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of limbs it is above this level and then joins the proximal
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10
popliteal or femoral vein.
Alow termination in the upper
calf joining the gastrocnemius veins or GSV occurs in about
8,11
Ultrasound shows that the junction is at the poste-
1%.
rior aspect of the popliteal vein in just 15%, and it joins on
the medial or lateral side in approximately 85% and even
11
anteriorly in 1% of limbs.
TE AND VEIN OF GIACOMINI
e TE is present in approximately 70% of limbs and is frequently as large as the SSV. e TE passes upward in a groove
between the semitendinosis and biceps femoris muscles in a
4,10
fascial compartment just as for the SSV and GSV.
It usually extends to the middle or upper thigh and terminates
in almost equal proportions into deep or super cial veins.
8
Giacomini clearly showed that what is now termed the TE
may terminate in veins in the buttocks, posterior thigh
perforators, or super cial tributaries (see Figure 29.2).
3,4
Acommunication of the TE with the posterior circum ex
thigh vein to connect to the GSV is now termed the vein of
10
Giacomini.
e terminal TE pierces the deep fascia if it
passes to deep veins but passes super cial to the membra-
10
nous fascia if it forms the vein of Giacomini.
Valves may
be oriented in the TE to allow normal ow either cepha-
3
lad or caudal
so that pathological “re ux” is de ned as
bidirectional o w .
Multiple veins draining from each muscle venous plexus
most frequently join to form a pair of veins, which then
become a single main trunk before joining the deep veins.
e main trunk varies from 0.5 to 5.5cm in length and usually has at least one valve. Drainage is to the popliteal vein
in over 85% of limbs and to crural veins in the remainder.
e main gastrocnemius veins can enter the popliteal vein
separate to the SSV or with a conjoint junction.
ACCOMPANYING NERVES
ANDARTERIE S
Ricci and colleagues have studied the anatomy of the sural
13
nerve by ultrasound.
It lies close to the SSV in the distal
third of leg with a highly variable and more distant relationship in the proximal calf. It usually lies lateral to the SSV
within the fascial space. e sural nerve does not share
a common association of the perivenous and perineural
fasciae as frequently occurs with the GSV and saphenous
nerve.
14
e sural nerve has two accompanying arteries.
Both the sural nerve and its arteries lying in close proximity
to the SSV can be damaged by any form of intervention.
e posterior tibial nerve lies lateral to the SSV in
two-thirds and medial in one-third of legs, and the peroneal
18,19
nerve almost always lies medially.
e posterior tibial
nerve lies close to the SSV near the SPJ and o en twines
around the vein. ese major nerves are prone to trauma
during surgery to ligate the vein at theSPJ.
15–17
GASTROCNEMIUSVEINS
Gastrocnemius veins drain from the medial and lateral
gastrocnemius muscles, and the medial are larger than the
lateral gastrocnemius veins. ey have a variable pattern.
Semitendinosis
Biceps
TE
VG
Muscular
GSV
Gastroc. m
Figure 29. 2 Course and terminations of the SSV and TE at the back
of knee and thigh. (VG—vein of Giacomini).
Muscular
TE
SPJ
SSV
Gastroc. m
12
P A T H O L O G Y
e larger proportion of limbs with varicose disease have
super cial re ux with or without deep re ux, with deep
re ux alone uncommon (see Table29.1).
REFLUX IN THE SSV TERRITORY
Approximately one-third of all limbs with saphenous
9
disease have re ux in the SSV.
