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11311 Treatment of Incompetent Perforating Veins
with only some being advanced disease (C5–C6).
The concept of a PPV vs. IPV is not usually
addressed in these studies [ 33 ] .
Conclusions
Currently we know that PAPS is ef fi cacious in
the short run. Ef fi cacy does not always corre-
late with patient improvement such as
decreased ulcer recurrence rates. It is beyond
the scope of this chapter to address that type of
clinical trials needed to answer these questions.
Presently, we do not have data that clearly
shows that isolated perforator ablation or SEPS
impacts on advanced disease recurrence or
Fig. 11.4 Post PAPS
changes paired veins and
artery. No fl ow above fascia
Fig. 11.5 Post PAPS
con fi ming fl ow in deep
system
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114
S. Elias
patient quality of life indicators. With a clearer
de fi nition of a pathologic perforating vein
these studies can now be done.
In this authors current practice PPV are ablated
only after all other sources of re fl ux have been
eliminated. (super fi cial axial disease, varicosi-
ties, proximal suprainguinal disease) Ulcers
do not necessarily need to be healed prior to
treatment. Many incompetent and some patho-
logic perforators will normalize once the
above procedures are performed. If after the
above treatment, patients (C5, C6) show mini-
mal improvement or have ulcer recurrences,
then the PPV’s are re-imaged. If they still fi t
the criteria as a PPV, PAPS is performed.
Currently, this author gives a grade 2C sug-
gestion for perforator ablation [ 30 ] although it
is recognized that the management of perfora-
tor disease is evolving.
References
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of the veins of the lower limbs: an international inter-
disciplinary consensus statement. J Vasc Surg.
2002;36:416–22.
2. Elias S. Perforators: incompetent or pathologic?
International vein congress, Miami; 2010.
3. Sandri JL, Barros FS, Pontes S, et al. Diameter re fl ux
relationship in perforating veins of patients with vari-
cose veins. J Vasc Surg. 1999;30:867–75.
4. Labropoulos N, Tassiopoulos AK, Bhatti AF, et al.
Development of re fl ux in the perforator veins in limbs
with primary venous disease. J Vasc Surg.
2006;43:558–62.
5. O’Donnell Jr T. Role of perforators in chronic venous
insuf fi ciency. Phlebology. 2010;25:3–10.
6. Marston W, Keagy B. Incidence of and risk factors for
iliocaval venous obstruction in patients with chronic
venous leg ulcers. Abstract AVF annual meeting,
Amelia Island; 2010.
7. Neglen P, et al. Stenting of the venous out fl ow in
chronic venous disease: long term stent related out-
come, clinical and hemodynamic results. J Vasc Surg.
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8. Sato DT, Goff CD, Gregory RT, et al. Subfascial per-
forator vein ablation: comparison of open versus
endoscopic techniques. J Endovasc Surg. 1999;6:
147–54.
9. Pierik EG, Van Urk H, Hop WC, et al. Endoscopic
versus open subfascial division of incompetent perfo-
rating veins in the treatment of leg ulceration: a ran-
domized trial. J Vasc Surg. 1997;26:1049–54.
10. Nelzen D. Prospective study of safety, patient satis-
faction and leg ulcer healing following saphenous and
subfascial endoscopic perforator surgery. Br J Surg.
2008;87:86–91.
11. TenBrook Jr JA, Iafrati MD, O’Donnell Jr TF, et al.
Systematic review of outcomes after surgical manage-
ment of venous disease incorporating subfascial endo-
scopic perforator surgery. J Vasc Surg. 2004;39:
583–9.
12. Elias SM. Single port SEPS: less is more. Presented at
the American Venous Forum annual meeting, Orlando;
2004.
13. Tawes RL, Barron ML, Coello AA, et al. Optimal
therapy for advanced chronic venous insuf fi ciency.
J Vasc Surg. 2003;37:545–51.
14. Whiteley MS, Smith JJ, Galland RB. Tibial nerve
damage during subfascial endoscopic perforator sur-
gery. Br J Surg. 1997;84:512.
