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External Valvular Stenting (EVS)
The principle behind external valvular stenting in the treatment of long saphenous varicose
veins is correction of valvular incompetence at the SFJ with preservation of venous return
via the LSV. This has been proposed to be beneficial as stripping or ablation of the LSV
results in a functional obstruction to the movement of blood upward from the limb,
possibly resulting in valveless collateral proliferation, which manifests as recurrent
varices. The Venocuffe and Venocuff IIe (Imthage Pty. Ltd, St. Leonards, NSW,
Australia) has been tested both in animal and human trials (68–70) and for the procedure to
be successful, functionally normal terminal and sub-terminal LSV valves within a dilated
LSV must be present.
Technique
The Venocuff IIe Kit consists of designated “L,” “R,” and “D” stents for repairing the left
and right SFJ, and deep venous valve or subterminal LSV valves, respectively. Cuffs have
three holes on the belt to allow variation of the cuff diameter. The approach to the SFJ is via a
standard groin incision. The Venocuffe is introduced around the terminal valve of the LSV
and the end of the Venocuffe belt is introduced into its buckle and tightened to an internal
diameter that is determined preoperatively by ultrasound assessment of the LSV internal
diameter. The cuff should be positioned as high as possible on the LSV or CFV using the
notch on the belt to ensure that it covers the valve ring. The valve repair can be tested by
inducing a Valsalva maneuvre, and if no reflux is demonstrated using intraoperative
ultrasound, the diameter of the Venocuffe is fixed with a Prolene
w
suture through the
buckle, the belt, and the common femoral vein.
As reported by Lane et al. (71), occasions where the SFJ valve cannot be made
competent warrant EVS of the sub-terminal valve as well. If both the terminal and
sub-terminal valves cannot be made competent, standard ligation and stripping should
be performed.
Postoperative compression is important to reduce the incidence of SFJ thrombo-
phlebitis, which is thought to be related to the rapid change in diameter of the SFJ.
Compression is applied with a wool and crepe bandage immediately postoperatively and
remains for three days. Thereafter further compression with single layer elastic
bandaging is continued for a further four days. Based on work by the pioneers of the
technique (70), the following situations are considered contraindications to the
procedure:
1. Thrombophlebitis affecting the LSV or its tributaries
2. Greatly dilated LSV, O11 mm in male and O10 mm in females
3. Gross tortuosity and aneurysmal dilatation along the course of the vein
Results Following EVS
There are no reported randomized controlled trials comparing the results of EVS to
conventional ligation and stripping. The largest reported case series assessed over 1500
Venocuffe stents inserted over 15 years (71) and the same authors compared EVS
with conventional surgery in contralateral limbs in the same patients. Studies have
shown that 25% of terminal and sub-terminal valves are destroyed, stunted, perforated,
split or in some other way damaged in patients with varicose veins. As a result the
procedure is only successful in 50% of patients presenting with varicose veins (71).
The technique has been found to be very useful in patients with varicose veins in
pregnancy, however.
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Recurrence in the long term has been reported at 8% in patients suitable for the
procedure and the main complications include wound infections, which necessitate
removal of the cuff (0.3%) and thrombophlebitis, which may or may not warrant
removing the LSV. DVT requiring anticoagulation therapy has not been reported.
Treatment of EVS failure as recommended by the advocates of this technique is by one
of three methods: external stenting of the sub-terminal valve, removal of the stent with
LSV disconnection, and stripping or preservation of the stent in situ with stripping of
the LSV distal to the stent. Preservation of the stent is thought to prevent the formation
of neovascularization. There are no trials assessing the efficacy and safety of this
procedure, therefore more research and evaluation is required before this technique can
be recommended.
