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GUIDELINES FOR PROSPECTIVE
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STUDIES
First of all an epidemiologic survey in the general population is desirable in order to know the prevalence and
incidence of PVI in CVI patients and the respective
numbers in the different classes (C
). Besides it would be essential to obtain full informa-
C
6
, C 4a , C 4b , C 5 , and
3
tion in each group on the different anomalies according
to the anatomical location: isolated superficial, perforator, and deep vein insufficiency and their various
combinations.
Concerning treatment the following studies should be
recommended:
In patients with isolated super cial re ux, RCT
comparing chemical ablation with open surgery
and thermal ablation. Many studies have been
published but only one with a middle term
follow-up.
In patients combining super cial and perforator
re ux RCT with two arms is needed:one arm
where patients will be treated by super cial
venous surgery, the other by a combination of
super cial surgery and perforator operative
treatme nt.
In patients with deep anomalies RCTs would be
di cult to put in place, as the number of patients
is small and their anatomic and physiopathologic
patterns aremixed.
C O N C L U S I O N S
Primary venous insu ciency is at least as frequent as secondary in CVI.
As a result, all patients with CVI should be investigated
with DCS to ful ll all the headings of the advanced CEAP
classi cation, but most importantly to identify super cial
venous insu ciency. Once identi ed, this isolated anomaly
is easily correctible by operative treatment.
When combined with perforator incompetence, there
is no consensus for treating them in combination as the rst
step.
Primary deep vein re ux when axial, needs complementary investigations. Valvuloplasty must be considered in the
absence of contraindications, particularly in patients not
improved by conservative and/or super cial vein treatment
with or without perforator surgery.
Primary deep vein obstruction seems to be underdiagnosed in patients when there is a discrepancy between
symptoms, C class, and DCS ndings.
R E F E R E N C E S
1. Eklof B , Perrin M , Delis K , Rutherford R , VEIN-TERM
Transatlantic Interdisciplinary Faculty. Updated terminology
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49 : 498–501.
2. Eklöf B , Bergan JJ , Carpentier PH , etal. For the American Venous
Forum’s International Ad Hoc Committee for Revision of the
CEAP Classi cation: Revision of the CEAP classi cation for
chronic venous disorders:Aconsensus statement , J Vasc Surg. 2004.
40 : 1248–1252.
3. Danielsson G , Eklof B , Grandinetti A , Kistner R L, Masuda EM ,
S a t o DT . R e ux from thigh to calf, the major pathology in chronic
venous ulcer disease:Surgery indicated in the majority of patients ,
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veins and chronic venous insu ciency in men and women in the
general population:Edinburgh vein study , J Epidemiol Community
Health. 1999 . 53 : 149–153.
6. Jawien A , Grzela T , Ochwat A . Prevalence of chronic venous insuf ciency in men and women in Poland:Multicentre cross-sectional
study in 40,095 patients , Phlebology. 2003. 18 : 110–122 .
7. Pannier-Fischer F , Rabe E . Epidemiology of chronic venous diseases ,
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J Vasc Endovasc Surg. 2001. 21 : 353–360.
9. Mac Daniel HB , Marston WA , Farber MA , et al. Recurrence of
chronic venous ulcers on the basis of clinical, etiologic, anatomic and
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35 : 723–728.
10. Grabs AJ , Wakely MC , Nyamekye I , Ghauri ASK , Poskitt KR .
Colour duplex ultrasonography in the rational management of
chronic venous leg ulcers , Br J Surg. 1996. 83 : 1380–1382 .
11. Tassiopoulos AK , Golts E , Labropoulos N. Current concepts in
chronic venous ulceration , Eur J Vasc Endovasc Surg. 2000. 20 : 27–32.
12. Adam DJ, Naik J , Harstone T , London NJM . e diagnosis and
management of 689 chronic leg ulcers in a single visit assessment
clinic , Eur J Vasc Endovasc Surg. 2003. 25 : 462.
13. Danielsson G , Arfvidssson B , Eklof B , Lurie F , Kistner RL . Deep
axial re ux, an important contributor to skin changes or ulcer in
chronic venous disease , J Vasc Surg. 2003. 38 : 1336–1341 .
14. Kistner RL, Ferris RG , Randhawa G, Kamida CB . A method of performing descending venography ,
15. 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.
16. Rutherford RB , Padberg FT , Comerota AJ, Kistner RL , Meissner
MH , Moneta GL . Venous severity scoring:An adjunct to venous
outcome assessment , J Vasc Surg. 2000. 31 : 1307–1312 .
17. Raju S , Neglen P . High prevalence of nonthrombotic iliac vein
lesions in chronic venous disease:Apermissive role in pathogenicity ,
J Vasc Surg. 2006 . 44 : 136–144.
18. Maleti O , Perrin M . Reconstructive surgery for deep vein re ux
in the lower limbs:Techniques, results, and indication , Eur J Vasc
Endovasc Surg. 2011 . 41 : 837–848.
19. Raju S , Hollis K , Neglen P . Use of compression stockings in chronic
venous disease: Patient compliance and e cacy , Ann Vasc Surg .
2007. 21 ( 6 ): 790–795 .
20. Vandongen YK , Stacey MC . Graduated compression elastic stockings reduce lipodermatosclerosis and ulcer recurrence , Phlebology.
2000. 15 : 33–37.
J Vasc Surg.
1986. 4 : 464–468 .
438 • CHRONIC VENOUS INSUFFICIENCY
21. Zamboni P , Cisno C , Marchetti P , etal. Minimally invasive surgi-
https://t.me/med1917
cal management of primary venous ulcers vs compression treatment:Arandomized clinical trial , Eur J Vasc Endovasc Surg. 2003.
25 : 313–318 .
22. Barwell J , Davies C , Deacon J , et al. Comparison of surgery and
compression with compression alone in chronic venous ulceration
(ESCHAR study): Randomised controlled trial , Lancet. 2004.
