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158 Superfi cial Surgery and Perforator Interruption in the Treatment
of pre-existing 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 insuffi ciency after intervention.
If surgical treatment is chosen, it remains prudent to perform a complete
branch ligation as previously described.
Numerous methods have been described for removal of the saphenous
veins after high ligation. The current trend is toward minimizing the inva-
siveness of surgical intervention, and numerous alternatives to surgical
stripping have been introduced. However, it should be noted that stripping
procedures themselves have undergone a signifi 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. Key advances have included the use of detailed preoperative
venous mapping to plan surgery and the use of intraoperative ultrasound
to locate the saphenofemoral junction and precisely place incisions. In the
absence of signifi cant obesity, the SFJ ligation can be performed through
a 2–3-cm modifi ed transverse incision. Using ultrasound guidance, the
GSV can be located just below the knee and encircled through an incision
no larger than 1 cm. We typically use tumescent anesthesia and temporary
packing along the saphenous tract to minimize bruising. Patients walk
upon leaving the ambulatory surgery center and routinely return to work
and other routine activities within several days. In many patients, the more
signifi cant morbidity comes from the associated stab or powered phlebec-
tomies performed concurrent to saphenous stripping to remove prominent
varicosities.
The following issues in superfi cial venous surgery will be discussed in
detail later in this chapter:
• Saphenofemoral ligation alone or ligation and saphenous stripping
• Saphenous stripping to the ankle or to the knee
• Small saphenous refl ux
• Need for concomitant varicosity ablation
• Concurrent deep and superfi cial insuffi ciency
SAPHENOFEMORAL LIGATION ALONE OR
LIGATION AND SAPHENOUS STRIPPING
It has long been debated whether high ligation alone or with varicosity
ablation is suffi cient for the treatment of superfi cial venous refl ux. Propo-
nents argue that preservation of the saphenous vein is preferable to allow
later use as a conduit and that the rate of recurrent symptoms without
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Superfi cial Surgery and Perforator Interruption in the Treatment 159
stripping is acceptable. Hammarsten et al. reported a random allocation
of 42 patients to high ligation with varicosity avulsion or high ligation with
saphenous stripping and varicosity avulsion.
6
In both groups, incompetent
perforators were ligated whenever present. At a mean follow-up of 52
months, there was no difference in the rate of recurrent symptomatic VV
between the two treatment groups (12% in those with stripping and 11%
in those without).
Proponents of high ligation with GSV stripping have noted the increased
incidence of recurrent refl ux in the saphenous vein after high ligation alone
and maintain that optimal results require routine saphenous stripping.
Investigators looking at the residual GSV after high ligation without strip-
ping have identifi ed frequent residual refl ux in the GSV. McMullin et al.
reported residual refl ux in 24 of 52 cases (46%) after SFJ ligation and found
that those with persistent refl ux did not correct venous refi lling times mea-
sured by PPG.
7
The Gloucestershire Vascular Group reported 5-year
follow-up of 110 limbs randomized to high ligation alone compared to
ligation plus stripping.
8
Although patient satisfaction was similar in the two
groups, signifi cantly fewer patients in the stripping group required reopera-
tion for recurrent saphenous refl 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. Studies following patients longer than 10 years report that many patients
develop recurrent varicosities of some severity. In Fischer’s defi nitive
report of the long-term follow-up of limbs treated with high ligation and
stripping, 47% of patients followed for an average of 34 years developed
clinically evident varicosity recurrence.
9
Although early recurrence was
less frequent in some studies in limbs treated with stripping, this benefi t is
probably lost over time. The primary benefi t of stripping appears to be a
reduction in the number of limbs requiring reoperation. It has been sug-
gested 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 anes-
thesia and other techniques, as noted previously. The most signifi cant
complication attributed to saphenous stripping involves injury to the saphe-
nous nerve. Fully described later in this chapter, there is a signifi cant
incidence of saphenous nerve defi cit after stripping, which is reduced when
stripping stops at the level of the knee. Overall, few patients appear to have
long-term defi 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
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160 Superfi cial Surgery and Perforator Interruption in the Treatment
recovery time and reduced potential for bruising and nerve injuries are
more important. But in patients with VLUs, 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 refl ux is
undesirable. The high incidence of residual saphenous refl ux and signifi -
cant frequency of reoperation when stripping is not performed argue in
favor of high ligation and stripping as the preferred surgical operation for
VLUs due to GSV refl ux.