e prevalence of SSV
re ux increases with greater clinical severity of disease
Table 29. 1 AN ULTRASOUND STUDY OF PROPORTIONS
OF LIMBS WITH REFLUX IN THE SUPERFICIAL
AND DEEP VEINS IN RELATION TO THE CLINICAL
SEVERITY OF VENOUS DISEASE
VENOUS
REFLUX
Super cial
alone
Super cial
and deep
Deep alone 29 2% 16 11% 45 3%
Total 1,827 154 1,981
(Myers and colleagues—unpublisheddata)
C23
NUMBER
1,626 89% 65 42% 1,691 85%
172 9% 73 47% 245 12%
% C46
NUMBER
% TOTAL
NUMBER
%
228 • PRIMARY SUPERFICIAL VENOUS INSUFFICIENCY
Table 29. 2 AN ULTRASOUND STUDY OF PROPORTIONS
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OF LIMBS WITH REFLUX IN THE GSV OR SSV IN
RELATION TO THE CLINICAL SEVERITY OF VENOUS
DISEASE
SUPERFICIAL
REFLUX
GSV alone 1,255 70% 65 47% 1,320 68%
SSV alone 242 13% 31 23% 273 14%
GSV & SSV 301 17% 42 30% 343 18%
Total 1,798 138 1,936
(Myers and colleagues—unpublisheddata)
C23
NUMBER
% C46
NUMBER
% TOTAL
NUMBER
%
Table 29. 4 AN ULTRASOUND STUDY OF THE
FREQUENCY OF ASSOCIATION BETWEEN REFLUX IN
THE TE OR VEIN OF GIACOMINI AND REFLUX IN THE
GSVORSSV
SAPHENOUS
REFLUX
GSV alone 922 6 1%
SSV alone 138 23 17%
GSV & SSV 166 47 28%
Total 1,226 76 6%
(From Reference2)
NUMBER NUMBER WITH
TE REFLUX
% WITH TE
REFLUX
(see Table29.2). e SPJ is competent in approximately
one-third of limbs with SSV re ux with other incompetent
connections to the SSV from popliteal perforators, pelvic
veins, GSV, or thigh veins (see Table29.3). Cavezzi and colleagues found with ultrasound that most limbs show re ux
a er release of calf compression but that a few show ow
through the SPJ during calf compression, particularly where
5
the destination for ow is into theTE.
SSV re ux is a signi cant risk factor for recurrence of
7
venous ulceration.
Ulcers associated with GSV re ux may
be on any aspect of the leg, but ulceration over the lateral
aspect of the ankle usually is associated with SSV re ux,
20
o en without associated pigmentation or eczema.
BIDIRECTIONAL FLOW IN THE TE
AND VEIN OF GIACOMINI
is is far more likely to occur in association with SSV than
4
GSV re ux (see Table29.4).
Saphenopopliteal incompetence can result in distal to proximal ow from the SSV to
GSV or thigh tributaries. Saphenofemoral or pelvic vein
incompetence can result in proximal to distal ow to the
Table 29. 3 AN ULTRASOUND STUDY OF THE
SOURCESAND DESTINATIONS OF REFLUX INTO
THESSV TERRITORY
DISTAL
DESTINATION
SSV
ONLY
& VG
SPJ only 169 11 5 1 186 (56%)
SPJ & VG 10 – – – 10 (3%)
VG only 54 – – 1 55 (17%)
GSV
tributaries
Perforators 11 – – – 11 (3%)
Unknown 15 – – – 15 (4%)
Total distal
destinations
(From Reference3)
55 – – 2 57 (17%)
314
(94%)
PROXIMAL CONNECTIONS
SSV
VG
ONLY
TRIBUTARIES
11
5 (1%) 4 (1%)
(4%)
SSV
TOTAL
PROXIMAL
CONNECTIONS
SSV through the vein of Giacomini and TE (see Figure29.3
and Table29.5).
R E F L U X I N T H E
GASTRO CNEMIUSVEINS
Re ux in gastrocnemius veins is reasonably common. It may
be symptomatic, causing aching from calf congestion, frequently without evidence of super cial varicoseveins.
MECHANISMS FOR DISEASE
It is now widely accepted that saphenous re ux is not initiated by retrograde pressures and that there is an antegrade
progression of disease from tributaries into the saphenous
veins with secondary incompetence at the saphenous junc-
21
However, most of this evidence comes from studies
tions.
of GSV disease.
If ultrasound is used to demonstrate SSV re ux then it
is also found that there are one or more intact valves in deep
veins above the SPJ or at the junction itself in most limbs.
Calf compression or cu in ation during scanning causes
approximately 20 to 30 ml of blood to re ux from deep
veins to the SSV if the SPJ is incompetent. is equates to
the volume in a 5 to 10cm length of deep vein above and
below the junction, approximately the distance expected
between competent valves. ere is no large central pool of
blood for re ux into the SSV in most patients.
e pathophysiology of blood accumulating in the SSV
and its tributaries is undoubtedly more complex than re ux
alone. It is probable that an ultrasound examination bears
little relation to everyday hemodynamics during standing
and walking, which are poorly understood. ere is probably a complex interaction of antegrade and retrograde ow
through the SSV and deep veins, and ow in either direction
through some calf perforators in the presence of disease.
