Ambulatory Phlebectomy

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BASIC AND CLINICAL DERMATOLOGY

Series EditorsALAN R. SHALITA, M.D.

Distinguished Teaching Professor and ChairmanDepartment of Dermatology

SUNY Downstate Medical Center

Brooklyn, New YorkDAVID A. NORRIS, M.D.Director of Research

Professor of DermatologyThe University of Colorado

Health Sciences CenterDenver, Colorado

1. Cutaneous Investigation in Health and Disease: Noninvasive Methods and Instrumentation, edited by Jean-Luc Lévêque

2. Irritant Contact Dermatitis, edited by Edward M. Jackson and Ronald Goldner

3. Fundamentals of Dermatology: A Study Guide, Franklin S. Glickman and Alan R. Shalita

4. Aging Skin: Properties and Functional Changes, edited by Jean-Luc Lévêque and Pierre G. Agache

5. Retinoids: Progress in Research and Clinical Applications, edited by Maria A. Livrea and Lester Packer

6. Clinical Photomedicine, edited by Henry W. Lim and Nicholas A. Soter 7. Cutaneous Antifungal Agents: Selected Compounds in Clinical Prac tice

and Development, edited by John W. Rippon and Robert A. Fromtling 8. Oxidative Stress in Dermatology, edited by Jürgen Fuchs and Lester

Packer 9. Connective Tissue Diseases of the Skin, edited by Charles M. Lapière and

Thomas Krieg 10. Epidermal Growth Factors and Cytokines, edited by Thomas A. Luger and

Thomas Schwarz 11. Skin Changes and Diseases in Pregnancy, edited by Marwali Harahap and

Robert C. Wallach 12. Fungal Disease: Biology, Immunology, and Diagnosis, edited by Paul H.

Jacobs and Lexie Nall 13. Immunomodulatory and Cytotoxic Agents in Dermatology, edited by

Charles J. McDonald 14. Cutaneous Infection and Therapy, edited by Raza Aly, Karl R. Beutner, and

Howard I. Maibach


15. Tissue Augmentation in Clinical Practice: Procedures and Techniques, edited by Arnold William Klein

16. Psoriasis: Third Edition, Revised and Expanded, edited by Henry H. Roenigk, Jr., and Howard I. Maibach

17. Surgical Techniques for Cutaneous Scar Revision, edited by Marwali Harahap

18. Drug Therapy in Dermatology, edited by Larry E. Millikan 19. Scarless Wound Healing, edited by Hari G. Garg and Michael T. Longaker 20. Cosmetic Surgery: An Interdisciplinary Approach, edited by Rhoda S.

Narins 21. Topical Absorption of Dermatological Products, edited by Robert L.

Bronaugh and Howard I. Maibach 22. Glycolic Acid Peels, edited by Ronald Moy, Debra Luftman, and Lenore S.

Kakita 23. Innovative Techniques in Skin Surgery, edited by Marwali Harahap 24. Safe Liposuction and Fat Transfer, edited by Rhoda S. Narins 25. Pyschocutaneous Medicine, edited by John Y. M. Koo and Chai Sue Lee 26. Skin, Hair, and Nails: Structure and Function, edited Bo Forslind and

Magnus Lindberg 27. Itch: Basic Mechanisms and Therapy, edited Gil Yosipovitch, Malcolm W.

Greaves, Alan B. Fleischer, and Francis McGlone 28. Photoaging, edited by Darrell S. Rigel, Robert A. Weiss, Henry W. Lim, and

Jeffrey S. Dover 29. Vitiligo: Problems and Solutions, edited by Torello Lotti and Jana

Hercogova 30. Photodamaged Skin, edited by David J. Goldberg 31. Ambulatory Phlebectomy, Second Edition, Stefano Ricci, Mihael Georgiev,

and Mitchel P. Goldman 32. Cutaneous Lymphomas, edited by Gunter Burg and Werner Kempf 33. Principles and Practices in Cutaneous Laser Surgery, edited by Arielle

Kauvar and George Hruza 34. Wound Healing, edited by Anna Falabella and Robert Kirsner 35. Phototherapy and Photochemotherapy for Skin Disease, Third Edition,

Warwick L. Morison


Stefano RicciAmbulatorio Flebologico

Rome, Italy

Mihael GeorgievUniversity of Ferrara, Italy

Mitchel P. GoldmanUniversity of California, San Diego

and La Jolla SpaMD, California, U.S.A.

AmbulatoryPhlebectomy

Second Edition


Published in 2005 byTaylor & Francis Group 6000 Broken Sound Parkway NW, Suite 300Boca Raton, FL 33487-2742

© 2005 by Taylor & Francis Group, LLC

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Contents

Foreword . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xv

Robert Muller

Preface . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xix

Interview of Dr. Robert Muller . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xxiii

A. A. Ramelet

Acknowledgments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xxv

Introduction to the Second Edition . . . . . . . . . . . . . . . . . . . . . . . . . . . xxix

Stefano Ricci

History of Ambulatory Phlebectomy . . . . . . . . . . . . . . . . . . . . . . . . . . xxxiii

Robert Muller

Who Discovered Saphenous Vein Incontinence? . . . . . . . . . . . . . . . . . xli

Stefano Ricci

Part I: General Considerations

1. Definition and Indications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3Indications . . . . 3

2. Anatomical Bases of Ambulatory Phlebectomy . . . . . . . . . . . . . . . 5General Organization of the Superficial Venous System . . . . 5

Great Saphenous Vein Compartment . . . . 11

Great Saphenous Vein . . . . 11

Small Saphenous Vein . . . . 17

Collateral Veins and Varicosities . . . . 20

Autonomous Collateral Varicosities . . . . 20

Combined Collateral and Saphenous Varicosities . . . . 22

Perforating Veins . . . . 24

vii

Topographic Description . . . . 27Upper Thigh . . . . 27

Medial Thigh . . . . 29

Posterior Thigh . . . . 30

Lateral Thigh . . . . 30

Anterior Thigh . . . . 32

Knee . . . . 32

Medial Knee . . . . 32

Anterior and Lateral Knee . . . . 33

Popliteal Area . . . . 34

Medial Leg . . . . 36

Anterior Leg . . . . 37

Lateral Leg . . . . 37

Posterior Leg . . . . 37

Foot . . . . 40

Deep Veins of the Lower Limb . . . . 42

Nerves and Lymphatics . . . . 43

Surgical Anatomy of Venous Leg Telangiectasia . . . . 44

References . . . . 45

Appendix A: Atlas of Varicose Vein Patterns . . . . 47

Patterns of Saphenous Vein Involvement in

Varicose Vein Disease . . . . 47Primary Varicose Veins Circuits . . . . 53

Patterns of GSV Involvement . . . . 53

Anatomical Arrangement of the GSV and Related

Varicose Patterns . . . . 53

Segmental GSV Involvement . . . . 54

Patterns of ASV Involvement . . . . 54

Patterns of SSV Involvement . . . . 56

Patterns Involving Both GSV and SSV . . . . 56

3. Examination of the Patient with

Varicose Veins . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 57Clinical Examination . . . . 57

Medical History . . . . 57

Physical Examination . . . . 58

Doppler Orthostatic Reflux Test . . . . 61Method . . . . 61

Groin Examination . . . . 63

Popliteal Examination . . . . 64

Interpretation and Pitfalls of Doppler Reflux Testing . . . . 64

Additional Investigation . . . . 67Color-Duplex Ultrasound Examination . . . . 69

Evaluation of the Leg Pump Function . . . . 71


viii Contents

4. Selection of Patients for Office Varicose

Vein Surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 75Varicose Vein and Leg Conditions . . . . 75

Asymptomatic Varicose Veins (CEAP 1–2) . . . . 75

Symptomatic Varicose Veins (CEAP 3–6) . . . . 76

Patient’s General Health Conditions . . . . 76Modifying the Procedure . . . . 78

Infectious Disease . . . . 78

Patient Consent . . . . 79


5. Staging of Surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 81

Part II: Technique of Phlebectomy

6. Pre-Operative Marking . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 91

7. Anesthesia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 97Preparations, Dosage, and Techniques . . . . 98

Traditional Technique . . . . 98

Preparations and Dosage . . . . 98

Tumescent Technique . . . . 99

Preparations and Dosage . . . . 99

Technique . . . . 102

Pre-Operative Anesthesia . . . . 102

Local Infiltration Anesthesia . . . . 102


8. Position of Patient During Surgery . . . . . . . . . . . . . . . . . . . . . . 107

9. Phlebectomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 109Incision . . . . 109

Vein Retrieval, Hooking, and Exteriorization . . . . 113Instruments . . . . 113

Hooks . . . . 113

Graefe Iris Forceps . . . . 114

Toothed Clamps . . . . 116

Technique . . . . 116

Vein Avulsion . . . . 121Dissection . . . . 121

Traction . . . . 121

Progression of Phlebectomy . . . . 125

Vein Division . . . . 130

End Division . . . . 130

PV Division . . . . 133

Side Branch Division . . . . 133

Contents ix

Technical Difficulties . . . . 135Vein Fragility . . . . 135

Varicose Clusters . . . . 135

Foot . . . . 136

Shin . . . . 138

Knee . . . . 138

Thigh . . . . 138

Great Saphenous Vein . . . . 139

Small Saphenous Vein . . . . 139

Varicose Veins Recurrent After Sclerotherapy . . . . 140

Varicose Veins Recurrent After Traditional Surgery . . . . 140

Superficial Thrombophlebitis . . . . 140

Lipodermatosclerosis . . . . 140

Thin Skin . . . . 141

Venous Leg Telangiectasia . . . . 142

Periorbital Veins . . . . 143

Hand . . . . 144

Reference . . . . 144

10. Post-Operative Medication and Bandaging . . . . . . . . . . . . . . . . 145Medication . . . . 145

Bandaging . . . . 146Adhesive Bandage . . . . 146

Removable Bandages . . . . 147

11. Patient Discharge . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 151Reference . . . . 152

12. Post-Operative Management and Follow-Up . . . . . . . . . . . . . . . 153Post-Operative Management . . . . 153

Between Phlebectomy Sessions . . . . 153

After the Last Operation . . . . 153

Further Compression . . . . 155

Type and Duration of Compression . . . . 155

Follow-Up . . . . 156Patients in Need of Special Care . . . . 157

13. Small Saphenous Vein Phlebectomy . . . . . . . . . . . . . . . . . . . . . 159Diagnostic Work-Up . . . . 159

Staging . . . . 162

Pre-Operative Marking . . . . 162

Anesthesia . . . . 162

Position of Patient . . . . 162

Technique . . . . 162Incisions . . . . 162

Starting the Phlebectomy . . . . 163

x Contents

Distal Progression . . . . 168

Proximal Progression . . . . 168

Saphenopopliteal Division and Ligation . . . . 169

Higher Popliteal Incision . . . . 169

Atypical Popliteal Terminations of the SSV . . . . 171

Post-Operative Compression . . . . 171

Advantages of SSV Phlebectomy . . . . 173


Part III: Selected Phlebological Techniques

14. Post-Operative Compression . . . . . . . . . . . . . . . . . . . . . . . . . . . 177Protective Skin Underwrapping . . . . 177

Local Compression Pads . . . . 177

Protective Pads . . . . 178

Adhesive Bandage . . . . 178Materials . . . . 178

Extension of the Bandage . . . . 179

Technique of Application . . . . 179

Degree of Compression . . . . 182

Testing the Bandage . . . . 183

Difficult Areas . . . . 183

Removable Bandage . . . . 184

Errors of Bandaging . . . . 184Insufficient Compression . . . . 184

Excessive Compression . . . . 184

Compression Stockings . . . . 185


15. High Ligation, Division, and Groin to Knee Strippingof the GSV: An Office Procedure . . . . . . . . . . . . . . . . . . . . . . . 187Indications . . . . 187

Saphenofemoral Junction Incompetence . . . . 188

GSV Dilatation . . . . 189

Preservation of an Incompetent GSV/Saphenopopliteal Junction . . . . 189

Alternative Treatments for GSV Incompetence . . . . 190Choice of Stripping Technique . . . . 191

Programing the Operation . . . . 191

Pre-Operative Marking . . . . 192


Patient Position and Skin Preparation . . . . 194

Instruments . . . . 194

Surgical Anatomy of the SFJ . . . . 197

Technique . . . . 198Ligation and Division of the SFJ . . . . 198

GSV Stripping . . . . 202

Contents xi

Post-Operative Bandage . . . . 207

Complications . . . . 208


Part IV: Conclusions

16. Complications and Untoward Sequela of Ambulatory

Phlebectomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 215Complications of Anesthesia . . . . 215

Allergic Reactions . . . . 217

Toxic Reactions . . . . 217

Local Complications . . . . 218

Late Reactions . . . . 218

Complications of Phlebectomy . . . . 218Hematoma . . . . 218

Hemorrhage at Home . . . . 219

Wound Infection . . . . 220

Lymphatic Disruption . . . . 222

Lymphocele . . . . 222

Lymphorrhea . . . . 223

Persisting Edema . . . . 223

Nerve Damage . . . . 223

Vein Thrombosis . . . . 223

Pulmonary Embolism . . . . 224

Telangiectatic Matting . . . . 225

Hypertrophic and Pigmented Scars . . . . 225

Rare Complications . . . . 225

Complications of Compression Bandage . . . . 226Excessive Compression . . . . 226

Blister Formation . . . . 228

Contact Dermatitis . . . . 228


17. Psychological Aspects . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 231Reference . . . . 234

18. Advantages of Ambulatory Phlebectomy and Office

Varicose Vein Surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 235References . . . . 238

19. Setting Up a Varicose Vein Surgery Practice . . . . . . . . . . . . . . 241Who Should Perform Office Varicose Vein Surgery? . . . . 241

Phlebectomy . . . . 241

High Ligation and Division of the Greater Saphenous Vein . . . . 241

Alternative Applications of Phlebectomy . . . . 242

xii Contents

Safety in Office Surgery . . . . 242Pre-Operative Management . . . . 243


Type of Surgical Procedure . . . . 244

Operator’s Experience . . . . 244

Post-Operative Management . . . . 244

Emergency Measures . . . . 245

The Free-Standing Surgical Office . . . . 245Operating Room . . . . 245

Bureaucratic and Accreditation Requirements . . . . 245

Equipment and Materials . . . . 247Room Equipment . . . . 247

Surgical Instruments . . . . 247

Specific Instruments for Phlebectomy (Single Set) . . . . 248

Materials for Anesthesia . . . . 248

Syringes . . . . 248

Needles . . . . 248

Materials for Bandaging . . . . 249

Additional Localized Pressure . . . . 249

Compression Bandages . . . . 249

Compression Stockings . . . . 249

Other Materials . . . . 250

Emergency Equipment . . . . 250

Examination Equipment . . . . 250

Marking Solution . . . . 250

Material for Local Anesthesia (MPG) . . . . 250

Medication Material . . . . 250


Bibliography . . . . 251

Part V: Advanced Techniques

20. Autologous Vein Transplantation for Correction of

Dermal Atrophic Changes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 255Technique . . . . 256


21. Treatment of the Great Saphenous Vein withEndoluminal Laser or Radiofrequency Closure . . . . . . . . . . . . 261Mitchel P. Goldman and Robert A. Weiss

History of Vein Obliteration . . . . 261

Introduction . . . . 263

RF Technology . . . . 266

Animal Studies . . . . 268

Histology . . . . 268

Contents xiii

Clinical Experience . . . . 270

RF Closure Without AP . . . . 270

RF Closure with AP . . . . 271

Side-Effects . . . . 274

Technique of Closure Without Phlebectomy (Video CD) . . . . 274

Technique for Closure with AP (Video CD) . . . . 277

Follow-Up Care . . . . 277

Closure of the GSV with Endoluminal

Laser Ablation . . . . 278

Technique for Closure Using Endoluminal

Laser (Video CD) . . . . 282

Summary . . . . 283


22. Ambulatory Phlebectomy of RecurrentVaricose Veins . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 287References . . . . 293

Part VI: Appendices

1. Instructions for Patients Affected by Chronic

Venous Insufficiency . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2972. Consent for Ambulatory Phlebectomy, Endovenous

Closure with Laser or Radiofrequency, Administration

of Anesthetics, and the Rendering of Other

Medical Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3013. Varicose Vein Surgery Suggestions

Following Surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3054. Nursing Instructions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3075. Ambulatory Phlebectomy Operative Report . . . . . . . . . . . . . . . 3096. Operative Report for Endoluminal

Radiofrequency Closure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3117. Operative Report for Endoluminal

Laser Closure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3138. Explanation Card for the Patient . . . . . . . . . . . . . . . . . . . . . . . 3179. Post-Operative Explanation Card

for the Patient . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32110. Duplex Evaluation Forms . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 323

Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 325

xiv Contents

Foreword

Robert Muller

The “Present,” inexorably, changes the “Future” into the “Past,” the dream into a

victorious reality or into a defeat. This reality should not be mistaken with truth.

It is the “acquired knowledge,” fully submitted to different interpretations, that

become illusory. Even if accepted in a general consensus it needs constant

revision. Men are extraordinarily lazy; their spirit, fighting against a metaphysical

anguish, opposes with doubts the comfort of stability of the so-called acquired

verities. Dogmas provide security. Those who try to abolish them are heretics.

These same men, paradoxically, are adventurers with the need to advance knowl-

edge. This is why, as much as we go back in history, there is always a conflict

between religion and science.

It is Hippocrates’ glorious merit to tear up medicine from religion. From

the beginning of his teachings, he refused traditional knowledge and burned,

symbolically, the Asclepiades medical treatises that were the dogmas dominating

all medical schools of that time: everything must be rediscussed. Doubt must

shake-up every doctrine. This is the base of science. Do believe only on what

you can verify personally. Hippocrates was a great revolutionary. However, des-

tiny’s irony stated that Hippocratic writings would be sacred and they became

dogmas themselves and a cause of stagnation. The scholastic, Great Spirit’s

enemy, fixed the knowledge. So, the same ideas along the centuries were

copied, repeated, and recalled.

The history of medicine shows us a peculiar aspect of its evolution. In

places far away from each other in time and space, wrong theories have inspired

therapeutic acts that were salutary or disastrous. “Humoral” theory, followed by

Hippocrates and Ambroise Pare, inspired the bleeding which was salutary for

pulmonary edema due to heart failure but disastrous in other patients, causing

exhaustion or even death. The total immobilization of operated patients helped

xv

in recovering body and mind, but predisposed them to deep veins thrombosis and

pulmonary embolism. Ambulatory phlebectomy (AP) of the 2nd century BC was

less dangerous than that of the 8th century ACE.

When studying a doctrine, we must compare it with the other contemporary

doctrines—it is the horizontal comparison—or with the development of historic

times—it is the vertical comparison.

AP was performed with success long before Christ, like in Marius, the

uncle of Julius Caesar, in 107 BC, cited by Plutarch in the “Vitae Parallelae.”

Marius was concerned about frivolity, as he was ashamed to exhibit his ugly

and ridiculous varicose veins. He preferred to show the more virile and honorable

scars. It is interesting to recall that in those times, it was believed that veins

carried blood and arteries air. No idea of blood circulation was present. It was

thought that blood impurities caused nearly all the diseases. The same great

Ambroise Pare shared this knowledge in the 16th century.

Time flew slowly. Two centuries after Marius’ operation, the famous Aulus

Cornelius Celsus first described a true AP. But as the humoral theory was strongly

believed, before the cauterization, a “reasonable” amount of impure blood was

evacuated (which was absurd). In opposition to the doctrine, the practice

showed that an exaggerated hemorrhage harmed the patient. AP ended by a

compression that permitted immediate walking.

History proceeds at an irregular speed. At Hippocrates’ times it was slow,

following the diffusion of knowledge. Ideas evolved along a long, lazy river. At

present, mass media takes only a few hours to extend worldwide those experi-

ences that, once, needed centuries.

Horizontal comparison is done nearly in real time. A false or wrong theory

is rapidly rejected. In the 6th and 7th centuries, Aetius of Amida and Paul of

Egina, the famous surgeons of Constantinople, favored the total immobilization

of varicose operated patients. This was absurd and harmful for the patients.

Immobility caused blood circulation stasis and that same thrombosis that it

ought to prevent. The circulation was completely ignored and this nonsense

became dogma, lasting for 14 centuries.

I remember that in 1950 my teacher, Professor Robert, chief of the derma-

tologic department in Berne (Switzerland), used to state preemptorily that we

should not touch the varicose veins of men over 60 or women over 40 and of sub-

jects having experienced a deep veins thrombosis. These absolute decrees had no

sense and were based only on incompetence and ignorance.

History is filled with such notions damaging patients and harming medi-

cine’s progression, particularly phlebology. It is humanly difficult or even

impossible for a chief or a “Mandarin” very qualified in a particular field, to

refrain from giving advice regarding fields that are closely related, if he

ignores them. Let us take the example of Ambroise Pare who is cited for his

modesty, honesty, and wisdom. In spite of the lack of pathophysiologic data,

he did not give up pontificating that the cause of varicose veins was the “melan-

cholic blood”: “Pregnant women often develop varicose veins, as the suppression

xvi Foreword

of the menstrual blood evacuation fattens this blood. It is better not to deal with,

as those varicose veins are untreatable.”

I dare think about the solidity of both the doctrine and the execution of the

AP technique. After 1957, it was improved vastly, but the main principles had to

resist strong oppositions, deviations, and even perversions.

In opposition to winds and tides, AP went through the trial of vertical com-

parison (50 contemporary years worth several past centuries) and horizontal

comparison (worldwide extension by the media). I had the luck of meeting extre-

mely good pupils. Some of them enhanced the diffusion of AP so that now all

over the world patients can benefit from a simple surgical treatment of their

varicose veins.

Foreword xvii

Preface

During the last century, great saphenous vein (GSV) ligation and stripping

(L&S) has been (and still is) the most common operation for varicose veins to

the point of becoming synonymous with varicose vein surgery. This has occurred

despite evidence that the “prefabricated” stripping operation, based on textbook

anatomy, poorly matched the clinical variability of varicose vein disease. In fact,

L&S is appropriate and successful in some cases only, because in many others it

leaves the collateral varicose veins untreated. There are cases where it is not even

indicated, because 20–30% of the limbs with varicose veins may not have an

incompetent GSV (1–3). Though possible on an outpatient basis under local

anesthesia, L&S of the GSV is almost always performed under general or

regional anesthesia.

The inadequacy of the stripping operation noted in the 1940–1950s stimu-

lated the development of sclerotherapy by Sigg in Switzerland (4), Tournay in

France (5), Fegan in Ireland (6), and Orbach in the United States (7). Though

some schools propose sclerotherapy as an alternative to the stripping operation,

the optimal use of sclerotherapy is to complement the treatment of the collateral

varicose veins not removed by the stripping operation.

Sclerotherapy is a versatile office procedure. Any varicose vein, including

telangiectasia, can theoretically be injected. In expert hands, treatment is safe and

results excellent. However, long-term results of sclerotherapy are conditioned by

a variable rate of recanalization in treated veins (8–15).

In the mid-1950s, Robert Muller, a Swiss dermatologist, developed a tech-

nique for varicose vein avulsion through multiple stab incisions and called it “la

phlebectomie ambulatoire.” Dr. Muller designed his own instruments and

reported that his procedure was appropriate for treating all varicose veins with

the exception of an incompetent saphenofemoral junction (16–20). This tech-

nique permits removal of any varicose vein—except telangiectasia and the prox-

imal portion of the GSV with the saphenofemoral junction—in an office setting

xix

under local anesthesia. The Muller technique is referred to in English literature as

“stab avulsion,” “office phlebectomy,” and “ambulatory stab avulsion phlebect-

omy.” It is only within the last decade that physicians recognized that it rep-

resents a major improvement in varicose vein surgery. This technique achieves

the long-term results of surgical treatment with less inconvenience, lower cost,

and better cosmesis as compared to traditional surgical treatment or combination

surgery/sclerotherapy. However, over 30 years after its introduction and despite

recent interest, ambulatory phlebectomy is still discussed more than practiced.

This may be due to the lack of a textbook that describes the technique in

detail. Our goal is to fill this gap. We believe that, especially for a manual tech-

nique, “details make the master”; we learned this from our teachers and from the

experience of the colleagues who visit our practice.

Although the description of ambulatory phlebectomy techniques is essen-

tial, it is more important to determine the proper method of treatment for each

type of varicose vein. This statement is controversial because the technique

can be employed in two different—and in a sense, opposite—ways. The first is

to employ it complementary to traditional surgery for the removal of the collat-

eral varicose veins left after the stripping operation. The second is for removal of

all varicose veins, thus limiting traditional surgery to only high ligation and

division of the GSV. Although the objectives of varicose vein surgery can be

achieved by both approaches, we propose the latter choice, which is described

in this text.

With ambulatory phlebectomy one cannot treat all varicose conditions;

venous telangiectasia are best treated with sclerotherapy, and GSV incompetence

with high ligation, division; and endoluminal laser or radio frequency ablation.

To provide a complete practical guide for office-based surgical treatment of

varicose veins, our technique for L&S of the GSV is also described.

This book is not a textbook of phlebology. The physiology, pathology,

investigation, and diagnosis of the venous disorders of the lower limb, as well

as the available wide range of nonsurgical, surgical, and sclerotherapy procedures

are not discussed here. Those who need or wish to improve their knowledge on

these and other topics should turn to other sources, some of which are listed

below.

The treatment of venous disease in the USA has been undergoing a rapid

evolution during the past decade. This was primarily stimulated by the popular-

ization of sclerotherapy for the treatment of varicose and telangiectatic leg veins.

However, it soon became apparent that many veins, especially those larger than

6–8 mm in diameter and those with reflux from various junctions were better

treated with surgical techniques. This led to an improvement and enhanced cosm-

esis of the traditional L&S procedures. In addition, the American physician has

once again borrowed concepts developed by our European colleagues to

modify the stripping part of the surgical procedure into one of stab avulsion or

ambulatory phlebectomy. It is therefore fitting that a textbook on this technique

be made available for the English-speaking physician.

xx Preface

We hope this text is useful for those who wish to include ambulatory phle-

bectomy in their phlebological practice. The techniques described here are per-

sonal. However, we have attempted to separate the essential points from the

many personal details, which in our hands are useful, but not mandatory. We

tried to create a text that might trigger an “imaginary movie” in the reader’s

mind; it is the reader who will judge how we succeeded.

Stefano Ricci

Mihael Georgiev

Mitchel P. Goldman

REFERENCES

1. Schwartz SI. Yearbook of Surgery. Chicago: Yearbook Medical Publishers, 1979

2. Goren G, Yellin AE. Primary varicose veins: topographic and hemodynamic correla-

tions, J Cardiovasc Surg 1990; 31:672–677.

3. Hanrahan LM, Kechejian GJ, Cordts PR et al. Patterns of venous insufficiency in

patients with varicose veins. Arch Surg 1991; 126:687–691.

4. Sigg K. The treatment of varicosities and accompanying complications. Angiology

1952; 3:355.

5. Tournay R et al. La Sclerose des Varices. 4th ed. Paris: Expansion Scientifique

Francaise, 1985.

6. Fegan WG. Continuous compression technique of injecting varicose veins. Lancet

1963; 2:109.

7. Orbach EJ. A new approach to the sclerotherapy of varicose veins. Angiology 1950;

1:302.

8. Chant ADB, Jones HO, Weddell JM. Varicose veins: a comparison of surgery and

injection/compression sclerotherapy. Lancet 1972; 2:118–1191.

9. Beresford SAA, Chant ADB, Jones HO, Piachaud D, Weddell JM. Varicose veins: a

comparison of surgery and injection/sclerotherapy. Five-year follow-up. Lancet

1978, 1:921–924.

10. Doran FSA, White M. A clinical trial designed to discover if the primary treatment

of varicose veins should be Fegan’s method or by an operation. Br J Surg 1975;

62:72–76.

11. Jakobsen B. The value of different forms of treatment for varicose veins. Br J Surg

1979; 66:182–184.

12. Hobbs JT. Surgery and sclerotherapy in the treatment of varicose veins. Arch Surg

1974; 109:793–796.

13. Hobbs JT. Surgery of sclerotherapy for varicose veins; 10-year results of a random

study. In: Tesi M, Dormandy J, eds. Superficial and Deep Venous Disease of the

Lower Limbs. Turin, 1984, Edizione Minerva Medica, pp. 243–246.

14. Einarsson E. Compression sclerotherapy of varicose veins. In: Eklof B, Gjores JE,

Thulesius O, Bergqvist D, eds. Controversies in the Management of Venous

Disorders. London: Butterworth, 1989:203–211.

15. Neglen P. Treatment of varicosities of saphenous origin: comparison of ligation,

selective excision, and sclerotherapy. In: Bergan JJ, Goldman MP, eds. Varicose

Preface xxi

Veins and Telangiectasias: Diagnosis and Treatment. St. Louis: Medical, Publishing,

Inc., 1993:148–165.

16. Gilliet F. Die ambulante Phlebektomie. Schweiz Rundsch Med (Praxis) 1980;

69:1398–1404.

17. Muller R. Die ambulante Phlebektomie netzformiger in der Angiologie: Die

Kniekehle. Bern, Switzerland: Hans Huber, 1975:116–118.

18. Muller R. La phlebectomie ambulatoire. Phlebol 1978; 31:273–278.

19. Muller R. La phlebectomie ambulatoire. Helv Chir Acta 1987; 54:555–558.

20. Muller R. Traitement des varices par la phlebectomie ambulatoire. Phlebol 1966;

19:277.

BIBLIOGRAPHY

Bergan JJ and Kistner RL. Atlas of Venous Surgery. Philadelphia: W. B. Saunders

Company, 1992.

Bergan JJ, Goldman MP, Weiss RA. Varicose Veins and Telangiectasias: Diagnosis and

Treatment. 2nd ed. St. Louis: Quality Medical Publishing, Inc., 1998.

Browse NL, Burnand KG, Lea Thomas M. Diseases of the Veins: Pathology, Diagnosis

and Treatment. London: Edward Arnold, 1988.

Goldman MP, Bergan JJ. Sclerotherapy: Treatment of Varicose and Telangiectatic Leg

Veins. 3rd ed. St. Louis: Mosby, 2001.

Nicholaides AN, Sumner DS. Investigations of Patients with Deep Venous Thrombosis

and Chronic Venous Insufficiency. London: Med-Orion Publishing Company, 1991.

Tibbs DJ. Varicose Veins and Related Disorders. London: Butterworth Heinemann, 1992.

xxii Preface

Interview of Dr. Robert Muller

A. A. Ramelet

Dr. Robert Muller was born in Neuchatel (Switzerland) on September 2, 1919.

After his medical studies in the Universities of Neuchatel, Bern, and Lausanne,

he served as a resident in both psychiatry and gynecology in Lausanne, followed

by surgery and internal medicine in Neuchatel. He finally settled into dermatol-

ogy, obtaining his title of specialist in dermatology in Bern as he was working in

the Department of Dermatology (Professor Robert) as a senior resident. His thesis

was dedicated to the rate of healing 20 years after syphilitic treatment with neo-

salvarsan and bismuth (the magna therapia sterilisans as described by Ehrlich).

He discovered that all the patients who could be controlled were healthy and

Wasserman negative.

He settled down in private practice in Neuchatel in 1951, practicing both

dermatology and phlebology. Teaching these fields in the local nursing school,

he developed ambulatory phlebectomy between 1951 and 1955, creating a phle-

bological team in 1960, including a surgeon, a radiologist, and himself as a

“dermato-phlebologist.” He treated innumerable patients, all of whom were

convinced of the superiority of phlebectomy. These qualities contributed to

Dr. Muller’s growing international fame.

Dr. Muller worked hard to introduce his technique to the medical commu-

nity. He suffered from lack of understanding of the technique coupled with great

skepticism and ridicule. He courageously ignored this scoffing while steadily

convincing more and more disciples. Physicians were received very generously

in Neuchatel or Dr. Muller would instruct increasingly successful conferences

throughout France, Italy, Netherland, Denmark, Austria, Yugoslavia, Iran,

Brazil, and Argentina. He also produced films and videos. He retired in 1994,

as a 75-year-old active phlebologist, honored by many national and international

scientific societies.

Dr. Muller had a rich personal life as well. He married his wife Simone in

1944, just before the end of his studies. Simone was a French national and her

xxiii

brother was active in the Resistance. As such, she was in danger and marriage

was hastily arranged to avoid her returning back to France during the war.

They had four children; three of them are presently alive. As a result, Dr.

Muller is an enthusiastic grandfather of nine granddaughters and grandsons.

Dr. Muller served as a physician to the Swiss army and had a reputation as a

fine sportsman. Unfortunately, he had to renounce his sporting activities because

of a damaged knee. Dr. Muller then developed a passion for the garden and is still

very busy attending 300 roses.

Dr. Muller has always been fascinated with the history of medicine. As a

humanist he discovered that ambulatory phlebectomy was already performed

during Roman times, in particular by Celsus. He relinquished giving his name

to his technique in deference to the ancients. Some other physicians, who

pretend to have invented phlebectomy, do not demonstrate this same humility.

I shall never forget Dr. Muller’s hospitality in Neuchatel. I visited him in

1977 with the task of developing ambulatory phlebectomy at the Department

of Dermatology, University of Lausanne. In Dr. Muller’s office, each patient

was first welcomed by Mrs. Muller with her smiling reassuring face and quiet

authority. She had a strong effect on the patient who would enter the operating

room totally in trust due to her reassuring manner.

As I observed, Dr. Muller operated in a quite simple, sterile, and highly

economical outpatient setting. An excellent teacher, he demonstrated all his

tricks with humor and precision, operating very quickly and effectively. He

spent still more time inviting me to a delicious fish meal with a fine local wine

while generously providing further explanation and instructions.

In much the same way, many disciples benefited from the remarkable hos-

pitality of Dr. and Mrs. Muller. Each of us will never forget their reception, their

kindness and respect to each patient. The Mullers now live happily in their house

in Neuchatel, cultivating their garden and roses, surrounded by their family and

friends. With great gratitude, let all of us proclaim our respect and affection.

xxiv Interview of Dr. Robert Muller

Acknowledgments

Dr: Robert Muller Dr: Lidio Ricci

At the Congress of Phlebology in Strasbourg (France), 1970, my father, Dr. Lidio

Ricci, a sclerotherapist with surgical experience, heard a certain Dr. Muller pre-

senting a paper about a strange method of ambulatory avulsion of varicose veins

through stab incisions. During the presentation most of the audience laughed at

the speaker, and some protested, especially for the “unorthodox” way of perform-

ing the operation: no surgical gloves, the instruments held in his mouth (!). Back

home my father told us: “I saw a guy who has for us the thing we need. He is

either crazy or a genius!”

Without losing time, Lidio Ricci went to visit Dr. Muller’s practice in

Neuchatel (Switzerland), took notes of everything, and, after preparing himself

for a start with the new method, invited Muller to his practice in Rome to give

him a hand for the treatment of the first few cases. This happened on May 1,

1971, and that was the beginning of our experience in ambulatory phlebectomy.

xxv

At about the same time, my brother, Michele, introduced in our practice the

office high ligation, division, and groin-to-knee stripping of the greater saphenous

vein (GSV) under local anesthesia according to the technique he learned from

Crosetti (a surgeon who worked at that time with Muller). At this point, we

were able to treat surgically any varicose case in a completely office setting.

Since then, we added to our experience many details and some original personal

solutions too, which, however, did not change the original idea of Muller that

“one should cure safely and with good cosmetic results the legs of all varicose

patients.”

It is only recently that Muller was able to see the fruit of his “craziness.” In

January 1992, he was nominated Honorary Member of the Swiss Society of Phle-

bology. His technique is already recognized, cited, and described worldwide, and

has been object of several publications and at least two editorials. It is, of course,

often imitated, presented under different names, and even “improved” or rein-

vented by the use of “personal” techniques and instruments. But to imitate or

to try to reinvent a product simply means to admit its importance and superiority.

While all this demonstrates that the importance of ambulatory phlebectomy is

already universally recognized, it took almost 20 years for this to happen.

During all these years, the technique was first ignored and later adversed,

especially by the academic world. In 1966, Raymond Tournay, President of

the French Society of Phlebology, invited Muller to present his technique at

the Society’s Meeting in Paris. “It turned to be a complete disaster,” Muller

himself recalls. “Surgeons and phlebologists submerged me in an ocean of criti-

cism and sarcasm, without even discussing the method. But this ‘accident’ only

stimulated the further development of the method.”

Despite this official hostility, more than 260 physicians from France, Italy,

Germany, England, USA, Israel, Venezuela, Switzerland, and other countries

have visited what could be called the “Neuchatel school,” and many of these

have in turn taught the technique to others: success greatly deserved for this

extremely modest person, who never refused—and still does not—to listen to

and counsel the colleagues who contact him.

It is my personal opinion that only a physician without a formal surgical

training (Muller is a dermatologist) could invent such a practical, simple, effica-

cious, safe, and economic technique, because of the absence of all traditions,

dogmas, and myths a surgeon usually has.

It is my father’s merit to have appreciated immediately and early the

importance and potential of Muller’s technique, thus allowing us to practice it

and gain experience 20 years ahead of the beginning of its large diffusion.

These 20 years of experience, until 1986 under the direction of Lidio Ricci,

are the basis of this book. During the first years of our experience our attitude

was rather egoistic, because we used to think that such a simple and efficacious

method would be immediately copied and practiced by those who would come in

touch with it. To our great surprise, colleagues proved rather conservative and

reluctant to apply the new method. With this book we are trying exactly the

xxvi Acknowledgments

opposite: to share our experience in such detail, as to permit the reader, if poss-

ible, to have the sensation of a physical presence in our practice. If we succeed in

this, we will have at least in part paid a debt to R. Muller, whom we owe so much,

and to Lidio Ricci, who would have seen with satisfaction the development of the

work he started.

Stefano Ricci

Acknowledgments xxvii

Introduction to the Second Edition

At present, nearly every physician involved in the treatment of varicose veins

(phlebologist) knows something about ambulatory phlebectomy (AP) and its

general indications. This book’s first edition represented the first textbook

devoted solely to this subject. Its purpose was to educate phlebologists through

the American edition (1995), followed by a Portuguese translation (1998) and

an Italian one (1999).

We believe that many patients now know that varicose veins may be

removed without visible scars and the need for hospitalization. Teaching the

latest advances in surgical treatments of varicose veins is important and advan-

tageous for both doctors and patients. This teaching has a medico-legal impli-

cation, in part by providing the basis for AP not to be considered as a strange

surgical procedure, but a procedure well founded in the tenets of cost-effective,

safe surgery.

The concern for surgery done with limited or no hospitalization, and for

economies in medical administration have enhanced Muller’s procedure. The

fact that many Phlebologist’s have “reinvented” this procedure after Muller

(sometimes giving their name to it) is the true confirmation of its validity:

many imitators, many honors.

A new edition of Ambulatory Phlebectomy may be viewed as a simple reprint

or, at the opposite extreme, may add new information to the previous edition.

In our case we are half-way. In fact, from 1995 to today, though

phlebectomy did not change, the world around phlebectomy has. That is to

say, many aspects remain unchanged, the technique per se is the same and

cannot be reinvented, but:

. The technique has expanded to other surgical procedures and now is

used not only like an ambulatory method;

. The fundamental rules can be left out;

xxix

. Duplex evaluation has enhanced the approach of single patient’s pathology;

. New treatments have been suggested to be associated to AP.

TECHNIQUE EXPANSION

AP was created to be a typical ambulatory technique, where ambulatory means

“in an ambulatory setting.” Its execution, simplicity, absence of post-operative

complications, and use of local anesthesia allows one to compare it to a

common dentistry procedure.

Its employment in association with a traditional saphenectomy procedure is

useful and appropriate, but alters, in part, its characteristics by not being per-

formed under local anesthesia. In fact, patient mobilization, although prompt,

nevertheless is not immediate because of the spinal or general anesthesia, post-

operative compression is done on an atonic leg making hemostasis less effective.

Surgeons are generally more concerned about the saphenous stem than

about collaterals, whose demanding and boring avulsion is often impossible in

a commonly busy operative session. Collateral varices, besides, may be treated

subsequently by sclerotherapy. AP consequently had a prevailing diffusion up

to those phlebologists who operate in an ambulatory setting and have limited sur-

gical experience (dermatologists, angiologists), and up to those surgeons practi-

cing phlebology, who operate by quality and economy (day surgery, short

hospital stay). In France, The Netherlands, Germany, Austria, Switzerland, and

the USA dermatologists are more interested in AP; in Italy, Spain, Latin

America, Asia, Australia, and England, surgeons and angiologists are.

LEAVING OUT FUNDAMENTAL RULES

Phlebectomy phases are well known: they are simple and easily performed by all.

In fact Muller’s technique is the ideal surgical method as it is easily reproducible.

However, an easy technique may be badly performed. Moreover, collateral vein

phlebectomy may be so trivial that poor attention may result to those (boring)

details, which are instead fundamental to achieve a good result.

. Limiting attention to the saphenous stem causes poor attention to var-

icose veins (always due to collateral veins) that should be appropriately

completely removed to avoid a subsequent “reactivation” of those

tracts left behind. In fact these may initially disappear after the saphe-

nectomy, but will be the first to reappear when a retrograde flow devel-

ops again.

. Incisions should be as small as possible relative to the treated vein

diameter (generally one-fifth of the diameter).

. Prolonged searching for a varicose vein in a difficult site, often done

with gross instruments, causes visible scars; better would be a sup-

plementary incision than skin damage.

xxx Introduction to the Second Edition

. Infiltrating (tumescent) anesthesia limits neural damage, bruising, post-

operative bleeding, and hematomas.

. A firm post-operative compression, followed by immediate ambulation

(possible only with tumescent anesthesia) avoids hematomas, throm-

boses, bleeding, infections. New adhesive acrylic bands, that may be

placed directly over the skin, avoid many cutaneous problems associ-

ated with tight bandaging (blisters and abrasions).

. Keeping graduated elastic compression for 2 months improves the

cosmetic result in some patients.

DUPLEX EVALUATION

During 1960s, when the Doppler was still to come into use, it was enough for the

patient to be “Muller positive” (visible varicose veins, deep vein potency) to have

an indication for surgery. The main step was mapping, clinically performed,

based on experience, on “flair,” and a few simple maneuvers (Trendelenburg,

Perthes, and Schwartz).

Today phlebologists have supplementary ears (Doppler) and eyes (ultra-

sound) to understand the venous system, detecting the incompetent points, asses-

sing the pathologic anatomy, the presence and the volume of reflux, re-entry

perforators, selection of healthy veins, malformations, deep thrombosis, and so

on. Apart from mapping integration with morphologic and hemodynamic

details, when personally done (or supervised) by the phlebologist, duplex

ultrasound allows a patient’s disease approach to be specific for that patients

needs. When fully explored, the single subject may be submitted to one of the

different current therapeutic choices appearing more appropriate in his case, as

an integration of AP.

Duplex ultrasound may be applied to phlebectomy in searching for deep

placed venous tracts (eco-phlebectomy), especially at the thigh, where fatty

tissue may hide the varicose vein. Same is the case for the saphenous stem

when it breaks down during the saphenectomy and must be retrieved back.

NEW TREATMENTS

New techniques of obliteration of the saphenous vein by heat—“closure” that

employs radiofrequency or lasers that causes the blood vaporization and/or

vein wall heating—may take advantage of collateral AP. In particular, the last

proximal incision in the site where the varicose vein enters the incompetent

saphenous vein, may be used for introducing the catheter in the saphenous

lumen, thereby eliminating the puncture or retrieval of the saphenous stem.

Where venous diameters do not allow AP, sclerotherapy may be used. It is

the case for many reticular varices or telangiectasia. At present, the introduction

of a sclerosing foam has made sclerotherapy a more effective and rapid treatment

Introduction to the Second Edition xxxi

for varicose veins and enhance AP. In association with AP, sclerotherapy may

also be used to treat the saphenous stem abolishing the reflux re-entry by

collateral veins. The saphenous vein is then submitted only to the physiological

centripetal flow, so that its sclerosis becomes more effective.

From these statements this new Edition finds its justification.

Stefano Ricci

Mihael Georgiev

Mitchel P. Goldman

xxxii Introduction to the Second Edition

History of Ambulatory Phlebectomy

Robert Muller

PRELIMINARY NOTE

In Mesopotamia, Egypt, Greece, Europe, and all over the world, medicine being

initially run by the magicians became sacred. The power of treating and healing

moved from the witch-doctor’s to the priest’s hands. The submission of medicine

to religion turned out to be beneficial for providing care to the poor and for idea-

lizing the medical art. The oath of Hippocrates was reserved to few medical

schools and not universally known; it became a widespread dogma only in the

11th century, under the influence of religion.

Unfortunately, this subjection to religion was an obstacle to the scientific

progress. Religion was deemed to possess the truth, “The” truth is fixed and com-

plete by definition from God, whereas medicine depends on science that is evol-

utionary and progressive: the doubt, the curiosity, and the experimentation tend

to produce novelty and continuously question the truths. These innovations are

dangerous for religion, but essential for science. Doubt is a sin for religion,

whereas it is an absolute necessity for science.

A further danger also threatened the practice of medicine in ancient times:

the attempt to freeze in a doctrine the experiences of men, even if geniuses.

The great Greek doctors have saturated medicine by systems inspired

a priori to contemporary philosophies. Considered as inviolable verities and

accepted as dogmas, those systems sterilized research. The doctor shall not

submit to revelation-based religious dogmas nor lay dogmas based on the absol-

ute and consequently exaggerated texts of the great geniuses. As Aristotele said,

“Plato is my friend, but also Truth is my friend. If I must choose between the two,

I choose the Truth.” Despite this sentence, in the name of the infallible philos-

ophy, Aristotele’s, Hippocrates’, and Galeno’s fans followed for 2000 years

the spirit constructions instead of the facts of reality.

xxxiii

In the 16th century, although ignoring the Latin and Greek language,

Ambroise Pare developed his genius at “the university of battlefields”. He was

the most clever of Renaissance surgeons and the craftsman of the surgery renais-

sance. In spite of being a devout Ugonot, he used religion only to love and respect

his patients.

HIPPOCRATIC TEXTS

In Hippocratic texts (dating back 2000 years ago), translated by Littre, the chapter

of ulcers revealed the necessity of incising the proximal varicose vein at different

levels when an ulcer is threatening, allthough never touching the dangerous black

spot. It was a phlebotomy, but not still a phlebectomy. Hippocrates thought that

the bad blood that “fed” the ulcer should be evacuated. Interestingly, a compres-

sive bandage was applied and the patient was invited to immediate deambulation.

On the magnificent marble exvoto found in a temple near Athens Partenos,

in a medallion in the lower left side, we can observe the image of a malleolar

ulcer ; in the middle there is an enormous leg, and on the right, the God Aesculap,

slightly bigger than the leg, while palpating in the area of Boyd’s perforator the

proximal end of a long and sinuous varicose vein, a longitudinal extra fascial

tributary of the great saphenous vein. This sculpture is the practical witness of

the ancient Greek doctors’ interest for the ulcer–varices relationship, as

learned from the Hippocratic texts.

PLUTARCH

Plutarch lived from 50 to 125 ACE. He was a sage, philolosopher, and writer

from Greece, who wrote “Parallel Lives.” Here he described the varicose vein

operation of Caius Marius, a Roman general and consul, uncle of Julius

Caesar, at the time of his second consulship (107 BCE). Unfortunately he was

not a doctor, consequently he reports only few details. He underlines the patient’s

courage in standing the terrible pains of the operation, without ties, excitement,

cries, but impassive and silent. However, when the surgeon asked to treat the

other leg, Marius refused: “I believe—he said—that the improvement is not

worth the pain.” In spite of the report of his sobriety, we can deduce that in

2nd century ACE in Rome varices were not simply incised, but were excised;

that it was a currently performed operation; that it was performed without

anesthesia, tying the patient so that both legs could be treated in a single

session. Concerning the patient’s motivation, we observe that it was not a

matter of healing an ulcer, but of eliminating horrible varices; an aesthetic

reason. Marius was embarassed of exhibiting varicose veins to his soldiers

under the tunic, his illness considered nonvirile and ridiculous.

xxxiv History of Ambulatory Phlebectomy

AULUS CORNELIUS CELSUS

He first described ambulatory phlebectomy in a complete, detailed, precise, and

exact way. He was a Roman, rich and extremely meticulous. He lived during

Tiberius between 56 BCE and 7, or even 40, ACE, a contemporary of Christ.

He wrote in a remarkable style (he was named the Cicero of Medicine) a

human’s knowledge encyclopedia, “De Artibus,” probably between 30 and 35

years BCE. It is the work of a talented, intelligent, common-sensed sage, with

an inexhaustible scientific and philosophical culture that concerns agriculture,

military art, rhetoric, philosophy, jurisprudence and . . . medicine (the 7th book).

Unfortunately this encyclopedia has disappeared, with the exception of the

7th book. This is so well documented and precise so as to induce many authors to

think, even today, that Celsus was a doctor. This is not likely as in 1st century

BCE in Rome, the doctors were liberated slaves or strangers, nearly always

from Greece. Celsus was the first Latin author, the one who created Latin termo-

nology. The Roman patricians considered the practice of medicine, especially

surgery, as absolutely unbecoming of their nobility. This is the reason for the

low success of this book. The Greeks did not easily read the Latin language;

they were upset that a nondoctor could be better updated than most of them

and did not forgive him his intelligence or his competence. This book disap-

peared, was lost and forgotten.

During Quattrocento, in 1426, Guerino from Verona found a manuscript, and

in 1443 it was found by Thomas de Sezanne, the future Pope Nicolas V, a 10th

century dated copy, inside the church of Saint Ambrogio in Milan. It was the

last ancient text to be discovered, but the first to be printed in Florence in 1478.

Celsus achieved in this way a sensational revenge. The surgical instruments

found in Pompei correspond exactly to those described by him. In the 31st chapter,

he deals with leg diseases. We can read in the translation by M. des Etanges:

The lower limbs are submitted to varices that are not difficult to elim-

inate . . . I will therefore say that all the varices becoming harmful

must be repressed by the fire or suppressed by the instrument. The

cauterization is preferred when the vein is straight; we should have

recourse to it also if, in spite of the present obliquities, the vein is iso-

lated and has a medium volume. At the opposite, if the varices are

winding, at the point of forming a kind of circumvolutions and plaits,

it is more advisable to excise them (utilius est eximere). Here is the

way of making cauterization: teguments are incised and after the vein

has been dissected, this is moderately touched by a red-hot iron with

a thin and blunt tip. Burning the wound edges, by separating them

with hooks (hamulus) will be easily avoided. Hooks are placed at a

four finger distance each other, all along the vein; when cauterization

has been completed, remedies are applied that are employed for burns

(. . . medicamentum, quo adusta sanatur). Excision instead is done as

following. After skin division as in the former way, the wound edges

History of Ambulatory Phlebectomy xxxv

are grasped with the hooks; then the scalpel is used to entirely isolate the

vein from the surrounding parts taking care not to injure it. This done,

blunt hooks are slipped under the vessel, while keeping them

separated as told before. To understand the varices direction, simply

lift the hook (‘when the vein is pulled, it easy to detect due to the

tension applied to the hook’; ndr. personal translation), and when all

varices are in this way ascertained, the vein is cut in the point where

the hook is lifted. Then we proceed to the nearest hook where the

same maneuver is done (‘where the vein is attracted and eradicated’;

trad. pers and translation); and the leg being freed from all the varices,

the wound lips are approached and a sticky poultice is applied (emplas-

trum glutinans).

We can notice that Celsus described in detail sclerosing thermocoagulation

and ambulatory phlebectomy, although done by large incisions. Pulling the vein,

he knew how to change a limp subcutaneous cord into a stiff rod. He states that

you must be radical: eliminate all the varices. Finally, he used an adhesive and

compressive medication that allowed walking. A lot of courage was needed to

stand such a treatment. Men preferred to have scars, which showed virility,

than varices, which were ridiculous. Celsus did not invent this treatment. So

we must speak about phlebectomy according to Celsus and not of Celsus.

CLAUDIUS GALENUS

In spite of his Latin name, he was a Greek, born in Pergamus in 130 and died in

Rome in 200. He was the last giant of Greek–Roman antiquity medicine. He

wrote more than 500 works. He was devoted to scientific research and contributed

to the development of anatomy. He represents the apex of the Greek medicine.

Monotheist, together with Aristotele, reigned as soverign over the Medieval scho-

lastic medicine. He treated the varices by the technique described by Celsus, avul-

sing them with the hook. He contributed greatly, unfortunately, to medicine

decadence, since after his death every serious anatomical or physiological research

was dismissed by the thought that whatever could be said had been said by Galenus.

AETIUS OF AMIDA AND PAUL FROM AEGINA

From Galenus to Renaissance, medicine degraded for more than a thousand

years, a period corresponding to one-quarter of the history of humanity, as far

as the christian occidental world is concerned. This obscurity was fortunately

cleared by flashes of geniality, particularly in the Roman Oriental Empire from

500 to 1500 and in the Islam Empire. They collected, saved, and translated the

writings of the ancient Greek and Latin authors; they submitted them to experi-

ence the criticism and transmitted them, ameliorated, to the occidental world for

their rebirth.

xxxvi History of Ambulatory Phlebectomy

Aetius of Amida (502–575) and Paul from Aegina (607–690) were both

Greek doctors living in Costantinople and concerned with varices. Aetius stressed

their compression with bandages, but unfortunately he prescribed convalescent

bed resting with elevation of the limb over the head. This bed resting became

a fixed dogma for more than 1400 years. Celsus did not avulse the varices

higher than the knee. Aetius and Paul, after a century, will ligate the greater

saphenous vein at the thigh, till below the second Dodd perforator.

Paul from Aegina placed a tourniquet at the thigh and invited the patient to

walk. He carried out what we call a Perthes–Delbet test. He drew out a practical

curious conclusion, totally different from the actual one. If he observed a distal

dilatation of the varice, he marked it for avulsion. Actually we deduce that the

deep vein is obstructed at the tourniquet level and the avulsion of the superficial

vein, although varicose, is avoided. Then Paul reclined the patient and placed a

second tourniquet behind the knee. He incised the skin over the varice between

the ties, isolated the vein, and took off the ties. He passed two strings under

the varice, then separated them and incised the vessel. He evacuated all the

blood that was felt necessary, then he ligated the vein tying the strings and

removed the vessel between. This partial avulsion of the GSV at the thigh is

exactly the same that Trendelenburg will perform 1200 years later.

Paul did not remove the proximal part of GSV as it may injure the stem of

vessel that, he thought, conveyed the nutritional blood. He believed, according to

Galenus, that arteries carried air (Hippocrates pneuma). As a humoralist he made

the vein bleed just to eliminate the impurities. Aetius and Paul from Aegina

obtained a practical progress, but their writings confirm complete scientific

research stagnation.

MIDDLE AGES

The fall of the Roman Western Empire in 476 and, a thousand years later, of the

Eastern Empire, in 1453, was followed by a long agony in science. The Church,

being adverse to cadaveric dissection and human blood manipulation, prohibited

all anatomical and physiological research. In 1163, the Tours Council pro-

claimed: “The Church abhors blood.” The same taboo reigned in China (dissec-

tion was permitted in 1916), in the Hindu, Arabic, and Islamic religions.

