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93
N.S. Sadick et al. (eds.), Practical Approach to the Management and Treatment of Venous Disorders,
DOI 10.1007/978-1-4471-2891-5_10, © Springer-Verlag London 2013
1 0
Introduction
Ambulatory phlebectomy is a safe and economi-
cal procedure that has proven to be an effective
method for treating tributary and other incompe-
tent veins. Through a small number of skin punc-
tures, undesirable veins can be permanently
removed with minimal scarring or adverse effects.
Today, patients are able to undergo this procedure
using local anesthesia with little or no recovery
time. A small, hook-like instrument and fi ne
clamps are utilized to extract the varix from a
small (~2 mm) incision made by an 18-gauge
needle or 15° ophthalmic blade. Postoperatively,
a dry sterile compression dressing or a graduated
compression garment is applied to the limb.
The quickness and ef fi cacy of ambulatory
phlebectomy have made it one of the preferred
methods for the treatment of varicose veins. In the
United States (US), it is estimated that over 65,000
ambulatory phlebectomy procedures were per-
formed in 2006 and this number is expected to
grow over the next several years [ 21 ] .
This chapter will cover several aspects of
ambulatory phlebectomy, including:
Indications and contraindications •
Diagnostic methods •
Treatment strategies •
Procedural technique •
Potential complications •
Clinical guidelines •
While this chapter contains detailed infor-
mation related to performing ambulatory phle-
bectomy, the learning curve for successfully
performing this procedure can be greatly
enhanced by seeking out an expert in the fi eld
of phlebectomy to observe the procedure.
History
Hippocrates was the fi rst to conceptualize phle-
bectomy in 400 BCE, theorizing that several
punctures in the vein would remove the “bad
blood” that fed an ulcer [ 1, 29 ] . Phlebectomy
was fi rst performed by the surgeon Aulus
Cornelius Celsus, 56 BCE to 40 ACE. Concerning
phlebectomy, Celsus wrote, “The varicose veins
were treated by exposure followed by avulsion
with a blunt hook or by touch of the cautery” [ 3 ] .
Celsus utilized relatively large incisions, and
applied compressive bandages that allowed
ambulation.
The modern day phlebectomy tech-
nique was fi rst described by Robert Muller,
a dermatology-trained phlebologist from
Neuchâtel, Switzerland, who reinvented and
re fi ned the technique that we know today as
Ambulatory Phlebectomy
Lowell S. Kabnick
For inclusion in Practical Approach to the Management and Treatment of
Venous Disorders.
L. S. Kabnick , M.D., FACS, FACPh
New York University Langone Medical Center ,
530 First Avenue, Suite 6D ,
New York, NY 10016 , USA
e-mail: lowell.kabnick@nyumc.org
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94
L.S. Kabnick
ambulatory phlebectomy (Fig. 10.1 ). When
performing large vein sclerotherapy, he
noticed that phlebitis developed in a number
of cases post-injection, followed by recanali-
zation and recurrent thrombus. The venous
wall was fragile and dif fi cult to remove with
sclerotherapy. This problem prompted Muller
to eliminate sclerotherapy and proceed directly
to removal.
Muller began by using broken forceps to cre-
ate small hooks that he utilized to remove vari-
cosities through small incisions. By 1956, he had
perfected this technique, which he presented in
1967 to the French Society of Phlebology and
to the International Congress of Phlebology in
1968. Although his initial presentations were
poorly received, Muller continued to teach his
technique [
23, 24 , 25, 26 ] .
Over time, Muller developed a great number
of disciples and his technique spread slowly
throughout the world. It was not until recently
that Muller’s phlebectomy technique was adopted
in the United States (US) as a procedure of choice
to remove segments of varicose and some reticu-
lar veins.
De fi nition
The term “ambulatory phlebectomy,” coined by
Dr. Muller, refers to the technique in which vari-
cose veins are extracted in an outpatient setting
under local anesthesia using small punctures and
hooks. This technique requires hemostatic com-
pression and immediate ambulation. Synonymous
terms used to describe this technique include:
ambulatory phlebectomy, stab avulsion, stab
phlebectomy, microphlebectomy, and microex-
traction. Caution should be exercised when dis-
cussing the procedure with a patient. Stab
avulsion and stab phlebectomy should be avoided,
as they imply that the patient will be stabbed dur-
ing the procedure.
