See discussions, stats, and author profiles for this publication at: https://www.researchgate.

net/publication/49841316

Varicose Vein Surgery

Article  in  Seminars in Interventional Radiology · September 2005

DOI: 10.1055/s-2005-921951 · Source: PubMed

CITATIONS READS

8 1,532

2 authors, including:

Lowell Kabnick
NYU Langone Medical Center
100 PUBLICATIONS   2,304 CITATIONS   

SEE PROFILE

Some of the authors of this publication are also working on these related projects:

First 10-month results of the Vascular Quality Initiative Varicose Vein Registry View project

MASTERCLASS MULTIMODALITY VENOUS IMAGING View project

All content following this page was uploaded by Lowell Kabnick on 19 May 2015.

The user has requested enhancement of the downloaded file.

Varicose Vein Surgery
Michael Ombrellino, M.D., F.A.C.S.,1 and Lowell S. Kabnick, M.D., F.A.C.S.1

ABSTRACT

The treatment of superficial venous disease and chronic venous insufficiency

continues to evolve, and the interest in venous disease has matched that in arterial disease in
vascular medicine. A better understanding of venous anatomy and pathophysiology and the
development of newer, more efficient diagnostic technology have allowed clinicians to
utilize minimally invasive techniques in the treatment of varicose veins. These techniques
have reduced recurrence and improved overall quality of life (postoperative pain and
bruising) following these procedures. This article provides an overview of basic venous
surgical anatomy and pathophysiology, along with several older and newer surgical options
in the treatment of superficial venous disease. Advantages and disadvantages of each
approach are briefly discussed so that the reader may gain better understanding of the
options available in the treatment of chronic venous insufficiency.

KEYWORDS: Chronic venous insufficiency, varicose veins, neovascularization,

endovenous vein obliteration

Objectives: Upon completion of this article, the reader should have a basic understanding of anatomy and pathophysiology as it pertains
to several surgical options for superficial venous surgery.
Accreditation: Tufts University School of Medicine (TUSM) is accredited by the Accreditation Council for Continuing Medical Education
to provide continuing medical education for physicians.
Credit: TUSM designates this educational activity for a maximum of 1 Category 1 credit toward the AMA Physicians Recognition Award.
Each physician should claim only those credits that he/she actually spent in the activity.

The history of venous disease dates back as far as vein excision and ligation.3 Celsus soon recognized
the early beginning of medicine. Early monographs on the importance of ligation and division of bleeding
varicose veins and their surgical treatment were pro- varicosities in first century Rome, and Galen, in the
duced as early as 1550 BC.1 One of the earliest illustrated second century, devised a method of ligation and vein
descriptions of a varix is found at the base of the avulsion using specially designed hooks.4,5 These early
Acropolis in Athens and dates to the fourth century BC principles and techniques formed the foundation of
(Fig. 1). This well-known tablet illustrates a large what we utilize today in the treatment of superficial
leg with a tortuous varicosity along its medial aspect. venous disease and are the framework of current techni-
Hippocrates was perhaps the first to recognize the ques such as varicose vein stripping and ligation and
relationship between venous disease and ulceration.2 phlebectomy.
He noted that proper leg elevation and compression Today, the treatment of venous disease continues
allowed faster wound healing and relief of discomfort. to evolve as newer techniques and technology have
Reports of venous interventions were made as brought this ancient staple of surgery into the 21st
early as 270 BC, in Egypt, with evidence of early varicose century. With the advent of minimally invasive

Venous Insufficiency; Editors in Chief, Brian Funaki, M.D., Peter R. Mueller, M.D.; Guest Editor, R. Torrance Andrews, M.D. Seminars in
Interventional Radiology, volume 22, number 3, 2005. Address for correspondence and reprint requests: Michael Ombrellino, M.D., F.A.C.S., Vein
Institute of New Jersey, 95 Madison Avenue, Suite 109, Morristown, NJ 07960. 1Vein Institute of New Jersey, Morristown, New Jersey. Copyright
# 2005 by Thieme Medical Publishers, Inc., 333 Seventh Avenue, New York, NY 10001, USA. Tel: +1(212) 584-4662. 0739-9529,p;2005,22,03,
185,194,ftx,en;sir00311x.
185
186 SEMINARS IN INTERVENTIONAL RADIOLOGY/VOLUME 22, NUMBER 3 2005

of venous ulceration, impairs overall quality of life and

accounts for a significant loss of work time. It has been
estimated that in excess of 2 million workdays are lost
annually in the United States because of venous ulcer-
ation and that 5% of individuals ultimately lose their jobs
because of this disease.9 Therefore, it is easy to under-
stand why this disease process has become more prom-
inent in the minds of vascular interventionists and has
gained the attention of the American media.
Aside from the late sequel of chronic skin changes
(lipodermatosclerosis) and ulceration, the most common
signs of chronic venous insufficiency are visible varicos-
ities and telangiectasia. Along with cosmesis, signs and
symptoms such as edema, leg fatigue, heaviness, and
discomfort are the main reasons for individual patients
seeking medical attention. The majority of those treated
report significant improvement in their quality of life
and an overall improvement in self-esteem.

