Role of Surgery in the Treatment of Varicose Veins

Principle and Controversies

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

• Reflux and dilatation are frequently segmental in any location of the saphenous and nonsaphenous systems.

• Onset of the VV can occur in any segment of the superficial veins without incompetence of the SFJ, SPJ and saphenous trunk itself.

• The VV reservoir volume favors magnitude and extension of reflux. Compression of an incompetent tributary vein termination can reduce or suppress reflux in the saphenous trunk when they are not dilated beyond 6 to 8 mm in diameter ( Fig. 10.1 )

  

• Furthermore we have learned that leak points between the DVS and the SVS can disappear after ablation of the VVs even though they have not been treated. After VV ablation 80% of previously incompetent perforator veins became competent.

• More surprisingly, incompetent terminal valves can recover their normal function after ablation of the refluxing varices.

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

Technical Information

• Ligation of the SFJ and SPJ can be performed by using a 4- to 6-cm transverse incision without cosmetic prejudice, particularly when the incision is made within the groin crease ( Fig. 10.2 ).

  

• Saphenous trunk stripping is most frequently performed using the endoluminal technique, with invagination or pin stripping, and is credited with causing fewer neurologic complications ( Figs 10.3–10.5 ).

  
  
  

• Extension of trunk resection depends more on operator conviction than on the extent of reflux.

• Incompetent tributary phlebectomy is performed through a very small skin incision, usually 2 to 3 mm in length.

• Surgical perforator ablation can be performed directly by skin incision overlying the perforator in the absence of overlying skin pathology. In the presence of lipodermatosclerosis, subfascial endoscopic perforator surgery is strongly recommended, at least for medial leg perforator veins.

Conventional Surgery Variants

Cryostripping

The only difference with cryostripping in comparison with classical surgery is the ablation modality of the saphenous trunk. After HL, the saphenous trunk is catheterized downward with the cryoprobe until reaching the lower limit of the vein to be stripped. The generator is activated and when the vein is attached to the cryoprobe (by freezing to it) the vein is broken off easily. No distal ligation is needed and the vein attached to the probe is progressively pulled up and extracted through the groin incision ( Fig. 10.6 ).

Cryostripping is said to cause less postoperative bruising and hematoma along the path of the saphenous trunk than conventional stripping, but this procedure has not been confirmed by others to be superior to current techniques.

Isolated Flush Ligation or Limited Resection

Isolated flush ligation or limited resection of the SFJ and/or SPJ is termed ‘crossectomie’ in Western Europe. This procedure is rarely performed as an isolated procedure since older studies demonstrated very poor outcome after this procedure. It has been proposed in association with sclerotherapy of the saphenous vein at thigh level to imitate the flush ligation and stripping. The target of associated sclerotherapy, obtained by means of a catheter inserted through the proximal incision performed for high ligation, is to reduce problems like pain and hematoma correlated to stripping. However, the risk of recanalization of the treated segment is particularly elevated; probably the employment of foam can reduce this recurrence.

SFJ and/or SPJ Ligation Plus Incompetent Tributary Phlebectomy with or Without Incompetent Perforator Interruption

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

SFJ Wrapping or Valvuloplasty Plus Incompetent Tributary Phlebectomy with or Without Incompetent Perforator Interruption

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

Ambulatory Phlebectomy

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

Muller used this procedure in isolation or in combination with trunk stripping to avulse tributary varices, as reported in 1996.

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

Varices Phlebectomy

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

CHIVA Method

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

According to CHIVA all the VI symptoms are the result of an obstacle to the flow and/or valvular incompetence, which increases the transmural pressure (TMP). Excessive TMP dilates the veins (varices) and impairs drainage (edema, lipodermatosclerosis and ulcer). The hemodynamic diagnosis consists of checking and correcting the causes of VI to normalize the TMP and consequently its clinical symptoms. According to the VI hemodynamic pattern, CHIVA involves fractioning the hydrostatic pressure, disconnecting the shunts and preserving the draining veins to cure all the symptoms of VI at the same time and avoid recurrence. Open Deviated Shunts Type II (varices + segmental saphenous trunk reflux) and Closed Shunts Type III (varices + segmental saphenous trunk reflux + SFJ reflux [SFJR]) are frequent patterns of VI because of superficial valve incompetence. In these specific cases, CHIVA divides the refluxing tributaries at their junction with the saphenous trunk. These divisions result in trunk reflux suppression and varices ‘remodeling’ to normal size, whereas the drainage is preserved to avoid short-term side effects and long-term recurrences (in the case of Shunt III SFJR, redo because of a trunk re-entry) ( Figs 10.10–10.13 ).