Controversial Question



Can varicose vein surgery prevent extension of venous reflux with time?

1. M. Bokuchava, Georgia
2. F. Calota, Romania
3. N. de Barros Jr, Brazil
4. L. Hnátek, Czech Republic
5. E. Ilyukhin, Russia
6. F. Islamoglu, Turkey
7. A. H. Kamhawy, Egypt
8. D. Radak and S. Tanaskovic, Serbia
9. K. Rerkasem, Thailand
10. N. Sánchez Nicolatt, Mexico
11. L. Tessari and S. Gianesini, Italy
12. M. Vuylsteke, Belgium
13. F. Zernovick´y, Slovakia

1. M. Bokuchava, Georgia

Mamuka BOKUCHAVA, MD, PhD
President, Georgian Association of
Angiologists and Vascular Surgeons; Deputy
Director, N. Bockhua Center of Vascular
and Heart Diseases, Tbilisi, GEORGIA
(e-mail: bmamuka@hotmail.com)

Reflux in the superficial veins, the most prevalent pathology in all chronic venous disease classes, is often collectively reported as great saphenous vein (GSV) or small saphenous vein incompetence.1 Labropoulos et al2 show that primary venous reflux can occur in any superficial or deep vein of the lower limbs and in the absence of saphenofemoral junction (SFJ) or GSV incompetence. It is often found at different sites that may not communicate with or affect each other. This suggests that reflux is probably due to a local or multifocal process in addition to or separate from a retrograde process.

Patients with chronic venous disease often ask whether elective vein surgery could be delayed without consequences. Stripping or ablation of the GSV is a useful procedure in the management of varicose veins. In a study in which patients underwent either GSV stripping or SFJ ligation alone, stripping reduced clinical recurrence of varicose veins by two-thirds after 5 years.3 Perrin et al in the REVAS study (REcurrent Varices After Surgery) identified several factors associated with recurrence and classified them as belonging to one of two groups: (i) those arising from inadequate or incomplete initial treatment, due to tactical or technical errors; and (ii) those arising from evolution or appearance of new sites of reflux secondary to neovascularization (defined as thin-walled, serpentine tributaries arising from a previously ligated SFJ), even after appropriate surgical intervention had been carried out.4

According to Turton et al, venous flow must be rechanneled after venous surgery in an anterograde direction through the remaining superficial and deep veins of the leg.5 This sudden hemodynamic alteration to the return of blood in the superficial and deep veins causes redistribution of venous flow and could overload veins that had been competent. It is possible that the main source of reflux previously “masked” an inherent weakness in such veins or others that were more partially incompetent. This so-called neoreflux may appear in a substantial number of patients, despite complete abolition of the sites of reflux identified preoperatively.

Van Neer et al6 shows that 91% of patients who undergo a short stripping procedure (above the knee) will have persistent reflux in the remnant GSV branches below the knee after surgery. This incompetence of the distal GSV is independent from the proximal GSV part and from incompetent perforating veins (IPV). There seems to be a tendency toward worsening of clinical signs and symptoms between 6 months and 2 years after surgery, and this goes along with an increase in reflux and in diameters of the GSV remnants below the knee.

In patients with SFJ insufficiency, GSV varicosities, and slight reflux in the GSV below the knee, my preferred choice for surgical intervention is to carry out either complete stripping or ablation of the GSV above and below the knee, with mini-phlebectomy or foam sclerotherapy of remnants below the knee. All this significantly reduces development of the risk for postoperative reflux (duplex ultrasound should be performed 6 and 24 months after surgery). Despite the new methods of treatment, the risk of development of recurrent varicose veins (based on 5-20 years of evidence) remains very high after surgical intervention. This finding indicates the necessity of further investigation and clinical trials.

References

1. Labropoulos N, Leon L, Kwon S, Tassiopoulos A. Study of the venous reflux progression. J Vasc Surg. 2005;41:291-295. 
2. Labropoulos N, Kang SS, Mansour MA, Giannoikas AD, Buckman J, Baker WH. Primary superficial vein reflux with competent saphenous trunk. Eur J Vasc Endovasc Surg. 1999;8:201-206. 
3. Dwerryhoouse S, Davies B, Harradine K, Sarnshow JJ. Stripping the long saphenous vein reduces the rate of reoperation for recurrent varicose veins: five-year results of a randomized trial. J Vasc Surg. 1999;29:589-592. 
4. Perrin MR, Guex JJ, Ruckley CV, et al. Recurrent varices after surgery (REVAS), a consensus document. REVAS group. Cardiovasc Surg. 2000;8:233-245. 
5. Turton EP, Scott DJ, Richards SP, et al. Duplex-derived evidence of reflux after varicose vein surgery: neoreflux or neovascularisation? Eur J Vasc Endovasc Surg. 1999;17:230-233. 
6. van Neer P, Kessels GF, Estourgie JR, de Haan F, Neumann AM, Veraart CJ. Persistent reflux below the knee after stripping of the great saphenous vein. J Vasc Surg. 2009;50:831-834.

 


2. F. Calotă, Romania

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Firmilian CALOTĂ, MD, PhD
Professor of General Surgery
University of Medicine and Pharmacy
The 2nd General Surgery Department
Craiova
200411, 2nd Alexandru Cel Bun Street Craiova, ROMANIA
(e-mail: fcalota@yahoo.com)

The pathogeny of chronic venous disease (CVD) has more shades than previously believed. There are primary varices with retrograde development, but also with orthograde development, with a continent saphenous crosse in an approximately similar percentage to suspended primary varices. The distribution of valves and their localization in the saphenopopliteal and saphenofemoral junction segments, in areas with highly mobile joints, and their ostial or subostial position are “discrete” elements (systemic “initial sensitivities”); the pathogenic involvement is difficult to assess at first glance. The muscle-pump activity, mainly in the calf and abdominal muscles, pushes venous flow distally. Thus, it influences active venous hypertension episodes, which have the biggest effect on the first upstream axial valve. When the common femoral vein has no valves, the pressure stress falls on the first (superficial) femoral valve, nearly always situated under the junction with the deep femoral vein. The ostial position of the great saphenous terminal valve directs the reflux preferentially toward the femoral valve and protects the crosse. The subostial valve position allows space for the pressure to be received within this largely distensible segment—the saphenous crosse. In the perforating vein, the first valve is extrafascial, sometimes in the ostial position, and the second valve is in a variable position, subfascial, providing conditions amenable to having pressure-reception “rooms.”

In all these situations, conditions are right for a functional insufficiency, especially in the perforator veins, especially of the saphenous crosse. The better the terminal and subterminal valvular continence, the higher the stress on the (superficial) femoral valve. In a patient with an inveterate CVD (more than 15 years in duration), using ultrasound, I found a mixed longitudinal reflux in the proximal (superficial) femoral axis and in the saphenous vein as well (in 1 out of 6 cases); therefore, the patient had venous hypertension. Consequently, we are convinced that every patient should benefit from a multifaceted, personalized treatment. In these situations, any intervention that addresses only the saphenous system would be insufficient. Ignoring an aggressive venous hypertension within the deep venous system—identified by ultrasound—that will become more intense after crossectomy, saphenectomy, and varicose excisions, will lead to variceal relapse.