ANATOMY, PATHOPHYSIOLOGY,
AND DIAGNOSIS
To offer each individual patient an appropriate treat-
ment strategy, it is essential to have a basic understand-
ing of venous anatomy and pathophysiology. A detailed
review of venous anatomy and its variations is beyond the
scope of this article, and this information can be found
in many fine anatomic texts as well as in other articles in
Figure 1 Votive tablet found at the base of the Acropolis in this issue.
Athens, Greece. It is believed to be the earliest known illustration The axial veins of the lower extremities include
of a varicose vein. the femoral vein (often and incorrectly referred to as
the ‘‘superficial femoral vein’’), the popliteal vein, and the
techniques, improved ultrasound technology, and a great and short saphenous veins (GSV and SSV). The
multidisciplinary approach, the treatment of superficial latter are superficial veins, so designated because they
venous disease has become a major discipline unto itself. are superficial to the muscular fascia of the leg. The
The following paragraphs give an overall view of the absence of fascial support is often cited as a contributing
indications and several of the most commonly used factor in the valvular incompetence and subsequent
techniques in the treatment of venous insufficiency, reflux in the saphenous system. It is these vessels that
varicose veins, and their sequelae. are most often addressed in surgery for venous disease.
The GSV originates at the dorsum of the foot,
passes anterior to the medial malleolus, and ascends up
EPIDEMIOLOGY AND SYMPTOMOLOGY the medial calf across the posterior-medial aspect of the
There are several risk factors associated with the devel- popliteal space. It then continues up the medial thigh
opment of superficial venous disease and varicosities. A and terminates at the femoral vein at the saphenofemoral
strong family history is perhaps the most common risk junction (SFJ). Clinicians should be aware of basic
factor,6 with other factors such as previous history of anatomic variations such as duplicate systems, particu-
phlebitis, female gender, pregnancy, and standing for larly in the thigh, which, if not identified, can be a source
prolonged periods contributing to the development of of recurrence and incomplete treatment. Important
venous insufficiency and varicosities.7,8 Venous insuffi- thigh tributaries of the GSV are the anterior-lateral
ciency afflicts both young and old patients with a slight superficial vein and the posterior-medial superficial
prevalence for the female gender. It is estimated that vein, which must be preoperatively identified and can
 27% of the adult population in the United States has be a significant source of reflux and visible varicosities.
some form of chronic venous insufficiency, which in- The SSV is located posteriorly on the leg; it
cludes a range of conditions from varicose veins and originates on the lateral aspect of the foot, ascends along
telangiectasias through chronic skin changes or ulcer- the midline of the calf, and terminates into the popliteal
ation, or both. The disease, particularly in the later stages vein at variable location in the leg or thigh. The exact
 VARICOSE VEIN SURGERY/OMBRELLINO, KABNICK 187

