Role of Surgery in the Treatment of Varicose Veins

CHAPTER 10 Role of Surgery in the Treatment of Varicose Veins






The Different Surgical Procedures


Procedures depend on the different concepts of VV disease progression and evolution as well as on the principles of hemodynamic anomalies correction, which are currently controversial and are reviewed below. The procedures discussed can be performed alone or in combination:






As this book is not an atlas of venous surgery, the different procedures will not be described in detail. However, the advantages and inconveniences of the different surgical methods will be underlined.



Surgery without saphenous trunk preservation


Conventional surgery includes GSV and/or small saphenous vein (SSV) termination ligation flush to the corresponding deep vein, plus saphenous trunk stripping with or without incompetent tributaries phlebectomy and/or incompetent perforator interruption.




Principle and Controversies


This method is based on the VV descending progression hemodynamic concept that was established at the beginning of the 20th century. It was believed that reflux always started at the SFJ and/or the SPJ, due to incompetence of the terminal valve, and extended progressively in a distal direction within the saphenous trunk and into the suprafascial accessory or tributary veins in which the varices developed. Consequently, SFJ and/or SPJ ligation completed by trunk stripping and/or phlebectomy of tributary varices was the ‘cure all’ method. But the systematic use of DUS for investigating VVs has shown that this concept was wrong in many cases:








All of these findings have enhanced development of new surgical procedures that will be described later.



Technical Information











Conventional surgery variants



Saphenous Trunk Stripping with Preservation of Saphenofemoral Confluence, with or without Incompetent Tributary Phlebectomy and/or Incompetent Perforator Interruption


Non-flush ligation at the SFJ and/or SPJ was, until recently, described as a technical mistake responsible for in situ recurrence in all cases as reflux through the incompetent terminal valve persisted. But preoperative ultrasound investigations have proved that in GSV varices the terminal valve is competent in approximately half the patients.11,12


In this situation it looks obvious that high flush tie is not recommended as tributaries of the saphenofemoral confluence can drain in a physiologic way into the common femoral vein. Besides neovascularization, elimination of normal physiologic reflux is the main cause of recurrence after flush ligation,13 but rarely identified after confluence conservation.14


When the terminal valve is incompetent, non-flush ligation was thought to promote recurrence, as previously stated (Fig. 10.4). However, one prospective study has demonstrated that this concept is wrong. In this large series neither postoperative outcome nor clinical and diagnostic evaluation found a difference in terms of recurrence if the terminal valve was competent or not.14



The explanation for this may be that suppression of the reservoir represented by an incompetent saphenous trunk and tributaries allows the terminal valve to recover its competence.




Surgery with saphenous trunk preservation


This is less invasive than other procedures, including vein stripping. The most aggressive part of vein stripping is the trunk excision. Besides, supporters claim that the preserved saphenous trunk might be used as an arterial substitute either for coronary surgery or as a bypass in femorocrural obliteration. Unfortunately there are no data on the real need for, or value of, the saphenous trunk as an arterial substitute after such surgery. Another argument in favor is the preservation of venous flow drainage, as ablation of the superficial system enhances varicose vein recurrence. The different procedures are depicted in Figure 10.6.





SFJ and/or SPJ ligation plus incompetent tributary phlebectomy with or without incompetent perforator interruption


Suppression of leak points between the DVS and the SVS combined with reservoir ablation is supposed to restore competence of the saphenous trunk.1518 This procedure was promoted during the last two decades but is presently rarely performed, probably because the myth of compulsory HL has been discredited on account of its lack of clinical efficacy.



SFJ wrapping or valvuloplasty plus incompetent tributary phlebectomy with or without incompetent perforator interruption


The remark made for the previous procedure – that is to say, on the one hand, the relationship between SFJ incompetence and the development of VVs, and, on the other hand, the fact that suppression of the refluxing SFJ is no longer compulsory – should explain the loss of interest in these techniques.





Ambulatory phlebectomy


Muller described this technique in 1956 and published it 10 years later.26 The method consists of extracting VVs in an outpatient setting under local anesthesia using small punctures and hooks, The procedure is described in detail elsewhere,2729 but it is worth mentioning here that phlebectomy is performed by using fine-pointed blades, mini-incisions, and crochet hooks or other specialized phlebectomy hooks (Fig. 10.8).



Muller used this procedure in isolation or in combination with trunk stripping to avulse tributary varices, as reported in 1996.30


A powered phlebectomy device, the Trivex system (InaVein LLC, Lexington, Mass.), was introduced by G. Spitz in1966. Briefly, the system contains a shaver and a transilluminator coupled with an irrigator (Fig. 10.9).




Varices phlebectomy


Varices phlebectomy with conservation of the refluxing saphenous trunk is named in French ‘ablation sélective des varices sous anesthésie locale’ (ASVAL; selective ablation of varices under local anesthetic).31 This process gathers and unifies techniques of phlebectomy that were previously scattered and insufficiently systematized and is based on the demonstrated fact that varicose disease most often begins at lower leg level (see above). According to ASVAL principles, the suppression of varicose reservoirs (especially extra fascial varicose clusters) can – at least to a certain extent – improve or restore to normal (centripetal) the reflux in saphenous trunks, thus preserving them.32



CHIVA method


CHIVA is the acronym of the French ‘Cure Conservatrice et Hémodynamique de l’Insuffisance Veineuse en Ambulatoire’.33 The pathophysiological basis of CHIVA relates to a ‘hemodynamicocentric model’ of venous insufficiency (VI).34


According to CHIVA all the VI symptoms are due to an obstacle to the flow and/or valvular incompetence which increases the transmural pressure (TMP). Excessive TMP dilates the veins (varices) and impairs drainage (edema, lipodermatosclerosis, and ulcer) (Fig. 10.10). The hemodynamic diagnosis consists of checking and, correcting the VI causes in order to normalize the TMP and, consequently, its clinical symptoms. According to the VI hemodynamic pattern, CHIVA involves fractioning the hydrostatic pressure, disconnecting the shunts, and preserving the draining veins in order to cure all the symptoms of VI at the same time and avoid recurrence. Open Deviated Shunts Type II (varices + segmental saphenous trunk reflux) and Closed Shunts Type III (varices + segmental saphenous trunk reflux + SFJ reflux (SFJR)) are frequent patterns of VI due to superficial valve incompetence. In these specific cases CHIVA divides the refluxing tributaries at their junction with the saphenous trunk. These divisions result in trunk reflux suppression and varices ‘remodeling’ to normal size while the drainage is preserved in order to avoid short-term side effects and long-term recurrences (in the case of Shunt III SFJR, redo due to a trunk re-entry) (Figs 10.1110.14).








Investigations to be Done Before VV Surgery


A thorough physical examination is important; it allows the clinical class (using the CEAP classification system) to be identified. Both symptom type and severity must be carefully recorded.


Systematic DUS prior to surgery for varicose veins is crucial. From a classification standpoint, DUS is used to complete CEAP sections E, A and P. In practical terms, it allows creation of a precise map that will be very useful during surgery (Fig. 10.15).



This examination is required and is sufficient in clinical practice for primary and isolated superficial VI (SVI). For secondary SVI or SVI associated with abnormalities other than associated perforator incompetence, complementary tests should be performed depending on the clinical context.


The assessment performed in preparation for surgical treatment of varicose veins should provide answers to the following questions:















Postoperative Care and Convalescence



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Jul 31, 2016 | Posted by in Dermatology | Comments Off on Role of Surgery in the Treatment of Varicose Veins

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