363 : 1854–1859.
23. Gohel MS , Barwell JR , Taylor M , etal. Long term results of compression
plus surgery in chronic venous ulceration (ESCHAR):Randomized
controlled trial , Br Med J. 2007 . 335 : 83–88.
24. Adam DJ , Bello M , Harstone T , London NJM . Role of super cial
venous surgery in patients with combined super cial and segmental
deep venous re ux , Eur J Vasc Endovasc Surg. 2003. 25 : 469–472 .
25. Cabrera J , Redondo P , Becerra A , et al. Ultrasound-guided
Polidocanol microfoam in the management of venous leg ulcers ,
Arch Dermatol. 2004 . 140 : 667–673.
26. Bergan J , Pascarella L , Mekenas L . Venous disorders:Treatment with
sclerosant foam , J Cardiovasc Surg. 2006 . 47 : 9–18 .
27. Darvall KAL , Bate GR , Adam DJ , Silverman SH , Bradbury AW .
Ultrasound-guided foam sclerotherapy for the treatment of chronic
venous ulceration:Apreliminary study . Eur J Vasc Endovasc Surg.
2009 . 38 : 764–769 .
28. Figueiredo M , de Araujo SP , Figueiredo MF . Late follow-up of
saphenofemoral junction ligation combined with ultrasound-guide d
foam sclerotherapy in patients with venous ulcers. Ann Vasc Surg.
2012 . 26 : 977–981 .
29. Magi G , Agus GB , Antonelli P , Nardoianni V , Sereni O , Bavera PM .
Long-term results of endovenous laser treatment of saphenous and
perforator re ux in cases of venous leg ulcers , Acta Phlebol. 2009 .
10 : 17–22.
30. Harlander-Locke M , Lawrence P , Alktai A, Jimenez JC , Rigberg
D , DeRubertis B . e impact of ablation of incompetent super cial and perforator veins on ulcer healing rates , J Vasc Surg. 2012 .
55 : 458–464.
31. Gloviczki P , Bergan JJ , Rhodes JM , Canton LG , etal. Mid-term results
of endoscopic interruption for chronic venous insu ciency:Lessons
learned from the North American Subfascial Endoscopic Perforator
Surgery Registry , J Vasc Surg. 1999. 29 : 489–502 .
32. Perrin M . Reconstructive surgery for deep venous re ux:Areport
on 144 cases, Cardiovasc Surg. 2000 . 8 : 246–255.
33. Guyatt G , Gutterman D , Baumann MH , et al. Grading strength
of recommendations and quality of evidence in clinical guidelines:Report from an American College of Chest Physicians Task
Force, Chest . 2006 . 129 : 174–181.
34. Neglén P , Hollis KC , Raju S. Combined saphenous ablation and
iliac stent placement for complex severe chronic venous disease.
JVasc Surg. 2006 .
35. Neglen P , Raju S . Intravascular ultrasound scan evaluation of the
obstructed vein, J Vasc Surg. 2002 . 35 : 694–700.
36. Neglen P , Hollis KC , Olivier J , Raju S . Stenting of the venous
out ow in chronic venous disease: Long-term stent-related
outcome, clinical and hemodynamic results , J Vasc Surg. 2007 .
46 : 979–990.
37. Masuda EM, Kistner RL. Long-term results of venous valve
reconstruction: A 4 to 21 year follow-up, J Vasc Surg. 1994. 19:
391–403.
38. Raju S, Fredericks RK, Neglen PN, et al. Durability of venous valve
reconstruction techniques for “primary” and post-thrombotic
re ux, J Vasc Surg. 1996. 23: 357–367.
39. Sottiurai VS. Results of deep vein reconstruction, Vasc Surg. 1997.
31: 276–278.
40. Raju S, Berry MA, Neglén P. Transcommissural valvuloplasty:
technique and results, J Vasc Surg. 2000. 32: 969–976.
41. Tripathi R, Sieunarine K, Abbas M, et al. Deep venous valve reconstruction for nonhealing leg ulcers: Techniques and results, ANZ J
Surg. 2004. 74: 34–39.
42. Rosales A, Slagsvold CE, Kroese AJ, et al. External venous valve
plasty (EVVP) in patients with primary chronic venous insu ciency (PCVI), Eur J Vasc Endovasc Surg. 2006. 32: 570–576.
43. Wang SM, Hu ZJ, Li SQ, Huang XL, Ye CS. E ect of external valvuloplasty of the deep vein in the treatment of chronic
venous insu ciency of the lower extremity, J Vasc Surg. 2006. 44:
1296–1300.
44. Lehtola A, Oinonen A, Sugano N, et al. Deep venous reconstructions: long-term outcome in patients with primary or post-thrombotic deep venous incompetence, Eur J Vasc Endovasc Surg. 2008.
35: 487–493.
44 : 828–833 .
THE PRIMARY CAUSE OF CHRONIC VENOUS INSUFFICIENCY • 439
52.
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CONVENTIONAL SURGERY FOR CHRONIC VENOUS
INSUFFICIENCY
William Marston
INTRODUCTION
Successful treatment of patients with symptomatic chronic
venous insu ciency (CVI) requires a detailed analysis of the
anatomic and physiologic correlates of venous dysfunction.
Using this information the physician may determine whether
correction of the source of CVI is possible and if so, which
procedures may be useful to do so. With the proliferation
of minimally invasive procedures in the last decade, conventional surgical correction of venous insu ciency is performed
less frequently. However these procedures remain useful in
some instances as the primary procedure of choice. Regardless
of whether a surgical, endovenous, injection-based, or other
procedure is performed, the goal is the same:Correction
of abnormal venous re ux or obstruction resulting in CVI.
Hemodynamic testing may be performed before and a er a
procedure is performed to document objective improvement
and predict long-term success.
Patients with CVI require treatment for limb swelling,
skin changes, and ulceration, as well as the pain and disability associated with these objective signs. Although cosmetic
considerations should not be ignored, the primary concern
in CEAP classes 3–6 is to e ectively obliterate abnormal
re ux and minimize recurrence for long-term symptom
resolution.
