Acs0618 Varicose Vein Surgery


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Acs0618 Varicose Vein Surgery

  1. 1. © 2007 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice 6 VASCULAR SYSTEM 18 VARICOSE VEIN SURGERY — 1 18 VARICOSE VEIN SURGERY John F Golan, M.D., F.A.C.S., Donald M. Glenn, P.A.-C., John J. Bergan, M.D., F.A.C.S., and Luigi Pascarella, M.D. . Varicose veins are a common problem, accounting for approximate- recommended in the Committee’s consensus statement; however, ly 85% of the venous conditions treated. Over the past decade, man- these changes have little bearing on the current discussion and thus agement options for varicose veins and venous insufficiency of the are not addressed further here. lower extremity have become more diverse. Operative vein stripping is rapidly being replaced with a variety of endovenous techniques, ranging from laser vein obliteration to radiofrequency (RF) closure Indications for Varicose Vein Surgery to foam sclerotherapy. Conventional surgical stripping has a poor The indications for surgical treatment of varicose veins are well image with the public, being associated with large unsightly inci- established [see Table 1]. Although many physicians believe that vari- sions, severe postoperative pain, and a significant risk of recurrence. cose veins are nothing more than a cosmetic nuisance, this is in fact Current evidence indicates that patients experience less pain and re- true only for some men. Women, for the most part, have specific turn to work more quickly after endovenous treatment of varicosities symptoms (e.g., aching, burning pain, and heaviness) that are relat- than after surgical vein stripping.1 In addition, the elimination of the ed to their varicose veins and are exacerbated by the presence of word stripping from the technical description has facilitated the progesterone. Such symptoms develop with prolonged standing or public’s growing preference for endovenous therapy over conven- sitting and reach maximal levels on the first day of the menstrual pe- tional surgical therapy (even though the basic therapeutic principles riod, when progesterone levels are at their peak. Men, lacking prog- are essentially similar for the two approaches). esterone, have few such symptoms until the varicose veins progress As a consequence of the minimally invasive nature of endovenous with aging to the point where they press on somatic nerves. In gen- therapy, treatment of vein disease is moving from the hospital to the eral, the severity of the symptoms bears no relation to the size of the office.This shift has allowed a diverse group of physicians (e.g., der- vessels being treated.Telangiectasias can produce symptoms identi- matologists, gynecologists, and cardiologists) to enter a field that cal to those of varicose veins, and such symptoms can be relieved by previously had been left to surgeons. Accordingly, to remain up to simple sclerotherapy [see 6:25 Sclerotherapy]. date with respect to the treatment of vein disease, it is essential for Longitudinal studies have shown that large varicose veins can surgeons to acquire the knowledge and skills required to use the produce venous ulcerations within 15 years. Given that the inci- new endovenous techniques. In this chapter, we review the proce- dence of venous ulceration is 20% in patients who are first seen with dures, results, and complications associated with endovenous thera- large varicose veins, large varicosities constitute an indication for py, as well as traditional surgical techniques. surgery.Various skin changes characteristic of chronic venous insuf- ficiency precede the development of venous ulceration. Varicose thrombophlebitis is followed by recurrent varicose Terminology thrombophlebitis in nearly every case, at intervals ranging from a All physicians treating lower-extremity venous disease should be few weeks to many months. Nevertheless, superficial throm- familiar with the current names for the veins of the thigh and leg, as bophlebitis, which can be quite disabling, can be prevented by re- specified in the 2001 revision of the official terminologia anatomica moving varicose vein clusters. by the International Interdisciplinary Consensus Committee on Ve- It is true that for many women, the undesirable appearance of nous Anatomical Terminology.2 Failure to employ current standard- varicose veins is a major reason for seeking surgical treatment.When ized terminology can hinder data exchange in translated research questioned, however, such patients often admit to having symptoms studies. In addition, retention of the traditional nomenclature can such as pain, heaviness, and fatigue. Typically, they do not relate result in potentially dangerous clinical scenarios. For instance, ultra- these symptoms to the varices themselves but instead attribute them sonographically diagnosed thrombosis of the superficial femoral to prolonged standing during daily work. vein might, because of the term used for the vein, be erroneously in- terpreted as superficial thrombophlebitis instead of true deep vein thrombosis (DVT).To prevent these and other errors, a more accu- rate delineation of the branches of the common femoral vein is re- quired.Thus, the terms femoral vein (instead of superficial femoral Table 1 Indications for Varicose Vein Surgery vein) and deep femoral vein (instead of profunda femoris) are now Pain: leg aching, leg heaviness employed. Patchy burning (venous neuropathy) Of particular significance for the purposes of this chapter is that Swelling: foot, ankle, leg the greater (long) saphenous vein is now referred to as the great Dermatitis: focal, extensive saphenous vein (GSV), and the lesser (short) saphenous vein is now Lipodermatosclerosis referred to as the small saphenous vein (SSV). In addition, the terms Ulceration: present or healed saphenofemoral junction and saphenopopliteal junction have been Superficial thrombophlebitis accepted into the official nomenclature—a change that is especially External hemorrhage relevant to endovenous treatment of varicose veins. Various other Appearance changes in the names of lower-extremity and pelvic veins were also
  2. 2. © 2007 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice 6 VASCULAR SYSTEM 18 VARICOSE VEIN SURGERY — 2 Preoperative Evaluation DUPLEX MAPPING Table 2 Interrogation Points in the Venous Reflux Examination Over the years, surgical treatises have devoted a great deal of space to clinical examination of the patient with varicose veins. Numerous Common femoral vein clinical tests have been described, many of which carry the names of Femoral vein famous persons interested in venous pathophysiology. This august Upper third history notwithstanding, the Trendelenburg test, the Schwartz test, Distal third the Perthes test, and the Mahorner and Ochsner modifications of Popliteal vein Sural veins the Trendelenburg test are, for the most part, useless in preoperative Saphenofemoral junction* evaluation of patients today.3 There is no doubt that clinical evalua- Saphenous vein, above the knee tion can be improved by using handheld Doppler devices. In our Saphenous vein, below the knee view, however, preoperative evaluation is best performed by combin- Saphenopopliteal junction† ing duplex scanning with physical examination.4 Duplex mapping Mode of termination, lesser saphenous vein defines individual patient anatomy with considerable precision and provides valuable information that supplements the physician’s clin- *Record diameter of refluxing long saphenous vein. † ical impression.This information allows the physician to develop a Record distance from floor. strategy that will treat abnormal refluxing veins while leaving normal portions of the venous system in place, thereby minimizing operative trauma and reducing long-term recurrence. ed for subsequent use in selecting the proper endovenous catheter A protocol for duplex mapping of incompetent superficial veins during saphenous ablation. has been published.4 In essence, the examination consists of inter- The GSV is identified on the basis of its relation to the deep and rogating specific points of reflux with the patient standing [see Table superficial fascia that ensheathe it to form the saphenous compart- 2]. Forward flow is produced with