15. Stuart WP, Adam DJ, Brandbury AW, et al. Subfascial
endoscopic perforator surgery is associated with
signi fi cantly less morbidity and shorter hospital stay
than open operation (Linton’s procedure). Br J Surg.
1997;84:1364–5.
16. La Croix H, Smeets A, Nevelsteen A, et al. Classic
versus endoscopic perforating vein surgery: a retro-
spective study. Acta Chir Belg. 1998;98:71–5.
17. Elias S, Peden E. Ultrasound guided percutaneous
ablation for the treatment of perforating vein incom-
petence. Vascular. 2007;15:281–9.
18. Elias SM. Will SEPS be around in the next 5 years?
Presented at the international vein congress, Miami; 2005.
19. Hobbs JT. Surgery and sclerotherapy in the treatment of
varicose veins, a random trial. Arch Surg. 1974;109:793–6.
20. Thibault PK, Lewis WA. Recurrent varicose veins.
Part 2: injection of incompetent perforating veins
using ultrasound guidance. J Dermatol Surg Oncol.
1992;18:895–900.
21. Guex JJ. Ultrasound guided sclerotherapy (UGS) for
perforating veins (PV). Hawaii Med J. 2000;59:261–2.
22. Gloviczki P, Bergan JJ, Rhodes JM. Mid-term results
of endoscopic perforator vein interruption for chronic
venous insuf fi ciency: lessons learned from the North
American Subfascial Endoscopic Perforator Surgery
Registry. The North American Study Group. J Vasc
Surg. 1999;29:489–502.
23. Ciostek P, Myrcha P, Noszczyk W. Ten years experi-
ence with subfascial endoscopic perforator vein sur-
gery. Ann Vasc Surg. 2002;16:480–7.
24. Ting ACW, Cheng SWK, Ho P, et al. Clinical out-
comes and changes in venous hemodynamics after
subfascial perforator vein surgery. Surg Endosc.
2003;17:1314–8.
25. Roka F, Binder M, Boher-Sommeregger K. Mid-term
recurrence rate of incompetent perforating veins after
combined super fi cial vein surgery and subfascial
endoscopic perforating vein surgery. J Vasc Surg.
2006;44:359–63.
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11511 Treatment of Incompetent Perforating Veins
26. van Rij AM, Hill G, Gray C, et al. A prospective study
of the fate of venous leg perforators after varicose vein
surgery. J Vasc Surg. 2005;42:1156–62.
27. Masuda EM, Kessler DM, Lurie F, et al. The effect of
ultrasoundguided sclerotherapy of incompetent perfo-
rator veins on venous clinical severity and disability
scores. J Vasc Surg. 2006;43:551–7.
28. Gales S, Chang D, Peden E, et al. Ultrasound-guided
percutaneous radiofrequency obliteration for treat-
ment of perforating vein incompetence. Presented at
the Society for Clinical Vascular Surgery annual
meeting, Las Vegas; 2006.
29. Proebstle TM, Herdemann S. Feasibility of incompe-
tent perforator vein ablation by endovenous laser
treatment. Presented at the German Phlebologic
Society annual meeting, Frankfurt; 2005.
30. Elias S. Chapter 48: Percutaneous ablation of perfora-
tors. In: Gloviczki P, editor. Handbook of venous
disorders. 3rd edn. London: Hodder Arnold; 2009.
Bacon J, et al. Five year results of perforator vein clo-
sure using transiluminal occlusion of perforator.
Phlebology. 2009;24:74–8.
31. Marsh P. One year outcomes of radiofrequency abla-
tion of incompetent perforating veins using RF stylet
device. Phlebology. 2010;25:79–84.
32. van Gent WB, Hop WC, van Pragg MC. Conservative
versus surgical treatment of venous leg ulcers: a pro-
spective, randomized, multicenter trial. J Vasc Surg.
2006;44:563–71.