This horror for blood has a historical base. In 3rd century BCE, Erophilous

of Calcedonia, a famous doctor of Alexandria’s school, disregarded deity

worship and probably was the first to dissect the human body in the dead and,

according to Celsus, also in living subjects. Authorized by his sovereign

(Alexander), he seems to have dissected some dead condemned and war prison-

ers. The other famous doctor charged with human vivisection was Erisitratus

from Chio, born in 310 BCE. Those acts horrified the world. When the Church

wanted to bring down an anatomist, it used to charge him with this awful

crime. This was done, above others, with Berengarius from Carpi and with

Vesalius (1514–1564), the famous Flemish anatomist from Montpellier and,

History of Ambulatory Phlebectomy xxxvii

particularly, from Padova. It is for this (wrong) reason that Vesalius was con-

demned to death by the Inquisition, even if his penalty was changed into a pil-

grimage to Jerusalem, as he was the personal physician of the king of Spain.

He died during his travel from a shipwreck.

Both philosophy and generally science disappeared in a most sterile

decline, but particularly medicine did as a consequence of the lack of doubt,

objection, experimental research, and even common sense. The bright Greek–

Roman–Byzantine inheritance disappeared forgotten in the scholastic march.

RENAISSANCE

The renaissance and our world culture holds an endless gratitude of debt towards

Islam, towards those illuminated and tolerant calyphs, and towards their doctors

(often Jews and Christians), who collected and translated the tradition and the

Greek–Roman texts. Arabs did not develop important progresses, but did recog-

nize the great evolution of the ancient thought towards the truth, the sublime goal

of the soul ascent to God, according to the Believers. During 13th century a

muslim from Fez, Maroc, said: “Men must glorify God with the means that

they have to disposal: modest spirits with pity and charity, excellent spirits

with the disinterested researches of Science.”

Albucasis (1013–1106)

He was Muslim and has been the greatest surgeon of Andalusia kingdom. He

clearly described multiple ligation of the varices and also, eight centuries

before Mayo, the GSV stripping.

Guy de Chauliac (1300–1368)

He was born in the Gevaudan region, he was Christian, he inspired to Albucasis.

He recommended multiple serial incisions of varices, followed by cauterization

or avulsion. These two great surgeons rediscovered the treatment described by

Celsus, although ignoring it.

Guy de Chauliac was a traveler. As an anecdote we remind the tremendous

hate he was submitted to by the poet Petrarca (born in Arezzo in 1304), the first

humanist of the renaissance. Guy de Chauliac really treated Laura from Noves,

but could not cure her from pestis. He deserved celebrity status for having

stated that the medicine base is that of anatomy, but studied by human dissection

either on books. Two years before his death the dissection was officially admitted

in Montpellier, in 1366.

Ambroise Pare (1510–1590)

He was the most clever surgeon of the Renaissance. He was a sincere but liberal

Uguenot, son of a surgeon–barber–healer. He ignored Latin and Greek

xxxviii History of Ambulatory Phlebectomy

languages, which was how he escaped from the pernicious scholastics. His

“university” was the battlefield. He has the great merit of having adopted arterial

ligation, opposed to the amputation stumps cauterization by boiling hot oil or

white-hot iron. He modestly recalled that a young French surgeon–barber

(Alois Carsena from Nice) had already tried to tie arteries. Alois, or Alohim,

learned arterial ligation with cutgut and analgesic inhalation (narcosis) during

his captivity in Algeri. Islam had preciously preserved those Greek–Roman

(ligation) and oriental (analgesia) customs.

Ambroise Pare was concerned about avoiding ugly scars (one of the prin-

ciples of aesthetic surgery). Concerning varices, he reinvented the technique of

Paul from Aegyna, even if he wrote about the pathogenesis: “The cause of

varices is melancholy blood. They develop in those subjects that complain a mel-

ancholy disposition and over-indulge in tasty meat. The blood often concentrates

melancholy humours. That is why pregnant women often develop varices, as the

abolition of menstrual blood evacuation encrusts their blood. It is better not to get

involved, as the pregnancy varices are not curable”.

MODERN TIMES

Jean Scultetus (1595–1645)

He was a German surgeon of the 17th century. He invented, described, designed,

and made up a kind of hooks and mini-strippers that allowed leg and thigh varices

avulsion. He nearly revived ambulatory phlebectomy.

Jean-Louis Petit (1674–1750)

He was the first director of Paris Surgery Academy. He treated pertinently the

varices etiology: whatever interfered with blood progression to the heart. He

was a participant of the radical excision school.

In conclusion, ambulatory and radical phlebectomy was forgotten after

Celsus. Surgery took care only of removing the blood reflux in the varicose

GSV: Celsus in the 1st century, till the knee; Aetius in the 6th century, Paul

from Aegyna in the 7th century and Trendelenburg in 1890, till the mid-thigh;

Moore in 1906 and Babcock in 1907, till the high thigh, at the junction. Moore

in 1896 and DeTakats in 1930 operated in an ambulatory setting. Finally, Schiassi

in 1908 added to the junctional ligation the distal sclerotherapy.

THE PIONEERS OF AMBULATORY PHLEBECTOMY REVIVAL

My master at the dermatologic clinic of Bern University gave me two fundamen-

tal dogmas: (1) never treat the varices of an old phlebitic patient and (2) never

treat the varices of men aged more than 60 or of women aged more than 40.

Half of the beds of our clinic were occupied by complications of chronic

venous disease.

History of Ambulatory Phlebectomy xxxix

In 1951, I began my activity as a private dermatologist. Sclerotherapy gave

good results although recurrences were the rule. In those times, the word

“phlebitis” gave rise to general panic; patients were immobilized, treated with

cold poultices, heparinized. Knowing that in Germany, Austria, and England

thrombus evacuation followed by compression and ambulation was the treatment

employed, I began to do the same using local anesthesia, with great success. As

the vein recanalized and thrombosis recurred, to avoid this occurrence I started to

take off not only the thrombus but also the wall of the affected vein.

I was doing the same procedure 3 days after sclerotherapy. I quickly

realized that the vein wall was rapidly became fragile and it was difficult to

remove without breaking it. I then decided to eliminate the injection and to

treat the vein directly. It is in this moment that I revived ambulatory phlebectomy.

In 2 years time I focused all the details concerning the doctrine, the technique,

and the instruments. In 1956, ambulatory phlebectomy was defined and achiev-

able in any medical office: marking (mapping), Trendelenburg tilt, local anesthe-

sia, multiple longitudinal incisions (3 mm, which then became 0.5 mm after the

hook introduction, created by the casual breakage of a forceps), excision of the

whole varicose vein together with perforators and tributaries, high compressive

bandage, immediate and vigorous ambulation.

The patient would be recommended to the surgeon (Dr. J.P. Crossetti)

when the GSV had reflux to the sapehnofemoral junction. We had learned that

in Bruxelles Dr. Ryckaert was easily and for a long time performing the groin

to knee saphenectomy in an ambulatory setting, under local anesthesia; after vis-

iting him, we immediately adopted this method. Our team was now able (1960) to

excise effectively, aesthetically, at low risk and at low cost all of the varices.

In 1964, I felt the disappointment (for my pride) and the satisfaction (for the

important roots of my technique) to find that 2000 years earlier some colleagues

had solved in the same way, the same problems. Obviously, the anatomy,

physiology, asepsis, anesthesia knowledge have nowadays changed the general

situation.

In 1967, Dr. Tournay invited me to Paris to present my technique to the

French Society of Phlebology. It was a total fiasco. Everybody agreed that it

was a ridiculous method, after which I could only bury myself together with

my invention. After a while, however, a young colleague (Dr. Dortu) asked me

to teach him the technique. From that time, the method started to diffuse and

to be accepted.

In spite of this official hostility, more than 260 doctors from France, Italy,

Germany, UK, USA, Israel, Venezuela, Switzerland, and other countries, have

visited my office; many of them have subsequently taught the technique to others.

The ways of vanity are subtle: many colleagues could not resist the tempta-

tion to claim not only the revival but also the discovery of ambulatory phlebect-

omy, simply by slightly modifying an instrument, the incision, or the bandage.

xl History of Ambulatory Phlebectomy

Who Discovered Saphenous VeinIncontinence?

Stefano Ricci

In 1890, Friedrich Trendelenburg published a fundamental paper entitled

“Ligation of the greater saphenous vein in varicose veins of the leg.” The

author describes the phenomenon of downward filling of the varicose bed

through the incompetent saphenous trunk; this can be temporarily stopped by

the digital compression over the saphenous trunk at the thigh during the

passage from horizontal to standing position. As a consequence some benefit

will follow from the “ligation and section of saphenous vein at the junction of

the lower and the middle third of the thigh” proximally to leg varicose veins.

From that historical moment on, ligation and section of the saphenous vein

is named the Trendelenburg operation, even if subsequently widely modified.

The true merit of this surgeon is connected to his skill in scientific diffusion of

his observation, to the good management of his reputation, to the absolute

need of finding a possible solution to varicose vein disease, and to the meaningful

historical changes in the surgical practice (antisepsis and anesthesia). He was,

above all, a very skillful and quick surgeon: he needed only few minutes to do

the operation so that anesthesia was useless (according to him).

In 1836, Tommaso Rima published in the “Giornale per servire i progressi

della Patologia e della Materia Medica” (Journal for Serving the Progresses of

Pathology and Medical Matter) a memory titled “On the near cause of varicose

veins to inferior limbs, and on their radical treatment.” Rima is a military

surgeon. He had the chance (1808) to observe a veteran operating with a

“Home method.” Over time he carried on his “experiments” concerning radical

treatment of varicose veins as a chief surgeon of Ravenna hospital (1820) and

Venice hospital (from 1822), till his death in 1843, one year before the birth of

Trendelenburg (1844–1924).

xli

“We thought to be able since then to prove by reasoning and facts (the near

cause of varicose veins) to consist of an inverted movement of blood in the great

saphena, that causes gravity in the column up downward, from the center distally.

By this means valves are paralyzed, exhausted in various ways the vein tunicae.”

On this basis, Rima performed excisions (41 cases) of few centimeters of the

saphenous trunk above the knee to interrupt the blood column weighing down.

Only two patients died in this series, which is an extraordinary result for those

times when hospital infections were frequent, even in an epidemic form. In

fact, post-operative thrombophlebitis, while recovering, contributed to oblitera-

tion of venous trunks, but could also cause fatal embolism and septicemia.

Evidently Trendelenburg knew how to better use the media of that time to

communicate and diffuse information throughout the scientific world, frustrating

the proper credit to Rima, who is never cited by his distinguished colleague.

Perhaps it is possible that Rima’s paper was issued in an obscure journal and

not known to the German medical society, at that time the most important

medical society of the world, and that, as a consequence, was not consulted in

Germany. However, at the beginning of the 19th century, Venice was still admi-

nistered by the Austro-Hungarian Empire and publications issued there were not

isolated from the German academic world.

By the way, it is curious that Thelwell Thomas refers to Rima, in his paper

on Liverpool Medico-Chirurgical Journal in 1896 where he suggests the ligation

of the saphenous vein at the saphenofemoral junction (“below the saphenous

opening”), although crediting a wrong date (1857) and a noncorresponding tech-

nique (excision of varicose veins). We suspect here a real knowledge of the

Italian author, but probably indirect (and inaccurate). Thomas even describes a

“Rima method,” that he used in two cases with “worst than ever” results.

Trendelenburg instead cites Edward Home (1799) as the supporter of the

saphenous ligation below the knee for “removing the pressure in the blood

column included in the common trunk,” but failing to recognize the valvular

absence and hydrostatic pressure not only limited to the saphenous length, but

also dependent on the distance from the heart. Rima too cites Home and refers

to his observation (however, not scientifically explained) that to make the vein

easier to operate on, it was not enough to put a tourniquet “as far as the veins

are most distended only when the patient stands up.” He made the patient sit

on a chair, positioned over the operating table, because “the natural circulation

order inverted, the blood flows down for the gravity law to fill the veins, so

presenting more apt to operation.”

If William Harvey’s discovery (1628) of blood circulation revealed that the

blood circulated in a centripetal direction, it also created some problems regard-

ing the comprehension of varicose vein pathophysiology until the discovery that

the blood in the varicose veins took the downward direction instead of towards

the heart.

Varicose vein surgery done in the times by Celsus, Galen, Avicenna, Paul

from Aegyna, Pare, Gagnabe, Velpeau, Bonnet, Fricke, Schede, Madelung, and

xlii Who Discovered Saphenous Vein Incontinence?

others, consisted essentially of varicose vein avulsion with distal and proximal

ligation, without any knowledge of saphenous reflux, consequently without any

hemodynamic explanation.

To whom then do we credit the discovery of saphenous reflux? When we

work out these “placings” we always have the risk of ignoring other authors

who contributed to the evolution of saphenous reflux. We have the impression,

in fact, that many did realize the importance of blood coming up from downward,

but few did understand and fix that mechanism and, overall, could employ it for a

therapeutic purpose.

So writes Benjamin Brodie (1846):

I had a patient in whom there was an unusually large cluster of varicose

veins on the inside of the leg, while the saphena major was of enormous

diameter, so that valves were evidently good for nothing. If I put on a

bandage, and squeezed the blood out of the veins below, and then put

my thumb on the vena saphena above, so as to stop the circulation

through it, I found, on taking off the bandage, the patient being in the

erect posture, that the cluster of veins below filled very slowly, and

only from the capillary vessels. But if, the patient was in the erect

posture, I removed the pressure from the vein, the valves being of no

use, the blood rushes downwards by its own weight, contrary to the

course of the circulation, and filled the varicose cluster below almost

instantaneously. I can understand that a ligature upon the vena

saphena under these circumstances, would to a great degree lessen the

inconvenience arising from the distention of the varicose veins below.

It would answer the same purpose as the pressure of my thumb, but

still it is not to be supposed that the good thus obtained would be perma-

nent, or that it would be sufficient to counterbalance the chance of

mischief resulting from the operation.

Here is perfectly described, although not in surgical function (but instead in

antisurgical purpose), the famous test described by Trendelenburg 44 years later.

A few years later, anti-sepsis (Lister, 1867) would efficiently enter (with

some initial resistance) the surgical art, radically changing the prognosis of

those poor patients, otherwise subjected to the infection lottery and, conse-

quently, changing the pessimistic vision of surgeons like Brodie. To Lister we

also owe the development of resorbable sterile sutures (catgut treated with phe-

nolic acid, 1869) to substitute those made of silk, whose ends needed to be left

long out of the wound for suture removal. With catgut, that was cut short and

buried in the tissues, the incision could be sutured completely, lowering the

infection risks.

Trendelenburg’s success is probably due to all of this. It is noteworthy that

in Germany antisepsis and, successively, the asepsis (von Bergmann, 1891) were

adopted much more rapidly than elsewhere.

Who Discovered Saphenous Vein Incontinence? xliii

Brodie also tells about Home: “Sir Edward Home recommended the appli-

cation of a ligature, where the veins of the leg were varicose, to the vena saphena

major. He performed this operation in a great number of cases, and in a few cases

he applied it to the vena saphena minor. When I was a student, nothing was more

common than to see a patient with varicose veins standing on a table, and leaning

over the back of a chair, for the purpose of undergoing the operation.” However,

this anecdote is referred mostly to underline the operation’s risks, according to

the repeated fatal outcome of patients of the same Home, caused by inflam-

mation: “There are indeed no circumstances here to justify the performance of

a dangerous operation” he wrote.

In conclusion, we can credit Home (1799) with the basic idea, Rima with

the comprehension of valvular incompetence with a cavo-iliac-femoro-saphe-

nous reflux and its practical application (1836), Brodie the description of the

clinical test (1846), and Trendelenburg the skill in scientific divulgation and

the diffuse therapeutic application (1890).

A nationalist vision of these primacies always inspired history writers.

Consequently, it is possible that on this subject some other author could raise a

compatriot contribution, and so on.

While waiting for further indications, we can clearly see how these dates

speak with evidence and allow an objective and possible universal vision.

Varicose vein treatment greatly improved but we still have not found the

definite solution. After the discovery of saphenous reflux as a cause of varices,

attention was directed for the most part to treatment of the saphenous vein, con-

sidering superficial varicose veins as the consequence rather than a cause of the

disease. Some surgeons did not treat them (they will disappear spontaneously),

others interrupted them by ligatures (big scars–big surgeons), others sent them

for post-operative sclerotherapy (big tour going on).

Results were ugly, patients accepted to be operated only when grossly

affected.

It became time to pay attention to the “periphery.” This led to the Mueller

procedure. Although the saphenous hemodynamics ought to be respected and

corrected (even if less “furiously” than before), varicose veins could be gently

and cosmetically treated, allowing simple cosmetic treatment. The latest

advance is in duplex ultrasound. This has changed craftsmanship into a science.

BIBLIOGRAPHY

Belloni L. Simposi Clinici CIBA- Vol 5, N.4,1968.: Valvole venose e flusso centrifugo del

sangue.

Benjamin Brodie. Lectures illustrative of various Subjects in Pathology and Surgery: On

Varicose Veins and Ulcers of the Legs. London: Longmans, 1846:157.

xliv Who Discovered Saphenous Vein Incontinence?

Rima T. Sulla causa prossima delle varici alle estremita inferiori e sulla loro cura radicale-

Memoria letta all’ateneo di Venezia 1836. Giornale per servire ai progressi della

Patologia e della Materia Medica. Appendice.fasc XIV pag 1–36; 1836.

Rose. Historical development of varicose vein surgery. Page 128–129 In: Bergan JJ,

Goldman MP. Varicose veins and telangectasias. Diagnosis and treatment. S. Louis,

Missoury: QMP, 1993.

Rutkow IM. Surgery: An Illustrated History. St. Louis, Missoury: Mosby Year Book,

1993.

Thelwall Thomas W. Operative treatment of varicose veins of the lower extremity by liga-

ture and division of the internal saphena vein at the saphenous opening—Liverpool

Medico-Chirurgical Journal 1896; 16:278.

Trendelenburg F. Ueber die Unterbindung der Vena saphena magna bei unterschenkelvar-

icen)—Beitrage zur klinischen Chirurgie 1890; 7:195.

Who Discovered Saphenous Vein Incontinence? xlv

Part I: General Considerations

1

Definition and Indications

“Ambulatory phlebectomy” (AP) is the term given by R. Muller to his technique

of ambulatory varicose vein avulsion through multiple stab incisions (0.5–4 mm

in length), under local anesthesia. These do not require skin sutures and are

followed by hemostatic compression and immediate ambulation.

INDICATIONS

Varicose veins of any size—except telangiectasia—and at any site—except for

the proximal end of the great saphenous vein (GSV) and its junction with the

common femoral vein (sapheno femoral junction, SFJ)—can be removed by

AP. These include small reticular (dermal) varicosities, subcutaneous extrafascial

varicose collaterals, and deeply situated superficial truncal varicose veins that lie

anterior to the aponeurotic fascia or are covered by a layer of the latter, the super-

ficial fascia, like the GSV and the small saphenous vein (SSV).

The technique of AP is particularly efficacious in several cases that are

difficult to treat by traditional surgical techniques:

1. varicose veins on the dorsal foot;

2. varicose side branches of the GSV and the SSV in limbs with compe-

tent saphenous trunks;

3. patients in early stages of varicose vein disease with isolated or short-

segment varicose veins;

4. patients with widespread varicosities;

5. lower leg hemorrhagic varicose “blebs”;

6. varicose veins residual or recurrent after traditional surgical

operations;

7. varicose veins recanalized after one or more sclerosing treatments or

thrombophlebitis;

8. varicose veins in lipodermatosclerotic areas;

9. dilated veins on other parts of the body; that is, abdominal wall, dorsal

hand, and face.

3

The incompetent SFJ can be ligated and divided or treated with endoluminal

radiofrequency or laser closure under local anesthesia in the office, so that prac-

tically all types of varicose veins can be treated in an office setting. The only

exceptions are some types of recurrent varicose cavernoma in the groin (second-

ary to SFJ ligation or to thrombotic occlusion of the GSV), which consist of many

small and thin-walled vessels and the muscular (gastrocnemius) calf veins that

are inaccessible under local anesthesia.

Telangiectasia cannot be directly avulsed by AP. Nevertheless, areas of

dense telangiectatic “flares” fed by a larger incompetent superficial or perforating

vein benefit from the avulsion of the latter. Telangiectasia can also be partially

destroyed (“scraped out”). However, sclerotherapy is necessary for the elimin-

ation of residual telangiectasia.

Despite the potential for wide application, AP is employed in different

ways and to different extent by different physicians. Therefore, its indications

depend on the surgeon’s experience. We employ it for the removal of all varicose

veins except for the SFJ and telangiectasia.

4 Ricci, Georgiev, and Goldman

2

Anatomical Bases of AmbulatoryPhlebectomy

The anatomic description of veins as taught in medical school is not useful in

everyday practice. This chapter describes the veins of the lower limb in a

method useful to those who practice phlebology.

Veins of the lower limb can be divided into three types: superficial, deep,

and perforating (crossing the aponeurotic fascia to connect the superficial to the

deep) according to their location relative to the deep (aponeurotic) fascia.

The vein’s most characteristic features are its valves, described in

1574–1603 by Hieronimus Fabritius d’Acquapendente in Padua. The valves

direct blood flow to the heart from superficial to deep veins and prevent reflux

of blood in the opposite direction. A varicose vein is a dilat0ed superficial vein

that has lost its valvular function in which blood flow is bi-directional. Normally,

.90% of the limb’s blood flow is carried by the deep veins. This fact, as well as

the large total capacity of the venous system, permits safe removal of diseased

superficial veins.

In this chapter, venous anatomy is described with special reference to the

superficial venous system. The description is related to varicose vein disease

and ultrasound vein imaging with reference to varicose vein surgery and the tech-

nique of stab avulsion phlebectomy.

GENERAL ORGANIZATION OF THE SUPERFICIALVENOUS SYSTEM

Unlike deep veins that accompany and are named after their matching arteries,

superficial veins do not usually have accompanying arteries, but are organized

in a series of subcutaneous channels that drain into two major and deeper super-

ficial veins: the great saphenous vein (GSV) (Fig. 2.1) and the small saphenous

vein (SSV) (Fig. 2.2) (1). These two larger vessels empty into deep veins

5

through the saphenofemoral junction (SFJ) in the groin, and the saphenopopliteal

junction (SPJ) in the popliteal fossa, respectively. In addition to these two “clas-

sical” junctions, superficial veins bypass the SFJ and drain into the iliac and caval

veins via numerous anastomotic branches of the abdominal wall and the puden-

dal, perineal, and gluteal areas through abdominal and pelvic anastomoses. These

branches are a potential source of “extrafemoral” reflux, which may fill the

incompetent GSV and other varicose veins even when the SFJ is competent

[Fig. 2.4(b) and (c)].

In addition to the aforementioned junctions and pelvic/abdominal anasto-

moses, superficial veins anastomize with deep veins through more than 140

perforating veins (PVs) distributed along the entire length of the limb (2). The

GSV, SSV, their constant (named) tributaries, and major perforators are illus-

trated in Figs. 2.1 and 2.2. However, this classical description is not sufficient

and may be even misleading for clinical practice because of the following ana-

tomical and clinical considerations.

1. The subcutaneous space in which all superficial veins run is divided by

a fascia, called superficial or membranous, in two layers or

Figure 2.1 The great saphenous vein system. AA,

abdominal and suprapubic anastomoses; PA, pelvic

(pudendal and gluteal) anastomoses; F, femoral

vein; SFJ, saphenofemoral junction; ALV, antero-

lateral thigh vein; PMV, posteromedial thigh vein;

GSV, great saphenous vein; ACV, anterior crural

vein; PAV, posterior arch (Leonardo) vein; P, per-

forating veins (from below): the (three) Cockett’s

perforators; the 24 cm perforator; Boyd’s perforator;

above-knee perforator; Dodd’s perforator(s).


compartments: deep and superficial. Accordingly, the superficial veins

are arranged in two layers, deep and superficial, which are divided by

the superficial fascia (3).

2. The two major collectors (GSV and SSV) lie into the deep compart-

ment of the subcutaneous space and are covered by the superficial

fascia, whereas all other superficial veins (tributaries or collaterals of

the saphenous) run subcutaneously into the superficial compartment.

Thus the superficial fascia, which is barely mentioned in standard text-

books, is a marker for distinguishing the two levels of superficial veins.

3. The distinction between the two levels of superficial veins is of clinical

and surgical significance. Subcutaneous collaterals can be mapped for

operation by means of clinical examination alone, and are easily

avulsed by ambulatory phlebectomy (AP). Deeper superficial trunks

that run into the intrafascial compartments can be examined and

mapped adequately only with the help of ultrasound (duplex)

Figure 2.2 The small saphenous vein. P,

popliteal vein; SPJ, saphenopopliteal junc-

tion; SSV, small saphenous vein; MC,

mid-calf perforating vein; PV, perforating

vein.

Figure 2.3 Transfer (cross-over) of

reflux between the varicose segments of

two different veins. Only the proximal

portion of the GSV is incompetent; reflux

is deviated distally to the varicose SSV

via the incompetent Giacomini vein

(GIA), intersaphenous thigh anastomosis.

Anatomical Bases of AP 7

imaging. They are difficult to avulse by AP, and may be treated by

alternative techniques as axial stripping or endovascular obliteration.

4. Superficial venous anatomy should be considered in statistical terms,

because all superficial veins have variants. In many cases, the vari-

ations are more frequent than the rule (3). Even the saphenous veins,

which are anatomically better defined, are present in many variants.

They may be present at different depths, often have double segments

(i.e., more than one vein is found where one expects a single

channel), and their junctions may vary in site (SPJ) and anatomy

(SFJ and SPJ).

5. This anatomical variability corresponds to a clinical one, which is even

more variable. This is because of superficial collateral veins (CVs)

being involved in varicose disease more often than saphenous veins.

Despite the opinion that varicose veins constitute a “saphenous”

system disease, they are not. In a series of 279 limbs with PVVs, 56%

proved to be collaterals. The latter were present in 84% of the limbs

and were the only varicose veins in .25% of the limbs (Tables 2.1

and 2.2) (4). Similar findings have been reported by others (6).

Figure 2.4 Origin of reflux in the varicose GSV trunk. (a) Reflux originates from the

incompetent SFJ. (b) Reflux originates from the incompetent SFJ and from incompetent

collaterals, pelvic (PA), and/or abdominal wall anastomoses. (c) Collateral (pelvic/PA

and/or abdominal/AA) reflux only, with competent SFJ. (d) Reflux originates from

incompetent thigh (Dodd’s) PV while the proximal GSV portion is competent.


Therefore, varicosis is a polymorphic disease. It is difficult to find two

limbs with identical varicose veins.

6. Usually only a portion, not the entire length, of an anatomical vein

becomes varicose (Table 2.4). Sometimes, there is cross-over reflux

from the varicose portion of one vein to another vein via connecting

(anastomotic) collateral varicose veins (CVVs) (Fig. 2.3). Therefore,

operations based on standard anatomy consisting of total (“anatom-

ical”) removal of a single vein, that is, GSV or SSV stripping, are

often inadequate—they remove competent (healthy) portions of

some veins, while leaving other varicose veins untreated.

7. The main anatomical saphenous junctions (SFJ and SPJ), which are

classical anatomical and surgical reference points, are not necessarily

involved in varicose vein disease. In many cases, the most proximal

deep to superficial reflux point (“escape” or “leak” point) may be a

Table 2.1 Number and Type of Different Varicose Veins

No. of veins Percentage of total

Saphenous trunks (GSV and SSV) 187 44

Named collaterals (ALVþ PMVþACVþ PAV) 88 21

Unnamed collaterals 149 35

Total 424 100

Note: 49% of the limbs had varicose veins of one type only and 51% had a combination of more than

one type.

Table 2.2 Varicose Vein Distribution in 279 Limbs

Type of varicose vein No. of limbs Percentage of all limbs

GSV 162 58

GSV alone 34 12

SSV 25 9

SSV alone 10 4

Named collaterals (total) 88 32

ALV (thigh) 21 8

PMV (thigh) 14 5

ACV (leg) 32 11

PAV (leg) 21 8

Unnamed (atypical) varicosities (total) 149 53

Atypical varicosities alone 71 25

Single collaterals 72 26

Diffuse networks 77 28

Note: 49% of the limbs had only one type varicose veins and 51% had a combination of more than

one type.


CV or PV different from the main (anatomical) saphenous junctions,

which may be competent [Fig. 2.4(a–d)]. In two series of 509 limbs

with PVVs, the SFJ was competent in 38% of cases (29% and 46%,

respectively) (Tables 2.3 and 2.4) (4,5). Therefore, SFJ or SPJ ligation

should not be performed for anatomical reasons alone; that is, assum-

ing that if the veins that drain into these junctions are varicose, then the

main junctions must also be incompetent. In one series, out of 218

reflux points in the groin, 151 (69%) corresponded to the SFJ, 39

(18%) to pelvic anastomoses, and 28 (13%) to abdominal or antero-

lateral collaterals of the SFJ. The most proximal reflux point was a

Table 2.3 Number and Level of Proximal Reflux Points

Number Percentage of total

Groin reflux points (total) 218 64

SJF reflux 151 45

Pudendal (pelvic) reflux 39 11

Anterolateral or abdominal collateral

of the SFJ (limbs with competent GSV)

28 8

Thigh perforators 55 16

Knee perforator (total) 57 17

SPJ or popliteal perforator 37 11

Other knee perforators 20 6

Below knee perforators 9 3

Total 339 100

Note: For each varicose vein (reflux pathway), only the most proximal reflux (leak) point(s) were

determined. Incompetent perforators distal to the latter were not considered.

Table 2.4 Extension of Reflux in the Varicose GSV: 162 Limbs

No. of limbs Percentage of all limbs

Most proximal reflux level

Groin 139 86

SJF alone 129/139 ¼ 93%

SFJþ collateral

(pelvic and/or abdominal reflux)

10/139 ¼ 7%

Thigh 18 11

Knee or below 5 3

Distal extension of reflux

Malleolus (total reflux) 72 45

Mid-calf 49 30

Above or below knee 41 25


thigh perforator in 20% of the limbs, knee perforator (including the

SPJ) in 20%, and leg perforator in 3%, with the SFJ incompetent in

54% of the limbs (Table 2.3) (4).

For these reasons, examining, planning treatment, and operating on varicose

veins must emphasize the specific varicose pattern of the individual case.

Great Saphenous Vein Compartment

On the medial aspect of the lower limb, the superficial and deep (aponeurotic)

fasciae form a space called “GSV compartment,” in which lie the GSV and the

anterior accessory saphenous vein (ASV) described in this section (Fig. 2.5 of

the compartment with the two veins) (7).

Great Saphenous Vein

The GSV begins anterior to the medial malleolus and ascends along the medial

aspect of the tibia and thigh to empty into the common femoral vein (CFV) in

the groin. [The junction of the GSV with the CFV (SFJ) is described in detail in

Chapter 15]. The average diameter of a normal GSV is 3.5–4.5 mm (range 1–

7 mm) (8). The GSV usually has a thick wall that permits it to be used as an

arterial bypass conduit. It lies deep to the superficial (membranous) fascia,

sometimes so deep as to lie adjacent to the aponeurotic (deep or fibrous)

fascia. Other times it can be so superficial as to resemble a CV. On contrast

venogram and ultrasound scans, in 10% of cases, the GSV may appear as a

Figure 2.5 The GSV lies into the interfascial space (saphenous

compartment) enclosed between the leaves of the superficial fascia

and the deep (aponeurotic) fascia. The entire length of the GSV is

in the compartment. In over 40% of cases, in the upper thigh,

lateral to the GSV, there is a second vein in the compartment called

anterior ASV.


totally double (sometimes even triple) vessel, and in 52% a combination of

single and double segments (9). In fact, in its middle third, the GSV is almost

always accompanied by two parallel CVs of smaller caliber. These veins run

anterior and posterior to the GSV and give rise to different clinical varicose

vein patterns (10), some of which are illustrated in Fig. 2.6. However, while

the main GSV trunk lies into the saphenous compartment, these parallel CVs

lie subcutaneously. Identification and precise marking of these variants prior

to surgery is important if precise and thorough varicose vein removal is to be

obtained. If the surgeon is unaware of the existence of two distinct parallel

veins, the classical endoluminal stripping is likely to remove only one (some-

times even the competent) channel.

In the lower leg and at the knee, the GSV is embedded in a compact

(fibrous) subcutaneous tissue, which may make its retrieval, hooking, and exter-

iorizing difficult. In the thigh, the GSV is often so deep that its hooking through

stab incision may be difficult. For the removal of that portion of the GSV, an

extraluminal stripper may be necessary (see Chapter 15).

The GSV is involved in varicose disease in about 60% of cases (58% and

64% in two series of total 509 limbs), but is the only site of varicose changes in

12% of the limbs (Table 2.2) (4,5).

Figure 2.6 Varicose patterns of a double GSV. (a) Double varicose GSV. (b) Bayonet

type varicosities developed from the posterior accessory saphenous vein (PAS), with com-

petent distal GSV portion. (Redrawn from Dortu J.) (10). (c) Double incompetent GSV

marked for stripping.


Often only a portion of the GSV is dilated and incompetent (Fig. 2.3;

Table 2.4). In about 50% of cases, only the proximal portion of the GSV is

incompetent (44%, 46%, 51%, and 55% in four different series of total 849

limbs) (4,5,9,10), so that its total stripping is often unnecessary (Table 2.4).

In 79% of cases, the varicose GSV is accompanied by CVVs (4). In these

cases, the largest varicose veins often develop from the CVs and not from the

GSV trunk (Fig. 2.7). Therefore, GSV ligation and stripping should be carefully

evaluated case by case, keeping in mind that it is not infrequent to find reflux in

normal-looking GSVs in healthy, asymptomatic legs.

Ultrasound identification of the GSV: The GSV is identified and distin-

guished from parallel running collaterals by its position in the saphenous com-

partment, under the superficial fascia. This position gives rise, on a transverse

scan, to specific ultrasound “identification signs.”

The “eye” sign. In the thigh, the saphenous compartment appears as an

“Egyptian eye,” in which the saphenous lumen is the iris, the superficial fascia

the superior eyelid, and the aponeurotic fascia the inferior eyelid (Fig. 2.8 of

eye) (11).

Figure 2.7 Errors in varicose

vein diagnosis: CVV mistaken for

GSV. (a) An independent CVV,

which runs parallel to a competent

GSV and is drained by the latter,

is erroneously diagnosed as an

incompetent GSV. This may lead

to stripping of a competent GSV.

(b) The situation after GSV strip-

ping. The CVV has lost its main

drainage channel and distends

further to become larger than

before surgery. The condition is

often described by the patient as

“worse after surgery.”


The tibia–gastrocnemius sign. Below the knee the fascial sheets are often

so close to each other that the interfascial compartment may be difficult to recog-

nize. In these cases, the GSV is distinguished from other closely running veins by

its position in the angle formed by the tibia and the medial gastrocnemius muscle

(Fig. 2.9 of sign) (12). This sign allows one to demonstrate, when the angle is

empty, that in some cases in this area the GSV is absent or hypoplastic.

Anterior accessory saphenous vein: In the proximal third of the GSV

compartment there is often a second vein, called “anterior accessory saphenous”

Figure 2.8 (a) Transverse scan of the GSV in the thigh. The GSV lies into the interfasial

(saphenous) compartment and appears as the iris of an “eye,” which has the superficial

fascia as its upper eyelid and the aponeurotic fascia as its inferior eyelid. (b) Longitudinal

scan of the saphenous compartment; note that the superficial fascia often has more than

one distinct layers.

Figure 2.9 Transverse scan of the medial aspect of the leg just below the knee. The GSV

(the round spot in the square) lies in a triangle formed by the medial head of the

gastrocnemius muscle (GCM), tibia (T), and the laminae of the superficial fascia.


(ASV), which runs lateral to the GSV (3). The ASV is recognized and distin-

guished from the GSV by its alignment with the deep (femoral) vessels on a trans-

verse ultrasound scan (“alignment sign,” Fig. 2.10) (13). Sometimes, beside its

alignment with the deep vessels, the ASV has its own eye (Fig. 2.11).

In 41% of cases, both GSV and ASV are present in the proximal portion of

the interfascial compartment. In these cases, the diameter of the ASV is inferior

Figure 2.10 Transverse scan of the upper thigh, showing the relationships between the

GSV (1), ASV (2), femoral artery (3), and femoral vein (4). Note that the ASV is aligned

with the axial femoral vessels (artery and vein).

Figure 2.11 Transverse scan of the upper thigh. Sometimes the superficial fascia divides

the saphenous compartment so that both GSV (left) and ASV (right) have their own “eye”.


to that of the GSV (2.4 vs. 4.0 mm). Proximally the ASV joins the GSV close to

the SFJ and only rarely (3%) terminates directly into the femoral vein. The

average length of the ASV from its proximal junction is 16 cm (7–30), then

the vein pierces the superficial fascia to continue distally as a subcutaneous col-

lateral(s) in anterolateral (72%) or medial/anterior (11%) direction, or divides in

more scattered subcutaneous branches (11%). In 6% of cases, the ASV does not

leave the interfascial compartment, but joins distally the main GSV trunk (3).

The ultrasound markers of GSV identification allow to distinguish several

patterns of relationship between the GSV and its side branching collaterals

(3,12,14). These patterns and their prevalence as determined in a series of 610

consecutive limbs with and without varicose veins are as follows (Fig. 2.12 with

patterns) (15).

Type A: Full size GSV trunk, present in all its length in the saphenous com-

partment, with no large subcutaneous side branches. This pattern is

found in 52% of cases. When such GSV becomes incompetent, it may

give rise to what Tibbs (16) calls “concealed” or “straight through”

form of incompetence, when the diseased GSV is not visible and

barely palpable because of its subfascial position.

Type B: The GSV trunk is double for a certain length, with both branches

lying into the saphenous compartment. This is the rare case (1%) of truly

double GSV.

Type C: The GSV trunk is present in all its length, but there is also a large

(or even larger) subcutaneous collateral. This is the second most

Figure 2.12 Ultrasound markers of GSV identification. (a) Type A, (b) Type B,

(c) Type C, (d) Type D, and (e) Type E.


common pattern and accounts for 26% of cases. In varicose limbs with

this pattern, often only the proximal portion of the GSV is incompetent,

while distally the reflux is deviated along the subcutaneous side

branch(es). This is probably the most common varicose vein pattern

and is one reason for limiting the GSV stripping to the proximal part

of the GSV only (short or groin-to-knee stripping).

Type D: In the proximal portion of the saphenous compartment, there are

two veins instead of one: the GSV and the ASV. This occurs in 41% of

the limbs; large subcutaneous side branches may or may not be present,

as in types A or C, respectively. This pattern is of clinical importance, as

the ASV is often (14%) involved in varicose vein disease. Failure to

recognize this prior to surgery may lead to removal of a normal GSV,

while leaving in place the incompetent ASV.

Type E: Single full size GSV is present only in the proximal part of the

saphenous compartment. At a certain point, the GSV pierces the

superficial fascia to continue downwards outside the compartment as a

subcutaneous collateral, while distal to this point the GSV itself is

barely visible or absent (hypoplastic). This pattern was found in 16%

of cases. In some of these cases only an intermediate segment of the

GSV is missing, whereas the proximal (thigh) and distal (lower leg)

portions are present.

Small Saphenous Vein

The SSV begins behind the lateral malleolus and ascends up the posterior aspect

of calf to empty into the popliteal vein in the popliteal fossa. Like the GSV it is

rather thick-walled (average diameter of 3.1 mm) (19), and is also embedded into

an interfascial compartment. On a transverse ultrasound scan, the interfascial

SSV compartment is typically of a triangular shape and is delimited by the

medial and lateral heads of the gastrocnemius muscle and the superficial fascia

that stretches over the intermuscular groove (Fig. 2.13) (3). This allows for

prompt identification of the SSV and its distinction from parallel running subcu-

taneous collaterals (Fig. 2.14).

Despite this interfascial position, the varicose SSV can be avulsed by stab

phlebectomy, which is described in Chapter 13.

Whereas the distal portion of the SSV has many collaterals and anasto-

moses with the superficial and deep veins of the leg, the proximal (transfascial)

portion is usually a single vessel without important collaterals (12). In most cases,

the SSV joins the popliteal vein at the SPJ, which corresponds typically to the

space between the popliteal crease (which corresponds to the knee joint) and

the proximal 5 cm. In 26% of cases, the SSV merges with the gastrocnemius

vein before joining the popliteal vein (Fig. 2.15) (20).

Thigh extension of the SSV: In about 50% of cases, the SSV extends

proximally into the thigh. In one-third of these cases, the SPJ is also present,


whereas in the remaining two-thirds of cases the SSV extends proximally into the

thigh without having connection to the popliteal vein. The SSV may connect to

the GSV in the thigh via an oblique anastomotic vein (Giacomini vein), or may

continue proximal under the superficial fascia of the thigh as a “femoropopliteal

Figure 2.14 A CV of the SSV is shown on longitudinal scan to pierce the fascia covering

the saphenous compartment and become subcutaneous. GCV running parallel but deeper

to the SSV and the saphenous compartment.

Figure 2.13 Transverse scan of the posterior aspect of the upper calf. The SSV is situ-

ated in the groove between the medial (M) and lateral (L) heads of the gastrocnemius

muscle, in a compartment formed by a duplication of the deep (aponeurotic) fascia. The

laminae of the superficial fascia are also evident between the saphenous compartment

and the skin.


vein” to join deep veins at variable locations up to the groin, or divide into many

muscular branches of the thigh (Fig. 2.16) (21–24). The thigh anastomosis

between the GSV and the SSV is of particular clinical interest, as it may transfer

reflux from the incompetent GSV into the SSV and its varicose collaterals.

Figure 2.16 Proximal termination of the SSV. L, low termin-

ation (below the knee joint, 2%); SPJ, standard termination (saphe-

nopopliteal junction) within 5–6 cm proximal from the knee joint;

in 42% of cases, this is the only termination. In addition, or in sub-

stitution of the latter, the SSV may continue up into the thigh and

terminate as follows: into the Giacomini vein (GIA, intersaphenous

thigh anastomosis), in 12% of cases, half of these have also a stan-

dard SPJ; into the femoropopliteal vein (FP, posterior subcutaneous

thigh vein), in 44% of cases; the FP vein may end into a thigh per-

forator (TPV, “high SSV termination”), 4%, or split in two or more

branches that may reach the gluteal area (GA, gluteal anasto-

moses), 40%; one-third of the latter have also a standard SPJ.

(Figures from HM Hoffman and J Staubesand.) (21).

Figure 2.15 In 26% of cases, the SSV merges with a GCV before joining the PV. PA,

popliteal artery.


The SSV is involved in varicose disease in about 15% of cases (7.4%, 9%,

15%, 20%, 21% in five different series of total 2142 limbs with PVVs

(4,5,9,10,13). When the SSV is varicose, dilatation and incompetence is

limited in 46% of cases to its proximal portion (42% and 50% in two series of

total 269 limbs) (7,13). In many cases, the varicose side branches of the SSV ana-

stomize with the GSV and its collaterals [Fig. 2.4(b) and (c)]. These collaterals

are often diagnosed erroneously as GSV disease, as the SSV incompetence

may be difficult to diagnose with a clinical examination alone, because of the sub-

fascial position of the vein.

Collateral Veins and Varicosities

As mentioned earlier, the superficial venous system is built of a network of

subcutaneous channels called “collateral” (i.e., nonsaphenous) veins. Some of

the CV are rather constant side branches of the GSV and have names

(Fig. 2.1), but most are unnamed. The individual variability of the CV networks

is so great that their detailed anatomical description is impossible. A separate dis-

cussion of the CV is, however, of great practical importance, because it is from

them that most varicosities develop. So-called “recurrent” (after stripping)

varicose veins are usually CVVs. On the other hand, in many cases, CVV

avulsion—with or without high ligation of the GSV, but without stripping the

latter—may give better results than GSV stripping alone (14).

The understanding of CV anatomy and their involvement in varicose

disease—topics largely ignored in the past—was stimulated and became possible

by the practice of AP and Doppler ultrasound (8).

The superficial CV network consists of many longitudinally and obliquely

oriented long channels (“drainage” veins), which are richly interconnected by

shorter transverse (“anastomotic”) veins (Fig. 2.17). In normal conditions the

caliber of the CV is very small, but when varicose, they may dilate to even a

few centimeters. The CV are subcutaneous and therefore, easier to avulse

through stab incisions than the saphenous trunks. They are also thin-walled,

and it is therefore often possible to avulse a CVV 5–7 mm in diameter

through a 1 mm stab incision. Exteriorization of the often thick-walled saphenous

trunks of similar caliber requires larger incisions.

The CVs drain into deep veins, not only via saphenous veins, but also inde-

pendently via numerous (.100) PVs that are distributed along the entire length

of the lower limb. Proximally they also drain via anastomotic veins of the

abdominal wall and perineal and gluteal areas. Therefore, CVVs develop either

in combination with saphenous vein incompetence or independently, that is, in

limbs with competent saphenous veins.

Autonomous Collateral Varicosities

This term is used here to describe CVVs that develop in limbs with competent

saphenous veins (and thus are functionally or hemodynamically “autonomous”

or “independent”). The independence of many CVV from the GSV is confirmed


by surgical experience. It is often possible, with the stripper passed into the GSV

and kept in situ, to avulse the varices without encountering the stripper (14).

Autonomous CVV may be filled from incompetent perforating, abdominal

or pelvic veins, while the main saphenous junctions (SFJ and SPJ) remain

competent [Fig. 2.18(a) and (b)]. Alternatively, the origin of reflux may be the

SFJ or SPJ (of which the CVV is a branch), while distal the saphenous trunk

remains competent [Fig. 2.18(c)].

Though more superficial than saphenous trunks, CVV may be confused

with the latter when they descend along the course of the saphenous veins. In

these cases, duplex scan will readily distinguish between the two, showing the

saphenous vein in its interfascial compartment and the CV in the subcutaneous

space outside the saphenous compartment. This is important, because in such

cases high ligation and stripping of the normal GSV or SSV is not necessary.

(Of course, it is not uncommon that both the saphenous trunk—single or

double—and the CVV parallel to it be incompetent, in which case both are

removed.) Finally, the CVV may be autonomous even in the presence of saphe-

nous vein incompetence, if there is no (or negligible) transfer of reflux between

the two systems.

Figure 2.17 General organization of the superficial collateral

(nonsaphenous) veins. L, longitudinal (drainage) veins. A, trans-

verse (anastomotic) veins.


Combined Collateral and Saphenous Varicosities

This is the most common varicose pattern that is present in .50% of cases

(Table 2.1–2.2). According to the anatomic position and functional role of the

CV segment involved, there are several possible combinations between collateral

and truncal (saphenous) varicosities. These combinations give rise to specific

clinical varicose vein patterns, which are described separately.

The most frequent combination is that of partial (proximal) or total GSV

dilatation and incompetence with one or more distal varicose side branches

(Fig. 2.19). The latter usually originate from the area of Boyd’s PV below the

medial knee, but may arise at any point along the GSV.

Figure 2.18 Origin of reflux in CVV. (a) Reflux from groin anastomoses with competent

SFJ. PA, pelvic anastomoses. (b) Reflux from incompetent thigh perforator (TPV).

(c) Reflux originates from an incompetent SFJ and continues along the varicose anterolat-

eral thigh vein (ALV), while the GSV is competent. (d,e) Large collateral bilateral vari-

cose veins with pelvic reflux via pudendal anastomoses and competent SFJs and GSVs.

(f) Large anterolateral varicosities with competent GSV.


Sometimes, the CVV may lie proximally to the incompetent portion of the

GSV (or SSV); in these cases, the proximal reflux point may be either a combi-

nation of incompetent main junctions (SFJ/SPJ) plus collateral reflux or collat-

eral reflux only with competent SFJ or SPJ (Fig. 2.20). In the latter scenario,

high ligation of the GSV/SSV may not be necessary.

Another possible combination is for the CVV to bypass a competent

middle saphenous vein segment and transmit reflux between proximal and

distal incompetent segments (Fig. 2.21). A particular combination is that of a

Figure 2.18 Continued.


varicose collateral transferring reflux from the proximal varicose segment of one

vein to a distal varicose segment of another vein; a typical example is that of a

varicose Giacomini vein transferring reflux from the proximal GSV to the SSV

[Figs. 2.3 and 2.35(b)]. Recognition and mapping of these clinical variants

permits precise surgery, which spares normally functioning superficial veins.

Perforating Veins

PVs connect superficial to deep veins crossing (“perforating”) the aponeurotic

fascia. They have valves that direct flow from the superficial to the deep veins

[exceptions are the PV of the foot, most of which are valveless and some of

which permit reverse (deep to superficial) one-way flow].

More than 150 PVs have been described, 60% of which accompany

an artery (2). Most PVs are tiny, long vessels with an oblique course terminating

in muscular branches (“indirect” PV), some are shorter and almost perpen-

dicular (“direct” PV); this latter group are fairly constant and named

(Figs. 2.1 and 2.2). PVs are not regularly distributed along the limb’s surface,

but increase in density from proximal to distal in a 1:2:8 proportion between

Figure 2.19 Common type of advanced varicose vein disease

of the GSV system. In most cases, varicose veins present as

combination of GSV incompetence and CVVs.


thigh, leg, and foot. Thus, .30% of all perforators are in foot, despite its small

surface area (27).

Normally, flow through the PV is minimal, given their small caliber and the

extreme abundance of venous anastomoses. Attempts to ascribe a major role to

some PV in pathologic conditions have been attempted, but in the varicose

limb incompetent PV rarely enlarge. Their caliber usually remains smaller than

that of varicose superficial veins.

When incompetent, a PV permits flow from deep to superficial veins

termed escape or leak points. The most proximal leak point of a varicose vein

is rather easy to detect with Doppler ultrasound, but the detection of all leak

points is difficult, time-consuming, and unreliable. Detection is improved with

duplex imaging and further enhanced with venography/varicography.

While determining the most proximal leak point of a varicose vein is

important (because the latter should be avulsed as close as possible to it)

Figure 2.20 Varicose veins with collateral origin of reflux. (a) Combined (collateral and

truncal) varicose veins with partial (distal) truncal involvement and competent main junc-

tion. CVV, collateral varicose veins; GSV, great saphenous vein. (b) Clinical presentation.


(Tables 2.3 and 2.4), the importance of all other (distal) leak points is probably

overestimated, at least when the limb has competent deep veins. In these

conditions, during ambulation, flow in any incompetent lower leg perforator is

directed mainly inward so that the latter (called also “re-entry perforator”)

drains retrograde saphenous flow into the competent deep veins, where flow

becomes physiologic (upward) (Fig. 2.22) (27,28). While about 45% of limbs

with PVVs have multiple incompetent perforators, these are hemodynamically

and clinically significant only when there is concomitant deep vein incompetence

(17). When deep veins are competent and saphenous vein incompetence co-exists

with lower leg perforator incompetence, the former appears to be of major

pathological significance, because proximal occlusion of the saphenous trunk

normalizes the pathological high ambulatory pressure in the perforator (16–

18). Furthermore, the pathologic significance of an incompetent PV cannot be

considered out of context to varicose vein disease. When outward flow of an

incompetent PV reaches a competent superficial vein, it becomes physiologic

Figure 2.22 Flow in perforating veins.

At the end of the incompetent GSV portion,

retrograde flow becomes physiologic (in-

and upward) as it reaches the competent

deep veins via a re-entry perforator (PV);

even when the latter is incompetent, flow

in it is mainly inward during ambulation

(15,16).

Figure 2.21 Combined (collateral and

truncal) varicose veins with partial truncal

involvement. Reflux originates at the

incompetent SFJ and bypasses a competent

GSV portion via CVV.


(Fig. 2.23). In other words, deep and/or superficial valvular incompetence must

be present for outward perforator flow to become clinically important (27). In

fact, with foot perforators, physiologic outward flow does not induce varicose

veins. On the contrary, when outward perforator flow reaches an incompetent

varicose vein, it causes high pressure in the latter and ultimately distends it.

Here, avulsion of the varicose vein automatically disconnects the incompetent

PV (26,28).

TOPOGRAPHIC DESCRIPTION

The extension of a varicose vein is determined both by clinical examination and

by extension of its reflux. The most proximal reflux (escape) point is usually an

incompetent PV or main junction (SFJ or SPJ). Sometimes, a varicose vein may

originate from a competent superficial vein and have no real escape point from

the deep venous system. At the end of an incompetent superficial segment,

flow becomes physiologic as blood reaches either a deep vein through a

re-entry perforator or a competent superficial vein (Fig. 2.23).

Anatomically, every superficial vein has many proximal anastomoses with

both the superficial and deep veins. Thus, the total number of superficial and per-

forating veins is very high. Because any of these superficial veins may become

varicose, the number of possible (different) varicose vein patterns is large. In

clinical practice, however, what matters is not the detailed description of all

anatomical anastomoses, but the identification of those which are incompetent.

In other words, it is the reflux pathway—the origin and propagation of

reflux—that is of clinical interest.

While superficial reflux is easy to trace with Doppler ultrasound, the exact

origin of reflux from deep veins and the exact involvement of the veins lying into

the intrafascial saphenous compartments (GSV, SSV, ASV, thigh extension of

the SSV) may be difficult to determine unless a duplex scan or a venogram is per-

formed. In this section, we describe the most common types of varicose veins that

may develop in different areas of the lower limb and the possible origin and

propagation of their reflux.

Upper Thigh

Varicose veins in the upper thigh are usually located on the medial and anterior

aspect (4). The GSV terminates in this area and its proximal branches (up to 12

collaterals) of the SFJ have been described (Fig. 2.24). The anatomy of the SFJ is

described in detail in Chapter 15. The varicose GSV may be dilated as to bulge at

its termination in the groin. In 41% of limbs, there is a second vein in the intra-

fascial saphenous compartment, the ASV. CV in this area form a complex

network. Some are longitudinal channels that run along the thigh either parallel

to the GSV and ASV or divergent from these, along the posterior, medial,

anterior, and lateral aspects of thigh; others are transverse anastomotic channels,


which connect longitudinal veins. These CVs anastomize freely with each other

and proximally with veins of the abdominal wall and pelvis. Thus, reflux into the

GSV, ASV, and CV may originate from the incompetent SFJ and/or incompetent

extrafemoral (pelvic or abdominal) anastomoses [Fig. 2.4(b) and (c)]. In a series

of 279 limbs with PVV, SFJ incompetence was found in 151 limbs (54%), puden-

dal reflux in 39 limbs (14%), and abdominal or collateral of the SFJ reflux in 28

Figure 2.24 Superficial vein topography:

upper and medial thigh. SA, suprapubic

anastomoses; AA, abdominal wall anasto-

moses; PA, pelvic anastomoses (pudendal

and gluteal veins); ALV, anterolateral thigh

vein; PMV, posteromedial thigh vein; SC,

subcutaneous saphenous collateral veins;

GIA, Giacomini vein (intersaphenous thigh

anastomosis); GSV, great saphenous vein;

P, perforating veins; DP, Dodd’s perfora-

tor(s). (Redrawn from Dortu J.) (10).