muscular compression, and re- ment. High-resolution B-mode ultrasonographic imaging of the su- verse flow is then assessed in the crucial areas that are important to perficial fascia in the transverse plane has shown that this structure subsequent procedural planning. reflects ultrasound strongly, yielding a characteristic image of the The patient is placed in an upright position so that the leg veins GSV known as the saphenous eye [see Figure 1].The saphenous eye are maximally dilated. No clothing is worn on the lower extremities is a constant marker that is clearly demonstrable in transverse sec- from the waist down, except for nonconstricting underwear. The tions of the medial aspect of the thigh and that readily differentiates patient is instructed to inform the sonographer of any sensation of the GSV from varicose tributaries and other superficial veins. Casu- light-headedness, faintness, dizziness, or nausea.These symptoms al examination of the thigh often reveals an elongated, dilated vein seem to be associated with the overall atmosphere of the room and that is incorrectly assumed to be the GSV.This mistaken assump- the presence of Doppler velocity signals; they appear to be less like- tion can be corrected by means of ultrasound scanning with the ly to occur when the examination itself is performed silently. If a saphenous eye as an anatomic marker. tendency to fainting because of vagovagal reflux is encountered, the Venous reflux can be elicited manually by calf muscle compres- examination may have to be modified so that the patient is in a sion and release, by the Valsalva maneuver, or by pneumatic tourni- semiupright position instead. quet release. In terms of efficacy, there is no difference between Examination should include both lower extremities, though post- pneumatic tourniquet release and manual compression and release. treatment examinations may target a single extremity or a single However, pneumatic tourniquet release is cumbersome and re- area of an extremity.The full length of the axial venous system from quires two vascular sonographers, which makes the manual com- ankle to groin is examined.The probe is aligned transversely so that pression and release method very attractive by comparison. If specific named veins can be identified and their relations to other saphenofemoral reflux lasting longer than 0.5 second is present, the limb structures determined.The veins are scanned by moving the diameter of the GSV is recorded 2.5 cm distal to the sapheno- probe up and down along their courses. Double segments, sites of femoral junction. tributary confluence, and large perforating veins (along with their The examination continues distally along the GSV, with distal deep venous connections) are identified. (Perforating veins are augmentation of flow performed at intervals to check for reflux. Re- those that course from the subcutaneous tissue through deep fascia flux frequently ends in the region of the knee.The point at which re- to anastomose with one of the named deep venous structures; com- flux stops is recorded in terms of distance from the floor in centime- municating veins are those that anastomose with one another with- ters. The femoral vein (i.e., the vessel formerly termed the in a single anatomic plane.) Varicose veins are often arranged in superficial femoral vein) is checked at midthigh for reflux and vein multiple parallel channels. It is unnecessary to follow reflux into all wall irregularities. of the varicose clusters, because these are obvious to the treating The posterior examination is also done on the non–weight-bear- physician. Augmentation of flow (distal compression) is done ing lower extremity, with attention paid to reflux in the popliteal sharply, quickly, and aggressively, and pressure is applied to the calf vein, the saphenopopliteal junction, and the SSV.The Valsalva ma- to activate the gastrocnemius-soleus pump.When a color or pulsed- neuver may be used to stimulate reflux, as may distal augmentation wave Doppler device is used, the probe is angled to provide an in- and release.Valsalva-induced reflux is halted by competent proxi- sonation angle of 60º or less. mal valves.The SSV is followed from its retromalleolar position on For the anterior examination, the patient faces the sonographer the lateral aspect of the ankle proximally to the saphenopopliteal with his or her weight borne on the lower extremity that is not being junction, and augmentation maneuvers are performed every few examined. The non–weight-bearing extremity is then evaluated. centimeters. The common femoral vein and the saphenofemoral junction are as- The termination of the SSV is noted. If the vein terminates prox- sessed with the Valsalva maneuver and with distal compression and imally in the vein of Giacomini, the femoropopliteal vein, or anoth- release. If reflux is present, the diameter of the refluxing GSV is not- er vein, a specific check is made for a connection to the popliteal
  3. 3. © 2007 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice 6 VASCULAR SYSTEM 18 VARICOSE VEIN SURGERY — 3 vein. If the SSV shows reflux, the distance from the sapheno- thetized (and consequently obliterated) at one time. Epinephrine popliteal junction to the floor is measured and recorded. can be added to the solution to improve postoperative hemostasis, A search for incompetent perforating veins is necessary only in increase venous contraction around the heat-generating catheter, limbs with chronic venous insufficiency (CVI) manifested by hyper- and lengthen the duration of postprocedural analgesia. A common pigmentation, atrophie blanche, woody edema, scars from healed ul- formula for the tumescent anesthesia solution is 450 ml of normal ceration, or actual open ulcers. Incompetent perforating veins in saline mixed with 50 ml of 1% lidocaine with epinephrine limbs without CVI are associated with varicose veins and can be (1:100,000 dilution) and 10 ml of sodium bicarbonate to buffer the controlled with varicose phlebectomy. Identification of perforating acidity of the lidocaine. veins in the lower extremity can be difficult even for the experienced Duplex ultrasonography has revolutionized treatment of varicose sonographer. veins. It dramatically enhances physicians’ ability to evaluate the cause of varicosities and to tailor treatment so that only the diseased vein segments are ablated while the normal segments are preserved. Procedural Planning It also serves to guide placement of sheaths and heat-generating For varicose vein treatment to be successful, two goals must be catheter tips, allowing these devices to be situated very precisely met: (1) reflux must be ablated from the deep veins to the superficial within the vein. veins, and (2) all branch varicosities must be removed. Reflux must TECHNIQUE be eliminated from all major problem areas, including the saphe- nofemoral junction, the saphenopopliteal junction, and the Laser Vein Ablation midthigh Hunterian perforator vein. To identify these problem ar- eas, careful preoperative duplex mapping of major superficial venous Laser vein ablation [see Figure 2] may be performed either in the reflux is essential. All varicose vein clusters are meticulously marked office or in the hospital. Reimbursement issues make in-office treat- before operation; they may be difficult to identify during the proce- ment advantageous for most physicians. Neither conscious sedation dure, when the patient is supine. nor noninvasive monitoring is required. On occasion, a nervous pa- At present, three techniques are approved for the elimination of tient may benefit from administration of an oral anxiolytic agent 1 to axial reflux in the GSV and the SSV: (1) traditional surgical strip- 2 hours before the procedure. ping, (2) laser vein ablation (i.e., endovenous laser therapy [EVLT]), Standard surgical preparation and draping are indicated, including and (3) radiofrequency (RF) ablation. Regardless of which tech- the use of sterile gowns, masks, drapes and aseptic technique. De- nique is employed, the principal goals of treatment (see above) are pending on the results of the preoperative physical examination and the same. In addition, the procedure must be done in a manner that duplex ultrasonography, the GSV, the SSV, the anterior accessory