33. Stacey MC, Burnand KG, Layer GT, Pattison M. Calf
pump function in patients with healed venous ulcers is
not improved by surgery to the communicaitong veins
or by leastic stockings. Br J Surg. 1988;75:436–9.
34. Gloviczki P, Comerota A, Dalsing MC et al. The care
of patients with varicose veins and associated chronic
diseases: Clinical practice guidelines of the Society
for Vascular Surgery and the American Venous Forum.
J Vasc Surg 2011;53:2S–48S.
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117
N.S. Sadick et al. (eds.), Practical Approach to the Management and Treatment of Venous Disorders,
DOI 10.1007/978-1-4471-2891-5_12, © Springer-Verlag London 2013
1 2
In this chapter we will review the logic behind
the treatment selection for eliminating varicose
tributary veins in a given patient. These decisions
are based on data, clinical and anecdotal experi-
ence and represent the perspective of the author.
The reader should understand that some of these
recommendations may not be the opinions of all
practitioners or even all of the editors; when such
a recommendation exists this author will try to
present alternative approaches and some of the
logic behind the speci fi c recommendation. Also
recognize that the choice of a treatment option
when several are appropriate should re fl ect the
skill set of the practitioner.
There is a clear understanding of the aesthetic
bene fi ts of eliminating varicose veins. However, the
physiological value of eliminating of these low-pres-
sure varicose tributaries is often not appreciated. The
discomfort patients’ with SVI feel is related to
venous hypertension in these dilated veins.
Eliminating the truncal re fl uxing fi lling these tribu-
taries does lower their pressure, but most patients
still have residual symptoms since veins still have
higher than normal pressures. Eliminating the
remaining tributaries invariably relieves this discom-
fort and further improves patients’ quality of life.
Another consideration is that the residual
re fl uxing veins, often described as the “varicose
reservoir” [ 1 ] act as low-pressure sumps, recruit-
ing blood from other upstream tributaries in order
to re fi ll after re fl uxing downward. I appreciate that
many dilated tributaries shrink and venous hyper-
tension and it’s associated symptoms are improved
after procedures such as endovenous thermal abla-
tion (EVTA). However, it is my opinion based on
clinical experience that a reasonable fraction of
clinical recurrences are caused by these untreated
persistently re fl uxing tributaries. These observa-
tions include re fi lling of a varicose tributary reser-
voir after successful truncal ablation by a parallel
truncal vein that re fl uxes in spite of the fact that it
was normal before (Fig. 12.1 ). Elimination of the
tributary varicosities will likely help minimize
such occurrences and in my opinion provide
increased durability for symptomatic control.
Treatment of varicose tributaries is accom-
plished with microphlebectomy or “chemical
ablation”, also commonly known as sclerother-
apy. Sclerotherapy is a misleading term to the
non-phlebological community to whom in some
part of the world the terms implies purely cos-
metic treatment. In reality, sclerotherapy as dis-
cussed in this chapter is a chemical ablation
treatment to eliminate physiologically important
abnormal veins. It has been suggested the term
sclerotherapy be replaced by “chemical abla-
tion”. This term can refer to all uses of an inject-
able liquid or foamed drug delivered with visual,
trans-illuminated, ultrasound or fl uoroscopic
guidance, to cause the ablation of veins.
Tributary Treatment Strategies:
Treatment of Varicose Veins
Neil M. Khilnani
N. M. Khilnani , M.D.
Weill Cornell Vascular and
the Division of Interventional Radiology,
New York Presbyterian Hospital-Weill Cornell
Medical Center , 416 East 55th Street,
New York , NY 10022 , USA
e-mail: nmkhilna@med.cornell.edu
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118
N.M. Khilnani
Recommendation 1: Eliminate Truncal
Re fl ux
As already discussed in prior chapters, it is
generally felt that the identi fi cation and elimi-
nation of sources of truncal re fl ux in most cases
should precede the direct treatment of any asso-
ciated varicose tributaties. Using an analogy,
the varicose veins are much like the puddle near
the kitchen sink. If the cause of this spill is a
leaky pipe under the sink, the puddle will come
back if the only solution offered is to dry the
puddle. However, sealing the leaky pipe fol-
lowed by elimination of the puddle will provide
a durable solution to the problem. This recom-
mendation is not based on clinical trial but
Great saphenous vein
a b
Fig. 12.1 Diagrams demonstrating a common pattern of
recurrence of varicose veins and symptoms following
EVTA highlighting the importance of eliminating the
varicose reservoir. After ablation of a re fl uxing GSV ( a )
the varicose veins related to it are decompressed. However,
although they might shrink in size they still persist as a
low-pressure sump. Often, the varicose veins can re-pres-
surize and again be associated with symptoms by fi lling
from new re fl ux in the parallel AAGSV that had previ-
ously been normal ( b )
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11912 Tributary Treatment Strategies: Treatment of Varicose Veins
rather on a long experience with the care of
varicose veins. This recommendation is gener-
ally accepted.
There is some evidence that not all incompe-
tent trunks need to be treated fi rst. Pittaluga and
colleagues [
1 ] have suggested using certain DUS
criteria to identify some forms of saphenous
re fl ux which may not need to be treated fi rst.
These investigators have used microphlebectomy
to eliminate the varicose tributaries and have had
durable elimination of the veins and symptoms
and has seen resolution or improvement in the
degree of truncal re fl ux in some of these patients.
His preliminary work suggests that with properly
selected patients this treatment can be durable. In
the author’s experience, when the saphenous
trunk is small and the re fl ux is mild, microphle-
bectomy without truncal ablation can be success-
ful as described. The criteria for this selective
approach are evolving and may include the diam-
eter of the truncal vein (under about 7 mm) and
the degree and pattern of re fl ux and its complete
coverage is beyond the scope of this text.
However, keep in mind that for most patients,
elimination of truncal re fl ux followed by elimi-
nation of the varicose veins will be the best means
of getting durable treatment.
Recommendation 2:
Microphlebectomy (aka Ambulatory
Phlebectomy (AP) or Stab
Phlebectomy)
Table 12.1 reviews some of the criteria for select-
ing microphlebectomy over chemical ablation for
the treatment of speci fi c varicose veins.
Microphlebectomy is recommended when
treating large visible varicose veins for several
reasons. First, it is very ef fi cient, as most
signi fi cant accessible veins can be removed in a
single setting. Microphlebectomy is also very
easy to learn. The alternative approach, large ves-
sel chemical ablation, obligates the physician to
periodically express intravascular thrombus or so
called “trapped blood” that is invariably associ-
ated with signi fi cant tenderness and skin pigmen-
tation after treatment. As discussed earlier, the
trapped blood that is much more signi fi cant in
large diameter tributary veins after treatment
needs to be expressed to eliminate the discomfort
associated with it and minimize the duration of
skin pigmentation and the risk of permanent pig-
mentation. Patients who undergoing large vessel
sclerotherapy should be informed that they are
committed to several sessions of trapped blood
removal for this reason.
There is one randomized evaluation compar-
ing visually directed chemical ablation with a liq-
uid agent with microphlebectomy for the
treatment of varicose veins of the anterolateral
thigh. In this study, microphlebectomy was asso-
ciated with a signi fi cantly lower risk of recur-
rence of varicose veins at the expense of a higher
rate of self-limited blisters following phlebec-
tomy [
2 ] . This trial is confounded by the fact that
it involved only one investigator, that the sclero-
therapy technique involved only one treatment
visit and that the vein treated may have re fl ected
a heterogeneous population which may have dif-
fered between groups. The veins treated were not
described using antiquated nomenclature. The
patients in this study may have had a heteroge-
neous collection of re fl ux in an AAGSV, the ante-
rior circum fl ex vein of the thigh and proximal
GSV. Despite these limitations, this paper does
suggest a possible advantage for phlebectomy
when treating varicose veins particularly when
the source of the re fl ux is not be eliminated.
