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23
Surgical Treatments and New
Technologies/Day Care Strategies
Ronald K. G. Eifell
Department of Vascular and General Surgery, Queen Elizabeth Hospital,
Gateshead, U.K.
Tim A. Lees
Department of Vascular Surgery, Freeman Hospital, Newcastle upon Tyne, U.K.
INTRODUCTION
Historical Perspective
Venous ulceration had been documented as a medical problem since the fourth century
B.C., and the association between venous disease and lower limb ulcers was most likely
made by Hippocrates (1) who was also the first to propose the treatment of venous ulcers
using compression bandaging. Open surgery and elastic compression therapy have long
been the mainstay of treatment of varicose veins and chronic venous insufficiency (CVI);
however, relatively high recurrence rates and postoperative complications have led to the
search for more efficient and less invasive treatments. As a result, the treatment of
varicose veins has started to undergo a transformation.
Injection sclerotherapy has been used for many years with interest in foam
sclerotherapy initially developing in the 1950s, although the technique never really
became popular due to complications. Over the last 10 years there has been renewed
interest in foam sclerotherapy with the development of techniques that have improved the
quality of the foam sclerosants, enabling the treatment of varices that cannot be
successfully treated with liquid sclerosants.
Subfascial endoscopic perforator surgery was described in the mid 1980s, but its role
in the treatment of CVI remains uncertain and controversial, and as a result the technique
has been losing popularity. Other less invasive methods of treating varicose veins such as
endovenous ablation were pioneered over 40 years ago, but the techniques have only
recently been developed using radiofrequency and laser energy to produce promising
results. Other techniques such as transilluminated powered phlebectomy (TIPP) and
external valvular stenting (EVS) have been reported in Belgium and Australia,
respectively, over the past 2 years, but their benefits have not yet been proven over
other techniques.
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With the advent of less invasive, shorter duration procedures that do not necessarily
require an operating theater environment, more healthcare professionals such as
specialist nurses and radiologists have become involved in the treatment of varicose
veins and CVI.
Indications for Treatment
The presence of varicose veins is not in itself an indication for surgery, but patients with
symptoms and complications secondary to varicose veins should be considered for
treatment (2). Signs and symptoms of varicose veins and chronic venous insufficiency are
listed below:
† Venous ulcer
† Atrophie blanche
† Lipodermatosclerosis
† External bleeding
† Cosmetic appearance
† Aching
† Leg heaviness and leg fatigue
† Superficial thrombophlebitis
SURGICAL TREATMENTS
The objectives behind open surgery on incompetent superficial veins are the correction of
the hydrostatic forces of saphenous vein reflux and removal of hemodynamic forces
Treatment Options for Varicose Veins
These can be divided into surgical and non-surgical methods.
Conventional surgical options for varicose vein surgery include:
1. Saphenofemoral disconnection and groin-to-knee long saphenous stripping
2. Saphenopopliteal disconnectionG short saphenous stripping
3. Multiple phlebectomies
Non-surgical options include:
1. Reassurance
2. Elastic compression therapy
3. Sclerotherapy
New treatments include:
1. Subfascial endoscopic perforator surgery (SEPS)
2. Radiofrequency endovenous ablation (RFA)
3. Laser endovenous ablation (EVLT)
4. Powered phlebectomy (TIPP)
5. Venous cuffs/external valvular stenting (EVS)
6. Foam sclerotherapy
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of perforating vein reflux, along with improved cosmesis. These can be achieved by the
following methods:
† Ligation and disconnection of the long saphenous vein (LSV) and short
saphenous vein (SSV) at the saphenofemoral and saphenopopliteal
junctions, respectively
† Stripping of the LSV and SSV
† Avulsion of varices by performing multiple phlebectomies
† Ligation and division of incompetent perforators
SAPHENOFEMORAL DISCONNECTION (SFD) COMBINED
WITH LSV STRIPPING
Technique
In stripping the LSV, a 2–3 cm oblique incision is made in or 1 cm above the inguinal
skin crease, the lateral one-third of the incision being over the femoral pulse. All
tributaries at the saphenofemoral junction are ligated and divided and the junction is
flush ligated, taking special care not to narrow the lumen of the common femoral vein.