SAPHENOUS STRIPPING TO THE ANKLE OR
TO THE KNEE
If GSV stripping is chosen as a component of a procedure for the treat-
ment of CVI, the surgeon must determine the length of vein to remove. In
most cases, the vein refl uxes at both the saphenofemoral junction and
throughout its course. Traditionally, many surgeons have elected to strip
the entire vein from groin to ankle. The saphenous vein is easily identifi ed
at the ankle, and retrograde passage of the stripper is generally unob-
structed. 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 the knee.
To determine whether a limited GSV stripping to the knee would be
suffi cient to yield improvement in venous hemodynamics, Nishibe et al.
studied 110 limbs before and after removal of the above-knee segment of
GSV using duplex ultrasound APG.
10
They found that venous hemody-
namics as measured by APG were markedly improved after limited GSV
stripping. The majority of patients experienced correction of the abnormal
preoperative VFI (4.0 ± 0.35 ml/sec) to the normal range (1.4 ± 0.15, p <
0.001). The incidence of apparent saphenous nerve injury on assessment
at 2–3 weeks after surgery was 4.5%, with most of these patients reporting
numbness, mild to moderate pain, or sensitivity to touch in the affected
areas.
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 (Group A) compared to high ligation and stripping to
the knee (Group B).
11
Three months after surgery, 94% of patients
in Group A reported good or excellent relief of symptoms compared
to 97% of patients in Group B (p = NS). Evidence of saphenous injury
was identifi ed in 39% of limbs in Group A compared 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. Three years after randomization,
29% of limbs in Group A were reported to display symptoms of permanent
saphenous nerve injury compared to only 5% in Group B (p < 0.01). At 5
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Superfi cial Surgery and Perforator Interruption in the Treatment 161
years of follow-up, recurrent varices were seen in 10% of patients in each
group.
In a detailed study of the incidence and clinical impact of saphenous
nerve injury, Morrison and Dalsing evaluated 127 limbs treated with saphe-
nous stripping to the ankle at a mean follow-up of 4.5 years.
12
Overall, 40%
of patients reported symptoms of saphenous nerve injury at some point
after operation. At last follow-up, 17% reported the symptoms were per-
sistent, but only 2.3% reported that the symptoms negatively affected their
quality of life.
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. Therefore, most authors have recommended stripping to the knee
as the treatment of choice for axial GSV refl ux.
Small Saphenous Refl ux
Often overlooked is the possibility that ulceration may be due solely to
refl ux in the SSV. In a report of 20 limbs with isolated lateral perimalleolar
ulcers, Bass and colleagues found isolated SSV refl ux at the saphenopop-
liteal junction in 15 limbs (75%).
13
After SSV ligation at the junction, all
ulcers healed within 12 weeks. In general, SSVs with suffi cient refl ux to
cause severe CVI are large, dilated veins with numerous varicose tributar-
ies. Hemodynamic evaluation with plethysmography is often useful to
determine whether isolated SSV refl ux is hemodynamically signifi cant.
Patients with SSV refl ux are unlikely to result in leg ulceration without an
abnormal venous fi lling index.
Prior to intervention for patients with SSV incompetence, the anatomy
of the vein must be carefully determined. The variable course of the SSV
has been well documented, and the vein may terminate at numerous points
into the popliteal vein, the femoral vein, the vein of Giacomini, or else-
where. The presence of a large persistent superfi cial vein in the lateral thigh
that does not join the deep system should alert the clinician to the possibil-
ity of a variant of Klippel-Trenaunay syndrome with hypoplastic deep
veins.
Preoperative mapping of the SSV with ultrasound and marking of the
saphenopopliteal junction (SPJ) will assist with operative planning. Sur-
geons performing SPJ ligation frequently are using intraoperative ultra-
sound to guide surgical decision making. The SSV may give off several
branches just distal to the SPJ, and it is believed to be benefi cial to ligate
these branches to minimize residual collateral refl 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 saphe-
nopopliteal ligation to ligation with SSV stripping, most authors have rec-
ommended stripping a portion of the SSV. Stripping should generally not
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162 Superfi cial Surgery and Perforator Interruption in the Treatment
involve the lower third of the calf given the increased risk of injury to
the sural nerve.