optimizes cosmetic results and minimizes complications. saphenous vein, or the posterior accessory saphenous vein may be treated, either alone or in combination with other vessels as neces- sary.The GSV is usually treated from the upper third of the calf to Endovenous Procedures the saphenofemoral junction. If the calf portion of the GSV is to be Current endovenous techniques for treating varicose veins are treated, tumescent anesthesia should be liberally employed to reduce based on three major developments: (1) the availability of laser and the risk of saphenous nerve injury.The SSV is treated from the distal RF probes that deliver heat endovenously, (2) the introduction of third of the calf to the point where it angles toward the popliteal vein tumescent anesthesia, and (3) the evolution of duplex ultrasonogra- in the popliteal fossa.The relation of the sural nerve to the distal third phy. Tumescent anesthesia allows physicians to use large volumes of the SSV precludes safe treatment of this portion of the vein, and (500 ml) of dilute (0.1%) lidocaine in a single session while achiev- the proximity of the popliteal nerve to the SSV in the popliteal fossa ing anesthesia levels equivalent to those achieved with 1% lidocaine. precludes safe treatment of the most proximal portion of the vein. In this way, the entire thigh portion of the GSV can be safely anes- The procedure does not allow flush ligation of the saphenofemoral junction, but current evidence suggests that this measure may not be indicated: flush ligation eliminates normal venous drainage from the saphenofemoral junction and may increase the risk of neovasculariza- tion of the saphenofemoral junction and recurrence of varicosities. The saphenous vein being treated is accessed with a microp- uncture system after a small amount of lidocaine (sufficient to raise a small skin wheal) is injected into the dermis.The position of the 0.015-in. wire in the saphenous vein is confirmed by means of ultrasonography. A 4 French catheter is then passed over the wire, allowing the placement of a 0.035-in. wire for access to the proximal portion of the saphenous vein. Next, the 0.035-in. wire is positioned at the appropriate saphenous junction, and a 5 French vascular sheath is advanced over the wire to the junction. The sheath is positioned either just below the superior epigastric vein or 1 to 2 cm distal to the junction of the GSV; if the SSV is being treated, the tip is positioned 2 to 3 cm below the junction at the point where the vein makes its transition from an oblique course to a parallel path under the fascia of the leg. The 600 μm laser Figure 1 Shown is an ultrasonographic image of the so-called fiber is then passed to the tip of the sheath, which is pinned and saphenous eye. Correct identification of this marker is crucial to pulled to expose the tip of the laser fiber.The rigidity and sharp- correct performance of the preoperative ultrasonographic reflux ness of the laser fiber makes advancing its tip dangerous. Most examination. laser systems allow the fiber to be locked to the sheath, so that the
  4. 4. © 2007 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice 6 VASCULAR SYSTEM 18 VARICOSE VEIN SURGERY — 4 Saphenofemoral Figure 2 Ablation of great saphenous vein. Shown is percutaneous place- Junction ment of a quartz fiber for laser ablation of the GSV. In practice, the catheter used for RF ablation is placed in a similar fashion. Both laser ablation and Femoral RF ablation deliver electromagnetic energy to the vein wall to destroy the Artery vessel and remove it from the circulation. Femoral Vein Laser Fiber Greater Saphenous Vein two devices can be advanced and positioned as a single unit. solution are administered when the vein being treated lies in close To this point in the procedure, no anesthesia other than the initial proximity to one or more nerves (e.g., the SSV and the calf portion dermal injection has been employed.The next step, accordingly, is of the GSV). As a rule, we prefer not to treat the subdermal portions to initiate tumescent anesthesia, with or without epinephrine, along of the GSV with laser ablation; the presence of an inflamed and ten- the saphenous compartment. The addition of epinephrine to the der vein just beneath the dermis is likely to lead to increased postop- anesthetic solution results in improved constriction of the vein erative pain and noticeable skin discoloration. The superficial seg- around the laser sheath, particularly when a saphenous vein larger ments of the GSV are best treated with phlebectomy at the time of than 12 mm in diameter is being treated; it also prolongs the anal- laser ablation. gesic effect of lidocaine, providing pain relief for as long as 6 to 8 When administration of the tumescent anesthesia solution is hours after the procedure. A particular benefit of tumescent anes- complete, the position of the laser fiber’s tip is again confirmed. As thesia is that the large volume of the injectate constitutes a heat sink the vein constricts, it also shortens, and this process may advance the that absorbs the heat created by the laser, thereby eliminating injury tip of the laser fiber into the saphenofemoral or saphenopopliteal to surrounding soft tissue structures (e.g., nerves, fat, and skin). Fur- junction. If the tip is found to have moved in this manner, it is with- ther protection against injury is provided by rapid pullback of the drawn until it is again 1 to 2 cm below the junction. A quick scan laser fiber. As a result, the reported incidence of thermal skin or down the vein is done to confirm that the entire vein is surrounded nerve injuries with laser vein ablation is almost zero. by the anesthetic solution and is at least 1 cm from the skin. Administration of the tumescent anesthesia solution starts at the At this point, the laser may be safely activated.The laser is always sheath entry site and continues proximally until the entire vein seg- used in the continuous mode.The power setting may range from 10 ment to be treated exhibits a circumferential zone of echolucence. to 12 W, depending on the physician’s personal preference.We typi- The vein is generally treated in the saphenous compartment be- cally employ a 10 W setting for veins smaller than 10 mm and a 12 tween the superficial and deep fasciae of the leg. The anesthetic is W setting for veins larger than 10 mm.The essential point is that be- administered via a 22-gauge needle with a 20 ml syringe or, alterna- tween 50 and 100 J must be delivered to each centimeter of vein tively, via a 10 ml autofill syringe or a Klein pump (both of which treated; according to one study, 70 J/cm is the ideal amount for reli- have the advantage of allowing more rapid administration with less able long-term vein obliteration.5 Energy delivery can easily be de- risk of needle-stick injury to the staff).The needle is kept in a static termined as the laser fiber is withdrawn. Most laser sheaths have position during administration, and the fluid is allowed to dissect up markings 1 cm apart, and the laser machines have digital readouts and down the fascial compartment. that indicate the total amount of energy (J) delivered in real time. A Besides providing pain relief, tumescent anesthesia serves to simple calculation after 10 cm of the catheter has been withdrawn move the saphenous vein being treated away from any structure that provides instant feedback on the energy delivered per centimeter of might be injured by the heat produced by the laser (e.g., the skin vein. On the 12 W power setting, delivery of the recommended and the femoral vein). A 1 cm distance between the skin and the amount of energy generally necessitates a pullback rate of 1 cm laser fiber is optimal. More liberal amounts of tumescent anesthesia every 4 to 5 seconds (2.0 to 2.5 mm/sec). One group has advocated