The Current Procedural Terminology (CPT)
code book of the American Medical Association
lists three codes for the billing of the procedure:
(1) 37765, stab phlebectomy of varicose veins,
one extremity, 10–20 stab incisions; (2) 37766,
stab phlebectomy of varicose veins, one extrem-
ity, more than 20 incisions; and (3) 37799, for
less than 10 incisions [
10 ] .
Indications
The objective of ambulatory phlebectomy is to
provide de fi nitive treatment for removal of the
target vein after the highest point of re fl ux is
treated and/or eliminated. Indications for ambu-
latory phlebectomy vary depending on the skill
set and other techniques with which the phlebo-
logist is comfortable. If the veins are symptom-
atic, the treatment may be medically indicated;
whereas, asymptomatic veins are classi fi ed
as cosmetic. Ambulatory phlebectomy can
be performed by itself or in conjunction with
another procedure such as endovenous thermal
ablation.
Varicose veins of any size, in any location
excluding the cephalad end of the great or small
saphenous veins, are candidates for ambulatory
phlebectomy. These include the epifascial great
saphenous vein, collateral varicosities, and
reticular veins. Also appropriate for ambulatory
phlebectomy are regional venous networks,
Fig. 10.1 Muller
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9510 Ambulatory Phlebectomy
including accessory saphenous veins of the
thigh, pudendal perineal veins, reticular veins of
the lateral subdermic plexus and popliteal fossa,
as well as veins of the hands and feet [
5, 27, 28 ] .
Dilated veins in other parts of the body includ-
ing the periorbital, abdominal, and chest areas,
medial thigh perforators and small lateral perfo-
rators can be removed by this technique with
success [ 41 ] .
Areas of dif fi culty for removing the veins by
hook are the knee, tibial, and foot. In these areas,
the veins are tethered by connective tissue, mak-
ing their removal somewhat challenging. Areas
of caution are the following: the distal great
saphenous vein in the saphenous nerve distribu-
tion and the small saphenous vein in the sural
nerve region. Lateral varicosities by the fi bular
head are in the region of the peroneal nerve and
should be approached with caution, as should
many areas of the hand and foot. In addition, var-
icose veins that recur after phlebitis or sclerother-
apy may be challenging to extract due to adhesions
or local scar tissue [ 39 ] .
Contraindications
There are a limited number of contraindications
to ambulatory phlebectomy. The following con-
ditions should be considered as relative
contraindications:
1. Infectious dermatitis or cellulitis in surround-
ing areas,
2. Severe peripheral edema,
3. Severe arterial insuf fi ciency,
4. Serious illness,
5. Anticoagulated state – e.g., patient receiving
warfarin,
6. Hypercoagulable state,
7. Pregnancy.
Bene fi ts of Ambulatory Phlebectomy
Ambulatory phlebectomy is an economical, cos-
metic, and effective method to remove veins.
Improvements in anesthetic technique, namely,
the use of tumescent anesthesia, have limited the
amount of pain both intraoperatively as well as
postoperatively. Patients can return to daily activ-
ities after the procedure and to work the next day.
Because of the paucity of reported complications,
the procedure is considered safe [
27, 28, 31, 33 ] .
Long term results are assumed to be optimal;
however, substantial long-term data has not been
well-studied to date.
Diagnostic Methods
A complete history and physical examination
should be performed on every patient. As with all
procedures involving the administration of anes-
thesia, patient records should be checked to
assure that the patient does not have a contraindi-
cation to local anesthesia. Additionally, in most
cases, a duplex ultrasound is performed as part of
the preoperative evaluation. Ultrasound examina-
tion allows for the identi fi cation of sources of
re fl ux that may require treatment before moving
forward with phlebectomy of the target vein.
Transillumination is very helpful for identify-
ing reticular and feeding veins associated with
telangiectasias. Common transilluminating
devices include the Veinlite® (TransLite, Sugar
Land, Texas, US) and VeinViewer by Luminetx™
(Memphis, Tennessee, US) (Fig. 10.2a, b ).
Treatment Strategies
Accepted treatment strategies in phlebology
include: compression therapy, sclerotherapy,
ambulatory phlebectomy, endovenous thermal
ablation, and topical laser. While each treatment
modality has its speci fi c advantages and indica-
tions, there is signi fi cant overlap.