In this chapter, diagnostic evaluation and indications
for intervention in these patients will be discussed. e
options for surgical management of various anatomic types
of venous insu ciency will be reviewed and contrasted to
nonsurgical techniques.
PRESENTATION OF PATIENTS
WITHCVI
is associated with deep venous re ux. For this reason, the
majority of patients treated with venous leg ulcers never are
referred to a venous specialist for consideration of a corrective procedure. Several authors have de ned the anatomy of
re ux in patients with advanced CVI, and isolated saphenous
or saphenous and perforator re ux is not uncommon, occurring in 20–35% of patients in various series. Also, as outlined
by Drs. Neglen, Raju, and Kistner in other chapters, many
patients with deep venous insu ciency causing severe CVI
may be improved with surgical or endovenous procedures,
reducing symptoms and the incidence of recurrent ulcers.
For these reasons, all patients with advanced CVI with
or without limb ulceration who are candidates for corrective procedures should be studied with diagnostic studies to
determine the anatomy and physiology of their individual
case. Referral to a venous specialist familiar with surgical
and nonsurgical options will allow the optimal method of
correction to be selected.
D I A G N O S T I C T E S T I N G F O R
PATIENTS WITHCVI
e rational treatment of patients with chronic venous
insu ciency (CVI) and its sequelae requires the use of noninvasive studies performed by experienced vascular technologists to identify dysfunction in the patient’s venous system.
Information on both the anatomic sites of venous dysfunction and its hemodynamic importance are required to allow
treatment plans to be formulated and optimal results to be
achieved. Selecting surgical therapy without a knowledge of
which vein segments are abnormal is essentially blind surgery and cannot result in optimal results.
A commonly held perception is that less severe CVI (CEAP
clinical classes 2–3) is typically a sequela of super cial
venous re ux while more severe CVI (CEAP classes 4–6)
DUPLEX ULTRASOUND
Imaging techniques using ultrasound combined with
Doppler interrogation of the venous system have been
440
validated as sensitive methods of diagnosis of deep venous
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thrombosis. Important information for patients with CVI
that would be detected with this technique includes the
presence or absence of venous obstruction or other changes
typical of previous deep venous thrombosis (DVT). is
information will help to determine whether the patient’s
CVI is due to obstruction, re ux, or both (pathophysiology). e presence of out ow obstruction in the iliac veins
and/or IVC can o en be detected looking at ow patterns,
phasicity, and respiratory variation in the common femoral
vein. In addition to an examination of the deep and super cial systems, the perforator veins are carefully examined for
evidence of incompetence.
Secondly, venous re ux in the deep and super cial
venous systems is evaluated with the patient in the standing position using duplex ultrasound and either manual
compression or a rapid in ation/de ation system to elicit
re ux. Systematic interrogation of the common femoral,
super cial femoral, popliteal, greater saphenous, and lesser
saphenous veins is conducted, allowing an anatomic map of
venous re ux in the limb to be constructed.
Using this information, the clinician can determine the
etiology, anatomy, and pathophysiology of CVI for the
patient. For example, the patient that has super cial and
perforator disease may be di erentiated from the patient
with super cial and deep re ux, allowing alternate treatment plans to be selected. Although duplex evaluation
provides detailed information on the anatomy of venous
disease, it cannot de ne the importance of anatomic abnormalities in the venous function of thelimb.
PHOTOPLETHYSMOGRAPHY
Plethysmography is de ned as the determination of changes
in volume, and various techniques of plethysmography
have been evaluated in the noninvasive examination of the
venous system. A representative photoplethysmography
(PPG) tracing is reproduced in Figure52.1 and illustrates
the primary measure obtained, the re ll or recovery time
(VRT), which represents the time required for the PPG
tracing to return to 90% of baseline a er cessation of calf
contraction. PPG does not produce a quantitative measure,
but the re ll time has been found to correlate closely with
ambulatory venous pressure (AVP) measurements. e use
of an above-knee tourniquet in ated to 50mm Hg has been
described to di erentiate the contribution of the deep and
super cial venous systems to venous re u x .
Limbs a ected with CVI typically have a much shorter
VRT than normal limbs. As such, PPG can provide a relatively simple measure of whether venous insu ciency is
present or not. However, the technique can vary depending
on the site of photosensor placement and the small sample
area obtained.
PPG measurements have not been proven to be a strong
discriminator of the severity of CVI. Nicolaides and Miles
reported that normal limbs were well identi ed by a PPG
re ll time of greater than 18 seconds with their protocol.
Abnormal limbs with CVI consistently had a re ll time of
<18 seconds. However, in the abnormal group, PPG re ll
time could not di erentiate between degrees of CVI, with
similar PPG re ll times obtained in patients with AVP measurements ranging from 45 to 100mm Hg. erefore, PPG
is a poor test for assessing the results of venous corrective
surgical procedures.
AIR PLETHYSMOGRAPHY
Air plethysmography (APG) uses a technique to improve
on the shortcomings of PPG and other types of plethysmography that have limited sampling areas. It employs a
low-pressure air- lled cu measuring 30 to 40cm in length
that is applied to the lower leg, allowing quantitative evaluation of volume changes of the entire lower leg from knee
to ankle. e technique is described in Chapter5. In 1988,
Christopoulos etal. described the use of APG for evaluation
of normal limbs and those a ected with CVI. Avenous lling index (VFI) < 2 ml/s was associated with clinically normal limbs, and increasing levels of VFI were associated with
1
e VFI is believed to
provide a reasonable approximation of the global function
of the lower extremity venous system in resisting re ux in
the standing position.
a
ml
VFT 90
sec
90% VV
Figure52.1 APG values measured.