Figure 2.23 Flow in perforating veins.

When outward flow in an incompetent per-

forator (PV) reaches a competent super-

ficial vein (PAV), it is drained upward,

that is, becomes physiologic. For outward

flow to become clinically important, deep

and/or superficial axial incompetence is

also necessary. DV, deep vein.


(10%) (5). Duplex scan of this area is mandatory if one is to distinguish between

GSV and ASV incompetence.

When varicose, many groin collaterals become visible and palpable. Here,

careful Doppler examination with a superficial, narrow-focused high frequency

(8–10 mHz) probe allows one to determine exact reflux patterns to separate

incompetent and competent branches.

CVV of the groin are not rare in PVV and are common finding in women

with pelvic (ovarian) varices. They are regularly found in cases of chronic post-

thrombotic occlusion of the common femoral and external iliac veins, where they

function as a natural bypass of the obstructed deep veins and drain limb blood

flow into the caval veins via extrafemoral (pelvic and abdominal) anastomoses.

They are also commonly found in recurrent (post-stripping) varicose veins; in

a series of 78 limbs with recurrent varicose veins, extrafemoral (pelvic or

abdominal) reflux was found in 53 limbs (68%). (Georgiev M. et al., unpublished

data.)

Medial Thigh

The medial thigh is crossed by the GSV and longitudinal, oblique, and transverse

(anastomotic) CVs (Fig. 2.24). Most varicose veins of the thigh develop in this

area, which is, therefore, of great practical interest for the phlebologist.

The thigh portion of the GSV is covered by the superficial fascia, which is

usually deep and may even lie adjacent to the deep fascia. It has two constant per-

forators: the mid-thigh perforator in Hunter’s canal and the above-knee perfora-

tor(s) [Dodd’s perforator(s)] (Fig. 2.1). Sometimes, the GSV may course inward

or outward lying at different depths in different segments of the thigh. Therefore,

it is often difficult to follow in its entire length with palpation and percussion

alone, even when dilated and incompetent. Often only a saccular dilatation

(usually at the site of Dodd’s PV) is palpable. For these reasons, determining

the presence—and especially the course and extent—of reflux in the GSV may

be difficult and unreliable with clinical examination alone and must be confirmed

by Doppler or duplex ultrasound.

Sometimes, the GSV may be very superficial and thus easy to examine

clinically. However, a superficial varicose vein should not be assumed automati-

cally to be the GSV, as there are often one or two parallel veins that run anterior

and posterior to the GSV, while the main GSV trunk lies deep to them under the

superficial fascia (10). One or more of these collateral channels may be involved

in the varicose disease. Sometimes, only the proximal portion of the main GSV

trunk is incompetent and reflux is then deviated along one of the subcutaneous

CVs, which are varicose. This specific and quite common varicose pattern is

termed a “bayonet” type varicosity [Fig. 2.6(b)] (10). In this case, the distal (com-

petent) portion of the GSV (below the cross-over of reflux into the bayonet) need

not be stripped. These variants are evident during GSV stripping with the external

stripper, but are often missed (bypassed) by internal strippers, which can only


pass through one of the multiple channels, usually the most direct one, but not

necessarily the varicose one. The aforementioned varicose variants are some-

times difficult to assess in detail by clinical and Doppler examination alone,

but their diagnosis is easy with duplex scan.

Reflux in the varicose GSV may originate in the groin, from an incompe-

tent SFJ and/or extrafemoral (pelvic/abdominal) anastomose (86%), or from a

mid-thigh (Dodd’s) perforator (11%) in one series (Table 2.4) [Figs. 2.4(a–d),

2.20] (5).

CVV in the medial thigh may be branches of the varicose GSV or ASV

[Figs. 2.6(b), 2.19, 2.21] or independent (autonomous) [Fig. 2.17(a) and (b)].

Reflux in them may originate from the incompetent SFJ or pelvic/abdominal

anastomoses [Fig. 2.16(a)], or from incompetent thigh perforator(s) (saphenous

or not) [Fig. 2.16(b)]. Sometimes, CVV appear as localized clusters, but usually

extend beyond the medial thigh to continue along the medial aspect of knee, and

leg or the anterior/posterior aspect of thigh, knee, and leg, in which case they trans-

fer reflux to varicose veins in the respective areas or to the SSV (Fig. 2.3).

Posterior Thigh

The CVs of the posterior thigh have perforators that connect to the deep femoral

vein, and also have anastomoses to the GSV. The latter has a constant side branch

in this area, the posteromedial thigh vein (PMV), which was varicose in 5% of the

limbs in one series (Table 2.2) (5). The PMV often continues distally as a Giaco-

mini vein, or thigh intersaphenous anastomosis, to join the SSV in the popliteal

fossa. Reflux in posterior thigh CVV originates from the incompetent SFJ, from

an incompetent thigh perforator, or from incompetent pudendal/gluteal anasto-

mosis. The posterior thigh CVV may extend to the leg, empty into the SSV in

the popliteal fossa, or transfer reflux from an incompetent GSV to an incompetent

SSV or vice versa (varicose Giacomini vein) (Fig. 2.25). A particular varicose

pattern is present when varicose veins of the posterior thigh are filled by

upward reflux from the incompetent SPJ (Fig. 2.26) (41).

Lateral Thigh

The most common varicose vein on the lateral aspect of thigh is the lateral sub-

dermal plexus (reticular vein), which accompanies venous telangiectasias of the

lateral thigh and leg. The lateral subdermic venous system consists of veins that

are the size of reticular veins, 2–4 mm in diameter, which course just beneath the

dermis. They transverse the lateral thigh and calf, often having complex com-

munications at the lateral knee. This system may become varicose alone or in

association with other larger varicose veins. Independent dilatation of this

system occurs through incompetent PVs that connect the lateral venous system

directly to the deep femoral or popliteal veins (31,32). It is proposed that

reflux through these lateral knee perforator veins into the lateral venous system

accounts for the vast majority of painful telangiectatic groups on the lateral


Figure 2.25 (a) Superficial vein topography: posterior thigh. GA, gluteal anastomoses;

PMV, posteromedial thigh vein; GIA, Giacomini vein (intersaphenous thigh anastomosis);

L, lateral subdermal plexus (reticular) vein; P, perforating veins; FP, femoropopliteal vein

(posterior subcutaneous thigh vein), which may terminate into posterior perforator (P) or

split in two or more thigh/gluteal branches (GA); GSV, great saphenous vein. (b) Clinical

appearance. (c) Duplex scan of incompetent posterolateral thigh perforator causing back

flow from the deep femoral vein into the posterolateral varicose veins. P, perforating

vein; PL, posterolateral varicose vein.


half of the thigh and upper calf (33). Larger varicosities in this area are usually

branches of the varicose anterolateral thigh vein (discussed later) (Fig. 2.27).

Anterior Thigh

Varicose veins of the anterior thigh develop mostly from the branches of the

incompetent ASV, and also from the GSV (Figs. 2.1 and 2.5 see if adequate).

Reflux in them may originate from an incompetent SFJ, veins of the abdominal

wall, an incompetent anterior thigh perforator situated at any level along the

thigh, or a combination of these. A grossly dilated ASV may originate from an

incompetent SFJ, whereas the GSV remains normal and competent (Fig. 2.28).

The ASV was found varicose in 8% and 14% of the limbs in two series

(Table 2.2) (3,5).

Knee

The knee area is characterized by an extremely rich superficial anastomotic

collateral venous network and by the presence of many PVs. In addition, the

GSV passes along its medial aspect and the SSV terminates (or transits) in the

popliteal fossa.

Medial Knee

At knee level, the GSV is almost constantly accompanied by two superficial and

parallel CVs that run anterior and posterior to it (10). The main GSV channel is

deeper, embedded in a compact subcutaneous tissue and covered by the

Figure 2.26 (a) Varicose veins of the posterior thigh filled by a “paradoxical” upward

reflux, which originates at the saphenopopliteal junction and proceeds upward along the

thigh extention of the SSV. (b) Longitudinal scan showing the dilated thigh extension

of the SSV (FPV) transmitting reflux to the thigh varicose veins. PV, popliteal vein.


superficial fascia. This makes its retrieval often difficult. At the upper end of the

knee there is a constant perforator that connects the GSV to the superficial

femoral vein. Many varicose collaterals transit here or originate from the knee

portion of the GSV or from an incompetent knee perforator (Fig. 2.29).

Anterior and Lateral Knee

This area contains longitudinally, obliquely, and transversely oriented superficial

veins that form a rich network. Varicose veins in this area may be branches of the

incompetent GSV, CVVs of the thigh, or may have local origin from an incom-

petent knee perforator (Fig. 2.30). The skin (especially over the patella) is thick

and the subcutaneous tissues rather compact and fibrous, so that phlebectomy

may be time-consuming. Infiltration anesthesia in the area just anterior to the

head of fibula may reach the peroneal motor nerve and cause “drop-foot” for

the duration of anesthesia (Fig. 2.30).

Figure 2.27 Superficial vein topo-

graphy: lateral thigh. L, lateral subdermal

(reticular) plexus; ALV, anterolateral

thigh vein.


anterior thigh. AA, abdominal wall anasto-

moses; SA, suprapubic anastomoses; ASV,

anterior accessory saphenous vein; ALV,

anterolateral thigh vein; A, anastomotic

veins; GSV, great saphenous vein; SC,

subcutaneous saphenous collateral veins;

P, perforating veins.


Popliteal Area

Deep anatomy of the popliteal fossa is complex. The popliteal artery and vein(s),

the short saphenous vein, the muscular (gastrocnemius and soleus) arteries and

veins, additional (up to eight) popliteal PVs, and collaterals of the aforemen-

tioned vessels plus nonvascular structures, like tendons, motor and sensory

nerves, are all clustered in relatively little space. However, the description of

veins in the popliteal area with reference to their involvement in varicose vein

disease and the technique of stab avulsion phlebectomy is much simpler.

The SSF usually joins the popliteal vein in the segment that extends from

the knee joint proximally for �5 cm. (The skin projection of the knee joint cor-

responds to the popliteal crease.) The termination of the SSV may differ from this

standard type in up to 50% of cases (21). In some cases, it terminates above or just

below this segment. In about one-third of cases, the SSV and the gastrocnemius

vein merge just before the SPJ. In addition to its junction with the popliteal vein


medial knee and leg. GSV, great saphenous

vein; SC, subcutaneous saphenous collat-

eral veins; AK, anterior knee anastomoses;

PK, posterior knee anastomoses; BPV,

Boyd’s perforating vein; ACV, anterior

crural vein; PAV, posterior arch (Leonardo)

vein; CPV, Cockett’s perforating veins.


anterior knee. AK, anterior knee anasto-

moses; SC, subcutaneous saphenous collat-

eral veins; GSV, great saphenous vein;

CPN, common peroneal nerve; DPN, deep

peroneal nerve; SPN, superficial peroneal

nerve.


(SPJ), the SSV may continue up the thigh as femoropopliteal vein, or may join the

GSV via the Giacomini vein (Fig. 2.7). The varicose SSV can usually be palpated

in the popliteal area over the point where it courses anteriorly to approximate the

popliteal vein (for more detail see Chapter 13).

Dodd popliteal area vein is close to the SSV, but superficial and lateral to it.

It may originate from a proper incompetent popliteal perforator (which often

presents as a very large sacciform vein), or may share the SPJ with the SSV

(Fig. 2.31) (34,35).

CVVs different from the popliteal area vein may also develop in the

popliteal area. They may be side branches of the SSV, originate from the GSV

or other varicose thigh collaterals, or an incompetent popliteal perforator (up

to eight popliteal perforating veins have been described).

As points of origin of varicose veins (most proximal leak points), SPJ or

popliteal perforator incompetence was found in 13% of limbs, and other (nonpo-

pliteal) knee perforator incompetence in 7% of limbs in one series (Table 2.3) (4).

Veins that terminate in the popliteal fossa (especially the SSV and the

popliteal area vein) may lie in close proximity to the sural (sensory) nerve and

its branches, so that attention must be paid during phlebectomy to avoid nerve

damage. For this reason, we prefer to use Graefe forceps instead of hooks in this

area. The skin over the popliteal area is soft and delicate; careless manipulation

may lacerate it, causing unsightly scars.

Figure 2.31 Superficial vein topography: popliteal area. FP,

femoropopliteal vein (thigh extension of the SSV); G, Giacomini

vein (intersaphenous thigh anastomosis); P, popliteal vein; GSV,

great saphenous vein; SPJ, saphenopopliteal junction; PA, popli-

teal area vein (Dodd) (collateral channel of posterior leg with

proper popliteal perforator; sometimes joins the SPJ); A, intersa-

phenous leg anastomosis; M, muscular (gastrocnemius) calf

veins; S, small saphenous vein.


Medial Leg

The medial aspect of leg is the most important area in phlebology, because most

varicose veins and most stasis changes occur in this area. It is crossed by the

GSV, by the posterior arch vein (PAV), by many other collateral and perforating

veins, few of which are direct (Figs. 2.1 and 2.29).

The GSV begins anterior to the medial malleolus where it is usually visible

and palpable. It runs along the medial aspect of tibia and is covered with a layer of

the superficial fascia. For this reason, its palpation is difficult and its avulsion by

stab phlebectomy time-consuming. (A readily visible varicose vein in this area is

usually not the GSV, but a superficial CV.) The saphenous (sensory) nerve lies

close to the GSV. Care must be taken not to damage it when manipulating the

GSV trunk. Fortunately, the lower leg portion of the GSV is rarely incompetent

and varicose and its stripping is seldom necessary.

In the upper end of the medial leg, the GSV is connected to the deep (pos-

terior tibial) vein by a constant (Boyd’s) PV. The area of this perforator is an

important superficial venous “crossroad” (Fig. 2.29); many GSV side branches

depart from this area and are better illustrated in separate groups.

1. Anterior group. Anterior collaterals are the anastomotic veins of the

anterior knee and the anterior accessory leg vein (discussed later).

2. Superior group. Superior collaterals may be double or triple subcu-

taneous collaterals, parallel to the GSV trunk or anastomoses with

thigh CVs.

3. Posterior group. This consists of anastomotic channels with the SSV

and CVs of the popliteal area and posterior leg.

4. Inferior group. Inferior collaterals may be double or triple subcu-

taneous collaterals, parallel to the GSV, superficial medial collaterals,

anastomotic channels with the SSV, CVs of the posterior and anterior

leg, and the PAV.

The only named CV of the medial leg, the “posterior arch” or Leonardo vein

(PAV), lies posterior and almost parallel to the GSV. It is recognized by its

subcutaneous position outside the interfascial saphenous compartment, and its

connection to the posterior tibial vein by four direct, constant PVs: the (three)

Cockett perforators plus the 24 cm perforator (Figs. 2.1 and 2.28). In one

series of 279 limbs with PVV, the PAV was varicose in 8% of the limbs (13%

if only the limbs with incompetent GSV are considered) (5).

There are many unnamed superficial veins on the medial aspect of leg; it is

not rare to find, especially in advanced cases of varicose vein disease, four or

even more separate varicose veins in this area. Most often the leg portion of

the GSV is competent and the varicose veins are collaterals that are conveniently

removed by stab phlebectomy.

Reflux in the varicose veins of the medial aspect of leg may originate from

the incompetent proximal GSV, from the incompetent proximal portion of the


SSV, from incompetent thigh, knee, or leg perforator(s) or a combination of

these. Therefore, the presence of varicose veins on the proximal aspect of leg

does not automatically imply proximal GSV incompetence. The medial leg

varicose veins often transfer reflux between the GSV and SSV.

Anterior Leg

A constant branch of the GSV, the anterior crural vein (ACV) crosses the tibia

obliquely from the dorsal foot to the area of Boyd’s perforator, and may

become very large when varicose. It was varicose in 11% of cases in one series

(20% if only the limbs with incompetent GSV are considered) (5). Few additional

collaterals are often found over the tibia. These often lie close to sensory nerves

and lymphatics that may be damaged during the operation. As the subcutaneous

tissues over the tibia are thin, veins in this area may be visible—and considered

unsightly by the patient—even when competent and not varicose. Varicose

veins in this area are usually branches of the incompetent GSV, but may also orig-

inate from incompetent tibial perforators (Figs. 2.4 and 2.32).

Lateral Leg

Varicose veins of the lateral leg may be branches of the anterolateral thigh vein,

lateral thigh vein (lateral subdermal plexus), SSV, GSV, or popliteal area vein,

but may also originate from an incompetent local (lateral or paraperoneal) PV.

The skin in this area is thick and the subcutaneous tissues compact. The veins

may be embedded in the membranous fascia and their avulsion, therefore,

time-consuming (Fig. 2.33).

Posterior Leg

There are two types of veins on the posterior aspect of the leg: the SSV and CVs.

The SSV begins behind the lateral malleolus and ascends the posterior

aspect of the leg to join the popliteal vein in the popliteal fossa. The SSV is

covered by the superficial fascia for its entire length. Near the level between the

lower and medial third of the leg it perforates the deep fascia and lies in a compart-

ment formed by a duplication of the deep (aponeurotic) fascia. For this reason,

prior to hooking and exteriorizing the proximal part of the SSV, it is necessary

to perforate and dissect the aponeurotic fascia. The distal part of the SSV,

though superficial to the deep fascia, may be embedded in compact fibrous

tissue, which makes its avulsion time-consuming. The sural (sensory) nerve lies

close to the SSV, especially in its distal portion; occasionally vein and nerve lie

so close to each other that it may be difficult or even impossible to separate

them without damaging the nerve (40). Fortunately, as with the GSV, in most

cases only the proximal portion of the SSV is incompetent and dilated, so that

its total avulsion is seldom necessary (17,25).


The SSV is connected to the deep veins by a few large and direct PVs,

which are illustrated in Figs. 2.2 and 2.7. There is sometimes a varicose vein

on the posterior aspect of the leg, which lies superficial to the SSV and may be

confused with it. This vein is extrafascial and usually lateral to the SSV and

has a proper popliteal perforator; it has been called by Dodd popliteal area

vein (34). It may co-exist with SSV incompetence and may even share a

common popliteal junction with the SSV, but most often is independent and

may develop in legs with competent SSV.

Most of the collaterals on the posterior aspect of leg are short (transverse or

oblique) anastomotic branches that connect the SSV with the GSV and its

branches (intersaphenic anastomoses) or with other lateral and medial leg

veins (Fig. 2.34).

Reflux in the SSV and varicose veins on the posterior aspect of leg may

have different origins and may be difficult to trace by clinical and Doppler

examination, because it may run along the subfascial portion of the SSV

(difficult to palpate) or along some of the deep (muscular) veins of the calf


lateral leg. ALV, anterolateral thigh vein; L,

lateral subdermal plexus vein; A, transverse

(anastomotic) collateral veins; PP, paraper-

oneal perforating veins; SSV, small saphe-

nous vein; R, retromalleolar collaterals.


anterior leg. AK, anterior knee anasto-

moses; BPV, Boyd’s perforating vein;

ACV, anterior crural vein(s); GSV, great

saphenous vein.


(difficult to distinguish from the SSV) [Fig. 2.35(a–e)]. Reflux may originate

from:

1. Incompetent SPJ and/or popliteal perforator(s) [Fig. 2.35(a)];

2. Incompetent superficial veins of the thigh: GSV via the Giacomini vein

or veins of the posterior aspect of thigh (femoropopliteal vein) [Figs.

2.3, 2.35(b) and (c)] (21);

3. Incompetent superficial leg veins: GSV, PAV via transverse (anasto-

motic) collaterals [Fig. 2.35(d)];

4. Incompetent posterior leg perforators: These originate not only from

the axial (tibial posterior) deep leg veins, but also from the muscular

(gastrocnemius and soleus) veins of the calf. These veins have an

oblique course. Proximally they join the popliteal vein close to the

SPJ (and may even share the latter with the SSV). Distally they join

the SSV and/or the collateral superficial veins via the soleus and gas-

trocnemius perforators [Fig. 2.35(e)]. Because the muscular veins lie

deep and almost parallel to the SSV, they are not palpable and difficult

to identify by Doppler examination. Reflux in them is difficult to loca-

lize and differentiate from popliteal (deep) or SSV reflux, unless a

duplex scan or a venogram is performed. While venogram gives an

excellent general view of the region, duplex scan has the advantage

of permitting a repeatable visualization and determination of the direc-

tion of flow in each of these vessels.

Figure 2.34 Superficial vein topography: posterior leg. S,

small saphenous vein; M, muscular (gastrocnemius) calf

veins; PA, popliteal area vein (posterior subcutaneous leg

vein); A, intersaphenous leg anastomoses; MC, mid-calf (gas-

trocnemius point) perforating vein; P, posterior leg perforators;

BP, Bassi’s perforator; R, retromalleolar SSV collaterals.


There is some controversy regarding the role muscular calf veins may play in var-

icose disease. According to some authors, dilatation of these veins is most often

an aging phenomenon (4). Others argue that these veins are often responsible for

the development of varicose veins on the posterior aspect of leg and for the

impairment of calf muscle pump function (35). In our experience, isolated gastro-

cnemius or soleus vein incompetence is rare, often of post-thrombotic origin, and

may feed varicose veins to the medial and lower third of the leg. Muscular calf

veins cannot be avulsed by stab phlebectomy; if necessary, they must be

excised according to one of the available specific techniques (24,25).

Foot

Superficial veins of the foot can be divided into two types: the dorsal venous arch

and the CVs [Fig. 2.36(a) and (b)]. A peculiar characteristic of foot veins is

the great abundance of perforators and venous anastomoses. Approximately

one-third of all perforators are located in foot. In the resulting rich network, all

veins freely communicate with each other, thereby allowing safe removal of

any varicose foot vein.

The dorsal venous arch is formed by continuations of the GSV and SSV and

is covered by the superficial fascia (Fig. 2.37). It is thick-walled and rarely

enlarges to become grossly varicose. It is connected to the deep (plantar) veins

by thick-walled perimalleolar and transmetatarsal perforators. Avulsion of the

dorsal venous arch is rarely indicated.

Figure 2.35 Origin of reflux in the varicose short saphenous vein. (Modified from J Van

der Stricht. Varicographie et Phlebographie dynamique, Lettre chirurgicale, 1991;

103:13.) Reflux in the varicose SSV (S) may originate from: (a) incompetent SPJ (standard

type SSV); (b) incompetent GSV via the Giacomini vein (G); (c) posterior thigh perforator

(high termination) or posterior subcutaneous thigh veins via the femoropopliteal vein

(F, posterior subcutaneous thigh vein); (d) incompetent GSV or medial leg perforator(s)

via intersaphenous leg anastomoses (A); (e) incompetent muscular (gastrocnemius) calf

vein(s) (M), and also from an incompetent posterior leg perforator (data not shown).

P, popliteal vein.


The dorsal foot CVs are a continuation of collateral leg veins, thin-walled

and lie subcutaneously, outside the superficial fascia. They form a network that

has many perforators and anastomoses with the dorsal venous arch and with

the most distal portion of the GSV and its anterior leg collaterals. In the lateral

retromalleolar fossa there are many collaterals of the SSV; these often become

varicose when the distal portion of the SSV is incompetent (Fig. 2.33).

Figure 2.36 Superficial vein topography: the foot. (a) Medial foot. GSV, great saphenous

vein; PAV, posterior arch vein; C, collateral veins of dorsal foot; D, dorsal venous arch.

(b) Lateral foot. SSV, small saphenous vein; ACV, anterior crural vein; R, retromalleolar

collaterals of the SSV; C, collateral veins of dorsal foot; D, dorsal venous arch.

Figure 2.37 Transverse scan of the foot portion of the GSV. A fascial (superficial fascia)

layer separates the GSV (left) from the subcutaneous collateral veins also at foot level.


The CVs on the dorsal foot may enlarge and become grossly varicose; most of the

varicose veins of the foot develop in fact from the CVs.

On the dorsal foot there is only a thin layer of subcutaneous tissue; thus,

veins, sensory nerves, and even tendons lie very close to each other. For this

reason, phlebectomy in this area is difficult and time-consuming, because great

care must be taken not to damage nerves (or even tendons).

DEEP VEINS OF THE LOWER LIMB

Deep veins accompany corresponding arteries under the deep fascia and normally

drain .90% of the limb’s blood flow. Thus, they are the major transport vessels

of the leg and their permanent (usually post-thrombotic) damage—chronic

obstruction of valvular incompetence (deep venous insufficiency, DVI)—

causes impairment of calf pump function. (Other types of deep venous pathology

are congenital aplasia and extrinsic compression syndromes, which are beyond

the scope of this text.)

There are many deep venous channels in the leg (usually two for each artery),

and at least two major deep channels in the thigh, the superficial and the deep

femoral veins. Short segment damage of one of these veins can therefore be compen-

sated by the remaining collateral (deep) veins, and consequently lead to only mod-

erate clinical symptoms. On the contrary, in the popliteal fossa and in the groin, deep

blood flow passes through a single vessel: the popliteal vein (which is often double)

and the CFV; therefore, damage to these veins (especially if extensive) causes severe

impairment of venous pump function, with the classic symptoms of acute deep

venous thrombosis and its chronic sequalae—the post-thrombotic syndrome.

Some limbs may tolerate considerable impairment of venous pump func-

tion and develop relatively few (and mild) symptoms, but most will ultimately

develop classic post-thrombotic syndrome with chronic edema, dermatitis, pig-

mentation, lipodermatosclerosis, and cutaneous ulceration. For most of these

patients, lifelong compression is the only treatment available. However, it is

important that patients with suspected deep venous pathology undergo a thorough

investigation, because a small percentage of them may benefit from the available

techniques of reconstructive deep vein surgery. They may also benefit from cor-

rection of co-existent superficial venous insufficiency (38).

DVI may co-exist with varicose veins and may also play a role in their

development. Patients with mixed deep and superficial venous insufficiency

benefit from varicose vein avulsion (17,27). Therefore, varicose veins are

avulsed regardless of the presence of DVI. Exceptions are the dilated but compe-

tent superficial veins in limbs with DVI. Deep venous thrombosis may cause

enlargement of some superficial veins that may become varicose in appearance,

but nevertheless remain competent. Such normally functioning superficial veins

are easily identified by Doppler ultrasound and should not be avulsed.

Though DVI does not influence the decision to operate on varicose veins, it

is important for long-term prognosis. Patients with DVI must be told that their


deep vein pathology makes varicose vein recurrence (and, more important, the

development of stasis changes) more likely, so that lifelong compression

therapy is mandatory (see Appendix A).

NERVES AND LYMPHATICS

Cutaneous (sensory) nerves and lymphatic vessels lie in close relationship

with superficial veins. Consequently, sensory nerve damage, lymphocele,

Figure 2.38 Venous leg telangiectasia. (a) Telangiectasia along the course of an incom-

petent GSV. These telangiectasia are usually spider (star) shaped and may be the only

symptom of GSV incompetence. (b) Different types of telangiectasia. C, cart-wheel telan-

giectasia of lateral thigh; L, lateral subdermal plexus (reticular) vein; I, isolated telangiec-

tasia (not related to larger vein incompetence); S, spider (star) shaped telangiectasia with

superficial (F) or perforating (P) feeding vein; B, bleb type (large blue telangiectasia,

which may rupture causing hemorrhage). Except for the isolated type, all other types of

telangiectasia may benefit from phlebectomy of the feeding veins.


lymphorrhea and, more rarely, lymphedema are potential complications of vari-

cose vein surgery (4). Lymphatic damage is most likely to occur in the Boyd per-

forator area below the medial aspect of knee and the area along the anterior aspect

of tibia (39).

Sensory nerves lie close to dorsal foot veins, along the distal portion of the

GSV and especially along the distal part (sometimes the entire length) of the

SSV, and it is in these areas that nerve damage most frequently occurs.

SURGICAL ANATOMY OF VENOUS LEG TELANGIECTASIA

Leg telangiectasia measure 0.1–1.0 mm in diameter. They may appear at any site

of the lower limb and are best treated by sclerotherapy. Some of these tiny vessels

are isolated, that is, not directly connected to an incompetent larger vein, others—

especially those which appear as a dense telangiectatic network—may be

connected to an incompetent vein, filling with retrograde flow appropriately

Figure 2.39 Telangiectatic flare of lower leg in 23-year-old patient. The flare is filled

by retrograde flow into the GSV, which is incompetent from its junction with the

femoral vein in the groin to the enlarged perforator situated in the middle of the flare.

Despite being incompetent, this GSV is not visible or palpable and measures only

3–3.5 mm in diameter all along its course, so that the only “symptom” of GSV incompe-

tence is the telangiectatic flare.


called a “feeding” vein. It is this second type of telangiectasia that is of surgical

interest, because the avulsion of feeding veins by stab phlebectomy usually

attenuates the telangiectasia (which may disappear completely) facilitating

sclerotherapy of the remaining vessels. Personally, we consider this “cosmetic

frontier” of stab phlebectomy most rewarding, because the use of a hypodermic

needle or blood lancet (for the incisions) and a 0.1 mm pointed (n.1) Muller hook

(for vein hooking and exteriorizing), permits avulsion of the feeding veins with

scars that become virtually invisible after a few weeks.

Occasionally, a telangiectatic flare may be “fed” directly by an incompetent

saphenous trunk, and may be the only symptom of saphenous trunk incompetence

[Fig. 2.38(a)]. However, the feeding vein is usually of small (1–3 mm diameter)

caliber [Fig. 2.38(b)].

The feeding vein may be visible (when superficial) and its reflux is easily

detected by an 8–10 mHz Doppler probe. However, it may also be deep and per-

pendicular to the skin surface (i.e., tiny perforator) and thus impossible to see or

palpate. In such case, it is usually still possible to detect a reflux point by Doppler

ultrasound (Fig. 2.39).

There is not always such a clear relationship between telangiectatic and

reticular (feeding) veins. Common types of telangiectasia are those of cart-

wheel or radiating pattern on the lateral thigh [Fig. 2.38(b)]. The relationship

between this type of telangiectasia and the larger (reticular) vein is ambiguous.

In the upright position, flow may be downward; that is, from the telangiectasia

to the reticular vein, which thus behaves as a drainage and not feeding vein. In

the recumbent position, on the contrary, flow in the reticular vein is upward

and the latter becomes a feeding vein. Confirmation of this “ambiguity” is the

observation that it is often possible, in these cases, to obtain excellent and

long-lasting results by sclerotherapy of the telangiectasia alone, while leaving

the reticular vein untreated.

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24:433–440.

APPENDIX A: ATLAS OF VARICOSE VEIN PATTERNS

PATTERNS OF SAPHENOUS VEIN INVOLVEMENT INVARICOSE VEIN DISEASE

Varicose veins develop from subcutaneous saphenous collaterals. Because of

their superficial position, they are visible and easily marked for operation by

clinical examination alone. On the contrary, the interfascial superficial veins

lay in the saphenous compartments and are covered by the superficial fascia.

They are not visible and may not be palpable even when dilated and incompetent,

but can be thoroughly visualized and marked precisely under ultrasound (duplex)

guidance. These interfascial veins include the GSV, the anterior ASV, the SSV

and its thigh extension, and the thigh intersaphenous anastomosis (Giacomini’s

vein) (Fig. A1).

When the interfascial veins are incompetent and transmit reflux to the var-

icose veins, best functional and cosmetic results are obtained when both the var-

icose veins and incompetent segments of the saphenous truncs are removed.

Traditionally, this was done by total stripping of the GSV or SSV. Later on

short groin to knee stripping of the GSV became the standard treatment and,

more recently, “custom-made” stripping of only the incompetent segment has

been proposed. However, there are also surgeons who demonstrated that in

some patients, it is possible to avulse the subcutaneous varicose collateral


only, obtaining satisfactory results. This approach spares the saphenous veins and

is often called “conservative” varicose vein surgery. Its rationale is the fact that it

is not rare to find incompetent but small calibre saphenous truncs in people

without varicose veins and without signs or symptoms of venous insufficiency.

“Conservative” surgery is performed basically for two reasons. The first

one is to obtain same functional and cosmetic results with a minimal surgery.

The second is to preserve veins that may serve as an arterial bypass conduit.

What are the criteria for sparing the incompetent saphenous truncs? In the

Figure A1. GSV, great saphenous vein; ASV,

anterior accessory saphenous vein; GIA, Giaco-

mini vein; SSV, small saphenous vein; TE, thigh

extention of the SSV.

Figure A2. Primary varicose vein circles are typically composed of a

proximal deep-to-superficial leak (reflux) point, retrograde flow

pathway, and distal (perforator) re-entry point. The source of proximal

reflux could be a main saphenous junction (J), a large named perforator

(D, Dodd’s perforator), or small perforators and collaterals (A, abdomi-

nal collaterals; P, pelvic collaterals). Downward flow may involve the

saphenous truncs (S) and/or subcutaneous varicose collaterals (V).

Downward flow may re-enter into the deep veins through perforators

connecting the saphenous truncs with the deep veins (B, Boyd’s perfora-

tor), or perforators connecting the subcutaneous varicose collaterals to

the deep veins (G, gastrocnemius perforator; C, Cockett’s perforators).


Figure A3. Varicose veins have no direct connection with the deep

veins, but have their both endings (proximal reflux point and distal

re-entry point) connected only to the saphenous trunc.

Figure A4. Anatomic types of the GSV with respect to the compartment enclosed

between the superficial and deep (aponeurotic) fasciae. (a) “I” type: the GSV is present

as a main intrafascial trunc along its entire length. (b) “h” type: there is a subcutaneous

collateral, running parallel and superficial to the main saphenous trunc (left); the extrafas-

cial position of the collateral (ouside the intrafascial csaphenous compartment) is easily

appreciated on transverse ultrasound scan (right). (c) “S” type: a middle portion of the

GSV is “substituted” by a subcutaneous collateral, as shown in transverse ultrasound

scan (right), where there is not a clearly visible vein in the interfascial saphenous

compartment.


Figure A5. Varicose patterns of the different IhS anatomic types. (a) In the “I” type, the

incompetent saphenous trunc is usually not visible. (b) In the “S” type, the visible enlarged

straight vein in the thigh and knee region is the subcutaneous extrafascial vein. The “h”

type gives rise to two different varicose patterns: (c) only the superficial collateral is

involved, whereas the main intrafascial saphenous trunc is competent and (d) both the col-

lateral and the saphenous are incompetent. This last pattern is important to recognize,

otherwise one of the two veins may be missed at surgery.

Figure A6. Patterns of segmental GSV involvement. (a) The most common type, from

groin to below the knee; in such cases, the leg portion of the GSV may be competent

(left) or incompetent but very small (right). (b) Total GSV incompetence. (c) Groin-to-

midcalf incompetence. (d) Groin-to-above knee incompetence. (e) Groin-to-midthigh

incompetence. (f) Only short segment from the groin down (left), in which case, varicose

vein avulsion without ligation of the saphenofemoral junction may be sufficient and restore

practically normal pattern of physiologic upward flow (right). (g) Small caliber GSV with

a varicose cluster as the only clinical expression (left); avulsion of the varicose cluster

could be tried as first surgical approach (right). (h) Same as (g) but with the distal GSV

portion competent, before (right) and after (left) avulsion of the varicose vein only.

(i) GSV incompetence with competent terminal (saphenofemoral) valve and secondary

(collateral) proximal relfux source. ( j) Segmental GSV incompetence with the mid-

thigh (Dodd’s) perforator as most proximal reflux source.


absence of evidence-based criteria, we propose the following list of “common

sense” criteria:

1. small calibre saphenous veins;

2. segmental incompetence (with long segments competent);


3. veins that could be potential bypass conduits (without grossly dilated

or hypoplastic segments);

4. presence of a competent terminal (saphenofemoral) valve;

5. very slow retrograde filling of varicose veins during Trendelenburg test;

6. presence of a competent (iliofemoral) valve proximal to the sapheno-

femoral junction.

The earlier-listed criteria are, however, rather subjective and personal,

because no data are available to help predict the long-term fate of the spared

saphenous trunc.

The drawings in this atlas (section) illustrate some basic varicose vein

patterns involving the interfascial superficial veins.

Figure A7. ASV anatomy. (a) Absence of the ASV (48%). (b) Presence of both ASV and

GSV (41%). (c) Only one vein, in the position of the ASV, is present in the upper thigh,

with a large posterior collateral of the saphenofemoral junction. (d) Often the posterior

collateral joins directly the SSV as Giacomini’s thigh intersaphenous anastomosis.


Primary Varicose Veins Circuits

Primary varicose veins present reflux (downward flow) that typically starts from a

proximal deep-to-superficial leaking point(s) (incompetent major junction and/or

perforators), then proceeds along the incompetent saphenous and/or varicose

collaterals, and finally re-enters distally into the deep veins through one or

more re-entry points (distal or re-entry perforators) (Fig. A2), Varicose veins

may also exist without a proximal deep-to-superficial reflux and/or without a

re-entry perforator (Fig. A3), but such patterns are not considered in the

present section.

Patterns of GSV Involvement

Anatomical Arrangement of the GSV and Related Varicose Patterns

The GSV has three basic anatomic arrangements illustrated in Fig. A4: a full-

length main trunc (“I” type), main trunc plus one or more parallel subcutaneous

collaterals (“h” type), and main trunc absent in the middle third, with a sub-

cutaneous vein bypassing the missing segment (“S” type). These three types of

arrangements give rise to specific varicose patterns, which are illustrated

in Fig. A5.

Figure A8. Varicose patterns involving the ASV. (a) Anterior and lateral thigh and leg

varicose veins. (b) Medial varicose veins. (c) Only the ASV is incompetent (left); after avul-

sion of the ASV and the varicose collaterals, with preservation of the saphenofemoral

junction, a normally functioning GSV is preserved (right). (d) Incompetence of both ASV

and GSV.


Segmental GSV Involvement

According to the length of the incompetent GSV portion, there are different var-

icose vein patterns, illustrated in Fig. A6. The most common is with the GSV

incompetent from the groin to just below the knee, with the segment distal to

this point competent, or incompetent but very small [Fig. A6(a)]. The frequency

of this pattern is the rationale for changing the standard GSV treatment from full

length to short (groin to below the knee) stripping. If only the saphenofemoral

(terminal) valve is incompetent, the GSV may not be stripped at all, but only

the varicose collaterals avulsed [Fig. A6(f)]. Avulsin the varicose collateral

only may be considered also when the GSV is of very small calibre

[Fig. A6(g) and (h)].

Sometimes the terminal (saphenofemoral) valve is competent, and the

proximal reflux point is a secondary (pelvic and abdominal) source [Fig. A6(i)]

or a more distal incompetent saphenous perforator [Fig. A6(j)].

Patterns of ASV Involvement

The anatomical arrangements of the anterior ASV are shown in Fig. A7. In a per-

sonal series of 172 normal limbs, the ASV was present in 41% of cases, anterior

and parallel to the GSV [Fig. A7(b)]. In 48% of cases, there was no ASV

Figure A9. Varicose patterns involving the SSV. (a) Only the proximal portion of the

SSV is incompetent and dilated, while the distal portion is either competent (left) or

incompetent but of very small calibre (right). (b) Total SSV incompetence. (c) The thigh

extension of the SSV is present in�50% of cases and may transmit reflux from the gluteal

and muscular veins of the posterior thigh toward the SSV. (d) The thigh extension of the

SSV may transmit upward (“paradoxical”) reflux from the saphenopopliteal junction

toward varicose veins of the posterior thigh.


[Fig. A7(a)], and in 11%, there was only one vein in the upper thigh, but in the

position of the ASV instead of GSV. In this last arrangement, the GSV appears to

be missing, but there is often a large Giacomini vein joining in proximity of the

saphenofemoral junction [Fig. A7(c) and (d)].

The ASV may be involved several varicose vein patterns presented in

Fig. A8. The most common one is with varicose veins on the anterior and on the

lateral thigh and leg. Varicose veins along the course of the GSV are also quite

Figure A10. Varicose patterns involving both GSV and SSV via the intersaphenous

anastomoses. (a) Incompetent Giacomini vein transferring reflux from the GSV to the

SSV. (b) Competent Giacomini vein tranfering reflux from the saphenopopliteal junction

(left) to the GSV and the varicose collaterals (center); it is possible to avuls only the veins

with downward flow, restoring normal function to the Giacomini anastomosis (right).

(c) Leg intersaphenous anastomosis transferring reflux from the GSV to the SSV (left),

with a possible treatment the stripping of the incompetent GSV portion and avulsion of

the varicose collaterals, without interruption of the SSV (right). (d) Leg intersaphenous

anastomosis transferring reflux from the SSV to the GSV.


common. If only the ASV is incompetent and the GSV not, a rationale approach

would be to remove only the ASV and spare the GSV. Sometimes, both ASV

and GSV are incompetent. The nonawareness of all these possibilities may lead

to incomplete surgery or to the removal of the wrong (competent) vein only.

Patterns of SSV Involvement

Some typical varicose patterns involving the SSV and its thigh extension are

shown in Fig. A9.

Patterns Involving Both GSV and SSV

When both GSV and SSV are involved in varicose vein disease, one or more

thigh (Giacomini) or leg intersaphenous anastomotic veins are involved. The

most common of these patterns are presented in Fig. A10.


3

Examination of the Patient withVaricose Veins

Varicose veins are recognized and reported by patients themselves, but a detailed

diagnosis may require the employment of several clinical and laboratory investi-

gation techniques. This is important because a thorough diagnosis may include

not only the origin and extension of reflux in the varicose veins, but also infor-

mation regarding deep and perforating vein function, calf pump function, and

other pathologies, orthopedic, neurologic, cardiac, hepatic, dermatologic, and

so on, which may cause or enhance the symptoms and signs of venous

insufficiency.

The discussion of all aspects of venous diagnostics is beyond the scope of

this book. The examination of patients with varicose veins is described here with

reference to the technique of ambulatory phlebectomy and is therefore limited to

accurate varicose vein mapping necessary to formulate an adequate treatment

plan. This information is provided by clinical examination, Doppler ultrasound,

or duplex ultrasound.

CLINICAL EXAMINATION

Medical History

Directed medical history provides important information that is useful to diagno-

sis, further testing and treatment, and is also important for understanding the

patient’s expectations of treatment. If deep vein thrombosis (DVT) is suspected,

it must be ruled out or diagnosed and adequately treated before planning varicose

vein surgery.

Symptoms referred by the patient must be carefully evaluated. These may

be caused not only by varicose veins, but also by orthopedic or other disorders,

which must be explained to patients prior to their consent to surgery. Patients are

57

often concerned more with the discomfort attributed to the varicose veins than

with the varicose veins themselves. In a recent report of a series of 413 consecu-

tive patients treated for varicose veins with surgery and sclerotherapy, 4% were

not satisfied with the treatment because of persistence of symptoms that were

later diagnosed as lumbar spine pathology (1).

Previous treatments must also be discussed in detail. Veins recanalized

after sclerotherapy may be more difficult to evaluate because of irregular

caliber and wall thickness. “Recurrent” varicose veins after surgery are better

classified, if it is clear which veins have been surgically removed. Finally, the

patient’s general medical condition, diseases and medications are discussed, as

these may lead to changes in the treatment plan or contraindicate office surgery.

Physical Examination

Physical examination is the most important part of a patient’s evaluation, because

the decision if, when, and how to operate is primarily based on it. Observation

gives information about the type and distribution of varicose veins, the presence

and degree of stasis changes or superficial thrombophlebitis. In the presence of

stasis changes—edema, dermatitis, lipodermatosclerosis, and ulceration—

surgery is postponed until these heal under compression therapy.

Superficial (thrombo)phlebitis is a common finding in patients with vari-

cose veins and is often the event that brings the patient to the doctor. It should

be treated immediately with compression bandage or stocking and—in the

presence of large thrombi—with thrombectomy. In this case, varicose vein

surgery is performed as soon as possible. However, in some cases the opportunity

to remove the affected varicose segment may be difficult to evaluate for weeks or

months, when inflammation has subsided. A history of recurrent thrombophlebi-

tis anticipates difficult vein avulsion because of perivenous adherences.

The patient is next examined by palpation and percussion (Schwarz test).

Palpation is the most important clinical test and provides information not only

about the veins, but also about other limb structures. When standing, the type,

size, and consistency of the varicose veins is best appreciated. We therefore

request that patients stand when placed into the examination room. The longer

they are standing, the better. In addition, the examination room should not be

too cold as cold air can cause vasoconstriction. Venous trunks that do not

bulge and are missed by observation are more readily palpated. Veins in areas

with chronic edema or lipodermatosclerosis are difficult to evaluate by palpation

and must be re-examined after healing of edema under compression therapy.

Patients who wear elastic stockings (or bandages) should be examined after

10–15 min in a standing position without compression, so that the varicose

veins are fully distended.

In the supine position, palpation permits an appreciation of soft-tissue

consistency and fascial defects. Painful sites, which may be due to phlebitis,


lymphangitis, or inflammation of other leg structures ( joints, tendons, etc.), are

also evaluated by palpation. Posterior tibial and dorsal pedal arterial pulses

must be palpated and, if necessary, ankle blood pressure measured to rule out

occlusive arterial disease.

Percussion is the most sensible test and assists tracing the course of super-

ficial veins that are otherwise not visible or palpable. This test, however, is not

reliable in assessing valvular incompetence. Percussion (tapping) on a vein

with one hand causes blood displacement and vein wall movement, which pro-

duces an impulse that can be detected by the other hand at a variable distance

along the same vein or its branches.

Tapping in the standing patient—especially on a weight-bearing limb—

may be difficult to interpret. This is especially true for obese patients and

for veins with thick and rigid walls, which, at maximum filling, may not

expand further with tapping. These are usually veins recanalized after throm-

bophlebitis or sclerotherapy. Tapping may also cause limb movement, which

makes the impulse perception difficult. In our experience, performing the per-

cussion test with the patient in a semisitting position enhances the performance

of the test and permits tracing veins that are otherwise not detectable in the

standing position. For this purpose, the patients lean with their buttocks

against the edge of the examination table, with the foot rested on the platform

and the limb flexed and externally rotated for optimal groin exposure. The

entire limb is thus relaxed and the veins sufficiently—but not maximally—

filled. In this position, tapping causes greater blood displacement and vein

wall movement.

The detecting hand lies flat with minimum pressure over the presumable

course of the proximal segment of the vein, whereas the other hand taps over a

distal part of the same vein (or a collateral). For the detection of the thigh

portion of the great saphenous vein (GSV), tapping at knee level is most effica-

cious. If tapping causes excessive movement of the perivenous tissues, which

makes it difficult to recognize the impulse of the vein, then holding the leg

firmly with the tapping hand and pressing against the vein with the thumb (or

other fingers) without lifting it, may produce an impulse free of “noise.” With

some experience, even transfascial segments of veins [thigh portion of the

GSV, proximal portion of the small saphenous vein (SSV)] may be at least par-

tially traced by percussion (Fig. 3.1).

The well-known clinical tests for the study of valvular incompetence—

Trendelenburg (Fig. 3.2) and Perthes—are less reliable and difficult to interpret

in obese patients and those with deeply situated superficial trunks, in the initial

stages of varicose disease, with widespread varicosities, superficial thrombophle-

bitis, recurrent varicose veins after surgery or sclerotherapy, SSV incompetence,

and so on. Fortunately, important information is obtained in all these cases with

the help of the Doppler ultrasound. The latter is the simplest instrument that gives

the greatest amount of useful information and is part of the routine examination in

our practices.

Examination of the Patient 59

Figure 3.1 Percussion (tapping) test. Percussion test may be performed in standing (a) or

sitting (b) position. The receiving hand lies flat, without much pressure, over the proximal

(a) or distal (b) segment of a superficial vein, whereas the other hand is producing the wave

impulse by tapping or pressing repeatedly on the other end of the vein.


DOPPLER ORTHOSTATIC REFLUX TEST

Doppler ultrasound is the phlebologist’s stethoscope and permits auscultation of

blood flow. The device is best employed by the surgeon himself. Nondirectional,

bi-directional, continuous wave (CW), or pulsed devices may be employed. The

Doppler ultrasound confirms or detects the origin and extent of reflux in super-

ficial veins of any size, avoiding time consuming and less reliable clinical

tests. Atypical origins and/or reflux are also easily detected. Deep veins may

also be evaluated in certain locations.

Method

Doppler ultrasound is performed with the patient standing and the weight borne

on the opposite leg (Fig. 3.3). The Doppler probe is placed over a proximal

portion of a vein at a 458 angle. Superficial veins may be conveniently marked

in a few points during clinical examination to facilitate placement of the

probe, whereas deep veins are recognized by auscultation together with or next

Figure 3.2 Selective occlusion (Trendelenburg) test. Selective occlusion and release of

the proximal portion of the GSV, after emptying the varicosities by leg elevation, demon-

strates the incompetence of the SFJ and the velocity of retrograde filling. (a) Compression

of the GSV after emptying at the SFJ. (b) Release of compression causes rapid filling.


to the adjacent arteries. Cephalad (physiologic) flow is auscultated by increasing

its velocity with manual compression (squeezing) of the limb distal to the probe.

Compression is then suddenly released. If the vein is competent, no signal is

heard upon release of compression; if the vein is incompetent, a long signal of

reflux flow is heard. For an optimal reflux signal, it is essential that the examined

limb be relaxed; otherwise, retrograde filling may be difficult and the reflux signal

shorter and more difficult to interpret. The Valsalva maneuver may be less

reliable because it depends on patient’s performance, uncomfortable for the

standing patient, and may not detect reflux in distal perforators or in patients

who have a competent femoroiliac valve. Origin and endpoint of reflux in a

superficial vein is determined by moving the probe cephalad and downward

along the vein while repeatedly compressing and releasing the leg distally. The

exact reflux pathway can be determined by digital compression of the investi-

gated vein distal to the probe; if reflux is completely abolished, it is concluded

that the vein is the only incompetent channel between the probe and the point

of compression. With a high-frequency (10 mHz) probe, a very precise and

Figure 3.3 Doppler orthostatic reflux test is performed with the leg relaxed, the weight

borne on the opposite leg. The probe is placed over the proximal portion of the examined

vein and adjusted to obtain a maximum flow signal upon distal compression/release of the

limb by the other hand. Flow signal upon release of compression indicates reflux.

(a) Examination of the CFV and GSV in the groin. (b) Examination of the popliteal

vein and SSV in the popliteal fossa.


detailed superficial reflux mapping can be obtained; segments of the same vein,

as well as parallel veins ,1 cm apart, can be individually investigated.

Veins already identified by clinical examination are easily examined for

presence of reflux and the latter traced to its origin (most proximal reflux

point). (On the contrary, detection of all incompetent distal perforators is less

reliable, but is also not necessary for planning a phlebectomy.)

Reflux in a collateral varicose vein sometimes originates from incompetent

“indirect” thigh perforators. The latter may join the deep veins much higher than

the most proximal palpable point of the varicose vein and may have a long

oblique subfascial segment. In these cases, CW Doppler may still identify the

highest level of reflux, but will not identify the vessel; if more detailed infor-

mation is desired, duplex scan or varicogram must be performed.

Groin Examination

In the groin the GSV, accessory saphenous vein (ASV), saphenofemoral junction

(SFJ), pelvic and abdominal anastomoses, and the common femoral vein (CFV)

can be investigated. The CFV is auscultated just medial to the common femoral

artery and may be followed above the SFJ [Fig. 3.3(a)]. If no reflux is detected in

the CFV (but there is reflux in the GSV), it is concluded that there is at least one

competent valve in the femoroiliac segment. If, on the contrary, reflux in the CFV

is detected up to the highest auscultation point, a competent valve may not be

present. While the latter condition is normally present in 30–40% of the popu-

lation, there is some evidence that in such cases varicose vein disease may

have a more aggressive course (2).

If reflux is completely abolished by digital compression of the GSV at knee

level, it is concluded that the thigh portion of the GSV is incompetent; failure to

abolish reflux means that there are incompetent high collaterals or deep veins,

with or without GSV incompetence. The level at which compression/release is

performed is also important, because reflux much shorter than the distance

between the probe (auscultation point) and the site of release may not be detected,

for example, short segment GSV reflux—from groin to Dodd’s perforator—will

be detected by compression/release at middle thigh level, but not calf level. In

examining the groin, one must remember that in about 40% of patients the

ASV is present lateral and parallel to the GSV. Though the ASV might be

detected with the hand-held Doppler by the surgeon who is aware of it, it is

best examined with the duplex scan.

Another important detail that will be disclosed only by duplex scan is the

frequent case of GSV (or ASV) incompetence with a competent saphenofemoral

valve. In these cases, retrograde flow depends on the incompetence of the second

(more distant) valve, and reflux may originate in the collaterals (abdominal,

pudendal) of the SFJ. This pattern has been described in up to 40% of patients

with GSV incompetence, especially in the early stages of varicose vein

disease (Fig. 3.4).


Popliteal Examination

In the popliteal area, the SSV, saphenopopliteal junction (SPJ), and the popliteal

vein can be investigated [Fig. 3.3(b)]. The presence and identification of reflux in

the SSV presents little difficulty when the latter is palpable. The origin of reflux in

the SSV is investigated by moving the probe cephalad along the vein, while

repeatedly compressing and releasing the leg distally. The highest reflux point

indicates the level of the incompetent SPJ. The level of a “standard” SPJ

(within 5–6 cm from the knee joint) can be localized to �2 cm precision, but

a higher origin of reflux (incompetent femoropopliteal vein or posterior thigh

perforator) is difficult to examine with Doppler alone and requires duplex scan

or venogram.

The popliteal vein is auscultated together with the popliteal artery and is

therefore easily separated from the SSV in most cases. Abolition of reflux in

the popliteal vein by digital compression of the incompetent SSV is not sufficient

to rule out popliteal vein incompetence; if the incompetent SSV is the only run-

off channel of the incompetent popliteal vein, compression of the SSV will

abolish reflux in the popliteal vein, as well.

The presence of reflux in the popliteal area in the absence of palpable SSV

or other varicose veins, as well as failure to abolish reflux with digital com-

pression along the course of the SSV, indicates that there are deeply situated

incompetent veins (double popliteal vein, muscular calf veins, deep leg veins,

etc.), which cannot be identified by CW Doppler ultrasound. If more detailed

information is desired, additional testing (duplex scan, venogram) must be

performed (Fig. 3.4).

Interpretation and Pitfalls of Doppler Reflux Testing

Doppler findings must be interpreted in the light of medical history and clinical

examination, which are the bases of clinical decision making. The priority of

clinical examination is evidenced by the fact that it is not unusual to detect

reflux in normal sized GSV or other veins of asymptomatic limbs with no clinical

signs of venous disease (reflux of no clinical significance). Even in limbs with

varicose veins, the mere presence of Doppler detectable GSV reflux may not

be sufficient reason to strip the vein. If there are no other clinical signs of GSV

incompetence, that is, dilated and palpable vein, rapid filling of collateral varic-

osities upon release of digital GSV compression, and so on, GSV stripping may

not be necessary. However, clinical and Doppler findings concur in most cases.