Sclerotherapy is the closest alternative treat-
ment strategy to ambulatory phlebectomy. At
present, there is still a debate as to which is better
as well a scarcity evidenced-based literature to
support the superiority of either procedure. A
single randomized, controlled trial by de Roos
et al. [ 6 ] demonstrated the superiority of ambula-
tory phlebectomy over sclerotherapy for the treat-
ment of the anterior thigh circum fl ex vein.
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96
L.S. Kabnick
Thorough comparative publications of ambula-
tory phlebectomy and sclerotherapy do not cur-
rently exist which creates debates about the
superiority of one over the other. Until conclusive
evidence emerges, it is critical for the phlebolo-
gist to know both procedures.
Staged Versus Unstaged Procedures
There is substantial controversy over whether
ambulatory phlebectomy should be performed at
the same time that truncal re fl ux is being abol-
ished [
11 , 18 ] . The existing data suggests advan-
tages to both phlebectomy in conjunction with
truncal re fl ux treatment and to performing the
procedures independently. In a retrospective
study by Welch [ 42 ] , the initial success of
endovenous ablation to treat truncal re fl ux
allowed most patients to defer stab phlebectomy.
Conversely, in a controlled study by Mekako
et al. [ 19 ] , patients who underwent concomitant
endovenous laser therapy and ambulatory phle-
bectomy did not need to return for subsequent
phlebectomy procedures.
When considering the treatment algorithm, the
phlebologist must be selective and make decisions
based on the needs of each individual patient.
Combined procedures should be indicated if the
varicose veins involve the zone of in fl uence
regarding the truncal re fl ux. Staging is appropri-
ate if the varicose veins lie outside the zones of
in fl uence.
Technique
Preoperative Preparation
All target veins should be traced with a surgical
marker while the patient is standing as they may
be dif fi cult or impossible to identify during
recumbency. Surgical markers include those
using gentian violet-colored solution, for exam-
ple, Vismark
®
surgical skin markers (Viscot
Medical, East Hanover, New Jersey, US). Use of
a permanent marker to trace the veins should
be avoided because of risk of tattooing. After
the patient has been placed in the recumbent
position, the vein marks are adjusted using a
transilluminator such as the VeinLite or
VeinViewer (see Fig.
10.2a, b ). Because veins
tend to shift, this subsequent adjustment adds to
the ef fi cacy and speed of extraction (Fig.
10.3 )
[ 40 ] .
a
b
Fig. 10.2 ( a ) Veinlite. ( b ) Veinveiwer
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9710 Ambulatory Phlebectomy
Premedication should be carefully considered
by the phlebologist, as administration to the
patient may impair immediate postoperative
ambulation. Postoperative walking by the patient
is critical in reducing potential complications.
Surgical Plan
The timing of ambulatory phlebectomy depends
on the nature and type of other venous procedures
being performed. Effective staging involves treat-
ment of the great or small saphenous vein fi rst,
with ambulatory phlebectomy following several
weeks after. This method allows the existing trun-
cal varicosities to decrease in size or disappear
before further procedures [
12, 22 ] .
Anesthesia
Historically, local anesthesia with or without epi-
nephrine was used to provide a painless
phlebectomy. Current thought leaders now sug-
gest using tumescent anesthesia for ambulatory
phlebectomy.
Tumescent Anesthesia
Tumescent
Function: adjective
Etymology: Latin tumescent-, tumescens,
present participle of tumescere to swell up, incho-
ative of tumEre to swell: somewhat swollen
< tumescent tissue> [20] .
Tumescent anesthesia exploits the principles
of pharmacokinetics to achieve anesthesia of the
epidermis, dermis, and subcutaneous tissues. The
subcutaneous in fi ltration of a large volume of
dilute buffered lidocaine and epinephrine causes
the targeted tissue to become swollen and fi rm,
or tumescent. Because the subcutaneous tissue
is relatively avascular, a large volume of diluted
epinephrine injected into this area produces
widespread and prolonged vasoconstriction.
Vasoconstriction appears to diminish the rate of
systemic lidocaine absorption, thus reducing the
peak plasma lidocaine concentration, reducing
potential toxicity, and permitting a much larger
dose of lidocaine to be administered [ 14– 17 ] .
When combined with 8.4% sodium bicarbonate
solution, the lidocaine and epinephrine mixture
takes on a more neutral pH which allows for vir-
tually painless injection into the patient.