among individuals, certain perforating veins are seen

commonly enough to be named. These include Cockett’s
perforators located at the lower leg, Boyd’s perforators
located at the knee, and Dodd’s perforators located along
the lower thigh. Burnand et al established the relation-
ship between incompetent communicating perforator
veins, varicose veins, and ulcerations.10 Reflux in these
veins can worsen superficial venous insufficiency and
ultimately lead to skin changes and ulcerations. Identi-
fication of the perforators and their potential treatment
(obliteration) is essential to the overall management of
superficial venous disease.
The development of and advances in venous
duplex ultrasonography have made this the most essen-
tial tool in the diagnosis and treatment of superficial
venous disease and valvular reflux. Each practitioner
should have a basic understanding of ultrasound imaging
as it pertains to venous disease (Fig. 3). It is essential in
the identification and diagnosis of anatomic variations
and is used to identify the source of venous valvular
reflux at its most cephalad point (‘‘point of highest
reflux’’). Valvular reflux is defined as abnormal—and
the valve incompetent—when retrograde flow through
Figure 2 Perforator vein anatomy. the valve lasts longer than 0.5 seconds by duplex
criteria.11 Reflux should be measured with the patient
identification of the location of the saphenopopliteal in an upright position and the limb non–weight bearing.
junction (SPJ), as the SSV dips below the fascia, is It is imperative that the clinician identify the point of
particularly important when treating reflux originating highest reflux to treat the patient properly, that is, the
from this vein. Large, unnamed tributaries originating most cephalad point at which valve failure is present. It is
from this vein can be a source of significant visible also important to identify any large tributary branches of
varicosities, particularly behind the knee and the calf. the GSV, SSV, and incompetent perforators to manage
A detailed venous examination must also identify the patient adequately.
the location and competence of perforating veins Much has been written on the topic of recurrence
(Fig. 2). These are veins that connect the superficial of chronic venous insufficiency and varicose veins fol-
and deep systems either directly, by crossing the fascia, or lowing traditional therapeutic options (vein ligation
indirectly, through muscular tributaries. Their presence alone or vein ligation and stripping).12 Over the past
is particularly important when treating patients several years, the concept of ‘‘neovascularization’’ has
with chronic venous ulcers and recurrent varicosities. gained increasing popularity and attention.13–16 It is
Although the pattern of perforating veins varies widely defined as growth and development of new venous

Figure 3 SFJ reflux. Venous duplex ultrasound of the SFJ, demonstrating SFJ reflux and an incompetent terminal valve.
188 SEMINARS IN INTERVENTIONAL RADIOLOGY/VOLUME 22, NUMBER 3 2005

Figure 4 Neovascularization. Venous duplex ultrasound of a symptomatic patient, demonstrating ‘‘neovascularization’’ at the SFJ,
6 years after standard stripping and ligation. (Courtesy of the Vein Institute of New Jersey.)

tributaries (angiogenesis) at the site of previously ligated 3. Minimizing the number of potential complications
or stripped varicosities. It is particularly prevalent at the
SFJ but may occur at any point of previous vascular Several procedures available today meet these require-
surgery (Fig. 4). Its exact prevalence and time of occur- ments and are described subsequently.
rence are difficult to establish because most patients are Despite this general overall approach to venous
lost to follow-up. It can manifest itself as long as 10 years surgery, the reality is that each procedure must be
after the initial surgery and often leads to recurrence of tailored to meet the anatomic and pathophysiologic
symptoms and unsightly visible varicosities. It has been needs of the individual patient and should be based
postulated that surgical trauma or venous congestion upon a detailed venous ultrasound duplex study of the
caused by high ligation of venous tributaries of the SFJ affected limb. The vast majority of varicose vein surgery
may lead to this phenomenon. Although symptom today is performed on an outpatient or same-day basis,
recurrence may, in fact, be a multifactorial event and and most patients are able to resume normal activity with
neovascularization but one of several factors that con- relatively little discomfort within a relatively short time
tribute to the recurrence of venous insufficiency and period. Many surgical options are available, although
varicose veins, it stands to reason that avoiding surgical some of these have fallen out of favor because of
trauma (e.g., groin incisions, skeletonization) improves unnecessary potential complications and unacceptably
the likelihood of successful treatment of venous insuffi- high incidences of recurrence. We describe several of
ciency. New, minimally invasive techniques such as the procedures most commonly performed so that the
endovenous obliteration, which avoid a groin incision reader may obtain a basic fundamental knowledge of
and closure of SFJ tributaries, seem at this early point in varicose vein surgery, from both a historical and current
our experience to have a theoretical benefit in this regard. prospective.
Longitudinal follow-up will be necessary to determine The surgical options are:
whether this theoretical benefit is truly present.
1. Stripping and ligation of the great saphenous vein
2. Varicose vein ligation
SURGICAL OPTIONS 3. Phlebectomy
As previously stated, the main indications for seeking 4. Endovenous vein obliteration
treatment of chronic venous insufficiency are symptoms 5. Perforator vein surgery
(pain, discomfort, swelling, ulceration, etc.) and cosm-
esis (visible varicosities) (Table 1). Regardless of the
reason, Bergan17 suggested that three main objectives be
met when planning a surgical treatment strategy for Table 1 Treatment of Varicose Veins: Indications
superficial venous disease: for Therapy
Cosmesis Bleeding
1. Permanent removal of the varicosities along with
Leg pain Lipodermatosclerosis
the source of venous hypertension (highest point of
Leg heaviness Venous ulceration
reflux)
Leg fatigue Dermal hyperpigmentation
2. Obtaining as cosmetic a result as possible
 VARICOSE VEIN SURGERY/OMBRELLINO, KABNICK 189