VFT 90
bc d e
×10
EV
90%
VV
VV
RV
EV
VV
×100=EF
=VFI
CONVENTIONAL SURGERY FOR CHRONIC VENOUS INSUFFICIENCY • 441
RV
×100=RVF
VV
Table52.1 PREVALENCE OF THE SEQUELAE OF
VENOUS DISEASE IN RELATION TO VFI IN 134
LIMBS WITH VENOUS DISEASE STUDIED WITH AIR
PLETHYSMOGRAPHY
VFI,
ML/S
<3 0 0 0
3–5 12 19 0
5–10 46 61 46
>10 76 76 58
(From Reference17)
SWELLING
%
SKIN CHANGES
%
ULCERATION
%
e ejection fraction (EF) and residual volume frac-
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tion (RVF) are measures of the e cacy of the calf muscle to
pump blood out of the leg. e RVF was found to correlate
closely with AVP throughout the range of AVP measurements, with lower RVF values representing better calf pump
function (normal RVF de ned as<35%).
In an evaluation of 186 limbs, Criado etal. assessed the
ability of APG parameters to predict the clinical severity
of CVI. ey reported that, of the APG parameters measured, VFI was the best predictor of the clinical severity of
CVI with an 80% sensitivity and 99% positive predictive
2
value for detecting abnormal re ux.
EF measurements
were unable to di erentiate between classes of CVI, and
RVF measurements, though able to di erentiate, were less
useful than the VFI. Further work with APG measurements has demonstrated that the postoperative VFI can
predict the long-term symptomatic outcome for patients
a er venous surgical procedures. Ninety-four percent of
patients in whom the VFI corrected to <2 ml/s a er surgery
were asymptomatic at a mean follow-up time of 44months
3
(Figure52.2).
In summary, APG, by sampling a large portion of the
calf area, provides a better measure than PPG of the global
venous function of the limb. It provides a quantitative analysis that appears to be useful in the selection and follow-up
of patients undergoing venous reconstructive or ablative
surgery.
INDICATIONS FOR
INTERVENTION
e indications for intervention in patients with CVI are
variable and depend on the severity of symptoms, options
for correction, and the functional and medical status of the
patient. Patients in CEAP clinical class 3 and 4 su ering
symptoms of swelling and skin changes may be managed
with compression stockings and skin lubricants with general improvement. However, compliance with compression
stocking use is generally believed to be poor in the long
term. Patients who are candidates for a corrective procedure
will typically choose intervention, particularly younger,
more active patients. In clinical classes 5 and 6, the primary
indication for intervention is to reduce the risk of recurrent ulceration. Patients with active ulcers can expect ulcer
healing in 10–12 weeks on average using various high com-
4
pression bandaging systems.
Unfortunately, patients with
larger ulcers and those of long duration heal more slowly
in most cases. It is not clear whether intervention with correction of CVI will accelerate healing in these cases, but it
is reasonable to perform corrective procedures if possible
prior to ulcer healing.
Anatomically, any combination of super cial, perforator, and/or deep venous disease may result in severe CVI.
Marston etal. reported that 29% of limbs with CVI and
leg ulceration displayed super cial or super cial and perforator disease on standing re ux examination (Table52.2).
4
Small saphenous re ux may also be su cient to cause leg
ulceration with no other abnormalities, typically resulting
in ulceration near the lateral malleolus. e contribution
of incompetent perforators to global venous insu ciency
remains controversial and will be discussed in detail below,
but it is clear that some leg ulcers are associated with large
incompetent perforators that should be ligated.
A signi cant percentage of patients with severe CVI
are found to have abnormal venous function in multiple
systems. Over 27% percent displayed both deep and super cial re ux in a study of 138 limbs with leg ulceration
(Table52.2). It is not always clear whether these patients
will experience an improvement in the severity of symptoms
if their super cial or super cial and perforator abnormalities are corrected. is issue will be discussed in detailbelow.
Hemodynamic evaluation using APG is very useful in
the management of patients with multisystem venous insuf ciency. Patients with deep and super cial re ux may be initially treated with super cial stripping or ablation, and the
APG can be repeated to determine the degree of improvement without addressing the deep venous re ux. As noted
above, postoperative normalization of the VFI is associated with minimal symptoms at late follow-up. erefore,
a patient who has improvement in the VFI with correction
of only one anatomic component of their venous re ux can
be followed conservatively, while a patient with a persistent
hemodynamic abnormality with a poor VFI can be considered for further intervention. Ulcer recurrence can also be
predicted based on the VFI. McDaniel etal reported that a
10
8
6
4
VFI (cc/sec)
2
0
Figure52.2 Owens VFI post-opdata.
Table52.2 ANATOMIC DISTRIBUTION OF VENOUS
REFLUX IN 138 LIMBS WITH CEAP CLINICAL
preop
postop
p < 0.0001
Normal < 2.0 cc/sec
442 • CHRONIC VENOUS INSUFFICIENCY
CLASS6C VI.
ANATOMIC SITE INCIDENCE
Deep alone 43.5%
Deep and super cial 21.0%
Deep, perforator, and super cial 6.5%
Super cial alone 18.1%
Super cial and perforator 10.9%
postintervention VFI > 4 was associated with a signi cantly
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increased incidence of recurrent limb ulceration. erefore,
patients who are treated conservatively with venous leg
ulcers resulting in healing may be considered for intervention to correct venous insu ciency based on the risk of
recurrence predicted by APG evaluation.
C O N V E N T I O N A L S U R G I C A L
PROCEDURES FOR
CORRECTIONOFCVI
SUPERFICIAL VENOUS REFLUX
GREAT SAPHENOUSVEIN
Traditional surgical techniques for removal of the great
saphenous vein (GSV) have typically employed ligation of
the vein at the saphenofemoral junction (SFJ) and removal
of the vein between the groin and knee or groin and ankle
using a stripping technique. e goal of high ligation is to
identify and divide all venous branches communicating
with the SFJ to minimize the potential for recurrent re ux
pathways resulting in recurrent symptoms. Unfortunately
it appears that many patients developing recurrent venous
insu ciency do so because of neovascular generation of new
venous communications reestablishing the SFJ, or dilation
of preexisting venous tributaries. At this point it is theorized
that the surgical procedure itself is the primary stimulus for
neovascularization, and there is hope that endovenous techniques may prove to be associated with a lower incidence of
recurrent venous insu ciency a er intervention.
