Treatment of Varicosed Tributary Veins

Historical Background

Ambulatory phlebectomy (AP) is a minor surgical procedure designed to remove varicose vein clusters located close to the skin surface. Originally performed in ancient Rome, the technique was published by Robert Muller in 1966. In many office-based, venous surgery practices in the United States, AP is performed with the use of local tumescent anesthesia. The six basic features of the technique are as follows:

• 1.

  Absence of venous ligatures

• 2.

  Exclusive use of local infiltration anesthesia

• 3.

  Immediate ambulation after surgery

• 4.

  Incisions of 2 mm

• 5.

  Absence of skin sutures

• 6.

  Postoperative compression bandage kept in place for 2 days, then replaced with daytime compression stockings for 3 weeks

Complete surgical removal of varicose veins may be achieved in a single session or in separate sessions. Endovenous ablation and AP are suitable for the office and, in the author's practice, are routinely performed together. All procedures are guided with duplex ultrasound to get a “roadmap underneath the skin.” The advantage of this combination technique is that patients can expect all varicose veins to disappear after a 1-hour procedure.

Etiology and Natural History of Disease

Bulging varicose veins on the surface of the skin can originate from diverse sources. Identification of these sources is important because the source influences the treatment plan. Varicosities on the medial aspect of the thigh and calf are usually the result of great saphenous vein (GSV) incompetence. To minimize the chance for recurrence, the incompetent GSV must be eliminated from the circulation. This concept has been substantiated in several prospective randomized clinical trials involving patients who were treated with or without saphenectomy by conventional vein stripping. The recurrence rates for limbs without saphenectomy were much higher than those for limbs with saphenectomy. Of course, now thermal ablation techniques, with either radiofrequency or laser, have proved to be the methods of choice for eliminating the GSV from the circulation.

Varicosities on the anterior thigh usually result from anterior, accessory saphenous vein incompetence. These veins usually course over the knee and into the lower leg. Small saphenous vein (SSV) reflux produces varicosities on the posterior calf. When also present on the posterior thigh, the surgeon must consider a cranial extension of the SSV, which can be identified with duplex ultrasound imaging. Cranial extensions may enter the GSV (Giacomini vein) or enter the femoral vein directly.

In cases where no “feeding source” is found, phlebectomy of the varicosities may be all that is required. Labropoulos et al. have shown that varicose veins may result from a primary vein wall defect and that reflux may be confined to superficial tributaries throughout the lower limb. Without great and small saphenous trunk incompetence, perforator and deep vein incompetence, or proximal obstruction, their data suggest that reflux can develop in any vein without an apparent feeding source. This is often the case when bulging reticular veins are seen along the course of the lateral leg. This lateral subdermic complex and its vein of Albanese are often dilated and bulging in elderly patients. The underlying source of venous hypertension is usually perigeniculate, perforating veins, not easily identifiable with duplex imaging. AP using an 18-gauge needle stab incision and a small crochet hook for exteriorization of the vein is an excellent procedure for this clinical problem.

Patient Selection

AP is indicated for the removal of varicosed venous tributaries when visible and palpable on the surface of the skin. AP is simple to perform and well tolerated and can be used in conjunction with other treatment modalities. As stated earlier, it is critical to recognize that bulging veins are usually associated with an underlying source of venous hypertension, and treatment of the source is as important as the vein removal. Before AP, the treating physician must perform a thorough evaluation with duplex ultrasound imaging to determine whether a source is present for venous hypertension. The source of venous hypertension should be eliminated before, or in conjunction with, AP.

Before placing the patient in the supine position on the operating table, the veins of interest must be marked in the standing position with an indelible marker. This is critical. Marking is performed in the standing position because hydrostatic pressure is elevated, and the pressurized veins become visible and palpable. Bulging veins literally disappear when patients lie supine because the venous pressure drops to near 0 mm Hg. Without the marking, the surgeon will surely leave disease behind, which of course will result in an unsatisfied patient.