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Figure30.1 Neovascularization identi ed by color duplex ultrasound. (A) e saphenofemoral junction a er  ush ligation of the SFJ. CFV, common

femoral vein. (B)At initial surgery the incompetent termination of the small saphenous vein had been tied  ush to the popliteal vein (PV). Neovascularization has developed, and very small veins connect the remaining varicose network to the popliteal vein at the site of the previous SPJ and are identi ed by duplex scanning a er the compression-decompression maneuver.

CLASSIFICATION

Many classi cations other than REVAS have been devel-

115,116

oped concerning recurrences,

but they have not been widely used. At the consensus meeting held in 1998 we decided to use both the previously reported CEAP clas-

si cation and a speci c REVAS classi cation.

 is new classi cation was intended to serve everyday clinical practice as well as research studies into epidemiology, clinical status, and treatment of recurrent varicose veins. Asurvey was undertaken in order to test its intraobserver and

interobserver reproducibility.

 e conclusion of this study was that intraobserver reproducibility is quite satisfactory, and making slight changes in the answers to one question, might increase interobserver reproducibility. However, the fact that interobserver reproducibility was less than intraobserver reproducibility re ects conditions of real life, and especially interobserver di erences. Such interobserver di erences may arise from interobserver technical di erences, but this  nding emphasizes the need for validating a duplex scanning protocol and a standardizing duplex scan reports (see below, “Investigations”)

 e REVAS classi cation (Table 30.1) includes six items: T is for topographic sites of REVAS; S for sources of re ux; R for degree of re ux ; N for nature of sources ( Nss for same site of previous surgery, and Nds for di erent sites); P for contribution from a persistent incompetent saphenous trunk; and F for possible contributory factors ( Fg for general and Fs for speci c factors).

This classification has been used only for REVAS, but it might be used for any kind of recurrence after

operative treatment in combination with the CEAP classification. Nevertheless it looks that a new classification—PREVAIT classification—not yet drawn up might be a bettertool.

DIAGNOSIS

MODES OF PRESENTATION

Patients who have previous nonconservative treatment may consult their physicians for various reasons: unsightly recurrent varicose veins or related emotional problems that are especially common in female patients, discomfort (in other words venous-related symptoms), appearance of cuta- neous or subcutaneous changes, concerns about the health risk related to their veins, or limitation of activity. Also PREVAIT may be found at routine follow-up.

MEDICAL HISTORY

Family and Personal History

Family history of varicose veins and personal history including pregnancies, hormone therapy, super cial thrombophlebitis, deep vein thrombosis, and so forth, should be recorded.

Previous Treatment

 e date of previous treatment(s) for varicose veins must be reported, as well as the age of the patient at the time of operative treatment, occurrence of new pregnancies a er initial

238 • PRIMARY SUPERFICIAL VENOUS INSUFFICIENCY

REVAS Classiﬁcation sheet

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Date of examination

Day Month Year Patient Rename: First name or given name Last name or family name

Topographical sites of REVAS

Since more than one territory may be involved, several boxes may be ticked

Groin igh Popliteal fossa Lower leg including ankle and foot Other

Source(s) of recurrence

Since more than one Source may be involved, several boxes may be ticked

No source of reﬂux For petvic or abdominal Saphenofemoral junction igh perforator(s) Saphenopopliteal junction Popliteal perforator

Lower leg perforator(s)

Reﬂux

Only one box can be ticked

PROBABLE Clinical signiﬁcance R+ UNLIKE Clinical signiﬁcance R– UNCERTAIN Clinical signiﬁcance R?

Nature of sources

Only one box can be ticked

N classiﬁes the source as to whether or not it is the site of previous surgery and describes the cause of recurrence.

N Ss is for same site

Only one box can be ticked

Technical failures Tactical failures Neovascularization Uncertain Mixed

N Ds is for diﬀerent (new) site

Only one box can be ticked

Persistent (Known to have been present at the time of previous surgery)

New (Known to have been absent at the time of previous surgery)

Uncertain/not known

(insuﬃcient information at the time of previous surgery)

3 4 5

0 1 2 3

4 5 6 7

1 2 3

1 2 3 4 5

Contribution from persistent incompetent saphenous trunks

Since more than one territory may be involved several boxes may be ticked

AK great saphenous (above knee) BK great saphenous (below knee) SSV short saphenous 0 neither/other Comment:

Possible contributory factors

Several boxes may be ticked

General factors

Family history Obesity Pregnancy* Oral contraceptive Lifestyle factors** * Pregnancy since the intial operation **Prolonged standing, lack of exercise, chair siting

Speciﬁc factors

Several boxes may be ticked

Primary deep vein reﬂux Post-thrombotic syndrome Iliac vein compression Angiodysplasia Lymphatic insuﬃciency Caly pump dysfunction

1 2 3 4

1 2 3 4 5

1 2 3 4 5 6

Table30.1  e REVAS classi cation includes six items as demonstrated on this intake sheet.

treatment, and the name of therapist and the place of the operation in order to retrieve the operative record; postoperative complications; and date of the onset of PREVAIT and reappearance of symptoms. Other treatment received a er initial operative treatment, such as veinoactive drugs, use of compression stockings, and leg elevation must also be documented.

PHYSICAL EXAMINATION

Presence and intensity of the various vein-related symptoms have to be noted:pain, throbbing, heaviness, itching, feeling of swelling, night cramps, heat or burning sensations or restlesslegs.

Some data are available on patients presenting

PREVAIT, including severity of leg symptoms and clinical

65,81,83,97

disability scores.

In an international REVAS survey, there was a statistical di erence in terms of the presence or absence of symptoms between CEAP classC

( P =0.0001). di erence between the C except itching ( P < 0.001).