The widely accepted maximum safe dose for
the subcutaneous administration of lidocaine
with epinephrine is up to 7.0 mg/kg. However,
J.A. Klein, the fi rst to describe tumescent anes-
thesia, has stated that tumescent technique per-
mits safe lidocaine dosage of at least 35 mg/kg of
body weight and provides effective local anesthe-
sia for as long as 10 h [ 17 ] . Klein and others
observed that the pharmacokinetics of dilute lido-
caine with epinephrine are different from those of
1–2% lidocaine. With undiluted lidocaine, a mea-
surable plasma level appears in 15 min and peaks
soon after; lidocaine is metabolized in a few
hours. Absorption of the tumescent solution is
slower, causing peak plasma levels to occur many
Fig. 10.3 Circle drawn tracing photo
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98
L.S. Kabnick
hours later, and thus the anesthetic effect is lon-
ger. Patients receiving large volumes can have
plasma levels that peak in 4–14 h and linger for
greater than 24 h.
Administration of Tumescent
Anesthesia
The in fi ltration of dilute anesthesia in a perivas-
cular position, epidermal and dermal, serves sev-
eral purposes [ 4 , 36 ]:
1. The anesthetic effect is long lasting, and sen-
sation returns slowly.
2. With the use of longer needles and dilute solu-
tion, fewer needle punctures and less pain
upon administration are observed.
3. Tumescent technique causes more compres-
sion of surrounding tissues leading to less
hematoma and ecchymosis.
4. Hydrodissection occurs around the vein, facil-
itating the removal.
5. Reduction of infection, usually limited to the
incision site, is a result of the bacteriostatic
and bacteriocidal properties of lidocaine con-
centration [ 35 ] .
The methods of delivering and mixing the ingre-
dients of tumescent anesthesia vary among users.
The following tumescent preparation for ambula-
tory phlebectomy is utilized by the author:
445 ml of 0.9% saline, •
50 ml of 1% lidocaine with 1:100,000 epi-•
nephrine, and
5 ml of 8.4% sodium bicarbonate. •
Presently, most operators use either a regular
syringe, a self- fi lling syringe, or a pump to deliver
tumescent anesthesia (Fig. 10.4 ). The latter two
methods facilitate delivery of higher volumes of
tumescent anesthesia. Microcannulas, 22-gauge
(author’s preference), or 25-gauge needles are
used for the delivery of the solution.
Procedural Equipment
Incisions or punctures can be made with various
devices, including hypodermic needles and surgical
blades. The most common instruments are 18-gauge
needles, number 11 blades, and 15° ophthalmic
blades. The number 11 blade is designed to perform
incision depths that are greater than what is needed
for phlebectomy. From the author’s experience, the
number 11 blade causes greater scarring at the inci-
sion site. After phlebectomy is completed, ½-in.
adhesive strips are placed to close the punctures.
Several different hooks are available for pur-
chase, varying in size, shape, and sharpness. The
most widely known are the Muller, Oesch,
Tretbar, Ramelet, Verady, Dortu-Mortimbeau,
and Kabnick-Goldman hooks (Fig. 10.5a, b ) [ 7 ] .
One particular phlebectomy instrument is not
superior to another. Therefore, when choosing
phlebectomy instruments, it is important for the
user to try different hooks to ensure comfort with
a particular set of hooks.
The clamps used for the vein extraction should
have a fi ne tip so that they can grip close to the
skin. A serrated face is helpful in maintaining fi rm
traction without slippage. The operator should
have at least three fi ne mosquito clamps available,
but fi ve or more are preferable (Fig.
10.6 ).
Procedure
After the tumescent anesthesia has been injected
into the perivenous tissues, a microincision or
puncture is made near the vein (Fig. 10.7 ). Most
Fig. 10.4 Tumescent pump
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9910 Ambulatory Phlebectomy
incisions are oriented vertically, except around
the knee, where they should be oriented along
the tension lines (Langer’s lines). A blunt-tip
spatula may be inserted into the opening,
although this is not mandatory (Fig.
10.8 ). The
advantage of its use is that it enables the hook to
be inserted without interference from surround-
ing tissues and without enlarging the entrance
hole. Once the hook has been inserted, the vein
is grasped blindly and brought up and out of the
opening (Fig. 10.9a ). The vein is then grasped
between clamps and transected by a small scis-
sors (Fig.
10.9b, c ). Using gentle traction on the
hemostat in a “windshield wiper movement,”
one end of the varix is teased out of the puncture
site. Successive mosquito clamps are applied to
the varix as it is extracted from its position,
keeping in mind that the vein will eventually
tear (Fig. 10.9d ). Very long segments can often
be removed through a single puncture site. Once
a segment has been extracted, the operator
moves along the vein and makes another inci-
sion, and the process is repeated. The distance
between incisions varies and depends on the
experience of the operator and the size of the
vein.