Stripping and Ligation of the Great Proponents of this procedure point to the fact that
Saphenous Vein complete saphenectomy eliminates any possibility of
Until recently, ankle-to-groin stripping of the GSV with persistent axial reflux through the segment of the vein
ligation of branch tributaries was considered the ‘‘gold removed. Winterborn et al demonstrated a 60% reduced
standard’’ in varicose vein surgery. However, with a risk of reoperation at 11 years after ligation and strip-
better understanding of both anatomic relationships ping.16 Opponents of this procedure cite the increased
and associated venous physiology, this excessively radical postoperative pain, bruising, and longer overall recovery
procedure has, for the most part, been abandoned. It is time resulting in decreased overall quality of life.
now recognized that stripping of the GSV to the level of Neovascularization, particularly at the groin, has also
the knee is sufficient to obtain optimal results and avoids been associated with traditional stripping and may in-
the troublesome complication of saphenous nerve injury crease the possibility of recurrences.13 Despite this po-
associated with stripping in the calf.18 The practice of tential for eventual occurrence, stripping and ligation
ligating and disconnecting each saphenous vein tributary remain a viable option in the treatment of saphenous
in the groin (a process called skeletonization) is now vein disease.
believed to contribute to venous congestion and angio-
genesis, resulting in SFJ neovascularization and recur-
rence, and has also fallen out of favor. Varicose Vein Ligation Only
The most popular current technique for stripping Popularized in the 1970s and 1980s, the concept of
(more appropriately called saphenectomy) utilizes a dis- ligating visible varicosities utilizing multiple incisions
posable, flexible, plastic internal stripper (i.e., Codman has fallen out of favor as both ineffective and cosmeti-
stripper) (Fig. 5). A small transverse incision is made cally unacceptable. Multiple small incisions are made
along the skin creases at the groin. The GSV is isolated along the course of visible varicosities and the veins are
at the SFJ and ligated at the junction. A venotomy is segmentally ligated and cut. With the current under-
then made and the stripper is passed into the GSV at the standing that venous insufficiency must be addressed at
groin and threaded caudally through the incompetent its point of highest reflux, it is easy to understand why
vein caudal to the level of the knee, where it is brought simple ligation of visible varicosities is bound to fail.
out through a small skin incision and externalized. After Only after correcting the origin of highest reflux in
the vein has been transected at the SFJ and at the knee, the axial vein can secondary visible varicosities be ligated
an acorn-shaped stripping head is attached to the strip- and removed. Failure to do so results in predictably early
per and the entire device drawn caudally. The stripping local recurrences at the sites adjacent to the previous
head prevents the stripper from passing through the end incisions.15 Sarin et al have shown a recurrence rate as
of the vein, which is instead inverted and pulled through high as 45% after ligation alone as early as 3 months after
the thigh, tearing away from its branches as it proceeds. treatment.20 Dwerryhouse et al reported a recurrence
Both incisions are then closed and a compression dress- rate of 71% after high ligation alone.14 The majority of
ing applied. This procedure is usually done under general the clinicians who perform venous surgery have therefore
anesthesia, although advances in tumescent anesthesia mostly abandoned varicose vein ligation as an isolated
have allowed some clinicians to avoid the use of general procedure.
anesthesia.19 Ligation of the SSV at the SPJ through a small
skin incision is still performed in the presence of vari-
cosities originating from the SSV. Preoperative venous
ultrasound mapping of the junction is imperative to
perform this procedure properly and safely. Intraoper-
ative identification of the sural nerve, which lies in close
proximity to the vein at the junction, is important in
avoiding injury to this nerve. Ligation of the vein at the
junction addresses the underlying problem of reflux at
the most cephalad point (SPJ). This procedure is usually
combined with an extensive phlebectomy to eliminate
visible varicosities.

Phlebectomy
First described by Cornelius Celsus in the first century
Figure 5 Codman Stripper. After exposing the GSV, a flexible AD and perfected in modern Europe, phlebectomy
plastic stripper is inserted within the vein and subsequently pulls is today an essential part of the armamentarium of
out through a separate incision. venous surgery.21 Phlebectomy of varicose veins may
190 SEMINARS IN INTERVENTIONAL RADIOLOGY/VOLUME 22, NUMBER 3 2005