Need for Concomitant Varicosity Ablation
Correction of saphenous and perforator insuffi ciency will improve
hemodynamics with reliable reduction in VFI. For patients with VLU,
there usually is no medical need to perform concomitant varicosity abla-
tion. Some clinicians recommend removal of prominent varicose veins in
the area of the VLU, believing that this will reduce perforator refl ux into
the periwound area. However, there is no direct evidence that this will
improve the results of intervention, and most venous specialists recom-
mend specifi c treatment of incompetent perforators using a procedure
designed primarily to eliminate perforator refl ux as described in the fol-
lowing text.
Results of Conventional Saphenous Surgery
The hemodynamic improvement in patients undergoing saphenous
surgery has been well documented. Using APG, correction of saphenous
refl ux has been demonstrated to result in marked improvement in venous
fi lling index, ejection fraction, and residual volume fraction.
2
Patient satis-
faction 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
stripping assessed by a questionnaire.
14
Nearly two-thirds of patients
reported a perceived postoperative complication within the fi rst 2 weeks
after surgery, most relating to bruising, pain, and numbness. Six months
after surgery, 80% of patients were satisfi ed with the outcome, with the
most common reason for dissatisfaction being residual varicosities.
For patients with VLU, the ESCHAR study described previously found
a signifi cant benefi t for saphenous stripping in reducing the incidence of
ulcer recurrence, but no benefi t was demonstrated in accelerating the time
of ulcer healing.
5
Chronic venous disease has been reported to negatively affect patient
quality of life as assessed by a variety of outcomes measures. Using various
methodology, investigators have reported that saphenous vein surgery sig-
nifi cantly improves quality of life both initially following surgery and at
mid-term follow-up several years later.
In summary, saphenous stripping procedures have a proven ability to
correct venous hemodynamic dysfunction due to abnormal refl ux, resulting
in reduced ulcer recurrence and improved quality of life in the majority of
patients. Complications of surgery are most often minor and self-limited,
but an occasional patient may develop nagging discomfort from saphenous
neuralgia, and a rare possibility of DVT cannot be ignored.
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Superfi cial Surgery and Perforator Interruption in the Treatment 163
Alternatives to Conventional Saphenous Surgery
Numerous alternatives to conventional saphenous surgery have been
promoted to effectively eliminate saphenous refl ux without the need for
surgical incisions or saphenous removal. They include
• Hemodynamic correction of varicose veins (CHIVA)
• External banding to restore saphenous competence
• Endovenous ablation
䊊
Radiofrequency
䊊
Laser
• Sclerotherapy
䊊
Ultrasound guided
䊊
Foam
When we consider the optimal management of patients with VLUs, the
primary anatomic goal is to abolish axial refl ux and prevent its recurrence.
In these patients, recanalization or reopening of the previously treated
saphenous vein usually results in recurrence of the preintervention symp-
toms, including pain, swelling, worsening skin changes, and possibly ulcer-
ation. Most patients who have suffered 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 benefi t in reducing venous
ulcer recurrence. Many authors have assumed that if the GSV or SSV
remains closed with no refl ux throughout the length from groin to knee,
the patient should experience a benefi t similar to high ligation and strip-
ping procedures.
Saphenous banding procedures to attempt to re-establish competence
of the sentinel valve at the SFJ using either external banding materials or
endovenous radiofrequency have met with variable results. Despite encour-
aging reports of success in some studies, others have generated disappoint-
ing 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 refl ux. Initial attempts
employed liquid sclerosants, and though many saphenous veins were suc-
cessfully 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 fi 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 the GSV
under duplex guidance.
15
Three weeks after treatment, repeat examination
with duplex ultrasound revealed that only 40% of patients treated in the
liquid sclerotherapy group had eliminated refl ux throughout the GSV
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164 Superfi cial Surgery and Perforator Interruption in the Treatment
compared 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 signifi cantly
increase success rates, but long-term success may still be inferior to high
ligation and stripping. Randomized studies including quality of life evalu-
ations would further determine whether sclerotherapy has a role in the
treatment of saphenous refl ux for patients with VLU.