The pathophysiological argument encouraged us to propose a more complex surgical procedure, comprising a femoral tangent crossectomy, followed by venorrhaphy, with saphenectomy or intraoperative catheter-directed vein sclerotherapy, and varicose excision. The femorofemoral junction is wound with a synthetic rectangular patch about 5-6 cm high, so that the patch can slightly dip down. In the patch, we make a hole for the deep femoral vein passage. The patch descends about 2 cm onto the (superficial) femoral vein. We did not record any postoperative complications.

Patients were selected on the basis of ultrasound detection of valve and transvalvular reflux. Patients were excluded for having a post-thrombotic syndrome, valvular destruction, or parietal changes. The physiopathological objectives achieved include (i) restoration and maintenance of valvular continence, via a “fixed splint” (synthetic patch that is wound around the site); (ii) eradication of venous hypertension in the deep venous axis, and distal relapse prevention; (iii) cancellation of the saphenous “reflux gate”; and (iv) groin neovascularization prevention.

In up to 10 years of ultrasound monitoring of this group of 88 patients, no axial reflux greater than 0.3 seconds was found, and neither were any varicose relapses. Thus, we conclude that varicose vein surgery is effective in preventing the extension of venous reflux in rigorously selected cases, when the ultrasound diagnosis is complete and surgery occurs early and is adapted to the specific pathogenesis.


3. N. de Barros Jr Brazil

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Newton DE BARROS Jr, PhD
Associate Professor of Vascular and
Endovascular Surgery Division
Surgery Department of Paulista School
of Medicine of the Federal University
of São Paulo Rua Marselhesa, 515 Vila Clementino – São Paulo
SP – BRAZIL 04020-060
(e-mail: nbarrosj@uol.com.br)

In my experience, the direct answer is yes. I do believe that varicose vein surgery has beneficial effects on the venous system in the leg and even on the segments that were not targeted by the surgery. Most of my patients have shown improvement in their venous competence, but in accordance with the pathophysiological concept that chronic venous disease is a progressive disease, some patients also may develop incompetence in other segments during their lifetime.1 I always tell my patients that varicose disease has an important characteristic: it is progressive and long lasting. I advise them to be evaluated periodically even after being treated. These patients must be followed-up with duplex scanning and evaluation for clinical criteria in order to assess the hemodynamics of the venous system after varicose vein surgery. Most studies have revealed that even with thermal ablation surgery (radiofrequency ablation [RFA] and endovenous laser therapy [EVLT]), the patients have showed improvement in venous hemodynamic abnormalities.2 We agree and believe that duplex ultrasonography is a fundamental component of the investigation of the lower limb venous system after treatment for varicose veins. The timing of such imaging depends on what we are trying to determine: immediate (1-4 weeks), either to know whether the intervention has achieved the goal or when intended to be a part of sequential treatments; shortterm or mid-term (1-3 years), to detect newly developed incompetent veins or to reveal ultrasound features that predict longer-term outcome after thermal ablation treatment of great or small saphenous veins; and long-term (5 years or more), to assess the development of clinical recurrence, which may have arisen as a consequence of the incompetent veins detected by the short-term or mid-term scan. In addition to duplex ultrasound imaging, clinical findings should be evaluated according to a clinical score and quality of life assessment at the same time intervals.3 We also know that surgical treatment of calf perforator veins results in reduced deep vein reflux, and the improvement is most marked in cases of primary venous insufficiency.4 It is also important to emphasize—although we already know that selective stripping has the same rate of recurrence as standard stripping5—that some studies have shown that complete stripping (long and short saphenous vein) abolishes deep vein reflux in a significant proportion of limbs, and that if failure of stripping occurs, new deep venous reflux may develop. These findings support routine stripping and suggest that the benefits of stripping may relate, at least in part, to a favorable impact on deep venous function.6,7

References

1. Blomgren L, Johansson G, Dahlberg-Åkerman A, Thermaenius P, Bergqvist D. Changes in superficial and perforating vein reflux after varicose vein surgery. J Vasc Surg. 2005;42:315-320. 
2. Marston WA, Owens LV, Davies S, Mendes RR, Farber MA, Keagy BA. Endovenous saphenous ablation corrects the hemodynamic abnormality in patients with CEAP clinical class 3-6 CVI due to superficial reflux. Vasc Endovasc Surg. 2006;40:125-130. 
3. De Maeseneer M, Pichot O, Cavezzi A, et al. Duplex ultrasound investigation of the veins of the lower limbs after treatment for varicose veins. UIP Consensus Document. Eur J Vasc Endovasc Surg. 2011;42:89-102. 
4. Ciostek P, Michalak J, Noszczyk W. Improvement in deep vein haemodynamics following surgery for varicose veins. Eur J Vasc Endovasc Surg. 2004;28:473- 478. 
5. Hammarsten J, Pedersen P, Cederlund CG, Campanello M. Long saphenous vein saving surgery for varicose veins: a long-term follow-up. Eur J Vasc Surg. 1990;4(4):361-364. 
6. MacKenzie RK, Allan PL, Ruckley CV, Bradbury AW. The effect of long saphenous vein stripping on deep venous reflux. Eur J Vasc Endovasc Surg. 2004;8: 104-107. 
7. Jibiki M, Inoue Y, Terasaki H, et al. The effect of short saphenous vein stripping in patients with deep venous reflux. Ann Vasc Dis. 2013;6(3):612-616.

 


4. L. Hnátek, Brazil

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Lukáš HNÁTEK, PhD
Centre of Venous Disorders
Angiocor s.r.o., Zlin
CZECH REPUBLIC
(e-mail: hnatek.lukas@gmail.com)

Whereas compression therapy is the main treatment option for chronic venous disease (CVD), intervention therapy is considered a causal one. Conventional surgery consists of crossectomy, stripping of the great or small saphenous vein (GSV or SSV), and phlebectomy. With crossectomy, a number of studies point out a risk of recurrence; however, study results differ significantly. In 2003, Van Rij reported that the recurrence rate 3 years after surgery reached 23%.1 On the other hand, in 2013, a large multicenter study called “LaVaCro-study”2 showed a recurrence risk of 2.57% with the same follow-up as in the previous study and a risk of 2.92% with a 4-year follow-up. In that study, the authors emphasized the great importance of the quality of crossectomy, during which the GSV is ligated directly to the femoral vein and so does not generate a stump in the junction. Furthermore, all branches that drain into the saphenofemoral junction (SFJ) and branches that also drain directly into the femoral vein are ligated and intersected. Subsequently, the hiatus saphenus is closed with nonresorbable material. De Maeseneer published an approach that creates a mechanical barrier of free endothelium at the site of crossectomy, using a special patch sutured onto the vein instead of a GSV ligation. The radical procedure is performed even for crossectomy of the saphenopopliteal junction. Despite the above-mentioned efforts, the recurrence of varicose veins still occurs. In the SFJ region, the cause seems to be neovascularization, in which vascular endothelial growth factor and its receptors play an important role.3 Our experience with conventional surgical procedures correspond to the above-described results. Therefore, to minimize the risk of recurrent varicose veins, the key is to perform a radical crossectomy.