Numerous methods have been described for removal of
the saphenous veins a er high ligation. e current trend
is toward minimizing the invasiveness of surgical intervention, and numerous alternatives to surgical stripping have
been introduced. However, it should be noted that stripping
procedures themselves have undergone a signi cant evolution. Using minimal incisions, tumescent local anesthesia,
ultrasound guidance, and careful dissection, the GSV can
be removed through two small incisions with relatively little
bruising or postoperative discomfort in the majority of cases.
In Chapter23, saphenous stripping techniques are reviewed in
detail. Key advances have included the use of detailed preoperative venous mapping to plan surgery and the use of intraoperative ultrasound to locate the SFJ and precisely place incisions.
e following issues in super cial venous surgery will be
discussed in detailbelow:
•
Saphenofemoral ligation alone or ligation and saphenous
stripping
•
Saphenous stripping to the ankle or to theknee
•
Small saphenousre ux
•
Need for concomitant varicosity ablation
Saphenofemoral Ligation Alone or Ligation
andSaphenous Stripping
It has long been debated whether high ligation alone or with
varicosity ablation is su cient for the treatment of super cial venous re ux. Proponents argue that preservation of the
saphenous vein is preferable to allow later use as a conduit
and that the rate of recurrent symptoms without stripping
is acceptable. Hammarsten etal. reported a random allocation of forty-two patients to high ligation with varicosity
avulsion or high ligation with saphenous stripping and varicosity avulsion.
was no di erence in the rate of recurrent symptomatic varicose veins (VV) between the two treatment groups (12%
in those with stripping and 11% in those without). Venous
Doppler evaluation of the residual saphenous vein revealed
that 78% would be suitable for use as an arterial conduit.
Proponents of high ligation with GSV stripping have
noted the increased incidence of recurrent re ux in the
saphenous vein a er high ligation alone and maintain
that optimal results require routine saphenous stripping.
Investigators looking at the residual GSV a er high ligation
without stripping have identi ed frequent residual re ux
in the GSV. McMullin etal. reported residual re ux in
twenty-four of y-two cases (46%) a er SFJ ligation and
found that those with persistent re ux did not correct VRTs
measured by PPG.
and velocities at several levels in the GSV before and a er
high ligation in twenty-nine limbs.
had re ux in the proximal saphenous vein abolished, 52%
demonstrated persistent saphenous re ux at theknee.
e Gloucestershire Vascular Group reported 5-year
follow-up of 110 limbs randomized to high ligation alone
compared with ligation plus stripping.
satisfaction was similar in the two groups, signi cantly fewer
patients in the stripping group required reoperation for
recurrent saphenous re ux with symptomatic varicosities
(6%) compared to the high ligation–only group (20.8%).
Regardless of the type of intervention, VV recurrence
appears to depend on the length of follow-up. In Fischer’s
de nitive report of the long-term follow-up of limbs treated
with high ligation and stripping, 47% of patients followed
for an average of 34years developed clinically evident varicosity recurrence.
to be a reduction in the number of limbs requiring reoperation. It has been suggested that this relates to the improved
hemodynamic outcome in limbs treated with stripping,
resulting in a lower incidence of persistent pain and swelling that would require reoperation.
Balancing the improved hemodynamic result with
saphenous stripping has been the occurrence of increased
complications with this procedure. While there is an
increased incidence of bruising and hematoma in the thigh
with stripping, this can be minimized by the use of tumescent anesthesia and other techniques as noted above. e
5
At a mean follow-up of 52months there
6
de Haan etal. measured re ux duration
7
While nearly all (97%)
8
Although patient
9
e primary bene t of stripping appears
CONVENTIONAL SURGERY FOR CHRONIC VENOUS INSUFFICIENCY • 443
most signi cant complication attributed to saphenous strip-
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ping involves injury to the saphenous nerve. Fully described
below, there is a signi cant incidence of saphenous nerve
de cit a er stripping, which is reduced when stripping
stops at the level of the knee. Overall, few patients appear to
have long-term de cits from this injury.
In summary, high ligation and varicosity ablation is
likely to be an acceptable procedure for less severe classes
of CVI where the reduced recovery time and reduced
potential for bruising and nerve injuries is more important. Although some patients develop recurrent re ux,
several authors have reported that sequential sclerotherapy
of saphenous branches is able to eliminate recurrent re ux
when it develops.
However, in more severe classes of CVI, the primary
aim is to correct the hemodynamic abnormality resulting
in symptoms. For many patients, the need for repeat procedures to maintain control of saphenous re ux is undesirable. e high incidence of residual saphenous re ux and
signi cant frequency of reoperation when stripping is not
performed argue in favor of high ligation and stripping as
the preferred surgical operation for CVI with symptoms
due to GSV re ux.
Saphenous Stripping to the Ankle or to theKnee
compared to high ligation and stripping to the knee
11
(GroupB).
ree months a er surgery, 94% of patients
in Group Areported good or excellent relief of symptoms
compared to 97% of patients in Group B (p=NS). Evidence
of saphenous injury was identi ed in 39% of limbs in Group
Acompared to 7% in Group B (p < 0.001). In a subsequent
report, the same authors reported long-term follow-up of
the same patient cohort. ree years a er randomization,
29% of limbs in group Awere reported to display symptoms
of permanent saphenous nerve injury compared to only 5%
in Group B (p < 0.01). At 5years of follow-up, recurrent
varices were seen in 10% of patients in eachgroup.
In a detailed study of the incidence and clinical impact
of saphenous nerve injury, Morrison and Dalsing evaluated
127 limbs treated with saphenous stripping to the ankle at
12
a mean follow-up of 4.5years.