be performed alone or in combination with other vein short-term results but ultimately leads to early recur-
procedures. Referred to in the past as ‘‘stab avulsion rence and an unhappy patient. Phlebectomy procedures
phlebectomy’’ and today as ‘‘microphlebectomy,’’ this can be performed in an ambulatory setting, utilizing local
ancient procedure has undergone significant refinements anesthetic, tumescent anesthesia, and/or light sedation.
and a newfound renaissance over the last several years. They can be done at the same setting as other vein
The procedure involves utilizing a small blade (11 procedures, be performed as the second part of a staged
scalpel, 18-gauge needle, or small ophthalmologic blade) procedure, or be done as a stand-alone procedure for
to make a cutaneous microincision. Incisions should recurrent veins. As with any form of treatment for
generally be vertically oriented along the thigh and lower varicose veins, new varicosities may develop over time
leg and should follow the dermal lines at the knees and and patients should be informed of this potential.
ankles to obtain optimal cosmetic results. Phlebectomy
hooks (Muller, Oesch, Varady, etc.) are used to pick up
the vein and bring it through the incision, where it is Endovenous Vein Obliteration
grasped, transected, and avulsed (Fig. 6). The use of the In the age of minimally invasive surgery, endovenous
small blades allows cosmetically acceptable results and vein obliteration is quickly gaining popularity among
allows resumption of normal activity within a relatively clinicians and patients alike. It offers a highly effective
short period of time. Microphlebectomy is appropriate and cost-effective alternative to traditional stripping and
after other venous procedures (stripping and ligation or ligation, utilizing one of two distinct forms of thermal
endovenous obliteration) when established visible vari- energy—radiofrequency (RF) and laser—to destroy the
cose saphenous tributaries or clusters are associated with vein in situ endovascularly and eliminate the highest
incompetent perforating veins.22 point of reflux. Most frequently, it is utilized to treat
Recently, a technique known as power axial vein reflux (GSV and SSV), but many clinicians
phlebectomy (TriVexTM) has gained favor with some have expanded its use to large venous tributaries. Both
clinicians. It involves the use of a transilluminated power modalities rely heavily on the use of tumescent anes-
phlebectomy device that macerates and extracts visual- thesia to insinuate fluid between the skin and the vein
ized veins through a small incision site. The technique under treatment, thereby reducing the potential for
is particularly effective when dealing with a large area thermal damage to the skin. The use of intraoperative
of vein clusters and significantly reduces operative ultrasound is essential in completing the procedure.
time. Advances in tumescent anesthesia have reduced RF endovenous vein obliteration involves the
the postoperative pain associated with this procedure, use of a 460-kHz, 25-W generator with a specially
although bruising still remains an issue. devised disposable electrode catheter to deliver bipolar
The results of phlebectomy are excellent when the RF energy to the vein. This accomplishes controlled
procedure is performed for the appropriate indications heating (85 C) of the vessel wall, causing collagen
and when, as stated before, more cephalad reflux is also destruction and contraction, which results in obliteration
addressed. Performing this procedure without address- of the vein. By limiting the temperature of the electrodes
ing an underlying reflux problem may offer satisfactory in contact with the vessel wall to less than 100 C,

Figure 6 Microphlebectomy. Visible varicosities are preoperatively marked. A small blade is used to make a micro-incision and hooks
and clamps are used to avulse the vein through the incisions. (Courtesy of the Vein Institute of New Jersey.)
 VARICOSE VEIN SURGERY/OMBRELLINO, KABNICK 191