Apart from conventional surgery, endovascular interventions have recently become popular, and most involve thermal ablation. Thermal ablation, such as endovenous laser therapy (EVLT) and radiofrequency ablation (RFA), aims to remove the saphenous veins, usually the GSV or the SSV. Based on the hemodynamic theory, this procedure eliminates the primary source of reflux from the saphenous vein, which leads to remodeling of the flow in epifascial varicosities and their subsequent regression. There are two approaches to the management of saphenous vein branches in endovascular surgery. In the first, epifascial varicose veins are treated simultaneously by ablation of the saphenous vein. In the second, varicose branches are treated in the second phase, assuming that the quantity and capacity will be reduced with time. However, according to the largest published meta-analysis, the results are not unambiguous, and for EVLT or RFA combined with mini-phlebectomy, there is a better outcome when the epifascial varicose branches are removed simultaneously with the saphenous vein.4 However, we have a different personal approach and perform surgery in two phases, with an endovascular ablation of the saphenous veins completed with a foam sclerotherapy of residual varicosities in the second phase. According to our results, on average, 11.11% of varicose branches completely disappear within half a year. These procedures are performed on an outpatient basis. They do not require hospitalization and are very comfortable for the patient.5 Similarly, we use this approach for perforator vein removal if the perforator vein is the primary source of reflux.

There are also saphenous vein–sparing procedures, such as CHIVA (Cure Hémodynamique de l’Insuffisance Veineuse en Ambulatoire) and ASVAL (Ablation Sélective des Varices sous Anésthesie Locale), which aim only to remodel hemodynamics in the venous bloodstream and restore conditions for blood flow normalization.6 These procedures are generally considered to be very patient-friendly, with a significant benefit for the patient. However, we always expect a higher risk of residual varicosities with these procedures and a possible need for further treatment.

Generally, we consider intervention treatment for CVD, either conventional or endovascular, to be a causal treatment, despite the recurrence risk. This therapeutic approach has a long-lasting effect on the elimination of reflux.

References

1. van Rij AM, Jiang P, Solomon C, Christie RA, Hill GB. Recurrence after varicose vein surgery: a prospective long-term clinical study with duplex ultrasound scanning and air plethysmography. J Vasc Surg. 2003;38(5):935-943. 
2. Papapostolou G, Altenkämper H, Bernheim C, et al. Die LaVaCro-Studie: Langzeitergebnisse der varizenoperation mit crossektomie und stripping der v. saphena magna. Interimsergebnisse nach 1 jahr. Phlebologie. 2013;42(5):253-260. 
3. Rewerk S, Noppeney T, Winkler M, et al. Niedergethmann. Pathogenese der Primär- und Rezidivvarikosis an der Magna-Krosse - Die Rolle von VEGF und VEGF-Rezeptor. Phlebologie. 2007;36:121-176. 
4. Lane TR, Onida S, Gohel MS, Franklin IJ, Davies AH. A systematic review and meta-analysis on the role of varicosity treatment in the context of truncal vein ablation. Phlebology. 2015;30(8):516-524. 
5. Hnatek L. Ist es immer notwendig, seitenastverizen und die insuffiziente stammvenen gleichzeitig zu behandeln? Vasomed. 2015;27(5):232. 
6. Onida S, Davies AH. CHIVA, ASVAL and related techniques—concepts and evidence. Phlebology. 2015;30(2 suppl):42-45.

 


5. E. Ilyukhin, Russia

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Evgeny ILYUKHIN, MD, PhD
St. Petersburg, Medalp Private
Surgery Clinic
RUSSIA
(e-mail: evgeny@ilyukhin.info)

This is a difficult question to answer. On one hand, “yes,” because when the vein is successfully ablated, reflux also disappears, and this can have a significant effect on reflux progression in other parts of the venous system. On the other hand, “no,” because new reflux develops much more often than most of us would expect. However, this is just an opinion, an intentionally simplified view of such a challenging issue.

If we say “yes,” that surgery prevents extension of reflux, then we have to believe that in the vast majority of patients, the reflux will never occur again. So, if we stop reflux extension with surgery, the patients should never have new varicose veins appear on their legs. This speculation seems logical, because reflux is considered to be the source of varicose veins. This also seems very optimistic: perform a good surgery and as a consequence there will be no reflux, no varices. Indeed, there is a lot of evidence in the literature for such a view. Removing saphenous veins via any kind of invasive treatment is extremely effective. For thermal ablation techniques, the immediate success rate exceeds 90%.1,2 Some studies report an occlusion rate close to 100%! 3 There is a 14-year follow-up study showing a recurrence rate of less than 10%.4 On the basis of such findings, we should be able to confidently state that surgery is effective in preventing reflux extension. But can we?

How should we treat other evidence from the literature? Rasmussen et al5 points out recurrence rates of 47% at 5-year follow-up after laser ablation and 55% after stripping. What is even more impressive is that new reflux developed, respectively, in 18% and 10% of patients who underwent successful ablation of saphenous veins. This means that despite the majority of patients having no reflux after surgery, new varicose veins did develop in some cases. If such a high rate of technical or clinical failure (recurrence) was found in only one study, we could consider it to be an exception to the rule. However, we can easily find similar data elsewhere. For example, Proebstle et al1 report varicose vein recurrence after radiofrequency ablation in 41% of cases at 5-year follow-up. We can take into account the author’s remark that in the region of an ablated vein, the recurrence rate was only 6%, but this seems to be too simple an explanation for a highly complicated issue. So, one could say that surgery is not effective in preventing reflux extension.

Moreover, to answer this discussion question as thoroughly as possible, I looked into our postsurgery outcomes. As I was convinced that the recurrence rate in our institution would support the answer “yes,” I was surprised to find records of residual veins, recurrent varicosities, or target vein recanalization in 36 of 97 (37%) cases at 1-year follow-up, and that we had performed an additional treatment in 29 (30%) cases.

In conclusion, I would prefer to avoid choosing between a clear yes or no. It may be that both answers are correct. First of all, I believe that we should include more than just reflux in the discussion. Results from many studies convince us that “no reflux” does not mean “no varices,” and also that the presence of reflux does not necessarily mean the presence of varices. We must learn to determine the value of both new reflux and recurrent or residual veins, and, in particular, the associated risk of thrombosis or skin changes. The variations in assessment of such events lead to differences in the statistics and treatment approaches. Finally, despite all of the above, including the high recurrence rate, surgery provides a high level of patient satisfaction.6 In my opinion, though surgery may not be that effective in elimination of reflux, it does provide an adequate solution for clinical issues.

References

1. Proebstle TM, Alm BJ, Göckeritz O, et al. Five-year results from the prospective European multicentre cohort study on radiofrequency segmental thermal ablation for incompetent great saphenous veins. Br J Surg. 2015;102(3):212-218. 
2. Wittens C, Davies AH, Baekgaard N, et al. Management of chronic venous disease. Eur J Vasc Endovasc Surg. 2015;49:678-737. 
3. Vuylsteke ME, Thomis S, Mahieu P, Mordon S, Fourneau I. Endovenous laser ablation of the great saphenous vein using a bare fibre versus a tulip fibre: a randomised clinical trial. Eur J Vasc Endovasc Surg. 2012;44(6):587-592. 
4. Hartmann K, Klode J, Pfister R, et al. Recurrent varicose veins: sonography-based re-examination of 210 patients 14 years after ligation and saphenous vein stripping. Vasa. 2006;35(1):21-26. 
5. Rasmussen L, Lawaetz M, Bjoern L, Blemings A, Eklof B. Randomized clinical trial comparing endovenous laser ablation and stripping of the great saphenous vein with clinical and duplex outcome after 5 years. J Vasc Surg. 2013;58(2): 421-426. 
6. Nelzén O, Fransson I. Varicose vein recurrence and patient satisfaction 10-14 years following combined superficial and perforator vein surgery: a prospective case study. Eur J Vasc Endovasc Surg. 2013;46(3):372-377.