DAY CARE STRATEGIES
The Royal College of Surgeons of England published Guidelines for Day Case Surgery
in 1985, later republished in 1992 (72), which set the College’s views on the scope of
day case surgery and the facilities required. Since then reports by the Audit Commission
for the National Health Service (73) endorsed the College’s views and encouraged an
increased provision of day surgery. Similar recommendations have also been made by
the Department of Health Value for Money Unit (74) and the Bevan Report (75) on the
management and utilization of operating departments. Since then the Department of
Health launched the Day Surgery Strategy in January 2002 with the aim of improving
day surgery strategies in the NHS. It was recognized that there is a need to increase the
capacity within the NHS to meet current surgical demands, and day surgery has an
important role to play in achieving this (76).
Day surgery is defined by the department of health as “the admission of selected
patients to the hospital for a planned surgical procedure, returning home on the same day”.
Day case patients require operating theater facilities including general anesthetic and
recovery facilities. This excludes minor operative procedures undertaken in outpatient or
Accident and Emergency departments.
Selection Criteria
Suitability for day case surgery is determined by the type of operation performed, and
the patient’s health and social circumstances. The anesthetic and social criteria for day
case surgery can be found in the Royal College of Surgeons of England Guidelines for
Day Case Surgery (72) and is summarized in Table 7. These criteria should serve as
guidelines for the surgical team and not restrict clinical judgment of the surgeon for
individual patients.
The Audit Commission published an updated “basket” of procedures in 2001
that lists 25 operations that can frequently be performed as day cases. “Varicose vein
stripping or ligation” is included in this list and “varicose veins, ligation and
avulsions” is included in the list of appropriate operations for day case surgery
provided by the Royal College of Surgeons. This includes saphenofemoral and
saphenopopliteal disconnection and perforator surgery. SEPS, RFA, and EVLT should
meet the anesthetic and social criteria set out for day case surgery (72,77) and based
on these criteria they are suitable for day case surgery in the U.K. Redo and bilateral
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varicose vein surgery are associated with prolonged general anesthetic times and redo
surgery also has an increased risk of postoperative bleeding and hematoma. There are
no set guidelines with regard to redo or bilateral surgery; however, these factors
should be taken into consideration when planning day surgery for such patients.
More experience and published data on TIPP and EVS are needed, however, in order
to fully inform patients as to the risks and possible outcomes of the procedures before they
can be widely accepted as day case strategies in the United Kingdom.
Liquid and foam sclerotherapy are performed in out-patient departments as they
do not require an anesthetic or any supervision post-procedure. The suitability of
various procedures for day case, in-patient, and out-patient surgery is summarized in
Table 8.
Table 8 Suitability of Techniques of Day Surgery, In-Patient, and Out-Patient Procedures
Suitable for
Procedure Day case In-Patient Out-Patient
SFD, LSV stripping and MSA ##X
SPD and MSA ##X
Redo surgery #
a
# X
Bilateral surgery #
a
# X
RFA ##X
EVLT ##X
TIPP ##X
EVS ##X
SEPS ##X
Liquid sclerotherapy X X #
Foam sclerotherapy X X #
a
The decision for day case surgery should be made on an individual basis.
Abbreviations: SFD, saphenofemoral disconnection; MSA, multiple stab avulsions.
Table 7 Criteria for Day Case Surgery
Criteria
Patient information Patients must be fully informed of the procedure to be undertaken and
their likely postoperative course
Anesthetic Age !65 years (Dependent on the individuals state of health)
Patients requiring general anesthesia should be of physical status ASA
IorII
General anesthetic should last no longer than 1 hour
The procedure should have a low postoperative complication risk
Social Housing conditions must be sufficient to allow comfortable recovery
and have an inside lavatory
A responsible adult must be with the patient for 24–48 hr post surgery
An escort must be available to take the patient home by car (not public
transport)
The patient/guardian must have access to a private telephone
The journey home should take no longer than 1 hr by car
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APPENDIX I
CEAP Classification of Venous Disorders
American College of Phlebology (Revised Version 2004)
The letter “C” is based on the clinical findings, usually easily seen on physical
examination.