boiling, vaporization, and carbonization of the tissue are preoperatively vein mapped using duplex ultrasound.
avoided. One such device on the market is the Closure1 Local anesthetic is used at the puncture site, which is
catheter system (VNUS Medical Technologies, Sunny- often at or just below the knee. Utilizing duplex guid-
vale, CA). It is approved by the Food and Drug Admin- ance, an entry needle is inserted into the saphenous vein
istration (FDA) and widely available in the United (Fig. 8). Once entry is established with confirmation of
States for the treatment of GSV reflux. It is available venous return from the needle, a wire is advanced under
in two sizes—5 and 8 Fr—to reflect the diameter of the ultrasound guidance into the vein. A vascular sheath is
vein being treated (Fig. 7). Early results have been then inserted over the wire and positioned  2 cm caudal
promising, and both patients’ satisfaction and quality to the SFJ. A catheter electrode (RF) or laser fiber is
of life are improved after this procedure even at 2 years.23 placed through the sheath to a point just caudal to the
Opponents of RF cite a higher learning curve and the SFJ (Fig. 9). Tumescent local anesthesia (0.15–0.25%
higher cost of this procedure when compared with diluted and buffered lidocaine) is then infiltrated around
standard stripping and ligation and with vein obliter- the entire length of the vein to be treated. A pullback
ation using laser energy. technique is then used to ablate the vein endothermally.
Endovenous laser vein obliteration utilizes one of Typical pullback rates are 2–3 cm/min with RF and 10–
four different wavelengths (810, 940, 980, and recently 12 cm/min with laser. At the termination of the proce-
1320 nm) to destroy the lining of the vein wall endo- dure, an intraoperative ultrasound examination is done at
thermally and thereby cause vein wall contraction and the SFJ to rule out a deep venous thrombosis (DVT) and
obliteration. Wavelength does not seem to influence the a compressive dressing (class 2) is applied. The patients
efficacy of treatment, although anecdotal evidence sug- are sent home following a brief recovery period.
gests that higher wavelengths may reduce postprocedural Patients are encouraged to resume normal daily
bruising and pain. There are several manufacturers in the activity as soon as possible and are seen in follow-up 24–
United States who distribute these devices, which are 72 hours postoperatively. A venous duplex examination
FDA approved for endovenous ablation of axial varicose is performed at the postoperative visits to confirm vein
veins. Lower overall cost and significantly faster proce- obliteration and rule out DVT. At our institution,
dure times (versus RF ablation) make this modality follow-up venous duplex studies are done at 4 months
particularly appealing to some clinicians. and 1, 2, and 3 years. It has been our experience that if
Procedural techniques are similar with both the vein remains closed at 4 months, the GSV will
modes of endovenous vein obliteration. Patients are remain closed, fibrosed, and unrecognizable from the
surrounding tissue at 1 year.

Figure 8 Ultrasound guided entry into the GSV. An entry needle

Figure 7 RF electrode. Electrodes are available in two sizes is placed into the GSV at the knee, under ultrasound guidance,
depending on the size of the vein to be treated. (Courtesy of and entry is confirmed by aspirating blood into the syringe.
VNUS Medical Technologies, Sunnyvale, CA.) (Courtesy of the Vein Institute of New Jersey.)
192 SEMINARS IN INTERVENTIONAL RADIOLOGY/VOLUME 22, NUMBER 3 2005

Figure 9 Endovenous sheath and laser fiber. Once entry into the vein is established, a 6 French sheath is inserted into the vein over a
wire and the laser fiber placed into the sheath. Both sheath and fiber should be at least 2 cm proximal to the SFJ. (Courtesy of the Vein
Institute of New Jersey.)

Although endovenous obliteration is a relatively among clinicians and patients as a minimally invasive
safe procedure, the performing clinician must be aware alternative to varicose stripping and ligation.
of several unwanted postprocedure complications and Results with endovenous obliteration have thus
results. There have been reports of DVT following this far been good (Fig. 10). In a multicenter study involving
procedure.24,25 This can easily be avoided by remaining 286 patients and 319 limbs treated utilizing RF, 83.6%
at least 2 cm from the SFJ utilizing ultrasound con- and 85.2% of the limbs treated remained closed at 12 and
firmation. In the event that a DVT does occur, it should 24 months, respectively. The failure rate (recanalization)
be treated accordingly with anticoagulation therapy was 10.8% at 12 months and 11.3% at 24 months. There
and close clinical follow-up for progression or regression was a significant reduction in visible varicosities and
with venous duplex ultrasound. Paresthesia and thermal patients’ satisfaction was achieved in 92% at 1 year and
skin injury have been reported in several patients under- 94.5% at 2 years.26 The results utilizing laser vein
going endovenous obliteration. These can easily be obliteration, although not as extensively published, ap-
avoided with utilization of an adequate amount of pear to be just as good.27 Certain modifications of the
tumescent anesthesia to insulate the surrounding tissue procedure have significantly reduced the failure rates
from the vein being treated. It is recommended that a since the early trails.23
cuff of at least 1 cm of tumescent anesthesia around
the vein be infiltrated to avoid these complications. If
paresthesia does occur, it is typically self-limiting and Perforator Vein Surgery
usually resolves in several months. Bruising and post- Incompetent perforating veins are often seen in patients
operative pain, although significantly less than those with chronic venous ulcerations, and understanding of
found with standard stripping and ligation, can occur their treatment is important to any clinician treating
but are usually well tolerated and should resolve com- these patients.28 Compression stockings (class 2 and 3)
pletely in several days. As stated earlier, it seems that and proper wound care are often sufficient to heal
higher wavelengths can reduce these symptoms. Persis- these troublesome wounds.29,30 In the event that these
tence of pain and swelling warrants further investigation ulcers do not heal or are frequently recurrent, primary
such as duplex ultrasound to exclude the possibility of perforator insufficiency or post-thrombotic syndrome
DVT. Finally, failure of the vein to close is sometimes can often be established as a contributing factor. In
encountered and is believed to occur when the amount of such situations, several surgical options are available.
tumescent anesthesia used is less than that necessary to Liton’s original operative technique, described in the
compress large-diameter veins against the energy source early 1950s, involved surgical ligation of subfascial per-
at initial treatment. These veins can usually be retreated forators through three long skin incisions along the
following a short recovery period. Despite these infre- medial, anterolateral, and posterolateral calf. This radical
quent complications and events, endovenous vein oblit- procedure has since been mostly abandoned because
eration is quickly becoming the treatment of choice of its high rate of wound complications. Subsequent
 VARICOSE VEIN SURGERY/OMBRELLINO, KABNICK 193