 


6. Fatih ISLAMOGLU, Turkey

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Fatih ISLAMOGLU MD
Professor, Department of Cardiovascular
Surgery
Ege University Medical Faculty, Izmir
Ege Üniversitesi Tıp Fakültesi,
Kalp ve Damar Cerrahisi Anabilim Dalı 35100 Izmir
TURKEY
(e-mail: fatih.islamoglu@ege.edu.tr fislamoglu@hotmail.com)

 In the treatment of chronic venous insufficiency (CVI), high ligation (HL) and stripping of the saphenous varicose veins, and percutaneous phlebectomy have been the main options for many years. Modern management of CVI includes treatment of the cause (reflux) and result (varicose veins). Reflux should be treated before varicosities because if the cause is not eliminated, the varicose veins will recur.1 Generally, the elimination of reflux has been accomplished with surgery. The new thermal ablation techniques, such as endovenous laser ablation therapy (EVLT) and radiofrequency ablation (RFA), have the advantage of being performed with only local anesthesia, but they have the potential to leave residual saphenofemoral reflux due to incomplete ablation of all side branches of the saphenofemoral junction (SFJ).1 These techniques can obliterate only the main trunk of the saphenous vein, and complete disconnection of all of the side branches draining to the SFJ is never accomplished. Classical surgical HL has also been shown to lead to recurrent varicose vein development due to neovascularization, but this is not completely true; real neovascularization demonstrated by Doppler is rare and is mostly related to the SFJ and side branches not being divided properly. Thus, the primary cause of varicose vein recurrence after surgery is inadequate surgical technique, and neovascularization is never the only cause of recurrence.2 Recurrence also has an incidence of 7.1% after EVLT and 2.2% after RFA. The development of arteriovenous fistulas and the intensity of the inflammatory response might be responsible for recanalization of ablated venous segments. This effect is due entirely to inadequate SFJ or side-branch division in the initial procedure.1,2 In support of the importance of complete SFJ ligation, small vessel networks and GSV recanalization at the SFJ have more commonly been found in patients undergoing RFA without ligation (46%) than RFA with ligation (14%).3 In a systematic review comparing recurrence rates, overall complication rates, and symptom relief, it was found that surgery was not inferior to endovenous procedures. Our past experience and results of previous studies comparing the results of three different surgical techniques (complete stripping with HL, partial above-knee stripping with HL, and HL alone) have shown that the best recurrence rate, best improvement in CEAP class (Clinical-Etiology-Anatomy-Pathophysiology classification), and best event-free survival rates are achieved using complete stripping with HL.4 The rate of residual reflux and recurrence after partial stripping can reach up to 20%, and this complication is found more often with patent below knee saphenous veins than with incompetent perforator veins (IPVs) undetected preoperatively. Given that these techniques are theoretically equivalent to stripping with low ligation of the proximal saphenous vein, it is not wise or completely true to claim that their recurrence rates and effectiveness are better than those of complete stripping with HL. Past experiments have shown that, for HL with complete division of the SFJ and all side branches, full-length obliteration of the saphenous vein for insufficiency was necessary to prevent recurrence.4

An incompetent SFJ, an incompetent small saphenous vein, IPVs, an incompetent superficial vessel in the thigh, HL without stripping, female sex, and post-thrombotic deep vein incompetence were all associated with greater risk of recurrence after a technically correct surgery.5 Our study on 372 patients showed that preoperative CEAP class, bilateral limb disease, occupation, family history or genetic predisposition, prior deep vein thrombosis (post-thrombotic etiology of varices), older age, and preoperative IPVs were predictors of early postoperative and later clinical status, outcome, and other events. The predictors of postoperative symptom recurrence and clinical and Doppler examination findings depend mostly on the preoperative characteristics of individual patients, and varicose vein surgery can prevent extension of venous reflux with a 5- year symptom-free survival rate of 51±0.8%.6

References

1. Merchant R, Pichot O. Long term outcomes of endovenous radiofrequency obliteration of saphenous reflux as a treatment for superficial venous insufficiency. J Vasc Surg. 2005;42:502-509. 
2. Labropoulos N, Bhatti A, Leon L, et al. Neovascularization after great saphenous vein ablation. Eur J Vasc Endovasc Surg. 2006;31:219-222. 
3. Salles-Cunha SX, Comerota AJ, Tzilinis A, et al. Ultrasound findings after radiofrequency ablation of the great saphenous vein: descriptive analysis. J Vasc Surg. 2004;40:1166-1173. 
4. Dwerryhouse S, Davies B, Harradine K, Earnshaw JJ. Stripping the long saphenous vein reduces the rate of reoperation for recurrent varicose veins: five-year results of a randomized trial. J Vasc Surg.1999;29:589-592. 
5. Allegra C, Antignani PL, Carlizza A. Recurrent varicose veins following surgical treatment: our experience with five years follow-up. Eur J Vasc Endovasc Surg. 2007;33:751-756. 
6. Islamoglu F. An alternative treatment for varicose veins: ligation plus foam sclerotherapy. Dermatol Surg. 2011;37:470-479.

 


7. A. H. Kamhawy Egypt

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Adel H. KAMHAWY, MD, PhD
Professor, Vascular Surgery
Tanta University
EGYPT
(e-mail: adelkamhawy@gmail.com
adelkamhawy@outlook.com)

Management of varicose veins (VVs) depends upon its etiology, whether it’s primary, secondary, or part of a congenital vascular malformation. Treatment options for VV with superficial venous incompetence include high ligation with and without stripping of the refluxing venous segment, ambulatory phlebectomy, endovenous thermal ablation, and sclerotherapy. Venous duplex imaging to assess venous reflux in both superficial and deep venous systems has a Grade 1A recommendation in the Clinical Practice Guidelines.1 Reflux (diagnosed by duplex imaging) with a duration of >0.5 seconds in the superficial system and >1 second in the deep system occurs when the valves are absent or incompetent due to degenerative processes in primary venous disease or as a sequel a subsequent to an episode of deep vein thrombosis.2 The correlation drawn from duplex imaging findings between the clinical picture and the severity of reflux is controversial. Whereas some studies deny such a correlation,3 others show one, suggesting that clinical signs of disease also correlate with great saphenous vein (GSV) diameter, with increasing diameter being associated with greater disease severity.4

Venous reflux after VV surgery—manifesting as VV recurrence— may occur, eg, as in post-thrombotic syndrome causing secondary VV or progressive reflux. Recurrent VVs develop in up to 40% of patients on long-term follow-up, and a 65% recurrence rate after treatment of secondary VVs is observed, regardless of the modality of saphenous vein ablation.5,6 No effect on deep venous system reflux has been observed after VV surgery for secondary VVs caused by post-thrombotic syndrome. Laser thermal endovenous ablation procedures have lower saphenofemoral reflux rates than surgical ligation and stripping in short- and mid-term timeframes and have shown improvement in venous hemodynamics. One year after such ablation procedures, residual saphenofemoral junction (SFJ) tributaries have been reported to be non-refluxing and clinically insignificant.7,8 Radiofrequency ablation (RFA) treatment of VVs and duplex imaging estimation of the postoperative effect on reflux was studied, comparing the incidence of neovascularization at the SFJ after RFA and open high saphenous ligation and stripping of the GSV.9 In the open surgery group, limbs (11%) showed clear evidence of tortuous refluxing veins related to the SFJ; in the RFA group, no limbs showed neovascularization at the SFJ.