Conversely in a Finnish series, there was no

–C 3 group and the C 4 –C 6 group



Inspection and palpation allow the C of the CEAP (clinical, etiological, anatomic, pathophysiologic) classi cation to be completed, but other signs such as corona phlebectatica should also be identi e d, and edema should be quanti ed.  e presence of scars on the lower limb must be noted, especially

CLASSIFICATION AND TREATMENT OF RECURRENT VARICOSE VEINS • 239

and C 3 –C 6

at the groin or popliteal fossa. Neurological abnormalities

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and particularly numbness must be documented. E ciency of the calf pump has to be assessed and particularly degree of ankle motion. Arterial pulses should be checked and ankle brachial index calculated. A general examination including abdominal palpation should be performed, and possible obesity can be identi ed by body mass index calculation.

I N V E S T I G A T I O N

Many investigations have been used in the past to assess REVAS. At the moment there is a large consensus for recommending DS in all cases of PREVAIT.  is investigation provides anatomical and hemodynamic data including

•

 e topographical sites of recurrence that can be mapped,

•

 e possible sources of re ux from the deep venous

system to the super cial (Figures30.2 and30.3),

•

 e intensity or degree of re ux,and

•

 e nature of sources keeping in mind that causes have

to be classi ed di erently if recurrence occurs in a site previously treated ornot.

Figure30.3 Recurrent varices a er surgery related to a non ush resection of the SPJ.  e postoperative duplex scanning identi ed re ux in the SSV stump, which feeds the varicose network a er the compression-decompression maneuver. SSV S, short saphenous vein stump; PV, poplitealvein.

In addition, DS gives information on perforator and

d e e p v e n o u s s y s t e m s .

One problem remains:a standardized DS investigation protocol was not universally used by the di erent investigators. But recently a consensus document has been published on postoperative DS that provides a precise investigation methodology as well as a better and more precise description of the anatomical and hemodynamic anomalies

A B

according to the operative treatment modalities, surgery or

117

endovenous treatment.

In few select cases ascending venography in threedimensional imaging may give complementary valuable information. PREVAIT related to re uxive pelvic varices is better investigated by selective descending phlebography ( Figure30.4 ). Other investigations such as air plethysmography and ambulatory pressure measurement may be useful for research studies but not for daily practice.

Figure30.2 Recurrent varices a er surgery related to a non ush resection of the saphenofemoral junction in a patient with an incompetent terminal valve. (A)B-mode ultrasound.  e terminal valve is identi ed at the saphenofemoral junction. (B)Same patient; color duplex ultrasound. Massive re ux induced by a Valsalva maneuver. CFV, common femoral vein; TV, terminal valve; SS, saphenousstump.

240 • PRIMARY SUPERFICIAL VENOUS INSUFFICIENCY

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Figure30.4 Selective pelvic venography at Valsalva maneuver. (A)Re ux through the internal pudendal vein feeding contralateral GSV. (B)Re ux through the obturator vein feeding nonsaphenous vein network.

(Courtesy Drs. Monedero and Zubicoa)

QUALITYOFLIFE QUESTIONNAIRES

To determine whether PREVAIT a ect patients quality of life, the health-related quality-of-life score of patients can been used in di erent ways for clinical studies. Beresford

compared patients presenting recurrence a er conventional surgery versus patients with untreated varicose veins. No survey has compared operated patients with or without PREVAIT a er endovenous ablation.

T R E A T M E N T

M E T H O D S

Compression

Compression in varicose veins is frequently recommended and improves both symptoms and signs, but it does not cure the disease.

D r u g s

In varicose veins phleboactive drugs are prescribed mainly to improve edema and symptoms.  e most commonly used are  avonoids, but othersexist.

Operative Procedures

Operative procedures share the same goals:(1)to supress re ux from deep to super cial systems when present, (2)to supress varices, and (3)in some speci c cases to suppress deep vein abnormality to prevent new recurrences.

 e  nal goals are multiple: decrease the ambulatory

venous pressure, prevent worsening of chronic venous

disorders, avoid further recurrences and of course improve patients’ in terms of cosmetic appearance, symptoms andsigns.

Ultrasound-Guided Sclerotherapy

Sclerotherapy has been used for a very long time for treating REVAS, but ultrasound-guided sclerotherapy (USGS) has improved the e cacy. Di erent protocols have been used, but no comparative study with other operative treatment is available. Recently polidocanol foam has entered the ring, but currently no consensus exists on the techniques, doses, concentrations, or sclerosing agents for PREVAIT.

Nevertheless one of the main advantages of sclerotherapy with or without foam is that the process is cheap, simple, less invasive, and repeatable. USGFS can both obliterate the re uxive varices and suppress most of the leak points between deep and super cial venous system including pelvic, SFJ or SPJ, and perforator re ux as well as varices not connected to the deep venoussystem

Open Surgery

Procedures can be classi ed into three groups according to their objective, and should be used in combination.

 1:           

the SFJ or SPJ, if the site has previously been operated and depending on the extent of postoperative  brosis, redo surgery may be di cult. It is recommended that the deep vein be approached  rst in order to avoid dissection of scar tissues, lymphatic nodes, and cavernoma.  e last does not need to be ablated. Flush ligation of the stump is then performed and can be completed by patch interposition at the SFJ for avoiding new recurrence.

24,25

Complications

A t

CLASSIFICATION AND TREATMENT OF RECURRENT VARICOSE VEINS • 241

following re-exploration of the groin are common. 54 No

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data are available concerning redo surgery at theSPJ.

 e second procedure of this group is perforator ligation. When severe cutaneous and subcutaneous changes are present, subfascial endoscopic perforator surgery (SEPS) is the favored technique.

2:     

varicose veins, various techniques can be used. Stab avulsion and phlebectomy are the most used techniques. Stripping is sometimes used for treating the residual saphenoustrunk.

 3:      

press deep vein re ux, as several studies have demonstrated that primary deep axial re ux is frequently associated with REVAS. compression is also probably guilty in PREVAIT, but no data are available on this possiblecause.

re ux this procedure is less invasive than direct ligation.

Valvuloplasty and valve transfer are used to sup-

118,119

Embolization and Coils of the Pelvic and

GonadicVeins

In patients whose varices are fed by pelvic or gonadic

According to the location and type of

Primary obstruction represented by iliac vein

R E S U L T S

Compression andDrugs

We have no speci c data on the e cacy of compression treatment and drugs in PREVAIT patients.

 e results of two studies using an interposition patch

for treating recurrence at the SFJ have been published.