Accordingly, it is naive to anticipate that simple interruption at the junction would restore normal venous function. is suggests that destruction of the entire diseased
segment of SSV and TE is required for best results from
treatment. is is not common surgical practice.
TREATMENT OF SMALL SAPHENOUS VEINREFLUX • 229
V
12
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Pelvic
igh vs.
igh vs.
VG
VG
Figure 29. 3 Re ux through the vein of Giacomini from the GSV territory to the SSV (1)and from the SSV to the GSV territory(2).
SSV
GSV
DIAGNOSIS
VG
GS
SSV
but it will provide false-positive results that could lead to
unnecessary popliteal fossa exploration in at least 10% of
22
C L I N I C A L
Inspection, palpation, and the percussion test may reveal a
dilated SSV or tributaries behind the knee in the SSV territory,
but provide no information regarding the SPJ. Tourniquet tests
are of little value for re ux into the SSV if there are competent
patients.
and in particular the information required regarding the SPJ.
CW Doppler is widely used to exclude SSV re ux because it
has a low false-negative rate, but this seems pointless if the
policy is to perform routine duplex ultrasound scanning.
CW Doppler cannot de ne variations in anatomy
valves in deep veins above the SPJ preventing deep re ux, as
is usually the case. Even if there is full-length deep re ux, it is
di cult to be sure that a tourniquet selectively occludes super cial veins and not deep veins. Interpreting results in patients
with combined GSV and SSV re ux is almost impossible.
DUPLEX ULTRASOUND SCANNING
Anatomy needs to be de ned before treating SSV re ux.
However, results are reliable only if performed by specialist vascular sonographers or sonologists. Principles relating
to preoperative ultrasound evaluation have been described
23
CONTINUOUSWAVE CW DOPPLER
e handheld CW Doppler probe is considered by many to
be a convenient way to record popliteal vein or SSV re ux,
Table 29. 5 AN ULTRASOUND STUDY OF THE SOURCES
AND DESTINATIONS FOR REFLUX THROUGH THE TE
OR VEIN OF GIACOMINI FROM PROXIMAL SOURCES
TO THE SSV OR FROM THE DISTAL SSV TO PROXIMAL
DESTINATIONS
SOURCE OF
REFLUX
GSV SSV 15 20%
igh veins SSV 18 24%
Pelvic veins SSV 20 26%
Total distal re ux 70%
SSV GSV 18 24%
SSV igh veins 5 6%
Total proximal
re ux
(From Reference2)
DESTINATION
OF REFLUX
NUMBER WITH
TE REFLUX
% WITH TE
REFLUX
30%
in a consensus document.
request a duplex ultrasound scan prior to treatment for var-
24
icose veins.
Asurvey from the Vascular Surgical Society
of Great Britain and Ireland found that 90% of surgeons
obtained duplex scans in all patients with suspected SSV
25
re ux.
In addition, approximately 60% routinely obtained
a further scan to mark the SPJ and SSV immediately before
surgery. ABritish report found that the preoperative scan
did not improve outcome a er SSV surgery, but the recurrence rate was high with or without preoperative scanning.
Our technique is to examine with the patient standing
or tilted on a table with the knee slightly exed and weight
taken on the opposite side. We prefer to test for re ux with
manual calf compression and release.
e routine scan for the SSV territory in our practice is
to examinefor:
•
Incompetence at the SPJ and re ux in theSSV;
•
R e ux in the popliteal vein proximal and distal to the SPJ;
•
R e ux in gastrocnemius veins;and
Many surgeons now routinely
26
230 • PRIMARY SUPERFICIAL VENOUS INSUFFICIENCY
• Alternative connections including the TE or vein of
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Giacomini, popliteal fossa perforators, intersaphenous
veins, or pelvic veins traced to the buttocks or
perineum.