  5. 5. © 2007 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice 6 VASCULAR SYSTEM 18 VARICOSE VEIN SURGERY — 5 delivery of 140 J/cm proximally (pullback rate of 1 mm/sec) and taining the benefits of saphenous vein ablation, RF alternating cur- roughly 70 J/cm distally (pullback rate of 3 mm/sec), theorizing that rent has been employed to effect rapid thermic electrocoagulation of for long-term success, more energy is required proximally.6 At the the vein wall and its valves.This approach is exemplified by the Clo- completion of the procedure, the laser is deactivated before the fiber sure procedure (VNUS Medical Technologies, Inc., San Jose, Cali- is withdrawn from the skin. Ultrasonography is then performed to fornia). Prolonged exposure to the high-frequency energy results in confirm that the common femoral vein and the superficial epigastric total loss of vessel wall architecture, disintegration, and carboniza- vein are patent and that the GSV is occluded. tion.12 Ultrasonographic follow-up shows that treated saphenous An adhesive strip (e.g., Steri-Strip; 3M, St. Paul, Minnesota) cov- veins disappear after the 2-year point. Clinical observations suggest ered by a transparent surgical adhesive dressing is applied over the that patients are much more comfortable after RF ablation than af- entry site.The patient is then placed in a prescription compression ter surgical stripping.13 stocking, which is worn for 1 to 2 weeks after the procedure.Where- The technique of RF ablation is somewhat similar to that of laser as most physicians use a class 2 (30 to 40 mm Hg) compression ablation [see Figure 2] but differs in several important respects [see stocking, we have switched to using a class 1 (20 to 30 mm Hg) Laser Vein Ablation, above].After percutaneous access is obtained, ei- stocking without observing any changes in complications (e.g., post- ther a 6 or an 8 French RF radiofrequency catheter is placed 1 to 2 operative pain and swelling) or results.This switch has enhanced pa- cm from the saphenofemoral junction, and tumescent anesthesia is tient satisfaction, in that a class 1 stocking is easier to don and more instituted.The probe is connected to the RF generator box, the tines comfortable to wear. of the probe are exposed, and the unit is activated. The catheter is A 2003 study that followed 499 limbs over 2 years demonstrated pulled back slowly (1 cm every 30 seconds) while its temperature a varicosity recurrence rate of less than 7% after ablation of the GSV and impedance are monitored. In the procedure as originally per- with an 810 nm diode laser.7 This rate is comparable to or lower formed, the catheter was heated to 85° C, but current approaches of- than those reported after traditional surgical stripping, RF ablation, ten involve heating the catheter to 90° or 95° C with the aim of short- and ultrasound-guided sclerotherapy. Several smaller studies docu- ening the pullback time (to compete with the shorter pullback times mented similar outcomes, making it evident that laser vein ablation characteristic of laser ablation). In general, however, pullback times is both effective and safe when compared to other means of treating are still somewhat longer with RF ablation than with laser ablation, varicose veins [see Table 3].1,6,8-11 allowing more dissemination of heat to surrounding tissue; postpro- At present, the question of how to manage residual varicosities af- cedural paresthesia continues to be reported in about 12% of cases.14 ter laser ablation remains controversial. The two main options are The technical results of RF ablation are excellent: with the Closure (1) to perform phlebectomy simultaneously with laser vein ablation procedure, the closure rate at 4 years is 89%.14 However, the contin- and (2) to perform laser ablation alone, then observe the patient for ued occurrence of paresthesias and the slower pullback times associ- spontaneous regression of varicosities.When the residual varicosities ated with RF ablation still appear to make laser vein ablation a safer are left untreated, 10% to 20% of patients show sufficient regression and more rapid procedure. to render further intervention unnecessary; however, 5% to 10% of The issue of recurrent varicosities after obliteration of the GSV patients experience superficial thrombophlebitis in the residual vari- without disconnection of the saphenofemoral junction tributaries is cosities as a consequence of stasis from altered venous drainage. If unsettled at present. It does appear, however, that endovenous RF delayed treatment of residual varicosities proves necessary, it may be ablation of the GSV (e.g., with the Closure procedure) prevents accomplished with either phlebectomy or sclerotherapy, depending subsequent neovascularization in the groin. Many centers have re- on the physician’s preference. Our treatment of choice is laser vein ported that neovascularization does not occur in the absence of a ablation with concurrent phlebectomy.This approach adds only 10 groin incision. to 20 minutes to the length of the procedure while offering the pa- The specific goal of endoluminal treatment of venous reflux is tient a more rapid and complete resolution of visible varicose veins obliteration of the saphenous vein. Follow-up to 4 years shows that and greatly reducing the risk of secondary thrombophlebitis. RF ablation with the Closure procedure accomplishes this goal.14 Radiofrequency Ablation OUTCOMES AND COMPLICATIONS In an attempt to minimize postoperative discomfort while main- Both EVLT and RF ablation have proved to be effective and safe Table 3—Complications of Laser Vein Ablation and Radiofrequency (RF) Ablation in Selected Studies15 Ablation Method Study LimbsTreated (N) Skin Burn (%) Paresthesia (%) Phlebitis (%) DVT (%) Recanalization (%) Navarro43 40 0 0 0 0 0 Proebstle44 109 0 0 10 0 10 Laser Min7 504 0 0 5 0 2 Perkowski45 154 0 0 0 0 3 Weiss46 140 0 4 0 0 10 Merchant47 318 4 15 2 1 15 RF Hingorani48 73 0 0 0.3 16 4 Merchant14 1,078 2 12 3 0.5 11
  6. 6. © 2007 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice 6 VASCULAR SYSTEM 18 VARICOSE VEIN SURGERY — 6 Circumflex It is true that the GSV is largely preserved after proximal ligation17; Iliac Vein however, reflux continues, and hydrostatic forces are not con- trolled.18 Recurrent varicose veins are more frequent after saphe- nous ligation than after stripping.19 Varicosities also recur more fre- quently after ligation and sclerotherapy than after stripping and Femoral sclerotherapy.20 A prospective, randomized trial that compared Vein proximal GSV ligation and stab avulsion of varices with stripping of the thigh portion of the GSV and stab avulsion of varices showed Epigastric the latter approach to be superior.21,22 Routine GSV stripping re- Vein duces the rate of recurrent varicosities and the need for reoperation for recurrent saphenofemoral incompetence. External Although it can be argued that the GSV should be retained for Pudendal Artery possible use in arterial bypass grafting, the relatively high (> 20%) reoperation rate makes this strategy undesirable. Almost three quar- ters of limbs that undergo GSV ligation alone have an incompetent GSV on follow-up duplex imaging. Until studies show a clear ad- vantage to retaining the GSV in defined patient populations, surgi- cal stripping should remain a routine part of primary GSV surgery. Greater Saphenous In several studies, preservation of the patency of the GSV and con- Vein tinuing reflux in this vein were found to be the factors most fre- quently associated with recurrence of varicosities.23-25 In one study Anterolateral of patients who underwent reoperation for relief of recurrent variceal Tributary Vein symptoms, two thirds of the patients required removal of the GSV as part of the procedure.23 Posteromedial Tributary Vein Over the past 100 years, ankle-to-groin stripping of the GSV has been the dominant approach to treatment of varicose veins.26-28 It has been argued, however, that routine stripping of the leg (i.e., an- Figure 3 Shown are a typical saphenofemoral junction and the kle-to-knee) portion of the GSV is inadvisable. One argument most important tributary vessels. The classic surgical approach against this practice is that there is a significant risk of concomitant dictates total disconnection of all tributaries at this junction. saphenous nerve injury [see Figure 4].19 Another argument is that whereas the objective of GSV removal is detachment of perforating for the treatment of venous reflux disease. Several studies that fol- veins emanating from the GSV in the thigh, the perforating veins in lowed treated limbs for 2 years or longer have shown that with re- the leg are actually part of the posterior arch vein system rather than spect to efficacy, these modalities are equivalent or superior to stan- of the saphenous vein system.This latter argument notwithstanding, dard surgical techniques.7,11,15,16 It is noteworthy that neovasculari- preoperative ultrasonography often demonstrates that the leg por- zation seems to be almost nonexistent with endovenous procedures; tion of the GSV is in fact directly connected to perforating veins. It is this result appears to be related exclusively to standard ligation clear, however, that elimination of the refluxing thigh portion of the surgery. GSV frequently eliminates reflux in the calf portion of the vein, even Multiple studies have reported similar end-point results for when the calf portion is left behind.Therefore, removal of the GSV EVLT and RF ablation: long-term occlusion of the GSV is consis- from ankle to knee generally is not necessary. If reflux subsequently tently achieved at rates approaching or exceeding 90%. In general, becomes a problem in this portion of the vein, it can usually be con- EVLT has somewhat better long-term success rates, ranging from trolled with sclerotherapy. 