Creton,

using this procedure without resection of the groin cavernoma but with combined resection of varices (saphenous trunks and/or tributaries) had only 4.2% recurrences at the SFJ at 4.9years mean follow-up (range 3 to 7years) in 119 extremities. Nevertheless, 22.6% of patients had di use varices, with a new site of incompetence between the deep and super cial systems.

24,25

De Maeseneer

has compared the results at 5years of two nonrandomized groups with and without patch, respectively group 1 and 2 in a prospective study. All patients had recurrent SFJ incompetence. At 5-year follow-up, recurrent thigh varicosities were observed in 58% of group 2 versus 26% of group1.

 ermal Ablation

Only one series reported a randomized control trial in patients with recurrent varices initially treated by isolated SFJ ligation and presenting a persistent re ux at the SFJ and in the patent

GSV trunk.

Radiofrequency caused less pain and bruising

and was performed more quickly than traditional open surgery.

Pelvic and Gonadal Vein Embolization

At 6-month follow-up, 90% of 215 patients treated by embolization of gonadal and pelvic veins were signi cantly improved in both signs and symptoms, but relief of pelvic pain or lower limb symptoms or signs were not evaluated separately ( Figure30.5 ).



Chemical Ablation

 e value of REVAS treatment by USGFS has been assessed in several studies.  e Birmingham study has the longest follow-up and is fully documented in terms of ultrasound

investigation.

 ere is no data concerning USGFS in treatment of PREVAIT a er thermal or chemical ablation, but it seems reasonable to state that results should be as good as a er surgery.

S u r g e r y

Surprisingly very few data are available on the results provided by redo surgery in patients investigated preoperatively withDS.

We reported a series of 145 limbs with a 5- to 6-year

120

follow-up. SFJ or SPJ feeding recurrent varices that were treated by surgery. Postoperative sclerotherapy was performed in all patients during the  rst 2years. An external audit revealed a global objective improvement of 85%, but there was better improvement of signs and symptoms than cosmetic appearance.

All had major re ux from the deep system at the

INDICATIONS

Indications for treating patients with recurrent varices.

Patients can be roughly divided into two groups:

1. Patients complaining of symptoms or aesthetic concerns, or presenting with signs of chronic venous disease (C

–C 6 ). In all cases these patients need to be

investigatedbyDS.

2. Subjects attending a routine follow-up.  e decision whether to undertake DS or not depends on the presenting complaint and physical  ndings. In practice, DS is almost alwaysdone.

A S Y M P T O M A T I C

When hemodynamic or anatomic abnormalities are found in asymptomatic patients without severe signs who are not concerned by their minor varices as cosmetic problems the decision to treat depends of the severity of the noninvasive  ndings. In all cases follow-up is required, because abnormal DS  ndings precede symptoms andsigns.

242 • PRIMARY SUPERFICIAL VENOUS INSUFFICIENCY

A B

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Figure30.5 Venography using brachial access and internal iliac vein tributary vein catheterization. (A)Re ux  lling both pelvic varices and lower-limb varicose veins is identi ed a er injection into internal pudendal vein and Valsalva maneuver. (B)Same patient a er embolization. No more re ux into internal vein and no lower limb varices.

(Courtesy Drs. Monedero and Zubicoa)

S Y M P T O M A T I C

In symptomatic patients presenting with recurrent varices and hemodynamic anomalies, operative treatment must be considered.

Although there is no randomized controlled trial comparing redo surgery to chemical ablation, there is a consensus for treating recurrences with USGFS as  rst-line

21,60,84

treatment

for reasons discussed above. In very few cases when duplex scanning reveals an intact and large incompetent saphenous stump at the SFJ or SPJ with a massive re ux  lling the varicose network, redo surgery at the junction should be considered in combination withUSGFS.

In patients with severe disease (C

–C 6 ) with

PREVAIT and primary deep vein axial re ux, USGFS and valvuloplasty in association must be considered in active patients reluctant to wear lifelong compression or with recurrentulcer.

Table30.2 THE VENOUS CLINICAL SEVERITYSCORE

CHARACTERISTIC ABSENT=0 MILD=1 MODERATE=2 SEVERE=3

Pain None Occasional/nonanalgesia

Varicose Veins > 4mm None Few Multiple GSV Extensive GSV and SSV

Venous Edema None Evening/Ankle A ernoon/Above knee Morning/ requiring

Skin Pigmentation None Limited/Brown Di use lower 1/3/ purple Wide/purple

In ammation None Mild cellulitis in

Induration None Focal <5cm Medial or lateral less

Number of active ulcers None 1 2 3

Active ulcer duration <3months >3months <12months > 12months

Active ulcer diameter None <2cm 2-6cm >6cm

Compression None or noncompliant Intermittent use Compression stockings

restricting

marginal area

In order to know the prevalence and annual incidence of PREVAIT a er nonconservative treatment we need prospective studies well documented in detail from the outset of surgical treatment as in the series by Kostas etal. and van Rij etal.

63,107

–  e value of routine postoperative scanning in the

early detection of persisting re ux;

–  e relationship between hemodynamics and

clinical recurrence;and

–  e possible role of compression therapy or/and

complementary postoperative sclerotherapy in preventing recurrence.

GUIDELINES FOR

PROSPECTIVE STUDIES

 ese studies may give informationon:

With moderate

activity/analgesia use

Moderate involving most

ofgaiter area

than lower 1/3

worn most days

Daily pain, limitations

to activities or regular analgesia

elevation

Severe cellulitis or

signi cant eczema

1/3 of leg or more

Compression stockings

worn daily

CLASSIFICATION AND TREATMENT OF RECURRENT VARICOSE VEINS • 243

 ese studies may use both the updated CEAP and

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REVAS classi cation or better a PREVAIT classi cation to be established a speci c quality of life questionnaire and

121

venous clinical severity score (Table30.2).

C O N C L U S I O N

PREVAIT is a frequent condition frustrating both patients and physicians that has been poorly evaluated. In order to build a scienti cally convincing evidence base and to achieve a greater degree of comparability between studies, an international consensus on conformity is required.