Overall, 40% of patients
reported symptoms of saphenous nerve injury at some
point a er operation. At last follow-up 17% reported the
symptoms were persistent, but only 2.3% reported that the
symptoms negatively a ected their quality oflife.
Although the symptoms of saphenous nerve injury may
rarely be severe, minor complaints are frequent. It appears
that the hemodynamic results of stripping to the knee are
similar to total saphenous stripping in most cases. erefore,
most authors have recommended stripping to the knee as
the treatment of choice for axial GSV re ux.
If GSV stripping is chosen as a component of a procedure
for the treatment of CVI, the surgeon must determine the
length of vein to remove. In most cases, the vein re uxes
both at the SFJ and throughout its course. Traditionally,
many surgeons have elected to strip the entire vein from
groin to ankle. e saphenous vein is easily identi ed at
the ankle, and retrograde passage of the stripper is generally unobstructed. However, the saphenous nerve is in close
proximity to the vein beginning just below the knee in many
patients and may be susceptible to injury during stripping
procedures. For these reasons, some surgeons have recommended limiting stripping at a point just below theknee.
To determine whether a limited GSV stripping to the
knee would be su cient to yield improvement in venous
hemodynamics, Nishibe et al. studied 110 limbs before
and a er removal of the above knee segment of GSV using
10
duplex ultrasound APG.
ey found that venous hemodynamics as measured by APG were markedly improved
a er limited GSV stripping. e majority of patients experienced correction of the abnormal preoperative VFI (4.0±
0.35 ml/s) to the normal range (1.4± 0.15, p < 0.001). e
incidence of apparent saphenous nerve injury on assessment at 2–3 weeks a er surgery was 4.5%, with most of
these patients reporting numbness, mild to moderate pain,
or sensitivity to touch in the a ectedareas.
Holme and colleagues conducted a prospective randomized study in which 163 patients were randomized to high
ligation and stripping of the GSV to the ankle (GroupA)
Small SaphenousRe ux
O en overlooked is the possibility that severe CVI may
be due solely to re ux in the small saphenous vein (SSV).
Labropolous etal. studied 226 limbs with re ux isolated to
the SSV, comprising approximately 10% of their patients
with CVI.
only 18.5% were severe enough to be classi ed as CEAP
clinical class 4–6. In a report of twenty limbs with isolated
lateral perimalleolar ulcers, Bass and colleagues found isolated SSV re ux at the saphenopopliteal junction (SPJ) in
15 (75%).
healed within 12 weeks. Lin etal. found that SSV incompetence was frequently associated with severe CVI and is less
commonly corrected surgically than GSV insu ciency.
ey recommended that SSV examination and correction
should assume greater importance in the management of
symptomatic CVI. In general, SSVs with su cient re ux
to cause severe CVI are large, dilated veins with numerous
varicose tributaries. Hemodynamic evaluation with plethysmography is o en useful to determine whether isolated SSV
re ux is hemodynamically signi cant. Patients with SSV
re ux are unlikely to have signi cant symptoms without an
abnormal venous llingindex.
tence, the anatomy of the vein must be carefully determined.
e variable course of the SSV has been well documented,
13
Symptoms were present in 61% of patients, but
14
A er SSV ligation at the junction, all ulcers
Prior to intervention for patients with SSV incompe-
15
444 • CHRONIC VENOUS INSUFFICIENCY
and the vein may terminate at numerous points into the
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popliteal vein, the femoral vein, the vein of Giacomini,
or elsewhere. e presence of a large persistent super cial
vein in the lateral thigh that does not join the deep system
should alert the clinician to the possibility of a variant of
Klippel-Trenaunay syndrome with hypoplastic deepveins.
Preoperative or intraoperative mapping of the SSV with
ultrasound will assist with operative planning and identi cation of the SPJ. e SSV may give o several branches
just distal to the SPJ, and it is believed to be bene cial to
ligate these branches to minimize residual collateral re ux.
Similar to GSV surgery, controversy has existed concerning
the need for stripping of a portion of the SSV. Although no
randomized trials have compared sahpenopoliteal ligation
to ligation with SSV stripping, most authors have recommended stripping a portion of the SSV. Stripping should
generally not involve the lower third of the calf, given the
increased risk of injury to the suralnerve.
Need for Concomitant Varicosity Ablation
Correction of saphenous and perforator insu ciency will
improve hemodynamics with reduction in symptom severity. However, to many patients, the primary sign of their
“vein problem” is the visible varicosities, and most prefer
varicosity removal or ablation whenever necessary. In conventional surgical treatment, this typically has been performed at the time of saphenous stripping, taking advantage
of the anesthetic and eliminating the need for subsequent
procedures. Some practitioners prefer to perform saphenous stripping alone, noting that many varicosities will
improve a er this procedure, never requiring removal. Since
the introduction of endovenous ablative techniques, more
patients are treated initially with endovenous ablation without varicosity ablation. In many limbs, residual varicosities
contract and fade in the absence of continued venous hypertension so that no further ablative procedures are required.
Ambulatory phlebectomy or sclerotherapy may be performed a er endovenous ablation for limbs with residual
varicosities as needed at the patient’s request.
Patients with more severe CVI typically have large varicosities, which may be less likely to resolve without removal.
e author’s practice has been to recommend elimination
of these varicosities at the time of saphenous correction. If
incompetent perforating veins (IPVs) are present in the calf,
they typically communicate with the posterior arch vein
rather than the GSV. Varicosity ablation may be important
to eliminate out ow pathways for IPVs as described below.
ere is little evidence that hemodynamic or symptomatic improvement depends on varicosity removal in most
patients, so this decision must be individualized based on
the status of the varicosities and the patient’s wishes.