Figure 10 Results of endovenous laser. Preoperative picture of extensive varicosities and improved cosmetic results 4 months after
endovenous laser obliteration. (Courtesy of the Vein Institute of New Jersey.)

authors, including Cockett and DePalma, modified the vascular medicine. The concept of initially treating the
procedure utilizing smaller, more strategically placed highest point of reflux is now widely accepted among
incisions, combined with excision of axial superficial clinicians who perform venous procedures and has dras-
vein and placement of skin grafts. Despite these mod- tically improved overall long-term results. With the use
ifications, wound complications were still prevalent and of emerging technologies and an ever-present consumer
better alternatives were sought. demand, this once overlooked discipline of vascular
In the hope of eliminating wound complications, medicine has come to the forefront as a specialty. The
Edwards devised a device called a phlebotome, which is use of minimally invasive techniques such as endovenous
introduced through a small medial skin incision just vein obliteration has opened this field to multiple spe-
below the knee and advanced subfascially toward the cialties and has significantly increased the quality of life
medial malleolus, disrupting the perforators blindly as it of the patients undergoing these procedures. The next
is advanced. The advantage of the technique is that the challenges for clinicians who treat venous disease are
incision is remote from the skin being compromised by those of limiting recurrence and—the last frontier of
venous disease, which reduces local complications. Its venous disease—the effective correction of deep venous
disadvantage is the blind nature of branch disruption. insufficiency. As newer technology and a better under-
With these issues in mind, subfascial endoscopic perfo- standing of our current failures progress, we may ulti-
rator surgery (SEPS) was born. During SEPS, instru- mately resolve these pending issues.
ments are introduced into the subfascial space through
two or fewer small, remote incisions and each perforator
is identified, clipped, and divided with endoscopic visu-
REFERENCES
alization. Because this procedure is often combined with
concomitant saphenous vein ablation, the isolated value 1. Majno G. The Healing Hand. Cambridge, MA: Harvard
of SEPS is difficult to assess. University Press; 1975
Early results of perforator vein surgery were 2. Hippocrates. The Genuine Works of Hippocrates.
promising, but recurrence of venous ulcers years after Adams EF, trans. Vol 2. New York: Wm Wood & Co;
the procedure has lately become an issue. This has 1886
been particularly true with ulcer patients who presented 3. Anning ST. Historical aspects. In: Dodd H, Cockett FB, eds.
The Pathophysiology and Surgery of Veins of the Lower
with post-thrombotic syndrome as their underlying
Limb. 2nd ed. Edinburgh: Livingstone; 1976:3–17
factor.31–34 Preliminary results with the use of sclero- 4. Celsus AC. Of Medicine in Eight Books. Grieve J, trans.
therapy under ultrasound guidance are promising and London: Wilson & Durham; 1756
this may one day supplant SEPS as the procedure of 5. Walsh J. Galen’s writing and influences inspiring them. Ann
choice for local control of perforator incompetence. Med Hist 1934;I:14
6. Jamieson WG. State of the art of venous investigation and
treatment. Can J Surg 1993;36:119–128
7. Brand FN, Dannenberg AL, Abbott RD, Kannel WB. The
SUMMARY
epidemiology of varicose veins: the Framingham study. Am J
With new insights into the anatomy, pathophysiology, Prev Med 1988;4:96–101
and progression of venous disease and with recent 8. Scott TE, LaMorte WW, Gorin DR, Menzoian JO. Risk
technical advances, the treatment of superficial venous factors for chronic venous insufficiency: a dual case-control
disease has gained its rightful place in the realm of study. J Vasc Surg 1995;22:622–628
194 SEMINARS IN INTERVENTIONAL RADIOLOGY/VOLUME 22, NUMBER 3 2005