R E F E R E N C E S

1. Perrin M , Guex JJ , Ruckley CV , etal. Recurrent varices a er surgery

(REVAS), a consensus document , Cardiovasc Surg . 2000 . 8 : 233–245.

2 . A g u s B , M an c i n i S , M a g i G .  e  rst 1000 cases of Italian

Endovenous-Laser Working Group (IEWG):Rational, and long terms outcomes for the 1999–2003 period , Int Angiology . 2006 . 25 : 209–215.

3. Ali SM , Callam MJ . Results and signi cance of colour duplex assess-

ment on the deep venous system in recurrent Varicose veins , Eur J Vasc Endovasc Surg . 2007 . 34 : 97–101.

4. Allaf N , Welch M . Recurrent varicose veins: Inadequate surgery

remains a problem , Phlebology. 2005 . 20 : 138–140.

5. Allegra C , Antignani PL , Carlizza A . Recurrent varicose veins fol-

lowing surgical treatment:Our experience with  ve years follow-up , Eur J Vasc Endovasc Surg . 2007 . 33 : 751–756.

6. Belcaro G , Nicolaides AN , Cesarone NM , etal. Flush ligation of the

sapheno-femoral junction vs simple distal ligation:Arandomised, 10-year, follow-up: e safe study , Angeiologie. 2002 . 54 : 19–23.

7. Belcaro G , Cesarone NM , Di Renzo A , et al. Foam sclerother-

apy, surgery, sclerotherapy, and combined treatment for varicose veins: A 10-year, prospective, randomised, controlled trial (VEDICO trial), Angiology. 2003 . 54 : 307–315.

8. Bhatti TS , Whitman B , Harradine K , Cooke SG , Heather BP ,

Earnshaw JJ . Causes of re-recurrence a er polytetra uoroethylene patch saphenoplasty for recurrent varicose veins , Br J Surg. 2000 . 87 : 1356–1360.

9. Beresford T , Smith JJ , Brown L , Greenhalgh RM , Davies AH . A

comparison of health-related quality of life of patients with primary and recurrent varicose veins, Phlebology. 2003 . 18 : 35–37.

10. Blomgren L , Johansson G , Dahlberg-Akerman A , etal. Recurrent

varicose veins:Incidence, risk factors, and groin anatomy , Eur J Vasc Endovasc Surg . 2004 . 27 : 269–274.

11. Blomgren L , Johansson G , Dahlberg-Akerman A,  ermaenius P,

Bergqvist D . Changes in super cial and perforating vein re ux a er varicose vein surgery , J Vasc Surg. 2005 . 42 : 315–320.

12. Bountourouglou DG , Azzam M , Pathmarajh M , Young P ,

Geroulakos G . Ultrasound guided foam sclerotherapy combined with sapheno-femoral ligation compared to surgical treatment of varicose veins:Early results of a randomised controlled trial , Eur J Vasc Endovasc Surg. 2006 . 31 : 93–100.

13. Bridget M , Donnelly M , Tierney S . Recurrent varicose veins a er

surgery , Bri J Surg. 2006 . 38 : 49.

14. Campanello M , Hammarsten J , Forsberg C , Bernland P , Henrikson

O , Jensen J . Standard stripping versus long saphenous vein saving surgery for primary varicose veins:Aprospective, randomized study with the patients as their own controls , Phlebology.

15. Carandina S , Mari C , De Palma M , etal. Stripping vs haemodynamic

correction (CHIVA): A long term randomised trial , Eur. J Vasc Endovasc Surg. 2008 . 35 : 230–237.

1996 . 11 : 45–49 .

16. Creton D . Surgery of great saphenous vein recurrences: e presence of di use varicose veins without a draining residual saphenous trunk is a factor of poor prognosis for long-term results , JP 2002 . 2 : 83–89.

17. Creton D . Surgery for recurrent saphenofemoral incompetence using expanded polytetra uoroethylene patch interposition in front of the femoral vein:Long-term outcome in 119 extremities , Phlebology. 2002 . 16:  93–97.

18. Creton D . 125 réinterventions pour récidives variqueuses poplitées après exérèse de la petite saphène. Hypothèses anatomiques et physiologiques du mécanisme de la récidive , JMV. 1999 . 24 : 30–36.

19. Creton D , Uhl JF . La sclérothérapie à la mousse dans la chirurgie des varices:Résultats précoces:130 cas , Phlebologie. 2005 . 58 : 343–348.

20. Creton D . A nondraining saphenous system is a factor of poor prognosis for long-term results in surgery of great saphenous vein recurrences , Dermatol Surg. 2004 . 30 ( 5 ): 744–749.

21. Darvall KAL , Batev GR, Adam DJ , Silverman SH , Bradbury AW . Duplex ultrasound outcomes following ultrasound-guided foam sclerotherapy of symptomatic recurrent great saphenous varicose veins , Eur J Vasc Endovasc Surg. 2011 . 42 : 107–114.

22. De Maeseneer MG .  e role of postoperative neovascularisation in recurrence of varicose veins:From historical background to today’s evidence , Acta Chir Bel. 2004 . 104 : 281–287 .

23. De Maeseneer MG , Tielliu IF , Van Schil PE , De Hert SG , Eyskens EJ . Clinical relevance of neovascularization on duplex ultrasound in long term follow up a er varicose vein operation , Phlebology. 1999 . 14 : 118–122 .

24. De Maeseneer MG , Giuliani DR , Van Schil PE , De Hert SG . Can interposition of a silicone implant a er sapheno-femoral ligation prevent recurrent varicose veins, Eur J Vasc Endovasc Surg. 2002 . 24 : 445–449 .

25. De Maeseneer MG , Vandenbroeck CP , Van Schil PE . Silicone patch saphenoplasty to prevent repeat recurrence a er surgery to treat recurrent saphenofemoral incompetence: Long-term follow-up study, J Vasc Surg. 2004 . 40 : 98–105 .