Incompetent perforating vein (IPV) associated
varicose veins have the possibility of returning
unless the source of incompetence itself is elimi-
nated. The intuitively ideal procedure would
remove or durably close the perforator from its
source from the deeper vein without adversely
Table 12.1 Criteria for selecting microphlebectomy
over chemical ablation for the treatment of speci fi c vari-
cose veins
Visible veins (or visible with transillumination)
Larger veins ( ³ 6 mm)
Veins associated with incompetent perforator vein
(IPV)
Bucket handle vein pattern (varicose tributary veins
potentially isolated by truncal ablation)
Varicose tributaries associated with truncal re fl ux that
will not be treated (rare situation)
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120
N.M. Khilnani
affecting the deep vein or causing any injury to
adjacent structures. However, access to accom-
plish this, including the cosmetic morbidity asso-
ciated with a larger scar and in some locations
like the popliteal fossa neurovascular complica-
tions associated with deeper exploration has led
to more conservative treatment recommendations
as a fi rst approach. Thermal ablation and subfa-
cial endoscopic perforator ligation (SEPS) are
not recommended as a fi rst approach for treat-
ment of IPV related uncomplicated varicose veins
(CEAP C2–C3 disease) because of the complex-
ity and cost of these treatments. Direct elimina-
tion of the varicose veins with chemical ablation
or AP as close as possible to the IPV is generally
recommended with the goal of isolating the per-
forators out fl ow to the super fi cial venous system.
In practice both approaches may address the IPV
itself in some cases by either avulsion or sclerosis
but the reliability has not been investigated. As
mentioned the choice of the technique parallels
the physician’s skill set; there is little evidence to
support one technique over another at this point.
My preference is if I see a large out fl ow vari-
cose vein from an IPV leading to a discrete path-
way of incompetence is to use AP. For larger
veins, AP is very safe and may avoid the risks
posed by high concentration liquid and foamed
sclerosants fl owing into the deep venous system
through the IPV. AP has the potential to remove
the IPV or a portion of it when attempting to
remove the fi rst visible varicose vein it produces.
AP may also minimize the risk of telangiectatic
matting that can occur if chemical ablation is
unsuccessful in occluding a feeding IPV. AP is
used to completely eliminate the IPV associated
pathway or to at least debulk it. Subsequent
chemical ablation, usually directed visually or
with trans-illumination, can then be used to elim-
inate the remainder of the pathway after the con-
nections to the high-pressure source have been
disconnected.
I use visual or trans-illumination directed
chemical ablation to treat the varicose cluster
originating from an IPV if the veins are small, if
they are part of a diffuse network of veins and if
the IPV itself is small. When performing the scle-
rotherapy I would choose visually directed injec-
tions. If the only visible veins are relatively far
from the IPV, US guided injections into some-
what deeper veins leaving the IPV may be more
desirable. It is important to recognize that an
artery frequently accompanies the IPV through
the fascia. As a result there is a risk of arterial
injection and possible ulceration if an injection is
directed into the artery. There is also a risk of
thrombosis of the deep vein from which the IPV
is connected to if the sclerosant enters the deep
veins with a suf fi cient concentration and contact
time.
After truncal ablation, larger varicose veins
(>6–8 mm in diameter) or those of even a smaller
size that are “isolated” by the truncal ablation, in
a so-called “bucket handle” appearance, are prone
to spontaneous thrombosis (Fig.
12.2 ). Once
thrombosed they can be dif fi cult to treat with
either subsequent chemical ablation or AP and
can causes tender lumps for the patients that are
prone to skin pigmentation. It is recommended
that these types of veins be treated with AP at the
time of the ablation procedure to minimize this
risk.