Even in those with purely cosmetic varicose veins, when the small dermal reticu-

lar veins assume a varicose appearance, they invariably lose their valvular func-

tion demonstrating reflux (3,4).

An important exception is a varicose vein secondary to deep vein incom-

petence (usually of post-thrombotic origin). Though obviously varicose, such

veins may be competent, while deep vein (usually popliteal) reflux is invariably


Figure 3.4 Duplex and color flow examination yields information that is difficult or

impossible to obtain by clinical and Doppler examinations alone. (a) Color flow examin-

ation of popliteal fossa. G, Giacomini vein (incompetent); SSV, small saphenous vein

(incompetent); GCA, gastrocnemius artery; PV, popliteal vein (incompetent); PA, popli-

teal artery. (b) Color flow examination of the SFJ showing that both GSV and ASV are

incompetent. B1, transverse view; B2, longitudinal view. GSV, greater sapheneous

vein; ASV, anterior accessory saphenous vein; CFV, common femoral vein; CFA,

common femoral artery. (c) Color flow examination of the mid-thigh portion of the

GSV showing a “bayonet” type varicose vein with the GSV trunk competent distally to

the origin of the bayonet (arrow). (d) Duplex scan of popliteal fossa. Longitudinal (sagit-

tal) scan (e) showing the small sapheneous vein (SSV), gastrocnemius vein (GCV), and

popliteal vein (PV). Transversal scan (f) showing the SSV (incompetent) and gastrocne-

mius vein (competent) joining the popliteal vein at the same level, the SSV laterally

and the GCV medially. Scanning in different planes is essential for obtaining three-

dimensional information. (a, b, c, and d courtesy G. Belcaro, M.D.)


present. Such competent varicose veins are easily recognized by Doppler and

need not be removed.

It is widely accepted that for reflux examination, a nondirectional CW

Doppler device is sufficient. While this is true in almost all cases, there are

some in which the nondirectional Doppler signal may be erroneously interpreted.

This happens when distal release triggers cephalad (physiologic) flow instead of

reflux in the auscultated superficial vein. Such “paradoxical” phenomena occur

when the examined superficial vein (in our experience most often the middle

third of the GSV) is competent and functions as a main drainage channel for a

parallel incompetent vein. In this case, downward flow in the varicose vein

becomes cephalad as it reaches the competent parallel vein, and distal release

triggers—at the same time—centrifugal flow in the former and centripetal flow



in the latter (Fig. 3.5). If not correctly interpreted, this finding may lead to incor-

rect diagnosis of GSV incompetence. Directional Dopplers demonstrate this

“paradoxical” flow pattern.

ADDITIONAL INVESTIGATION

The routine examination described in this chapter is largely sufficient for plan-

ning varicose vein avulsion. It permits a correct diagnosis in a large majority





of patients with varicose veins (92%, according to Nicolaides) (5). In particular

situations—discordance between clinical and Doppler examination, suspected

occlusion/incompetence of veins not accessible to the CW Doppler examination,

recurrent varicose veins (especially in the groin, popliteal fossa, and posterior

leg), necessity to evaluate the venous calf pump function, and so on—additional

laboratory investigations may permit more precise diagnosis. A wide range of

noninvasive and invasive investigation techniques are available. These permit

morphologic and flow pattern studies of veins not accessible to clinical and

Doppler examination (duplex scan, venography, or other imaging techniques),

and evaluation of the venous pump function (plethysmography, ambulatory

venous pressure). Of these, the single most useful instrument for venous investi-

gation—after the CW Doppler—is the color-duplex scanner (combined B-mode

imaging Doppler and color-Doppler ultrasound).

Color-Duplex Ultrasound Examination

B-mode ultrasound imaging with a high-frequency (usually 7.5 mHz) transducer

permits visualization of superficial veins, their junctions with the popliteal,

Figure 3.5 Pitfalls of nondirectional Doppler. Reaching the competent GSV, the reflux

flow in the varicose collateral (VC) becomes physiologic (upward). When the examiner

listens to flow in the GSV, it will be heard upon release of digital compression, giving

the erroneous impression of reflux in the GSV.


femoral, and muscular veins of the calf. In normal sized (not obese) limbs, deep

veins can also be visualized along their entire length. Duplex scanners also permit

a flow study of each visualized vein by Doppler. Color duplex allows direct visual

representation of flow, with a change of color from red to blue, depending on

whether the flow is towards or away from the probe.

The availability of color-duplex ultrasound has enabled us to add important

details to our clinical and Doppler examination, and we now employ and rec-

ommend it as a routine examination, especially for pre-operative varicose vein

marking. In addition to its diagnostic use, duplex scanning allows hard-copy docu-

mentation to compare pre- and post-operative records with treatment evaluation.

The technique of duplex examination, that is, patient’s position and man-

euvers for the detection of venous flow and reflux, is basically the same as

with the hand-held Doppler test. Veins are best examined with the transducer

horizontal with respect to the limb axis (transverse scan). This allows immediate

recognition of the vein as a round anechogenic (dark) image, in which flow may

be evoked and detected by the Doppler or color flow capabilities of the scanner.

Veins can be followed along their entire course by moving the transducer, always

in a transverse position, up and down along the leg. The position of the veins with

respect to the superficial fascia is readily appreciated. This allows precise separ-

ation of the intrafascial (saphenous) trunks from their subcutaneous side

branches. The use of ultrasound imaging immediately prior to phlebectomy for

more detailed varicose vein mapping is discussed in Chapter 6. Our use of

B-mode and duplex scanning during examination of varicose veins and the

information provided by such testing may be summarized as follows:

. Suspected DVT may be easily confirmed or ruled out. Failure to com-

pletely obliterate the vein by compression (with the transducer) and an

absence of respiratory flow indicates (thrombotic) occlusion of the

examined vein.

. Deep vein incompetence can be confirmed or diagnosed by direct

examination of the deep veins for reflux. This is done with the patient

standing and the maneuvers for Doppler reflux testing already

described.

. Superficial veins that are difficult (or impossible) to palpate (i.e., obese

limbs, vein segments situated under the superficial fascia, veins recana-

lized after thrombophlebitis, or sclerotherapy) can be immediately

visualized, thus simplifying the clinical examination itself. Visualizing

incompetent superficial veins permits measuring their diameter, which

may assist surgical planning. For example, very thin (hypoplastic) GSV

or SSV, though incompetent, may not need to be removed.

. Collateral reflux in the groin can be differentiated from a competent SFJ

sparing an unnecessary GSV ligation and division.

. “Borderline” or “ambiguous” cases of GSV reflux, frequently found in

the early stages of varicose vein disease, may be studied in detail. For


example, there are cases in which slight compression with the transdu-

cer or a change in leg position may abolish the reflux at the SFJ.

In many of these cases, apparently normal valves are seen, so that

“limited” or “intermittent” GSV incompetence may be postulated.

However, the clinical significance and prognostic value of such ultra-

sound findings are not yet clear (we are unaware of conclusive data

regarding the natural history of borderline GSV incompetence); we

postulate that these patients often evolve to permanent incompetence.

Therefore, early intervention and supportive conservative techniques

can be prescribed. The decision to operate on the GSV is based on clini-

cal symptoms as discussed in Chapter 15.

. The reflux originating from the incompetent SFJ may be distinguished

from the one that originates from the “second valve,” and in selected

cases this may lead to GSV-sparing surgery.

. The GSV and ASV can be examined separately and their involvement

in varicose vein disease determined with precision.

. Complex patterns of venous reflux that are often found in the advanced

stages of varicose vein disease or in limbs with deep vein incompe-

tence, can be studied in detail. This is especially useful in the popliteal

fossa and posterior leg, when the popliteal vein, the SSV, the muscular

calf veins, and the superficial collateral veins can be individually

checked for valvular incompetence.

. Varicose veins recurrent after surgery may be studied for appropriate

phlebectomy. For example, if recurrent reflux in the groin originates

from one or more tiny collaterals, surgical revision of the area of the

SFJ may be unnecessary.

Evaluation of the Leg Pump Function

In addition to vein imaging and flow studies, several noninvasive plethysmo-

graphic techniques are available to evaluate venous pump function. However,

these investigations are of little help to AP and will not be discussed in detail.

Our use of strain-gage and photoplethysmography are limited to documenting

normal venous pump function in patients with stasis changes (edema, dermatitis)

in legs with normally functioning deep and superficial veins. They are also useful

for post-operative follow-up testing of patients with DVT, in order to document

persistent impairment of venous leg pump function. This reinforced the need for

continuing compression therapy to prevent stasis changes.

Some of the most popular methods of investigation and their respective

areas of application are presented in Table 3.1. In some cases the same infor-

mation may be obtained—though sometimes to a different extent—by several

different examination techniques. For example, superficial vein incompetence

might be detected by clinical, Doppler, or duplex examination. We believe that

for optimal cost-effectiveness, information should be collected by the simplest


Table

3.1

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possible method. Sophisticated and costly examinations should not be employed

for collecting data obtainable by simpler methods. Though sophisticated equip-

ment may give extremely detailed diagnostic information, this becomes mean-

ingful only if interpreted in light of the clinical examination, on which the

decision to operate is still ultimately based.

For a further discussion of the different methods of investigation, the reader

is referred to other sources (5–11).

REFERENCES

1. Hubner K. The out-patient therapy of trunk varicosis of the greater saphenous vein by

means of ligation and sclerotherapy: a contribution from a German phlebology

practice. J Dermatol Surg Oncol 1991; 17:818.

2. Schultz-Ehrenburg U, Weindorf N, Tourbier H. Moderne hamodinamisch orientierte

Richtlinien fur die Sklerosierung die Stamm- und Seitenastvaricosis der Vena saphena

magna und parva. Phlebol u Proktol 1988; 17:83.

3. Weiss RA. Weiss MA. Doppler ultrasound findings in reticular veins of the thigh sub-

dermic lateral venous system and implications for sclerotherapy. J Dermatol Surg

Oncol 1993; 19:947–951.

4. Tretbar LL. The origin of reflux in incompetent blue reticular/telangiectasia veins.

In: Davy A, Stemmer R, eds. Phlebologie: ’89 London: John Libbey Eurotext Ltd.,

1989:95–96.

5. Nicolaides AN, Fernandes e Fernandes J, Zimmerman H. Doppler ultrasound in the

investigation of venous insufficiency. In: Nicolaides AN, Vao JST, eds. Investigation

of Vascular Disorders. New York: Churchill Livingstone, 1981.

6. Nicolaides AN, Sumner DS. Investigation of patients with deep vein thrombosis and

chronic venous insufficiency. London: Med-Orion Publishing Company, 1991.

7. Bernstein EF. Noninvasive Diagnostic Techniques in Varicose Disease. St. Louis: The

C. V. Mosby Company, 1982.

8. Lea Thomas M. Phlebography of the Lower Limb. Edinburgh: Churchill Livingstone,

1982.

9. Fronek HS. Noninvasive examination of the patient before sclerotherapy. In: Goldman

MP, Sclerotherapy Treatment of Varicose and Telangiectatic Leg Veins. St. Louis:

Mosby Yearbook, 1991:108–157.

10. Van Bemmelen JS, Sumner DS. Laboratory evaluation of varicose veins. In Bergan JJ,

Goldman MP, eds. Varicose Veins and Telangiectasias: Diagnosis and Treatment.

St. Louis: Medical Publishing Inc., 1993:73–84.

11. Van Bemmelen JS, Bergan JJ. Quantitative Measurement of Venous Incompetence.

Austin: R. G. Landes Co., 1992.


4

Selection of Patients for OfficeVaricose Vein Surgery

The selection of patients for ambulatory phlebectomy (AP)—and office varicose

vein surgery in general—is based on the type of varicose vein, patients’ general

health conditions, and consent. As most varicose veins can be treated by AP,

exclusion criteria are related primarily to the patients’ general health.

VARICOSE VEIN AND LEG CONDITIONS

At the patient’s initial visit, the type of varicose vein disease is diagnosed and the

treatment program discussed. Though any varicose vein can be avulsed by AP,

there are a few exceptions. These are the muscular (gastrocnemial) calf veins,

which cannot be removed by office phlebectomy. Recurrent varicose groin caver-

noma [after sephenofemoral junction (SFJ) division] should also not be operated

in the office. The incompetent SFJ must be ligated and divided as an office pro-

cedure as described in Chapter 15.

Asymptomatic Varicose Veins (CEAP 1–2)

Varicose veins are removed for cosmetic, symptomatic, and prophylactic

reasons. Patients with uncomplicated, asymptomatic varicose veins should be

encouraged to remove them early to slow down the progression of the disease

and prevent its complications. A distinction between purely “cosmetic” and

“clinically significant” varicose veins is not always easy to make. In its natural

course, varicose vein disease invariably progresses to more severe forms, with

about one-third of patients with large and/or widespread varicosities developing

one or more complications like superficial thrombophlebitis, dermatitis, lipoder-

matosclerosis, skin pigmentation, and ulceration (1,2). Many patients suffer these

chronic complications simply because they did not get proper treatment in

time. Another important reason to treat asymptomatic varicose veins is that

75

phlebectomy is easier to perform, and its functional and cosmetic results are best

when patients are operated in the early stages of varicose vein disease, before the

development of the aforementioned complications.

Symptomatic Varicose Veins (CEAP 3–6)

Patients with large, symptomatic or complicated varicose veins must be not only

encouraged, but also strongly advised to have them treated. Some of these

patients are operated on only after adequate leg preparation. This is done in

cases of stasis changes—recurrent or chronic edema, lipodermatosclerosis, der-

matitis, or leg ulcer (Fig. 4.1). This is because vein avulsion is difficult in lipo-

dermatosclerotic skin. Lipodermatosclerosis invariably yields to compression

bandage, but may require months to a year of compression therapy. Only then

can the local varicose veins be adequately evaluated and removed. Sometimes,

however, varicose veins in the upper leg and thigh may be avulsed before com-

plete softening of lower leg lipodermatosclerosis. This may enhance the healing

of the latter under compression therapy.

Acute superficial thrombophlebitis is treated first by thrombectomy and

compression bandage that is worn until local symptoms disappear—usually

from 1 to 3 months—then the varicose vein can be adequately evaluated and

removed.

Acute deep vein thrombosis (DVT) is treated with compression therapy and

anticoagulation. Varicose vein surgery is not attempted until symptoms of deep

vein occlusion disappear, that is, until adequate venous outflow becomes clini-

cally evident. In limbs with chronic edema, recurrent DVT may be difficult to

recognize even by duplex ultrasound; this is another important reason to postpone

varicose vein surgery until edema is stable and eliminated by compression

therapy.

PATIENT’S GENERAL HEALTH CONDITIONS

Varicose vein surgery is an elective procedure and patients must be—and usually

are—in good health. It is therefore important to obtain a detailed medical history

and appropriate laboratory examinations from all patients with indications for

phlebectomy.

AP is a very limited surgery that utilizes a low dosage of local anesthesia

(LA) so that it is possible to operate—with very few exceptions—on practically

all patients, including many who are considered “at risk” for general anesthesia or

traditional surgery. Moreover, in 40 years, there have been no reports of serious

untoward reactions or complications with Muller’s technique. However, some

selection is mandatory, at least for defensive reasons, considering the high

level of personal responsibility in private practice. Generally, only healthy

patients or patients with well-controlled systemic disease should be operated in


Figure 4.1 In case of stasis changes—recurrent or chronic leg edema, lipodermato-

sclerosis, dermatitis, or ulcer—surgery is postponed until the stasis changes heal under

compression bandage. (a) Chronic leg edema that hides the varicose veins, (b) five

weeks after treatment with adhesive bandage followed by 30–40 mm/Hg below-knee

graduated compression stocking. Regression of edema allows the varicose vein to be

clearly seen, (c) chronic leg edema with acute stasis dermatitis, (d) six months after com-

pression treatment. There are no signs of inflammation. Pressure with the finger demon-

strates the previously indurated lower leg to be soft. It is at this point that the varicose

veins can be adequately appreciated and removed.

Office Varicose Vein Surgery 77

the office. Examples of patients who may be excluded are:

1. Patients with history of untoward reactions to LA, unless specific

allergy is excluded by careful evaluation.

2. Patients in poor health, that is, impaired blood coagulation, systemic

cancer of any type, congestive heart disease, severe anemia, infectious

disease, uncontrolled diabetes, immunodeficiency, or multisystem

disease.

3. Patients with specific heart disorders, like clinically significant arryth-

mia or symptomatic coronary artery disease.

4. Elderly patients who live alone and are not self-sufficient. On the con-

trary, age is not a contraindication if the patient’s health is satisfactory.

If phlebectomy is performed not by the solo practitioner alone, but in

the presence of an anesthesiologist, it is the latter who should decide

which patients are not operable in an office setting.

5. Patients who are unable to walk for at least 20 min four times a day.

Modifying the Procedure

In certain cases the patient is not rejected, but the procedure is modified in order

to reduce its impact on the patient’s general conditions, or delayed in order to

permit better evaluation of patient’s physical and psychological conditions. For

example, in patients with diabetes, glaucoma, high blood pressure, coronary

heart disease, and so on, LA without epinephrine may be preferred. In other

cases, AP is postponed until a chronic disease is brought under control; for

example, diabetes compensated, high blood pressure lowered, anemia cured,

and so on. Phlebectomy may also be postponed for climatic reasons; if the

patient is concerned with the cosmetic outcome, it is advisable not to schedule

the operation during the hot season, as inadequate patient compliance with

post-operative compression may cause poor cosmetic result.

It must be kept in mind that most problems that may arise are not due to the

procedure itself, but are of an emotional nature. Therefore, in selected cases,

phlebectomies of even more limited extension may be performed in order to

further reduce the dosage of LA and patient stress.

Infectious Disease

A problem is presented by carriers of blood-borne infectious viruses. Examples

are the hepatitis B and C (HepB and HepC) and human immune deficiency

virus (HIV) positive patients, operating on whom carries a risk of contamination.

If staff members are vaccinated against HB—and this is strongly advised—oper-

ating HB carriers poses only the problem of avoiding office contamination.

Another argument for pre-operative screening for blood-borne infections is that

such practice makes it impossible for the carriers to claim they have contracted

the virus in our office. However, though HepB and HepC screening is accepted


as a routine practice, HIV screening is not, for the well-known emotional reasons

that do not allow a rational medical approach to the problem. It is to be hoped that

in the future a more rational approach to HIV screening becomes possible.

PATIENT CONSENT

Informed patient consent is obviously mandatory prior to the operation. After a

thorough explanation of the treatment procedure, we do not ask patients for

immediate consent or appointment for surgery, but first give them a request

form for routine laboratory evaluations. The time needed to complete the

check is a good test for the patient’s acceptance of the procedure; in case of

doubts, they may opt for more traditional or in-hospital treatment. An example

of patient consent form is found in Appendix 2.

REFERENCES

1. Widmer LK. Peripheral venous disorders: prevalence and socio-medical important

observations in 4529 apparently healthy persons. Basle Study III. Bern, Switzerland:

Hans Huber Publishers, 1978.

2. Beebe HG, Bergan JJ, Bergqvist D, Eklof B, Eriksson I, Goldman MP et al. Classifi-

cation and grading of chronic venous disease in the lower limbs: a consensus statement.

Vasu Surg 1996; 30:5–11.

Office Varicose Vein Surgery 79

5

Staging of Surgery

The surgical treatment that we describe is a “true” ambulatory procedure, which

is, performed in an office setting. This regimen does not require hospitalization,

not even for few hours, does not require the presence of an anesthesiologist, and

may be compared to a dental procedure, but with some more attentive cautions

(laboratory exams, emergency facilities, and patient selection). Safety in office

surgery cannot be overestimated. In cases of widespread varicosities, the best

way to achieve maximum safety is to divide vein avulsion into several operations

of limited extent, performing these during separate sessions.

The extent of the single phlebectomy is programed to limit anesthesia and

operative time to�1 h. It is usually possible to divide varicosities in well-defined

areas to be operated on in separate sessions (Fig. 5.1).

A typical case of greater saphenous vein (GSV) incompetence with few

varicose leg collaterals usually requires two 1–2 sessions: one for the leg varic-

osities and one for GSV ligation and groin to knee stripping. There are, of course,

cases of isolated varicose veins that are avulsed completely in a single session,

and also limbs with such a widespread disease that more than three (or more)

sessions are needed. In some difficult areas, such as foot, phlebectomy may be

time-consuming, so that it is preferable to limit the extent of veins to avulse in

a single session.

Phlebectomy sessions are performed 2–5 days apart, or, if the patient

prefers, weekly. If sclerotherapy is planned on smaller veins we advise a

6 week hiatus.

As a rule, we start operating from the distal part of the limb and proceed

proximally. Exceptions to this practice are some cases of extremely large vari-

cose veins, with grossly enlarged (.1 cm diameter) thigh GSV, and very large

and widespread leg varicosities (Fig. 5.2). In these cases, we usually avulse the

GSV portion first between the Dodd and Boyd perforators, next divide and

strip the remaining thigh portion of the GSV, and only then avulse the leg

81

Figure 5.1 Organization of multi-session phlebectomy. (a) Widespread bilateral vari-

cose veins with incompetent saphenofemoral junction (SFJ) on the right leg. (b) Preopera-

tive marking of the right leg (SFJ not marked, June 24). (c) Two days after the first

phlebectomy (June 26). The distal varicose veins are removed first and treatment proceeds

upwards. (d) Three days after the second phlebectomy, the patient is now marked for GSV

ligation and division (July 1). (e) Ten days after GSV ligation and stripping (July 10). The

patient does not have groin bandage anymore (band-aids are still visible over the groin

incision). Left leg marked for phlebectomy. (f) Four days after the first phlebectomy on

the left leg, the patient is marked for the last operation (July 14). (g) Six days after the

last phlebectomy.



Staging of Surgery 83


varicosities. Starting at the first session, compression pads are placed over the

veins left for the next session(s), and the limb is bandaged from foot to groin.

Operating in this order causes less bleeding during surgery, makes phlebectomies

easier to perform, and it is less likely that large thrombi form in the veins left for

the next session. Another exception are some cases of lower leg lipodermato-

sclerosis, when the veins proximal to the dermatosclerotic zone may be

avulsed first, in order to enhance the healing of the lower leg under compres-

sion therapy; at this point lower leg varicosities are better assessed and avulsed

more easily.

Except for the earlier listed exceptions, when GSV stripping or endolum-

inal laser or radiofrequency (RF) closure is necessary, it is left for the last

session. In these cases, phlebectomy almost always involves the GSV trunk,

which can be divided at various levels (between Boyd’s and Dodd’s perforators),

leaving a proximal GSV segment of various length for the last session (see

Chapter 15). There are several reasons for leaving GSV high ligation and strip-

ping or endoluminal laser or RF closure for the last session. First, GSV stripping

is the “major” procedure and is better performed last, when the patient is already

“prepared” by previous operations. (This may not hold for the simpler and less

invasive endoluminal RF or laser closure procedures). Second, as more than

double the amount of anesthesia is necessary for treating the GSV than for the

average phlebectomy, it is useful to have checked in advance (with lower

dosage) the patient’s tolerance to local anesthesia. Third, GSV stripping or

closure is simplified when all distal varicose veins have been removed; there is

less bleeding, and the remaining GSV trunk, divided and ligated at knee level,

is easily pulled out from the groin incision. However, some authors (MPG) do

exactly the opposite; Muller himself has the proximal portion of the GSV stripped

first, and evaluates the leg for eventual phlebectomy a few months later. While

this approach may lead to the same end result, more time is needed to complete

the treatment. This behavior may also hide some varicose veins that could be

better removed immediately; treating the GSV first causes resolution of many

distal veins, thus simplifying subsequent procedures.

Figure 5.2 Starting the operations from the middle third of the limb. In case of extre-

mely large and/or widespread varicose veins, we usually start operating from the

middle third of the limb. This simplifies each session and avoids formation of large

thrombi in the veins left for the next operation. (a) Saccular dilatations of the GSV at

the knee. (b) Site and extension of the first phlebectomy. The grossly enlarged parts of

the GSV are removed and this greatly facilitates the next operation. (c) Large and wide-

spread leg varicose veins with GSV incompetence, the day of the first session (October

21). (d) Two days later (October 23). The largest varicosities have been removed, while

the rest of the limb has been kept bandaged to prevent thrombosis in the remaining vari-

cose veins. The lower leg varicosities are marked for phlebectomy, while the GSV will be

divided and ligated at the groin 2 days later.


When possible, it is better not to end phlebectomy with division and lig-

ation of a large trunk. If a large vein is ligated, thrombus may form at the site

of the ligature. This is, however, of little importance because symptomatic

inflammatory reactions rarely occur if proper compression is used. After a few

days the vein is avulsed without difficulty. If the vein ruptures under traction,

the thrombus is easily squeezed out through the incision.

The practice of performing varicose vein avulsion in several separate ses-

sions is often criticized by authors who advocate ambulatory varicose vein

surgery in a single session. However, the latter is not possible in all cases in an

ambulatory setting. There is major stress to the patient and general anes-

thesia may be required necessitating the use of a “day hospital” rather than an

office base.

Dividing the operation into two or more sessions has the following

advantages:

1. A low dose of local anesthesia is employed, which limits potential

untoward (toxic) reactions to the anesthetic.

2. Reduction of surgical time (per session) allows more precision,

especially in cases of very widespread varicosities. In these cases

thorough vein avulsion in single session would require more time or

a quicker surgical procedure with the risk of neglecting details of

minor or purely cosmetic significance.

3. Immediate discharge of the patient, which permits operation in an

office setting.

4. With operations of so limited extent, complications are rare and corre-

spondingly insignificant.

5. Bilateral varicose veins may be treated at the same time, alternating

operations on both sides.

6. Seeing the patient with such frequency permits detailed evaluation of

previously operated sites and, if needed, allows modification of local

compression to enhance healing.

At the time of the last operation, the previously operated sites are often

completely healed and little further compression is needed, so that total com-

pression time is not prolonged by multi-session avulsion.

In addition to the aforementioned advantages, this approach is particularly

indicated in situations like:

1. Patients “at risk” because of advanced age, difficult ambulation, poor

general health, obesity, cardiac or pulmonary disease, and so on. In

these cases, extension of phlebectomy and dose of anesthesia may

be further reduced, increasing the number of sessions, and patients

otherwise not operable may be operated upon.

2. Patients with exaggerated emotional reactions. Exaggerated individual

reactions are usually revealed at the first session (which therefore


should be as short and simple as possible), with subsequent sessions

modified as necessary, that is, reassuring the patient, giving more

anesthesia, performing shorter operations, giving inhalation seda-

tion/analgesia, and increasing the interval between sessions.

There are, of course, disadvantages of multi-session vein avulsion.

1. The most obvious is that patient must attend the office more times.

While this is compensated by the fact that the patient does not lose

much time at each session and can resume activities immediately, it

is less convenient for patients who travel a long distance to reach the

office.

2. Increased stress. For some patients attending the operation is major

cause of stress, and this is repeated before each session.

3. It is more time-consuming for the surgeon, who must repeat the same

procedures many times: anesthesia, bandaging, and so on.

Despite these inconveniences, in our experience there is a net advantage in

favor of multi-session vein avulsion.


Part II: Technique of Phlebectomy

6

Pre-Operative Marking

Pre-operative varicose vein marking is an important part of the procedure; the

more precise and thorough the marking, the better the result of stab phlebectomy.

Marking is therefore best performed by the surgeon. Sufficient time must be set

apart for the procedure: a minute more spent for marking is well worth it.

Veins are marked with a cotton swab dipped in a 7.5% (saturated) water

solution of KMnO4. The latter will not get wiped-off by the common surgical

skin disinfectants and will remain visible for a few days; it eventually fades com-

pletely and never permanently stains the skin. The permanganate solution is not

irritating and allergic reactions to it have not been reported.

Marking is performed with the patient standing, except for the smaller

dermal varicose veins that are better observed in the recumbent position. Obser-

vation of the latter is further improved by skin translucidation with an alcoholic

disinfectant. Patients who wear compression bandage or hosiery may need to

remain in the standing position without compression for 15–20 min to allow

sufficient distention of the superficial veins.

The patient stands on an examination platform to permit easy observation by

the examining physician. Adequate illumination is essential. As for clinical exam-

ination, the knee of the limb to mark is slightly flexed and the weight borne on the

opposite leg. Marking is guided by observation, palpation, percussion, Doppler and

Duplex ultrasound, which are performed as described in Chapter 3.

All visible varicose veins are marked first. Careful palpation and percussion

will often disclose some nonvisible varicose segments and permit their marking.

Finally, reflux is traced with Doppler ultrasound to check the precision of

marking and to detect any segments missed by clinical examination alone.

These are usually veins more deeply situated and covered by a layer of the

fibrous fascia: the proximal portion of the great and small saphenous veins is

those most frequently marked with the help of the Doppler (Fig. 6.1). We routi-

nely perform duplex imaging immediately prior to surgery to assist pre-operative

marking. The few minutes spent visualizing the marked veins are worth the

details obtained.

91

Figure 6.1 Pre-operative marking. (a) Prior to marking. (b) A dotted line marks the com-

petent distal portion of the GSV. Transverse sign marks the site above the knee, where the

GSV is more dilated and palpable, and thus more easy to retrieve. (c) Three weeks after

last treatment session.


In this situation, the examination is being performed by the surgeon with

the patient standing. A high-frequency (7.5 mHz) transducer is employed for

optimal imaging of the superficial veins and their junctions. Vein diameter,

sites of saccular dilatations, distance of the vein from the skin surface, and its

relation to the superficial fascia are noted. This helps localize the points where

the vein is easier to hook, and is especially useful in patients with deeply situated

superficial veins. Double (or even triple) segments, as well as the sites of side

branch confluence, are also visualized and marked, thus facilitating vein discon-

nection (Fig. 6.2). Pathologically dilated perforating veins (PVs), including those

of the Cockett group, are relatively easy to localize (for eventual ligation),

whereas most perforators, being ,1 mm in diameter, are more difficult (but

also less important) to mark.

In the groin, the size of the great saphenous vein (GSV) and location of the

collaterals of the saphenofemoral junction (SFJ) are determined. This is

especially important in the presence of a very large ASV that joins the GSV or

the common femoral vein. This prevents the ASV from being confused at oper-

ation with the GSV itself (Fig. 6.2).

In the popliteal fossa, the level and type of saphenopopliteal junction (SPJ)

can be determined. If duplex capability is available, the individual veins can be

tested for reflux. An incompetent popliteal fossa perforator can be distinguished

from the SPJ. The absence of SPJ, with the SSV continuing into the posterior

thigh muscles as the femoropopliteal or Giacomini vein, can also be diagnosed.

Complex patterns of the SPJ, that is, gastrocnemius vein(s) joining the small

saphenous instead of the popliteal vein, can also be diagnosed. Nonpalpable,

incompetent subcutaneous “feeder” veins can be detected in areas of dense telan-

giectatic flares.

The patient is then placed in the recumbent position, and the skin wiped

with alcohol for better visualization of the smaller varicose veins, which are

also marked. An example of such veins are the pelvic anastomoses at the root

of medial thigh and the small dermal (“reticular”) varicose veins that typically

accompany telangiectasias. The areas of telangiectatic flare, when related to

larger varicose veins, are also marked with a circular sign.

The size of the marking sign roughly corresponds to the size of the varicose

veins. When only a part of an anatomical vein is varicose, the competent segments

may also be marked with a different (dotted) line, as this may allow more precise

surgery with maximum sparing of normally functioning veins (Fig. 6.1).

The most prominent varicose sites, as well as the sites more easily palpated,

and fascial defects are marked with a separate (transverse) sign. These sites cor-

respond to either a saccular dilatation, or side branch and/or incompetent per-

forator confluence. The signs are useful because in these sites the vein is more

easily retrieved and side branch and/or perforator disconnections are more

easily performed. Precise mapping of all incompetent PVs is, however, not

necessary because it is the varicose veins that are avulsed by stab phlebectomy.

The PVs are not necessarily given special attention.

Pre-Operative Marking 93

In a very obese patient, marking a deeply positioned thigh segment of the

GSV may “move” (usually anteriorly) when the patient changes the position

from standing to recumbent, and may thus not correspond to the skin projection

of the GSV in the recumbent position. For this reason it is advisable to check

the position of the vein with the patient sitting—or even in a semirecumbent

position—and the limb flexed in maximal external rotation (a position similar

to that used for GSV high ligation and stripping) (see Chapter 15).

When more than one operation is planned, all varicose veins are marked

prior to the first operation. This is done to permit a general view of the work

Figure 6.2 Incompetent GSV and ASV trunks at the saphenofemoral junction in the groin,

detected by color flow imaging. CFV, common femoral vein; GSV, great saphenous vein.


to be done and its optimal subdivision, that is, to better determine the site, extent,

and order for the separate sessions. Another reason for marking all the varicose

veins prior to the first surgical session is that, if not marked, residual varicose

veins may be difficult to identify later on, because of the favorable hemodynamic

conditions created by the first operation(s) and the effect of post-operative

compression.

The drawn map is referred on a stylized leg model as a graphic reference of

the anatomical and hemodynamic condition. One may chose between many of

these models. Some are reported in Appendix 10.

Pre-Operative Marking 95

7

Anesthesia

At its inception, ambulatory phlebectomy (AP) was performed strictly under

local infiltration anesthesia (LIA) with lidocaine. Further refinements brought a

reduction in lidocaine concentration from the initial 1% to 0.5%. The latter

dosage proved sufficient and allowed for a more extensive surgery without

exceeding the recommended maximum dosage.

AP can be, and nowadays often is, performed under a vast range of different

types of anesthesia, from loco-regional, and spinal to general. However, these

techniques have major disadvantages when compared with LIA. These include:

1. The presence and assistance of highly specialized personnel.

2. Temporary loss of motor function of the limb with problems in

fitting the post-operative bandage and impossibility of immediate

ambulation.

3. Side effects and delays in full recovery after surgery due to the admin-

istration of anesthetics and pre-medication drugs.

4. Emotional stress due to a more complex hospital-like procedure.

Perhaps the only indication for modification of LIA procedure is the

strongly emotional patient who expressly requests other types of anesthesia. In

these cases we found that optimal solution is LIA and intravenous sedation/analgesia with short-acting drugs (like midazolam), which, of course, requires

the assistance of specialized personnel.

For use in the free-standing surgical practice, LIA remains the standard of

care. Keeping the dosage of anesthetic as low as possible and avoiding pre-

operative medications keep the LIA procedure on the safest side.

97

PREPARATIONS, DOSAGE, AND TECHNIQUES

Currently LIA is practiced basically in two ways:

1. Traditional technique. This is performed with 0.1–0.4% anesthetic

solution and achieves limited tumescence along the course of the

veins targeted for avulsion.

2. Tumescent technique. This is performed with a large amount of

strongly diluted (0.07–0.1%) anesthetic solution and achieves major

tumescence along the veins targeted for avulsion.

In absence of comparative studies that indicate the clear superiority of one

of these techniques upon the other, the preference of the specific technique

depends on operator’s experience. The description of both traditional and tumes-

cent techniques for LIA as practiced by us is as follows.

Traditional Technique

Preparations and Dosage

LIA is applied exclusively along the course of the marked varicose veins. It is

performed with 0.4% mepivacaine (or other suitable local anesthetic) with

1:500,000 epinephrine in saline, neutralized with 40–60 mg/L of sodium

bicarbonate to reduce pain of injection (1–3). If not available, the earlier-

mentioned concentration must be prepared by dilution of a commercial solution.

We dilute 4 mL of 2% mepivacaine/1:100,000 epinephrine solution (available in

Italy in 20 mL vials) with 12 mL of saline and 4 mL of 1.4% sodium bicarbonate,

obtaining 20 mL of neutralized 0.4% mepivacaine/1:500,000 epinephrine sol-

ution. This solution is injected at body temperature (378C) instead of room temp-

erature for further reduction of pain, as suggested in a recent report (4). To obtain

�378C, we warm up the saline and bicarbonate solutions at �508C and then

add the anesthetic. (Curiously, many authors, on the contrary, refrigerate the

anesthetic solution in order to reduce pain. However, it is not clear how refri-

gerated solution can reduce pain, but this practice is not validated by objective

studies.)

In our experience, the 0.4% solution proved to be the lowest efficacious

concentration, but lower (5) or higher (6–8) concentrations are employed by

others. About 0.5 mL of LIA per linear centimeter is sufficient, though larger

amounts may be necessary if a larger and/or deeper infiltration is needed (i.e.,

for large, tortuous, multiple, or deeper varicose veins). Usually 20 mL of 0.4%

solution is sufficient for a 20–40 cm long strip (vein).

We employ an average 20–40 mL (80–160 mg mepivacaine) for

each session and limit the extension of phlebectomy accordingly. This is less

than one-third the recommended maximum dosage for mepivacaine, which

is 550 mg (or 7 mg/kg) (8). An exception is GSV high ligation with groin to

knee stripping for which 320 mg may be necessary (see Chapter 8). However,


there is evidence that even dosages larger than the latter are safe. In a recent

study it was found that during phlebectomy under LIA with �600 mg lidocaine

(8–15 mg/kg) (18 patients), intravascular lidocaine levels averaged 0.6 mg/mL

with a maximum of 1.8 mg/mL in one patient only. The latter is still less than

one-half the concentration considered neurologically toxic (4–12 mg/L) and

less than one-twelfth the one considered toxic to the cardiovascular system

(24 mg/L) (10).

The preparation of the anesthetic solution employed by us is illustrated in

Table 7.1.

Tumescent Technique

Preparations and Dosage

The development of tumescent anesthesia is generally credited to Dr. Jeffrey

Klein, a dermatologist looking for ways to improve the technique of liposuction.

It began with simple local anesthesia and dilution to allow larger areas to

be anesthetized without exceeding the published maximal dose of lidocaine

for local infiltration. The dilution of lidocaine had a surprising effect, however.

As the concentration was lowered, the anesthetic effect actually improved until

a threshold of �0.04% was reached. After large volumes of dilute anesthetic

were administered, concerns arose over the blood levels of lidocaine that patients

were being exposed to. It was then recognized that when lidocaine was given in

this dilution via a subcutaneous route, only slow, gradual elevations in plasma

lidocaine levels were seen. This gave way to questioning and then exceeding

the published maximal doses for lidocaine when given for local infiltration.

Further documentation and now years of safe use have made it the standard for

anesthesia in liposuction surgery (Table 7.2).

The induction of any anesthesia should have safety as its primary concern.

For this reason, we examined the complications found in our cases to determine

whether this form of anesthesia put patients at any greater risk. We discovered a

higher than expected rate post-operative hematoma formation. This may reflect

only some lack of operator skill, poor post-operative care, or may be an effect

of the anesthetic technique. The anesthetic fluid used did not contain epinephrine.

Early consultation with surgical colleagues convinced us not to use epinephrine

for concerns of toxicity given the large volumes of anesthetic sometimes used.

Subsequent to the findings of this study we have reintroduced epinephrine into

Table 7.1 Preparation of the Anesthetic Solution:

Dosage for One Syringe (20 mL) of Anesthesia

Mepivacaine 2% with epinephrine 1:100,000 4 mL

Sodium bicarbonate 1.4% 4 mL

Saline, warmed at �378C 12 mL

Anesthesia 99

the anesthetic fluid. This may decrease the incidence of hematoma formation.

More importantly, it may be a crucial component of the tumescent technique

by limiting lidocaine absorption.

Studies of liposuction cases using lidocaine and epinephrine have shown

that when very dilute lidocaine is infiltrated into the subcutaneous space,

amounts are slowly absorbed and peak levels are achieved much later than

would be expected with “typical” local infiltration. This is thought to occur

partly because of the dilute nature of the solution and also due to the prolonged

vasoconstrictive effects seen with epinephrine. Without epinephrine, vessels are

more “open”, anesthesia wanes more quickly, and lidocaine enters the blood-

stream more rapidly. Thus, a more sudden, dramatic peak in plasma lidocaine

concentration is likely to occur without the use of epinephrine, and the possibility

of exceeding the toxic level of lidocaine (5 meq/dL) is increased.

Tumescent anesthesia has been applied to a variety of surgical procedures,

including scalp surgery and hair transplantation, facelifts, dermabrasion,

mastectomy, and simple excisional surgery. Its application to phlebectomy

takes advantage of the ease of use and adds several benefits not found with

LIA. The anesthetic effect is long-lasting and return of sensation occurs

slowly. This contributes to the low post-operative pain reported in our series.

With large volumes instilled and longer needles used, only a few needle punctu-

res are required to completely anesthetize even long segments of veins. The

tumescence or firmness of the tissue seems to aid in “hooking” of the vein.

Duplex images of vein position upon instillation of tumescent fluid show a

decrease in vein diameter, a small amount of perivenular clear space (c/w hydro-

dissection), and slight elevation of superficial veins toward the dermis. The

tumescent swelling may provide an internal compression of the limb and the

affected vessels. It is customary when infiltrating local anesthetic to draw back

with the syringe to insure that the needle tip is not intravascular. The dilute

nature of the infiltrating fluid in the tumescent technique allows some inadvertent

intravascular administration without consequences. Thus, as long as the needle

tip is not kept in one position for a prolonged period of time, there is no

concern for substantial intravenous lidocaine/epinephrine administration. A

complete discussion on the safety of tumescent anesthesia with lidocaine is

found in Chapter 16.

LIA is applied exclusively along the course of the marked varicose veins. It

is performed with 1% lidocaine with 1:100,000 epinephrine diluted 1:10 with

Table 7.2 Preparation of Tumescent Anesthetic Solution: 0.1% Lidocaine

0.9% Normal saline 950 mL

2% Lidocaine 50 mL

Epinephrine 1 mL (1 mg, 1:1,000,000 final concentration)

Sodium bicarbonate 8.45% 12.5 mL (final solution pH 7.4)


bacteriostatic in saline. This solution is injected at body temperature (378C)

instead of room temperature for further reduction of pain (4).

We employ on average 250–1000 mL for each session. Utilizing this quan-

tity of anesthesia is essentially an adaptation of the tumescent technique that has

been previously described by Klein for liposuction surgery (10). The benefits of

the tumescent technique are most likely due to extensive diffusion throughout

subcutaneous and adipose tissues through the use of large volumes of fluid.

A mechanical effect from the pressure generated by engorging fatty tissue with

the anesthetic solution may also result in enhanced anesthesia. Both volume

and pressure result in a thorough permeation of even the smallest capillaries

and nerve endings (11). The anesthetic effect of this dilute lidocaine mixture in

subcutaneous fat has been shown to persist for up to 16 h post-operatively. There-

fore, supplemental post-operative analgesia is usually not necessary. Although

the tumescent technique was originally developed for the use in liposuction

surgery, its use has been expanded for scalp surgery, dermabrasion, and soft-

tissue reconstruction (12).

Although different anesthetic solutions such as bupivacaine or etidocaine

can be utilized, we prefer lidocaine as the drug of choice for dermatologic

surgery and tumescent anesthesia. This is because other anesthetic agents are

more likely than lidocaine to produce cardiovascular toxicity (13). However,

lidocaine toxicity may occur when plasma concentrations exceed 5 meq/mL.

The use of tumescent anesthesia requires less total milligrams of lidocaine to

achieve the same or better anesthesia, therefore limiting its toxicity (3,14).

Klein recommends a maximum dose of 35 mg/kg when the tumescent technique

is employed in liposuction surgery (11). For nerve blocks and LIA, the

Physicians’ Desk Reference and the Xylocaine (lidocaine hydrochloride,

Astra Pharmaceutical Products, Inc., Westboro, MA) package inserts state,

“For normal healthy adults, the individual maximum recommended dose of

lidocaine HCl with epinephrine should not exceed 7 mg/kg of body weight,

and in general, it is recommended that the maximum total dose not exceed

500 mg” (15). However, neither the initial manufacturer of lidocaine nor the

United States Food and Drug Administration has data to support this recom-

mended maximal safe dosage (11). Klein has estimated that the maximal safe

dosage of lidocaine using the tumescent technique is 35 mg/kg. This would be

equivalent to 2000 mg in a 57 kg (125 lb) patient and 2500 mg in a 73 kg

(160 lb) patient (11). He has shown that the use of diluted lidocaine delays

absorption. A complete discussion on the potential toxicity of rapid infiltration

of dilute lidocaine is found in Chapter 16.

Although a diluted lidocaine mixture is extremely safe, lidocaine toxicity

can occur with rapid intravascular injection of concentrated solutions. Initial

clinical stages of lidocaine toxicity are lightheadedness, euphoria, restlessness,

and/or drowsiness that appear with levels of 3–6 mg/mL. Objective toxicity

occurs with doses of 5–9 mg/mL seen as nausea, vomiting, tremors, blurred

vision, tinnitus, confusion, excitement, psychosis, and muscular fasciculations.

Anesthesia 101

Doses over 8–12 mg/mL may lead to seizures, cardiorespiratory depression,

coma, respiratory arrest, and terminating in cardiac standstill (11).

Diseases or drugs that decrease lidocaine metabolism may accentuate the

development for lidocaine toxicity. Patients with liver disease have a decreased

metabolism of lidocaine (16). Lidocaine metabolism may be diminished

indirectly by diseases that diminish hepatic perfusion such as heart disease

(17). Several drug interactions can occur to decrease either lidocaine metabolism

or hepatic flow. The most commonly associated drugs with these interactions

include cimetidine, beta-adrenergic receptor blockers, phenytoin, and procaina-

mide (18–24).

Technique

Pre-Operative Anesthesia

Perioperative analgesia is not necessary in the vast majority of patients. In the

anxious patient, intravenous medazolam 2.5–3 mg usually is sufficient to limit

pre-operative anxiety. When utilizing this form of conscious sedation, we rec-

ommend that appropriate respiratory and cardiac monitoring be performed.

Local Infiltration Anesthesia

The pain of LIA injection is due more to infiltration than needle puncture. LIA

injection is therefore less unpleasant when needles are small and infiltration

slow. With the traditional technique, we perform LIA with a 20 mL excentric

cone disposable syringe and 2 cm long 27 gage needle (Terumo 27 gage,

0.40 � 20 mm2). This needle exerts moderate resistance to injection so that infil-

tration is slow and less painful. It also permits optimal control of the injected

amount and maximum spare of anesthetic. With larger needles, injection is inevi-

tably faster and more painful, and there is also waste of anesthetic, that is,

amounts larger than necessary are injected. When using the tumescent technique,

greater amounts of anesthetic are used. Here, we use an infiltration pump set to

the maximum tolerated infiltration rate with a spinal needle of 22 or 25 gage.

Though infiltration of warmed LIA is almost painless, it is still the most

uncomfortable part of the procedure and also the one with which the invasive

part of the treatment begins. Therefore, it is important to perform it in the most

painless and comfortable manner, as this will reassure patients and make them

more relaxed and cooperative for the rest of the operation. For this purpose, con-

versing with the patient in a warm and interested manner is of great help and has a

positive psychological effect, which no medication can match.

The patient is placed in slight Trendelenburg position (head-down foot-up

tilt) to avoid emotional vagal reactions. The skin is prepared with a suitable sur-

gical disinfectant. The patient must be informed before of the first injection in

order to avoid “surprise” and possible defensive reaction. Perception of pain

and reaction to it vary from patient to patient; individual reaction is evaluated

during the first injection, and infiltration is then slowed or accelerated as needed.


Superficial (intra- and subdermal) infiltration around the vessel is sufficient

unless there are deep trunks (e.g., thigh portion of the GSV), large perforators,

operation at the saphenofemoral or saphenopopliteal junctions, in which case

deeper infiltration may be necessary.

Injection begins immediately after the insertion of the tip of the needle and

proceeds as the latter is pushed forward. If the needle is in the perivenous space,

LIA often dissects the latter infiltrating a tunnel that may extend a few centi-

meters beyond the tip of the needle; a longitudinal wheal and/or bleaching

results are clearly visible (Fig. 7.1). In such case, the next injection is made at

the end of the wheal, which is longer than the needle’s length, so that fewer injec-

tions are needed.

Aspiration to check for intravenous position of the needle is usually

unnecessary. Correct position is recognized by wheal formation. Moreover, the

small diameter of the needle, its continuous movement, and the slow rate of

injection make an accidental intra-arterial or venous injection of large amounts

of LIA unlikely. On the contrary, aspiration is performed when deep (perpendicu-

lar) infiltration is needed, that is, in the groin.

When infiltrating a long and straight segment, we start injecting from the

middle (or from a bi-trifurcation) and then proceed alternatively in both (or more)

Figure 7.1 Anesthesia with epinephrine-containing solutions causes vasospasm evi-

denced as skin blanching over the marked vessel. If infiltration is performed in the

perivenous cleavage plane, the anesthetic solution may spread for many centimeters

further along the vein, as seen by blanching beyond the injection site (“A”).

Anesthesia 103

directions. Injections are thus made from points already anesthetized to adjacent

and still sensible areas. In this way, needle insertion is not averted by the patient,

and pain of infiltration is also reduced. Not all areas of the limb are equally sen-

sible to LIA infiltration. Injection is more painful on the foot, ankle, and medial

knee—areas where injection should be slower—and is practically painless in the

groin.

At the end of infiltration the anesthetized skin appears pale because of

epinephrine-induced vasoconstriction. However, it is useful to test the degree of

anesthesia with a second series of injections and inject more if needed. LIA is

effective almost immediately and lasts 1–2 h. It is advisable to keep a sterile

syringe with some LIA ready in case supplementary infiltration is needed during

surgery; because of insufficient dosage, errors in marking, unexpected collaterals,

deviations in the course of the marked veins, bad diffusion of LIA due to cicatrix

tissue, and so on.

In other cases, for example, diabetes, glaucoma, coronary heart disease,

cardiac arrhythmias, arterial hypertension, hyperthyroidism, and advanced occlu-

sive arterial disease, mepivacaine may be employed without epinephrine. Unlike

other local anesthetics, mepivacaine does not cause vasodilation, but causes even

some vasoconstriction. It is therefore more suitable than other local anesthetics

for use without epinephrine. However, in such case, one must also expect—

besides more bleeding—major and more rapid mepivacaine absorption and

shorter duration of LIA.

At the dosage employed by us, adverse reactions to LIA are exceptionally

rare and mild. It has been calculated that more than one million APs have been

performed in Europe without a single major accident (5,6,8,9). This is because

adverse reactions to LIA are dose-dependent, and it has been shown that systemic

concentrations of the anesthetic during LIA for phlebectomy are many times

lower than maximal. However, one must be able to recognize promptly and

treat adequately any untoward reaction should it appear. Adverse reactions to

LIA and their diagnosis and treatment are discussed in Chapter 17.

REFERENCES

1. McKay W, Morris R, Mushlin P. Sodium bicarbonate attenuates pain on skin

infiltration with lidocaine, with or without epinephrine. Anesth Analg 1987; 66:572.

2. Stewart JH, Cole GW, Klein JA. Neutralized lidocaine with epinephrine for local

anesthesia. J Dermatol Surg Oncol 1989; 15:1081.

3. Stewart JH, Chen SE, Cole GW et al. Neutralized lidocaine with epinephrine for local

anesthesia. J Dermatol Surg Oncol 1990; 16:842.

4. Davidson JAH, Boom SJ. Warming lignocaine to reduce pain associated with

injection. Br Med J 1992; 305:617–618.

5. Ilieff P. Office varicose vein surgery. J Dermatol Surg Oncol 1992; 18:640.

6. Vidal Michel JP, Arditti J, Bourbon JH et al. L’anesthesie locale au cours de la

phlebectomie ambulatoire selon la methode de R. Muller, Phlebologie 1990;

43:305–315.


7. Carbocaina: description leaflet. Astra Dental SpA, Milano, licensed by Astra Pharma,

Sweden.

8. Muller R. La phlebectomie ambulatoire. Phlebologie 1970; 31:273–278.

9. Ricci S, Georgiev M. Office varicose vein surgery under local anesthesia. J Dermatol

Surg Oncol 1992; 18:55.

10. Klein JA. Anesthesia for liposuction in dermatologic surgery. J Dermatol Surg Oncol

1988; 14:1124–1132.

11. Klein JA. Tumescent technique for regional anesthesia permits lidocaine doses of

35 mg/kg for liposuction. J Dermatol Surg Oncol 1990; 16:248–263.

12. Coleman WP, Klein JA. Use of tumescent technique for scalp surgery, dermabrasion

and soft tissue reconstruction, J Dermatol Surg Oncol 1992; 18:130–135.

13. Malamed S. Handbook of Local Anesthesia. 2d ed. St. Louis: CV Mosby, 1986:44.

14. Lillis P. The tumescent technique for liposuction surgery. Dermatol Clin 1990;

8:439–450.

15. Physicians’ Desk Reference. 47th ed. Montvale, New Jersey: Medical Economics,

Inc., 1993:662.

16. Selden R, Sasahara AA. Central nervous system toxicity induced by lidocaine: report

of a case in a patient with liver disease. J Am Med Assoc 1967; 202:908–909.

17. Prescott LF, Adjepon-Yamoah KK, Talbot RG. Impaired lidocaine metabolism with

patients with myocardial infarction and cardiac failure. Br Med J 1976; 1:939–941.

18. Knapp AB et al. The cimetidine–lidocaine interaction. Ann Intern Med 1983;

98:174–177.

19. Feely J, Wilkinson GR, McAllister CR et al. Increased toxicity and reduced clearance

of lidocaine by cimetidine. Ann Intern Med 1982; 96:592–594.

20. Tucker GT, Bax NDS, Al-Asady S et al. Effects of b-adrenoceptor antagonists on the

pharmacokinetics of lignocaine. Br J Pharmacol 1984; 17:21S-28S.

21. Ochs HR, Carstens G, Greenblatt DJ. Reduction in lidocaine clearance during

continuous infusion and by coadministration of propranolol. N Engl J Med 1980;

303:373–376.

22. Branch RA, Shand DS, Wilkinson GR et al. The reduction of lidocaine clearance by dl

propranolol: an example of hemodynamic drug interaction. J Pharmacol Exp Ther

1973; 184:515–519.

23. Conrad KA, Byers JM III, Finley PR et al. Lidocaine elimination: effects of

metoprolol and of propranolol. Clin Pharmacol Ther 1983; 33:133–138.

24. Karlsson E, Collste R, Rowlins MD. Plasma levels of lidocaine during combined

treatment with phenytoin and procainamide. Eur J Clin Pharmacol 1974; 7:455–459.

Anesthesia 105

8

Position of Patient During Surgery

The patient is operated in mild Trendelenburg position (head-down, foot-up tilt)

of various degrees, according to the presumable blood pressure in the varicose

veins. This is done to avoid excessive bleeding and emotional vagal reactions.

If necessary, the limb may be further elevated by means of thick pads.

The head is placed on a flat pillow, but a higher one should also be available

in case the patient is unable to keep the head flat on the table (i.e., elderly patients,

cervical spine pathology, pronounced dorsal kyphosis, etc.).

The skin is prepared again with surgical disinfectant and a sterile drape of

suitable size is placed under the limb.

Phlebectomy is best performed on a horizontal plane. When possible, the

area to be operated on is chosen in a way that the patient should not have to

Figure 8.1 Supine position with one knee flexed for exposure of medial aspects of thigh

and leg.