If there is re ux then wenote:
•
Diameters at the SPJ and along the SSV andTE;
•
e level of the SPJ in relation to the skin crease on the
posterior aspect of theknee;
•
e position of the SSV in relation to the midline axis in
the popliteal fossa—midline, lateral, or medial;
•
A common insertion of SSV and gastrocnemius veins
into the poplitealvein;
•
Alternative destinations for re ux including the TE or
vein of Giacomini, or tributaries;and
•
Ve n o g r a p h y a n d v a r i c o g r a p h y
A minority of surgeons use this technique prior to or at
the start of the operation, to con rm the presence of SSV
re ux and to de ne the anatomy.
TREATMENT FOR SSVREFLUX
Re ux in the SSV or TE can be treated by surgery,
ultrasound-guided sclerotherapy (UGS), endovenous laser
ablation (EVLA), or endovenous mechanical ablation
(ClariVein). We have found no reference to speci c treatment of SSV re ux by radiofrequency closure.
Surgery appears to be the most frequently recom-
24
mended treatment for SSV re ux in most countries,
but
many phlebologists now prefer endovenous techniques.
Repeat surgery for recurrent SSV re ux to remove the
saphenous stump or other connections is technically
demanding and prone to complications from damage to
the popliteal vein or adjacent nerves, and it is our practice to always recommend endovenous treatment for
recurrence.
It is not known whether perforators with valvular
incompetence are an avenue for outward ow into super cial varicose veins or whether perforators act as safety
valves for blood to escape from diseased super cial veins
to be removed through normal functioning deep veins.
Accordingly, there is debate as to whether or not they
should be interrupted during treatment.
Gastrocnemius vein re ux can be treated by ush ligation at the junction with the popliteal vein or excision of
the terminal SSV if the gastrocnemius veins drain to the
SSV. However, recurrence a er ligation is common because
of failure to ligate all connections or revascularization.
Recently, treatment by EVLA has been described.
28
27
S U R G E R Y
Surgery is usually directed toward dividing the SPJ, presupposing that re ux through the junction causes varicose veins
in the SSV territory. Ultrasound is required prior to surgery,
for if an operation is to be performed to ligate the SSV ush
with the popliteal vein then it is necessary to know that the
junction is present as well as its exact location and any other
variations in anatomy.
TECHNIQUE
A survey of members of the Vascular Surgical Society of
Great Britain and Ireland found that most surgeons performed ush ligation and that few extensively exposed the
popliteal vein unless surgery was for recurrent SSV re ux.
ere was a degree of caution about the extent of surgery,
for only 15% routinely stripped the SSV and approximately
one-quarter simply ligated the vein, while over one-half
avulsed or excised as much as possible within the operation
eld. Practice patterns in other countries do not appear to
have been documented.
e operation usually is performed under general anesthesia, although spinal anesthesia or popliteal nerve and posterior nerve of thigh blocks can be used. Most surgeons operate
with the patient prone, which requires intubation for general
anesthesia. Atransverse popliteal fossa incision is favored by
most, although an incision for a high SPJ can be dis guring.
Each surgeon has a favored technique:
•
Flush ligation and division require precise
identi cation of the point where the SSV joins the deep
vein. It is important not to leave a stump, particularly if
it includes a tributary.
•
Excision of the terminal SSV within the operation eld
is preferred by many to eliminate tributaries near the
junction that could contribute to recurrence. Care must
be taken to identify and ligate the gastrocnemius veins if
they join theSSV.
•
Retrograde stripping to mid calf or further, now
favoring invagination stripping. ere is no evidence as
to whether stripping reduces recurrence rates or increases
risk of sural nerve damage, or whether invagination
reduces the incidence of nerve injury.
•
Antegrade stripping from the ankle. e presence of
the stripper in the SSV at the junction makes it easier to
identify the veins. Care must be taken to avoid damage
to the sural nerve during the distal dissection.
O U T C O M E
e small number of prospective studies published that
used ultrasound for surveillance a er SSV surgery show
25
TREATMENT OF SMALL SAPHENOUS VEINREFLUX • 231
disturbingly high recurrence rates. Van Rij and colleagues
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reported that recurrence rates at 3 weeks and 3years were
23% and 52% respectively compared to 1% and 25%
29
respectively a er GSV surgery.
Smith and colleagues
studied thirty-seven limbs treated by SSV ligation with
excision within the popliteal fossa and showed that the
recurrence rate at 12months was 38% (due to inadequate
26
surgery in 27% and neovascularization in 11%).