As mentioned, there is a recent debate about
whether mild re fl ux in small truncal veins requires
treatment prior to direct treatment of the varicose
veins it is associated with. The data collected by
Pittaluga and colleagues was for patients with
truncal re fl ux treated only with AP. Although
chemical ablation may be equally ef fi cacious in
this role, it has not been investigated. As a result
I would recommend using AP rather than sclero-
therapy if one is planning not to treat related
saphenous re fl ux.
Recommendation 3: Chemical
Ablation
Chemical ablation is an important technique for
eliminating varicose tributaries and is recom-
mended as a primary treatment of veins which
can be categorized as in Table 12.2 .
Smaller varicose veins and particularly those
with more complex interconnected networks are
best treated with this technique. Smaller veins do
develop trapped blood, but to a lesser extent, and as
a result permanent pigmentation is less likely. For
such veins less numbers of microthrombectomy
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12112 Tributary Treatment Strategies: Treatment of Varicose Veins
sessions would be required to remove the trapped
blood. Also, the number and the size of the AP
nicks that are likely required to deal with the more
intricate networks of veins would pose a greater
cosmetic risk than that of the lesser degree of pig-
mentation itself. A classic example of such a vein
network is the reticular vein varicosities frequently
seen on the lateral thigh often associated with spi-
der telangiectasias which are easily treated with
visual and trans-illuminated liquid ablation.
Patients with pudendal or gluteal vein varicose
pathways are great candidates for chemical abla-
tion. The largest veins in these pathways are usu-
ally £ 6 mm. I routinely use a combination of
visual and tran-illuminated liquid sclerotherapy
with great success and a high rate of durability.
Of course, with very large veins, AP may be
required. With very large veins, AP can also be
used to de-bulk the venous burden in the thigh
and calf of these patterns. Visual and trans-illu-
minated chemical ablation can then be used to
eliminate the veins near the groin or gluteal crease
and the smaller veins downstream.
The degree of pelvic incompetence is almost
always minor and the infrainguinal varicosities
and associated symptoms are almost always suc-
cessfully managed by compression sclerotherapy.
Only in the small minority of patients in whom
there is an early recurrence or veins or symptoms,
when the veins are >8–10 mm or when severe
pelvic pain of a character strongly suggesting
substantial pelvic venous insuf fi ciency exists
does one need to search and potentially address
ovarian or internal iliac vein incompetence.
Anecdotally, chemical ablation works very
well in anticoagulated patients without an
increased rate of complications. Also, anecdot-
ally, AP can be performed safely in patients with
INRs up to the 2.0 range. For patients with large
varicose veins, in whom there is medical risk or
inconvenience associated with stopping or lower-
ing the dose of a Vitamin K antagonist, chemical
A
B
C
Fig. 12.2 Diagram depicting re fl ux in the GSV. In this
case, the re fl ux leaves the GSV at Point A and re-enters the
GSV at Point B . Durable treatment would require elimina-
tion of re fl ux in both segments and may be accomplished
using EVTA with one puncture at Point C if the GSV
between Points A and B is traversable with the treatment
catheter. Otherwise it may require two punctures at Points
C and A . Also, treatment of the GSV in such a case is
associated with an increased incidence of super fi cial phle-
bitis in the so called “bucket handle” pattern of associated
varicose veins. This is true since the primary in fl ow and
out fl ow of tese varicose veins are simultaneously ablated
with EVTA as described
Table 12.2 Criteria for selecting chemical ablation for
the treatment of speci fi c varicose veins
Smaller varicose veins (<6 mm)
Reticular veins
Varicose tributaries derived from a pudendal or gluteal
pathway of incompetence
Varicose veins in patients on warfarin
Veins in AP “cautions zones”
Patients with risk of keloid
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122
N.M. Khilnani
ablation is a reasonable option, regardless of veins
size, as long as the patient understands the need
for several sessions of trapped blood removal.
Another situation to consider chemical abla-
tion is when treating vein in the region of the
common peroneal nerve. The CPN is super fi cial
and therefore vulnerable to injury along the lat-
eral popliteal fossa and again just under the
fi bular head. Certainly caution can be exercised
in these areas when performing AP. However,
visually or trans-illuminated chemical ablation
can be considered as an alternative in patients
with veins in these areas, even if it is just applied
to the veins in the vulnerable sites as an adjunct
to AP.