107

change position during surgery. Limited rotation of the limb does not present pro-

blems. If, on the contrary, the patient has to change position completely, the limb

may be wrapped in the drape and the latter opened in the new position.

Anterior, anterolateral, and anteromedial aspects of the leg are operated

with the patient in supine position (Fig. 8.1). The latter is easy to maintain, but

other positions may not, so care should be taken to insure maximum comfort

and relaxation of the patient.

In the prone position, a support pad under the ankle makes it more easy to

maintain the leg in position, while the other leg may rest on the table with the

knee slightly flexed.

Lateral position may be difficult to maintain. We place the patient in a

semiprone position with the inferior leg straight on the table and the superior

leg flexed with the knee rested on the table (Fig. 8.2). In this position, one can

operate on the posterolateral aspect of the superior and posteromedial aspect of

the inferior leg.

Figure 8.2 Lateral position for exposure of posterolateral and posteromedial aspects of

thigh and leg.


9

Phlebectomy

INCISION

The incisions are the most characteristic feature of Muller’s technique. There are

techniques described as “stab avulsion” that use common hemostatic forceps,

which cannot be introduced and maneuvered through an incision ,4–5 mm

long. Muller himself calls a 2 mm incision “large” and a 3 mm one “enormous.”

This “obsession” with the size of the incisions is based on the observation of the

scars: the difference between a practically invisible scar and an unsightly scar

could be no more than 1 mm. This is true for normal skin, and even more for

skin that tends to form reddish, brown, hypertrophic or keloid scars: the

smaller the incision, the smaller the risk of adverse sequelae. Therefore, one

should make the smallest possible incisions, even if vein avulsion becomes

more time consuming. During the operation many of the smaller stab incisions

may enlarge. This enlargement is primarily due to stretching of cutaneous

elastic fibers. Fortunately, at the end of surgery, with compression, incisions

retract to their original size.

A series of different instruments are used for the incision: a hypodermic

needle (18 gage), a blood lancet, or a common number 11 scalpel blade

(Fig. 9.1). The latter may be held with a forceps close to the tip, which limits

its penetration and makes it operate as a blood lancet. Not all commercially avail-

able number 11 blades have well-sharpened tips; we found the carbon–steel

blades (Feather Safety Razor Co., Ltd., Medical Division, Japan) superior to

the common blades.

Puncture with an 18 gage (1.2 mm diameter) hypodermic needle (Terumo

blood transfusion 18 gage needle) results in a 1 mm large semicircular incision.

The latter is even smaller when the skin is so elastic as to get dissected rather than

cut by the tip of the needle. (Even smaller needles are used by some authors, but

in our experience, their use prolongs the time of the operation without increased

cosmetic benefit.) Needle incision, even when enlarged by subsequent

109

manipulation and passage of the vein, will result almost always—and often in a

few weeks—in a practically invisible scar. Even when visible, such scars are

usually round and not linear, and thus not readily noticed. They tend to be

perceived as common and not surgical scars.

Incisions made with blood lancet have similar characteristics, and, like

those made with needle, are all of the same size and shape, given the shape of

the lancet permits penetration only to a fixed depth (1–2 mm) so that deeper

structures cannot be accidentally damaged. With these small (up to 1 mm)

incisions we use a number 1 Muller hook (0.1 mm tip) to hook the vein.

When a number 11 blade is used, the scalpel is held as a pencil and the skin is

incised with vertical pressure only (as with a blood lancet). The cutting edge of the

blade is held up and the skin is kept stretched to become tense (Fig. 9.2). This

permits better eye control of the depth (and size) of the incision. It is advisable to

press firmly with the top of the third finger against the skin, so that the progression

of blade penetration is controlled. Sometimes, the skin is very resistant to puncture,

but once perforated may yield abruptly, causing a larger than desired incision.

When incising close to a bony surface (knee, tibia, malleoli, and foot), it is

necessary to hold up a skin fold and incise on it in order to avoid damage to

deeper structures.

Figure 9.1 Instruments for skin incision. From left to right: blood lancet, 18 gage hypo-

dermic needle, and number 11 surgical blade.


The size of the incision depends on the size of the varicose vein, the thick-

ness of the vein wall, and its adherence to the perivenous tissues; an adherent vein

may require larger incisions and thorough dissection before its avulsion or it will

continuously rupture. It is also better to avoid excessive trauma to the edges of the

incision or to lacerate the skin, as this may result in unsightly scarring. Therefore,

when an incision is inadequate, it is better to lengthen it.

Small dermal veins (usually mixed with telangiectasia) are invariably

avulsed through incisions made by a puncture with hypodermic needle or

blood lancet. Even larger varicose veins, when thin walled and without perive-

nous adherence, may need no more than a needle or lancet incision (such as col-

lateral varicose veins, CVVs). It is amazing how often a 6–7 mm diameter

varicose vein may be avulsed through a 1 mm incision (Fig. 9.3).

For larger varicose veins or for thick-walled veins (saphenous trunks)

incisions larger than 1 mm are necessary. We make such incisions with a

number 11 carbon–steel scalpel blade. These incisions are vertically oriented

to prevent inadvertent lymphatic damage except for areas—like the popliteal

fossa and the anterior knee—where skin tension lines are too obviously horizon-

tal and thus the incisions are oriented accordingly.

Unlike Muller who makes all the incisions together and at a regular dis-

tance (3–5 cm) from each other, we prefer to make one incision at a time and

place the next one at the most distant point where the vein, kept in traction, is

still palpable as a hard cord through the skin. However, the incisions—especially

the smaller—usually have an excellent cosmetic outcome, so that it is better to

make one more incision rather than risk to leave segments of vein not avulsed,

or lose time with a “fruitless” incision in order to spare an additional one.

Figure 9.2 Technique of microincision with number 11 scalpel blade. The incision is

made by puncture. The skin is held tight, the cutting edge of the blade up for better

visual control of the depth and size of incision.

Phlebectomy 111


VEIN RETRIEVAL, HOOKING, AND EXTERIORIZATION

Vein hooking and exteriorization are the most specific phlebectomy maneuvers

and permit varicose vein avulsion through 1–3 mm stab incisions.

Instruments

Three types of instruments are employed for vein retrieval and hooking: hooks of

different size and shape, Graefe iris forceps, and fine-pointed toothed clamps

(Fig. 9.4). Small size hooks allow the operation to proceed through stab incisions

,1 mm long (i.e., needle punctures), Graefe forceps require incisions 1–2 mm

long, whereas toothed clamps (hemostatic forceps) require incisions over 3 mm

long.

Hooks

After the introduction of the Muller hook during the 1970s, many authors

designed their own hooks, so that many different types of hooks are now available

(Varady, Oesch, Ramelet, Trauchessec, Dortu, Villavicencio, etc.). The purpose

of the hook is to operate through very small incisions, including simple punctures


Figure 9.3 Avulsion of larger varicose veins through needle puncture. (a) Posterolateral

thigh varicose vein, 5–6 mm diameter. Scars from previous “classical” varicose vein

surgery. The circular sign marks the incompetent perforator at the origin of the varicose

vein. (b) B-mode scan of the perforator, which measures 5–6 mm in diameter. This per-

forator typically connects the posterolateral superficial thigh veins to the deep femoral

vein. (c) Pre-operative marking. Double marking (arrow) indicates the point where phle-

bectomy was started, which is shown in the next photographs. (d) Needle puncture with 18

gage (1.2 mm) needle. (e) Hooking the varicose vein with number 1 Muller hook. Note

how the needle puncture dilates to allow the passage of a much larger vein. (f) Grasping

the vein with mosquito clamp. The vein is next put under traction until a loop is exterior-

ized and divided, and second needle puncture is made a few centimeters proximally.

(g) The segment between the two incisions has been avulsed through the second incision.

Note how the first incision has retracted to almost its original size (about 1 mm). (h) Exter-

iorization of the incompetent perforator at the proximal end of phlebectomy.

Phlebectomy 113

with a 18–19 gage hypodermic needle or blood lancet (Figs. 9.5–9.7). However,

some hooks have larger points and need larger incisions to operate.

Graefe Iris Forceps

Muller developed his method of phlebectomy with the small toothed ophthal-

mologic forceps. The type used for phlebectomy has a right-angled point

(Graefe iridectomy forceps number 35-367-10, Martin, Germany); less curved

variants are available, but are not suitable for phlebectomy.

Though Muller himself has abandoned the use of the Graefe forceps in

favor of his series of hooks, we prefer it to hooks for phlebectomy of larger var-

icose veins, that is, when incisions are made with a number 11 scalpel blade and

are larger than 1.5 mm. Our (MG and SR) preference is due to the fact that, unlike

hooks, the Graefe forceps is a versatile instrument that combines at least five

different functions. It can be used for the following (Fig. 9.8):

1. as a small hook (only one branch) or as a large hook (closed, both

branches);

2. for hooking in two directions (clockwise and counterclockwise), and

with both hands, features available only with the addition of left-

handed hooks;

3. as a dissector, to free the vein from its perivenous attachments;

4. to grasp the vein, before or after its exteriorization;

5. to clean the exteriorized vein from its investments and separate the two

branches of the venous loop.

Another advantage is that, because of its small size, Graefe forceps permits

better definition of the type or structure touched and hooked; forceps, in fact, can

Figure 9.4 Muller hook (number 1) on right and Graefe forceps on left with 18 gage

needle (1.2 mm diameter) in middle for comparison.


Figure 9.5 A phlebectomy hook designed by A.A. Ramelet. (Reproduced with per-

mission from Ramelet AA. Muller phlebectomy. J Dermatol Surg Oncol 1991; 17:814–

816.) (a) Two different sized hooks. (b) Magnification of tips. (c) Appearance of the

vein on the hook.

Figure 9.6 Four sizes of Muller hooks. (a) Overall appearance. (b) Magnified view of

specially designed curved end. (Reproduced with permission from Bergan JJ. Surgical pro-

cedures for varicose veins: axial stripping and stab avulsion. In: Bergan JJ, Kistener RL,

eds. Atlas of Venous Surgery. W.B. Saunders, 1992.)

Phlebectomy 115

be considered an extension of the fingers, whereas hooks are rather an extension

of the hand.

Toothed Clamps

Fine-pointed toothed clamps (Halsted mosquito clamp or Debakey hemostatic

forceps) are used mainly for traction on the exteriorized veins, but may also be

used to grasp the veins through skin incisions (see Chapter 13, Fig. 13.14).

This can only be done with incisions .2–3 mm, and is employed for deeply

and/or subfascially located trunks, like the proximal portion of the small saphe-

nous vein (SSV) or the thigh portion of the GSV.

Technique

Small dermal varicosities are hooked, teased out and avulsed through needle or

lancet punctures, with the use of number 1 Muller hook (Fig. 9.9). Once intro-

duced into the incision, the hook is rotated in a clockwise direction to hook the

vein, and then pulled out of the incision with abrupt movement. In many

cases, this maneuver will tease out the vein, breaking it at the same time. As a

result a stump (or two) of various lengths come out of the incision and are

clamped, teased out, and avulsed.

If this maneuver is “fruitless,” that is, if the vein does not come out, the

hook is maneuvered gently until the vein is hooked. When only the perivascular

Figure 9.7 Oesch hooks in various sizes. (a) Overall appearance. (b) Magnified view of

specially designed “grasping” end. (Reproduced with permission from Bergan JJ. Surgical

procedures for varicose veins: axial stripping and stab avulsion. In: Bergan JJ,

Kistener RL, eds. Atlas of Venous Surgery. W.B. Saunders, 1992.)


connective tissue is hooked, it is clamped with a mosquito clamp and kept in trac-

tion while the hooking maneuver is repeated until a venous loop is exteriorized.

At this point, the vein can be teased out and avulsed.

Some larger, but thin-walled CVVs can be successfully avulsed through

needle/lancet incision, especially if the skin is elastic and does not lacerate

during the passage of the vein. However, most larger varicose veins are

avulsed through scalpel blade incisions 2–3 mm long. In these cases, we use

the Graefe iris forceps and proceed as follows (illustrated in Fig. 9.10).

Figure 9.8 Graefe iris forceps can be used as a bi-directional hook in clockwise (a) and

counterclockwise (b) directions, and with both hands. Either single branch or both

branches together (closed) may be used for hooking. (c) Hooking with one branch of

the Graefe forceps. The vein wall is recognized by its white color. (d) The exteriorized

vein wall is grasped with mosquito clamp. (e) A loop is now completely exteriorized.

Phlebectomy 117


One or both branches of the forceps are introduced through the incision and

passed first in both directions along the vein in order to dissect it from surround-

ing tissues. The forceps is then passed under the vein and the latter hooked with

rotatory movement of the wrist (in clockwise or counterclockwise direction).


Figure 9.9 Serial diagrams illustrating varicose vein retrieval, hooking, and exterioriz-

ing with the Muller sharp hook (number 1 TF). (a) Needle puncture is sufficient for extrac-

tion of small varicosities and for operating with the number 1 Muller hook. (b) The hook is

inserted into the incision with its point down, and then rotated in a clockwise direction (c)

until the vein is hooked (d). (e) Once hooked, the vein is pulled out with an abrupt upward

movement. In many cases, this maneuver will break the vein and tease out one or both ends

(f). (g) If the earlier described maneuver fails, the hook may be maneuvered gently until

the vein or its investments are hooked and exteriorized, and clamped with mosquito

forceps for further traction.

Phlebectomy 119

Once hooked, the vein is pulled out with alternative rotatory movement of the

forceps’ tip (similar to windshield wiper motion). The hooked vein gives a

precise and specific sensation of an elastic, rubber-like structure.

The pulling and rotating maneuver brings the tip of the forceps closer to the

skin surface, and, if the vein is hooked, it comes out of the skin opening, and is

recognized by its white, lustrous appearance. At times, the perivascular connective

tissue is hooked and teased out without the vein. In this case, it is clamped with the

hemostatic forceps and kept in traction with the left hand, while the Graefe forceps

repeats the initial maneuver until the vein is hooked and pulled out.

Once exteriorized, the vein is clamped with the hemostatic forceps and the

perivascular tissue is dissected with the Graefe forceps until a loop is completely

defined. At this point, the vein can be pulled out and avulsed.



VEIN AVULSION

Dissection

Veins are pulled out more easily when they are separated from the surrounding

connective tissue. Therefore, the exteriorized vein is first “peeled off” with the

scalpel or with the tip of the Graefe forceps (Fig. 9.11). Further dissection may

be achieved with a blunt probe passed along the perivenous cleavage plane

around the entire circumference of the vein (Fig. 9.11). When adequately dis-

sected from its attachments, the vein stretches and becomes tense under traction.

It can be palpated as a hard cord for a variable length under the skin.

Traction

Varicose veins are avulsed by traction maneuvers as illustrated in Fig. 9.12. For

traction on very small dermal varicosities, nontoothed, fine-pointed 9–10 cm

mosquito clamps may be employed, but for larger varicose veins, 12–14 cm

toothed clamps (hemostatic forceps) are preferred; the latter grasp better and

permit stronger traction without breaking the vein.

Small dermal varicosities are fragile and break easily upon traction. There-

fore, they must be clamped close to the skin opening and pulled gently or twisted

Figure 9.10 Serial diagrams illustrating vein retrieval, hooking, and exteriorization with

the Graefe forceps. (a) One or both branches of the Graefe forceps are introduced through

the skin incision and passed along the vein to create a cleavage plane. (b) The forceps is

passed under the vein and the latter hooked with clockwise (or counterclockwise) rotation

of the wrist. (c) Once the vein is hooked, it is pulled out by alternating rotatory movement

of the forceps’ tip, similar to windshield wiper motion. Sometimes a complete venous loop

comes out (d–f), other times, only the investments of the vein are exteriorized (g and h),

clamped with a mosquito forceps (i), and put in traction until a complete loop is

exteriorized (j).

Phlebectomy 121



on the forceps. Despite careful manipulation, these veins often break and are

therefore removed piecemeal; attention must be paid to not leave behind non-

avulsed segments. This minimizes excessive post-treatment inflammation. If,

however, a small vein is resistant to traction, it is better not to break it, but

hook it and tease it out from a separate incision, which is the way larger varicos-

ities are avulsed.

When a loop of a larger varicose vein is exteriorized, it is pulled with

to-and-fro rocking and circular motions. These alternating traction movements

permit detachment from perivenous tissue. The loop is then doubly clamped

and divided, and its two segments are avulsed separately.

To tease out the vein, it must be held with the clamp close to the skin

opening to minimize breaking and pulled slowly with a progressively increasing

force; abrupt pulling may break the vein. Linear traction is alternated with

“to-and-fro” rocking and circular movements. While pulling the vein with one


Phlebectomy 123



hand, to-and-fro traction on the skin over the vein with the other hand facilitates

further detachment of the vein from the perivenous tissues. All these maneuvers

may free 10 or even more centimeters of the vein. In cases of varicose clusters or

meandering veins, even longer segments may be avulsed from a single incision.

Progression of Phlebectomy

The marked vein must be avulsed in all its length, but which end to start with is

not important. We usually begin from the distal end of a varicose vein and

proceed proximally. However, retrieval and hooking the vein from the first

incision may be difficult so that it is often more convenient to start phlebectomy

from a site of side branch confluence or where the vein is readily accessible, that

Figure 9.11 Diagrams illustrating dissecting maneuvers. (a) Stripping the vein off its

connective tissue investments with Graefe forceps. (b) Dissecting the vein from its

attachments along the perivenous cleavage plane by repeatedly passing a blunt probe

along the vein.

Phlebectomy 125


is, more superficial or bulging, and proceed from that point in both directions

(illustrated in Fig. 9.13).

When resistance to traction increases and the vein does not yield any more,

it may rupture. Before this happens, the next incision is made, as far as possible


Figure 9.12 Diagrams illustrating traction maneuvers. The exteriorized loop is put

under traction, then divided (a), and its both ends avulsed separately. The vein is held

close to the wound opening (otherwise it breaks easily), and pulled with slow, progressive

linear traction (b), or twisted on the forceps (c) until it yields. To-and-fro rocking move-

ments (d and e) and circular movements (f and g) help free gradually the perivenous attach-

ments all around the vein. Further detachment may be achieved by countertraction on the

skin with the other hand (h).

Phlebectomy 127

along the palpable vein cord, usually where the vein has not been dissected from

the subcutaneous tissues, and therefore pulls the overlying skin. The distance

between incisions varies from 1 to .10 cm, according to the resistance of the

vein and its subcutaneous attachments.

The Graefe forceps (or a hook) is introduced into the new incision; while

the free end of the vein is kept under traction, the latter is easily recognized as

a hard cord and hooked and exteriorized through the new incision. Once the

vein is hooked, traction on it is released and it is exteriorized through the new

incision. The segment between the two incisions is pulled out through the

second incision. The next incision can now be made and the procedure repeated

as many times as needed until the entire length of the previously marked varicose

vein is avulsed. In many cases, long segments—even the entire length—of the

vein may be avulsed undivided; if, however, the vein breaks upon traction, it

is retrieved and hooked again from a new incision.



Figure 9.13 Serial diagrams illustrating progression of phlebectomy through the second

incision. (a) The free end of the vein is kept under traction so that the vein is palpated as a

hard cord for a variable distance under the skin. Next incision is placed over the most

distant point where the vein is still palpable. The vein is easily recognized as a hard

cord, hooked, exteriorized (b), and avulsed (c) through the new incision (d).

Phlebectomy 129

Vein Division

Varicose veins are not “solitary” trunks. They are part of a superficial venous

network connected by perforating veins (PVs) to the deep (subfascial) veins.

These side branches and PVs increase in density distally along the limb. All of

these anastomotic veins, as well as both ends of the varicose vein itself, must

be divided in order to avulse the marked varicose veins (Fig. 9.14).

End Division

At its distal end, the varicose vein is pulled to maximal stretch and divided close

to the skin opening. The residual stump retracts and usually does not bleed; if it

bleeds, digital compression for a few seconds will stop the bleeding. At its prox-

imal end, the vein is divided in different ways according to the type of proximal

ending.

Small dermal veins without well-defined proximal connections are teased out

until they break or are pulled to maximal stretch and cut at the skin opening. The

proximal segment of a large vein, left in place (or removed at the next session) is

ligated with #3-0 catgut, Vicryl or Dexon suture. If the vein begins from a small

incompetent perforator, the latter is put under traction and/or torsion and divided,

followed by digital pressure for a few seconds to prevent bleeding. If the vein

begins from a large perforator, this is best ligated, especially at the upper thigh

where compression may be inadequate to prevent bleeding (otherwise—though

very rarely—hemorrhage or hematoma formation may follow).

The general rule is to avoid ligatures as much as possible, because—

especially when superficial—these may cause granuloma formation; however,

ligatures are used for large PVs and in obese patients or in areas, as the upper

thigh, where a compression bandage may not be sufficient to stop bleeding.



Figure 9.14 Diagrams illustrating vein division. Terminal (distal or proximal) discon-

nection is performed by pulling the vein to maximal stretch and dividing it at the skin

opening (a), or teasing it out until it breaks (b). (If a large incompetent proximal

segment is left in place to be avulsed at the next session, it is, of course, ligated). (c)

Small perforators are either put under traction and divided, or twisted until they break

(d); a few minutes of digital pressure prevents bleeding (e). Larger incompetent perforators

are best ligated (f and g). (h) Side branches may rupture upon traction of the main trunk,

but may also cause the main trunk to break (i). (j) If the incision has been made close to

side branch confluence, the latter may be exteriorized and divided. Keeping the vein under

traction, it is transformed into a hard cord that can be divided by needle puncture without

skin incision. Side branches (k and l), as well as the main trunk (m), may be divided by

needle puncture. This way, longer varicose vein segments (�20 cm) can be avulsed

through only two incisions.

Phlebectomy 131



The saphenofemoral and saphenopopliteal junctions are, of course,

always ligated. For vein ligation, we use #3 catgut suture or #2-0 or #0 Vicryl

or Dexon suture.

PV Division

PVs are usually not given special attention; most of them rupture upon traction

and do not impede varicose vein avulsion. If an incision is made exactly over

a perforator, the latter may be recognized by its T-shape junction when the super-

ficial vein is exteriorized (Fig. 9.15). Characteristically, pulling the perforator

beyond its stretching capacity causes discomfort to the patient. In these cases,

the perforator is put under torsion until it breaks, or is pulled to maximal

stretch and divided at (or below) the skin opening without ligature. Digital pres-

sure is immediately applied and maintained for a few minutes to prevent bleed-

ing. Though phlebectomy could be performed without vein ligature, large

incompetent perforators of the “direct” type, as well as those in the medial and

upper thigh, are better ligated; otherwise, one has to rely only on the compression

bandage for prevention of bleeding.

Side Branch Division

While pulling the vein, its side branches are also pulled. Some of them will break

under traction without impeding varicose vein avulsion, but some are strong


Phlebectomy 133

enough to cause the varicose vein to break instead of breaking themselves. More-

over, they counteract traction and prevent it to be transmitted at a longer distance

along the main vein. Their pulling may cause discomfort to the patient because

there is no anesthesia along the side branches. For these reasons, it is advisable

to divide them. Side branch division enhances vein avulsion and permits

longer varicose vein segments to be avulsed with fewer incisions and less

discomfort to the patient.

Side branches (and perforators as well) can be disconnected by traction

and/or torsion until they break, divided through the skin incisions, or divided

by needle puncture without skin incision.

If incisions are placed over side branch confluences, the latter may be exter-

iorized and divided. However, it is not necessary to make an incision over every

vein bifurcation, because many collaterals break upon traction or can be divided

by needle puncture without a skin incision.

It is possible to divide a vein using a hypodermic needle as a blade. The

beveled tip of a hypodermic needle has sharp cutting edges that allow it to be

used as a microblade, and divide veins by puncture without skin incision or

exposure of the vessel. To do this, the vein to divide must be kept in traction.

The needle is held close to the tip, like a pencil. The skin is punctured and the

tense collateral is recognized as a hard cord and cut with the needle’s tip.

Large needles (number 18 or 19) are easier to use as blades, but smaller

needles may also be employed. In addition to superficial side branches, perfora-

tors and even the main varicose trunk may also be divided by needle puncture.

This may be done during GSV stripping, to divide the GSV at the knee, and

also to cut a varicose vein away from the point it is clamped, or to divide the

vein between two incisions. In this last case, it is possible to avulse longer

(�20 cm) segments of a vein with only two incisions (avoiding the third incision

Figure 9.15 Isolation of the Boyd (below knee) PV.


in the middle). Keeping the vein in traction from both ends, the latter is divided in

the middle by needle and the two segments are teased out separately. Vein section

by needle puncture permits side branch disconnection without excessive traction

and rupture, with fewer incisions and less discomfort to the patient. We find this

procedure very useful and use it routinely.

TECHNICAL DIFFICULTIES

Despite its apparent simplicity, phlebectomy may be difficult and even discoura-

ging to the inexperienced operator. The difficulties depend on the type, localiz-

ation, and conditions of the varicose veins and surrounding tissues.

Vein Fragility

Optimally, long segments of varicose veins are easily avulsed through a few stab

incisions. However, some veins are fragile and rupture with the slightest traction.

In these cases, more incisions are needed and the vein has to be avulsed piece-

meal. Careful dissection and gentle pulling may permit avulsion of longer

segments, but short segments of the vein may be left in place. When a vein is

avulsed, the empty tunnel along its course can usually be palpated as a skin

depression, so that the sites where the vein has not been avulsed appear indurated.

It is often possible to “scratch out” the residual piece through the old incision and

thus avoid making additional incisions over the remaining segment. However,

“blind” avulsion far from the incision may damage nerves and lymphatics.

Usually this damage is insignificant, but must still be minimized.

Varicose Clusters

Sometimes, varicose veins are arranged in clusters or complex patterns, which

may make marking difficult. In such cases, very abundant venous material may

be avulsed from a rather limited area (Fig. 9.16). However, despite careful

marking and thorough avulsion, some vein segments may remain in place.

This is recognized after the removal of the bandage (here we avulse the residual

veins free of charge). The more experienced the operator, the less frequently this

occurs (Fig. 9.17).

Examples of veins that not only rupture easily but also form complex net-

works are some reticular (dermal) varicosities, which often accompany telangiec-

tasia. As their removal is requested mainly for cosmetic reasons, it is important to

remove them thoroughly. Good pre-operative marking—with the patient in the

recumbent position—is essential for this purpose. In some areas, phlebectomy

is more difficult and the maneuvers of retrieval, hooking, and avulsion have to

be modified accordingly.

Phlebectomy 135

Foot

Although a simple dilatation may be due to blood overflow and may recover after

proximal varicose correction, in a number of cases foot varices need to be treated.

Over 100 consecutive cases, one of the authors (SR) found that 12 required foot

phlebectomy, bilaterally in two cases. Generally foot dorsal veins, in continuity

Figure 9.16 Complex patterns of varicose veins. (a) Varicose clusters over the right knee.

(b) Large number of veins avulsed from a limited area. (c) Three weeks after phlebectomy.


with leg collateral veins, are those most involved in varicose veins (75%), while

dorsal marginal and arch veins, in continuity with the saphenous veins, are more

rarely involved, laying under a fascial shelter (Figure Saphenous eye of the foot).

Due to their great elasticity, CVVs on the dorsal foot may become very

large in the upright position, but shrink in Trendelenburg position, making retrie-

val difficult. Moreover, they are often accompanied by sensory nerves. Manipu-

lation must therefore be delicate in order to avoid nerve damage. Because the

subcutaneous layer is very thin, it is often necessary to pull up a skin fold to

make the incision and hook the vein.

If a number 1 Muller hook is used, it is better to hook only part of the vein or

its perivascular tissue. If larger incisions are made and the Graefe forceps is used

instead of a hook, it is preferable to grasp—not hook—the vein with the forceps.

Nerves and veins may be difficult to distinguish, so one has to make sure

that the exteriorized cord-like white structure is a vein and not a nerve. Touching

or manipulating a sensory nerve is usually painful or causes an “electric shock”

Figure 9.17 Complex varicose vein patterns may cause incomplete avulsion. (a) Pre-

operative varicose vein marking in patient with long-standing varicose veins and stasis

changes of lower leg. (b) Ten days after phlebectomy it became evident that there is

another varicose vein originating from an incompetent below-knee perforator. This vein

is now marked for avulsion. The black dotted line indicates the course of the varicose

veins avulsed at the first phlebectomy. The missed vein runs close and parallel to the

one marked and avulsed.

Phlebectomy 137

sensation. The vein can also be better recognized by filling it with blood (by

squeezing the foot proximally and distally), or by a longitudinal incision that

allows better exposure of the vein “lumen.” Another sign is that collateral foot

veins usually yield upon traction without much resistance or pain so that long

segments are easily avulsed through a single incision, whereas nerves are less

yielding and obviously do not have a lumen.

Phlebectomy is more difficult when treating the dorsal marginal and arch

veins. These veins are very thick walled and run under the connective fascia

similar to the saphenous veins. As a consequence the incision must be larger, the

search must go deeper, the traction needed is stronger and some risks are higher.

These veins may be more easily removed by introducing a metallic probe into

the lumen of the vein to retrieve it through a more proximal extracted vein. The

probe is felt through the skin, which facilitates venous wall identification. Owing

to the very rich vascularization in the foot, bleeding after vein disconnection is

often quite strong, but ceases promptly after a few minutes of digital compression.

Shin

The veins over the tibia may become visible and unsightly, even when not grossly

varicose, so that their removal is often requested for cosmetic reasons. These

veins are embedded into a thin, but compact layer of subcutaneous connective

tissue and are difficult to hook. A skin fold should be pulled up with the left

hand, and the vein searched and hooked delicately in order to avoid trauma to

the periosteal tissue or damaging the tiny sensory nerves that often accompany

the veins. These veins are not superficial and failure to avulse them will be

immediately noticed by the patient.

Knee

The skin over the anterior aspect of the knee is particularly thick, and the subcu-

taneous connective tissue, fibrous and compact. Therefore, larger incisions may

be necessary and the vein has to be thoroughly dissected from the surrounding

tissue prior to hooking and avulsion.

In the popliteal area, the skin is, on the contrary, thin and delicate, and scars

tend to be more visible. Careless manipulation may lacerate the incisions, causing

unsightly scars. The area is rich in tiny sensory nerves, the rupture of which

causes burning pain, but does not lead to appreciable loss of sensitivity.

Thigh

Thigh varicose veins may be independent from the GSV. If reflux in them orig-

inates from an incompetent thigh perforator, the latter is often fragile and must be

carefully isolated and ligated because the compressive bandage—especially in

obese thighs—may not be sufficient to prevent bleeding with hemorrhage or


hematoma formation. In this area, bruising or hematoma may cause skin dis-

coloration, which may take many weeks or even months, to disappear.

Incompetent pudendal varicose veins are usually of small caliber. They are

avulsed as high as possible and disconnected proximally by twisting, which invari-

ably stops bleeding; an occasional large vein may be, of course, ligated. The var-

icose thigh branches of the GSV are ligated as close to the GSV trunk as possible,

while the latter is left in place if, of course, there are no indications to strip it.

Great Saphenous Vein

While we ligate the SFJ and strip the thigh portion of the GSV through the groin

incision (see Chapter 15) or close the GSV with endoluminal laser or radio-

frequency closure (Chapter 21), distal (knee and leg) GSV segments are often

avulsed by phlebectomy.

Unlike its side branches, the GSV lies deeper and is covered by a fascial

layer that encloses it within a relatively restricted space that prevents varicose

formation. It may therefore be difficult to retrieve and exteriorize. However,

the vein often presents more superficial segments or bulging and palpable

spots, which correspond to sacular dilatations, side branch and perforator conflu-

ence, and it is in these sites that it is more easily retrieved and hooked. Once

exteriorized, the GSV is put under traction and its deeper and nonpalpable

portions are more easily recognized as a hard cord and hooked from the next

incision. Alternatively, like in SSV and foot vein phlebectomy, a probe can be

introduced inside the lumen through a more distally extracted vein. The

probe will assist the surgeon to the location of the saphenous vein helping its

retrieval.

The distal portion of the GSV—below the Boyd perforator—is invariably

embedded in a compact fibrous tissue and covered by layers of fibrous fascia.

Therefore, it is difficult to hook and exteriorize. This may require larger incisions.

It also may have many side branches, which must be disconnected; otherwise the

saphenous trunk may break upon traction. The saphenous (sensory) nerve runs

close to the distal portion of the GSV and may be easily damaged; therefore,

the vein must be delicately hooked (or grasped) and dissected, and manipulation

must stop in case of pain or an “electric shock” sensation. Because of these diffi-

culties, the distal portion of the GSV is better left in place and not avulsed; for-

tunately, in most cases it is competent, not enlarged and without varicose side

branches, and can be spared. Alternatively, once the feeding incompetent vari-

cose vein is removed, sclerotherapy can be more easily performed. When a

duplex ultrasound is available, it assists in localizing the deep and sometimes

nonapparent location of the saphenous vein.

Small Saphenous Vein

Owing to its subfascial course, the technique of SSV phlebectomy differs from

that of the superficial CVVs, and is described in detail in Chapter 13. Many

Phlebectomy 139

patients who need varicose vein surgery have one or more local complications

like phlebitis, dermatitis, chronic edema, lipodermatosclerosis, leg ulcer, or

signs of previous treatments like surgical scars, neurogranulomas, paresthesia,

veins sclerosed or recanalized after sclerotherapy, and all these conditions

make phlebectomy more difficult.

Varicose Veins Recurrent After Sclerotherapy

Varicose veins recurrent after sclerotherapy may present segments of different

diameter and consistency that may be difficult to evaluate and mark by clinical

examination alone. Some segments may be stiff and their caliber may appear

much smaller than it really is. If the sclerotherapy-induced inflammatory reaction

has involved the outer layer of the vein and the perivenous tissue (excessive

dosage of sclerosant or insufficient compression), then the recanalized vein

may be adherent to surrounding tissues. In this case, more and larger incisions

may be necessary; the vein may be difficult to dissect and avulse, and

removal may be incomplete. In the presence of thick perivenous fibrous invest-

ment, diffusion of anesthesia may be inadequate and supplementary anesthetic

injections may be necessary.

Varicose Veins Recurrent After Traditional Surgery

The areas of surgical scars are also difficult to operate through. Supplementary

anesthesia is often needed because of poor diffusion in the fibrous tissue.

Veins around the scars are adherent and break easily upon traction. Occasionally,

a segment of the GSV or other varicose veins left in place develop thrombophle-

bitis. If not adequately treated, such segments may become very adherent to the

surrounding tissue and be extremely difficult to avulse.

Superficial Thrombophlebitis

As previously mentioned, superficial thrombophlebitis is first treated by throm-

bectomy and compression. Larger incisions and thorough dissection are necess-

ary to avulse the thrombosed segments. If phlebectomy is performed too early,

some segments may stay in place and later recanalize with varicose vein

recurrence.

Patients with long-standing varicose veins sometimes develop extensive

perivenous adherence as a result of recurrent subclinical phlebitis, and in such

cases, phlebectomy is unexpectedly difficult.

Lipodermatosclerosis

As previously mentioned, lipodermatosclerosis is best treated with graduated

compression with phlebectomy performed only after adequate cutaneous soften-

ing. However, when little improvement is expected by compression treatment,

that is, in cases with diffuse perivenous and venous wall calcifications,


phlebectomy can be performed in the lipodermatosclerotic area. In this case, at

best only pieces of veins are avulsed (Fig. 9.18). However, the resulting damage

to multiple vein segments, combined with compression therapy, causes signifi-

cant obliteration of the abnormal varicose venous network, followed by clinical

improvement. Sclerotherapy may be useful for treating residual varicose veins.

Thin Skin

In some patients the skin of the lower leg may be thinned and fragile because of

age or prolonged steroid treatment. Such skin may easily lacerate during phle-

bectomy, but heals promptly under compression therapy.

Figure 9.18 (a) Phlebectomy within a lipodermatosclerotic area is a difficult procedure.

Bleeding is common. Only small pieces of veins are avulsed. (b) This is in contrast with

phlebectomy in early stages of varicose vein disease: virtually no blood loss, long segment

avulsed through few minimal incisions.

Phlebectomy 141

Venous Leg Telangiectasia

Venous leg telangiectasia are tiny superficial vessels, 0.1–1 mm diameter. They

may appear alone or associated with larger (1–4 mm diameter) incompetent

dermal (“reticular”) veins. We first avulse the larger veins through needle punc-

ture incisions, with the number 1 Muller hook. This procedure invariably reduces

the number and size of associated telangiectasia. Even some large blue telangiec-

tasia, 0.5–1 mm diameter, can be directly avulsed or at least partially destroyed

[Fig. 9.19(a, b)]. In addition, further destruction of telangiectasia may be

Figure 9.19 Treatment of venous leg telangiectasias. (a) Some large blue telangiectasia

(�1 mm diameter) may be—at least partially—avulsed. (b) Two days after phlebectomy.

Post of the blue telangiectasia has been avulsed, but some of the tiny red telangiectasias are

still visible. Further destruction of telangiectasia may be achieved by subdermal scratching

of areas of dense telangiectatic flares. (c) Technique of subdermal scratching with 0.1

Muller hook. (d) Directions of scratching. P, point of entry of the hook. (e) Telangiectatic

flare crossed by an incompetent dermal (reticular) vein. (f) Five days after avulsion of the

reticular vein and scratching of the telangiectatic flare. Some bruising in the upper left

angle of photogram. Needle puncture points are clearly visible. Telangiectasia have

been greatly reduced in number and size, but need further treatment (sclerotherapy) to

completely disappear.


achieved during phlebectomy, by “scratching” areas of dense telangiectatic

“flares” with number 1 Muller hook, as illustrated in [Fig. 9.19(c, d)].

However, phlebectomy cannot completely eliminate telangiectasia, most of

which have to be destroyed by sclerotherapy if the best possible cosmetic result is

to be achieved. Sclerotherapy may start as soon as 1–3 weeks after phlebectomy.

We inject telangiectasia with 72% glycerin or with sodium salicylate, and, if

these sclerosing solutions are too mild, with 0.5% polidocanol (Aethoxysklerol,

Kreussler, Germany), or with sodium tetradecyl sulfate (S.T.D. Limited,

Hereford, England). These two last agents may be used in a foam form (1:3 or

1:4 with air, at 0.5% or 0.25%, respectively). All our patients wear elastic

stockings, 20–30 to 30–40 mm/Hg (Class I–II) as needed, for the entire

duration of treatment. The discussion of sclerotherapy is beyond the scope of

this book, but may be found in many excellent sources. Our technique for scler-

otherapy of telangiectasia is described in detail elsewhere (1).

Periorbital Veins

Their avulsion is requested for cosmetic purposes only. They are very thin and

delicate and sometimes difficult to identify because of a spasm reaction to

trauma (anesthesia, incision). Skin incisions are made by needles and the finest

hooks are used. Only one or two skin incisions are needed for the whole pro-

cedure. The dangerous site is the temporal because of the proximity of motor

branches of the facial nerve. Compression is applied directly after the avulsion

and maintained for 10 min. Bleeding is uncommon as the venous pressure is

usually low, unless a Valsalva-like activity is made.


Phlebectomy 143

Hand

Hand veins may become cosmetically upsetting by aging, as a consequence of the

skin atrophy. Their avulsion is easy. They are superficial and often mobile in the

subcutaneous space and, like in the foot, it is often necessary to pull up a skin fold

to make the incision and hook the vein. Small nerve branches run superficially

below and around the veins. If their damage is limited the consequences are

inconsistent, but patients must be aware of the potential for sensory impairment.

For this reason the extent of the phlebectomy should be limited and the mani-

pulation is particularly delicate.

REFERENCE

1. Goldman MP, Bergan JJ, eds. Sclerotherapy Treatment of Varicose and Telangiectatic

Leg Veins. 3rd ed. St. Louis: Mosby, 2001.


10

Post-Operative Medicationand Bandaging

MEDICATION

At the end of surgery, the skin is cleansed with saline or hydrogen peroxide to

remove blood residue and Hibiclens solution as an antiseptic, followed by dry

gauze. Any residual bleeding is stopped by digital pressure, and, if needed,

the Trendelenburg tilt of the table is increased. Any fibrous and/or adipose

tissue extending from the incisions is torn off or cut to insure optimal wound

closure and to prevent bacterial migration from the skin surface into the surgical

wound.

Sometimes, adherence at the incision sites may form between skin and sub-

cutaneous tissues. If this occurs, the skin edges may retract and form a depressed

scar. This is more likely to occur at sites of vein ligature from retraction

of the ligated vein that pulls on the perivenous tissues. To avoid this, a hook

or one branch of Graefe forceps is introduced through the incision, and the

skin is pulled up abruptly a few times until the adherent subcutaneous layers

are detached.

Incisions are not sutured but closed with simple band-aid or surgical

tape. A skin adhesive is applied first to the skin to increase the adherence of

the tape dressing. When the incisions are small, no attempt is made to approxi-

mate their edges further; the elasticity of the tape is sufficient to insure optimal

wound closure. On the contrary, the edges of larger—greater than 3 mm—

incisions are approximated with 5-O Vicryl dermal suture and then closed

with band-aids or surgical tape. If necessary, we apply the tape with overlap-

ping in a zig-zag pattern; this way, when removing them, pulling the first one

detaches them all.

145

BANDAGING

Adhesive Bandage

The purpose of the adhesive compression bandage is to prevent bleeding, avoid

post-surgical edema, and allow comfortable ambulation. In addition, it produces

an analgesic effect, making systemic analgesic medication unnecessary in a large

majority of patients.

Before applying the adhesive bandage, the limb must be prepared with

some “lining.” The skin is first protected by a few layers of thin polyurethane

underwrap or absorbent gauze, then local gauze or cotton pads are placed over

the operative sites to enhance local compression to absorb any bleeding. These

are fixed with a few more layers of underwrap. Joints and bone prominence

are protected by protective cotton wool or rubber pads fixed also with underwrap;

then the adhesive bandage is applied. This consists of overlapping layers of

Figure 10.1 One week after phlebectomy; hematoma formation above the upper end of

a postoperative bandage that was too short.


8–10 cm large elastic adhesive bandage. It must not be applied at maximum

stretch; if additional compression is needed, more layers are applied.

The adhesive bandage must extend, both distally and proximally, �10 cm

beyond the operated area to avoid bruising, edema, and hematoma formation

(Fig. 10.1).

In the past, the adhesive bandage was applied proximally for several centi-

meters directly on skin contact to obtain a firm anchorage of the whole bandage

and prevent slipping during ambulation. This very helpful detail was frequently

followed by blister, erosions and pain, and skin lesions at the moment of bandage

removal, caused by the excessive glue adhesion to the skin. At present we

perform the same anchorage using bandages with acrylic glue. The adhesion is

lower but sufficient while the harm to the skin has nearly disappeared.

As a rule, the compressive bandage includes the foot to prevent pedal

edema. An exception is made in purely “cosmetic” cases without edema, when

the foot and lower leg may be left without adhesive bandage. In such cases,

however, the patient must put a bandage or graduated elastic stocking over the

foot and lower leg to prevent a tourniquet effect from the bandage.

It must be realized that it is the compression bandage that makes ambula-

tory phlebectomy possible. In other words, it is mandatory to acquire skill

in applying adhesive compression bandages prior to engaging in phlebectomy.

Because of its importance, the technique of leg bandaging is described separately

and in detail in Chapter 14.

Before applying the adhesive bandage, the operating table is returned to

horizontal position so that the patient may gradually resume an upright position.

Once the leg is bandaged, the patient is invited to sit with the legs off the table,

and if this change of position does not cause dizziness, to step down. A few

minutes of walking in the operating room is necessary to test the bandages.

The bandages must not cause pain or obstruct normal walking. Bleeding must

not occur. If compression is inadequate to prevent bleeding, it is usually

noticed during the first few minutes while in the upright position. In this case,

the patient is put back in Trendelenburg position and the bandage is partially

(or completely) removed. Local compression is reinforced and/or more layers

of adhesive bandages are applied as needed (Fig. 10.2). The possibility of such

bleeding, although rare, must be explained to the patient in advance to avoid a

potentially frightening experience. Bleeding is always caused by inadequate ban-

daging, never by “bad luck” (or by the patient).

Removable Bandages

After 5 min of walking with the adhesive bandage alone, a short- or medium-

stretch bandage or graduated stocking is applied from foot to knee (or thigh).

This bandage is to be worn during the day, in upright position, and taken off

during the night, in the recumbent position. The purpose of this removable

bandage is to give supplementary compression and avoid foot swelling,

Medication and Bandaging 147

Figure 10.2 In case of bleeding: (a) the bandage is partially removed; (b) the compression

pads soaked with blood are replaced with new pads; and (c) the bandage is reapplied.


especially if there is no adhesive bandage on the foot. If only dermal (reticular)

varicosities have been removed, an 18–21 or 30–40 mm/Hg graduated stocking

(compression Class I–II) may be applied instead of bandages.

With the leg so bandaged, the patient leaves the operating room and walks

in the hallway or recovery room for 5–30 min, according to the type of surgery

and the patient’s conditions. It is exceptionally rare for a patient to be in the office

for a longer time period. Bleeding with the patients already dressed—or out of the

office—is extremely rare and very unpleasant to both the patients and every-

body around them. It is to be avoided at any cost, but still may rarely occur.

Such “late bleeding” is probably due to insufficient muscular contraction

during the first few minutes of walking; later on, the patient starts walking

more vigorously and venous pressure may reach a “critical” threshold and

cause bleeding, which is initially absorbed by the lining pads and comes out later.

Medication and Bandaging 149

11

Patient Discharge

In the beginning, patients tend to keep the operated leg stiff, because of the press-

ure and traction exercised by the bandage. They must be therefore encouraged to

relax the leg and ambulate vigorously, so that the bandage may adapt to the

limb’s shape. Upon resuming normal walking, the patient can leave the office.

Elderly or anxious patients, as well as those operated on for the first time,

are advised not to come alone, but with an accompanying person; patients

familiar with the procedure often choose to come alone. If the patients go

home by car, they are advised to sit on the front seat with the leg only slightly

flexed in the groin and knee. Though it is possible for the patients to drive—as

practiced during the 1920s in Chicago by De Taketz (1)—they are advised not

to do so immediately after surgery, as they may not yet feel the leg fully efficient

with the bandage.

Anti-inflammatory/analgesic medication (e.g., piroxicam, 20 mg, Tylenol

with codeine, etc.) is prescribed, though many patients do not feel the need

to take it. Information regarding the post-operative period is given orally and

in a written form; the written instructions given to every patient are reproduced

in Appendix 1.

It is mandatory to be personally available on call so that the patient may

contact the surgeon at any time, should the need arise. In our experience such

calls are not frequent, and it is usually possible to reassure the patient—or give

instructions—on the telephone. We recommend routinely calling each patient

in the evening after surgery to answer any additional questions they might

have and encourage proper post-operative care. However, if needed, the

patient must be seen before the scheduled appointment or even at home (which

is, in our experience exceptionally rare).

Once, a patient was admitted to the hospital during the day after the oper-

ation. This was an older lady, left home alone, who started bleeding a few hours

151

after surgery. Caught by panic, she was unable to follow the instructions—“lay

down, elevate the leg, then call us”—but instead ran out of her home crying

for help, so that her neighbors called an ambulance and brought her to the

nearest hospital. This “unique” case emphasizes the importance of giving

detailed instructions prior to discharging the patient, as well as avoiding office

surgery on patients who live alone and are not self-sufficient.

REFERENCE

1. de Taketz G. Ambulatory ligation of the saphenous vein. J Am Med Assoc 1930;

94:1194.


12

Post-Operative Managementand Follow-Up

POST-OPERATIVE MANAGEMENT

Between Phlebectomy Sessions

When further phlebectomy or sclerotherapy sessions are scheduled within

1 week, the adhesive bandage and compression pads applied at the previous

session are removed, whereas the protective underwrap and band-aids are

left in place (Fig. 12.1). The adhesive bandage is then reapplied directly over

the underwrap, without local compression pads. If there is any pain or bleeding,

the underwrap is also removed, so that the leg may be directly examined; if there

is induration, local compression pads are reapplied.

After the Last Operation

The post-operative adhesive bandage (POB) is removed completely 5–7 days

after the last operation. It is cut longitudinally and delicately detached from

the skin; any residual adhesive material is wiped off with Detachol (Ferndale

Laboratories, Inc., Ferndale, MI) adhesive remover.

The limb is then examined by observation and palpation, in a recumbent

and upright position. Bruising may be completely absent, or may be due to the

bandage rather than to the phlebectomy itself; however, some bruising is normal

and has no clinical significance. Failure to completely remove the marked vari-

cose veins may also sometimes be appreciated early; residual vein segments

are palpated as painless fluctuating spots or cords, and can be removed immedi-

ately or later. If the skin is irritated, absorbent powder and/or a 2.5% hydrocor-

tisone lotion is applied prior to the application of the new compression bandage

(or stocking).

153

Figure 12.1 Management between phlebectomy sessions. (a) On the day of the first

phlebectomy (September 29); (b) two days later, the adhesive bandage, local compression

(cotton) pads, and protective underwrap (blue) are removed, but the band-aids are left in

place (October 1); (c) after finishing the second phlebectomy, the leg will be bandaged

again (October 1). Note the extent of vein avulsion with second operation.


Further Compression

The duration and type of further compression are decided individually and may

vary considerably from one patient to another. This depends on the underlying

disease and the conditions of the limb prior to surgery and upon removal of

the POB. The general rule is that some compression is applied to all limbs

while the signs and symptoms of surgery persist.

In cases of edema-free limbs with only dermal varicosities, without exten-

sive bruising, hematomas, or tender spots, a Class I 20–30 mm/Hg graduated

stocking (pantyhose) may be sufficient. These should be worn for at least

2 months or until local tenderness disappears.

At the other extreme are limbs with very large and/or widespread varicose

veins, chronic edema, extensive bruising, hematomas, local inflammation, and

tenderness. These patients must have adhesive compression bandages until most

symptoms disappear, usually 1 or 2 more weeks. If, of course, the underlying

disease, that is, symptomatic post-thrombotic deep vein incompetence, warrants

lifelong compression treatment, adequate compression—bandage or stocking—is

continued indefinitely.

The importance of continuing compression beyond the first week after

surgery must not be underestimated. Sometimes, upon the removal of the POB,

the limb is in excellent condition, so that further bandaging may seem unnecess-

ary. However, this may be due to the action of the POB, while the limb itself has

not yet healed from trauma of surgery. In such cases, if only a Class I graduated

compression stocking is prescribed, it may not be sufficient to protect the limb

from the action of the force of gravity, and local edema, inflammation, and dis-

comfort may appear. Stronger compression bandages may thus become necessary

again—and for a longer period of time—until all local symptoms disappear.

Continuing compression is also important for cosmetic reasons; inadequate or

too short a time for compression is probably responsible for many cases of per-

sistent skin discoloration, scar hyperpigmentation, and telangiectatic matting

around the scars and along the operative sites.

Type and Duration of Compression

After removal of the POB, compression may be continued by four means:

adhesive bandages, removable bandages, high compression, Class II–III 30–40,

36–46 mm/Hg, stockings or Class I 20–30 mm/Hg stockings. The choice

depends on the limb’s condition and necessity of sclerotherapy. The guidelines

for employing different types of compression are outlined as follows.

If there is only localized induration, the segment involved is compressed by

a ring of adhesive bandage, with or without compression padding. This segmental

adhesive bandage is kept in place for a few days or a week. During the day, the

patient applies an additional graduated compression stocking or bandage.

If there is extensive induration and/or edema, the entire leg must be ban-

daged. In these cases, especially if there is pain, a short-stretch adhesive bandage

Management and Follow-Up 155

is preferred. This is because, in case of pain, the patient may find it difficult to

apply the bandage alone, and thus give up bandaging, which will only increase

the symptoms and delay healing.

If symptoms are mild, the patient may apply a removable bandage for

daytime use only. A tubular plastic bandage (i.e., Tubigrip) under the removable

bandage remains on the leg at night.

If the leg is relatively asymptomatic, a double layer of graduated com-

pression stockings is worn during the day. One stocking is kept in place during

the night, and the patient applies the other stocking over it during the day.

Once most symptoms—especially pain—disappear, the bandage may

be replaced by light-weight compression stockings, which are preferred by

many—especially female—patients. The stockings are worn until all signs of

surgery and/or sclerotherapy disappear, or for �2 months; 10–20 mm/Hg or

20–30 mm/Hg stockings may be employed as needed. Though 10–20 mm/Hg

stockings are easy to use, higher compression (20–30 mm/Hg to 30–40 mm/Hg)

stockings are difficult to put on and take off, so that their use requires some

skill. The patient must be therefore adequately instructed by a staff member on

stocking application.

It is important not to replace bandages with high compression stockings if

pain is still present at the operated sites, because the stocking may not only be

insufficient to control the symptoms, but also painful to put on. If the patient

fails to put it on, this will only aggravate the symptoms the stocking was sup-

posed to control. How to put on and remove compression stockings is described

in Chapter 13.

FOLLOW-UP

Adequate follow-up is important for the successful management of patients with

venous disorders. The follow-up program is decided individually and varies from

patient to patient.

For patients who do not need continuous treatment and control, follow-up

visits are scheduled at 2 and/or 12 months after surgery. Two months after

phlebectomy, the functional and cosmetic results of surgery can be appreciated.

Scars still may be erythematous or not visible. Patients are reassured that these

red spots will disappear with time. This varies individually and may take, in

some cases, 12–18 months for complete resolution.

All patients are advised to come back for a check-up 6–12 months later

(though many—especially those with no problems—will not come). These

visits are important and useful to both patient and surgeon. Surgeons have the

opportunity to check the results of their work, while the patient may benefit

from the early diagnosis of an eventual varicose vein recurrence or other symp-

toms related to venous insufficiency. Patients must be told that surgery is limited

to the elimination of the clinically evident varicose veins. Though for some


patients this may result in a definitive cure, it is not always so, as varicose veins

are a chronic and progressive disorder. Though the removal of clinically evident

varicose veins probably slows down disease progression, there are cases in

which, no matter what the initial treatment, other veins may dilate and become

varicose. Therefore, all patients are advised to use regularly light-weight gradu-

ated pantyhose (or below-knee stockings for the male patients), as this is the best

way to counteract the force of gravity, and prevent the development of varicose

veins and symptoms of venous insufficiency. Insisting on these concepts is

important and useful to both patient and surgeon. Patients are less likely to

neglect their legs, and surgeons may—with a few simple treatments over many

years—maintain the patients’ legs and their own reputation in good condition.

Patients who disappear for 10 years and only then report back often have their

legs in poor condition, and may blame the physician.

Patients in Need of Special Care

For some patients, the general recommendation to use light-weight graduated

compression stockings is not sufficient. Major and continuous compression is

necessary to control the signs and symptoms of venous insufficiency. These

patients should be seen more frequently. A typical example is patients with

post-thrombotic syndrome, who need lifelong adequate compression to prevent

the recurrence of varicose veins and/or symptoms of venous insufficiency.