Of the listed alternatives to saphenous ligation and stripping proce-
dures, endovenous ablation has been the most widely studied, including
randomized comparisons to stripping. The goal of radiofrequency ablation
(RFA) or endovenous laser ablation (EVLA) is to ablate the saphenous
vein percutaneously eliminating saphenous refl ux, thereby producing the
same hemodynamic benefi t as high ligation and saphenous stripping with
no incisions, fewer complications, and faster recovery to full activity. Early
studies with both techniques have demonstrated initial saphenous closure
rates of over 90%. Long-term reports on the incidence of saphenous recan-
alization are now emerging, with acceptable 3–5-year results. In the
EVOLVeS study, RFA was compared to ligation and stripping in 86 limbs,
including quality of life measures and follow-up ultrasound examinations
at routine intervals. Initial success rates at elimination of saphenous refl ux
were 100% in the stripping group and 95% in the RFA group.
16
Time to
return to normal activities and return to work were signifi cantly less in the
RFA group. Quality of life surveys revealed a signifi cantly better global
score and a signifi cantly better pain score for RFA 1 week postprocedure,
but these differences progressively decreased over time. At 2 years 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).
No studies have compared the outcome of endovenous ablation to saphe-
nous stripping for patients with VLUs, and little information is available
on the incidence of ulcer recurrence after saphenous ablation using any of
the previously described methods. Most data on endovenous ablation have
been reported on procedures performed in CEAP class 2 and 3 patients.
One study reported the hemodynamic results of patients in CEAP classes
3–6 treated with radiofrequency or laser saphenous ablation. It included
29 patients in CEAP classes 5 and 6, and found that ablation resulted in
reliable correction in venous hypertension.
17
Seventy-eight percent of limbs
demonstrated a normal VFI postablation, and 95% had a VFI <4 ml /
second. Based on previous studies of post-stripping VFI, these patients
would be expected to have a low incidence of recurrent ulceration unless
saphenous recanalization were to develop.
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Superfi cial Surgery and Perforator Interruption in the Treatment 165
Combined Deep and Superfi cial Venous Insuffi ciency
Treatment of patients with leg ulceration and isolated superfi cial venous
insuffi ciency is usually recommended given the reproducible improvement
with correction of saphenous refl ux and the low-risk procedures available
for this patient group. In patients with CEAP classes 5 and 6 disease,
superfi cial insuffi ciency is often identifi ed in combination with deep disease.
As noted previously, 27% of these limbs studied were reported as having
combined refl ux. In this situation, the clinician must determine whether
benefi t is likely from treatment of superfi cial refl ux alone, or if the patient
is more likely to require deep venous reconstruction.
Several authors have reported that when superfi cial refl ux in the GSV
or SSV is present, the more proximal deep vein segment will occasionally
refl ux solely due to the superfi cial vein incompetence. Correction of the
superfi cial refl ux reliably results in resolution of the deep vein segment
refl ux. In this situation GSV incompetence would be seen along with refl ux
in the common femoral vein, but the femoral and popliteal veins would be
competent. With SSV refl ux, popliteal refl ux would be noted cranial to the
SPJ, but not caudal to the junction. With these patterns of refl ux, superfi cial
ablative procedures are recommended using the same criteria used for
superfi cial incompetence alone.
Treatment of limbs demonstrating true deep venous insuffi ciency,
defi ned as refl ux in the femoral and popliteal veins, combined with super-
fi cial refl ux, is controversial. Walsh and Sales reported resolution of deep
venous refl ux after GSV stripping in over 90% of cases, but Scriven
reported that deep venous refl ux usually did not correct. Puggioni et al.
reported a study of 38 limbs with combined deep and superfi cial refl ux
studied with duplex US before and after saphenous stripping.
18
Deep
venous refl ux was corrected in one-third of patients, and femoral vein
refl ux corrected more frequently when only segmental refl ux was present
in that vein rather than axial refl ux throughout the deep venous system.
The authors noted that the majority of limbs reported by Walsh and Sales
demonstrated segmental refl ux that may be more likely to correct with
superfi cial surgery than axial refl ux.
Padberg and colleagues reported a hemodynamic follow-up of 11 limbs
with deep and superfi cial disease treated with superfi cial stripping in all
cases and perforator ligation in some cases.