A disposable, flexible vein stripper, such as a Codman
w
Disposable Vein Stripper
(Johnson & Johnson, Raynham, MA, U.S.A.) or a rigid stripper such as the perforate-
invaginate PIN
w
stripper (Credenhill Ltd, Derbyshire, U.K.) is then introduced into the
cut end of the vein at the groin and passed distally along the LSV in the thigh. It is
exposed distally through a short incision made close to the knee. The stripper is pulled
through the wound and the distal end of the vein is ligated or avulsed. The proximal end
is ligated around the stripper with a strong suture, which is left long. The stripper is then
pulled distally, inverting the LSV, which is then removed through the lower incision.
The groin wound is closed with absorbable sutures and the distal wound for stripping
can be closed with Steri-Strips
w
. If concomitant multiple phlebectomies are required
(see below), these are performed following stripping and the avulsion wounds closed
with Steri-Strips
w
.
Results
The recurrence rate following SFD and LSV stripping is reported to be between 20% and
28% at five years (3,4) and Fischer et al. found that the prevalence of recurrent varicose
veins following SFD approached 60% in patients surviving 30 years or more (3). In
comparison, SFD alone has a five-year recurrence rate that is double that of disconnection
and stripping (3,5).
Complications following SFD depend on whether surgery is done for primary or
recurrent disease. The overall rate of minor complications (wound hematomas, wound
abscess, cellulitis and minor neurological symptoms) is about 17% (6), whereas major
complications such as deep femoral vein or arterial injuries occur in 0.05% to 0.8% of
patients who have undergone primary surgery (Table 1) (6,7). The overall complication
rate for primary SFD and LSV stripping is between 17% to 20% (6), while that reported
for recurrent groin exploration is 40% (8). Lymphatic complications and infection are
more common following surgery for recurrent varicose veins, where the incidence of
each complication is 26% and 16% respectively (8). The reported prevalence of
symptoms related to the saphenous nerve following surgery ranges from 6% to 40%
immediately postoperatively (6,9,10), but in the long term, the patient’s quality of life is
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only affected by saphenous nerve injury, which occurs in approximately 6.7% of
operations (9).
Discomfort and skin pigmentation can result from extravasation of blood
subcutaneously during and after stripping. Methods employed to try to minimize this
include leg elevation before and during stripping, use of a thigh tourniquet, and injection
along the vein tract prior to stripping with a solution of lignocaine and adrenaline (2).
There is no clear difference in the outcome whether the PIN
w
or the Codman
w
stripper is
used, but the exit wound with the PIN stripper has been shown to be smaller (11,12). The
risk of saphenous nerve injury is higher with full length stripping of the LSV to the ankle
(13) and is reduced if stripping is performed from groin to the knee. In addition, the most
significant calf perforators, known as Cockett’s perforators, do not originate from the LSV
but rather from the posterior arch vein of the calf. Therefore, stripping the LSV below the
knee will not treat perforator reflux (14).
SFD ONLY
Saphenofemoral junction disconnection has been practiced with the objectives of
controlling gravitational reflux while preserving the vein so that it may be used for arterial
bypass in the future. Hydrostatic forces, however, are not controlled along the vein distal
to the disconnection and reflux continues (15). Stripping of the LSV results in greater
diminution of the hydrostatic forces that result from venous reflux than that achieved
following high ligation and disconnection alone. As a result, recurrence of varicose veins
is more common when compared with disconnection and LSV stripping with or without
concomitant multiple phlebectomies or sclerotherapy (16,17).
SAPHENOPOPLITEAL JUNCTION DISCONNECTION (SPJ)
Saphenopopliteal and SSV incompetence occurs in approximately 15% of patients with
primary varicose veins. It is well known that the anatomy of the saphenopopliteal junction
(SPJ) is highly variable, as 60% of cases lie between 2 cm and 7 cm above the level of the
knee joint (18). The SSV joins the deep venous system in the thigh or joins the LSV in 30%
of individuals, and in 10% it joins the gastrocnaemius vein or LSV in the calf (18). It is for
this reason that pre-operative duplex mapping and marking of an incompetent SPJ is
essential. Ideally, both the junction and the point at which the vein penetrates the deep
fascia of the leg, as well as the course of the proximal segment of the vein, should
be marked.
Table 1 Complications of saphenofemoral Disconnection and Stripping with Stab Avulsions
Complication Overall incidence
Minor Wound hematoma/infection 2.8%
Nerve injury (numbness/tingling/pain) 6.6%
Lymphatic leakage !1%
Major CFV or CFA injury 0.05% to 0.8%
Abbreviations: CFV, common femoral vein; CFA, common femoral artery.