To give these patients the illusion that varicose vein removal “cured” their

legs—and fail to provide further assistance—is irresponsible. Though varicose

vein surgery is certainly of benefit in these cases, it does not cure the underlying

deep vein incompetence (or occlusion) and thus does not restore a physiologic

vein flow pattern. These patients need lifelong compression treatment and

must be controlled in the office as often as needed.

Optimal compression may be achieved by different means according to the

patient’s and doctor’s preference. No matter what type of compression is chosen,

its efficacy is checked by the patient every evening: if there is pitting tibial

edema, then more compression is needed. Continuous daytime compression is

limited almost always to the leg (below-knee support) and can be obtained

basically in two ways.

First, by short- or medium-stretch bandages applied by the patient every

morning and removed in the evening. If patients pass much time at home, they

may wear the bandages only at home, and replace them with 20–30 mm/Hg

graduated stockings when out. Some—especially elderly—patients find this

program optimal to maintain their legs symptom-free.

Secondly, one is to wear high compression (30–40 mm/Hg or 40–

50 mm/Hg) below-knee stockings instead of bandages. This may be preferred

by many, especially young patients. Lower leg stasis changes must be completely

healed under the compression bandage, before stockings are applied. For older

Management and Follow-Up 157

patients who are unable to put on high compression stockings, two lower

compression (10–20 mm/Hg) stockings put one over the other may have the

same effect.

Leg conditions of patients with chronic and surgically incurable venous

disease depend on the patients’ knowledge of the nature of the disease and

the ability to manage it. We find it useful to provide selected patients with

written instructions on how to maintain their legs in good condition (see

Appendix 1).


13

Small Saphenous Vein Phlebectomy

The varicose small saphenous vein (SSV), treated by most authors by the tra-

ditional ligation and stripping operation, can also be avulsed—and in our

opinion advantageously—by ambulatory phlebectomy (AP) (1,2). The vein is

in fact accessible to phlebectomy from its origin behind the lateral malleolus,

to its termination in the popliteal fossa. However, phlebectomy of the SSV is

more difficult than that of the epifascial collateral veins and differs in some

aspects from the general description of phlebectomy in Chapter 9. It is therefore

described separately in this chapter. The difficulties particular to this vein are due

primarily to two anatomical features:

1. The SSV is enveloped into a duplication of the aponeurotic fascia and

is therefore subfascial.

2. The distal portion (and sometimes the entire length) of the SSV lies in

close approximation with the sural sensitive nerve, to a point that

occasionally may make it impossible to separate vein from nerve.

DIAGNOSTIC WORK-UP

The diameter of the normal SSV is 1.7–4.5 mm (average 3.1 mm) (3), but when

the vein is incompetent and dilated, it usually exceeds 6 mm and may reach

�10 mm. The dilated and incompetent SSV is almost invariably accompanied

by collateral varicose veins. Quite often only the latter are clinically evident,

whereas the SSV, due to its subfascial course, may not be visible, even when

grossly dilated (Fig. 13.1). For this reason, SSV incompetence is probably the

most frequently missed diagnosis in varicose vein disease. It is therefore import-

ant to investigate the SSV for dilatation and incompetence in every patient with

varicose vein and/or venous disease.

With some experience, the dilated SSV can be appreciated by manual

examination (palpation and percussion, see Chapter 3), at least in some points

159

Figure 13.1 The dilated and incompetent SSV is almost invariably accompanied by col-

lateral varicose veins. (a) Preoperative marking of the incompetent segment of the SSV; A,

level of saphenopopliteal junction; B, uppermost palpable point; C, distal end of the

incompetent portion. (b) Anterior view of the same leg; often only the collateral varicose

veins are visible, although the SSV itself is not, due to its subfascial course. (c) The

anterior and medial varicose veins remain empty while the saphenopopliteal junction is

kept obliterated by digital pressure (and rapidly fill upon release), confirming the retro-

grade filling through the incompetent saphenopopliteal junction.


where it is more dilated, and in the popliteal fossa, where the overlaying connec-

tive tissue layers are less tight. Doppler reflux examination confirms the presence

and extent of reflux. However, pre-operative duplex scanning of this area is extre-

mely useful. It allows one to obtain information not accessible to clinical and

Doppler examination, that is, visualize and localize the saphenopopliteal junction

(SPJ), reveal other sources of reflux in the popliteal or muscular calf veins

that may superimpose with SSV reflux (and thus be confused with the latter

by Doppler examination alone), and detect unanomalous termination of the

gastrocnemius veins into the SSV (Fig. 13.2). Double SSV segments, as well

as large popliteal perforators (popliteal area vein), may also be diagnosed and

properly treated. In the absence of precise anatomical diagnosis, even the experi-

enced operator may remove a long varicose vein but still miss a second one, that

is, a double SSV segment, popliteal area vein, and varicose collateral, or even the

SSV itself.

Figure 13.2 Duplex scan of the popliteal fossa; PV, popliteal fossa (competent); SSV,

short saphenous vein (incompetent); GCV, gastrocnemius veins (incompetent). Note

how in this case two gastrocnemius veins terminate into the SSV instead of directly

into the popliteal vein. Such anatomic and functional details (complex reflux patterns)

are impossible to appreciate by clinical and Doppler examination alone. (From Belcaro

GV: Vene, Edizioni Minerva Medica, Torino, 1992.)

Small Saphenous Vein Phlebectomy 161

STAGING

The SSV is always avulsed in a single session, and usually 1–1.5 h is scheduled

for this operation, which may prove to be time consuming. Varicose collaterals

on the posterior aspect of calf and leg, especially if fed directly by the incompe-

tent SSV, are usually avulsed together with the SSV.

Varicose collaterals on the medial, lateral, or anterior aspect of the leg may

be avulsed at a separate session(s). The order is not important. If they are avulsed

together with the SSV, the patient must change position during surgery, and some

of the operative sites could be moved out of sight, increasing the risk of bleeding,

and hematoma formation. If the great saphenous vein (GSV) has to be removed

too, this is done after avulsion of the SSV.

PRE-OPERATIVE MARKING

The SSV is marked with the patient standing, the leg in nonweight-bearing

position, and the knee slightly flexed. All varicose veins and the incompetent

portion of the SSV are marked. It is of utmost importance to mark with a separate

(transverse) sign the sites where the SSV is more easily palpable. In these sites,

as well as the sites of side branch confluence, the SSV is more easily retrieved and

hooked. In the popliteal fossa, two points are marked with a transverse sign: the

uppermost palpable point and the uppermost reflux point as determined by

Doppler and/or duplex examination [Fig. 13.1(a)].

ANESTHESIA

Total SSV avulsion can be usually performed with as little as 40 mL of anesthetic

solution. Superficial infiltration is performed first, then deeper infiltration of

the anesthetic is given into the popliteal fossa and along the proximal portion

of the SSV.

POSITION OF PATIENT

The patient is placed in prone Trendelenburg position, with a support under the

ankle, so that the patient may keep the leg relaxed (Fig. 13.3).

TECHNIQUE

Incisions

The incisions are vertical and longer (2–4 mm) than usual. Only the uppermost

(popliteal) incision, 3–5 mm, is horizontal within skin tension lines. To start the

operation, the first incision is made as described subsequently and the vein exter-

iorized; then the next incision is made along the course of the vein proximally.


Starting the Phlebectomy

Few instruments are necessary for this operation: Graefe forceps, toothed clamp,

and an endoluminal probe (Fig. 13.4). As a rule, the operation is started from the

distal point of the segment to remove [Fig. 13.5(a)]. If the SSV is to be totally

removed, then the vein is first hooked in its extrafascial portion. Nevertheless,

even this distal portion is not easy to retrieve and hook. It is embedded into a

Figure 13.3 Position for phlebectomy of the SSV; the patient is in the prone

Trendelenburg position with a support pad under the ankle.

Figure 13.4 Instruments for ambulatory phlebectomy of the SSV; (a) Graefe iridectomy

forceps; (b) Toothed clamp (12 to 14 cm); (c) Endoluminal probe (blunt needle);

(d) Endoluminal probe (curved tip).


Figure 13.5 The technique of phlebectomy of the SSV. (a) As a rule the operation is

started from the distal (extrafascial) portion of the SSV, preferably over a saccular dilata-

tion for easier hooking. (b) In the presence of a large varicose side branch, it is con-

venient to start operating by hooking the side branch. (c) With the side branch kept

under traction, the SSV trunk becomes tense and easier to identify and hook from a sep-

arate incision after perforating the overlying fascial layer. (d) Piercing the overlying

fascia with to-and-fro longitudinal rocking action (or rotary movement) with the tip of

the Graefe forceps. (e) If the previous maneuver fails, the fascia may be hooked with

one branch of the Graefe forceps and cut with the point of the no. 11 scalpel blade.

The resulting incision is then enlarged bluntly with the tip of the Graefe forceps. (f) If

hooking of the SSV trunk proves difficult or causes an “electric shock” sensation due

to touching the accompanying nerve, the vein may be grasped with a toothed clamp.

This is done by introducing the closed mosquito (or Graefe), forceps, pushing it deep

until it stops, then opening and closing it repeatedly until the vein is grasped. Once

the SSV trunk is hooked and exteriorized, its retrieval is greatly enhanced by the use

of an endoluminal probe.

Continued


Figure 13.5 Continued For this purpose the probe is inserted into the SSV and the

SSV is hooked with the Graefe forceps (g) or grasped with the toothed clamp (h) together

with the probe.

Continued


Figure 13.5 Continued (i) The probe is then pulled out, leaving the SSV trunk in the

forceps. ( j) The free end of the SSV is avulsed and the procedure repeated until the

entire length of the SSV is exteriorized from the uppermost (popliteal) incision.


compact fibrous connective tissue layer and often lies close to the sural nerve. For

this reason, the SSV trunk should be manipulated with the Graefe forceps only

and toothed clamp, and never hooked with a Muller hook, pulled abruptly, or

divided percutaneously by needle, because of the risk of nerve damage.

If during the search and manipulation of the SSV trunk the patient feels

an “electric shock” sensation, manipulation must stop and then start again. If

the SSV cannot be hooked without causing electric shock sensation, it must

be tried again from a new (more proximal) incision. Sometimes the nerve is

exteriorized together with the vein. In this case, it can be separated and left in

place, but its manipulation may be followed by a loss of sensitivity, which

may last from days to weeks. Occasionally it may be impossible to separate

the vein from the nerve, and in such case it might be advisable to leave the

distal portion of the SSV in place rather than damage the sural nerve; a short

distal incompetent SSV segment may be of little clinical significance.

If only the proximal—subfascial—portion of the SSV is to be removed, the

first incision is placed over a palpable point of the SSV or a side branch. A side

Figure 13.5 Continued The SSV is pulled up until it yields, force from its perivenous

tissue, ligated with #3-0 catgut or Vicryl suture (k), and divided (l).


branch is usually easier to hook, and, kept in traction, may put tension on the SSV

trunk to facilitate its retrieval and hooking [Fig. 13.5(b) and (c)].

Prior to hooking the subfascial portion of the SSV, it is necessary to pierce

the overlying fascia. This can be done by a to-and-fro longitudinal rocking action

(or rotary movement) of the tip of the Graefe forceps [Fig. 13.5(d)]. If this man-

euver fails, then the fascia is hooked with one branch of the Graefe forceps, exter-

iorized through the skin incision, and cut with the point of number 11 scalpel

blade [Fig. 13.5(e)]. The resulting incision is then enlarged bluntly with the tip

of the Graefe forceps.

Owing to its deep position, the SSV is rarely hooked completely. Instead,

its perivascular connective tissue or upper wall is hooked. It is then pulled out

[Fig. 13.5(f )] and grasped with the toothed clamp until a loop is exteriorized.

If the hooking maneuver is fruitless, the SSV may be grasped with either the

Graefe or the hemostatic forceps, and pulled out. In this scenario, the forceps

are introduced closed, pushed deep until it stops, then opened, and closed

again repeatedly until the vein is grasped.

Once the loop is exteriorized, it is double clamped and divided. If the incision

is not at the most distal end of the portion to be avulsed, then the distal segment of

the SSV is avulsed first, followed by avulsion of the proximal portion.

Distal Progression

When phlebectomy needs to be continued distally, the free end of the distal SSV

segment is kept under traction, so that it can be palpated under the skin as a hard

cord. The next incision is placed over a point where the cord is still palpable (the

cord in fact “fades” at a certain distance), and the vein is hooked and extracted

through the new incision. The procedure is repeated until the entire marked

segment is completely exteriorized. The vein is then divided at its lowest end

without ligating the residual distal stump; bleeding is prevented by a few

minutes of digital pressure.

Proximal Progression

To proceed proximally, the next incision is performed at a distance of 5–15 cm,

and the fascia is pierced or cut and dissected as described. SSV retrieval through

the new incision is facilitated by the use of an endoluminal probe (blunt needle

type probe or our specially designed probe, Sonda BD 14700-16; Chirurgica

SpA, San Lazzaro di Savena, Bologna 40068, Italy) (see Fig. 13.4). The probe

is inserted into the free end of the SSV and pushed upwards. With the probe

inside, the vein is easily localized and hooked with the Graefe forceps, or

grasped with either the Graefe or the hemostatic forceps, through the previously

prepared fascial incision together with the probe [Fig. 13.5(g) and (h)]. The probe

is then pulled out, leaving only the vein in the forceps [Fig. 13.5(i)]. The portion

of the SSV between the two incisions is then pulled out from the proximal

incision and the procedure is repeated as many times as needed until the entire


length of the SSV is exteriorized from the uppermost (popliteal) incision

[Fig. 13.5( j]). The use of the endoluminal probe allows one to reduce the

number of incisions, especially over the proximal portion of the SSV, which is

often avulsed through two incisions only: one in the popliteal fossa and one at

the gastrocnemius point (mid-calf perforator).

The proximal half of the SSV typically has only few side branches and

perforators. Often there is no branching between the gastrocnemius point and

the SPJ (4) (J Staubesand and H.M. Hoffman, personal communication, 1992).

Typically, the proximal portion is elongated, so that it yields and stretches

upon traction, facilitating avulsion. If there are collaterals, it is usually possible

to palpate them when they are under traction, and divide them by needle punc-

ture, especially if they are accurately marked.

Saphenopopliteal Division and Ligation

The horizontal popliteal incision is usually performed at the uppermost palpable

point of the SSV, at (or close to) the popliteal crease, which corresponds to the

knee joint (see Fig. 13.7). This palpable, or even bulging, point usually corresponds

to the site where the varicose SSV bends anteriorly to approach the popliteal vein.

In fact, as the varicose SSV is almost always elongated, but cannot become sinus-

oid because of its tight fascial “envelope,” it often tends to form this bulging angle

in the popliteal fossa, where the overlying connective tissue layers are less tight and

resistant. The SSV is retrieved from the popliteal incision with the help of an endo-

luminal probe and is avulsed as previously described. Once a loop is exteriorized,

the distal part is avulsed completely with traction on the vein and skin (and discon-

nection of the collaterals, if any). At this point, the terminal portion of the SSV is

pulled until it yields (1–2 cm), freed of its perivenous investments and ligated as

high as possible with #3-0 absorbable suture and divided [Figs. 13.5( j–l)]. If the

duplex scan has shown that a competent gastrocnemius vein terminates into the

SSV, then the SSV may be ligated below this termination, to avoid interruption

of physiologic gastrocnemius vein drainage (see Fig. 13.2).

The exact site of saphenopopliteal ligation was investigated by duplex scan

in 18 limbs with “standard” type SSV and SPJ within 5 cm proximal to the popli-

teal crease. In four limbs (22%) no stump was found, whereas in the remaining

14 limbs there was a short stump, running subfascially, almost parallel to the popli-

teal vein. In 12 cases (67%), the stump was 1.0–2.5 cm long and in two cases

(11%) 3.4 and 4 cm, respectively (Fig. 13.6). This study demonstrated that high

(not flush) ligation of the SSV in the popliteal fossa, considered adequate by

authors who practice traditional surgery (5–8), is also achievable by AP.

Higher Popliteal Incision

The standard type SSV may join the popliteal vein at—or close to—the level of

the uppermost palpable point [Figs. 13.7 and 13.8(a)], so that incision at this point

will allow optimal saphenopopliteal ligation [see Fig. 13.6(a)]. However, when


the SSV joins the popliteal vein �3 cm higher than the uppermost palpable point

[Fig. 13.6(a)], an incision over the latter may result in low SSV ligation with a

longer residual stump [Figs. 13.6(b) and 13.8(b)]. Here, it may be possible to

make the incision higher than the uppermost palpable point and obtain higher

SSV ligation, with the help of the endoluminal probe [Fig. 13.8(c) and (d)]. For this

purpose, the endoluminal probe is pushed upwards into the SSV, and the incision

is made at the uppermost point where the probe’s tip is still felt close to the skin

surface [Fig. 13.8(c)]. With this maneuver, it is usually possible to make the

popliteal incision within 3 cm distally to the SPJ when the latter is situated up

to 5–6 cm proximal to the popliteal crease.

Figure 13.6 Postoperative duplex scan of the popliteal fossa to determine the level of

saphenopopliteal ligation. (a) Minimal (shorter than 1 cm) stump; (b) longer (1.4 cm)

stump. (A courtesy PL Antiganni, MD.)


Atypical Popliteal Terminations of the SSV

The standard type SSV with termination within 5–6 cm proximal to the popliteal

crease is the one most frequently encountered. However, rarely there is no con-

nection between the SSV and the popliteal vein. In these patients, the main SSV

trunk joins the GSV via the intersaphenous thigh anastomosis (Giacomini vein),

or continues deep into the posterior thigh as the femoropopliteal vein, or divides

into many small thigh branches. If these terminations are incompetent, they are

treated as follows: the Giacomini vein is traced with Doppler and/or duplex

scan and avulsed (in these cases, the GSV is invariably incompetent and is

also removed) (Fig. 13.9). The femoropopliteal vein is ligated as high as possible,

whereas the small thigh branches are torn off without ligature.

POST-OPERATIVE COMPRESSION

After closure of the wounds with tapes, a compression adhesive above-knee

bandage is applied and kept in place for 1 week. It is then usually replaced

with a below-knee adhesive bandage for one more week. After that, removable

bandages, 30–40 mm/Hg graduated below-knee stocking, or pantyhose is

Figure 13.7 X-ray film of the knee joint. The marker placed over the popliteal crease

shows that the popliteal crease corresponds to the knee joint. (Courtesy G Izzo, MD.)




worn by the patient until all signs of surgery disappear or at least for 2 months.

Post-operative management is discussed in detail in Chapters 10–18.

ADVANTAGES OF SSV PHLEBECTOMY

In addition to the general advantages of AP, SSV phlebectomy has, in our

opinion, some specific advantages over the traditional surgical or sclerotherapy

methods of treatment.

The SSV is a rather “controversial” vessel, with many contradictory opinions

regarding the choice of treatment, as evidenced by a recent review of over 120

articles on the topics (2). While sclerotherapy is followed by a high recanalization

rate (9), and traditional surgical techniques are considered difficult and less gratify-

ing (than GSV stripping) by many (7,8,10), AP can produce excellent results. This

may be because of the thorough removal of the collateral varicosities and an extre-

mely low complication rate. Muller reports only five cases of popliteal recurrence,

three of which needed traditional surgical revision (1).

AP permits removal of the varicose SSV under local anesthesia (LA), in an

office setting, at low cost and with excellent cosmetic results. Complications are

Figure 13.8 Different levels of the saphenopopliteal junction. On these figures the upper-

most palpable point coincides with the popliteal crease (dotted line), where the uppermost

incision is usually made and the SSV is more easily retrieved. (a) Saphenopopliteal junction

situated at the level of the uppermost palpable point. In this case an incision over the joint

allows optimal (highest possible) ligation of the SSV. (b) Saphenopopliteal junction higher

than the uppermost palpable point. In this case an incision over the joint is likely to leave

a longer residual SSV stump. (c) With the endoluminal probe pushed upward into the

SSV, it is sometimes possible to palpate the vein higher than the popliteal crease and exter-

iorize the SSV through a higher incision to ligate it closer to its junction with the popliteal

vein. (d) Higher popliteal incision. In this patient, after exteriorizing the SSV from the incision

over the uppermost palpable point at the popliteal crease (P), it was possible, with the help of

the endoluminal probe, to extract the SSV through a higher incision, 3.5 cm away from the

popliteal crease and only 1 cm below the level of the saphenopopliteal junction (SPJ).


infrequent, mild, and are represented by sural nerve damage with loss of

sensitivity or paresthesia. However, even this is largely avoided by limiting the

operation, whenever possible, to the proximal portion of the SSV. In addition,

under LA, manipulation of the sural nerve is felt by the patient and can be

therefore avoided.

REFERENCES

1. Muller R. Traitement de la saphene externe variqueuse per la phlebectomie

ambulatoire. Phlebologie 1991; 44:687.

2. Georgiev M, Ricci S, Carbone D et al. Stab avulsion of the short saphenous vein:

technique and duplex evaluation. J Dermatol Surg Oncol 1993; 19:456.

3. Kupinski AM et al. The lesser saphenous vein: an underutilized arterial bypass conduit

(abstr). J Vasc Technol 1987; 11:145.

4. Hoffman HM, Staubesand J. Die venosen Abflussverhaltnisse des Musculus triceps

surae. Phlebologie 1991; 20:164.

5. Hobbs JT. Preoperative venography to ensure accurate saphenopopliteal vein ligation.

Br Med J 1980; 1:1578.

6. Van der Stricht J, Dorignaux JP, Ledant P et al. La phlebographie saphene externe

selective. Phlebologie 1980; 33:281.

7. May R. Chirurgie der Bein- und Beckenvenen. Stuttgart: Geog Thieme Verlag, 1974.

8. Browse NL, Burnand KG, Thomas ML. Diseases of the Veins. London: Edward

Arnold, 1988.

9. Schultz-Ehrenburg U. Sclerotherapy of the popliteal junction in primary varicose

veins (abstr). J Dermatol Surg Oncol 1992; 18:61.

10. Fischer R. Wo in der Fossa poplitea soll man die Vena saphena parva beim Stripping

ligieren? Phlebol u Proktol 1985; 14:129.

Figure 13.9 Long segment of the Giacomini vein (GCV) avulsed during phlebectomy of

the short saphenous vein.


Part III: Selected PhlebologicalTechniques

14

Post-Operative Compression

The scope of post-operative compression is to insure hemostasis, avoid post-

surgical edema, and allow comfortable ambulation. In addition, it exercises

strong analgesic action, making analgesic medication unnecessary in a large

majority of patients.

Techniques and materials for bandaging may vary. Bandaging is an art,

with skill being more important than materials: the experienced phlebologist is

able to perform an adequate compression bandage with many different—and

even “improper”—materials. However, there are some basic rules to respect if

a bandage is to function properly. These rules, as well as the properties and

use of some basic materials, are illustrated in this chapter.

The post-operative bandage (POB) is composed of five parts: (i) protective

skin underwrapping; (ii) local compression pads; (iii) protective pads;

(iv) adhesive bandage; and (v) removable bandage.

PROTECTIVE SKIN UNDERWRAPPING

Before applying the compression bandage, the skin must be protected with an

underwrap such as a Mueller wrap, (Mueller Sports Medicine, Inc., Prairie du

Sac, WI 53578, USA), which is a thin polyurethane foam bandage. Its purpose is

to protect the skin from the edges of the local compression pads and the glue of

adhesive bandages. If the protective underwrap is not used, bruising, blistering,

and transverse linear skin pigmentations may occur and persist for many months.

LOCAL COMPRESSION PADS

The scope of local compression pads is to achieve maximal hemostatic, anti-

exudative, and analgesic effects in the tunnel remaining after vein avulsion,

avoiding excessive general compression of the limb. In fact, general compression

177

alone—even when excessive and poorly tolerated by the patient—may not be

sufficient at the operated sites.

Local compression is obtained by compression pads made of cotton wool,

foam rubber, gauze strips, or other relatively hard material commercially

available. These pads may increase local compression by up to 50% (1).

The size of the pads depends on the circumference of the limb and the size

and localization of the avulsed veins. On the medial aspect of the limb and on the

thigh, larger pads are necessary. Compression pads should not have hard edges

and should be placed as a continuum; otherwise, they may cause skin bruising

and blistering.

PROTECTIVE PADS

On joints and bone prominences (shin, dorsum of foot), the bandage may trauma-

tize skin, nerves, and tendons, causing pain, which inhibits normal ambulation. It

is therefore advisable to protect the earlier-mentioned areas with 5 mm thick

(“three-dimensional”) foam rubber (or cotton wool) strips.

Both compression and protective pads are fixed with a few loops of

underwrap; this way the adhesive bandage will not stick to the pads, but to the

underwrap that is easily cut before removal.

ADHESIVE BANDAGE

The adhesive bandage is the most important part of the POB (Fig. 14.1). A

properly applied bandage will remain in place without losing its efficacy for

several days. It will allow normal ambulation while exercising adequate com-

pression, and, during the night—in the recumbent position—will not produce

excessive compression. In short, it will have a high working pressure and low

resting pressure.

To achieve this, the bandage must have a short stretch, its action due not as

much to the pressure exercised by the bandage as to its resistance to leg expansion

during ambulation. Such a bandage exercises the highest pressure in upright

position and during walking (high working pressure), while in the recumbent

position, when the limb is “empty” of blood, it does not compress as much

(low resting pressure). There are numerous papers that describe the use of com-

pression therapy on the lower extremities in great detail. The reader is referred to

them for further information, which is beyond the scope of this text (2–4).

Materials

We prefer short-stretch lengthwise (one-way) elastic bandages; however, at ankle

and knee (two-way stretch), elastic bandages conform to the shape of the joints

and are more comfortable. Bandages of 10 cm width are suitable, but in very

small legs, 7.5–8 cm wide bandages may fit the foot and ankle better.


The quality of adhesive bandages is important. If, for example, the adhesive

is too sticky and much force is required to unroll the bandage, it will be difficult to

apply it with an even and desired pressure.

Extension of the Bandage

Local compression pads must be applied for at least 5–10 cm beyond the

operated zones to avoid bruising, hematoma, edema, and inflammatory reactions.

Distally, the compression bandage starts at the bases of toes to prevent pedal

edema. When the lower leg has not been operated on, it can be left without

adhesive bandage, provided there is no underlying disease causing leg edema.

In these cases, patients apply a removable bandage or graduated compression

stocking during the day and night to avoid a tourniquet effect.

Technique of Application

The bandage is applied with the patient in recumbent position. The surgical part

is bandaged first, then the bandage is continued distally and proximally

Figure 14.1 Adhesive compression below-knee bandage. The adhesive bandage is

applied after covering the skin with protective underwrap and protective pads over

ankle and shin. Only the uppermost border of the bandage (�1 in.) is applied directly to

the skin to insure that the bandage stays in place. A 10 cm wide one-way stretch

bandage is adequate in most cases. It is applied in 8-shaped loops over foot and ankle,

then in spiral loops over the rest of the leg. Each loop overlaps the preceding one

�50% so that a double-layer bandage is made.

Post-Operative Compression 179

(Fig. 14.2). The foot is flexed at a right angle with the knee slightly flexed, in

order to better shape the bandage around the joints. This avoids excessive

tension and rubbing during maximal joint movement. The bandage must

conform to the limb’s shape; foot and ankle are bandaged with figure 8-shaped

loops and 7.5–8 cm wide bandage, whereas the rest of the limb with spiral

loops and 10 cm wide bandage.

When applying the bandage, it is kept close to the skin and unrolled around

it with slight, constant tension, without stretching it to its maximal extension.

Figure 14.2 Techniques of applying removable elastic compressive bandage. Patients

who are going to bandage themselves must have adequate instruction and given an illus-

trated guide. (a) Long-stretch strong elastic bandage with one, preferably 7 m long 10 cm

wide bandage. Foot and ankle are bandaged with 8-shaped loops (loops 1–5), the rest of

the leg with spiral loops (loops 6–10). (b) Short-stretch compression bandage according to

Karl Sigg. Two bandages, each 5 m long, are employed. Before application, the bandages

must be rolled stretched, so they are not stretched during application, but unrolled over the

leg to insure even pressure in all points. The first bandage, 8 or 10 cm wide, is applied over

foot and ankle only and terminates just below the calf. The second bandage, 10 or 12 cm

wide, is applied from ankle to below the knee; it is first crossed over the tibia, then applied

with spiral loops up- and downward along the leg. The result is a 10 m long, 4–6 layers,

almost inelastic bandage. It is comfortable to the patient and exerts very high pressure

during ambulation, whereas is well-tolerated in the recumbent position.




Both edges must be pulled with the same force; otherwise, compressive “laces”

may form. Applying the bandage under the same tension results—due to the

conical shape of the limb—in gradually decreasing pressure from distal to prox-

imal (Laplace’s Law).

Each loop overlaps the preceding one �50%. This way, the entire limb is

covered by two layers of bandage, and the latter becomes less elastic. If maximal

compression is desired, a greater width of each loop is overlapped, or more layers

are applied: the more the layers, the more rigid and compressive the bandage is.

Proximally, the bandage must continue beyond the protective underwrap

and stick directly to the skin; otherwise, it may slip or roll down.

Rarely a patient may be allergic to the glue of the adhesive bandage; in such

cases, the loops applied directly to the skin must be made with a nonallergic

(i.e., acrylic) adhesive, or of “cohesive” bandage, which sticks to itself, but not

the skin. These two types of bandages are, however, less adhesive and must be

kept in place by a loop of the usual adhesive bandage applied over it.

Degree of Compression

The bandage must prevent edema formation during the day and must not exces-

sively compress the leg at night.



All patients do not require the same compression. For small, edema-free

limbs with small dermal varicosities, mild compression may be sufficient. In

obese, edematous limbs, with large varicose veins, stronger compression is

needed. The latter is obtained by applying more bandage layers, not by stretching

the bandage to its maximal extension, as this may cause excessive compression in

the recumbent position.

Proper bandage tension is learned by experience. Bandaging is usually

mastered by treating patients with chronic edema and stasis changes. For the

beginner, it is helpful to see the bandaged patients daily in order to insure ade-

quate compression. It is of great help to bandage one’s own leg, both with

adhesive and removable bandages, and wear these for several days.

Testing the Bandage

A good bandage is readily recognized by its perfect stay on the leg. When com-

pression is adequate, toes, especially the first toe, become mildly cyanotic. This

discoloration must disappear after a few steps (sign of adequate venous outflow),

and the skin of forefoot must remain warm. The patient, though feeling the com-

pression, must not feel pain or discomfort, and must be able to walk normally; the

bandage takes its final shape with ambulation.

Difficult Areas

On the foot, ankle, and knee it may be difficult, even with figure 8-shaped loops,

to follow the shape of the limb while maintaining both edges of the bandage

under the same tension. In such cases, it is preferable to cut the bandage and

apply it again in the desired direction.

The foot does not tolerate excessive compression. The foot and ankle

should be bandaged with overlapping loops of slightest tension, so that the

bandage becomes more rigid, but less compressive. Such bandaging does not

allow the foot to swell, but is well-tolerated in the recumbent position.

In the obese, conically shaped thigh, the upper edge of the bandage may roll

down, forming compressive painful rings that leave the upper thigh noncom-

pressed. In these cases, a two-way stretch elastic bandage is preferable to a one-

way stretch elastic bandage. However, irrespective of the material used, there

are several ways to keep the upper edge of the bandage in place. First, start the

bandage high proximally than necessary, applying the first loop without

tension. Then, gradually increase tension while proceeding distally. Secondly,

apply a “fish-bone” bandage, made of oblique separate loops, as follows: the

central part of the adhesive strip is placed on the posterior aspect of the thigh,

whereas both ends are applied obliquely in an anterior–superior direction

crossed on the anterior aspect of the thigh. Another method is to fix the

bandage on the hip and lower abdomen, which is done after great saphenous

vein (GSV) stripping and is described in Chapter 15.


REMOVABLE BANDAGE

The removable bandage is applied by the patient every morning over the adhesive

one, and removed every evening. It provides additional compression during the

day. This is because the compression necessary when standing may not be toler-

ated when lying down. In other words, if the bandage is comfortable during the

night, it might be insufficient during the day. In addition, the removable bandage

“fixes” the freshly applied adhesive one and prevents it from yielding. (The remo-

vable bandage may not be necessary if the adhesive bandage is “personalized” by

applying more layers.)

The removable bandage is applied without much tension and the patient

must be adequately instructed and given an illustrated leaflet explaining how

to put it on. Short-stretch (semirigid) bandages are preferable, but medium or

long-stretch (elastic) bandages may be employed as well, as these are also toler-

ated in the upright position.

ERRORS OF BANDAGING

The most frequent inconvenience is edema of dorsal foot caused by inadequate

compression of the foot. Should this occur, it is sufficient to apply the removable

bandage tighter on the foot.

Insufficient Compression

If the bandage is too loose, pain may occur at the operated sites. Edema and/or

hematoma may follow, causing discomfort or pain that requires additional weeks

of compression bandaging.

Excessive Compression

Excessive compression may not be tolerated by the patient, especially when over

the shin and dorsal foot. Here, it may traumatize the skin, sensory nerves, or

tendons through anoxia, causing pain, numbness, or even skin necrosis. At

times, the patient may not complain during the day, but cannot tolerate com-

pression during the night.

On the knee, the bandage may cause rubbing with bruising, skin abrasion,

or blistering. Though of little importance, such lesions may cause severe pain and

inhibit adequate ambulation.

The alleged danger of compression bandages, arterial ischemia, secondary

to excessive pressure, is a commonplace. Except for cases of severe arterial

occlusive disease, the compression bandage is unlikely to exceed arterial press-

ure. Moreover, except for cases of limb anesthesia (diabetic neuropathy, etc.),

excessive compression causes such a severe pain that the patient seeks help

much before any ischemic damage occurs.


COMPRESSION STOCKINGS

Instead of removable bandages, compression stockings may be employed for

post-operative compression, over the adhesive bandage or after its removal.

Stockings are applied over the adhesive bandage mostly in cosmetic

treatments, where minimal compression is sufficient. When only dermal (reticular)

varicosities have been avulsed, the adhesive bandage is put only on the operated

segment of the limb. The stockings are then put over the bandage, so that com-

pression is extended to the entire limb. In most of these cases, a Class I pantyhose

is sufficient. After removal of the adhesive bandage, 2–5 days later, the patient con-

tinues to wear the Class II or I pantyhose until the signs of phlebectomy disappear.

After removal of adhesive bandage, in cases of larger varicose veins,

Class II single compression stockings may be used. Unlike Class I pantyhose,

such stockings are more difficult to put on and remove. They should not be pre-

scribed as if they were an oral medicine. The patient must be trained on their

application and removal in the office. Therefore, they must be put on for the

first time in the office by a staff member.

Prior to using these stockings, skin lesions and tender spots must heal under

the compression bandage. This is because if the leg is still aching, putting on a Class

II–III stocking is painful, increasing the difficulty in applying it. It is of great help

to wear an ordinary nylon stocking under the compression stocking. With this tech-

nique, the latter can glide easily over it. A foot slip (provided by the manufacturer)

is then put on. The stocking should not be pulled at the top, but, slipped on and

spread over the leg with the flat of the hand using rubber gloves. To remove it,

the stocking is held at the upper edge and pulled down inside out, then its distal

end is worked over the heel, with the flat of the hand, and removed.

REFERENCES

1. Raj TB, Goddard M, Makin GS. How long do compression bandages maintain their

pressure during ambulatory treatment of varicose veins? Br J Surg 1980; 67:122.

2. Partsch H. Compression therapy of the legs: a review. J Dermatol Surg Oncol 1991;

17:799–805.

3. Stemmer R, Marescaux J, Furderer C. Compression treatment of lower extremities, par-

ticularly with compression stockings. The Dermatologist 1980; 31:355–365.

4. Neumann HAM, Tazalaar DJ. Compression sclerotherapy. In: Bergan JJ, Goldman MP,

eds. Varicose Veins and Telangiectasias: Diagnosis and Treatment. St. Louis: Quality

Medical Publishing Inc., 1993:103–122.


15

High Ligation, Division, and Grointo Knee Stripping of the GSV:

An Office Procedure

INDICATIONS

At the end of the last century, Trendelenburg drew attention to the importance of

the incompetent great saphenous vein (GSV) in varicose vein disease. This is how

he described, in 1890, patients on whom the GSV ligation was indicated:

The cases of varicosities of the leg in the domain of the great saphenous

vein can be separated into two different groups. There are cases in which

the varicose deterioration is limited to the branches of the great saphe-

nous vein, while the trunk shows no changes of any sort, and, on the

other hand, there are those in which the trunk of the saphenous is like-

wise markedly dilated and varicose. Only the last-named group, the

cases of simultaneous varicose dilatation of the trunk and the branches

of the saphenous, will be considered in the following discourse (GSV

ligation, e.n.) (1).

It was thus well established, early, that only some patients with varicose

veins may benefit from the GSV division. In the following century, however,

the opposite was taught and practiced, that is, removal of the GSV was necessary

in all patients with varicose veins.

Recently, utilization of the GSV as an arterial graft led to “pleas” to save the

GSV (2), as stripping the GSV regardless of its involvement in the varicose vein

disease was widespread. Such practice was further questioned by studies demon-

strating that the GSV trunk may be competent in �40% of the varicose patients

(3,4), and by surgical experience demonstrating satisfactory results by varicose

vein removal without the GSV stripping at 3 year (5) and 5 year (6) follow-up.

187

Although the aforementioned studies report excellent long-term results

with ligation of the saphenofemoral junction (SFJ) followed by ambulatory phle-

bectomy (AP), additional studies performed with more than a mere clinical exam-

ination and patient opinion disclose persisted reflux in up to 50% of patients

treated in this manner (7–9). In addition, if one strips the GSV from the SFJ

to the knee there is a decreased incidence of reflux recurrence, as cited in numer-

ous studies (7–10).

Finally, in assessing whether the GSV has potential as use as vascular

conduit is also of great importance. Corcos et al. (11) have found that virtually

all of the lower extremity veins have evidence of histopathological damage

when major varicose veins are present. They demonstrated that peripheral

venous biopsy of the dorsal vein of the foot revealed parietal lesions of various

types and grades in patients who had varicose veins. The normal dorsal vein of

the foot had lesions similar to those found histologically in the varicose veins.

This suggests that peripheral veins in patients who have varicose veins may

not be suitable as vascular conduits. This finding has been partly corroborated

by Marin et al. (12) who studied the relationship between the histologic condition

of the GSV at the time of grafting and subsequent stenosis of vein grafts. Here,

Marin et al. concluded that when the GSVs had thick or calcified walls, or a

hypercellular intima, there was an increased risk of developing intragraft

lesions which could lead to graft failure. These veins did not have grossly appar-

ent disease as noted by inspection or palpation. Unfortunately, the authors did not

know whether the patients had co-existing varicose veins. In an effort to assess

potential vascular graft conduits preoperatively, Davies et al. (13) demonstrated

that preoperative assessment of vein wall compliance can be used to predict vein

grafts at risk for failure. These studies have led to a more detailed assessment of

the GSV for its potential as a useful vascular conduit with duplex scanning

(14,15). These latter two studies provide the best evidence that stripping of the

GSV should be selective, most likely to the knee. AP and/or sclerotherapy

should be used to eradicate and/or obliterate other varicose veins, with the

GSV distal to the knee being preserved for potential use as a vascular conduit,

if necessary.

In our opinion, GSV high ligation and stripping to the knee is indicated by

the simultaneous presence of two symptoms:

1. Incompetent SFJ and GSV trunk.

2. Dilated GSV.

Saphenofemoral Junction Incompetence

The detection of a retrograde flux by Doppler at the SFJ is not decisive for a term-

inal valve incompetence. The Doppler device is so sensitive that it may detect

reflux of little clinical significance which occurs or fluxes originated by incom-

petent junction communicating veins, with competent ostial valve (30% of

cases) (Chapter 2). Therefore, the mere presence of an otherwise normal and


nonsymptomatic GSV reflux does not automatically indicate the necessity to

operate on the GSV. An equivocal clinical/noninvasive examination must be sup-

plemented with duplex ultrasound evaluation. The reader is referred to two excel-

lent texts on venous Doppler (16) and duplex testing (17) for further reading.

GSV Dilatation

The average diameter of the normal GSV is 3.5–4.5 mm (range 1–7 mm) (18). A

grossly dilated (.1 cm) GSV is readily appreciated by palpation and percussion

even in the obese patient, but even a competent GSV may be clinically detectable

in some patients.

In most cases, the GSV is not dilated along its entire length, but has only a

few focal saccular dilatations. In any case, the entire course of the GSV should be

traced by Duplex in order to verify calibers at different levels, the depth and the

effective incompetence, having always in mind the US “eye sign.” It is not rare

to find that the reflux spills out from the saphenous stem into a more superficial

collateral vein (CV), the saphenous vein being in part competent (see Chapter 2,

the Atlas). In these patients, there is no need to remove the normal part of the

GSV (as previously discussed). Moreover, the saphenous vein may be partly

hypoplasic (absent), the flux being completely shunted on the collateral (see

Chapter 2, the Atlas).

Preservation of an Incompetent GSV/Saphenopopliteal Junction

In a certain number of cases, we consider GSV incompetence to be of little clini-

cal significance and do not recommend ligation and stripping. The common

denominators in these cases is an incompetent but not dilated GSV.

Duplex examination of the SFJ allows the detection of cases of “borderline”

or even “intermittent” GSV reflux due to valve closure delay. In these cases there

is reflux, but apparently normal valves are also seen. Slight compression with the

transducer—without obliterating the GSV but only slightly narrowing its lumen—

may abolish the reflux. (Although the pragmatic value of such finding is unclear,

in few selected cases we were able to observe restoration of normal flow pattern at

the SFJ, after avulsion of the varicose collaterals but leaving the proximal GSV

portion in place.) Sometimes the terminal valve is competent, whereas the retro-

grade flow comes from incompetent collaterals emptying into the saphenous stem.

However, the earlier described situation may not be sufficient for leaving

the incompetent GSV in place, unless one or more of the following conditions

are also present.

. Few and small leg varicosities without symptoms.

. Competence of the ostial valve at the Valsalva maneuver.

. Presence of a re-entry perforator centered on the saphenous stem

(usually Boyd or Paratibial perforator), able to efficiently empty the

refluxing volume, once the collateral varices have been removed.

Ligation, Division, and Stripping of GSV 189

. Slow filling of the varicose veins upon release of proximal compression

(Trendelenburg test) corresponding to a duplex signal of low velocity

retrograde flow.

. Presence of a competent femoroiliac valve proximal to the SFJ; this

valve prevents abdominal reflux into the GSV.

. Large incompetent mid-thigh perforator with dilatation of the GSV

only distal to it (in these cases, the perforator is considered to be a

more important reflux source than the SFJ, and the GSV is removed

distal to the perforator).

. Reflux in a collateral of the SFJ (typically an anterior accesory saphe-

nous vein) with competent pre-ostial valve and GSV trunk (in this case,

avulsion and high ligation of the collateral varicosity is sufficient).

. Reflux from the saphenous stem to a CV of the thigh, with a competent

distal saphenous stem. If the refluxing collateral emergence is high,

only the collateral may be eliminated. A short proximal tract of incom-

petent saphenous stem will be left, deserving conservative treatment.

. Very young patients. Here, one cannot predict if the disease is going to

progress toward important dilatation of the GSV.

. Very old patients, in which minimal surgery may be functionally

adequate.

. Presence of nonsymptomatic GSV reflux in the opposite leg, which

may also suggest little clinical significance.

. Patient with chronic ischemic cardiac and/or peripheral arterial

disease, in whom the other GSV has been stopped.

It may appear from this description that the decision to leave the GSV is

somewhat complex and confusing. The use of duplex examination possibly

done by the same surgeon may greatly help in dealing all these different

aspects. However, the alternative is indiscriminate removal of all incompetent

GSVs even if only partly involved.

The decision not to operate on the GSV is greatly facilitated by varicose

vein surgery based on phlebectomy. This implies simple and easily repeatable

surgical procedures. This advantage allows one to leave rather than to remove

the GSV, which can be easily removed later, should it become necessary.

ALTERNATIVE TREATMENTS FOR GSV INCOMPETENCE

It has been our practice so far to either divide and strip the GSV or leave it in

place. This all-or-nothing attitude simplifies decision-making and is also based

on consistent evidence that removal of all dilated and varicose veins with interrup-

tion of all sources of deep to superficial reflux has been shown to give the best

functional and cosmetic results (19). However, some alternative treatments do

exist and may give comparable long-term results. The only such treatment we

occasionally perform is GSV division and ligation alone, usually when minimal


surgery is considered more convenient, that is, patients in advanced age or chronic

systemic disease. We have no experience with other alternative surgical pro-

cedures like SFJ valve repair (20,21), ligation of the SFJ and ligation of the

GSV trunk just below each incompetent perforator (CHIVA) (22), or GSV

avulsion by phlebectomy without division of the SFJ and its collaterals (23–25).

Choice of Stripping Technique

Three different stripping methods are known: The Babcock technique, which

strips the vein on the outer side in distal direction of the vein, using an olive strip-

per inserted inside the vein and fixed to it (26). The invaginating technique,

according to Keller (24), is performed with a suture or a wire passed inside the

vein: the vessel is inserted in its own lumen and pulled out by traction in

“glove finger” way. Mayo performs this procedure with stripper with a ring at

the tip. The vein is introduced through the ring; this is pushed distally in the sud-

cutaneous tissue of the thigh by dissecting the vessel (24).

When using local infiltration anesthesia (LIA), where only a limited strip of

skin is involved, it is necessary to use that technique, of the three, that produces the

least traction on the collaterals during saphenous extraction. Those veins translate

the traction to surrounding tissues that are not, anesthetised, causing pain.

The technique of Babcock is the most traumatic in this sense and cannot be

employed. The invagination technique is much more “friendly,” although

keeping traction on the collaterals is important to allow interruption of the

CVs by small phlebectomy counter incisions, according to Oesch (25). Further-

more, it requires a certain “open vein” manipulation (sound introduction, coun-

terincision and distal recovery, skilled ligation of invaginating stump, etc).

This makes it not suitable for operation under local anesthesia (LA).

Mayo’s technique, modified by the use of rings with sharp cutting edges, is

performed on a “closed” vein without manipulation, and allows excision of the

collaterals without any traction (28). In this way, LIA is sufficient and effective.

Mayo’s modified technique seems best for the demands of our method for treat-

ing varicose veins and is the one that we are going to describe in this chapter. A

different type of anesthesia (truncal, spinal, and general) is best for treating var-

icose veins with the other techniques of stripping. However, our experience

suggests that this method has value for its ease, execution rapidity, cleanliness

of operating field, and effectiveness, particularly if an ambulatory practice is

foreseen.

PROGRAMING THE OPERATION

The GSV is involved in the varicose syndrome in �60% of the cases. The reflux

spills out from the saphenous stem at a variable height, mostly below the knee.

Phlebectomy deals with superficial (collateral) varices, whereas the saphenous

stem varicose veins require stripping techniques.


Only the incompetent saphenous tract is usually avulsed, whereas the healthy

saphenous part is basically conserved. In fact, there is no reason or right for elim-

inating a well-functioning part of a vein. Therefore, removal or closure of only the

incompetent portion of the GSV is performed. This requires accurate duplex

mapping of GSV incompetence. If the incompetence occurs along the entire

GSV that is dilated [usually .7 mm in diameter to the mid-calf (20% of cases)

or even to the foot (in up to 10% of patients)], the vein is removed through phle-

bectomy and/or stripping and/or an endolumenal closure technique.

If the extension of the disease is limited, the whole procedure (saphenect-

omy and phlebectomy) is performed in a single procedure, otherwise we prefer to

perform CV phlebectomy 3–5 days before the saphenectomy. We avoid operat-

ing on the GSV during patient’s menstrual cycle for hygienic rather than surgical

reasons (this limitation does not apply to phlebectomy in general). The decision

to strip the GSV must be made prior to operating on the collateral varicose veins.

This is because if the distal varicosities are removed first, the diameter of the

GSV may reduce and the reflux disappears (lacking the re-entry point) although

the incompetence persists.

The GSV is stripped from its junction with the femoral vein down to the

most distal point where it is dilated and incompetent, which in most cases does

not go beyond the Boyd (below-knee) perforator. If necessary, the GSV distal

to the Boyd perforator is avulsed by phlebectomy. In easy cases, during phlebect-

omy even the saphenous stem may be avulsed in a proximal direction over the

knee, making the consequent saphenectomy shorter and quicker [Fig. 15.1(b)].

When previously performed, ligation of the GSV at the knee may give rise

to formation of a thrombus of limited extension. The post-operative compression

bandage and anti-inflammatory medication may avoid or reduce the consequent

local inflammation. Occasionally, when the GSV is stripped by phlebectomy,

the remaining GSV trunk may be completely obliterated up to the groin. In

this case, it is not operated on, but kept under compression bandage (like after

sclerotherapy) until it turns into a fibrotic cord, and the patient is evaluated

6–12 months later.

PRE-OPERATIVE MARKING

The GSV is marked with the patient standing, its course followed by palpation,

percussion, and Doppler and/or duplex ultrasound. Its course is then checked

again with the patient sitting and the marking adjusted as needed (in the obese

patient, the markings may “move” from standing to recumbent position).

Pre-operative duplex scanning of the SFJ provide helpful details of the

anatomy we are going to operate on (number and site of collaterals, diameter

and shape of the junction, possible anomalies, and lymph nodes). The evaluation

of the thigh portion of the GSV allows more precise marking of saccular dilata-

tions, GSV duplication, and side branch and/or perforator confluence. This is

useful in planning supplementary anesthesia at the sites of GSV branching.


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The groin crease must also be marked from the point the femoral pulse is palpated

to the insertion of the abductor’s tendon. This is done with the patient standing

and/or sitting, because in the recumbent position it may be impossible to appreci-

ate the groin crease [Fig. 15.2(d)].

ANESTHESIA

Anesthetic solution of 60–90 mL (240–450 mg of mepivacaine with epineph-

rine) or 60–180 mL (1:10 dilution of 1% lidocaine) is employed, with 10 mL

kept aside for supplementary anesthesia, if necessary.

For groin infiltration 20 mL, for the skin and superficial layers 10 mL, and

for deep tissues 10 mL are used. Test suction is always performed during deep infil-

tration to avoid accidental intravascular injection. For the infiltration along the

marked vein, 40–100 mL is then employed first superficial then deeper. The saphe-

nous vein running in an anatomical space is limited by a connective fascia (saphe-

nous fascia) (see Chapter 2); the infiltrating anesthesia must necessarily involve

this same space for obtaining an effective anesthesia. By US it is possible to

verify the effective infiltration of this area especially in obese or “difficult” patients.

Wider areas are infiltrated in the upper third of the thigh, where there are constant

collaterals and possibly more pain receptors in the perivenous tissue (Fig. 15.3).

PATIENT POSITION AND SKIN PREPARATION

The operation is performed according to classical surgical standards regarding

patient and surgeon preparation. The patient is operated in supine Trendelenburg

position, with the knee and hip flexed and the limb externally rotated for optimal

exposure of groin and medial thigh (Fig. 15.3). If the patient has difficulty in

maintaining this position, a support pad under the knee may help.

The groin must be shaved, preferably 2–3 days before surgery. Male

patients are advised to remove the hair from the thigh to avoid pain when the

post-operative adhesive bandage is removed. Female patients cover genitalia

with tanga-type disposable bikini, while male genitalia are covered with a

drape and taped to the opposite side.

Patients are asked to keep their arms under the head during the operation, to

avoid involuntary touching of the sterile area. When using pulse-oximetry, it is

wise to position it out of the patients’ view to avoid anxiety reactions.

INSTRUMENTS

The surgical instruments employed are common and nonspecific, except for the

Mayo and Corcos extraluminal phleboextractors (strippers) and Graefe iris

forceps. The set includes the following:

. two 20/30 mm retractors (Richardson-Easmann or Goelet);

. two standard 14 cm 2 � 3 teeth dissecting forceps;


Figure 15.2 Patient preparation for GSV stripping. (a) Removing the adhesive bandage

placed after previous phlebectomy. (b) Thick cotton strip placed over the GSV for

additional (local) compression. (c) The GSV marking is checked again by percussion

test. Impulse is given by quickly pressing the GSV distally with the thumb of the right

hand, while the wave is received at the groin by the left hand. (d) The GSV is marked

again. The groin crease is marked in the standing position, because it may be difficult to

localize it later in the recumbent position. (e) B-mode scan is performed to check the

marking and localize the major side branches of the GSV. (f) Marking is now completed

with side branches indicated by transverse signs.


. one 14 cm Mayo dissecting scissors;

. three curved toothed 13 cm Halsted hemostatic forceps;

. three straight toothed 13 cm Halsted hemostatic forceps;

. two curved nontoothed 12 cm Halsted hemostatic forceps;

. two curved 14 cm Kocher hemostatic forceps;

. one 15 cm Lahey (Mixter or Meeker) forceps;

. one Graefe iris forceps (for phlebectomy);


Figure 15.3 The area of LA is larger in the upper thigh.


. one regular 14 cm Hegar-Baumgartner needle holder;

. one number 15 scalpel blade with holder;

. two Mayo external anular strippers, 6 and 8 mm diameter;

. two 50 cm Corcos external strippers, 6 and 8 mm diameter;

. Vicryl #3-0 without needle;

. Vicryl #3-0 with needle.

SURGICAL ANATOMY OF THE SFJ

At the groin (as in its entire course until the foot), the GSV lies beneath two fatty

layers and a fibrousfascia (fascia superficialis), the so-called “saphenous com-

partment” (27). As it approaches the femoral vein, it receives several tributaries

(Fig. 15.4). These vary in number and position, and may directly join the femoral

vein instead of the GSV.

The tributaries are usually easily recognized because of their small caliber.

However, a very large ASV or posteromedial thigh vein joining the GSV close to

the femoral vein (or joining the femoral vein directly) may be confused with the

GSV. In this instance, it is not uncommon for only one of the veins to be ligated,

while the other is missed. The presence of two large veins (instead of one) that

join the femoral vein together or separately can be confirmed by duplex scan,

which also determines the presence of reflux in each of the veins separately

(Fig. 15.5).

Figure 15.4 The SFJ, Dotted line: common femoral vein GSV, great saphenous vein;

AL, anterolateral thigh vein; PM, posteromedial thigh vein; SI, superficial iliac vein;

SE, superficial epigastric vein; SP, superficial pudendal vein. The diagram shows a

“typical” SFJ with two distal (AL and PM) and three proximal (SI,SE, and SP) collaterals.

However, less than three as well as more than ten collaterals may be encountered here.


The groin tributaries and collaterals anastomize freely with each other

demonstrating why even a correct ligation of both saphenous and CVs cannot

eliminate all potential sources of groin reflux (Fig. 15.6).

TECHNIQUE

Ligation and Division of the SFJ

Unlike phlebectomy, which could be performed by a solo operator without general

surgical training, GSV division must be performed with an assistant and by a

surgeon with adequate general (or vascular) surgical training, who is able to

cope with any eventual complication that might occur during groin dissection.

The incision is made exactly over the (previously marked) groin crease,

between the point of palpation of the femoral pulse and the abductor tendons.