Another
British report found an “ideal” outcome in only 39% of 67
limbs at 6 weeks, with persistent SSV re ux from tribu-
30
taries in 20% and an intact patent SPJ in 36%.
ADutch
study found that only ve of thirty-two limbs treated by
SSV ligation were completely controlled at 3months, with
persisting re ux into adjacent tributaries in fourteen and
31
a patent junction in thirteen limbs.
ere is a need for
larger prospective objective studies using ultrasound surveillance for outcome a er ligation alone or ligation and
stripping.
Sites for recurrence a er SSV surgery have been de ned
by retrospective ultrasound studies. Tong and Royle
showed an intact SSV to be the most common nding,
with varices from the popliteal vein to residual SSV in the
32
remainder.
COMPLICATIONS
e risk of deep vein thrombosis a er SSV surgery has not
been de ned. Many surgeons use deep vein thrombosis prophylaxis selectively prior to varicose vein surgery, but few
use it routinely. Nerve injury a er venous surgery is the most
common reason for medicolegal claims in vascular surgical
33
practice.
Asurvey from the Vascular Surgical Society of
Great Britain and Ireland found that nerve injury is perceived to be more likely a er SSV surgery since two-thirds
of surgeons were more likely to warn of this complication
25
for SSV surgery compared to GSV surgery.
However, the
incidence of sural or popliteal nerve injuries a er SSV sur-
34
gery has not been determined and may be low.
Damage
to the sural nerve during SSV surgery probably results from
straying away from the vein during dissection.
in the vein as possible, controlling communications to deep
veins at the SPJ or through large perforators with a nger or
the ultrasoundprobe.
POSTOPERATIVE MANAGEMENT
AND SURVEILLANCE
All limbs are bandaged or compressed with classII stockings continuously for 24 hours and then compressed with
stockings during the day for 1 to 2 weeks. However, a
recent study showed no di erence in outcome according to
36
whether or not compression stockings were worn.
Patients
are reviewed with ultrasound at 3 to 7days to con rm occlusion of the treated veins and to exclude deep vein thrombosis. ey are then followed by ultrasound surveillance at 6
weeks, semiannually for 2years, then annually.
S T A T I S T I C A L M E T H O D S
We used Kaplan-Meier methods to generate survival
curves for time to failure (primary or secondary).
Univariable and multivariable survival hazard ratios and
their con dence intervals were computed using Cox
regression methods, with veins clustered within patient
to account for within-patient similarities. We classed each
continuous predictor variable into two groups using its
median value. ese were:age (55 yrs), diameter (4mm),
concentration of scleroscant (1.5%), foam volume (5 ml).
We used Stata Release 11 for all computations and statisti-
37
cal graphs.
O U T C O M E
In our series, the primary success rate at 4years a er UGS
for SSV re ux determined by ultrasound surveillance using
Kaplan-Meier analysis was 46%, with a secondary success rate of 62% with repeat UGS as required for clinical
recurrence (see Figure29.4). Patients should be told that
100
ULTRASOUNDGUIDED
SCLEROTHERAPYUGS
Techniques are described in Chapter18, and our technique
has been presented in detail elsewhere.
summarize particular features relating to SSV re ux in our
practice. UGS has been used by our group to treat 264 SSV
systems in 207 patients. We favor aethoxysklerol or sodium
tetradecyl sulfate in varying concentrations. e sclerosant
may be used as liquid or as foam, and foam may be made
2
with air or a CO
/0 2 mixture. Injection is made as far distal
TECHNIQUE
232 • PRIMARY SUPERFICIAL VENOUS INSUFFICIENCY
35
is chapter will
80
60
40
% Success
20
0
0
N-prim.
259
sec.
259
Figure 29. 4 Kaplan-Meier analysis of primary and secondary success
rates from ultrasound surveillance for UGS for SSV re ux.