19
Although only 27% of limbs
studied postoperatively were found to have correction of deep venous
refl ux, marked hemodynamic improvement was demonstrated. The venous
fi lling index decreased from 12 ml/second preoperatively to 2.7 ml/second
postoperatively, and clinical symptom scores decreased from 10 to 1.4.
These data suggest that, though superfi cial and perforator surgery in the
presence of deep venous incompetence may not correct deep refl ux, it will
usually result in signifi cant hemodynamic and symptomatic improvement.
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166 Superfi cial Surgery and Perforator Interruption in the Treatment
In summary, it is reasonable to consider superfi cial ablative intervention
in patients with leg ulceration due to combined deep and superfi cial insuf-
fi ciency. Those with proximal or segmental refl ux are more likely to benefi t
than patients with full axial refl ux in the entire deep system. Hemodynamic
evaluation with plethysmography before and after saphenous stripping or
ablation can determine the degree of improvement and predict long-term
symptomatic improvement.
The Signifi cance of Perforator Refl ux in CVI
The incidence of perforator incompetence increases as the clinical
severity of CVI worsens. The majority of limbs in CEAP clinical classes 5
and 6 have been reported to contain perforators with incompetence on
duplex imaging. For this reason, some clinicians believe that incompetent
perforators should be corrected whenever they are diagnosed. Unfortu-
nately, it is diffi cult to clearly determine the hemodynamic signifi cance of
incompetent perforators because they are usually seen in limbs that also
display superfi cial and/or deep system incompetence. There clearly are
cases in which incompetent perforators are seen in a limb previously treated
with saphenous stripping with persistent leg ulceration. In these patients,
perforator interruption is necessary. But it is unclear whether perforators
should routinely undergo ligation in patients with VLU at the time of
saphenous ablation.
CONVENTIONAL SURGICAL LIGATION OF
INCOMPETENT PERFORATOR VEINS (IPVs)
When the surgeon believes that IPVs are associated with clinical symp-
toms, elimination of perforator refl ux can be performed using a variety of
techniques. Open surgical ligation, mini-incision ligation, subfascial endo-
scopic ligation, and percutaneous ablation can all be considered. Until the
last decade, only open surgical perforator ligation was performed, usually
using the Linton procedure. As originally described by Linton, the proce-
dure involves a medial lower limb incision placed over the site of the clini-
cally signifi cant IPVs. Dissection proceeds down to the level of the fascia
where the perforators are located and ligated with suture ligatures (Figure
12-5). The use of skin fl aps was advocated to help reduce the potential for
skin breakdown at the incision site postoperatively.
Though the Linton procedure was effective at eliminating perforator
refl ux, it has been associated with a high incidence of complications, mostly
occurring at the incision site in the area of hyperpigmented, scarred skin
typical of advanced CVI. In a report of 37 limbs treated with the Linton
procedure, Stuart et al. reported that calf wound complications occurred
in seven patients (19%), and the average hospital time was 9 days.
20
Recur-
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Superfi cial Surgery and Perforator Interruption in the Treatment 167
rent ulceration was reported in 7% to 22% of treated limbs at varying
lengths of follow-up after the Linton procedure.
For these reasons, alternate methods were developed to ligate IPVs
while eliminating the need for surgical incisions in the area of poor skin
expected to be at risk for compromised wound healing. The most widely
performed alternative to the Linton procedure is the use of endoscopy to
facilitate subfascial perforator ligation (SEPS) through a remote incision
in more healthy tissue just below the knee. The primary benefi ts of this
technique have been reported to include more rapid recovery and fewer
perioperative complications with equivalent hemodynamic results in com-
parison to the Linton procedure. In a retrospective comparison of SEPS
(n = 27) to the Linton procedure (n = 29), Sato et al. reported similar rates
of ulcer healing and recurrence, as well as a similar improvement in venous
dysfunction scores in the two groups. In the Linton group, 45% of patients
developed incision-related complications, compared to only 7% in the
SEPS group (p < 0.005).
21
In a prospective comparison of the Linton pro-
cedure to SEPS, Pierik et al. randomized 39 patients to open or endoscopic
perforator ligation.
22
In the open group, 53% of patients developed
FIGURE 12-5 Incision with fl ap dissection for Linton procedure.
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