92% to 95%; RF ablation generally yields success rates between OPERATIVE TECHNIQUE 85% and 91%.The incidence of DVT (which is more accurately de- scribed as extension of thrombus from the treated vein into the deep The surgical approach to vein stripping must be tailored to the in- venous system) is low with both procedures but is slightly higher dividual patient and the individual limb being treated. As a rule, with RF ablation. No cases of life-threatening pulmonary embolism general or spinal anesthesia is required, though the procedure can have been reported with either EVLT or RF ablation, and both are also be performed with tumescent anesthesia. Groin-to-knee strip- associated with only negligible rates of superficial thrombophlebitis, ping of the GSV should be considered in every patient requiring sur- cellulitis, (excessive) pain, and transient paresthesias. gical intervention.29 In nearly all patients, this measure is supple- A 2006 study stressed the importance of treating the posterior mented by removal of the varicose vein clusters via stab avulsion or thigh circumflex vein so as to lower the incidence of recanalization.15 some form of sclerotherapy [see Table 4]. A large posterior thigh circumflex vein can drain cool blood into the segment being ablated, thus inhibiting proper heating of the reflux- Step 1: Placement of Incisions ing segment and making adequate closure more difficult. Accord- Preoperative marking, if correctly performed, will have docu- ingly, the authors recommended ablating any posterior thigh cir- mented the extent of varicose vein clusters and identified the clinical cumflex veins larger 4 mm in tandem with the primary procedure. points where control of varices is required. Incisions can then be planned. As a rule, incisions in the groin and at the ankle should be transverse and should be placed within skin lines. In the groin, an Surgical Vein Stripping oblique variation of the transverse incision may be appropriate.This Ligation of the GSV at the saphenofemoral junction [see Figure 3] incision should be placed high enough to permit identification of the has been widely practiced in the belief that it would control gravita- saphenofemoral junction [see Figure 3].The use of a portable ultra- tional reflux while preserving the vein for subsequent arterial bypass. sound unit in the operating room facilitates placement of the inci-
  7. 7. © 2007 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice 6 VASCULAR SYSTEM 18 VARICOSE VEIN SURGERY — 7 sion directly over the saphenofemoral junction. Generally, through- out the leg and the thigh, the best cosmetic results are obtained with Table 4 Methods of Variceal Ablation vertical incisions.Transverse incisions are used in the region of the knee, and oblique incisions are appropriate over the patella when the Formal ligation, division, and excision incisions are placed in skin lines. Stab avulsion A major cause of discomfort and occasional permanent skin pig- Sclerotherapy With liquid sclerosant mentation is subcutaneous extravasation of blood during and after With foamed sclerosant saphenous vein stripping. Such extravasation can be minimized by Sclerotherapy aided by transillumination using tumescent anesthesia around the vein to be stripped. Sclerotherapy aided by ultrasound guidance The practice of identifying and carefully dividing each of the trib- utaries to the saphenofemoral junction has been dominant over the past 50 years.The rationale for this practice is to avoid leaving be- hind a network of interanastomosing inguinal tributaries. Accord- scriptions of residual inguinal networks as an important cause of ingly, special efforts have been made to draw each of the saphenous varicose vein recurrence.23 Currently, however, this central principle tributaries into the groin incision so that when they are placed on of varicose vein surgery is under challenge, on the grounds that traction, their primary and even secondary tributaries can be con- groin dissection can lead to neovascularization and hence to recur- trolled.The importance of these efforts has been underscored by de- rence of varicosities [see Outcome Evaluation, below]. Step 2: Introduction of Stripping Device Preoperative duplex studies having already demonstrated incom- petent valves in the saphenous system, a disposable plastic Codman stripper can be introduced from above downward; alternatively, an Oesch stripper can be employed.30 Both of these devices can be used to strip the GSV from groin to knee via the inversion technique [see Figure 5]. This approach has been shown to reduce soft tissue trauma in the thigh.31 In the groin, the stripper is inserted proximally into the upper end of the divided internal saphenous vein and passed down the main channel through incompetent valves until it can be felt lying distally approximately 1 cm medial to the medial border of the tibia at a point approximately 4 to 6 cm distal to the level of the tibial tuber- cle.The GSV is anatomically constant in this location, just as it is in the groin and ankle. If the GSV is removed from the groin to this level, both the midthigh perforating vein, which usually enters the GSV, and the most distal incompetent perforating veins, which are in the distal third of the thigh, will be treated. A small incision is made over the palpable distal end of the strip- per. The GSV will subsequently be divided through this incision, and the stripper and the inverted vein will be delivered through it. In exposing the GSV at knee level, the superficial fascia must be in- cised because the vein lies between this structure and the deep fascia of the thigh. If the stripper passes unimpeded to the ankle, it can be exposed there with an exceedingly small skin incision placed in a carefully chosen skin line. Passage of the stripper from above downward to the ankle serves to confirm the absence of functioning valves, and stripping of the vein from above downward is unlikely to cause nerve damage. At the ankle, the vein should be carefully and cleanly dissected to free it from surrounding nerve fibers. If this is not done, saphenous nerve injury will result, and the patient will experience numbness of the foot below the ankle. Step 3: Removal of Saphenous Vein The previously placed stripper is pulled distally to remove the GSV. Although plastic disposable vein strippers and their metallic equivalents were designed to be used with various-sized olives to remove the GSV, in fact, a more efficient technique is simply to tie the vein to the stripper below its tip so that the vessel can then be Figure 4 Surgical stripping of great saphenous vein. Illustrated inverted into itself and removed distally, usually at knee level. is an early attempt to minimize distal incisions and prevent Phlebectomy for Management of Residual Varicosities saphenous nerve injury at the knee. The stripper and its obturator are pulled to knee level, then retrieved through the groin incision. Management of residual varicose veins after vein stripping tradi- (Note division of perforating and communicating veins.) tionally has been done at the same time as the surgical procedure.