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Technique
With the patient in the prone position, a 2 to 3 cm transverse skin incision is made
between the pre-marked sites of the junction and point at which the vein pierces
the fascia. The fascia is opened transversely or vertically and the vein is ligated deep to
the fascia. Any tributaries connected to the SSV are also ligated and as long a segment
of the SSV as possible should be removed (2). Some surgeons advocate stripping of the
SSV to the mid or distal third of the calf. Stripping the full length of the vein is
unnecessary as reflux in the SSV is usually segmental (19) and the sural nerve is in
close proximity to the SSV in the lower two-thirds of the calf. During stripping, the
stripper and vein are brought through the skin distally through a small transverse skin
incision and the vein is carefully separated from the sural nerve prior to stripping to
avoid damage to the nerve.
Results
Relatively high reflux recurrence rates (40%–61%) have been reported following SPJ
disconnection (20,21), despite the use of preoperative duplex marking. This has been
attributed to poor operative technique (missed SPJ or suprafascial SSV disconnection),
inadequate preoperative duplex mapping (poor identification of SPJ anatomy or
perforators) or neovascularization reconnecting the popliteal vein to the SSV.
These recurrence rates might reflect a wide variation in practice by vascular
surgeons performing saphenopopliteal disconnections. In a large survey of over 370
vascular surgeons in the United Kingdom, there was much diversity in the management of
saphenopopliteal reflux (22). Duplex scanning was arranged for all patients by 89%
of surgeons, while preoperative duplex marking of the SPJ was practiced by only 59% of
surgeons (22). The low usage of preoperative duplex marking may contribute significantly
to the recurrence rate, as failure to identify the junction is known to be a major cause of
recurrence (23).
Complications include hematoma formation, bruising, popliteal DVT, sural and/or
cutaneous nerve injury, and herniation through a residual defect in the fascia of the
popliteal fossa, with an overall complication rate (excluding recurrence) reported in
the region of 5% of cases (21).
SAPHENOFEMORAL JUNCTION (SFJ) RECURRENCE
AND REDO SURGERY
It is estimated that up to 20% of all varicose vein operations are done for recurrent
varicose veins (24) and the recurrence rate following SFD has been reported to be
between 20% to 28% at five years (3,4). Stonebridge et al. found that the majority of
SFJ recurrences appear to be due to inadequate groin surgery resulting from failure to
ligate the saphenous vein flush with the common femoral vein or failure to strip the
LSV (25). This is thought to result in dilatation of small venous channels due to
altered venous hemodynamics and is one theory on the development of groin reflux.
Later ultrasound and histological studies have found that neovascularization
(serpentine, irregular tributaries) appears to be a principle cause of recurrence at
the saphenofemoral junction, but only in the presence of a persistent LSV or major
thigh vein (26–28). These findings support the discovery that using interposition
silicon or PTFE (polytetrafluoroethelyne) implants may lower the incidence of
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neovascularization after SFD and LSV stripping (29,30). Only one recently published
histological study failed to demonstrate that neovascularization occurs, favoring the
argument that new vessels at the site of groin recurrence represent adaptive dilatation
of pre-existing venous channels due to the change in venous hemodynamics (31). This
finding, however, has not been reported by other researchers.
The commonly held practical principle in performing redo varicose vein surgery
in the groin is to approach the SFJ laterally, by first exposing the artery, then
continuing the dissection medially, as described by Li (32). Ideally the recurrent SFJ
should be ligated and divided before more superficial dissection is performed. This
approach is preferred to direct dissection to the SFJ through the previous scar, which is
often associated with significant bleeding from irregular friable neovascularization
around the wound, damage to the common femoral vein, and consequently inadequate
surgery. Hayden et al. reported that this approach is associated with an increased
incidence of lymphatic leakage resulting from disruption of lymphatic channels around
the femoral artery (8). Such leakage, however, tends to settle with conservative
management but can last for several weeks. The LSV should be stripped if still present.
Occasionally a residual LSV may not be accessible from the groin if the upper portion
of the vein has been stripped. This should be documented by preoperative ultrasound
scanning and the course of the LSV marked on the skin before operation. The vein can
then be accessed at the knee and a stripper passed from knee to groin allowing
retrograde stripping of the vein. As mentioned, there is an increased incidence of
lymphatic leakage and infection following redo groin dissection for recurrence (8),
indicating that there may be a role for routine antibiotic prophylaxis in patients
undergoing redo groin dissection.