Another study evaluated phlebectomies alone as primary prevention in selected patients.10 This prospective, multicenter study, including 94 patients, aimed to analyze hemodynamic, clinical, and patient-reported outcomes after phlebectomies in order to determine predictors of treatment success, that is, restoration of GSV competence. One year after treatment, GSV reflux had disappeared in 50% of patients (P<0.01), and GSV diameter had decreased significantly (P<0.01).

Another study11 investigated the effects of either aggressive or less-aggressive treatment for superficial venous disease on deep venous insufficiency. Aggressive therapy included high ligation with partial selective perforation-invagination, axial stripping of the GSV, ambulatory stab phlebectomy of the VVs, and transdermal treatment of spider veins; less-aggressive treatment included all but the spider vein treatment. Results showed a marked decrease in the size of the deep veins in 80% of patients and a decrease in the reflux closure time of the deep venous valves in 83% of patients. Only 28% of patients receiving less-aggressive treatment without transdermal laser therapy of the spider veins showed improvement in reflux-valve closure time; the remaining 72% showed either no change or deterioration.

Surgical treatment of VVs and of calf perforator veins results in reduced deep vein reflux. The improvement is most marked in cases of primary venous insufficiency.12

References

1. Malgor RD, Labropoulos N. Diagnosis and follow-up of varicose veins with duplex ultrasound: how and why? Phlebology. 2012;27(suppl 1):10-15. 
2. Back TL, Padberg FT Jr, Araki CT, et al. Limited range of motion is a significant factor in venous ulceration. J Vasc Surg.1995;22:519-523. 
3. Gibson K, Meissner M, Wright D. Great saphenous vein diameter does not correlate with worsening quality of life scores in patients with great saphenous vein incompetence. J Vasc Surg. 2012;56:1634-1641. 
4. Navarro TP, Delis KT, Ribeiro AP. Clinical and hemodynamic significance of the greater saphenous vein diameter in chronic venous insufficiency. Arch Surg. 2002;137:1233e7. 
5. MacKenzie RK, Paisley A, Allan PL, et al. The effect of long saphenous vein stripping on quality of life. J Vasc Surg. 2002;35(6):1197-1203. 
6. Winterborn RJ, Earnshaw JJ. Crossectomy and great saphenous vein stripping. J Cardiovasc Surg. 2006;47(1):19-33. 
7. Theivacumar NS, Dellagrammaticas D, Beale RJ, et al. Fate and clinical significance of saphenofemoral junction tributaries following endovenous laser ablation of great saphenous vein. Br J Surg. 2007;94(6):722-725. 
8. Park Y, Kim YW, Yang-Jin P, Kim DI. Postoperative hemodynamic changes after endovenous laser ablation and phlebectomy in varicose vein surgery. J Vasc Surg Venous Lymphat Disord. 2015;3(1):54-57. 
9. Kianifard B, Holdstock JM, Whiteley MS. Radiofrequency ablation VENUS closure does not cause neo-vascularisation at the groin at one year: results of a case controlled study. Surgeon. 2006;4(2):71-74. 
10. Biemans AA, Van den Bos RR, Hollestein LM, et al. The effect of single phlebectomies of a large varicose tributary on great saphenous vein reflux. J Vasc Surg Venous Lymphat Disord. 2014;2(2):179-187. 
11. Ahmad I, Ahmad W, Dingu M. Prevention or reversal of deep venous insufficiency by aggressive treatment of superficial venous disease. Am J Surg. 2006;191 (1):33-38. 
12. Ciostek P, Michalak J, Noszczyk W. Improvement in deep vein haemodynamics followingsurgery for varicose veins.Eur JVasc Endovasc Surg.2004;28:473-478. 

 


8. D. Radak and S. Tanaskovic, Serbia

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Djordje RADAK, MD, PhD1,2,3
DSlobodan TANASKOVIC, MD1
1Vascular Surgery Clinic, “Dedinje” Cardiovascular
Institute, Serbia
2Faculty of Medicine, University of Belgrade,
3Serbian Academy of Science and Arts Vascular Surgery Clinic “Dedinje” Cardiovascular Institute
Heroja Milana Tepica 1 street, 11000 Belgrade
SERBIA (e-mail: radak@ikvbd.com,
radak@rcub.bg.ac.rs)

In patients having undergone a superficial or deep venous procedure, the hemodynamic and clinical status remains stable over time, as opposed to those having only been treated with elastic compression.1 However, studies have shown that after varicose vein surgery, up to 40% of patients eventually develop neovascularization, and one-third of patients develop an extension of preexisting reflux or reflux in a new segment.2 In a randomized controlled trial by Sell et al,3 the effectiveness of compression therapy and surgical treatment was evaluated for superficial venous reflux. A total of 153 patients were randomized to compression stocking therapy (77 patients) and surgery (76 patients). Surgical treatment included ligation of the great saphenous vein (GSV) and all side branches, with GSV stripping. Insufficient perforator veins were ligated and cut, and all patients underwent local phlebectomy. After 2 years of follow-up, the authors found that surgical treatment had significantly better results than compression therapy for elimination of superficial venous reflux.3

Blomgren et al4 evaluated the effect of surgical treatment for primary varicose veins on the development of venous insufficiency 2 years after surgery. In 293 patients, surgical treatment consisted of GSV or small saphenous vein removal, extra-fascial perforator vein ligation and local phlebectomy. After 2 years, new vessel formation was seen in 40% of the patients with surgically obliterated saphenopopliteal junction and 11% of patients with treated saphenofemoral junction (SFJ).

A substantial number of patients in this study developed new reflux during the follow-up, possibly as a result of progression of the venous disease. However, redirection of venous flow via a weakened venous segment becoming varicose after GSV removal cannot be ruled out. The authors of this study found that the reflux in GSV below the knee was abolished after the above-knee GSV stripping, suggesting that the practice of below-knee GSV stripping is unnecessary.

Endovenous laser treatment (EVLT) is described as a less-invasive treatment option that provides a better cosmetic outcome than the standard surgical procedure.4 Myers et al5 assessed the efficacy of EVLT for the treatment of saphenous reflux with varicose veins. Over a 5-year period, EVLT was performed in 361 patients. EVLT was used for the proximal part of the saphenous vein, and ultrasound-guided sclerotherapy was used for the distal saphenous vein and tributaries. Primary failure was defined as failure to occlude the venous lumen, with reflux in part or all of the treated saphenous veins, whereas secondary failure was defined as failure to occlude the lumen, and reflux after the primary failure. The primary success rate at 4 years was 76% and the secondary success rate was 97%.

As radiofrequency ablation (RFA) is one of the potential ways to treat varicose veins, Salles-Cunha et al6 evaluated 106 extremities treated with RFA and concomitant ligation and division of the SFJ tributaries, except in 13 patients that were treated with RFA alone. The authors found a significantly lower prevalence of small-vessel networks at the SFJ level and of GSV recanalization in patients with combined RFA and SFJ ligation than in patients with RFA alone.6

To conclude, although a high reflux rate could be seen in some studies following surgery,2,4 the majority of papers published thus far favor surgical treatment (open surgery, endovenous laser ablation, RFA)1,3,5,6 as an appropriate option for varicose vein treatment, with better results than that seen with compression therapy only. Stripping or endovenous obliteration of the above-knee GSV combined with high GSV ligation and local phlebectomy seems to be a better option than stocking therapy alone for preventing extension of venous reflux over time.
Acknowledgments. This case report was partly funded by the Serbian Ministry of Science and Technological Development – Project No. 41002.