† C0Zno visible venous disease
† C1Ztelangiectasies or reticular veins
† C2Zvaricose veins; distinguished from reticular veins by a diameter of 3 mm
or more
† C3Zedema
† C4Zskin changes without ulceration
(i) C4aZpigmentation or eczema
(ii) C4bZlipodermatosclerosis or atrophie blanche
† C5Zskin changes with healed ulceration
† C6Zskin changes with active ulceration
After this number, the letter “a” is assigned if the patient is asymptomatic, and the
letter “s” is assigned if the patient experiences symptoms. An additional number may
follow the “s” to denote the severity of the symptom. More than one number may be
assigned if the patient has several findings on clinical examination.
The “E” stands for etiology, and the options are “c” for congenital disease, “p” for
primary disease (not due to another cause), “s” for secondary venous disease, usually due
to prior deep venous thrombosis and “n” if no venous cause is identified.
The “A” refers to anatomic findings, and is usually based on duplex ultrasound
examination. The options are as follows:
Superficial Veins (As)
1. Telangiectasias or reticular veins
2. Greater saphenous vein—above the knee
3. Greater saphenous vein—below the knee
4. Lesser (short) saphenous vein
5. Nonsaphenous
Deep Veins (Ad)
6. Inferior vena cava
7. Common iliac
8. Internal iliac
9. External iliac
10. Pelvic: gonadal, broad ligament, etc.
11. Common femoral
12. Deep femoral
13. Superficial femoral
14. Popliteal
15. Crural: anterior tibial, posterial tibial, peroneal
16. Muscular: gastrocnemius, soleus, etc.
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Perforating Veins (Ap)
17. Thigh
18. Calf
The “p” refers to the pathophysiologic component, and the notations “r” for reflux,
“o” for obstruction, or “r,o” for both reflux and obstruction may be used.
In addition, a disability score for chronic venous insufficiency may be used, with:
† “0” denoting a patient who is asymptomatic, and thus has no disability
† “1” denoting a patient who is symptomatic but can function without a
support device
† “2” denoting a patient who can work an 8 hour day only with a support device
† “3” denoting a patient who is unable to work even with a support device
APPENDIX II
KEY POINTS
Saphenofemoral Disconnection (SFD), Stripping to Knee
and Multiple Phlebectomies:
† Widely accepted practice for the conventional treatment of SFJ and LSV reflux.
† The recurrence rate following SFD is between 20% and 28% after 5 years.
Saphenopopliteal Disconnection
† Preoperative ultrasound guided marking of the SPJ is essential.
† The recurrence rate is between 40% and 61% after 2 years.
Saphenofemoral Junction Recurrence and Redo Surgery
† Neovascularization appears to be the major cause of groin recurrence.
† Complication rate is twice that of primary surgery.
American Society of Anesthesiology (ASA) Classification of Patient Status
Class 1 Healthy patient, no medical problems
Class 2 Mild systemic disease
Class 3 Severe systemic disease, but not incapacitating
Class 4 Severe systemic disease that is a constant threat to life
Class 5 Moribund patient
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Scierotherapy
† Liquid sclerotherapy is useful in treating small varicose veins without truncal
saphenous incompetence.
† Foam sclerotherapy allows treatment of truncal varices.
† The recurrence rate following foam sclerotherapy is less than 7% with the
Tessari Technique.
Subfascial Endoscopic Perforator Surgery
† The ulcer healing rates are comparable to open surgery with fewer
complications.
Endovenous Ablation
† Overall complication risks are low with no evidence of groin neovascularization.
† The procedures can be performed safely under local (tumescent) anesthesia.
† Radiofrequency ablation achieves 85–90% vein occlusion rate after 2 years.
† Laser ablation achieves 97–100% vein occlusion after 9 months.
† Larger vessels can be treated with endovenous laser rather than with
radiofrequency ablation.
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