12
Years after operation
116
97
48
66
345
24
42
Secondary
Primary
14
24
62%
46%
6
12
100
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100
80
GSV
GSV
P=0.049
6
28
47%
SSV
345
24
60
14
37
53%
6
16
% Success
N-SSV
GSV
60
40
20
0
259
690
0
12
Years after operation
230
97
106
48
Figure 29. 5 Kaplan-Meier analysis of primary success rates from
ultrasound surveillance for UGS for GSV and SSV re ux.
future repeat treatment by UGS may be required. ese
results were signi cantly worse than for patients treated
for GSV re ux (see Figure29.5); the reason is not apparent. Multivariate Cox regression analysis showed signi cantly worse results for patients younger than 55years and
veins greater than 4mm diameter but no worse according
to other patient or vein characteristics or technique (See
Table29.6 and Figures29.6 and 29.7). Alarge, multicenter
European study has shown a relatively small incidence of
complications including migraine, visual disturbance, chest
38
pressure, and thromboembolic events.
e few reported
transient strokes appear to have all followed treatment of
theGSV.
In our practice, concern regarding long-term results for
surgery has made UGS the preferred treatment for older
75
% Success
N-older
younger
50
25
0
12
Years after operation
41
56
17
31
132
127
0
> 55 yr
<= 55 yr
345
8
16
3
11
P=0.002
53%
38%
2
4
Figure 29.6 Kaplan-Meier analysis of primary success rates from
ultrasound surveillance for UGS for SSV re ux according to the
patients’ages.
patients with small-diameter re uxing SSVs or their tributaries, while EVLA or ClariVein are preferred for younger
patients with larger diameterveins.
E V L A
Techniques are described in Chapter28 and our technique
39
has been presented in detail elsewhere.
is section will
summarize particular features relating to SSV re ux in our
practice. EVLA has been used by our group for 164 limbs of
146 patients with SSV re ux using 810-nm and 1500-nm
systems. e procedure is performed with perivenous
tumescent anesthesia injected into the saphenous compartment along the vein. Perivenous uid injection provides a
Table 29. 6 MULTIVARIATE ANALYSIS OF COVARIATES
THAT MIGHT AFFECT OUTCOME AFTER UGS FOR SSV
RE FLUX .
VARIABLE HAZARD
Sex 0.83 0.28 0.589 0.43 1.61
Side 0.90 0.20 0.649 0.59 1.39
CEAP 1.58 0.63 0.254 0.72 3.45
Primary/
Recurrent
Foam/Liquid 2.02 1.20 0.234 0.63 6.45
Sclerosant 0.92 0.45 0.872 0.36 2.39
Concentration 0.73 0.28 0.414 0.35 1.55
Volume 1.38 0.38 0.241 0.80 2.38
Age 0.44 0.12 0.004 0.25 0.76
Diameter vein 1.95 0.50 0.009 1.18 3.21
RATIO
STANDARD
ERROR
P 95% CIS
0.71 0.35 0.490 0.27 1.88
TREATMENT OF SMALL SAPHENOUS VEINREFLUX • 233
100
75
<= 4 mm 63%
50
% Success
N-older
younger
25
0
12
49
48
Years after operation
28
20
143
116
0
> 4 mm
345
14
10
11
3
30%
P=0.003
Figure 29. 7 Kaplan-Meier analysis of primary success rates from
ultrasound surveillance for UGS for SSV re ux according to the vein
diameters.
5
1
% Success
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N-prim.
100
sec.
Secondary
80
60
40
20
0
164
164
0
12
Years after operation
59
63
18
19
345
7
7
3
3
Primary
98%
81%
3
3
Figure 29. 8 Kaplan-Meier analysis of primary and secondary success
rates from ultrasound surveillance for EVLA for SSV re ux.
heat sink and compresses the vein onto the probe as well
as producing anesthesia. Residual tributaries are treated by
UGS but can be well treated by ambulatory phlebectomy.
Postoperative management and surveillance are identical to
that a erUGS.
O U T C O M E
e cumulative primary success rate at 3years from serial
ultrasound studies using Kaplan-Meier analysis was 81%,
and the secondary success rate with UGS for recurrences
was 98% (see Figure 29.8). Multivariate analysis showed
no signi cant e ects from patient or vein characteristics,
or from technique. e only complications encountered
were permanent partial sural nerve palsy in one limb and
asymptomatic minor extension of a tongue of thrombus
into the popliteal vein in another. Arteriovenous stula
15,16
has been reported as a rare complication.
Others have
found excellent patient satisfaction and return to work at
40
a mean 4days a er EVLA for the SSV.
ese results persuade us to favor EVLA for SSV re ux where the vein has
been shown to be straight and of diameter greater than an
arbitrary 4 to5mm.