  8. 8. © 2007 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice 6 VASCULAR SYSTEM 18 VARICOSE VEIN SURGERY — 8 Figure 5 Surgical stripping of great saphe- nous vein. Inversion stripping of the GSV decreases soft tissue trauma in the thigh. However, tearing of the vein occurs on occa- sion. This problem may be largely prevented Saphenous by attaching a corner of a 2 in. gauze roll Vein soaked in lidocaine-epinephrine solution to the end of the stripper. As the stripper is Posterior Arch pulled, the gauze is drawn into the vein, Vein thereby assisting hemostasis. The gauze can then be left in place for 10 to 20 minutes while the stab wounds from the avulsion part of the procedure are being closed. COMPLICATIONS Management of residual varicose veins after vein ablation is more controversial. Currently, many physicians who treat vein disease are Surgical removal of the GSV on an outpatient basis still requires not familiar with the surgical technique of phlebectomy and there- two incisions, one in the groin and the other near the knee. Postoper- fore elect to wait for varicosities to regress after vein ablation. In 10% to 20% of cases, enough regression of varicose veins occurs after ab- lation that no further treatment is required. If delayed treatment proves necessary, it may be accomplished by means of either phle- bectomy or sclerotherapy, depending on the physician’s preference. The technique of phlebectomy is easy to learn. A tumescent anes- thesia solution is infused between the skin and the superficial fascia of the leg in the area of the previously marked varicosities.The infusion a of the anesthetic tends to dissect the GSV away from the surround- ing tissue and causes vasoconstriction.Vertical incisions 1 to 3 mm in length are made where appropriate. In the anterior knee and ankle regions, where skin lines are obviously horizontal, incisions are hid- den in the lines [see Figure 6].Varicosities are exteriorized by means of hooks or forceps; particularly useful for this purpose are specially de- signed vein hooks such as the Varady dissector, the Muller hook, and 1–3 mm the Oesch hook [see Figures 7 and 8].32 Nothing should penetrate the skin other than the small end of the hook. Usually, the vein is easily distinguished from the surrounding fat by its taut rubber band feel. The vessel is brought out of the skin, then removed proximally and distally by using a hand-over-hand technique with mosquito clamps. Eventually, the vein tears in each direction, but because of the epi- nephrine in the tumescent anesthesia solution, very little bleeding oc- curs.The procedure is continued in a proximal-to-distal direction un- til all varicose clusters have been removed; generally, between 10 and b 15 incisions are required for removal of all clusters.Veins of any size can be removed by means of this technique, even in the office setting. In patients who have had superficial phlebitis or have previously un- dergone sclerotherapy, the veins typically are fibrotic and adherent to the surrounding tissue and cannot be easily removed. If treatment of such veins proves necessary at some point in the future, sclerotherapy is generally the method of choice. When all phlebectomies have been completed, small elastic strips are used to close the skin incisions. A compressive dressing is applied for 24 hours to minimize bleeding, bruising, and swelling.When the Figure 6 Surgical stripping of great saphenous vein: phlebectomy procedure is done properly, the incisions are invisible by 6 to 8 weeks for residual varicosities. (a) Skin incisions for stab avulsion of and the patients are very happy with the results. Experienced work- varicosities are limited with respect to both length and depth. (b) ers in Europe have achieved marked refinements of phlebectomy The dissector blade facilitates mobilization of the vein before techniques for varicose clusters.33 removal.
  9. 9. © 2007 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice 6 VASCULAR SYSTEM 18 VARICOSE VEIN SURGERY — 9 In addition to the four principal causes of recurrent varicosities, there is a fifth cause, which is beyond the operating surgeon’s con- trol—namely, the genetic tendency to form varicosities.This tenden- cy results in the development of localized or generalized venous wall weakness, localized blowouts of venous walls, or stretched, elongat- ed, and floppy venous valves.35,36 OUTCOME EVALUATION As a rule, when undesirable outcomes occur after surgical saphe- nous vein stripping, they become evident quite early.21 As noted (see above), it has long been accepted practice to dissect tributary vessels at the saphenofemoral junction very carefully, taking each of the ves- sels back beyond the primary and even the secondary tributaries if possible.31 In practice, however, such dissection appears to cause Figure 7 Surgical stripping of great saphenous vein: phlebectomy for residual varicosities. Shown are tools used for exteriorizing neovascularization in the groin37; surveillance with duplex ultra- varicosities: a Hartman clamp with its single tooth placed distally, sonography supports this finding.38 It has now been amply con- two Muller clamps, and a Varady hook and dissector (left to right). firmed that neovascularization causes recurrent varicose veins. Clearly, this is a significant disadvantage of standard surgical treat- ment of varicosities.This disadvantage has been a major impetus for ative compression bandaging is standard, and most patients experi- the development of less invasive alternatives to surgical saphenous ence little downtime. Some, however, do experience hematoma, vein stripping [see Endovenous Procedures, above, and Foam Scle- pain, and extensive bruising.These three complications are linked; rotherapy, below].These alternatives are proving to be effective and thus, every effort should be made to prevent oozing.The most feared may be superior to surgical stripping, if only because they are not fol- complication of varicose vein surgery is venous thromboembolism, lowed by groin neovascularization. but the incidence of this complication is quite low (probably about 1%). In countries where postoperative immobilization, hospitaliza- tion, and delayed ambulation are employed for patients with vari- Foam Sclerotherapy cosities, prophylaxis against venous thromboembolism is common. The prospect of a rapid, minimally invasive, and durable treat- In the United States, however, this measure is generally considered ment of varicose veins is an attractive one. Current evidence suggests unnecessary in these patients. The most common complication of that these objectives may be achieved without operative intervention varicose