26. De Maeseneer MG . Recurrent varicose veins a er surgery .  esis, University of Antwerp.  2005.

27. 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 .

28. De Maeseneer MG , Ongena KP , Van den Brande F , Van Schil PE , De Hert SG , Eyskens EJ . Duplex ultrasound assessment of neovascularisation a er saphenofemoral or sapheno-popliteal junction ligation , Phlebology. 1997 . 12 : 64–68.

29. De Maeseneer MG , Philipsen TE , Vandenbroeck CP , etal. Closure of the cribriform fascia:An e cient anatomical barrier against postoperative neovascularisation at the saphenofemoral junction? (A prospective study) , Eur J Vasc Endovasc Surg . 2007 . 34 : 361–366 .

30. Dwerryhouse S , Davies B , Harradine K , Earnshaw JJ . Stripping the long saphenous vein reduces the rate of reoperation for recurrent varicose veins , J Vasc Surg. 1999 . 29 : 589–592.

31. Edwards AG , Donaldson D , Bennets C , Mitchell DC .  e outcome of recurrent varicose veins surgery:  e patient’s perspective, Phlebology. 2005 . 20 : 57–59.

32. Egan G , Donnelly M , Bresnilhan M , Tierney S , Feeley M . Neovascularization: An innocent bystander in recurrent varicose veins , J Vasc Surg. 2006 . 44 : 1279–1284.

33. Einarsson E , Eklöf B , Neglén P . Sclerotherapy or surgery as treatment for varicose veins:Aprospective randomized study , Phlebology. 1993 . 8 : 22–26 .

34. El Wajew Y , Giannoukas CJ , Juvarna SK , Chan P . Saphenofemoral venous channels associated with recurrent varicose veins are not neovascular , Eur J Vasc Endovasc Surg. 2004 . 28 : 590–594.

35. Englund R . Duplex scanning for recurrent varicose veins , ANZ J Surg . 1996. 66 ( 9 ): 618–620.

36. Farrah J , Shami SK . Patterns of incompetence in patients with recurrent varicose veins:Aduplex ultrasound study , Phlebology. 2001 . 16 : 34–37.

37. Fassiadis N , Kianifard B , Holdstock JM , Hiteley MS . A novel approach to the treatment of recurrent varicose veins , Int Angiol. 2002 . 21 ( 3 ): 275–276 .

29 : 308–312.

244 • PRIMARY SUPERFICIAL VENOUS INSUFFICIENCY

38. Ferrara F , Bernbach HR . La sclérothérapie des varices récidivées ,

https://t.me/med1917

Phlebologie. 2005 . 58 : 147–150.

39. Fischer R , Chandler JG , De Maeseneer MG , etal.  e unresolved problem of recurrent saphenofemoral re ux , J Am Coll Surg. 2002 . 195 : 80–94.

40. Fischer R , Linde N , Du C , Je a n n e r e t C , C h a n d l e r J G , S e e b e r P . L a t e recurrent saphenofemoral junction re ux a er ligation and stripping of the greater saphenous vein , J Vasc Surg. 2001 . 34 : 236–240 .

41. Fischer R , Linde N , Du C . Cure and reappearance of symptoms of varicose veins a er stripping operation: A 34 year follow-up , J Phlebology. 2001 . 1 : 49–60.

42. Fischer R , Chandler JG , Stenger D , Puhan MA , De Maeseneer MG , Schimmelpfennig L . Patients characteristics and physician-determined variables a ecting saphenofemoral re ex recurrence a er ligation and stripping of the great saphenous vein , J Vasc Surg. 2006 . 43 : 81–87 .

43. Frings N , Nelle A , Tran P , Fischer R , Krug W . Reduction of neore ux a er correctly performed ligation of the saphenofemoral junction:Arandomized trial , Eur J Vasc Endovasc Surg. 2004 . 28 : 246–252.

44. Geir B , Stücker M , Hummel T , et al. Residual stumps associated with inguinal varicose vein recurrence:Amulticenter study , Eur J Vasc Endovasc Surg. 2008 . 36 : 207–210.

45. Geier B , Olbrich S , Barbera L , Stücker M , Mumme A . Validity of the macroscopic identi cation of neovascularization at the saphenofemoral junction by the operating surgeon , J Vasc Surg. 2005 . 41 : 64–68 .

46. Geier B , Mumme A , Hummel H , Marpe B , Stücker M , Asciutto G . Validity of duplex-ultrasound in identifying the cause of groin recurrence a er , J Vasc Surg. 2009 . 49 : 968–972.

47. Gibbs PJ , Foy DM , Darke SG . Reoperation for recurrent saphenofemoral incompetence:Aprospective randomised trial using a re ected  ap of pectineus fascia , Eur J Vasc Endovasc Surg. 1999 . 18 : 494–498.

48. Gillet JL , Perrin M . Exploration echo-Doppler des récidives variqueuses post-chirurgicales, Angeiologie. 2004 . 56 : 26–31.

49. Gillet JL . Traitement des récidives chirurgicales de la jonction saphèno-fémorale et saphéno-poplitée par echo -sclérose , Phlebologie. 2003 . 56 : 241–245.

50. Glass GM . Prevention of saphenofemoral and sapheno popliteal recurrence of varicose veins by forming a partition to contain neovascularisation ,

51. Haas E , Burkhardt T , Maile N . Recurrence rate by neovascularisation following a modi cation of long saphenous vein operation in the groin:Aprospective randomized duplex-ultrasound controlled study , Phlebologie. 2005 . 34 : 101–104.

52. Hamel-Desnos C , Ouvry P , Benigni JP , etal. Comparison of 1% and 3% polidocanol foam in ultrasound guided sclerotherapy of the great saphenous vein:Arandomized, double-blind trial with 2year-follow-up: e 3/1 study, Eur J Vasc Endovasc Surg . 2007 . 34 : 723–729 .

53. Hartman K , Klode J , P ster R , et al. Recurrent varicose veins: Sonography-based re-examination of 210 patients 14years a er ligation and saphenous stripping , VASA. 2006 . 35 : 21–26 .