This centers it over the marked GSV termination. A 3 cm incision is sufficient,

except in very obese patients where a 4–5 cm incision may be necessary.

Figure 15.5 Longitudinal and transversal color flow imaging of the saphenofemoral junc-

tion, showing both GSV and ASV incompetent. GSV, great saphenous vein, ASV, anterior

accessory saphenous vein, and CFV, common femoral vein. (Courtesy of G. Belcaro)


The edges of the skin incision are pulled up apart from each other with the

dissecting forceps (the operator holds the lower and the assistant the upper edge)

and the residual dermal and subdermal connective tissues are divided with scis-

sors until there is enough space for retractor insertion.

The subcutaneous fat is retracted until the layers of the superficial fascia are

exposed. The latter is divided with scissors and retracted to expose the second

layer of subcutaneous fat and the second connective tissue fascia. The latter is

then divided and retracted, bringing into view the dilated GSV.

The GSV is sometimes embedded in a dense adherent fibrous and

lymphatic tissue (especially where there is a history of thrombophlebitis or sclero-

therapy). In this case, its exposure and dissection may be difficult and time con-

suming. If during dissection the abductor tendons are exposed, the GSV must be

searched laterally. In this case, it is better to start dissecting from more superficial

layers, rather than simply moving laterally. If the dissection is particularly diffi-

cult, the GSV may be retrieved a few centimeters distally from the incision level.

Once the GSV is retrieved, it is grasped with the dissecting forceps and

pulled up until its inferior wall is visible [Fig. 15.7(a)]. With the vein kept in trac-

tion, the supporting tissues are bluntly dissected with Mayo scissors until the

latter is passed under the vein [Fig. 15.7(b)]. This maneuver may cause discom-

fort that disappears promptly once the perivenous tissues are dissected and

retract. Some adjunctive anesthesia may be added simply by dripping the solution

into the open wound.

The GSV is then doubly clamped with the curved Halsted forceps. Before

dividing the vein, its distal portion is put repeatedly under strong traction, while

the other hand checks, over the medial aspect of the thigh, the presence and

direction of skin traction. Once the GSV is divided [Fig. 15.7(c)]. the lower

Figure 15.6 Intraoperative finding of a collateral (COL) of the SFJ. The collateral (in

this case, the superficial iliac vein) divides into three branches (A,B, and C), which illus-

trates why groin reflux—retrograde flow from A to B and C—may not be abolished even

with flush saphenofemoral ligation.


retractor is placed over the distal stump, thus excluding the latter from the

operating field.

The proximal stump is pulled gently and freed of its investments

[Fig. 15.7(d)]. Sometimes the pudendal artery crosses the GSV anteriorly, in

which case we do not divide the artery but pass the GSV stump in front of it

(Fig. 15.8). Freeing the GSV, the collaterals of the SFJ are exposed and pulled

Figure 15.7 Serial diagrams illustrating GSV high ligation and division. (a) Once the

GSV is retrieved, it is grasped with the dissecting forceps and pulled up until its inferior

wall is visualized. (b) The GSV is freed from surrounding tissue with Mayo scissors passed

under the vein. (c) The GSV is doubly clamped and divided. (d) The proximal GSV stump

is pulled gently and dissected from its attachments, exposing the collaterals of the SFJ.

(e) The GSV stump is clamped proximally to the insertion of the collateral, and the

latter is also clamped, divided, and ligated. The procedure is repeated (f) until all collat-

erals are divided and ligated and the SFJ exposed (g). (i) The GSV is ligated at its junction

with the femoral vein. (k) Second transfixed ligature is placed just distal to the first one.




into the surgical site. Once isolated, the first collateral is clamped at �1 cm dis-

tance from the GSV trunk. The trunk is then clamped proximally to the insertion

of the collateral, the latter divided between the GSV and the forceps and only its

distal end is ligated [Fig. 15.7(e)]. Each collateral is pulled gently into the wound

until it breaks or is ligated [Fig. 15.7(f)]. At times, 6–10 cm of CV can

be removed as in a standard phlebectomy. The procedure is then repeated for

the remaining collaterals until the SFJ (white line) and lateral aspects of

the femoral vein are exposed [Fig. 15.7(g)]. We do not expose the femoral

vein above and below the SFJ and consider such maneuver unnecessary and

potentially harmful (angiogenetic stimulus).

The SFJ is ligated with #3-0 resorbable suture, paying attention not to

include part of the femoral vein into the ligature. It is better to leave a short

stump rather than strangle the femoral vein [Fig. 15.7(h)]. Distal to the ligature,

a second transfixed suture is placed and the GSV stump is trimmed at �1 cm

beyond the second ligature [Fig. 15.7(i)]. Careful inspection of the field for bleed-

ing completes this part of the procedure.

GSV Stripping

The superior retractor is removed, the GSV put under strong traction and the

inferior edge of the groin incision maximally retracted. The GSV is dissected

and freed of its perivascular adhesions distally as much as possible (usually 5–

10 cm). As a rule, the anterolateral and posteromedial thigh collaterals are

pulled into the wound, ligated, and divided [Fig. 15.9(a)]. If the CVs have a

low insertion, they may not be exposed but still hooked with a finger and

divided. Their division releases the GSV to stretch and exteriorize further.

Figure 15.8 (a) If the pudendal artery crosses anteriorly to the GSV it is left intact by

passing the GSV stump in front of it (b).


The GSV is clamped as distal as possible and its upper end ligated with a

long suture that serves to pass the vein into the 8 mm ring of the Mayo stripper

[Fig. 15.9(b)]. Passed through the ring, the vein is secured with two clamps and

put under strong traction, while the Mayo stripper is rotated with the ring down

[Fig. 15.9(c)] and slowly pushed down along the vein [Fig. 15.9(d)]. The Mayo

stripper is held with two hands by one of the operators (one hand at the holder, the

other close to the skin incision), while the other operator keeps the vein under

traction with one hand, and with the other hand exerts counter pressure on the

skin over the stripper’s tip [Fig. 15.9(e)]. This maneuver may break some tiny

collaterals, but a large and strong collateral (or perforator) will stop the pro-

gression of the stripper [Fig. 15.9(f)]. When this happens, the Mayo annular strip-

per is replaced with the Corcos 6 mm stripper (8 mm stripper is used only for very

large veins), whose dissecting end is a cylinder with a sharp cutting edge (28)

[Fig. 15.9(g)], derived from a similar instrument suggested by Thompson (29).

The Corcos stripper is used exactly as Mayo’s, but will usually cut, by

pressure and to-and-fro rotating movement, all collaterals and perforators, thus

dissecting and freeing the GSV down to the point it has been ligated at the pre-

vious operation or freed in the phlebectomy phase [Fig. 15.9(h)]. If the GSV has

not been divided at the knee level during a preceding operation, it can be divided

now, either by needle puncture [Fig. 15.9(i)] or by pressing it against the cutting

edge of the Corcos stripper [Fig. 15.9( j)], so avoiding a counter incision.

If there is pain during progression of the stripper, additional anesthesia may

be given at the stripper’s tip or over the previously marked site of branch conflu-

ence. Sometimes dissection is difficult and painful, especially if there are perive-

nous adherences from phlebitis or previous sclerotherapy, which causes poor

diffusion of anesthesia into the fibrous scar tissue. Also a vein dilatation, large

diameter collateral, or a calcification of the wall may stop the sound’s advance-

ment. Occasionally, it may be preferable (to avoid discomfort) to make an incision

over the point of stripper blockage, hook and exteriorize the vein and free it from

its fibrous adhesions. The remaining portion of the vein is then avulsed either by

phlebectomy or by passing the stripper through the new incision.

To overcome possible occasional discomfort during the dissection we have

modified the Corcos stripper (30), creating a channel along the stripper’s rod, with

a way in (for the syringe) at the handle [Fig. 15.9(o)], and a way out in proximity of

the cutting edge [Fig 15.9(p)]. If the patient feels pain during the instrument’s pro-

gression, some more anesthetic can be injected in the exact site of pain, with an

immediate relief of discomfort. About one-third of the procedures require this

adjunctive anesthesia. However, sometimes the cutting stripper may cut the

GSV (12% of a casuistic on 100 consecutive cases) (30). This may occur for a

number of reasons: (1) vein fragility, (2) large collateral that joins the GSV at

an acute angle (the stripper may follow the collateral and cut the GSV trunk),

(3) very large saccular dilatation of the GSV, and (4) poor alignment of the stripper

to the vein axis (obese patient). In case the GSV breaks, the remaining portion, if

long enough, must be avulsed through a separate incision(s), or may be left off if



very short and devoid of collaterals [Fig. 15.9(m)]. In case of difficulty in finding

the saphenous stem, intraoperative echography may be very useful.

After extraction of the GSV, a gauze pad is rolled a few times from knee up

to groin over the tunnel left after GSV stripping, so that any residual blood and/or

coagula are expressed through the groin incision [Fig. 15.9(m)]. Immediately, the

assistant applies a few layers of underwrap and adhesive compression bandage

along the thigh (Fig. 15.10). This bandage applied before the closure of the

groin wound substantially decreases the incidence of thigh hematoma and even

bruising.

The groin wound is closed with continuous intradermal suture with #3-0

Vicryl, followed by subcuticular buried closure [Fig. 15.9(n)] with band-aids

covering the wound after a skin adhesive is applied.

The above-described technique was introduced by Crosetti in Neuchatel

(Switzerland) for the purpose of removing the proximal portion of the GSV in

patients treated by Muller with phlebectomy (31). In 1970, M. Ricci learned

the technique from Crosetti. Since then, the only substantial difference

between the original technique and the one we perform now is the introduction

of the Corcos stripper, further modified by canalization for target anesthesia.

Figure 15.9 Serial diagrams illustrating stripping of the GSV. (a) The free end of the

distal GSV segment is put under traction and dissected from perivascular tissues. This

maneuver usually puts one or more of the distal collaterals (anterolateral and posterome-

dial thigh veins) in evidence, which are also divided and ligated. (b) The end of the GSV is

ligated with long suture and passed through the ring of a Mayo stripper. (c) The stripper is

rotated with the ring pointed down. (d) The stripper is now pushed down along the GSV,

while the GSV itself is kept in traction. (e) The advancement of the stripper and the

traction it exerts on the saphenous side branches may be visible from traction on the

skin. Dissection of the GSV from the surrounding tissue may be enhanced by exerting

counterpressure on the skin over the stripper’s tip. (f) The Mayo (ring) stripper may

break some collaterals, but a large collateral will stop its advancement. (g) When this

occurs, the Mayo stripper (left) is replaced by the Corcos stripper (right) which, instead

of a ring, has a cylinder with a cutting edge. The Corcos stripper is available with a

6 and 8 mm diameter cylinder. (h) Pushed down with a to-and-fro rotating movement,

the Corcos stripper will usually cut all collaterals and perforators and dissect the GSV

down to the end point of the operation. If the GSV has been ligated and divided during

the preceding operation, it is now pulled out from the groin incision. If the GSV has not

been divided at knee level during the preceding operation, it can be divided now either

by needle puncture (i), or by pressing it against the cutting edge of the cylinder stripper

( j), thus avoiding an incision at knee level. (k) Sometimes the Corcos stripper may cut

the GSV instead of its side branches. In this case, the remaining GSV portion has to be

avulsed by phlebectomy maneuvers through additional incision(s). (l) Removal of the

residual GSV trunk after its rupture. Note how in this case, due to the presence of large

side branches, the stripper has cut the GSV and the latter had to be avulsed through few

separate incisions. (m) Expression of coagula from groin incision. (n) The groin wound

is closed with continuous intradermal suture with #3-0 catgut absorbable suture.




POST-OPERATIVE BANDAGE

The groin is bandaged first [Fig. 15.10(a)]. A 1 cm thick 5 � 10 cm gauze pad is

placed over the groin incision [Fig. 15.10(b)] and secured with a 10 cm wide

acrylic adhesive elastic bandage applied as follows: The bandage is started

from the iliac crest [Fig. 15.10(c)], then rolled down over the groin to make a

double loop around the medial, posterior, and lateral thigh [Fig. 15.10(d)], then

crossed over the groin and terminated over the suprapubic area [Fig. 15.10(e)].

The inferior border of the groin bandage overlaps the annular mid-thigh

bandage. Next, the thigh is bandaged with a second adhesive bandage

(Fig. 15.11). First, a few layers of underwrap are applied, then compression

cotton wool pads are applied over the tunnel of the GSV and secured with a

few more layers of underwrap. The compression adhesive bandage is then

applied in spiral overlapping loops from below the lowest operated point up to

the groin, where it overlaps the groin bandage. The leg is also bandaged as

needed and the patient invited to walk for about a 30 min in the office. Analgesic

is prescribed during the evening after surgery, and the patient is discharged.

Patient will come back to the office a week later for the removal of the adhesive



bandage. The successive management of the operated patient does not differ from

that after phlebectomy in general and is discussed in detail in Chapter 12.

COMPLICATIONS

The procedure described earlier is simple and safe. No major complication has

occurred in more than 20 years in our practice. Our average complication rate

is illustrated well by a series of 141 consecutive operations of GSV stripping,

Figure 15.10 Post-operative groin bandage. (a) Mid-thigh adhesive bandage is applied

even before suturing the groin wound. (b) After closure of the groin wound, a thick gauze

pad is placed over the groin incision. A 10 cm wide elastic adhesive bandage is applied

over the iliac crest (c), rolled down over the groin to make a double loop around the

upper thigh (d), then crossed over the groin and secured over the suprapubic area (e).


performed in 1990: Three cases of groin hematoma, one case of groin wound

infection, and one of groin lymphocele occurred (32). A further study over 100

consecutive case made in 1997 registered a single case of hematoma at the

middle third of the thigh conservatively treated (30), without other complications.

REFERENCES

1. Trendelenburg F. Uber die Unterbindung der Vena saphena magna bei Unterschenkel-

varizen. Beitrage zur Klinische Chirurgie 1890, 7:199. (Cited in English from:

Laufman H. The Veins. Austin, Texas: Silvergirl, Inc. 1986).

2. Demos NJ. Plea to save the thigh segment of the saphenous vein. Angiology 1971;

22:428.

3. Georgiev M. Primary varicose veins: a topographic study. IV European-American

Symposium on Venous Diseases, Washington DC, Mar 31–Apr 2, 1987.

Figure 15.11 Finished full-length thigh bandage. This patient (shown on Fig. 15.1) has

her left limb bandaged after GSV ligation and stripping.


4. Goren G, Yellin A. Primary varicose veins: topographic and hemodynamic consider-

ations. J Cardiovasc Surg 1990; 31:672.

5. Large J. Surgical treatment of saphenous varices with preservation of the main great

saphenous trunk. J Vasc Surg 1985; 2:886.

6. Hammerstein J, Pedersen P, Cederlund et al. Long saphenous vein-saving surgery for

varicose veins. A long-term follow-up. Eur J Vasc Surg 1990; 4:361–364.

7. McMullin GM, Coleridge-Smith PD, Scurr JH. Objective assessment of high ligation

without stripping the long saphenous vein. Br J Surg 1991; 78:1139–1142.

8. Sarin S, Scurr JH, Coleridge-Smith PD. Should we strip the long saphenous vein? A

randomized controlled trial. In: Raymond-Martimbeau P, Prescott R, Zummo M, eds.

Phlebology ’92. Paris: John Libbey Eurotext, 1992:1081–1082.

9. Conrad P. Groin-to-knee downward stripping of the long saphenous vein. Phlebology

1992; 7:20–22.

10. MacFarlin R, Godwin RJ, Barabas AP. Are varicose veins and coronary artery bypass

surgery compatible? Lancet 1985; 1:859.

11. Corcos L, Peruzzi G, Romeo V et al. Peripheral venous biopsy: significance,

limitations, indications and clinical applications. Phlebology 1989; 4:271–274.

12. Marin ML, Veith FJ, Panetta TF et al. Saphenous vein biopsy: a predictor of vein graft

failure. J Vasc Surg 1993; 18:407–415.

13. Davies AH, Magee TR, Baird W. Vein compliance: the preoperative indicator of vein

morphology and of veins at risk of vascular stenosis. Br J Surg 1992; 79:1019–1021.

14. Koyano K, Sakaguchi S. Selective stripping operation based on Doppler ultrasonic

findings for primary varicose veins of the lower extremities. Surgery 1988;

103(6):615–619.

15. Fligelstone L, Carolan G, Pugh N et al. An assessment of the long saphenous vein for

potential use as a vascular conduit after varicose vein surgery. J Vasc Surg 1993;

18:836–840.

16. Schultz-Ehrenburg U, Hubner HI. Reflux Diagnosis with Doppler Ultrasound.

Vol. 35. Stugggart-New York: F. K. Schattauer Verlag, 1989.

17. Van Bemmelen JS, Bergan JJ. Quantative Measurement of Venous Incompetence.

Austin: R. G. Landes Co., 1992.

18. Berry S et al. Determination of a “good” saphenous vein for use in in situ bypass grafts

by real-time B-mode imaging. J Vasc Technol 1988; 12:184.

19. Bergan JJ. The role of surgery in treatment of varicose veins and venous telangiecta-

sias. In: Goldman MP, ed. Sclerotherapy. St. Louis: Mosby Year Book, 1991.

20. Belcaro GV. Plication of the saphenofemoral junction. VASA 1989; 18:296.

21. Corcos L, Procacci T, Peruzzi G, Macchi C, De Anna D. External valvuloplasty of the

sapheno-femoral junction versus high ligation or disconnection. Comparison of pre-

liminary results between two groups of patients. Phlebologie (D) 1996; 25:2–10.

22. Franceschi C. Cure conservatrice et hemodynamique de l’insufficiance veineuse en

ambulatoire. Precy-sous-Thil: Editions de l’Armancon, 1988.

23. Dortu JA, Constancias-Dortu J. Traitment des varices des membres inferieurs par la

phlebectolie ambulatoure. Etude critique sur 218 cas. Ann Chir 1997; 51:761–772.

24. Ricci S. History of stripping. Acta Phlebologica 2001.

25. Oesh A. Pin-stripping. Phlebologie 1996; 25:177–182.

26. Babcock WW. A new operation for extirpation of varicose veins. NY Med J 1907;

86:1553.


27. Caggiati Ricci. The long saphenous vein compartment. Phlebology 1997;

12:107–111.

28. Corcos L. Structure and use of the external phlebo-extractor. Phlebology 1989; 4:275.

29. Thompson W. A modified Mayo vein stripper. The Lancet 1950; 29:173.

30. Ricci S. Saphenectomie par stripper externe. Phlebologie 1999; 52:61–68.

31. Crosetti JP, Muller R. Traitement radical ambulatoire des varices. Proceedings of the

8th International and 19th Brazilian Congress of Angiology 439, 1972.


Surg Oncol 1992; 18:55.


Part IV: Conclusions

16

Complications and UntowardSequela of Ambulatory Phlebectomy

As with any surgical procedure, there are untoward reactions with ambulatory

phlebectomy (AP). However, these are less frequent than with the traditional

varicose vein surgery. It has been calculated that since the introduction of AP,

more than one million of such operations have been performed in Europe

without a single major complication reported (R. Muller, personal communi-

cation, 1990). Although �5% of the operated patients may call to complain

(or simply to be reassured), only a few need to be seen before their scheduled

return to the clinic.

Undesired reactions may be divided into two types: true complications

(events that require professional assistance and may leave sequela) and minor

inconveniences (which cause some nuisance to the patient, but resolve spon-

taneously and completely in a relatively short time).

The type and incidence of untoward reactions during AP are illustrated in

Tables 16.1, 16.2, and 16.3 with a review reported by Ramelet in 1997 (1). These

complications are discussed in further detail in relation to the different phases of

phlebectomy.

COMPLICATIONS OF ANESTHESIA

Local infiltration anesthesia (LIA), as employed for AP, has not caused major

complications (see Chapter 7). Transitory malaise is usually due to emotionally

induced hypotension. It is largely avoided by the Trendelenburg position, by

distracting patient’s attention, and by employing neutralized, warmed (378C)

solution and injecting slowly. All of these maneuvers help to reduce pain. It is

important to recognize emotional reactions as such and not to confuse them

with toxic or allergic reactions. Inappropriate initiation of emergency treatment

215

will only enhance the patient’s anxiety and worsen the situation. All that is

needed for emotionally induced hypotension or malaise is to stop injecting,

increase the head-down, foot-up tilt, and reassure the patient.

Most patients “at risk” for emotional reactions are identified in advance,

during the orthostatic clinical, ultrasound examination, and pre-operative

marking; emotional fainting in our experience is more frequent with these

Table 16.2 Complications of AP in 1000 Patients (2953

Operations) Treated by Muller from 1965 to 1975 (3)

Hemorrhage at home 11 (1.1%)

Hematoma 17 (1.7%)

Lymphocele 18 (1.8%)

Nerve damage 46 (4.6%)

Persistent pedal edema (more months) 13 (1.3%)

Infection 18 (1.8%)

Superficial thrombophlebitis 4 (0.4%)

Discolored scars 72 (7.2%)

Persistent pain (2 months) 2 (0.2%)

Blister 84 (8.4%)

Eczema 26 (2.6%)

Keloid 3 (0.3%)

Minor malaise during anesthesia 5 (0.5%)

Table 16.3 Complications of AP in 4000 Consecutive

Cases (4)

Blister formation 214 (5.4%)

Pigmentation (transitory) 183 (4.6%)

Telangiectasia matting 145 (3.6%)

Localized superficial phlebitis 110 (2.8%)

Temporary dysesthesia 15 (0.4%)

Lymphocele 6 (0.2%)

Extensive superficial phlebitis 5 (0.1%)

Delayed bleeding 4 (0.1%)

Hematoma 4 (0.1%)

Table 16.1 Complications of AP in 320 Consecutive Patients (852

Operations) Performed in Our Office in 1990 (2)

Hemorrhage at home 1 (0.3%)

Hematoma 1 (0.3%)

Lymphocele 5 (1.6%)

Nerve damage 3 (0.9%)

Persistent pedal edema (5 months after surgery) 1 (0.3%)


procedures than with anesthesia and phlebectomy performed in the Trendelen-

burg position.

Allergic Reactions

With the local anesthetics now in use, allergy is exceptionally rare and is due in

most cases to the psychogenic or vasovagal reactions (5). The amide class of

anesthetics has a very low risk of allergic reactions (6–11). Allergy is most

likely caused by methylparabens or sodium metabisulfite that is used as a preser-

vative in the anesthetic solutions (6,7,12–14). Therefore, to keep the allergic risk

as low as possible, one should use single dose vials of anesthetic without

preservatives.

Despite the low risk of allergenicity to lidocaine, multiple allergic reac-

tions, including anaphylaxis, have been reported (15–22). Patients with con-

firmed allergy to local anesthesia are excluded. Fortunately, most patients have

already had local anesthesia (usually for dental procedures) which has established

their allergic history.

In the case of a suspected allergic reaction, the injection must be stopped

immediately. If there is only a cutaneous rash, intravenous diphenhydramine

and/or cortisone may be sufficient. If bronchospasm occurs, IV cortisone plus

inhalatory beta-mimetic drug (salbutamol, Alupent) is given. If anaphylactic

shock occurs, oxygen must be immediately supplied, and IV cortisone and

epinephrine are given.

Toxic Reactions

Toxic reactions are either neurologic or cardiovascular. They occur from acci-

dental intravascular injection of the anesthetic agent, rapid absorption from the

injected site, or in the oversensitive patient. They are largely avoided by using

a low dosage of anesthesia, low absorption rate due to superficial infiltration,

and the presence of epinephrine to further decrease the systemic absorption of

the anesthetic agent. It is also important to consider excluding patients at risk,

that is, with important cardiac arrhythmias and blocks, uncontrolled hyperten-

sion, beta-blocker medication, hypokalemia, coronary heart disease, and so on.

The average dosage of mepivacaine for phlebectomy is 2 mg/kg with a

maximum of 6 mg/kg for great saphenous vein (GSV) stripping. The average

dosage of lidocaine (which is metabolized like mepivacaine) for phlebectomy

is 10 mg with a maximum of 20 mg for GSV stripping. Blood concentrations

of lidocaine were checked in a series of 50 patients treated by AP (23). With

dosages of 3–15 mg/kg (average 8.7 mg/kg), lidocainemia was found to be an

average of 0.6 mg/mL, which is less than one-sixth the neurotoxic concentration,

and less than one-thirty-sixth the cardiotoxic concentrations. A peak value of

1.8 mg/mL, found in only one patient, was still less than one-half the concen-

tration considered neurotoxic (4–12 mg/mL) and less than one-twelfth the one

considered cardiotoxic (24 mg/mL).

Complications and Untoward Sequela of AP 217

A neurotoxic reaction includes cortical excitement symptoms, such as

anxiety, tremor or convulsions, and/or respiratory depression. Cardiovascular

toxic reactions include arterial hypotension and bradycardia.

In these conditions, oxygen must be supplied. Convulsions are treated by

intravenous diazepam. Respiratory depression may require assisted respiration.

Hypotension and bradycardia require accentuated Trendelenburg position, IV

atropine, and/or ephedrine as needed.

Toxic reactions to epinephrine, such as sweating, tremor, tachycardia, and

hypertension, are unlikely at the dosage employed (20–100 mL of 1:500,000

solution). Should these occur, IV sedation (diazepam) and/or anti-hypertensive

medication may be indicated.

Although allergic and toxic reactions are extremely rare and may never

happen in many years of busy practice, one must not forget that they might

occur, and should this happen, they must be promptly recognized and adequately

treated. Therefore, the availability of emergency and resuscitation equipment and

drugs, as well as the ability to use them, is necessary for an office where varicose

vein surgery is performed (see Chapter 19).

Local Complications

Anesthesia on the anterolateral aspect of the knee, close to the head of the fibula,

may occasionally reach the motor branch of the external sciatic-popliteal nerve

with consequent foot drop. Even a minor impairment of foot dorsiflexion may

create ambulation problems. The effect of anesthesia ceases in �2–3 h.

Full thickness skin necrosis, 1 week after the procedure in the area anes-

thetized with 20 mL of 2% lidocaine with epinephrine 1:100,000, was

described (25). The procedure performed in the controlateral leg with lidocaine

without epinephrine was uneventful and suggest an exaggerated response to

epinephrine. The patient revealed a history of prolonged anesthesia following

dental procedure lasting up to 1 week. Her twin sister had a similar response

to local anesthetics.

Late Reactions

A small number of patients report (especially after higher dosage of anesthesia)

symptomatic orthostatic hypotension, which may persist for 24–48 h after

surgery. We do not have an explanation for this phenomenon. It might be a

rebound effect of epinephrine injections, but may also have an emotionally

based hypotensive reaction.

COMPLICATIONS OF PHLEBECTOMY

Hematoma

Significant hematoma formation is rare. AP is virtually a “bloodless” procedure.

Bleeding is avoided by placing the patient in the Trendelenburg position,


by peripheral vasoconstriction (epinephrine and emotionally induced), and by

digital compression of all bleeding sites and ligation of any large perforator

or collateral. After the operation, bleeding is avoided by the compression

bandage.

Limited nonvisible hematomas taking place in the fat tissue tunnel result-

ing from the venous avulsion are more frequent. They may explain some fat

tissues indurations or even inflammation lasting more than a week, or the for-

mation of subcutaneous cord-like reactions with (rare) retraction of the skin

(Fig. 16.1).

Hematoma is more likely to occur in the groin or in the patients with obese

limbs and over an incompetent perforator that has not been ligated, where effec-

tive local compression is more difficult to achieve. Hematoma usually requires no

other treatment than locally enhanced and longer lasting compression to hasten

reabsorption. Occasionally, a large hematoma has to be evacuated to accelerate

healing. Finally, unexpected hematoma formation may occur in patients with

impaired blood coagulation (Fig. 16.2).

Hemorrhage at Home

Although groin hemorrhage is avoided by careful ligation of all divided vessels,

bleeding from distal incisions is prevented primarily by the compression

bandage. Provided bleeding during phlebectomy has been treated adequately

(digital pressure, ligation of large incompetent perforators), post-operative bleed-

ing indicates that the compression bandage is inadequate.

Bleeding usually occurs within the first few minutes after surgery. For this

reason, it is important to keep the patient under observation in the office for at

Figure 16.1 Blood collection inside the tunnel resulting from the saphenous stem

avulsion (one week post operation). Longitudinal (left) and transversal (right) scans

show how a cord-like induration may appear.


least half-an-hour after the operation, with only the adhesive bandage applied

(Fig. 16.3). Only after, it is certain that there is no bleeding in the removable

stocking or bandage applied, and the patient discharged. During the office obser-

vation period, patients must walk and step up and down on a platform. Bleeding is

also checked by vigorously squeezing the bandaged leg with both hands. Some-

times, a collection of blood may not stain the bandage spontaneously, but will be

brought to the surface by such squeezing. If bleeding is noticed, the patient is

placed in the Trendelenburg position and the bandage reapplied.

Wound Infection

Wound infection is rare and promptly responds to antibiotic medication

(Fig. 16.4). Several factors determine the very low rate and benign nature of

such infections:

. minimal incisions and tissue trauma;

. surgery limited to the extrafascial compartment;

. absence of (or very limited) hematoma formation;

Figure 16.2 Extensive hematoma formation after phlebectomy of patient on (unre-

ported) oral anti-coagulant medication.


Figure 16.3 Bleeding usually occurs within the first few minutes after phlebectomy,

therefore, it is important to keep the patient under observation in the office for at least

half-an-hour after the operation.

Figure 16.4 Wound infection.


. anti-edema and anti-inflammatory effects of the compression bandage;

. absence of drug-resistant hospital acquired infections.

Wound infection is usually limited to one or two contiguous incisions and

not to the whole area of the procedure. Usually, it presents as local pain starting

during the third post-operative day in an otherwise uneventful follow-up. An

immediate pus evacuation and a local and general antibiotic medication for the

following 5 days will stop the infection. The wound will be more visible than

the normal incisions, but the result will be still satisfactory at 2 months.

Although skin preparation and draping are similar to any surgical pro-

cedure, all the usual rules of the hospital operating room are not applied in the

office surgical setting. The patients can wear their own clothes, the operator

does not change shoes, and the operating room is not sterile. Prophylactic

antibiotic medication is not necessary prior to, during, or after surgery.

Lymphatic Disruption

Lymphocele

Small lymphatic collections occasionally occur over the operated sites

(Fig. 16.5). They may be asymptomatic, but may also cause local inflammation

and pain. Sometimes, it is possible to break them by digital pressure, but they

may need to be evacuated, one or several times, by needle aspiration. Recently,

the injection of a small amount of sclerosing foam at low concentration (0.3%)

following aspiration has been demonstrated to be very effective in treating this

condition. Local compression is needed until symptoms disappear. This may

be minimized by keeping incisions small and vertically oriented. The anterolat-

eral tibial area is most prone to develop lymphatic damage due to the propensity

of the lymphatic system being just beneath the epidermis.

Figure 16.5 Lymphocele over tibia 5 days after phlebectomy.


Lymphorrhea

Rarely, a lymphatic vessel may exteriorize from an incision, causing lymphor-

rhea, which does not stop with compression bandaging alone, but ceases once

the lymphatic vessel has been identified and pushed back under the skin.

Persisting Edema

Very rarely varicose vein surgery may be followed by lymphatic edema that may

persist for many months. This complication, as well as lymphatic disruption, is

more likely to occur when the vein dissection is difficult and traumatic to the peri-

venous tissues. This is more likely to happen when there are extensive perivenous

adherences that may occur in limbs, which have had repeated superficial throm-

bophlebitis or have been treated by sclerotherapy and/or traditional stripping

techniques.

Nerve Damage

Sensory nerve damage occurs most often along the distal segments of the GSV

and short saphenous veins. Because these segments are not routinely removed,

the incidence of nerve damage is lower than with total stripping operations.

The use of low dosage LIA further decreases this complication, because manipu-

lation of the nerve is painful (electric shock sensation) and thus largely avoidable.

However, nerve damage does occasionally occur because veins and

sensory nerves may occur in close approximation. An empty vein may also

appear similar to a nerve, causing the latter to be mistaken for a vein. A small

nerve is occasionally hooked and avulsed without significant sequela at the

foot dorsal area, due to the absence of space between the skin and the fascia,

veins and nerves being in great proximity (24). Nerve damage is more likely

to occur when dissection is particularly difficult because of perivenous adher-

ences (previous surgery, sclerotherapy, phlebitis). The posterior ankle and

inferior calf are the most likely locations to induce nerve damage, especially to

the sural nerve, because of its close apposition to the GSV and its tributaries.

Division of a larger nerve causes permanent loss of skin sensitivity,

whereas nerve trauma may be followed by temporary loss of sensation. Although

rare, an annoying or painful hyperesthesia due to granuloma formation at the site

of nerve disruption or trauma may occur. In this case, local infiltration with cor-

ticosteroids may help. In one case, we had to surgically remove a 5 mm painful

granuloma from a phlebectomy scar in the Boyd area 3 years after phlebectomy.

Immediate disappearance of symptoms followed.

Vein Thrombosis

Superficial thrombophlebitis may occur in veins adjacent to those avulsed even if

normal, when the normal outflow is decreased or stopped. It is largely prevented


by adequate compression. Should it occur, prompt resolution occurs with com-

pression and anti-inflammatory medication.

Clinically manifested deep vein thrombosis is extremely rare having

occurred in our practice only in a recent case, a 70 years lady with a lymphoma

in remission phase, due to circulating thrombophilic factors. The thrombosis

appeared during the seventh post-operative day (she had also a short stripping)

as a popliteal pain. The popliteal and femoral veins were partially closed

(Fig. 16.6). Although establishing anticoagulation and continuing “heavy” com-

pression, a complete iliac-femoral thrombosis occurred. At 6 months follow-up,

the thrombosis partially recanalized. Curiously, the leg never became swollen as

it was compressed from the beginning. This experience is exceptional but shows

that in any case one must be aware that what is impossible to occur, can occur.

Clotting abnormalities, hereditary or acquired, should be considered when ana-

lyzing the history of patients. Leiden’s mutation of clotting factor V is the

most common cause of familial thrombophilia, which is present in 5% of the

European population, absent in Asians and Africans. Although thrombosis

rarely occurs in the deep venous system after AP, we believe that immediate

and sustained compression therapy and immediate ambulation prevents this

from occurring. However, our attention must be directed on suspecting early

symptoms and consequent early anticoagulating therapy with low-molecular

weight heparin at curative dosage.

Pulmonary Embolism

Clinically manifested pulmonary embolism has never occurred in our practice. In

the rare patient where it was clinically suspected, the patient was admitted to the

hospital and had a negative lung scan. In this case, a diagnosis of viral pulmonary

infection was made.

Figure 16.6 Transversal scan at the

groin level showing a partial obstruc-

tion of the Femoral Vein along the

deep side: deep vein thrombosys

appearing at the seventh post-operative

day.


Telangiectatic Matting

In a few patients (from 0.5% to 9%, according to different authors) (1), new tiny,

red telangiectasia may appear along the operated sites. It is the “worst”

complication of AP, and also of sclerotherapy and traditional venous surgery.

In AP, it is particularly annoying as far as the esthetic result is generally very

good. Telangiectatic matting may tend to fade in a few months and may be

related to excessive inflammation from aggressive phlebectomy and/or

inadequate compression, or the unwanted creation of areas of difficult akin drai-

nage. Hormonal influence may be suspected. Treatment can be attempted by

sclerotherapy or laser, but only after waiting for 6–9 months to allow for

spontaneous resolution.

Hypertrophic and Pigmented Scars

In a few patients, scars may persist as red, brown, or white spots (Fig. 16.7). In

some subjects, with very clear skin, the red phase of the scars may last for a long

time. We have never seen true keloids to occur, although an occasional patient

has developed a hypertrophic scar. In the patient with defective skin healing,

locally enhanced and prolonged compression may prevent the formation of

unsightly scars.

Rare Complications

A case of lipoidic necrobiosis and a case of granuloma due to talc powder

have been described. Recently, a case of vitiligo has been reported (26),

along the area where a varicose vein had been avulsed, appearing sometime

Figure 16.7 Red-brownish spots over needle puncture incisions 5 months after

phlebectomy.


after an uneventful phlebectomy. An auto immunization mechanism is con-

sidered, secondary to the trauma of anesthesia, or incisions or avulsion

(Kobner’s phenomenon).

COMPLICATIONS OF COMPRESSION BANDAGE

Excessive Compression

Excessive local compression and inadequate protection padding, especially over

bony prominences (shin, dorsum of foot, etc.), may cause trauma to skin, sensory

nerves, and tendons, with pain, numbness, or even skin necrosis (see Chapter 14).

It may also cause transverse hyperpigmented stripes, which may take many

months to disappear. Excessive ankle compression, combined with insufficient

foot compression, may cause pedal edema.

Blister Formation

Blister formation occasionally occurs. It is due to excessive skin tension or fric-

tion between bandage and skin. This is most common around the knee and pos-

terior thigh. It is very painful, but heals promptly once the blisters are punctured

and the bandage properly reapplied. If blister rupture exposes the underlying skin,

an occlusive hydrocolloid dressing is applied under the compression bandage.

Figure 16.8 Blister formation due to traction of the band-aids and the friction exercised

by the bandage. (a) Blisters. (b) Blisters causing brown pigmentations, which may take

many months to disappear.


Figure 16.10 Allergy with blister formation and sloughing to the band-aids used to

cover the stab incisions 48 h after GSV stripping with multiple phlebectomies. (No

allergy to the adhesive bandage applied directly on the skin at the groin and upper thigh.)

Figure 16.9 Allergy to the adhesive bandage over the site of direct contact with the skin.


Blister formation may be followed by skin discoloration, which may take many

months to disappear (Fig. 16.8).

Contact Dermatitis

Cutaneous reactions may range from skin irritation to allergic contact dermatitis

(Figs. 16.9 and 16.10). In these patients, alternative compression materials

must be employed at direct contact to the skin, that is, acrylic adhesive

bandage or glue.

REFERENCES

1. Ramelet A-A. Complications of ambulatory phlebectomy. Dermatol Surg 1997;

23:947–954.


Surg Oncol 1992; 18:55.

3. Muller R. La phlebectomie ambulatoire. Phlebologie 1978; 31:273.

4. Olivencia JA. Complications of ambulatory phlebectomy: a review of 4000 consecu-

tive cases. Am J Cos Surg 2000; 17:161–165.

5. DeShago RD, Nelson HS. An approach to the patient with a history of local anesthesia

hypersensitivity: experience with 90 patients. J Allergy Clin Immunol 1979;

63:387–394.

6. deJong RH. Local Anesthetics. 2nd ed. Springfield, Ill., 1977, Charles C. Thomas.

7. Swanson JG. Assessment of allergy to local anesthetic. Ann Emerg Med 1983;

12:316–318.

8. deJong RH. Toxic effects of local anesthetics. J Am Med Assoc 1978;

239:1166–1168.

9. Incaudo G, Schatz M, Patterson R. Administration of local anesthesia to patients with

a history of adverse reactions. J Allergy Clin Immunol 1978; 61:339–345.

10. Thomas RM. Local anesthetic agents and regional anesthesia of the face. J Assoc

Military Dermatol 1982; 8:28–33.

11. Fregert S, Tegner E, Thelin I. Contact allergy to lidocaine. Contact Dermatitis 1979;

5:185–188.

12. Covino BG, Vassallo HG. Local Anesthetics: Mechanisms of Action and Clinical Use.

New York: Grune & Stratton, 1976.

13. Eriksson E. Illustrated Handbook of Local Anesthesia. 2nd ed. Philadelphia:

W.B. Saunders, 1980.

14. Baker JD, Blackmon BB. Local anesthesia. Clin Plast Surg 1985; 12:25–31.

15. Kennedy KS, Cave RH. Anaphylactic reaction to lidocaine. Arch Otolaryngol Head

Neck Surg 1986; 112:671–673.

16. Promisloff RA, Dupont DC. Death from ARDS and cardiovascular collapse following

lidocaine administration. Chest 1983; 83:585.

17. Aldrete JA. Sensitivity to lidocaine. Anaesth Intens Care 1979; 7:73–74.

18. Gill C, Michaelides PL. Dental drugs and anaphylactic reactions: report of a case. Oral

Surg 1980; 50:30–32.

19. Chin TM, Fellner MJ. Allergic hypersensitivity to lidocaine hydrochloride. Int J

Dermatol 1980; 19:147–148.


20. Ravindranthan N. Allergic reaction to lidocaine: a case report. Br Dent J 1975;

111:101–102.

21. Lechner T. Lidocaine hypersensitivity. Lancet 1971; 1:1245–1246.

22. Fischer MM, Pennington JC. Allergy to local anesthesia. Br J Anaesth 1982;

54:893–894.

23. Vidal-Michel JP, Arditti J, Bourbon JH et al. L’snesthesie locale au cours de la

phlebectomie ambulatoire selon la methode de R. Muller. appreciation du risque

per dosage de la lidocainemie. Phlebologie 1990; 43:305.

24. Ricci S. Phlebectomie des varices du pied. Phlebologie 2000; 53:223–228.

25. Olivencia JA. Ambulatory phlebectomy. A rare complication of local anesthetic: case

report and literature review. Dermatol Surg 1996; 22:53–55.

26. Bullens-Goessens YIJM, de Roos KP, Kockaert MA, Neumann HAM. Survenue

d’une vitiligo apres phlebectomie ambulatoire. Phlebologie 2002; 55:275–277.


17

Psychological Aspects

Patients who undergo ambulatory phlebectomy (AP) or any surgical procedure

are more or less anxious about it and experience a certain degree of fear prior

to, during, and even after the operation. The surgeon should be aware of this

and also find the best approach to all patients and situations in order to both

win the patient’s confidence and deliver optimal care. This requires a rapid rec-

ognition of individual patient nuances to help identify patients who are not com-

patible to outpatient surgery. These patients are oversensitive to pain, have a

negative attitude to many situations, which produces dissatisfaction with the

results, and so on.

Patient fear is normal and should be treated with comprehension and

support. Comparing it to the common fear of the dentist is pertinent.

Surgeons must be firm in their ideas, but also reassuring in order to

obtain and maintain the patient’s confidence. The latter is easier to obtain if

the patient has already been treated (i.e., for leg ulcer or phlebitis), or if a rela-

tive or friend has described phlebectomy in positive terms. It is important to

explain in detail with simple words what will be done and why it should be

done. One should not deny or minimize some inconveniences (bandaging, dis-

comfort), but explain that these are largely overweighed by the benefits of the

procedure.

According to their behavior, patients may be divided into four groups.

Group 1: These are the “normals,” patients everybody would like to treat.

They have fears, but know that surgery is necessary. These patients ask

reasonable questions, collaborate with office staff, withstand incon-

veniences, and judge the procedure objectively. Reassured by the first

phlebectomy, they come back for the next operation with less fear.

Unfortunately, these patients are not the majority, but comprise �30%

of the population.

Group 2: These patients are able to manage their fear and anxiety only with

continuous exteriorization and support. They endlessly repeat the same

231

questions, such as, are there any problems, difficulties or complications,

how much time is left, and so on, in continuous need for reassurance and

encouragement. If continuously distracted, they behave like those of

Group 1, but are prone to become anxious about what is being done at

any new situation, such as, traction upon a vein, the sound of closure

of the clamp, and so on. Despite an ideal first phlebectomy, these patients

come back for the next operation with the classical statement: “This time

I am more afraid than the previous time.”

These are extroverted characters who need to continually “mani-

fest” their fears and sensations; if properly entertained and distracted,

that is, talking about arguments of interest to them, the operation pro-

ceeds normally.

About 50% of patients belong to this group. Though operating on

them may be quite demanding (as the operator must continuously

capture their attention), the results are rewarding. Once the “big trial”

has been overcome, these patients are often enthusiastic about the pro-

cedure and the results, and eager to communicate their sensations to

others, which gives them self-gratification. They often become strong

advertisers for AP.

Group 3: These patients, �10%, are the most difficult to manage. They

could be considered an exaggerated version of Group 2. These are

often overweight and insecure patients who need constant commisera-

tion and make of their “suffering” a means of capturing other’s attention.

They are unwilling to accept the minimal temporary discomfort to

gain a long-term benefit. Wenner defines them “infantile or regressed”

(1). During the operation, they call every touch or minimal discomfort

pain, moan continuously even if there is no pain, complain or even

panic at any minimal sensation, and ask the surgeon to stop operating.

Once bandaged, upon entering the waiting room, they start telling

everybody (the patients waiting for the operation included) how much

they suffered, even though the procedure was smooth and painless.

Many such patients will not consent to surgery, saving a great

deal of trouble to the doctor. Those who eventually get operated are a

tough test for the doctor’s patience and ability. Once operated, they

often forget pre-operative instructions and do not follow the prescribed

rules. Often, they do not come for follow-up visits until many years

later, sometimes in bad condition, and are often unsatisfied with the

result.

Group 4: This group consists of anxious and doubtful patients. They are

uncertain of everything, fear everything, and usually consult many

specialists even for trivial and insignificant pathology. Often these are

well-instructed persons in whom, however, anxiety sweeps intelligence

away. Often underweight, they may have vagal reactions triggered by


a simple orthostatic clinical or ultrasound examination. Many of them

have had previous treatments with poor results.

It is possible to treat such patients successfully, provided their con-

fidence is obtained and realistic goals of treatment are agreed upon, but

this is more difficult than with the patients of Group 2. Great patience is

necessary, and the same concepts must be repeated many times, with

friendliness or firmness. If good transference is achieved, these patients

may often come for a visit or counsel, often for problems not related to

phlebology. They do so not as much for a specific phlebological

problem (the proposed solution of which they still have doubts about),

but because of the relation they manage to establish with the doctor.

Many of these patients are “constitutionally” difficult—or imposs-

ible—to satisfy, because of their negative attitude. If it becomes clear

that reasonable goals of treatment are difficult to agree upon, underlining

the negative aspects of treatment may help dissuade such patients of being

treated.

The above-described “classification” is, of course, an oversimplification,

but gives an idea of the most common personality types and problems encoun-

tered in everyday practice. Moreover, doctors themselves belong to one of the

cited groups, too, and instead of conditioning patient’s behavior, may in turn

get conditioned by the patient with the result of not being able to deliver the

best possible care.

Practitioners engaged in office surgery under local anesthesia need, in

addition to clinical and surgical ability, a capacity to adapt their behavior to

the individual patient’s character. Such ability is difficult to teach. It is mastered

by experience and self-confidence. This “burden” may be—and should be—

shared by the office staff, whose role in patient support cannot be over

emphasized. The choice and training of the nurse, assistant, and even secretary

is, therefore, of primary importance.

Some suggestions on how to improve the doctor–patient relationship and

the patient’s comfort with phlebectomy are as follows:

. Create a pleasant environment.

. Treat patients friendly and make every effort to show an efficient office

organization.

. Supply pleasant background music.

. Assure the presence of an assistant, who may assume the role of the

“good one” as opposed to the “bad one,” that is, the operator.

. Avoid starting treatment with a difficult or complicated phlebectomy.

. Consider utilizing self-administered inhalation sedation–analgesia

with nitrous oxide/oxygen for the extremely anxious or oversensitive

patient.

Psychological Aspects 233

After surgery:

. Give simple written instructions that permit the patient to manage

eventual minor inconveniences.

. Supply telephone number(s) and assure 24 h availability should any

problems arise.

REFERENCE

1. Wenner L. Aspetti Psicosomatici in Flebologia. Napoli: Fratelli Conte Editori, SpA,

1979.


18

Advantages of AmbulatoryPhlebectomy and OfficeVaricose Vein Surgery

In medicine, few ideas stand up to the judgment of time. One has just proclaimed

an “important truth,” when a colleague promptly enjoys destroying it, proving the

exact opposite. Surgery represents a field most appropriate for such “cultural

massacre,” and varicose vein surgery, in particular, seems to offer the best pos-

sibilities for this “game.”

Indeed, a patient with an incompetent great saphenous vein (GSV) and

few varicose leg collaterals, even when thoroughly studied with the modern

investigation techniques and supplied with a precise diagnosis, may be advised

to consider the following wide range of different—and even opposite—

treatments.

1. Sclerotherapy alone (1,2).

2. Total GSV stripping with/without subfascial or epifascial perforator

ligation (3–8).

3. Total GSV and lesser saphenous vein stripping (9).

4. GSV stripping with sclerotherapy of the collateral varicose veins

(CVV) (10).

5. GSV division with intraoperatory sclerotherapy (11).

6. GSV stripping with eventual phlebectomy of CVV (12).

7. Ambulatory phlebectomy (AP) of the CVV with/without stripping of

the proximal portion of the GSV (13).

8. Phlebectomy of the CVV and of the GSV trunk up to the groin,

without flush ligation and division of the groin collaterals of the

GSV (14).

9. Cryosclerosis of the GSV (15).

10. Cryostripping of the GSV (16).

235

11. High ligation and division of the GSV alone (17).

12. Restoration of the competence of the saphenofemoral valve (18).

13. Step-by-step division of the incompetent perforators with/without

sclerotherapy (19).

14. High ligation and division of the GSV with ligature of the GSV trunk

distal to all incompetent perforators (20).

15. Radiofrequency ClosureTM of the GSV with/without sclerotherapy or

phlebectomy of distal veins (21–27).

16. Endovenous laser treatment of the GSV with a variety of laser

wavelengths (28–32).

17. Foam sclerotherapy of the GSV (33–38).

The earlier-mentioned operations (or groups of operations) may be classified as

“conservative,” or “ablative.” Conservative techniques aim at restoring valvular

competence or interrupting deep to superficial and/or downward flow without

removal or destruction of the incompetent superficial veins. Ablative techniques

aim at interrupting deep to superficial flow, as well as removing or destroying all

incompetent varicose veins.

Some of these methods are obsolete, others experimental or practiced by

only a few physicians, but almost all of these techniques are still performed.

With so many different procedures, the choice of the type of treatment often

depends on the doctor’s experience, rather than on the type of varicose vein

pathology.

A detailed discussion of each method of varicose vein treatment is beyond

the scope of this book. Most physicians agree that the best cosmetic and func-

tional results are obtained by ablative techniques. These remove or destroy all

varicose veins and interrupt all sources of pathological (deep to superficial)

reflux (39). These goals have been traditionally achieved by the stripping oper-

ation, varicose veins excision, perforator division, and sclerotherapy. The follow-

ing discussion is limited to the advantages of AP as compared to traditional

surgical and sclerotherapy methods of varicose vein removal and/or destruction.

If correctly applied, any treatment may give satisfactory results in selected

cases. An example is the excellent results achieved by GSV stripping in patients

without CVV. In fact, the great variety of treatments is partly justified by the

variety of clinical forms of varicose vein disease. As Charles Mayo stated in

1906, “There are many operations in use at the present time for the relief of var-

icose veins. The disease is one that manifests such diverse conditions and symp-

toms that no (single) method can be suited to all cases” (3).

Varicose vein disease may progress regardless of the initial treatment,

which further complicates our evaluation of treatment techniques. Therefore,

acceptable long-term results may be achieved, regardless of the initial treatment

when adequate patient education, cooperation, and follow-up visits with eventual

further treatments are given. An example is a patient treated by sclerotherapy


alone who may improve or maintain the good results of the first treatment by ade-

quate patient education, collaboration, and further treatment(s).

Introduced almost 100 years ago, the stripping operation is still the most

frequently performed varicose vein operation (3–6). The endoluminal stripper

is largely preferred to the extraluminal, because it may allow total stripping of

the GSV with only two incisions.

Though sufficient in some cases, a complete stripping operation from groin

to ankle is often “excessive,” as the distal portion of the GSV is competent in over

25% of the cases. This operation may also be insufficient as it leaves CVV

untreated, and in other cases, it is not indicated at all as 20–50% of the patients

with varicose veins may have a competent GSV (40,42). Varicosities left by the

stripping operation should be removed through additional incisions (often leaving

unsightly scars), treated by sclerotherapy, or even by operations more complex

than the stripping operation itself. Though possible on an outpatient basis and

under local anesthesia (LA) or regional anesthesia, it is still performed mainly

under general anesthesia, and thus at a considerable cost. In a 1988 survey, out

of 30 Italian Centers of Vascular Surgery, only 10 practiced varicose vein

surgery on an ambulatory basis, and only on selected patients (43).

The inadequacy of the stripping operation—and of the classical surgical

approach in general—stimulated the development of sclerotherapy. Sclerother-

apy is an office procedure that does not require anesthesia or interruption of a

patient’s work or social activities. However, its long-term results are conditioned

by a high rate of recanalization. Repeated treatments—or subsequent surgery—

are often needed to maintain acceptable cosmetic and physiologic results.

Although some schools advocated the employment of sclerotherapy as an

alternative to surgery in all varicose vein patients, the technique is mostly utilized

for the chemical destruction of the varicose veins left by the stripping operation

and for small caliber veins. This combined approach exploits the advantages and

reduces the drawbacks of the two methods (10,11).

Like the combination stripping/sclerotherapy, the one of stripping/phle-

bectomy/sclerotherapy also enhances treatment, reduces inconveniences, and

is even more efficacious. AP combines many of the advantages of both

methods and minimizes their drawbacks. Some specific advantages of AP are:

. is simple to perform;

. does not require complex and expensive equipment;

. is extremely safe;

. is suitable for the removal of any varicose vein in any site of the lower

limb (except for the saphenofemoral junction);

. causes minimal trauma and stress to the patient;

. can be easily repeated;

. excellent immediate and long-term results;

. excellent cosmetic results;

. can be associated with other treatments;

AP and Office Varicose Vein Surgery 237

. can be employed for the removal of veins in locations other than the

lower limbs;

. low-cost procedure (office treatment).

Unlike traditional surgery, which often makes subsequent operation(s) more dif-

ficult because of extensive scarring, adherence, and poor anatomical definition,

AP leaves a “clean field” because of the lack of extensive dissection and scarring.

AP is not a “textbook operation” devised to treat an anatomical (abstract)

vessel. It is a “custom-made” procedure adaptable to individual patients. It allows

early treatment of cases previously considered unsuitable for surgery. This

assumes additional importance in delivering optimal care for a progressive and

chronic condition like varicose veins. At the same time—complemented, when

needed, by GSV division, high ligation and stripping under LA, and/or scler-

otherapy of the residual telangiectasia—AP allows one to treat even the most

complicated cases of varicose veins in an office setting, with the long-term

results of surgery, with less inconvenience, better cosmetic results, at a lower

cost, and without interruption of the patient’s work or social activities.

REFERENCES

1. Sigg K. Varizen Ulcus Cruris und Thrombose. Berlin: Springer Verlag, 1976.

2. Fegan GW. Varicose Veins Compression Sclerotherapy. London: W. Heinemann Ltd,

1967.

3. Mayo CH. Treatment of varicose veins. Surg Gynecol Obstet 1906; 2:385.

4. Babcock WW. A new operation for the extirpation of varicose veins of the leg. NY

Med J 1907; 86:153.

5. Myers TT. Results and technique of stripping operation for varicose veins. J Am Med

Assoc 1957; 163:87.

6. Nabatoff RA. Importance of adequate excision of all incompetent perforator vessels in

the surgical treatment of varicose veins. Use of new marking ink to delineate varices.