Recommendation 4: Image Guided
Chemical Ablation
Image guided chemical ablation applies to the
treatment of varicose tributaries that are not visi-
ble to the naked eye or with trans-illumination.
Ultrasound guided Sclerotherapy (UGS) with
foam or liquid sclerosants is an important adjunct
for patients with veins that are not visible but are
signi fi cant conduits to propagate incompetence
to lower levels in the leg. Table
12.3 reviews
some of the indications for use of UGS.
I do not use UGS often as most varicose tribu-
taries can be treated with visual chemical abla-
tion or AP. The most common indication is to
treat the non-visible components of a neovascu-
larization recurrence beginning around the level
of the SFJ following a prior ligation and stripping
of the GSV. A similar pattern of abnormal veins
exists at the SPJ and with recurrences following
attempted closure of IPV. A similar pattern of
abnormal veins may exist at the groin in multipa-
rous woman even without prior surgery. In both
multiparous patients and patients with prior sur-
gery, tortuous tributaries in the saphenous space
without truncal re fl ux are occasionally seen and
can be treated with image guided chemical abla-
tion. The aforementioned patterns resemble
venous malformations which are treated in simi-
lar ways.
In obese patients, straight segment extra-fas-
cial varicose veins can be safely and ef fi ciently
treated with thermal ablation since the veins are
not close to the skin. However, UGS is very
useful in obese patients with deeper tortuous
varicosities.
Fluoroscopically guided chemical ablation is
another image guided approach to treating non-
visible varicose tributaries and has been widely
applied to treat venous malformations. There are
some situations where fl uoroscopically guided
treatment may have some advantages. Sclerosants
are mixed with iodinated contrast material and
injection is performed with image guidance. The
technique allows precise control of the extent of
sclerosing solution distribution, with injection
termination and manual external compression
with radio-opaque instruments such as a sponge
stick used to prevent fi lling of deep veins.
Situations where this technique has been
described as helpful are in obese patients with
long non-truncal varicose pathways including the
tortuous varicose veins running in the saphenous
sheath, in patients with pudendal vein varicies
where re fl uxing up into the pelvic source veins is
though helpful, in varicose tributaries associated
with recalcitrant IPVs or neovascularization fol-
lowing prior surgery.
The relative merits of both of these forms of
image-guided chemical ablation are anecdotal
and based on the skill sets of the operators.
Summary
Several choices exist for the elimination of vari-
cose tributaries. Size plays a large part of the
selection between techniques. However, practi-
cality, patient and operator preference are
Table 12.3 Criteria for selecting US-guided chemical
ablation for the treatment of speci fi c varicose veins
Veins associated with “neovascularization” seen after
saphenous ligation
Deeper varicose veins inaccessible to phlebectomy or
visual sclerotherapy and not amenable to EVTA
because of toruosity or short segments
Varicose veins associates IPVs, especially recurrences
following prior treatment
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12312 Tributary Treatment Strategies: Treatment of Varicose Veins
important issues to consider as well. In point of
fact, several of the approaches are often used in
a single patient. A typical example is AP may be
performed on the larger varicose veins at the
same time an ablation of a saphenous vein
occurs. This is followed later by several sessions
of visual sclerotherapy chemical ablation and a
session of UGS to eliminate the remaining
important re fl uxing tributaries.
References
1. Pittaluga P, Chastanet S, Rea B, Barbe R. Midterm
results of the surgical treatment of varices by phlebec-
tomy with conservation of a re fl uxing saphenous vein.
J Vasc Surg. 2009;50(1):107–18.
2. de Roos KP, Nieman FH, Neumann HA. Ambulatory
phlebectomy versus compression sclerotherapy: results
of a randomized controlled trial. Dermatol Surg.
2003;29(3):221–6.
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