9. Browse NL, Burnand KG, Thomas ML. Diseases of the 22. Kabnick LS. Should we consider a paradigm shift for the
Veins: Pathology, Diagnosis and Treatment. London: treatment of GSV and branch varicosities? 2003 UIP World
Hodder and Stoughton; 1988 Congress Phlebology Chapter Meeting, San Diego
10. Burnand KG, O’Donnell TF, Thomas ML, Browse NL. The 23. Manfrini S, Gasbarro V, Gudmundur D, et al. Endovenous
relative importance of incompetent communicating veins in management of saphenous vein reflux. J Vasc Surg 2000;32:
the production of varicose veins and venous ulcers. Surgery 330–342
1977;82:9–14 24. Merchant RF, DePalma RG, Kabnick LS. Endovascular
11. Vasdekis SN, Clarke GH, Nicolaides AN. Quantification of obliteration of saphenous reflux: a multicenter study. J Vasc
venous reflux by means of duplex scanning. J Vasc Surg 1989; Surg 2002;35:1190–1196
10:670–677 25. Min RJ, Khilnani NM. Endovenous laser treatment of
12. Royle JP. Recurrent varicose veins. World J Surg 1986;10: saphenous vein reflux. Tech Vasc Interv Radiol 2003;6:125–
944–953 131
13. Jones L, Braithwaite BD, Selwyn D, Cooke S, Earnshaw JJ. 26. Komenaka IK, Nguyen ET. Is there an increased risk for
Neovascularization is the principal cause of varicose vein DVT with the VNUS closure procedure? J Vasc Surg 2002;
recurrence: results of a randomized trial of stripping the long 36:1311
saphenous vein. Eur J Vasc Endovasc Surg 1996;12:442–445 27. Hingorani AP, Ascher E, Markevich N, et al. Deep venous
14. Dwerryhouse S, Davies B, Harradine K, Earnshaw JJ. thrombosis after radiofrequency ablation of the greater
Stripping the long saphenous vein reduces the rate of saphenous vein: a word of caution. J Vasc Surg 2004;40:
reoperation for recurrent varicose veins: five-year results of a 500–504
randomized trail. J Vasc Surg 1999;29:589–592 28. Delis KT. Perforator vein incompetence in chronic venous
15. Glass GM. Neovascularization in recurrence of varices of the disease: a multivariate regression analysis model. J Vasc Surg
great saphenous vein in the groin: phlebography. Angiology 2004;40:626–633
1988;39:577–582 29. Negus D. Prevention and treatment of venous ulcerations.
16. Winterborn RJ, Foy C, Earnshaw JJ. Causes of varicose vein Ann R Coll Surg Engl 1985;67:144–148
recurrence: late results of a randomized controlled trail of 30. Mayberry JC, Moneta GL, Taylor LM, Porter JM. Fifteen-
stripping the long saphenous vein. J Vasc Surg 2004;40:634– year results of ambulatory compression therapy for chronic
639 venous ulcers. Surgery 1991;109:575–581
17. Bergan JJ. Varicose veins: treatment by surgery and scle- 31. Burnand K, Thomas ML, O’Donnell T, Browse NL. Relation
rotherapy. In: Rutherford RB, ed. Vascular Surgery. 5th ed. between post-phlebitic changes in the deep veins and the
Philadelphia: WB Saunders; 2000:2011–2012 results of surgical treatment of venous ulcers. Lancet 1976;1:
18. Bergan JJ. Surgery of the Veins of the Lower Extremity. 936–938
Philadelphia: WB Saunders; 1985 32. Johnson WC, O’Hara ET, Corey C, Widrich WC, Nabseth
19. Proebstle TM, Paepcke U, Weisel G, Gass S, Weber L. High DC. Venous stasis ulceration: effectiveness of subfascial
ligation and stripping of the long saphenous vein using ligation. Arch Surg 1985;120:797–800
tumescent technique for local anesthesia. Dermatol Surg 33. Robison JG, Elliot BM, Kaplan AJ. Limitations of subfascial
1998;24:149–153 ligation for refractory chronic venous stasis ulceration. Ann
20. Sarin S, Scurr JH, Coleridge Smith PD. Assessment of Vasc Surg 1992;6:9–14
stripping of the long saphenous vein in the treatment of 34. Gloviczki P, Cambria RA, Rhee RY, Canton LG, McKusick
primary varicose veins. Br J Surg 1992;79:889–893 MA. Surgical technique and preliminary results of endoscopic
21. Olivencia JA. Ambulatory phlebectomy turned 2400 years subfascial division of perforating veins. J Vasc Surg 1996;23:
old. Dermatol Surg 2004;30:704–708 517–523

View publication stats