54. Hayden A , Holdsworth J . Complications following re-exploration of the groin for recurrent varicose veins , Ann R Coll Surg Engl. 2001 . 83 : 272–273.

55. Heim M , Negri M , Schlegel U , De Maeseneer M . Resecting the great saphenous stump with endothelial inversion decreases neither neovascularization nor thigh varicosity recurrence , J Vasc Surg. 2008 . 47 : 1028–1032.

56. Hinchli e RJ , Uhbi J , Beech A , Ellison J, Braithwaite BD . A prospective randomised controlled trial of VNUS Closure versus surgery for the treatment of recurrent long saphenous varicose veins , Eur J Vasc Endovasc Surg. 2006 . 31 : 212–218 .

57. 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 .

58. Jiang P , van Rij AM , Christie R, etal. Recurrent varicose veins:Patterns of re ux and clinical severity , Cardiovasc Surg. 1999 . 7 : 322–329.

59. Kakkos SK , Bountouroglou DG , Azzam M , Kalodiki E , Daskapoulos M , Geroulakos G . E ectiveness and safety of ultrasound-guided

Phlebology. 1998 .

18 : 494–498.

foam sclerotherapy for recurrent varicose veins:Immediate results , J Endovasc  er. 2006 . 13 : 357–364.

60. Kambal A , De’ath AD , Albon H , Watson A , Shandall A , Greenstein D . Endovenous laser ablation for persistent and recurrent venous ulcers a er varicose vein surgery , Phlebology. 2008 . 23 : 193–195 .

61. Khaire HS , Crowson MC , Parnell A . Colour  ow duplex in the assessment of recurrent varicose veins , Ann R Coll Surg Engl. 1996 . 78 : 139–141.

62. Kianifard B , Holdstock JM , Whiteley MS . Radiofrequency ablation (VNUS closure) does not cause neo-vascularisation at the groin at one year:Results of a case controlled study , Surgeon. 2006 . 4 : 71–74.

63. Kostas T , Loannou CV , Toulouopakis E , et al. Recurrent varicose veins a er surgery:Anew appraisal of a common and complex problem in vascular surgery , Eur J Vasc Endovasc Surg.

64. Kostas T , Loannou C , Veligrantakis M , Pagonidis C , Katsamouris A . 

e appropriate length of great saphenous vein stripping should be based on the extent of re ux and not on the intent to avoid saphenous nerve injury , J Vasc Surg . 2007 . 46 : 1234–1241 .

65. Kotoed SC , Qvamme GM , Schroeder TV , Jakobsen BH . Causes of need for reoperation following surgery for varicose veins in Denmark , Ugeskr Laeger. 1999 . 8 : 779–783.

66. Labropoulos N , Touloupakis E , Giannoukas AD , Leon M , Katsamouris A , Nicolaides AN . Recurrent varicose veins: Investigation of the pattern and extent of re ux with color  ow duplex scanning , Surgery. 1996 . 119 : 406–409 .

67. Labropoulos N , Bhatti A , Leon L , Borge M , Rodriguez H , Kalman P . Neovascularization a er great saphenous ablation , Eur J Vasc Endovasc Surg. 2006 . 31 : 219–222.

68. Lane RJ , Cuzilla ML , Coroneos JC , Phillips MN , Platt JT . Recurrence rates following external valvular stenting of the saphenofemoral junction:Acontralateral stripping of the great saphenous vein, Eur J Vasc Endovasc Surg. 2007 . 34 : 595–603.

69. Leal Monedero J , Zubicoa Ezpeleta S , Castro Castro J , Calderón Ortiz M , Sellers Fernández G . Embolization treatment of recurrent varices of pelvic origin , Phlebology. 2006 . 21 : 3–11.

70. Lemasle PH , Lefebvre-Villardebo M , Uhl JF , Vin F , Baud JM . Récidive variqueuse post-opératoire: Et si la neovascularisation inguinale n’était que le développement d’un réseau pré-existant , Phlebologie. 2009 . 62 : 42–48.

71. Lurie F , Creton D , Eklof B , etal. Prospective randomized study of endovenous radiofrequency obliteration (Closure) versus ligation and vein stripping (EVOLVeS): Two-year follow-up, Eur J Vasc Endovasc Surg. 2005 . 29 : 67–73.

72. McDonagh B , Sorenson S , Gray C , etal. Clinical spectrum of recurrent postoperative varicose veins and e cacy of sclerotherapy management using the compass technique, Phlebology. 2003 . 18 : 173–185.

73. Merchant RF , Pichot O . Longterm 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 .

74. Mikati A . Indications et resultants de la ligature coelioscopique des veines perforantes incontinentes dans les récidives variqueuses compliquées , Phlebologie. 2010 . 63 : 59–67.

75. Mouton WG , Bergner M , Zehnder T , von Wattenwyl R , Naef M , Wa g n e r H E . R e c u r r e n c e a  er surgery for varices in the groin is not dependent on body mass index , Swiss Med Wkly. 2008. 138 ( 11–12 ): 186–188.

76. O’ Hare JL , Parkin D , Vandenbroeck CP , Earnshaw JJ . Mid term results of ultrasound guided foam sclerotherapy for complicated and uncomplicated varicose veins , Eur J Vasc Endovasc Surg. 2008 . 36 : 109–113 .

77. Pavei P , Vecchiato M , Sprea co G , etal. Natural history of recurrent varices undergoing reintervention:Aretrospective study, Dermatol Surg. 2008 . 34 : 1676–1682.

78. Perala J , Rautio T , Biancari F , et al. Radiofrequency endovenous obliteration versus stripping of the long saphenous vein in the management of primary varicose veins:3-year outcome of a randomized study , Ann Vasc Surg. 2005 . 19 : 1–4.

79. Perrin M . Recurrent varicose veins a er surgery , Phlebolymphology. 31 : 14–20 .

2004 . 27 : 275–282.

CLASSIFICATION AND TREATMENT OF RECURRENT VARICOSE VEINS • 245

80. Perrin M . Recurrent varices a er surgery , Hawaii Med J. 2000 .

https://t.me/med1917

59 : 214–216.