MULTIPLE PHLEBECTOMIES (STAB AVULSIONS)
These are performed using a small blade and a special hook to deliver the vein through
the incision, such as a Mu
¨
ller hook. Incisions are made over visible varicosities and are
usually 2 to 3 mm in length. The risk of saphenous nerve injury is low compared to
stripping the LSV below the knee. There is also a theoretical risk of injury to the
common peroneal nerve during avulsions performed in the region of the neck of the
fibula where the nerve is relatively superficial, however the authors have never seen this
complication. Hemostasis is maintained with leg elevation, direct pressure, and
venospasm.
PERFORATOR SURGERY
Incompetent calf perforators in the presence of significant skin changes of CVI are
possible indications for perforator surgery. The most significant of the medial calf
perforators (named Cockett perforators) connect the paired posterior tibial veins to
the posterior arch vein rather than the LSV. There are three groups of Cockett
perforators, called Cockett I to III. Cockett I perforators lie just posterior to the
medial malleolus, while Cockett II and III perforators lie 7–9 cm and 10–12 cm
proximal to the lower border of the medial malleolus respectively (14,33). These three
groups of perforators lie 2–4 cm posterior to the medial border of the tibia (Linton’s
line or lane). Three other medial perforator groups known as the paratibials are
located at 18–22 cm, 23–27 cm, and 28–32 cm from the lower border of the medial
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malleolus, respectively (14,33). They lie in a column about 1–2 cm posterior to the
medial border of the tibia. Just distal to the knee is Boyd’s perforator, which is the
most proximal calf perforator that connects the LSV to the popliteal vein.
In the presence of a post-thrombotic syndrome, perforator surgery has been shown to
be ineffective, with 100% ulcer recurrence compared with a 6% recurrence in the absence
of post-thrombotic syndrome (34). This may be because the perforators are acting as
collaterals for venous outflow obstruction.
OPEN PERFORATOR SURGERY
Technique
Most surgeons will only perform open perforator surgery after any existing ulcers have
healed. Linton’s procedure and subsequent modifications of this operation sought to
eliminate perforator incompetence, so improving ulcer healing, but high morbidity
resulting from wound complications has led many surgeons to abandon this operation (35).
If the overlying skin is not in an acceptable state for open operation or in the presence of a
clean, granulating ulcer, the SEPS procedure is preferable. Incompetent calf perforators
should be confirmed and marked pre-operatively with duplex sonography. A longitudinal
incision made directly over the incompetent perforator allows targeted dissection down to
the incompetent vein. Sherman highlighted the importance of ligating perforating veins
deep to the deep fascia (36), because perforating veins branch as they pierce the fascia
from the deep compartment. This, however, is not proven necessary once the incompetent
perforators are identified pre-operatively with ultrasound. The Cockett I perforator is
inaccessible via endoscopic perforator surgery, so open ligation is indicated if this
perforator must be ligated.
HEPARIN PROPHYLAXIS
There is no general consensus on the use of heparin prophylaxis in varicose vein
surgery. There was notable variation in the use of prophylactic heparin reported in a
survey of the members of the Vascular Surgical Society of Great Britain and Ireland,
with just 12% of members using heparin routinely and 71% using it on a selective
basis (37). Patients with obvious risk factors such as poor mobility, obesity, and
advanced age should receive heparin prophylaxis (38).
NON-SURGICAL PROCEDURES
Liquid Sclerotherapy
Sclerotherapy involves the use of a sclerosing agent and has its greatest effect in the
smallest incompetent veins, usually non-truncal varices below the knee (macrosclero-
therapy) and telangiectasias (microsclerotherapy). The technique is not useful, however,
if proximal venous hypertension exists and any proximal venous reflux should be
corrected first. (With the new foam sclerotherapy techniques it is possible to treat
truncal incompetence).
Sclerotherapy relies on the basic principle of inducing fibrosis of the vein and
obliteration of the lumen by causing inflammation in the endothelial and subendothelial
layers of the vein wall, produced by introduction of an irritant followed by external
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compression of the vein so that the walls lie in apposition. Following a consensus
conference on sclerotherapy of varicose veins of the lower limbs in 1996 (39), it was
unanimously decided that sclerotherapy is the preferred treatment of small varicose veins.
These include telangiectasias, reticular veins, and venulectases. The definitions of these
veins are given below, and the contraindications to sclerotherapy (40) are listed in Table 2.