C O N C L U S I O N S
e hemodynamics of SSV re ux are poorly understood.
e concept of a “source” of re ux from a deep venous
pool does not seem to be valid at this stage. e variable
anatomy and re ux patterns are probably responsible
for the wide variation in treatment techniques and poor
results from surgery. Better techniques need to be de ned
to improve surgical outcome if it is to remain the preferred
technique for treatment. Otherwise, new endovenous
techniques will replace surgery as experiencegrows.
R E F E R E N C E S
1. Uhl J-F , Gillot C . Embryology and three-dimensional anatomy of
the super cial venous system of the lower limbs , Phlebology. 2007 .
22 : 194–206.
2 . B a r b e r i n i F , C a va l l i n i A , C a g g i a t i A . e thigh extension of the small
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234 • PRIMARY SUPERFICIAL VENOUS INSUFFICIENCY
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TREATMENT OF SMALL SAPHENOUS VEINREFLUX • 235
30.
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CLASSIFICATION AND TREATMENT
OF RECURRENT VARICOSE VEINS
Michel Perrin
INTRODUCTION
Recurrent varices a er operative treatment are a common,
complex, and costly problem both for the patients and
for the physicians who treat venous diseases. To deal with
this problem, in Paris in 1998 an international consensus
meeting was held, which proposed guidelines for the de nition and description of REcurrent Varices A er Surgery
(REVAS).
Since 1998, more than 100 new articles in English and
French have been published on the topic.
quent operative procedure used for treating varicose vein.
On the one hand chemical and thermal ablation and on
the other mini-invasive surgery including CHIVA (French
acronym for ambulatory conservative hemodynamic management of varicose veins)
for tributary varices phlebectomy under local anesthesia)
are currently taking over high ligation plus stripping.
e term “operative treatment” encompasses open surgery
with and without conservation of the saphenous trunk as
well as all kinds of endovenous procedures including thermal and chemical ablation.
the VEIN-TERM transatlantic interdisciplinary consensus
document.
1
In this article ninety-four references were listed. 1
2–113
Nowadays classical surgery is no longer the most fre-
15
and ASVAL (French acronym
86
DEFINITIONS
e following de nitions were published in 2009 in
114
Recurrent varices: Reappearance of varicose veins in
an area previously treated successfully
Residual varices: Varicose veins remaining a er
treatment
PREVAIT : PRE sence of V arices (residual or
recurrent) A er operat I ve T r e a t m e n t
e concept of PREVAIT was developed for two reasons: First, it is frequently di cult to classify correctly
the results of initial procedures done by others and consequently to di erentiate recurrent varices from residual varices. Second, REVAS, the previous concept, was limited to
patients previously treated by surgery, nowadays all kinds of
operative treatment should be assessed by the same protocol.
EPIDEMIOLOGY AND
SOCIOECONOMIC
CONSEQUENCES
PREVALENCE AND INCIDENCE
OF PREVAIT
e most documented outcomes are provided by classical surgery, but most studies are retrospective. In a 34-year
follow-up
41
varicose veins were present in 77% of the lower
limbs examined and were mostly symptomatic. Fi y-eight
percent were painful, 83% had a tired feeling, and 93%
showed a reappearance ofedema.
Two prospective studies concerning classical surgery are
63,107
available with a follow-up of 5years.
In both, the patients
had preoperative duplex scanning (DS) and were treated by
high ligation, saphenous trunk stripping, and stab avulsion.
In the Kostas et al. series, 28 patients out 100 had
PREVAIT. True recurrent varices were present in eight limbs
(8/28, 29%), primarily caused by neovascularization; new
varicose veins as a consequence of disease progression were
seen in seven limbs (7/28, 25%), residual veins were found
in three limbs (3/28, 11%) mainly due to tactical errors (e.g.
failure to strip the great saphenous vein), and complex pat-
63
terns were identi ed in ten limbs (10/28, 36%).
In the Van Rij etal. series 127 limbs (CEAP classC
were evaluated postoperatively by clinical exam, DS and
air plethysmography (APG). Clinical varices recurrence
was progressive from 3months onward (13.7%) to 5years
(51.7%). Corresponding to clinical changes, there was a
–C 6 )
2
236
progressive deterioration in venous function measured by
https://t.me/med1917
107
APG and recurrence of re ux evaluated byDS.
ese studies showed that recurrence of varicose veins
a er surgery in high-skilled centers is common. However,
the clinical condition of most a ected limbs remains
improved. Progression of the disease and neovascularization are responsible for more than half of the recurrences.