vein surgery is recurrence of varicosities, which is experi- by using sclerosant microfoam [see Figure 9]. In 1944 and 1950, E. J. enced by 15% to 30% of patients treated.24 Orbach introduced the concept of a macrobubble air-block tech- To speak of permanent removal of varicosities implies that all po- nique to enhance the properties of sclerosants in performing tential causes of recurrence have been considered and that surgical macrosclerotherapy.39,40 At the time, few clinicians evinced much in- management has been planned so as to address them.There are four terest in the subject, and the technique languished. principal causes of recurrence of varicose veins, three of which can be dealt with at the time of the primary operation. One cause of recurrent varicosities is failure to perform the prima- ry operation correctly. Common errors include missing a duplicated saphenous vein and mistaking an anterolateral or accessory saphe- nous vein for the GSV. Careful and thorough anatomic identification will help minimize such errors. It has long been held that a second cause of recurrent varicose veins is failure to do a proper groin dis- section; however, it is now known that such dissection causes neo- vascularization in the groin, leading to recurrence of varicose veins [see Outcome Evaluation, below]. A third cause is failure to remove the GSV from the circulation. A reason often cited for this failure is the desire to preserve the GSV for subsequent use as an arterial by- pass, but it is clear that the preserved GSV continues to reflux and continues to elongate and dilate its tributaries, thereby producing more varicosities even after primary operative treatment has re- moved the varicose veins present at the time. A fourth cause of re- current varicosities is persistence of venous hypertension through nonsaphenous sources—chiefly perforating veins with incompetent valves. Muscular contraction generates enormous pressures that are directed against valves in perforating veins.Venous hypertension in- duces a leukocyte endothelial reaction, which, in turn, incites an in- flammatory response that ultimately destroys the venous valves and weakens the venous wall.34 The perforating veins most commonly as- sociated with recurrent varicosities are the midthigh perforating vein, the distal thigh perforating vein, the proximal anteromedial calf per- Figure 8 Surgical stripping of great saphenous vein: phlebectomy forating vein, and the lateral thigh perforating vein, which connects for residual varicosities. The varix is exteriorized with a hook, then the deep femoral vein to surface varicosities. divided to permit proximal and distal avulsion.
  10. 10. © 2007 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice 6 VASCULAR SYSTEM 18 VARICOSE VEIN SURGERY — 10 a b Telangiectasia Dermis Varicose Tributary Recticular Vein Saphenous Perforating Vein Vein Supericial Fascia Perforating Vein Deep c Fascia Deep Vein Figure 9 Microfoam sclerotherapy. (a) The relationships among the venous structures in a lower extremity with varicosities explain why microfoam sclerotherapy can succeed. Injections into varices, reticular veins, or perfo- rating veins can place the foam into varicose structures and even into telangiectatic blemishes. (b) Sclerosant foam is made by mixing room air with 0.5% sodium tetradecyl sulfate (STS) in a 2:1 ratio via a three-way stopcock. The syringes are emptied 35 times to create a foam that lasts about 5 minutes. (c) A halogen light (vein light), as used here during a foam injection, is helpful for treating persistent or recurrent varices along with the GSV in situations where surgery is undesirable. Half a century later, the work of Juan Cabrera and colleagues in limbs could be safely and effectively treated by means of foam scle- Granada attracted the attention of some phlebologists and reawak- rotherapy combined with compression.42 In this study, limbs affect- ened interest in using foam technology for the treatment of venous in- ed by lipodermatosclerosis, atrophie blanche, or even open venous sufficiency.41 These investigators showed that foam sclerotherapy was ulcers showed statistically significant improvement after the injec- technically simple and worked well in small to moderate-sized vari- tion of a foamed sclerosant followed by compression with a medical- cose veins, and they demonstrated that the limitations of liquid scle- grade stocking or an Unna boot.The study results also underscored rotherapy could be erased by using microfoam.Their 5-year report the importance of applying compression immediately after the injec- represents the longest observation period to date for microfoam scle- tion of the sclerosant. Limbs that underwent foam sclerotherapy and rotherapy for varicose veins. In most of the cases, a single injection compression healed better and more quickly than limbs that were sufficed to treat saphenous veins and varicose tributaries. Extensive treated by sclerotherapy alone. vasospasm was seen immediately, but compression was applied after If subsequent work continues to confirm these favorable results, it treatment. Complete fibrosis of the saphenous vein was achieved in may be that microfoam sclerotherapy will eventually replace all oth- 81% of cases, and patency with reflux persisted in only 14%.Tribu- er methods of varicose vein treatment. As of December 2006, how- tary varicosities disappeared in 96% of cases.Vessels that remained ever, foam sclerotherapy had not been approved by the United open and were refluxing were successfully closed with retreatment. States Food and Drug Administration, because of concerns about A subsequent study demonstrated that even severely affected potential air embolization after the injection of the sclerosant. References 1. Rautio T, Ohinmaa A, Perala J, et al: Endovenous 4. Mekenas LV, Bergan JD: Venous reflux examina- 8. Sadick NS, Wasser S: Combined endovascular obliteration versus conventional stripping opera- tion: technique using miniaturized ultrasound laser with ambulatory phlebectomy for the treat- tion in the treatment of primary varicose veins: a scanning. J Vasc Technol 26:139, 2002 ment of superficial venous incompetence: a 2- randomized, controlled trial with comparison of 5. Timperman P, Sichlau M, Ryu R: Greater ener- year perspective. J Cosmet Laser Ther 6:44, the costs. J Vasc Surg 35:958, 2002 gy delivery improves treatment success of 2004 2. Caggiati A, Bergan J, Gloviczki P, et al: endovenous laser treatment of incompetent 9. Disselhoff B, Kinderen D, Moll F: Is there Nomenclature of the veins of the lower limb: saphenous veins. J Vasc Interv Radiol 15:1061, recanalization of the great saphenous vein 2 extensions, refinements, and clinical application. 2004 years after endovenous laser treatment? J J Vasc Surg 41:719, 2005 6. Min R, Khilnani N: Endovenous laser ablation Endovasc Ther 12:731, 2005 3. Ballard JL, Bergan, JJ, DeLange M: Venous of varicose veins. J Cardiovasc Surg 46:395, 10. Proebstle T, Gul D, Kargl A, et al: Endovenous imaging for reflux using duplex ultrasonography. 2005 laser treatment of the lesser saphenous vein with Noninvasive Vascular Diagnosis. AbuRahma AF, 7. Min R, Khilnani N, Zimmet S: Endovenous a 940-nm diode laser: early results. Dermatol Bergan JJ, Eds. Springer-Verlag, London, 2000, laser treatment of saphenous vein reflux: long- Surg 29:357, 2003 p 329 term results. J Vasc Interv Radiol 14:991, 2003 11. Puggioni A, Kalra M, Carmo M, et al:
  11. 11. © 2007 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice 6 VASCULAR SYSTEM 18 VARICOSE VEIN SURGERY — 11 Endovenous laser therapy and radiofrequency 23. Stonebridge PA, Chalmers N, Beggs I, et al: 38. Fischer R, Linde N, Duff C, et al: Late recurrent ablation of the great saphenous vein: analysis of Recurrent varicose veins; a varicographic analy- saphenofemoral junction reflux after ligation and early efficacy and complications. J Vasc Surg sis leading to a new practical classification. Br J stripping of the greater saphenous vein. J Vasc 42:488, 2005 Surg 82:60, 1995 Surg 34:236, 2001 12. Petrovic S, Chandler JG: Endovenous oblitera- 24. Darke SG: The morphology of recurrent vari- 39. Orbach EJ: Sclerotherapy of varicose veins: uti- tion: an effective, minimally invasive surrogate cose veins. Eur J Vasc Surg 6:512, 1992 lization of intravenous air block. Am J Surg for saphenous vein stripping. J Endovasc Surg 25. Conrad P: Groin-to-knee down stripping of the 66:362, 1944 7:11, 2000 long saphenous vein. Phlebology 7:20, 1992 40. Orbach EJ: Contribution to the therapy of the 13. Goldman MP: Closure of the greater saphenous 26. Mayo CH: Treatment of varicose veins. Surg varicose complex. J Intl Coll Surg 13:765, 1950 vein with endoluminal radiofrequency thermal Gynecol Obstet 2:385, 1906 41. Cabrera J, Cabrera J, Garcia-Olmedo MA: heating of the vein wall in combination with 27. Babcock WW: A new operation for extirpation of Treatment of varicose long saphenous vein with ambulatory phlebectomy: preliminary 6-month varicose veins. NY Med J 86:1553, 1907 sclerosant in microfoam form: long term out- followup. Dermatol Surg 26:105, 2000 comes. Phlebology 15:19, 2000 14. Merchant RF, Pichot O, Myers KA: Four-year 28. Keller WL: A new method for extirpating the internal saphenous and similar veins in varicose 42. Pascarella L, Bergan J, Mekenas L: Severe follow-up on endovascular radiofrequency oblit- conditions: a preliminary report. NY Med J chronic venous insufficiency treated by foam eration of great saphenous reflux. Dermatol Surg 82:385, 1905 sclerosant. Ann Vasc Surg 20:83, 2006 31:129, 2005 29. Goren G, Yellin AE: Primary varicose veins: 43. Navarro L, Min RJ, Bone C: Endovenous laser: 15. Almeida J, Raines J: Radiofrequency ablation topographic and hemodynamic correlations. J a new minimally invasive method of treatment and laser ablation in the treatment of varicose Cardiovasc Surg 31:672, 1990 for varicose veins—preliminary observations veins. Ann Vasc Surg 20:4, 2006 using an 810 nm diode laser. Dermatol Surg 16. Pannier F, Rabe E: Endovenous laser therapy 30. Goren G, Yellin AE: Invaginated axial saphenec- 27:117, 2001 and radiofrequency ablation of saphenous vari- tomy by a semirigid stripper: perforate-invagi- nate stripping. J Vasc Surg 20:970, 1994 44. Proebstle TM, Gul D, Lehr HA, et al: Infrequent cose veins. J Cardiovasc Surg 47:3, 2006 early recanalizaion of greater saphenous vein 17. Rutherford RB, Sawyer JD, Jones DN: The fate 31. Bergan JJ: Saphenous vein stripping by inver- after endovenous laser treatment. J Vasc Surg of residual saphenous vein after partial removal sion: current technique. Surg Rounds 23:118, 38:511, 2003 or ligation. J Vasc Surg 12:422, 1990 2000 45. Perkowski P, Ravi R, Gowda RC, et al: 18. McMullin GM, Coleridge Smith PD, Scurr JH: 32. Bergan JJ:Varicose veins: hooks, clamps and suc- Endovenous laser ablation of the saphenous vein Objective assessment of high ligation without tion: application of new techniques to enhance for treatment of venous insufficiency and vari- stripping the long saphenous vein. Br J Surg varicose vein surgery. Semin Vasc Surg 15:21, cose veins: early results from a large single-cen- 78:1139, 1991 2002 ter experience. J Endovasc Ther 11:132, 2004 19. Munn SR, Morton JB, MacBeth WAAG, et al:To 33. Ricci S, Georgiev M, Goldman MP: Ambulatory 46. Weiss RA, Weiss MA: Controlled radiofrequency strip or not to strip the long saphenous vein? A Phlebectomy: a Practical Guide for Treating endovenous occlusion using a unique radio fre- varicose veins trial. Br J Surg 68:426, 1981 Varicose Veins. Mosby, St Louis, 1995 quency catheter under duplex guidance to elim- 20. Neglen P: Treatment of varicosities of saphenous 34. Ono T, Bergan JJ, Schmid-Schönbein GW, et al: inate saphenous varicose vein reflux: a 2-year fol- origin: comparison of ligation, selective excision, Monocyte infiltration into venous valves. J Vasc low-up. Dermatol Surg 20:38, 2002 and sclerotherapy. Bergan JJ, Goldman MP, Eds. Surg 27:158, 1998 47. Merchant RF, DePalma RG, Kabnick LS: Varicose Veins and Telangiectasias: Diagnosis 35. Thulesius O, Ugaily-Thulesius L., Gjores JE, et Endovascular obliteration of saphenous reflux: a and Management. Quality Medical Publishing, al: The varicose saphenous vein, functional and multicenter study. J Vasc Surg 35:1190, 2002 St Louis, 1993, p 148 ultrastructural studies, with special reference to 48. Hingorani AP, Ascher E, Markevich N, et al: 21. Sarin S, Scurr JH, Coleridge Smith PD: smooth muscle. Phlebology 3:89, 1988 Deep venous thrombosis after radiofrequency Assessment of stripping the long saphenous vein 36. Rose SS, Ahmed A: Some thoughts on the aeti- ablation of greater saphenous vein: a word of in the treatment of primary varicose veins. Br J ology of varicose veins. J Cardiovasc Surg caution. J Vasc Surg 40:500, 2004 Surg 79:889, 1992 27:534, 1986 22. Dwerryhouse S, Davies B, Harradine K, et al: 37. Jones L, Braithwaite BD, Selwyn D, et al: Stripping the long saphenous vein reduces the Neovascularization is the principal cause of vari- rate of reoperation for recurrent varicose veins; cose vein recurrence: results of a randomized Acknowledgments five-year results of a randomized trial. J Vasc trial of stripping the long saphenous vein. Eur J Surg 29:589, 1999 Vasc Endovasc Surg 12:442, 1996 Figures 2 through 6, 8, and 9a Tom Moore.