References

1. Lurie F, Makarova NP. Clinical dynamics of varicose disease in patients with high degree of venous reflux during conservative treatment and after surgery: a 7-year follow-up. Int J Angiol.1998;7:234-237. 
2. Labropoulos N, Leon L, Kwon S, et al. Study of the venous reflux progression. J Vasc Surg. 2005;41(2):291-295. 
3. Sell H, Vikatmaa P, Albäck A, et al. Compression therapy versus surgery in the treatment of patients with varicose veins: a RCT. Eur J Vasc Endovasc Surg. 2014;47(6):670-677. 
4. Blomgren L, Johansson G, Dahlberg-Akerman A, Thermaenius P, Bergqvist D. Changes in superficial and perforating vein reflux after varicose vein surgery. J Vasc Surg. 2005;42(2):315-320. 
5. Myers KA, Jolley D. Outcome of endovenous laser therapy for saphenous reflux and varicose veins: medium-term results assessed by ultrasound surveillance. Eur J Vasc Endovasc Surg. 2009;37(2):239-245. 
6. Salles-Cunha SX, Comerota AJ, Tzilinis A, et al. Ultrasound findings after radiofrequency ablation of the great saphenous vein: descriptive analysis. J Vasc Surg. 2004;40:1166-1173.

 


9. K. Rerkasem, Thailand

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Kittipan RERKASEM, MD, PhD, FRCS(T)
Division in Vascular and Endovascular Surgery
Department of Surgery, Faculty of Medicine
Chiang Mai University, Chiang Mai
THAILAND
(e-mail: rerkase@gmail.com)

Varicose vein surgery, namely venous stripping (VS), has been a standard procedure in varicose vein treatment for 100 years, though today its efficacy is questioned by some. In one study, up to 40% of patients still had progression of venous incompetence afterwards.1 While true that after VS, many patients have progressive venous incompetence, the author of that study believes it is still an effective means to treat patients with symptomatic varicose veins. On the basis of our own postoperative interview, we found that patients who have this operation are happy with the procedure. There are several reasons for this.

Firstly, after the operation, patient clinical outcome improves markedly. In the landmark randomized controlled trial by Rasmussen and colleagues,2 two study arms designed to use VS and endovenous laser ablation (EVLA) were compared. Outcomes included open refluxing in the great saphenous vein (GSV), recurrent varicose veins, venous clinical severity score (VCSS), quality of life (QOL) scores (based on the Aberdeen Varicose Vein Symptom Severity Score [AVVSS] and Short Form-36 [SF-36]). After a 5-year follow-up, the incidence of open refluxing in the GSV in the VS group and the EVLA group was 10.1% and 17.9%, respectively (P=0.22). However, in the early postoperative period (1-3 months) and onwards, the VCSS and AVVSS improved significantly in both groups: the mean VCSS before the operation was roughly2.4, and1month afterwards was 0.2; the mean AVVSS before the procedure was around 16, and 3 months after VS was reduced to 8. Also, the SF-36 significantly improved compared with the preoperative data in several aspects—namely, bodily pain, mental health, social function, physical function, and vitality, as well as in the physical and mental component summaries. In short, the recanalization of the GSV appears to have no significant impact on the severity score or QOL. It is also important to note that, in all aspects, the results of VS and EVLA are not significantly different.

Secondly, although the recurrence rate in VS reaches as high as 54.6% in a 5-year period, based on the Rasmussen study,2 this can be treated easily by foam sclerotherapy or mini-phlebectomy.

Finally, nowadays, VS is used to strip the GSV from groin to knee, and quite often surgeons leave persistent incompetent GSV below the knee and residual perforator incompetence. In the study by Sugiyama and colleagues, the effect of VS on the venous filling index (VFI) in the calf vein segment below the knee was assessed both 1 month and 1 year after the procedure3; the study found that 1 year after VS, VFI was a little higher in patients who had residual calf incompetent GSV. Patient symptoms were significantly improved after the operations. This study suggested that ablation in the GSV below the knee is not necessary during VS.

In summary, it does not matter whether VS can prevent extension of venous reflux with time. Rather, as VS can make remarkable clinical improvements in terms of severity or QOL, it is a worthwhile therapy for symptomatic varicose veins.

References

1. Labropoulos N, Leon L, Kwon S, et al. Study of the venous reflux progression. J Vasc Surg. 2005;41:291-295. 
2. Rasmussen L, Lawaetz M, Bjoern L, Blemings A, Eklof B. Randomized clinical trial comparing endovenous laser ablation and stripping of the great saphenous vein with clinical and duplex outcome after 5 years. J Vasc Surg. 2013;58:421- 426. 
3. Sugiyama S, Uchida H, Miyade Y, Inaki Y, Matsubara S. The influence of residual below-knee reflux and incompetent perforating veins on venous function after stripping surgery. Ann Vasc Dis. 2013;6:159-163.

 


10. N. Sánchez Nicolatt, Mexico

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Nora SÁNCHEZ NICOLATT, MD, PhD
Hospital Regional Lic. Adolfo López Mateos
Servicio de Angiología y Cirugía Vascular
Avenida Universidad 1311, Álvaro Obregón
Florida, 01030 Ciudad de México
MEXICO
(e-mail: nsanicol@hotmail.com)

The treatment of venous disease dates back to the beginning of medicine. These early learnings are the tools that we use in the current treatment of superficial venous disease. Today, many surgical options are available, including great saphenous vein (GSV) stripping and ligation, varicose vein ligation, phlebectomy, endovenous vein obliteration, and perforator vein surgery. Nowadays, the techniques and technology have evolved to enable us to improve the short and long-term outcomes of vein surgery, but the real question is whether varicose vein surgery in any of its modalities prevents extension of venous reflux with time.

First of all, although varicose vein surgery is very common, data on long-term relief of symptoms and the incidence of recurrence are meager. What we currently know is based on the little data retrieved from a few trials; for example, in one trial in the United Kingdom in 2003, a consecutive cohort of 100 patients was reviewed 10 years after varicose vein surgery in order to detect rates of recurrence, symptom relief, and patient satisfaction.1 This study showed long-term symptom relief in 77% of patients 10 years after varicose vein surgery; however, the recurrence rate was high, with most patients having a few varicosities. Some studies report a clinical recurrence in 50% of patients 3 to 5 years after surgery. Although inadequate surgery is a considerable cause of recurrence, there are many other possible explanations. For example, after surgery, the early physiologic improvement is satisfactory, but the normalization of venous function is difficult to achieve, especially in patients with neovascular reconnection and persistent abnormal venous function, such as residual deep reflux and persistent incompetent perforator vessels.2 After varicose vein surgery, the failure to normalize venous function is more likely to result in recurrence.

Currently, the treatment of choice for a venous reflux in the GSV is endovenous laser ablation (EVLA), but there are few data on the long-term outcomes of this intervention. Disell-hoof et al3 and Rasmussen et al,4 developed the only two randomized clinical trials comparing conventional surgery and EVLA with a follow-up of 5 years. They found similar recurrence rates (90%-100% vs 82%-93%). Recently, van der Velden and colleagues (1 July 2015)5 published a new randomized clinical trial with 5-year results that compared the long-term outcomes of conventional surgery, EVLA, and ultrasound-guided foam sclerotherapy (UGFS) in patients with GSV varices. They demonstrated that absence of reflux in the GSV after 5 years of follow-up was more frequent with conventional surgery or EVLA than with UGFS. These trials show that varicose vein surgery, which has satisfactory results for early outcomes, can also avoid venous reflux in the long term.