† Telangiectasias: Flat red vessels between 0.1 mm and 1 mm in diameter
† Reticular veins: Dilated subcuticular veins, not connected to truncal veins or
their capillaries
† Intradermal venulectases: These are visible bluish intradermal vessels that are
sometimes visible above the skin surface, which measure from 0.1 mm to 2 mm
in diameter
Techniques
The veins should be distended before treatment begins, so the patient should be asked
to stand or sit up for at least five min to ensure adequate venous filling. An alternative is
Sclerosing Agents
Following the consensus conference on sclerotherapy in 1996, the recommended agents
for use in sclerotherapy (39) include:
† Sodium tetradecyl sulphate 0.2%–3%
† Chromated glycerine 25%–100%
† Polidocanol 0.2%–1%
† Sodium salicylate 6%–12%
† Hypertonic glucose
Other agents used include:
† Polyiodinated iodine 0.1%–2%
† Ethanolamine oleate
† Sodium morrhuate 1%–5%
Table 2 Contraindications to Sclerotherapy
Absolute contraindications Relative contraindications
Known allergy to the sclerosants Leg edema
Severe systemic disease Late complications in diabetes
(e.g., polyneuropathy)
Acute superficial or deep vein thrombosis Mild peripheral arterial occlusive disease
Local infection in the area of sclerotherapy
or severe generalized infection
Poor general health
Immobility Bronchial asthma
Confinement to bed Marked allergic diathesis
Severe peripheral arterial occlusive disease Known hypercoagulability
Hyperthyroidism (in the case of sclerosants
containing iodine)
Thrombophilia with history of deep vein
thrombosis
Pregnancy in the first trimester and after the
36th week of gestation
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to use a blood pressure cuff placed proximal to the veins to be treated and inflated to
40 mmHg. With the patient then lying supine or sitting with the legs horizontal, the skin
over the veins to be treated is prepared with either alcohol or acetic acid wipes. A small
caliber needle, usually between 25 and 30 gauge, is inserted into the lumen of the vessel
to be treated and blood should be aspirated back into the syringe to ensure accurate
placement of the needle prior to injection of the sclerosing agent (this, however, may not
be possible with telangiectasias). If there is any evidence of extravasation, injection
should be stopped immediately. The strength of the sclerosant used depends on the size
of the veins to be treated. The manufacturer’s recommendation of the maximum dose of
sclerosants should be noted before treatment, as this will vary with the concentration of
sclerosants. For example, a maximum dose of 4 ml of sodium tetradecyl sulphate–3%
(Fibro-Veine, STD Pharmaceuticals Ltd, Hereford, U.K.) can be injected per session.
The volume of sclerosant used can be maximized if an “air block” is used by injecting
the vein with air prior to injection of the sclerosant to empty it of blood and reduce
dilution of the sclerosants (41). Compression is applied post injection with the use of a
foam pad or cotton roll, a crepe bandage, and a TED stocking over the crepe bandage.
Repeat sessions are usually required, but the interval between sessions should not be less
than one week. Should further treatment be required in the same area, this should be
done after three weeks. Compression should be applied immediately and remain
uninterrupted for six weeks. After injection the segment of injected vein should have
become a palpable firm fibrous cord and there should be no surrounding tenderness.
Compression is best maintained with the use of cotton crepe bandages and firm cotton or
rubber pads over the sites of injection. Applying class 1 elastic stockings over the
bandage helps with compression and keeps the bandage in position.
Patients are encouraged to mobilize immediately after injections and should be
advised to avoid prolonged periods of inactive standing until the compression bandages
are removed.
Results
Recurrence of varicosities smaller than 4 mm in diameter is reported to be low. The
permanent closure rate is approximately 90% to 95% (39,42,43). In larger diameter vessels
(O4 mm), the recurrence rate is approximately 10% to 25%. Complications of liquid
sclerotherapy include allergic reaction, skin necroses, excessive sclerosing reaction
(thrombophlebitis), pigmentation, matting, nerve damage, scotomata orthostatic collapse,
and thromboembolism.
NEW TECHNOLOGIES
New treatment modalities have been developed to minimize surgical trauma, reduce post-
operative discomfort and shorten post-operative recovery.
Subfascial Endoscopic Perforator Surgery
The advantage of subfascial endoscopic perforator surgery (SEPS) is that it offers the
opportunity to treat perforating veins using an incision away from the diseased area of
skin, thereby avoiding many of the complications associated with open surgery. Hauer first
introduced the technique in 1985 (44) and since then two techniques for SEPS have been
developed. The “single port” technique (45,46), employs the use of a single scope with
channels for the camera and instruments. Newer scopes allow carbon dioxide insufflation
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