-
46,65
According to the ascending theory, the ablation of the
VR may lead to abolition of the saphenous re ux with the
elimination of the lling e ect and the disappearance of
the functional incompetence of the saphenous valves.
39–44
Furthermore, Lurie suggested the possibility of functional
insu ciency of the saphenous valves in the absence of
any anatomical lesions. e closing of the valves would be
caused by the existing pressure in the valvular sinus, which
pressure would increase in direct proportion to the velocity
of the anterograde ow. If this velocity fails to reach a critical value that allows pressure to reach a level su cient to
67
close the valve, the valve will not close.
is is why a re ux
may be present that passes through healthy valves when a
patient is in the decubitus position, because the velocity of
the anterograde ow is slight. Because ablation of the VR
makes it possible to improve the saphenous hemodynamics,
it may also make it possible to eliminate a functional valvular insu ciency by increasing the anterograde velocity.
according to a personal evolution factor. us, the endovenous treatments or the mini-invasive surgery can decrease
the aggressiveness of the initial treatment compared with
the CS, but its prognosis would not be changed in the
medium or long term, with an irreducible rate of clinical
recurrences (Table25.3).
O N T H E P R O G R E S S I V E
ABANDONMENT OF THE VALVULAR
HYPOTHESIS TO THE BENEFIT OF
THE PARIETAL HYPOTHESIS
e parietal etiopathogenic hypothesis of the origin of the
SVI gets its clinical illustration with the development of the
disease starting from suprafascial veins, the wall of which is
most fragile, causing an initial extension within this suprafascial network.
ON THE EXISTENCE OF PRIMITIVE
VARICES IN THE ABSENCE OF
REFLUX OF THE SFJ, EVEN THEGSV
e GSV is the super cial vein, the wall of which is thickest
and most muscular, protected moreover by the doubling of
63,64
the subcutaneous fascia in which it ows.
us, it could
logically be the last to be decompensated, which makes it
possible to explain the presence of a suprafascial SVI with
an absent or partial re ux in theGSV.
PERSPECTIVES
ON THE PROBLEM OF CLINICAL
VARICOSE RECURRENCES AFTER
ENDOVENOUS TREATMENT
In spite of the abolition of the re ux of the GSV, the natural
evolution of the SVI is not a ected in the medium or long
term, and the varices appear again more or less obviously
Table25.3 FREQUENCY OF VARICES RECURRENCES PREVAIT REFERENCE34
AFTER CS, ENDOVENOUS ABLATION BY RF, SWC, ANDASVAL
AUTHOR
REFERENCE
NUMBER
Van Rij AM [10] 2003 5 y CS 47.1 %
Kostas T [11] 2004 5 y CS 25 %
Merchant [27] 2005 5 y RF 27.4 %
Nicolini [28] 2005 3 y RF 22.8 %
Pittaluga [31] 2003 2 y SWC 6.7 %
Casoni [32] 2008 5 y SWC 11.1 %
Pittaluga [43] 2006 4 y ASVAL 11.5 %
(From Reference 32)
YEAR OF
PUBLICATION
FOLLOWUP TECHNIQUE REVAS
N E W T H E R A P I E S
e ascending theory validates the new therapeutic
approaches:
•
e RF or EVL treatment with conservation of the SFJ,
which is no longer considered to be the origin of the
204 • PRIMARY SUPERFICIAL VENOUS INSUFFICIENCY
SVI, and which even becomes a useful functional entity
https://t.me/med1917
for venous drainage of the inguinal region.
•
Foam echosclerotherapy, which makes it possible to have
great exibility in treatment adaptation according to the
evolutive stage of the patient since it will be capable of
treating the GSV but also theVR.
•
Mini-invasive surgery, whether it is ablative (SWC)
for the same reasons as RF or EVL treatment, or
conservative (ASVAL) since it limits the treatment
to the VR, starting point of the SVI according to the
ascending theory.
NEW STRATEGIES FOR TREATMENT
However, apart from the ASVAL, all the new SVI treatments up to now, whether they are surgical, thermal, or
chemical, have the goal of obliterating the re uxing SV,
which is the principal, and sometimes only, criterion for
evaluation of the result of these techniques in the literature.
e traditional descending theory bases its entire therapeutic position on the presence of a saphenous re ux with
its elimination as a goal, without real analysis of the subtleties of this re ux (re ux of the junction, extent of the re ux,
hemodynamic pro le) or analysis of the relationship of this
re ux to the patient’s complaint. us, the result is assessed
on the quality of the elimination of the saphenous re ux.
It is paradoxical to observe that one could consider that
treatment by stripping, RF, or EVL is a success because the
saphenous re ux no longer exists, while varices or symptoms are present.
If we accept the ascending theory as an explanation of
the SVI in the majority of cases, the treatment of the SV can
no longer be considered to be the goal with priority or even
the only goal of the therapy. It is the treatment of the VR
43,68
that becomes the treatment goal with priority.
In addition, the ascending theory leads to the question of treatment of varices preserving the SV in earlier
stages, especially for young patients, which might avoid or
slow down the progression to the higher stages of disease,
64
toward skin damage.
Obviously the answer to this ques-
tion requires longitudinal cohort studies.
Much work remains to be done, because if the VR is an
essential component for the treatment and prognosis of the
SVI, it is indispensible to integrate it as an assessment criterion in all studies of treatment of the SVI. However, there
are no reliable means currently for assessing theVR.
C O N C L U S I O N
e traditional descending physiopathological description
can no longer be considered to be the only explanation of
the SVI. More and more it appears that the evolution of
the SVI develops from the distal network ascendingly or
multifocally toward the saphenous axes. us, the systematic treatments of ablation of the saphenous vein or crossectomy are widely questioned. Treatment should be focused
on the VR and personalized according to the hemodynamic
and clinical checkup, but also according to the wish of the
patient. e scienti c studies necessary to validate the different therapeutic choices are indispensible with a long-term
follow-up.
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THE CHANGING IMPORTANCE OF THE SAPHENOUS VEIN • 207
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