Finally, current data for foam sclerotherapy, EVLA, and open surgery involving high ligation and stripping suggest that they have similar overall early and late outcomes6; however, these findings lack robustness due to incompatibility between studies, which impedes more accurate analysis toestablish whether varicose vein surgery has long-term benefits.

References

1. Campbell WB, Vijay Kumar A, Collin TW, Allington KL, Michael JA; Randomized and Economic Analysis of Conservative and Therapeutic Interventions for Varicose veins Study. The outcome of varicose vein surgery at 10 years: clinical findings, symptoms and patient satisfaction. Ann R Coll Surg Engl. 2003;85: 52-57. 
2. van Rjj AM, Jiang P, Solomon C, Christie RA, Hill GB. Recurrence after varicose vein surgery: a prospective long-term clinical study with duplex ultrasound scanning and air plethysmography. J Vasc Surg. 2003;38:935-943. 
3. Disselhoff BC, der Kinderen DJ, Kelder JC, Moll FL. Five-year results of a randomized clinical trial comparing endovenous laser ablation with cryostripping for great saphenous varicose veins. Br J Surg. 2011;98:1107-1111. 
4. Rasmussen L, Lawaetz M, Bjoern L, Blemings A, Eklof B. Randomized clinical trial comparing endovenous laser ablation and stripping of the great saphenous vein with clinical and duplex outcome after 5 years. J Vasc Surg. 2013;58: 421-426. 
5. van der Velden SK, Biemans AA, De Maeseneer MG, et al. Five-years results of a randomized clinical trial of conventional surgery, endovenous laser ablation and ultrasound-guided foam sclerotherapy in patients with great saphenous varicose veins. Br J Surg. 2015;102:1184-1194. 
6. Nesbitt C, Benedis R, Bhattacharya V, Satnsby G. Endovenous ablation (radiofrequency and laser) and foam sclerotherapy versus open surgery for great saphenous vein varices. Cochrane Database Syst Rev. 2014;7:CD005624.

 


11. L. Tessari and S. Gianesini, Italy

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Lorenzo TESSARI, MD
Sergio GIANESINI, MD
Fondazione Glauco Bassi
Trieste, ITALY
(e-mail: lorenzo@tessaristudi.it
www.sergiogianesini@gmail.com)

Despite a recognized genetic basis, many environmental factors are involved in chronic venous disease (CVD) development and progression. The most significant risk factors have been identified as age, obesity, sedentary lifestyle, lack of elastic stocking use, multiparity, and prolonged occupational exposure to heat sources. Ambulatory venous hypertension underlies the pathophysiological and clinical CVD condition, thus all the available treatments must be focused on restoring this parameter.

Varicose vein surgery is comparable to modern, technically innovative endothermal ablative techniques. Nevertheless, when describing varicose vein surgery, a fundamental distinction must be made among saphenous ablative and sparing procedures. Surgical saphenous stripping and endovenous thermal techniques suppress reflux by ablating the vein. In contrast, the saphenous-sparing approach suppresses the energy gradient feeding the reflux via selective interruptions of the venous network.

Despite a small number of clinical trials on the topic, a recent Cochrane review has demonstrated that the saphenous-sparing approach significantly reduces the recurrence of varicose veins, compared with the ablative techniques.1 The satisfying recurrence rate associated with the saphenous-sparing strategies1 together with the mini-invasiveness of the modern endovenous techniques have stimulated pioneering investigations regarding GSV competence restoration by means of endovenous devices.2,3

In a survey involving 1978 patients over an observation period of 6.6 years, the Bonn study demonstrated that class C2 disease evolved toward a more severe stage in 31.8% of saphenous refluxing cases and in 19.8% of nonsaphenous refluxing patterns.4 Indirectly, these data point out the possibility that varicose vein surgery can reduce the evolution of CVD by suppressing venous reflux. Of course, a distinction must be made between primary and secondary varicosity evolution, the latter being faster. Moreover, venous reflux has recently been weakly associated with clinical outcome impairment, highlighting the poorly understood relationship between these two parameters.5

In order to obtain an effective resolution of venous reflux and potentially of disease evolution, the presence of a physiological draining network has been shown to be a good prognostic factor for long-term results.6 A major cause of failure in CVD evolution control is an incomplete/inadequate treatment, associated with lack of patient compliance.

CVD is by definition a chronic pathology, with both genetic and environmental components that determine a hemodynamic and clinically extremely polymorphic condition. In order to significantly impact such a heterogeneous scenario, a single treatment option cannot be the panacea for all patients. On the contrary, a tailored diagnostic and therapeutic multimodal plan must be customized for every single case.

The combination of an accurate hemodynamic assessment, a proper therapeutic strategy and technique, and a lifestyle targeted on managing the specific risk factors are mandatory in order to restore healthy lower limb venous drainage, thus decreasing disease evolution over time. According to our personal experience, a mini-invasive saphenous-sparing surgery presents a therapeutic option that is not only esthetically satisfying, but also effective in the reduction of recurrence and in the prevention of venous reflux extension with time.

References

1. Bellmunt-Montoya S, Escribano JM, Dilme J, Martinez-Zapata MJ. CHIVA method for the treatment of chronic venous insufficiency. Cochrane Database Syst Rev. 2015;6:CD009648. 
2. Ferracani E. Internal laser valvuloplasty and venous remodelling using 1470 laser. Initial experience. Flebologia. 2013;(3):39-40. 
3. Gianesini S, Menegatti E, Zuolo M, et al. Laser-assisted strategy for reflux abolition in a modified CHIVA approach. Veins Lymphatics. 2015;4(2) doi:10.4081/ vl.2015.5246. 
4. Rabe E, Pannier F, Ko A, et al. Incidence of varicose veins, chronic venous insufficiency, and progression of disease in the Bonn Vein Study II. J Vasc Surg. 2010; 51(3):791. 
5. Shepard C, Shepherd AC, Lane TR, Davies A. The natural progression of chronic venous disorders: an overview of available information from longitudinal studies. Phlebolymphology. 2012;19(3):138-147. 
6. Creton D. A nondraining saphenous system is a factor of poor prognosis for longterm results in surgery of great saphenous vein recurrences. Dermatol Surg. 2004;30(5):744-749.