A variety of techniques have been described to address
prominent varicosities. e standard technique for surgical
removal has involved surgical incisions overlying prominent
Figure52.3 Stab phlebectomy.
varicosities and avulsion, followed by limb compression
to minimize bleeding and hematoma formation. Over the
years, this procedure has been performed through smaller
and smaller incisions to its current technique using ne
instruments speci cally designed to sh out varicosities
through microincisions (Figure 52.3). Cosmetic results
have improved markedly using this technique, which is fully
described in Chapter26.
Although varicosities can be reliably ablated with this
technique, it may be a tedious, time-consuming method in
patients with extensive varicosities. For this reason, Spitz
developed an alternative method for varicosity removal utilizing a powered phlebectomy device allowing large areas of
varicose veins to be rapidly removed through two small incisions (Trivex, Smith and Nephew, Inc., Andover MA). e
technique is fully described in Chapter27. In a randomized
study, the results of powered phlebectomy were compared
to surgical varicosity removal. Powered phlebectomy was
found to signi cantly reduce the number of required incisions and a trend toward shorter operative time was noted.
No di erence was found in the incidence of bruising, cellulites, pain, or recovery time. Cosmetic results were perceived by the patients to be equivalent, and no di erence
in varicosity recurrence was found 6 and 12months a er
surgery. e authors concluded that the results of powered
phlebectomy were equal to standard phlebectomy, with the
potential to shorten surgical time particularly in patients
with more extensive varicosities.
Residual varicosities may also be treated with sclerotherapy using a variety of sclerosants as discussed in
Chapters18–21.
R E S U L T S O F C O N V E N T I O N A L
SAPHENOUS SURGERY
Numerous studies have reported on short- and long-term
results a er saphenous surgery, including symptom relief,
varicosity resolution, recurrent varicosities, need for reoperation, and quality-of-life improvement. Bergan reported
CONVENTIONAL SURGERY FOR CHRONIC VENOUS INSUFFICIENCY • 445
on the results of 702 limbs undergoing conventional surgi-
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16
cal procedures in an outpatient setting.
e most common complication was ecchymosis in the medial thigh,
none severe enough to require further treatment. Less frequent complications included numbness in the saphenous
nerve distribution (6.5%) and lymphocele along the saphenous tract (2.5%). ere were no reported cases of DVT
in this series. Hospitalization was required in only three
patients.
e hemodynamic improvement in patients undergoing saphenous surgery has been well documented. Using
APG, correction of saphenous re ux has been demonstrated to result in marked improvement in venous lling
index, ejection fraction, and residual volume fraction.
3
Patient satisfaction with the procedure is generally high,
but not universally so. Mackay et al. reported on 155
patients who were treated with high ligation and GSV
17
stripping assessed by a questionnaire.
Nearly two-thirds
of patients reported a perceived postoperative complication within the rst 2 weeks a er surgery, most relating
to bruising, pain, and numbness. Six months a er surgery,
80% of patients were satis ed with the outcome, with the
most common reason for dissatisfaction being residual
varicosities.
Chronic venous disease has been reported to negatively
a ect patient quality of life as assessed by a variety of outcome measures. Using various methodology, investigators
have reported that saphenous vein surgery signi cantly
improves quality of life both initially following surgery, and
at midterm follow-up several yearslater.
For patients with CEAP clinical class 5 and 6 disease,
Barwell et al. performed a randomized study comparing
the e cacy of saphenous stripping plus compression compared with compression alone for healing and prevention
18
of venous leg ulcers.
Termed the ESCHAR study, 500
patients with isolated super cial re ux (60%) or combined
super cial and deep venous disease (40%) were enrolled.
Demographic factors were similar in the two groups.
Ulcer healing was no di erent with 65% healed in each
group by life table analysis at 24 weeks a er randomization. Signi cantly fewer patients in the surgery group experienced recurrent ulceration in 15% at 1year and 24% at
3years compared to 34% at 1year and 52% at 3years for the
group treated with compressionalone.
In summary, saphenous stripping procedures have a
proven ability to correct venous hemodynamic dysfunction due to abnormal re ux resulting in reduced patient
symptoms and improved quality of life in the majority
of patients. ough not able to speed healing for venous
leg ulcers, the rate of recurrent ulceration is signi cantly
reduced compared to treatment without surgical correction. Complications of surgery are most o en minor and
self-limited, but an occasional patient may develop nagging
discomfort from saphenous neuralgia, and the rare incidence of DVT cannot be ignored.
ALTERNATIVES TO CONVENTIONAL
SAPHENOUS SURGERY
Numerous alternatives to conventional saphenous surgery
have been promoted to e ectively eliminate saphenous
re ux without the need for surgical incisions or saphenous
removal. ese include:
•
Hemodynamic correction of varicose veins (CHIVA)
•
External banding to restore saphenous competence
•
Endovenous ablation
•
Radiofrequency
•
L a s e r
• Sclerotherapy
•
Ultrasoundguided
•
Foam
When considering the optimal management of patients
with more severe CVI, the primary goal is to abolish axial
re ux and prevent its recurrence. In these patients, recanalization or reopening of the previously treated saphenous vein
usually results in recurrence of the preintervention symptoms, including pain, swelling, worsening skin changes,
and possibly ulceration. Most patients who have su ered
leg ulcers related to CVI, if given a choice, will choose an
intervention that is most likely to minimize the risk of ulcer
recurrence. None of the alternatives to saphenous stripping have been studied in a randomized trial to prove bene t in reducing venous ulcer recurrence. As a surrogate we
can assume that if the GSV or SSV remains closed with no
re ux throughout the length from groin to knee, the patient
should experience a bene t similar to high ligation and
stripping procedures.
Saphenous banding procedures to attempt to reestablish competence of the sentinel valve at the SFJ using either
external banding materials, or endovenous radiofrequency
have met with variable results. Despite encouraging reports
of success in some studies, others have generated disappointing results with high recurrence rates, such that these
techniques are not widely used currently.