81. Perrin M , Labropoulos N , Leon LR . Presentation of the patient with recurrent varices a er surgery (REVAS ), J Vasc Surg. 2006 . 43 : 27–34.

82. Perrin M , Gillet J-M . Management of recurrent varices at the popliteal fossa a er surgical treatment, Phlebology. 2008 . 23 : 64–68.

83. Perrin M . Le pro l du patient REVAS: Résultats d’une enquête internationale, Angeiologie. 2006 . 58 : 44–45 . In French.

84. Perrin M , Allaert FA . Intra-and inter-observer reproducibility of the recurrent varicose veins a er surgery (REVAS) classi cation , Eur J Vasc Endovasc Surg . 2006 . 32 : 326–333.

85. Perrin M , Gillet JL . Récidive de varices à l’aine et à la fosse poplitée après traitement chirurgical , J Mal Vasc. 2006 . 31 : 236–246.

86. Pittaluga P , Chastanet S , Rea B , Barbe R . Midterm results of the surgical treatment of varices by phlebectomy with conservation of a re uxing saphenous vein , J Vasc Surg . 2009 . 50 : 107–118.

87. Pittaluga P , Chastanet S , Locret T , Rousset O . Retrospective evaluation of the need of a redo surgery at the groin for the surgical treatment of varicose vein , J Vasc Surg. 2010 . 51 : 1442–1450.

88. Pourhassan S , Zarras K , Mackrodt HG , Stock W . Recurrent varicose veins: Surgical procedure-results , Zentralbl Chir . 2001. 126 ( 7 ): 522–525 .

89. Rashid HI , Ajeel A , Tyrrell MR . Persistent popliteal fossa re ux following saphenopopliteal disconnection , Br J Surg. 2002 . 89 : 748–751.

90. Reich-Schupke S , Mumme A , Altmeyer P , Stuecker M . Decorin expression with stump recurrence and neovascularization a er varicose vein surgery:Apilot study , Dermatol Surg. 2011 . 37 : 480–485.

91. Rassmussen LH , Bjoern L , Lawaetz M , Blemings A , Lawaetz B , Eklof B . Randomized trial comparing endovenous laser ablation of the great saphenous vein with ligation and stripping in patients with varicose veins:Short-term results, J Vasc Surg. 2007 . 46 : 308–315.

92. Rasmussen LA , Lawaetz M , Bjoern L , Vennits B , Blemings A , Eklof B . Randomized clinical trial comparing endovenous laser ablation, radiofrequency ablation, foam sclerotherapy, and surgical stripping for great saphenous varicose veins , Br J Surg. 2011 . 98 : 1079–1087.

93. Rewerk S , Noppeney T , Winkler M , Willeke F , Duczek C , Meyer AJ . Pathogenese der Primär- und Rezidiv-varikosis an der Magna-Krosse (Die Rolle von VEGF und VEGF-Rezeptor) , Phlebologie . 2007 . 36 : 137–142.

94. Roka F , Binder M , Bohler-Sommeregger K . Mid-term recurrence rate of incompetent perforating veins a er combined super vein surgery and subfascial endoscopic perforating vein surgery , J Vasc Sur. 2006. 44 ( 2 ): 359–363.

95. Rutgers PH , Kitslaar PJEHM . Randomized trial of stripping versus high ligation combined with sclerotherapy in the treatment of the incompetent greater saphenous vein , Am J Surg . 1994 . 168 : 311–315.

96. Rutherford EE , Kanifard B , Cook SJ, etal. Incompetent perforating veins are associated with recurrent varicose veins , Eur J Vasc Endovasc Surg. 2001 . 21 : 458–460.

97. Saarinen J , Suominen V , Heikinen M , etal.  e pro le of leg symptoms, clinical disability, and re ux in legs with previously operated varices , Scand J Surg. 2005 . 94 : 51–55.

98. Stonebridge P , Chalmers N , Beggs I . Recurrent varicose veins:Avaricographic analysis leading to a new practical classi cation , Br J Surg. 1995 . 82 : 60–62.

99. Stücker M , Netz K , Breuckmann F , Altmeyer P , Mumme A . Histomorphologic classi cation of recurrent saphenofemoral re ux , J Vasc Surg. 2004 . 39 : 816–822.

100.  eivacumar NS , Dellagrammaticas D , Darwood RJ , Mavor AID , Gough MJ . Fate of the great saphenous vein following endovenous laser ablation: Does re-canalisation mean recurrence , Eur J Vasc Endovasc Surg. 2008 . 36 : 211–215.

101.  eivacumar NS , Gough MJ . Endovenous laser ablation (EVLA) to treat recurrent varicose veins , Eur J Vasc Endovasc Surg. 2011 . 41 : 691–696.

102. Tsang FJ , Davis M , Davies AH . Incomplete saphenopopliteal ligation a er short saphenous vein surgery: A summation analysis , Phlebology. 2005 . 20 : 106–109.

cial

103. Turton EPL , Scott DJA , Richards SP , etal. Duplex derived evidence of re ux a er varicose vein surgery:Neo re ux or neovascularisation , Eur J Vasc Endovasc Surg. 1999 . 17 : 230–233.

104. van Groenendael L , van der Vliet A , Flinken ögel L , Roovers EA , van Sterkenburg SMM , Reijnen MMPJ . Treatment of recurrent varicose veins of the great saphenous vein by conventional surgery and endovenous laser , J Vasc Surg. 2009 . 50 : 1106–1113 .

105. van Neer PAFA , Kessels AGH , de Haan MW , etal. Residual varicose veins below the knee are not related to incompetent perforating veins, J Vasc Surg. 2006 . 44 : 1051–1054.

106. van Neer P , de Haan MW , de Veraart JCJM , Neuman AM . Recurrent varicose veins below the knee a er varicose vein surgery , Phlebologie. 2007 . 36

107. 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 , J Vasc Surg. 2003 . 38 : 935–943 .

108. 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.

109. Vin F , Chleir F . Aspect échographique des récidives variqueuses postopératoires du territoire de la veine petite saphène , Ann Chir. 2001 . 126 : 320–324.