 


12. M. Vuylsteke, Belgium

top ↑
Marc VUYLSTEKE, MD, PhD
Vascular Surgeon
Sint-Andriesziekenhuis Tielt
BELGIUM
(e-mail: marc.vuylsteke@me.com)

Varicose disease is a progressive condition; if left untreated, it will become more extensive, resulting in more symptoms and a higher C-classification.1 Progression includes anatomic extension in most cases and may also involve development of reflux in new segments or a combination of both.2 Both clinical progression and progression of superficial venous reflux correlate significantly with age.1,2

Surgical treatments, such as high ligation and stripping, phlebectomy, and ligation of incompetent perforating veins, will remove the incompetent veins. More recently, these surgical treatments have often been replaced by endovenous techniques that are equally efficient in the treatment of venous insufficiency, but cause fewer side effects.3 After treatment, ulcers heal, varicose veins disappear, and symptoms decrease. Treatment should result in a lower C-score and fewer symptoms. Even incompetent deep veins can become competent after superficial treatment.4,5

Studies have shown, however, that the recurrence rate after varicose vein surgery is high and can reach 40% after 5 years and 70% after 10 years.5,6 About 20% of surgical procedures are carried out to treat recurrent disease. There are various causes of recurrence. Poor surgery was historically seen as a major cause. Other causes are a poor preoperative patient assessment, incorrect duplex mapping, and anatomical variability. After endovenous treatments, recanalization of the treated vein may occur. Changes in hemodynamics after treatment can cause new forms of incompetence, such as insufficiency of the anterior accessory vein after great saphenous vein ablation. Soon after surgery, there is often an increased number of incompetent perforator vessels.5

Varicose veins—primary or recurrent—can, however, develop throughout the entire lower limb. Reflux can develop in any vein with or without an apparent feeding source, and this as a part of disease progression. More recently, neovascularization— especially at the saphenofemoral or saphenopopliteal junction—has been confirmed to be a major cause of recurrent reflux. Initially, it was thought that neovascularization is caused by surgery, as a part of the normal process of wound healing. Neovascularization can also occur after endovenous ablation. The patterns of recurrence following thermal ablation of saphenous veins are different to those seen after surgery. Specifically, new reflux in other saphenous veins is responsible for most recurrent varicose veins and neovascularity seems to be less common after endovenous laser ablation.7

Still, there seems to be no overall difference in recurrence rates between surgical treatment and endovenous thermal ablation.Although recurrence of varicose veins is frequent 10 years after the operation, surgery provides long-term relief of symptoms in a large majority of patients.6 The effect of superficial venous surgery is dramatic. Improvement in symptoms, early patient satisfaction, and conditions favoring ulcer healing are consistent results.

Despite a fair number of ultrasound-detected recurrences, the overall long-term result from the patients’ point of view remains surprisingly favorable. The correlation between ultrasound- detected recurrence and residual symptoms and cosmetic results remains low. To enhance the durability of treatment, prevention—especially paying more attention to risk factors—could influence long-term results. However, regular clinical and ultrasound checks are imperative as part of a surveillance protocol. Early recurrences can be treated in a minimally invasive way with sclerotherapy or ultrasound-guided foam sclerotherapy.

We conclude that varicose vein surgery can prevent extension of venous reflux over time if there is regular follow-up after an efficient treatment and additional procedures are carried out where necessary.

References

1. Vuylsteke ME, Clman R, Thomis S, Guillaume G, Degrande E, Staelens I. The influence of age and gender on venous symptomatology. An epidemiological survey in Belgium and Luxemburg. Phlebology. 2015 Jun 1. Epub ahead of print. 
2. Labropoulos N, Leon L, Kwon S, et al. Study of the venous progression. J Vasc Surg. 2005;41:291-295. 
3. Wittens C, Davies A, Baekgaard N, et al. Management of chronic venous disease. Clinical practice guidelines of the European Society for Vascular Surgery. Eur J Vasc Endovasc Surg. 2015;49(6):678-737. 
4. Sales CM, Bilof ML, Petrillo KA, Luka NL. Correction of lower extremity deep venous incompetence by ablation of superficial venous reflux. Ann Vasc Surg. 1996;10:186-189. 
5. van Rij A, Jiang P, Solomon C, Christie RA, Hill GB. Recurrence after varicose vein surgery: a prospective long-term clinical study with duplex ultrasound scanning and air plethysmography. J Vasc Surg. 2003;38:935-943. 
6. Campell WB, Kumar AV, Collin TW, Allington KL, Michaels JA. The outcome of varicose vein surgery at 10 years: clinical findings, symptoms and patient satisfaction. Ann R Coll Surg Engl. 2003;85:52-57. 
7. Winokur RS, Khilnani NM, Min RJ. Recurrence patterns after endovenous laser treatment of saphenous vein reflux. Phlebology. 2015 Jul 16. Epub ahead of print. 
8. Flessenkämper I, Hartmann M, Hartmann K, Stenger D, Roll S. Endovenous laser ablation with and without high ligation compared to high ligation and stripping for treatment of great saphenous varicose veins: results of a multicentre randomized controlled trial with up to 6 years follow-up. Phlebology. 2016;31(1):23-33.

 


13. F. Zernovick´y, Slovakia

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Frank ŽERNOVICKÝ, MUDr
ANGIO CENTRUM s.r.o
Podhradie 55 Svätý Jur
SLOVAKIA
(e-mail: f.zernovicky@icloud.com)

This is a provocative question, with more than one component to consider. Rather than jump immediately to whether or not varicose vein surgery can prevent extension of venous reflux, I’d first like to address a somewhat related issue, looking at compression therapy as a conservative treatment versus surgical intervention, as some might ask whether surgery is even necessary. Clearly, compression therapy alone will never offer patients the same comfort and assurance that surgical intervention can provide. From the viewpoint of evidence-based medicine, although there is no evidence of faster healing of ulcers after surgery, there is a significantly lower re-ulceration rate. Moreover, there is abundant evidence that quality of life is better after surgery—endovenous, traditional, as well as sclerotherapy—than after conservative treatment alone. I am in agreement with the latest American Venous Forum (AVF) recommendation that when there is a surgically treatable source of reflux, the surgical treatment must be preferred over conservative treatment.

After that, pharmacological treatment is also necessary for successful management of chronic venous insufficiency. The reason for this is that there is no surgical intervention that can address the leukocyte-endothelial–interaction component of the disease. Even after the best surgery, adhesion molecules will still be present and at this point, nothing besides pharmacological treatment can decelerate the inflammatory reaction occurring at the vein wall.

Next, in a brief nod to the neovascularization component of the question—indeed, the discussion about neovascularization seems never-ending and is controversial itself—I personally accept its existence if there is ultrasound evidence for it; however, many so-called neovascularizations are actually due to inadequate surgery.

Now, let’s consider extension of reflux to new segments. In a subgroup of patients with isolated reflux in great or small saphenous veins and without reflux in the deep veins, there is a legitimate anticipation that after correct surgery on the reflux source, the risk of neovascularization or propagation of reflux to the intact part of the venous system will be lower. Of course, in everyday surgery, we have no significant information about the levels of adhesion molecules present (eg, intercellular adhesion molecule [ICAM], vascular cell adhesion molecule [VCAM]), as well as other influential factors, known and unknown.

In a subgroup of patients with simultaneous reflux to the superficial and deep veins, the conditions are more complicated; to understand the benefit of a procedure, it is necessary to understand the proximal point of insufficiency, the reflux path, and the distal point of insufficiency. These are the elementary questions that need to be answered to understand the prognosis of the disease. From my point of view, this is not something that will be settled within a short discussion!

Last, but not least, isolated reflux in the saphenofemoral junction is more complicated than it looks at first sight. In most cases, we think about the range of terminal or preterminal maximal ostial valve sufficiency, but what about suprasaphenous valve and infrasaphenous valve incompetence in the common femoral vein? These are the controlling ports for the reflux to the stump after surgery and also the crucial entries to the superficial and profundal femoral vein.

In conclusion, the answer is not as simple as it might seem at first glance! In my opinion, as long as we do not have satisfying answers for these basic questions, and as surgical intervention will not address detrimental leukocyte-endothelial interactions, there is a very strong incentive to do what we can to protect the venous system after operation, for example, with effective medications, such as micronised purified flavonoid fraction (MPFF).