Removal of all parts of the varix, without
leaving isolated segments behind, is ideal to
reduce a possible in fl ammatory response from
thrombosis of the retained segment. However, as
long as most of the segment is removed, the
patient should have an excellent result. There is
rarely cause to ligate a vessel. The author typi-
cally ligates when the vessel is a perforator, foot,
hand, or large vein (>1 cm) (Fig. 10.9e ).
Perforating veins are recognized as tributaries
off the vein, often with an orientation perpen-
dicular to the skin and associated with a deep
pulling sensation by the patient. Puncture sites
should not require skin closure if the user uti-
lizes small incisions and postoperative
compression.
Bandaging
The puncture sites should be covered with adhe-
sive strips, sterile dressings, and wrapped with a
soft gauze roll and stretch bandages (Fig.
10.10a–d ).
The stretch bandages should be started at the foot
and wrapped up the leg, covering all the inci-
sions. A class 2 (30–40 mmHg) compression
stocking may also be used as an alternative to the
stretch bandage. Postoperative compression plays
a vital role in reducing complications, as well as
reducing pain and bruising.
a
b
Fig. 10.5 ( a ) Muller hooks. ( b ) Variety of hooks
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100
L.S. Kabnick
Discharge Recommendations
The patient can be safely discharged from the
facility after ambulating. Discharge and follow-
up recommendations are as follows:
1. Provide a prescription for an oxycodone-acet-
aminophen combination tablet or capsule,
with instructions to try acetaminophen
initially (most patients take only acetamin-
ophen).
2. Instruct the patient to return to the of fi ce
(optional) the following day for bandage
removal and placement of 30–40 mmHg com-
pression hose.
3. Have the patient wear compression hose (30–
40 mmHg) for 10–14 days.
Fig. 10.6 Tray for phleb
Fig. 10.8 Spatula
Fig. 10.7 Incision
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10110 Ambulatory Phlebectomy
a
c
d
e
b
Fig. 10.9 ( a ) Hook. ( b ) Delivery loop. ( c ) Transection picture. ( d ) Traction. ( e ) Optional vein ligation
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102
L.S. Kabnick
4. Instruct the patient to return to activities of
daily living, with no heavy aerobic exercise
that would involve the lower extremities for
2 weeks.
5. Leave adhesive strips in place for 2 weeks.
6. Follow up at 2 weeks, 8 weeks, 6 months, and
1 year.
Complications
Complications arising from ambulatory phlebec-
tomy are quite rare but can occur, as listed in
Table 10.1 [ 12, 13, 24, 27, 28, 33 ] . Despite their
rarity, it is good practice to inform patients about
the potential complications and manage expecta-
tions of procedural results. The author has per-
formed more than 60,000 phlebectomies and has
experienced few complications. There have been
two large retrospective studies looking at compli-
cations of phlebectomy. The fi rst was a multi-
center French study that reviewed 36,000
phlebectomies [ 8 ] . The second was a literature
review by Albert-Adrien Ramelet in 1997 in
which he republished the complication rates of
several different authors. The rates of complica-
tions vary widely among the same listings, with
skin blistering being the highest, ranging from
1.3% [
27 ] to 20% [ 9 ] . Telangiectatic matting has
varied in the different studies from 1.5% in the
multicenter French review [ 8 ] to 9.5% in
Trauchessec and Vergereau’s report [ 38 ] . Isolated
authors have reported telangiectatic matting as
high as 2.4%. However, a review of modern day
reports reveals that common complications
appear to change in frequency. In the author’s
experience, the most common complications are
telangiectasia development, 2%; blistering, 0.5%;
hyperpigmentation (limited), 0.01%; and missed
varix, 0.3%.
Procedural experience has shown that patients
who are prone to telangiectasia have a higher
incidence of developing this complication than
patients who are not prone. The incidence of
hyperpigmentation depends on the size of the
veins being removed and the amount of blood
remaining in the vein tract. The occurrence of
skin blistering has decreased over time due to
improvement in proper bandage placement, as
well as alternatives to skin tapes.
a
b
c
d
Fig. 10.10 ( a ) Adhesive strip. ( b ) Sterile guaze. ( c ) Guaze wrap. ( d ) Stretch bandage
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