Rigorous evaluation of patients and assiduous surgical technique might reduce recurrence resulting from technical and
tactical failures.
A prospective study concerning recurrence a er radiofrequency procedure (ClosurePlus) has been reported. At
73
5-year PREVAIT is estimated at 27.4%.
ere is presently
no long-term data on ClosureFast.
A er endovenous laser (EVL) treatment the longest
2
follow-up has been reported by the Italian group.
ey
claim a PREVAIT rate of 6% at 36months.
52
Hamel-Desnos et al.
reported a 36% and 37%
recanalization rate at 2-year follow-up with 3% and 1%
ultrasound-guided foam sclerotherapy (USGFS) one injection with respectively 1% and 3% polidocanolfoam.
SOCIOECONOMIC CONSEQUENCES
ere are no available published socioeconomic data on
PREVAIT. When redo surgery is performed, its cost is
higher than rst-time surgery because of the number of
peri- and postoperative complications. In one observational
54
study 40% of patients had complications.
I d e n t i ed super cial incompetent veins were scheduled
to be treated, but surgery was incorrectly or
incompletely performed.
It must be kept in mind that both tactical or/and techni-
cal errors do not always lead toREVAS.
NEOVASCULARIZATION
PREVAIT a er surgery or endovenous obliteration cannot always be attributed to tactical errors or technical
inadequacy. Many clinical and instrumental studies have
indicated that postoperative neovascularization may frequently occur ( Figure 30.1 ). Tiny new venous vessels
developing in the granulation tissue mainly around the SFJ
and/or/ the SPJ may enlarge and connect deep to super cial veins, causing clinically obvious recurrence a er a
few years. Neovascularization is more frequent a er open
s u r g e r y.
Because in several endovenous obliteration DS studies
postoperative neovascularization is infrequent or absent,
it has been suggested that the absence of high ligation can
explain this phenomenon insofar as neoangiogenesis is a
normal process in tissue healing. Furthermore, the persistence of draining tributaries in the saphenous stump may
play arole.
But in one study neovascularization was identi ed at
1-week follow-up by DS both a er RF and endovenous
66
laser (EVL) respectively in 2.2% and 7.1% of cases.
MECHANISMS AND
PHYSIOPATHOLOGY
Several possible mechanisms have been implicated in
recurrence of varices. ese have been classi ed into four
groups:tactical errors, technical errors, neovascularization,
and progression of the disease.
TACTICALERRORS
Nonidenti ed re uxive connections between the deep
and super cial system, that is, saphenofemoral
junction (SFJ), saphenopopliteal junction (SPJ),
and perforators that have not been initially treated.
I d e n t i ed or nonidenti ed super cial incompetent
veins that have not been treated.
TECHNICALERRORS
I d e n t i ed re uxive connections between the deep and
super cial system, that is, SFJ, SFP, and perforators
were scheduled to be treated, but surgery was
incorrectly performed, and the re ux persists.
PROGRESSION OF THE DISEASE
Varicosity is a progressive disorder, and new territories are
a ected by the evolution of the disease.
P A T H O L O G Y
Two studies investigating the cause of the most frequent
recurrence, that at the SFJ, and taking account of the
pathology have been reported. eir conclusions are contradictory. In a German study, the most frequent pattern
identi ed (68%) was a persistent stump related to a possible non ush high ligation, but surprisingly a valve was
identi ed in only eighteen out of sixty-three cases with a
99
single channel.
Conversely, van Rij etal. found multiple
vessels in 94% at the stump site at the SFJ and concluded
that neovascularization was the most frequent cause of
108
recurrence.
previous clinical study.
is conclusion was in accordance with their
107
Geier etal. emphasized that the
only tool valid for the identi cation of neovascularization
remains the histologic and immunohistochemical work-up
45
of the resected vein.
But, this work-up is rarely performed.
Consequently, the real cause of recurrence remains debatable in many studies.
CLASSIFICATION AND TREATMENT OF RECURRENT VARICOSE VEINS • 237
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