110. 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 .

111. Winterborn RJ , Earnshaw JJ . Randomized trial pf PTFE patch for recurrent great Saphenous varicose veins , Eur J Vasc Endovasc Surg. 2007 . 34 : 367–373.

112. Wong JKF , Duncan JL , Nichols DM . Whole-leg duplex mapping for varicose veins:Observation on patterns of re ux in recurrent and primary legs, with clinical correlation , Eur J Vasc Endovasc Surg. 2003 . 25 : 267–275 .

113. Wright D , Rose KG , Young E , McCollum CN . Recurrence following varicose vein surgery , Phlebology. 2002 . 16 : 101–105.

114. Eklof B , Perrin M , Delis KT , Rutherford RB , Gloviczki P. Updated terminology of chronic venous disorders: e VE IN-TERM transatlantic interdisciplinary consensus document , J Vasc Surg. 2009 . 49 : 498–501 .

115. Browse NL , Burnand KG , Irvine AT , Wilson NM . Disease of the veins , 2e. London : Arnold . 1999 . 191–248 .

116. Stonebridge PA , Chalmers N , Beggs I , et al. Recurrent varicose veins:Avaricographic analysis leading to a new practical classi cation , Br J Surg. 1999 . 82 : 60–62 .

117. 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.

118. Almgren B , Eriksson I . Primary deep vein incompetence in limbs with varicose veins , Acta Chir Scand . 1989 . 155 : 445–460.

119. Guarnera G , Furgiuele S , Di Paola FM , Camilli S . Recurrent varicose veins and primary deep venous insu ciency:Relationship and therapeutic implications , Phlebology . 1995 . 10 : 98–10.

120. Perrin M , Gobin JP , Grossetete C , Henri F , Lepretre M . Valeur de l’association chirurgie itérative-sclérothérapie après échec du traitement chirurgical des varices, J Mal Vasc . 1993 . 18 : 314–319 . In French.

121. Vasquez MA , Rabe E , Mc La erty RB , et al. Revision of the venous clinical severity score: Venous outcomes consensus statement: Special communication of the American Venous Forum Ad Hoc Outcomes Working Group , J Vasc Surg . 2010. 52 : 1387–1396.

122. Darke SG , Baker SJA . Ultrasound-guided foam sclerotherapy for the treatment of varicose veins, Br J Surg . 2006 . 93 : 969–974 .

123. Coleridge Smith P . Chronic venous disease treated by ultrasound guided foam sclerotherapy , Eur J Vasc Endovasc Surg . 2006 . 32 : 577–583 .

124. Bergan JJ , Le Cheng V . Treatment of recurrent varicose veins by sclerosant foam. In: Bergan JJ , Le Cheng V, eds. Foam Sclerotherapy . London: Royal Society of Medicine Press . 2008 . 193–198 .

: 132–136.

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31.

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USE OF SYSTEMSPECIFIC QUESTIONNAIRES

A. C. Shepherd , Meryl Davis , and Alun H. Davies

he introduction of minimally invasive, endovenous therapies has revolutionized the treatment of varicose

between 2008 and 2009, approximately 37,000 procedures were performed, of which approximately 18,000 (49%) were combined procedures, 2,000 (5%) were open procedures, 7,000 (19%) were endovenous ablation procedures, and 6,000 (16%) were injection sclerotherapy; the remainder were unspeci ed. venous registries inpatient surgery toward minimally invasive outpatient treatments, a trend that appears set to continue. vein study described the incidence of varicose veins as 40% in men and 32% in women with the incidence increasing with age. formed has declined in recent years, able to venous disease and its complications is considerable and estimated at £600million to the National Health Service (NHS) per annum. Despite good evidence that the treatment of varicose veins is both bene cial in terms of quality-of-life improvements that are cost e ective, rationing the treatment of varicose veins in a number of health care trusts has led many to question the assessment of outcomes following treatment, in order to ensure that resources are allocated e ciently.

veins over the last decade. In the United Kingdom

Data from questionnaire surveys and

support a movement away from traditional

3–6

 e Edinburgh

Although the number of varicose vein procedures per-

1,8

the morbidity attribut-

9–11

recent introduction of

•

Of proven validity, with a high level of convergence

within patient groups, when applied across geographic, linguistic, and cultural boundaries.

Currently there is no quality-of-life tool that is su ciently sensitive to detect clinically signi cant changes and ful ll all of the above criteria; and a number of di erent generic health care questionnaires have been developed. In recent years the most popular tools for the measurement of venous disease have included the Nottingham Health Pro le (NHP), the EuroQol (EQ-5D), and the short form 36 (SF36).  e EQ-5D and SF36 are also validated in other major languages and are widely accepted internationally. Although applicable across a spectrum of disorders to allow a comparison of health-related quality of life across populations of patients with di erent diseases, these generic tools are frequently insu ciently sensitive to detect clinically signi cant changes in speci c disease processes over time. For this reason, disease-speci c quality-of-life tools have been designed, in order to be sensitive to these key dimensions in quality of life that are a ected by the disease. In 2007 the American Venous Forum (AVF) published a consensus of recommended reporting standards speci c to endovenous ablation of varicose veins, which supported the use of a combination of disease-speci c and generic quality-of-life questionnaires.

Q U A L I T Y O F  L I F E

Health is de ned by the World Health Organization as “a state of complete physical, mental and social well being and not merely the absence of disease”; and measuring health and improving quality of life is of major importance throughout all branches of medicine. In 1997 Beattie etal. suggested that the ideal quality-of-life measure shouldbe:

•

Equally applicable to any disease process or outcome,

•

Equally applicable across all levels of illness and degrees

of invalidity,and

MEASUREMENT OF OUTCOMES

In developing an outcome measure, the concepts of validity, reliability, and responsiveness arevital.

Validity is the extent to which a questionnaire measures what is intended.  is is frequently evaluated by comparing a new measure with an established one (criterion validity). In the absence of a gold standard, a construct’s validity can be measured; this allows comparison of a new tool with objective or clinical  ndings.

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