Sclerotherapy using ultrasound guidance has been
described as a means for occluding the GSV or SSV, thereby
correcting re ux. Initial attempts employed liquid sclerosants, and though many saphenous veins were successfully treated, recanalization rates were high in many studies
(18.8%—23.8%). More recently, foam sclerotherapy has
been studied for occlusion of the GSV, with several studies
nding improved results compared to liquid sclerotherapy.
In a randomized study, 88 patients were treated with either
sclerosing foam or sclerosing liquid via direct puncture of
19
the GSV under duplex guidance.
ree weeks a er treatment repeat examination with duplex ultrasound revealed
that only 40% of patients treated in the liquid sclerotherapy
19
446 • CHRONIC VENOUS INSUFFICIENCY
group had eliminated re ux throughout the GSV compared
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to 84% in the foam sclerotherapy group. From these studies,
it appears that the recurrence rate for liquid sclerotherapy is
unacceptably high for treatment of the GSV. Using a foam
sclerosant will signi cantly increase success rates, but they
may still be inferior to high ligation and stripping.
Of the listed alternatives to saphenous ligation and stripping procedures, endovenous ablation has been the most
widely studied, including randomized comparisons to stripping. Early studies with both techniques have demonstrated
initial saphenous closure rates of over 90%. Long-term
data reporting the incidence of saphenous recanalization
are now emerging, with acceptable3- to 5-year results. In
the EVOLVeS study, radiofrequency ablation (RFA) was
compared with ligation and stripping in eighty-six limbs
including quality-of-life measures and follow-up ultrasound
examinations at routine intervals. Initial success rates at
elimination of saphenous re ux were 100% in the strip-
20
ping group and 95% in the RFA group.
Time to return
to normal activities and return to work were signi cantly
less in the RFA group. uality of life surveys revealed a signi cantly better global score and a signi cantly better pain
score for RFA 1 week post procedure, but these di erences
progressively decreased over time. At 2years of follow-up,
two patients in the RFA group had developed recanalization of an initially closed saphenous vein (4%), but global
quality-of-life scores still favored RFA. One patient in the
RFA group and four treated with ligation and stripping
were found to have evidence of neovascularization on ultrasound examination. Recurrent VV occurred in 14% of RFA
limbs and 21% of stripped limbs (p=NS).
In another randomized study comparing RFA to saphenous stripping in eighty-eight patients, similar results were
reported as patient satisfaction, quality-of-life improvement, and analgesic requirements all signi cantly favored
21
RFA early a er surgery.
Clearly, further long-term study is required to de ne the
optimal use of endovenous procedures. However, in amenable patients, these techniques appear to be viable alternatives to surgical stripping. Long-term recurrence rates must
be carefully studied, but the possibility that endovenous
ablation will produce less neovascular regeneration at the
SFJ is intriguing and will certainly be followed closely.
COMBINED DEEP AND SUPERFICIAL
VENOUS INSUFFICIENCY
Treatment of patients with symptomatic CVI and isolated
super cial venous insu ciency is usually recommended
given the reproducible improvement with correction of
saphenous re ux and the low-risk procedures available
for this patient group. In patients with CEAP class 4–6
disease, super cial insu ciency is o en identi ed in combination with deep disease. As noted above, 27% of limbs
studied with active or healed ulcers were reported as having
combined re ux. In this situation the clinician must determine whether symptom improvement is likely from treatment of super cial re ux alone, or if the patient is more
likely to require deep venous reconstruction.
Several authors have reported that when super cial
re ux in the GSV or SSV is present, the more proximal deep
vein segment will occasionally re ux solely due to the super cial vein incompetence. Correction of the super cial re ux
reliably results in resolution of the deep vein segment re ux.
In this situation GSV incompetence would be seen along
with re ux in the common femoral vein, but the femoral
and popliteal veins would be competent. With SSV re ux,
popliteal re ux would be noted cranial to the SPJ, but not
caudal to the junction. With these patterns of re ux, super cial ablative procedures are recommended using the same
criteria used for super cial incompetencealone.
Treatment of limbs demonstrating true deep venous
insu ciency, de ned as re ux in the femoral and popliteal veins, combined with super cial re ux is controversial. Walsh and Sales reported resolution of deep venous
re ux a er GSV stripping in over 90% of cases, but Scriven
reported that deep venous re ux usually did not correct.
22
Puggioni etal. recently reported a study of thirty-eight limbs
with combined deep and super cial re ux studied with
duplex ultrasound before and a er saphenous stripping.
22
Deep venous re ux was corrected in one-third of patients,
and femoral vein re ux corrected more frequently when
only segmental re ux was present in that vein rather than
axial re ux throughout the deep venous system. Puggioni
etal. note that the majority of limbs reported by Walsh and
Sales demonstrated segmental re ux that may be more likely
to correct with super cial surgery than axial re ux.
Padberg and colleagues reported a hemodynamic
follow-up of eleven limbs with deep and super cial disease
treated with super cial stripping and perforator ligation in
23
some cases.
Although only 27% of limbs studied postoperatively were found to have correction of deep venous re ux,
signi cant improvement in both clinical symptom scores
and the venous lling index were demonstrated. Marston
et al. reviewed the clinical and hemodynamic results of
forty patients with both femoropopliteal and super cial
re ux treated with endovenous ablation of the GSV and/
24
or SSV.
ey found that the amount of clinical improvement depended on the maximal re ux velocity (MRV) in
the deep venous system. When MRV in the popliteal or
femoral vein was less than 10cm/s, limbs had signi cantly
better outcomes than limbs with MRV > 10cm/s as measured by both VFI (p=0.01) and venous clinical severity
score (VCSS) (p=0.03).
In summary, it is reasonable to consider super cial ablative intervention in patients with combined deep and super cial insu ciency. ose with proximal or segmental re ux
of lower velocity are more likely to bene t than patients
with full axial or higher velocity re ux in the deep venous
system.
CONVENTIONAL SURGERY FOR CHRONIC VENOUS INSUFFICIENCY • 447
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