NY J Med 1952; 52:563.

7. Linton RR. The communicating veins of the lower leg and the operative technique of

their ligation. Ann Surg 1938; 107:582.

8. Cockett FB. Diagnosis and surgery of high pressure venous leaks in the leg. Br Med J

1956; 2:399.

9. Frileux C, Pillot-Bienayme P, Gillot C. La role de la saphene externe dans les varices

essentielles. Phlebologie 1973; 26:143.

10. Hobbs JT. Surgery and sclerotherapy in the treatment of varicose veins. A random

trial, Arch Surg 1974; 109:793.

11. Kistner RL. Saphenous interruption and sclerotherapy. In: Bergan JJ, Kistner RL, eds.

Atlas of Venous Surgery, Philadelphia: W. B. Saunders Company, 1992.

12. Muller R. La phlebectomie ambulatoire. Phlebologie 1978; 31:273.


Surg Oncol 1992; 18:55.


14. Dortu J. La crossectomie sus-fasciale au cours de la phlebectomie ambulatoire du

complexe saphenien interne a la cuisse. Phlebologie 1993; 46:123.

15. Besset JF. Mon experience de la cryochirurgie. Phlebologie 1989; 42:579.

16. Milleret R. Mon experience de la cryochirurgie des varices. Phlebologie 1989; 42:573.

17. Trendelenburg F. Uber die Unterbindung der Vena saphena magna bei Unterschenkel-

varizen. Beitrage zur klinischen Chirurgie 1890; 7:195.

18. Belcaro G. Plication of the saphenofemoral junction: effects on incompetence after

two years. Phlebology 1991; 6:159.

19. Belcaro G, Christopoulos D, Vasdekis S. Treatment of superficial venous incompe-

tence with the SAVAS technique. J Mal Vasc 1991; 16:23.

20. Franceschi C. Concervatrice et hemodynamique de l’insufficiance veineuse en ambu-

latoire. Precy-sous-Thil: Editions de l’Armancon, 1988.

21. Weiss RA, Goldman MP. Controlled radiofrequency-mediated endovenous shrinkage

and occlusion. In: Goldman MP, Weiss RA, Bergan JJ, eds. Varicose Veins and

Telangiectasia: Diagnosis and Treatment. 2nd ed. Quality Medical Publishing Inc.:

St. Louis, 1999:217–224.

22. Goldman MP. Closure of the greater saphenous vein with endoluminal radiofrequency

thermal heating of the vein wall in combination with ambulatory phlebectomy: pre-

liminary 6-month follow-up. Dermatol Surg 2000; 26:452–456.

23. Danielsson G. New treatment options for venous disease: a minimally invasive

alternative treatment for patients with superficial venous insufficiency. Scope

Phlebol Lymphol 2000; 7:126–128.

24. Chandler JG, Pichot O, Sessa C et al. Treatment of primary venous insufficiency by

endovenous saphenous vein obliteration. J Vasc Surg 2000; 34:201–214.

25. Manfrini S, Gasbarro V, Danielsson G et al. Endovenous management of saphenous

vein reflux. J Vasc Surg 2000; 32:330–342.

26. Chandler JG, Pichot O, Sessa C et al. Defining the role of extended saphenofemoral

junction ligation: a prospective comparative study. J Vasc Surg 2000; 32:941–953.

27. Goldman MP, Amiry S. Closure of the greater saphenous vein with endoluminal radio-

frequency thermal heating of the vein wall in combination with ambulatory phlebect-

omy: 50 patients with more than 6-month follow-up. Dermatol Surg 2002; 28:29–31.

28. Min RJ, Zimmet SE, Isaacs MN, Forrestal MD. Endovenous laser treatment of the

incompetent greater saphenous vein. J Vasc Interv Radiol 2001; 12:1167–1171.

29. Navarro L, Min RJ, Bone C. Endovenous laser: a new minimally invasive method of

treatment for varicose veins—preliminary observations using an 810-nm diode laser.

Dermatol Surg 2001; 27:117–122.

30. Weiss RA. RF-mediated endovenous occlusion. In: Weiss RA, Feied CF, Weiss MA,

eds. Vein Diagnosis and Treatment. New York: McGraw-Hill, 2001: 211–221.

31. Proebstle TM, Lehr HA, Kargl A, Espinosa-Klein C et al. Endovenous treatment of

the greater saphenous vein with a 940-nm diode laser: thrombotic occlusion after

endoluminal thermal damage by laser-generated steam bubbles. J Vasc Surg 2002;

35:729–736.

32. Goldman MP. Endoluminal laser treatment of the greater saphenous vein at 810 nm.

Lasers Surg Med 2002; (suppl 14):121.

33. Cabrera Garrido JR, Cabrera Garcia-Olmedo JR, Garcia-Olmedo Dominguez MA.

Elargissement des limites de la schlerotherapie:noveaux produits sclerosants

Phlebologie 1997; 50(2):181–188.

AP and Office Varicose Vein Surgery 239

34. Monfreux A. Traitement sclerosant des troncs saphenies et leurs collaterales de gros

calibre par le methode MUS Phlebologie 1997; 50(3):351–353.

35. Henriet JP. Un an de pratique quotidienne de la sclerotherapie (veines reticulaires

et teleangiectasies) par mousse de polidocanol: faisabilite, resultats, complications

Phlebologie 1997; 50(3):355–360.

36. Cavezzi A, Frullini A. The role of sclerosing foam in ultrasound guided sclerotherapy

of the saphenous veins and of recurrent varicose veins: our personal experience. Aust

NZ J Phlebol 1999; 3(2).

37. Mingo-Garcia J. Esclerosis venosa con espuma: foam medical system. Revista

Espanola de Medicina y Cirugia Cosmetica 1999; 7:29–31.

38. Tessari L. Nouvelle technique d’obtention de la sclero-mousse. Phlebologie 2000;

53(1):129.

39. Bergan JJ. The role of surgery in treatment of varicose veins and venous telangiecta-

sias. In: Goldman MP. Sclerotherapy: Treatment of Varicose and Telangiectatic Leg

Veins, St. Louis: Mosby Year Book, 1991.

40. Schwartz SI. Yearbook of Surgery, Chicago: Yearbook Medical Publishers, 1979.

41. Goren G, Yellin AE. Primary varicose veins: topographic and hemodynamic

correlations. J Cardiovasc Surg 1990; 31:672–677.

42. Hanrahan LM, Kechejian GJ, Cordts PR et al. Patterns of venous insufficiency in

patients with varicose veins. Arch Surg 1991; 126:687–691.

43. Dedonato A, Piccolo GR, Mannelli MP. La chirurgia ambulatoriale delle varici. Quad

Med Chir 1990; 6:127 (Ital).


19

Setting Up a Varicose VeinSurgery Practice

WHO SHOULD PERFORM OFFICE VARICOSE VEIN SURGERY?

Phlebectomy

Phlebectomy maneuvers are simple enough to be performed by a physician

with manual dexterity without general surgical training. Although it cannot be

“performed” by every physician, it can be “learned” by any physician. Besides

the specific manual skill, to practice phlebectomy successfully, the surgeon

should possess:

1. thorough knowledge of venous anatomy, physiology, and pathology;

2. thorough knowledge and ability in applying compression—adhesive

and nonadhesive—bandages;

3. manual ability.

The technique, in fact, yields the best results in the hands of the experienced phle-

bologist, that is, the physician routinely involved in treatment of venous diseases.

As with any manual skill, phlebectomy is best learned under the super-

vision of an experienced surgeon. This is important not only for learning the

technique, but also for acquiring experience prior to initiating a completely

autonomous activity.

High Ligation and Division of the Greater Saphenous Vein

Unlike phlebectomy (which may be performed by a “beginner” without general

surgical training), high ligation and division of the great saphenous vein (GSV)

must be performed by an expert surgeon. This is because the operator must be

able to cope with the potential hazards of groin dissection. While in the hospital,

the junior surgeon can always obtain help from a senior colleague; in the office, it

is the operator him/herself who is “captain of the ship.” Therefore, as the same

241

patient may need phlebectomy and GSV division, the job may be done either by a

single operator (with adequate surgical experience), or by a team of phlebologists

and surgeons. Muller’s office, in fact, was organized on a team basis. A surgeon

performs GSV ligation and stripping, and Muller himself the phlebectomy of the

remaining varicose veins.

With newer methods of eliminating reflux from the saphenofemoral

junction (SFJ) including endoluminal radiofrequency or laser closure of the

GSV, the entire procedure can now be performed in an office setting under

local anesthesia (LA).

Alternative Applications of Phlebectomy

Phlebectomy is best performed in the office under local infiltration anesthesia

(LIA). It can, of course, be performed under regional, spinal, or general anesthe-

sia in the hospital, to complete the traditional stripping operation. Indeed,

phlebectomy has been modified and “reinvented,” especially by surgeons who

perform traditional stripping operations, to a point that it is hardly recognizable

as the original Muller’s technique. However, although the avulsion maneuvers

are the same, the technique loses many of its advantages, such as repeatable

office procedure, low cost, and no interruption of patient’s work. This is

without any advantage in terms of complications. Instead, the hospital operation

has the major risks of pulmonary embolism, sensory nerve damage, and the risks

of anesthesia.

SAFETY IN OFFICE SURGERY

In organizing a free-standing surgical office, one must keep in mind that safety

cannot be overemphasized. The matter is rather complex and involves pro-

fessional behavior in all of its phases, from patient selection and pre-operative

management, to the type of anesthesia utilized and procedure being performed,

and post-operative management. Besides these “active” aspects, safety measures

also involve a number of “passive” or defensive aspects, such as the availability

of adequate emergency equipment (and the ability to use it), in addition to con-

forming to all bureaucratic and accreditation requirements. Most of these aspects

have been discussed to some extent elsewhere in this text, and are summarized in

this chapter under separate headings.

Proper patient selection is critical in insuring both optimal surgical results,

as well as enhanced safety. Patients chosen for outpatient surgery must be gener-

ally healthy. The most appropriate types of patients are Class I or Class II as cate-

gorized by the American Society of Anesthesiologists (ASA) physical status

classification (see Table 19.1).

Criteria for assessing a patient’s fitness for anesthesia have been well

described. In addition to physical requirements for outpatient surgery, patients

must also be psychologically suitable. Their expectations must be realistic.


Patients who are excessively apprehensive and those with “a remarkably low pain

threshold” are best dealt with under general anesthesia.

Each patient should have a pre-operative evaluation appropriate to their

physical state. History should be directed towards uncovering previous adverse

drug reactions, results of previous surgeries, and/or any associated compli-

cations, medications taken regularly or intermittently, a history of hypertension,

cardiac arrhythmia, asthma, and kidney or liver disease. Physical examination

should be directed towards the cardiopulmonary status of the patient.

It is recommended that an appropriate routine pre-operative laboratory

evaluation be performed. The most useful tests include a complete blood

count, routine blood chemistries, prothrombin time, and partial thromboplastin

time. In addition, we recommend a serological test for human immunodeficiency

virus and hepatitis B and C surface antigen. Patients who are taking thyroid sup-

plementation should have thyroid hormone levels evaluated.

Although not absolutely necessary, patient monitoring during the pro-

cedure is helpful and may be considered standard of care in some communities.

Continuous verbal communication between the patient and surgeon is sufficient

for most procedures done under LA, including tumescent anesthesia. The inten-

sity of patient monitoring depends on the complexity of the surgery and the

patient’s general health.

Continuous monitoring of a patient’s arterial oxygen saturation by a pulse oxi-

meter has become an accepted standard for respiratory monitoring of patients under

deep intravenous or nitrous oxide sedation or general anesthesia. Continuous elec-

trocardiographic monitoring and automatic periodic blood pressure measurements

may also be important in selected patients. However, if such monitoring devices

induce complacency or divert the surgeon’s attention from the patient, they may

work to the patient’s detriment. It is up to the individual physician and ambulatory

surgical facility to determine appropriate standards of operation, with the earlier-

mentioned recommendations serving only to provide useful guidelines.

Pre-Operative Management

An optimal phlebectomy procedure begins with a thorough diagnostic work-up

leading to a precise, detailed diagnosis. Precise anatomical definition is

Table 19.1 ASA’s Physical Status Classification (1–3)

Class 1 Healthy patient

Class 2 Patient with mild systemic disease, such as mild hypertension, moderate

obesity, diet-controlled diabetes

Class 3 Patient with severe systemic disease, not incapacitating, such as

marked hypertension, morbid obesity, insulin-dependent diabetes

Class 4 Incapacitating systemic disease

Class 5 Moribund patient

Varicose Vein Surgery Practice 243

mandatory for an office surgical procedure. This enhanced accuracy allows for a

smoother, speedier surgery with a decreased likelihood for hematoma formation.

Patient selection is equally important, as exclusion factors are related more to

a patient’s general health rather than type of venous disorder. Office surgery should

be limited to anesthesia type I and II patients, that is, patients in good health or with

well-controlled systemic disease (Table 19.1). Borderline cases should be con-

sidered for office surgery only after a specialists’ explicit agreement. In these

patients, the surgical procedure(s) should be more limited than usual.

A warm and caring attitude with psychological support from the staff is

important to minimize emotional distress that remains the most common “com-

plication” of ambulatory phlebectomy (AP).

Anesthesia

Recommended dosage of anesthesia must never be exceeded, and in selected

cases, modified or further reduced as needed. With the type and dosage of

anesthesia used for AP, there is no need to monitor the patient’s vital functions

(unless it is considered standard of care in your community). However, the

patient must be carefully observed during anesthesia for any untoward reaction.

Type of Surgical Procedure

The type of operation performed in the office is important. This is well illustrated

by the experience of two masters of the past. During the 1920s in Chicago,

de Takatz routinely performed ambulatory ligation and division of the GSV

under LIA, permitting patients to drive themselves back home immediately

after surgery (4); whereas in 1957, Myers recommended keeping 500–

1000 mL of blood available for transfusion if needed after GSV stripping (5).

In other words, only office-tested operations should be performed in the office.

Operations that are technically correct, but have been performed only in the

hospital, should not be performed in the office. In addition, we recommend

multiple, short procedures that produce minimal stress to the patient.

Operator’s Experience

While in the hospital, the junior surgeon can obtain help at any time from a senior

colleague. This is not possible in the office. Therefore, the procedures performed

must be proportionate to the experience of the surgeon.

Post-Operative Management

Adequate written patient instructions are mandatory. The surgeon (or assistant)

must be available to answer patient questions and concerns 24 h a day after the

procedure.


Emergency Measures

The office and staff must be adequately equipped and prepared to cope with an

emergency situation. In the absence of specific mandatory standards for free-

standing surgical suites, the decision regarding what equipment to purchase is

left to the individual operator.

While patient safety depends primarily on the procedure itself, public (and

peer) opinion tends to identify safety with the availability of emergency facilities

with reference to those present in a well-equipped hospital. Therefore, this should

not be neglected.

The minimum emergency equipment and drugs may include the following:

1. stethoscope, blood pressure cuff;

2. oxygen source;

3. ambu bag with a variety of airways;

4. IV fluids and emergency drugs: epinephrine, hydrocortisone, atropine,

diazepam, ephedrine or mephentermine (for persisting hypotension),

and labetalol or hydralazine (for high blood pressure).

Additional equipment may include a defibrillator and cardiac/blood pressure

monitor. Finally, the presence of an anesthesiologist, though not necessary for

giving anesthesia, may enhance the efficiency of the office and also take some

of the professional and legal burden off the surgeon.

THE FREE-STANDING SURGICAL OFFICE

Operating Room

Office varicose vein surgery does not require a sophisticated operating room

or equipment. A 12 � 15 square foot operating room is sufficient and will

also provide space for a stock of the necessary materials. If the practice is busy

and phlebectomy organized as teamwork, that is, an anesthesiologist gives anesthe-

sia and an assistant (or nurse) does the post-operative bandaging, then two operat-

ing rooms instead of one will greatly enhance efficiency and permit one to perform

almost twice as many operations as when a single room is utilized.

The room must be adequately ventilated and have either windows for

outdoor light or emergency lighting. We find diffuse overhead fluorescent type

illumination adequate and do not use special surgical lighting. The operating

table must permit head-down, foot-up tilt (Trendelenburg) position.

Bureaucratic and Accreditation Requirements

In planning and organizing a surgical unit, one must, of course, comply with

all local laws and regulations. However, while bureaucratic regulations may

augment costs, they are not to be expected to be totally efficient in providing


the best conditions for both surgeon’s work and patient’s safety. It is the surgeon

who should strive for a higher standard of care. Accreditation programs and cer-

tification, as those provided by the Accreditation Association for Ambulatory

Health Care, Inc., (AAAHC, 9933 Lawler Avenue, Skokie, Illinois 60077-

3702) have been developed with the scope of assisting the surgeon in organizing

an efficient, high level of ambulatory care.

Accreditation may be required by insurance companies for reimbursement

of office surgical procedures. But, even if it is not, it is highly recommended for

it testifies to the surgeon’s commitment to the highest possible standards of care

and safety and thus may reassure both patients and colleagues. With the expansion

of office surgery, it is to be expected that pressure will grow toward enforcement of

higher standards of care and safety. Accreditation may well be an anticipated

answer of the medical profession to such a trend. The problems related to planning

and organizing a free-standing surgical office are discussed elsewhere (6–10).

Reimbursement claims to third part payments should be accompanied by a

proper operative report, an example of which follows.

OPERATIVE REPORT

AMBULATORY PHLEBECTOMY

Name of patient:

Date of birth:

Physician:

Date performed:

Site of phlebectomy:

Consent form explained and signed YES NO

Pre-operative photo YES NO

Laboratory tests performed

Test reports provided by referring physician YES NO

Varices were located visually, manually and/or with

DOPPLER ultrasound YES NO

DUPLEX ultrasonography YES NO

Cutaneous marking was performed using . . . The patient was placed in a

Trendelenburg position. Surgical asepsis was obtained using Hibiclens/Betadine/Technicare solution.

Local infiltration anesthesia was performed with

VOLUME INJECTED WAS RIGHT LEG LEFT LEG

microincisions were made (number 11 blade, 18 gage needle)


A cleavage plane was created between the epidermis and the varicosity to free

any adhesions.

A/an hook/Graefe iris forceps were used to grasp the vein.

Mosquito forceps were applied as a tractor to extract the vein.

An external stripper was used to perform a stripping on the varicose trunk

YES NO

(Number) varicose veins or vein segments were extracted.

(cm) length of vein extracted.

(cm) diameter of vein extracted.

Selective compression dressing of the varicose veins and compression bandages

and/or stockings were applied for 7 days.

Ambulation was prescribed.

was prescribed as an analgesic/anti-inflammatory.

Sporting activities were approved the day post-treatment.

FOLLOW-UP APPOINTMENT was scheduled for

SPECIMEN WAS SUBMITTED YES NO

EQUIPMENT AND MATERIALS

Following is a list of the specific equipment and materials necessary for varicose

vein surgery and sclerotherapy as described in this book.

Room Equipment

. Operating table. Need not be sophisticated surgical table. All that is

needed is to be comfortable and have head-down, foot-up tilt capacity;

. Mayo stand;

. Free-standing platform with handrails for long-lasting examination

(i.e., duplex scan) and pre-operative marking;

. Sterilization unit.

Surgical Instruments

Standard surgical instruments for ligation and stripping (single set)

. Two 20/30 mm retractors (Goelet or Richardson–Easmann);

. Two standard 14 cm 2 � 3 teeth dissecting forceps;

. One 14 cm Mayo dissecting scissors;

. Three curved toothed 13 cm Halsted hemostatic forceps;

. Two curved nontoothed 12 cm Halsted hemostatic forceps;


. Two curved 14 cm Kocher hemostatic forceps;

. One regular 14 cm needle holder;

. One number 15 scalpel blade with holder;

. Two Mayo external annular strippers, 6 and 8 mm diameter;

. Two 50 cm Corcos external strippers, 6 and 8 cm diameter;

. Catgut or Vicryl #3-0 without and with needle.

Specific Instruments for Phlebectomy (Single Set)

. Various phlebectomy hooks (Muller, Ramlet, Vardey, Oesch, Dorth,

Millet);

. One Graefe iridectomy forceps, curved at 908;

. One fine-pointed curved Halsted mosquito forceps (10–12 cm);

. One fine-pointed curved toothed mosquito forceps (12–13 cm);

. Six straight toothed hemostats;

. One blunt-pointed 14 cm probe (optional);

. One blunt curve-pointed 14 cm probe;

. Straight iris scissors;

. One number 11 scalpel blade with holder or needle driver, 18–19 gage

hypodermic needle and/or blood lancet;

. Vicryl #3-0 with or without needle.

Materials for Anesthesia

. Lidocaine 1%/epinephrine with/without 1:100,000;

. Sterile 1.4% sodium bicarbonate solution;

. Sterile saline solution;

. 500 or 1000 mL normal saline bag;

. Infiltration pump and tubing.

Syringes

. Luer Lok or non-Luer Lok 20 mL syringe for anesthesia Becton–

Dickinson & Company, Rutherford, NJ 07070.

. Plastipak eccentric syringe Becton–Dickinson & Company, Rutherford,

NJ 07070.

Needles

. 30 gage

– Air-Tite, 423, South Lynnhaven Road, Suite 104, Virginia Beach,

VA 23452.

– Precision Glide, Becton–Dickinson & Company, Rutherford,

NJ 07070.

– Acuderm, Acuderm, Inc., Ft. Lauderdale, FL 33314.

– Dermatologic Lab and Supply, Inc., Council Bluffs, IA 51503.


. 18–19 gage (Terumo) 1.5 in. (1.2 � 40 mm2) for skin incision and vein

dissection;

. 20, 22, or 25 gage spinal needles, Yale, Becton–Dickinson &

Company, Ft. Lauderdale, FL 33314.

Materials for Bandaging

. Protective skin underwrap;

. Tubular elastic bandage (i.e., Tubigrip);

. Short-stretch elastic bandages, 8 and 10 cm;

. Strong long-stretch elastic bandages (10 cm);

. Adhesive monoextensive bandages (10 cm);

. Adhesive biextensive bandages (10 cm).

Tubigrip Tubular Support Bandage, Seaton Products, Inc.,

Montgomeryville, PA.

Additional Localized Pressure

. Coban tape, Medical Surgical Division/3-M, St. Paul, MN 55144.

. Medi-Rip Bandage, Conco Medical Company, Bridgeport, CT 06610.

Compression Bandages

There are many companies that manufacture these bandages. The ones that we

recommend include Setopress (high compression bandage) (Setan Health Care

Group, PLC, Oldham OL1 3HS, England). This provides a reliable 30–40 mm

graduated compression.

Beiersdorf AG (Norwalk, Connecticut 06856-5529) manufactures a variety

of single, two-way, and three-way stretch bandages, including elastic adhesive

bandages such as “Elastoplast.” We have found that the Comprilan, Tricoplast,

and Acrylastic are particularly useful for providing short-stretch compression.

However, the reader should be aware that there are many other companies who

also provide very adequate bandages.

Compression Stockings

. class II–III: 30–40 mm graduated support stockings;

. class I: 15–18 mm stockings and pantyhose (many brands commer-

cially available).

The following are names and addresses of the most popular companies that dis-

tribute compression hosiery in the United States:

1. Jobst, 5825 Carnegie Blvd., Charlotte, NC 28209.

2. JUZO, 80 Chart Road, North Hampton, P.O. Box 1088, Cuyahoga

Falls, OH 44223.


3. Venosan North America, 718 Industrial Park Avenue, P.O. Box 1067,

Asheboro, NC 27204-1067.

4. Medi USA, 6481 Franz Warner Parkway, Whitsett, NC 27377-3000.

5. Sigvaris, 1119 Highway 74 S, Peachtree City, GA 30269.

Other Materials

. One inch paper tape (Micropore);

. Sterile band-aids, 2 � 7 cm2;

. Skin disinfectant;

. 10 � 10 cm2 gauze (sterile or to sterilize in the office);

. Cotton wool (for padding);

. Sterile disposable drapes.

Emergency Equipment

. Stethoscope and blood pressure cuff;

. Oxygen source;

. Ambu bag with airways;

. IV fluids and drugs: epinephrine, atropine, hydrocortisone, diazepam,

ephedrine/mephentermine, and labetalol/hydralazine;

. Optional equipment may include defibrillator and cardiac/blood press-

ure monitor.

Examination Equipment

. Doppler ultrasound with 8 mHz probe (or two probes, 5 and 8/10 mHz), preferably with directional capability;

. Optional ultrasound scanner with small parts probe (7.5 linear probe),

or better, echo-Doppler (duplex) scanner with peripheral vascular

(7.5–10 mHz) probe;

. Transillumination device.

Marking Solution

. Potassium permanganate 7.5% water solution or Sharpie permanent

marking pens for pre-operative marking.

Material for Local Anesthesia (MPG)

. Lidocaine 1% with epinephrine mixed 1:10 with sterile saline;

. Infiltration pump with appropriate sterile tubing;

. 20, 22, or 25 gage spinal needles.

Medication Material

. Sterile 40 � 70 cm2 drapes, surgical skin disinfectant, 10 � 10 cm2 gauze.


REFERENCES

1. Wilson ME, Williams NB, Baskett PFJ et al. Assessment of fitness for surgical

procedures and the variability of anesthetic judgement. Br Med J 1980; 1:509.

2. Malamed SF. Sedation, A Guide to Patient Management. St. Louis: CV Mosby Co,

1985.

3. Miller RD. Anesthesia. 2nd ed. New York: Churchill Livingston, 1986.

4. de Takatz G. Ambulatory ligation of the saphenous vein. J Am Med Assoc 1930;

94:1194.

5. Myers TT. Results and technique of stripping operation for varicose veins. J Am Med

Assoc 1957; 163:87.

6. Chrisman BB. Planning and staffing an appropriate outpatient facility. J Dermatol

Surg Oncol 1988; 14:708.

7. Tobin HA. Office surgery: the surgical suite. J Dermatol Surg Oncol 1988; 14:247.

8. Chrisman BB. Excellence in outpatient surgery. J Dermatol Surg Oncol 1988;

14:1300.

9. Chrisman BB, Watson MA, MacDonald DE. Outpatient anesthesia. J Dermatol Surg

Oncol 1988; 14:939.

10. Sebben JE. Sterile technique and the prevention of wound infection in office surgery.

J Dermatol Surg Oncol 1988; 14:1364 (Part I); 1989; 15:38 (Part II).

BIBLIOGRAPHY

1. Goldman MP, Bergan JJ. Scelrotherapy Treatment of Varicose and Telangiectatic

Leg Veins. 3rd ed. St. Louis: Mosby, 2001.

2. Weiss RA, Feied CF, Weiss MA, eds. Vein Diagnosis and Treatment. New York:

McGraw-Hill, 2001:211–221.


Part V: Advanced Techniques

20

Autologous Vein Transplantationfor Correction of Dermal

Atrophic Changes

Filling substances for dermal atrophic changes and tissue augmentation consist of

various compounds: autologous fat, bovine and human collagen, hyaluronic acid

from avian or bacterial sources, and various synthetic substances, such as Gortex,

silicone, and plastic beads. Each of these compounds has advantages and disad-

vantages. We have found that excised varicose veins on the legs and other

unwanted veins (such as dorsal hand veins) are easy to procure and long lasting

if not permanent.

Varicose veins are composed of endothelial cells surrounded by a layer of

collagen, elastin, and muscle. When the endothelium is removed or destroyed,

one is left with an excellent dermal filling substance. The extracted vein can

be used either as a tubular structure or cut into pieces as tailor-made dermal

implants. The vein wall, being autologous, will not be rejected and may

become more resistant to autolysis than other nonautologous materials derived

from human, avian, bacterial, or bovine sources.

Vein wall thickness varies with the size and location of varicose veins.

Veins that are located on the leg and those located distally have a thicker wall.

The increased thickness in these areas is due to the necessity for the vein to

contain and transport blood under increased hydrostatic pressures. This factor

is important when considering potential sources for a dermal filling substance.

Although other veins can be used (such as dorsal hand veins), they will

contain less collagen, elastin, and muscle.

One potential problem with using varicose veins as dermal implants is the

hypothetical development of new vascular conduits by migration and/or

extension of the intact endothelial cells. This adverse effect has not been

noticed previously in more than 10 patients some of whom were treated over

255

5 years (1). Nevertheless, as described later, we recommend placing the extracted

varicose or hand vein(s) into a solution of 23.4% hypertonic saline for 2 min to

destroy any viable cells before implantation.

TECHNIQUE

Varicose or unwanted veins larger than 2 mm in diameter are removed through

1–2 mm incisions under local anesthesia with ambulatory phlebectomy. Detailed

descriptions for removing veins with this technique are presented elsewhere in

this text as well as in numerous publications (2–6) (Fig. 20.1). Unused portions

of the veins are stored in a sub-zero freezer, as one would store autologous fat.

Figure 20.1 Vein to be extracted is marked and tumescent anesthesia is infiltrated

around the vein.

Figure 20.2 The extracted vein is placed in 23.4% hypertonic saline.


The extracted vein(s) are placed in a 23.4% hypertonic saline solution for

2 min. This results in total destruction of viable endothelial cells (Fig. 20.2). The

veins are then rinsed three times with normal saline. After rinsing, the vein is then

placed in the dermal defect or area requiring augmentation after the area is first

anesthetized with 1% lidocaine with epinephrine. One method to insert the vein

segment is to create a tunnel with a blunt dissector/hemostat. The vein is grasped

Figure 20.3 The vein is grasped with a long blunt forceps and then threaded into place.

Figure 20.4 Clinical appearance of (a) nasolabial groove and marionette lines prior to

autologous vein transplantation; (b) 6 months after transplantation.

Transplantation for Correction of Dermal Atrophic Changes 257

by the hemostat and then threaded into place, as one would do for other filling

substances such as Gortex into the subcutaneous compartment (Fig. 20.3).

We have not found it necessary to anchor the vein to any dermal structure.

The insertion holes are approximated with steri-strips or 6/0 prolene sutures that

are removed in 5–7 days. Figure 20.4 shows the clinical appearance before and

after autologous vein placement into the nasolabial groove.

An alternative technique is to chop-up the extracted vein with an instru-

ment consisting of five dermatome blades placed in a parallel manner

(Fig. 20.5). The chopped-up vein is placed into a 1 mL syringe with normal

saline and injected into place through an 18-gage needle (Fig. 20.6).

Figure 20.7 shows a patient before and 16 months after injection of autologous

vein fragments.

Figure 20.5 Dermatome for cutting vein in action.

Figure 20.6 Chopped-up vein in a 1 mL syringe.


Studies utilizing fresh-frozen autologous vein segments are underway to

determine the relative efficacy for delayed use of vein segments. We recommend

that patients who may desire soft-tissue augmentation or correction be advised to

save their extracted veins for later use.

REFERENCES

1. Blugerman G. 4th Internationales Darmstadter Live-Symposium fur Operative Derma-

tology. Nov. 18–22, 1998, Darmstadt, Germany.

2. Ricci S, Georgiev M, Goldman MP. Ambulatory Phlebectomy: A Practical Guide for

Treating Varicose Veins. St. Louis: Mosby-Year Book, Inc., 1995.

3. Fratila AAM. Surgical treatment of primary varicosis. In: Ratz JL, Geronemus RG,

Goldman MP, Maloney ME, Padilla RS, eds. Textbook of Dermatologic Surgery.

Philadelphia: Lippincott-Raven Publishers, 1998:593–620.

4. Goldman MP, Weiss RA, Bergan JD. Diagnosis and treatment of varicose veins: a

review. J Am Acad Dermatol 1994; 31:393–413.

5. Weiss RA, Goldman MP, Weiss MA. Transillumination mapping prior to ambulatory

phlebectomy. Dermatol Surg 1998; 24:447–450.

6. Smith SR, Goldman MP. Tumescent anesthesia in ambulatory phlebectomy. Dermatol

Surg 1998; 24:453–456.

Figure 20.7 (a) Traumatic dermal defect before treatment. (b) 16 months after injection

of 3 mL of chopped-up vein segments. Note the persistent correction.

Transplantation for Correction of Dermal Atrophic Changes 259

21

Treatment of the Great SaphenousVein with Endoluminal Laseror Radiofrequency Closure

Mitchel P. Goldman and Robert A. Weiss

HISTORY OF VEIN OBLITERATION

The obliteration and destruction of varicose veins as an alternative to surgical

avulsion has a long history. It is mentioned as early as 1 ACE by Celsus in

Medicinae libri octo, book VII/XXXI:

Igitur vena omnis, quae noxia est, aut adusta tabescit, aut manu eximitur.

(Any noxious vein is either burned or avulsed.)

Interestingly, Celsus also advises on selection of the appropriate procedure

according to the type of vein to be treated:

Si recta; si, quamvis transversa, tamen simplex; si modica est, melius

aduritur.

Si curva est, & velut in orbes quosdam implicatur, pluresque inter se

involvuntur,

utilius eximere est.

(If the vein is straight, or transverse, or simple and not much dilated, it is

better

burned; if [the vein] is curved, bent in more convolutions or there are

more veins

intertwined together, it is better to avulse.)

261

The instrument for burning veins, at the time of Celsus and for many cen-

turies, was the red-hot iron. It was only in the first half of the 19th century that

obliterating technique was to change and become endoluminal. The endoluminal

obliteration of an arterial aneurism was described in 1826 by Sir Everard Home,

surgeon in London, in the following terms:

In a case of aneurism in the external iliac artery, in Chelsea Hospital, for

the cure of which I tied the femoral artery below the sac, on the 16th

September 1825; upon finding that this operation neither diminished

the pulsation, nor arrested the increase of the size of the tumor, I was

led to introduce a needle, to which is given the name of acupunctorium,

into the center of the tumour where the pulsation was most violent [. . .]the needle was passed through a small orifice in a bar of steel three

inches long, the skin of the thigh was guarded by cork, and the needle

was heated through the medium of the steel by a spirit lamp. In a few

minutes the patient felt heat and pain in the center of the tumour, but

not very severe, so that the application was continued for fifteen

minutes, during which the pulsation in the tumour was diminished;

on withdrawing the needle the orifice was marked by a single drop of

coloured serum (1).

Home’s paper has three fine plates, one of which presents the endoluminal

aspect of the treated aneurism 3 months later, after the death of the patient (Plate 1).

Two inventions led to new methods of vein obliteration. The first one was

the invention of a source of electric power—the first battery—by Alessandro

Volta, in Pavia (Italy) in 1796. The second one, the invention of the syringe

for hypodermic and intravenous injections, by Pravaz in Lyon (France) in

1851. It thus became possible to obliterate veins by applying electric current to

them (electrocoagulation) and by injecting irritating solutions into them

(sclerotherapy).

Electrocoagulation of blood vessels was also performed first for the treat-

ment of arterial aneurisms, and only later extended by Italian surgeons to varicose

veins (2). The first endoluminal electrocoagulation of varicose veins was per-

formed by Bertani in Milan in 1846, and soon became so widespread that a com-

mision of enquiry into the general effects of galvano-puncture was nominated

and released its report in the January 1847 issue of Annali Universali di Medicina

(2). Few years later, in 1952, the first sclerotherapy of varicose veins was per-

formed by Petrequin in Lyon.

In the monograph “On the radical cure of varices, haemorrhoids and vari-

cocele according to the method of professor Palasciano,” Gaetano Conti

describes the electrocoagulation of the great saphenous vein (GSV) in the

Surgical Clinic of Palasciano in Naples, in 1852 (3). Six cases are described,

one of which, “on request of few Professors had his varices designed [. . .] and

included as illustration” (see Fig. 21.1). With this procedure, the “obliteration

is achieved by electropuncture with Pulvermacher’s chains, with the battery of

262 Goldman and Weiss

Bunsen, Wollaston or Volta [. . .] with the current directed towards the blood and

the internal wall of the varicose veins by two needles inserted into the vein at a -

cross, touching each other in the point of intersection.” To obtain permanent

results, once the GSV obliterated, Palasciano destroyed its varicose branches

by means of the corrosive Vienna paste, applied on the skin overlying the vari-

cose veins.

The major drawback of vein obliteration was described by Palasciano

himself in the following terms: “[. . .] after ceasing the application of electricity

[. . .] the clot softens and is even completely absorbed [. . .] This is a most

solid proof that varicose veins cannot be cured by methods which simply

form a clot, as electricity etc., since the obliteration of the varicose vein is not

a guarantee of success; sooner or later the clot dissolves and the circulation

resumes.”

During the 20th century, development of technology brought new methods

of vein obliteration. The most recent and advanced of these are the endoluminal

laser treatment and Closure (VNUS) described in this chapter. Although the

means of obliteration may change, both goals and concepts of treatment

remain much the same as during the 19th century pioneering works. In addition,

the challenge is the same as pointed out by Palasciano in 1854: to permanently

obliterate the vein and avoid its recanalization.

INTRODUCTION

Medical care in the 21st century is evolving into a minimally invasive specialty.

Procedures once performed under general anesthesia where patients’ bodies were

surgically opened to allow removal of organ systems are being replaced by tech-

niques that allow the treatment of damaged organ systems to occur with the

patient awake. This evolution has entered the field of phlebology. This chapter

will discuss two methods where a patient’s damaged and improperly functioning

axial vein is treated without requiring its removal—endovenous closure through

the thermal action of radiofrequency (RF) or a variety of lasers.

The first attempt at minimizing the extent of surgery for varicose vein

disease was to ligate the area of reflux from the saphenofemoral junction (SFJ)

into the GSV. Unfortunately, treatment of the GSV with incompetence through

the SFJ has been demonstrated to result in a high degree of recurrence when

the SFJ is merely ligated and the distal varicose veins are treated with

either sclerotherapy or ambulatory phlebectomy (AP) (4–8). This is secondary to

re-anastomosis through hemodynamically significant perforator veins present

extending from the knee to the groin, which are often not eliminated during the

surgical procedure. Therefore, to provide the maximal degree of improvement

in abnormal venous hemodynamics, complete removal of the GSV from the

SFJ to the knee is recommended after ligating the SFJ. This surgical procedure

is most often performed under general anesthesia with patients usually taking a

week or so to get back to normal activities.

Treatment of the GSV with Endoluminal Laser or RF Closure 263

Plate 21.1 An internal view of the aneurismal sac. (Fig. 1) The aorta and external iliac

passing on the outside of the aneurismal sac. The lamina of the coagulum first formed and

resembling those met with in other aneurismal tumors. The opening into the arterial trunk

from the coats having given way for the space of 1 in., exposing the upper and lower orifice

of the artery, and showing that the sac adhered to the artery even higher than the going off

of the internal iliac. (Fig. 2) A small portion of the blood coagulated by the heated needle,

which has a foliated structure, the leaves thin, compact, and connected together by thread-

like filaments. Both these figures of the natural size. (Fig. 3) One of these leaves magnified

10 diameters; its surface studded over with nodules of coagulable lymph, like so many

drops of melted wax.


Plate 21.2 Artist’s design of the leg of Giuseppe Costa, a 62-year-old pharmacist,

treated by electrocoagulation of the great saphenous vein and caustication of the sub-

cutaneous varicose branches in Ospedale degli Incurabili of Naples on July 23, 1852.

(Fig. 1) A needle indroduced in the vein; (a) second needle is passed through the vein

in a way to touch the other at a right angle inside the vein (x); chain of Pulvermacher,

which poles are attached to the needles to transmit galvanic current from a source

(Volta’s battery) to the internal wall of the vein (b). (Fig. 2) The extremities of needles

are placed over plates of plaster to guard the underlying skin (c, c0, and c00).


RF energy can be delivered through a specially designed endovenous elec-

trode to accomplish controlled heating of the vessel wall, causing vein shrinkage

or occlusion by contraction of venous wall collagen. With worldwide clinical

experience on thousands of patients since 1999, this technique is rapidly being

added to the armamentarium of ways to deal with axial venous reflux. Simultaneous

with development of RF closure, endoluminal lasers have also been demonstrated to

effectively close axial veins through thermal damage to endothelium with sub-

sequent thrombosis and resorption of the damaged vein. These endovenous occlu-

sion techniques are less invasive alternatives to saphenofemoral ligation and/or

stripping. They are typically performed under local anesthesia (LA) with patients

returning to normal activities within 1–2 days. They also can serve as a substitute

for duplex-guided sclerotherapy and other venous ablation techniques.

Although the concept of endovenous elimination of reflux is not new, pre-

vious approaches have relied on electrocoagulation of blood causing the resulting

thrombus to occlude the vein. The potential for recanalization of the thrombus is

high. Within cardiology, application of RF directly to tissue, not to blood, has

been effectively applied for ablation of abnormal conduction pathways for

arrhythmias (9). Venous occlusion with RF by the mechanism of venous blood

coagulation has been previously reported, but is different than the modern

approach (10,11). Another term in the medical literature is endovascular dia-

thermic vessel occlusion, a technique in which a spider-shaped intravascular

electrode produces venous occlusion by electrocoagulation with minimal

perivascular damage (12).

RF TECHNOLOGY

Directing RF energy into tissue to cause its destruction is potentially safer and

more controllable than other mechanisms for doing so. Delivered in continuous

or sinusoidal wave mode, there is no stimulation of neuromuscular cells using

a high frequency between 200 and 3000 kHz. The mechanism by which RF

current heats tissue is resistive (or ohmic) heating of a narrow rim (,1 mm) of

tissue that is in direct contact with the electrode. Deeper tissue planes may be

slowly heated by conduction from the small volume region of heating. This is

part of the process whereby heat is dissipated by conduction into surrounding

normothermic tissue (13). By carefully regulating the degree of heating with

microprocessor control, subtle gradations of either controlled collagen contrac-

tion or total thermocoagulation of the vein wall can be achieved.

When the RF catheter is pulled through the vein while feedback controlled

with a thermocouple, the surgeon can heat the section of vein wall to a specified

temperature. This is a relatively safe process because the temperature increase

remains localized around the active electrode provided that close, stable

contact between the active electrode and the vessel wall is maintained. By limit-

ing temperature to 858C, boiling, vaporization, and carbonization of the tissues

are avoided (14). In addition, we have shown that heating the endothelial wall


to 858C results in heating the vein media to�658C, which has been demonstrated

to contract collagen.

Electrode-mediated RF vessel wall ablation is a self-limiting process. As

coagulation of tissue occurs, there is a marked decrease in impedance that

limits heat generation (15). Alternatively if clot builds up on the electrodes,

blood is heated instead of tissue, there is a marked rise in impedance (resis-

tance to RF). The RF generator can be programed to rapidly shutdown when

impedance rises, thus assuring minimal heating of blood but efficient heating

of the vein wall.

Thus, recent technological advances including introduction of specific

application electrodes and accompanying microprocessor-controlled systems to

precisely monitor the electrical and thermal effects have allowed the safe app-

lication of this technology. One such system is the ClosureTM catheter (VNUS

Medical Technologies, Sunnyvale, CA, USA). This device produces precise

tissue destruction with a reduction in the occurrence of undesirable effects

such as the formation of coagulum. With the Closure catheter system, bipolar

electrodes are placed in contact with the vein wall. When the vein wall contracts,

the electrodes fold up within the vein that allows maximal physical contraction

(Fig. 21.1). Selective insulation of the electrodes results in a preferential delivery

of the RF energy to the vein wall and minimal heating of the blood within the

vessel. Animal experiments (described later) demonstrate endothelial denudation

along with denaturation of media and intramural collagen with a subsequent

fibrotic seal of vein lumen.

Figure 21.1 Schematic diagram of use of the Closure catheter. (Courtesy VNUS

Medical Technologies, Sunnyvale, CA, USA.)


The catheter design includes collapsible catheter electrodes around which

the vein may shrink and a central lumen to allow a guidewire and/or fluid

delivery structured within the 5F (1.7 mm) catheter. This permits treatment of

veins as small as 2 mm and as large as 8 mm. A larger 8F catheter allows treat-

ment of saphenous veins up to 1.2 mm in diameter. Both catheters have thermo-

couples on the electrodes embedded in the vein wall, which measure temperature

and provide feedback to the RF generator for temperature stabilization. The

control unit displays power, impedance, temperature, and elapsed time so that

precise control may be obtained. The unit delivers the minimum power necessary

to maintain the desired electrode temperature. For safety, if a coagulum forms on

the electrodes, the impedance rises rapidly and the programed RF generator auto-

matically cuts off.

ANIMAL STUDIES

Initial animal studies comparing RF ablation with a potent sclerosing solution

were performed on goat rear limb saphenous veins. Thirteen adult goats were

treated by the endovenous RF occlusion device with a pre-treatment mean vein

diameter of 5.3 mm. Percutaneous access obtained through a 5F introducer

sheath permits introduction of the RF catheter positioned at the treatment site

under fluoroscopic guidance. Blood flow is impeded and as RF is applied the

catheter is moved distally along the vein causing immediate contraction and ces-

sation of flow. The electrodes maintain direct contact with the vein wall to maxi-

mize vein wall heating and minimize blood coagulation.

Acute observations indicate that 92% of limbs treated resulted in significant

reduction of vein diameter with a mean diameter reduction of 5.3–1.1 mm. At

6 weeks, persistent occlusion is maintained with no flow through the treatment

site. Collateral flow is visible with high-pressure venography. Those veins that did

not immediately occlude demonstrated total occlusion within 1 week. Figure 21.6

summarizes treatment results of RF vein occlusion of goat saphenous vein.

In contrast, sclerotherapy of the posterior limb saphenous vein from five

goats utilizing 0.5–1 cc of 3% sodium tetradecyl sulfate delivered under

duplex guidance showed no evidence of occlusion. This was despite compressing

the limb for 72 h compared with no compression following RF occlusion. Mean

diameter change for sclerotherapy was from 5 mm pre-treatment to 4 mm post-

treatment with almost no change at 5 weeks follow-up. The goat saphenous

vein is a high-flow vessel so that sclerotherapy would not be predicted to be

very effective as sclerosing solutions require time to interact with the vessel

wall but are washed away quickly in these situations (16,17).

HISTOLOGY

Histologic changes confirm the clinical findings in the animal study described.

With sclerotherapy, limited endothelial denudation accompanied by some loss of


birefringence in vessel wall and 1 mm of surrounding tissue can be seen. No differ-

ences between acute and follow-up specimens are noted. For RF occlusion, the

acute changes show a 65% reduction in vessel lumen. Acute histologic features

include denudation of endothelium, some thrombus formation, thickened vessel

walls, denaturation of tissue with loss of collagen birefringence, and neutrophil

(PMN) inflammation (Fig. 21.2). Depth of vein wall damage is limited to 1–2 mm.

Chronic histologic changes 6 weeks following RF occlusion show further

reduction in lumen diameter to complete occlusion. A small residual lumen

may be recognized but occluded by organized fibrous thrombi through the

length of treated vein. Thrombus extension did not occur beyond the treatment

site. Birefringence is almost fully restored with new collagen growth detected.

Electron microscopic findings confirm the light microscopic findings with

marked endothelial damage and loss of the endothelium, neutrophils in vessel

lumen, and thickened, bulbous collagen fibrils. This indicates heat-induced con-

traction of collagen fibers and is indistinguishable from those changes seen with

CO2 laser resurfacing-induced collagen contraction.

From these histologic findings, the conclusions reached are that acute

contraction of myocytes and fibroblasts from thermal denaturation occurs.

This is accompanied by acute constriction and folding of intercellular matrix

and collagen bundles. Abundant new collagen and intercellular matrix formation

appear within several weeks following RF occlusion. The result is a thickened

vein wall with further constriction of lumen diameter. The potential safety of

this technique is supported by the fact that in animal studies there has been no

evidence of thrombus extension, whereas the zone of thermal damage has been

limited to �2 mm beyond the targeted vessel. A high acute success rate of

92% is followed by long-term vessel occlusion.

Figure 21.2 Histology of RF occlusion. (a) Before treatment. (b) Acute histologic

features of RF occlusion. (c) At 6 weeks after RF occlusion, demonstrating fibrous cord

with no recanalization. (H&E) 100�.


CLINICAL EXPERIENCE

Two years of clinical experience suggests that the Closure procedure is effective

at occluding saphenous veins and abolishing reflux. Two separate studies evalu-

ated patients treated with either a percutaneous approach or a vein cut-down

allowing access of the Closure catheter to treat the proximal GSV with phlebect-

omy of the distal GS and tributaries.

RF CLOSURE WITHOUT AP

Enrollment criteria for the first group of patients were symptomatic saphenous

reflux with a saphenous vein diameter of 2–12 mm. The genders of treated

patients included 24% male and 76% female. Mean age was 47.2 + 12.6 with

a mean vein diameter of 7.4 mm.

Most of the veins treated were above-knee greater saphenous (73%), some

entire greater saphenous (21%) with the remaining including below-knee greater

saphenous, lesser saphenous, and accessory saphenous. Adjunctive procedures

performed at the time of treatment were phlebectomy on more distal branches

in 61% and high ligation in 21%, but the adjunctive procedures did not affect

the outcome.

Vein occlusion at 1 week has been documented by duplex ultrasound in 300

out of 308 legs on a success rate of 97%. Occlusion persisted at 6 weeks in 95%

and 6 months in 92%. To date, all the patients followed from 6 to 12 months have

remained occluded; in other words, if the saphenous vein is closed at 6 months,

this will persist to 12 months and beyond. In our patients, we typically see closure

of all the major tributaries at the SFJ except for the superficial epigastric that con-

tinues to empty superiorly into the common femoral vein (CFV). We believe that

there is a high margin of safety by maintaining flow through this tributary. The

high flow rate appears to diminish the possibility of extension of any thrombus

(in the unlikely event that this would occur) from the GSV. In our personal

experience, thrombus has not been observed (18).

For clinical symptoms, the RF endovenous occlusion procedure rapidly

reduces patient pain, fatigue, and aching correlating with a reduction in CEAP

clinical class for symptoms and clinical severity of disease (Table 21.1). When

patients have had surgical stripping on the opposite leg, the degree of pain, ten-

derness, and bruising have been far greater on the leg treated by stripping. Side

effects of the Closure technique have included thrombus extension from the

proximal GSV in 0.8%, with one case of pulmonary embolus. Skin burn (prior

to the tumescent anesthesia technique) in 2.5%, clinical phlebitis at 6 weeks in

5.7%, temporary quarter sized areas of paresthesia in 18% with most of these

occurring immediately above the knee and resolving within 6 months to a

year. Thus, compared with most techniques but in particular traditional surgery

of ligation and stripping of similar size saphenous veins, the effectiveness of

endovenous RF occlusion is quite high.


RF CLOSURE WITH AP

Closure with AP was equally as effective as closure of the GSV described earlier.

The first 47 sequential, nonrandomized patients who presented to the clinic of one

of the authors (M.P.G.) having incompetent GSV from an incompetent SFJ and

painful varicosities in 50 legs were treated with the VNUS Closure procedure

after appropriate informed consent. Patient characteristics are detailed in

Table 21.2. The varicose veins were marked with the patient standing and

again with the patient lying down in the operative position with a VenoscopeTM

as previously described (19–21). Details of the operative procedure were pre-

viously reported (19). In short, after appropriate marking, the area surrounding

the GSV and distal tributaries to be treated was infiltrated with 0.1% liodcaine

tumescent anesthesia. The amount of tumescent fluid averaged 800 mL with a

lidocaine dose of 8 mg/kg. The GSV was then accessed through a 2–3 mm

Table 21.2 Patient Characteristics

50 patients (54 legs)

38 female, 12 male

Age 22–79 (avg. 47)

100% varicose veinsþ reticular and telangiectatic veins

100% reflux through SFJ with valsalva maneuver

81% moderate pain and/or leg fatigue

41% ankle and/or pedal edema

25% dermal sclerosis and pigmentation

Table 21.1 CEAP Class Description with Findings After Endovenous RF Occlusion

CEAP clinical class Description

0 Asymptomatic

1 Telangiectasia

2 Varicose veins

3 Edema

4 Skin changes

5 Healed venous ulcer

6 Venous ulcer

Mean CEAP class

Closure study population Pre-Tx 6 weeks 6 months

Pre-Tx CEAP Class ¼ 2 2.0 0.5 0.5



Total 2.4 0.8 0.6


incision in the medial mid-thigh, usually 20 cm inferior to the SFJ. The proximal

portion of the GSV was then treated with VNUS Closure and the distal portion

including all varicose tributaries were removed with a standard AP technique.

Thirty-nine patients with 41 treated legs were available for evaluation at the

longest follow-up period. Six patients (nine treated legs) could not be located for

re-evaluation after 6 months because of change in location (often out of state). The

average time to access the GSV in the medial thigh was 7 min (1–30 min).

Twenty-seven patients had the GSV accessed in �1 min. The average catheter

pull-back rate was 2.76 cm/min over an average length of treated GSV of

19 cm (6–42 cm). Complete surgical time including the phlebectomy portion of

the procedure was �20 min (range 13–35 min).

Ninety-five percent of all patients could resume all pre-operative activities

within 24 h. The other two patients could resume all activities within 48 h. Every

patient had complete elimination of leg pain and fatigue. Twenty-one of twenty-

two patients who presented with ankle edema had resolution of ankle edema. All

patients said that they would recommend this procedure to a friend.

Adverse sequelae were minimal with four patients complaining of heat

distal to the SFJ during the procedure that resolved with additional tumescent

anesthesia. Twenty-eight of fifty treated legs had some degree of purpura

lasting 1–2 weeks. Five patient legs developed mild-erythema over the GSV

closure site that lasted 2–3 days (Table 21.3). Eight legs had an indurated

fibrous cord over sites of AP that lasted up to 6 months.

Clinical and duplex evaluation performed by an independent laboratory

and/or physician at 6, 9, 12, 18, and 24 months are detailed in Table 21.4. No

new varicose veins were noted to appear in three patients with recurrent reflux

in the GSV. One patient who developed reflux had the development of new

veins at 1 year post-treatment (22).

Other surgeons have had a different experience with the use of VNUS

Closure in the treatment of incompetent GSV. The reason for the different

results is likely to be secondary to the anesthesia used as well as the technique

described subsequently.

Table 21.3 Treatment Complications

Edema 0

Phlebitis 0

Paresthesia 0

Sup. thrombophlebitis 0

Hematoma 0

Thrombus extension 0

Infection 0

Purpura 28/54 (lasted ,2 weeks)

Erythema 5/54

Fibrous cord 8/54


Three separate papers detail a similar cohort of patients treated in a multi-

center study ranging from 16 to 31 clinics with 210–324 patients with 6–12

month follow-up (23–25). The vein occlusion rate at 1 year examination was

91.6% from 9 centers and 81.9% from 14 centers. Forty-nine patients were fol-

lowed at 2 years with duplex scans and showed a 89.8% closure rate. There

was a 3% incidence of paresthesia as well as a 1.6% rate when treatment was

confined to the thigh. Two limbs (0.8%) developed scaring from skin burns

and three patients developed a deep vein thrombosis (DVT) with one embolism.

The reason for the increase in adverse effects appears to be the use of general

anesthesia without tumescent anesthesia by a majority of the surgeons.

Sybrandy and Wittens (26) from Rotterdam reported 1 year follow-up of

26 patients treated with VNUS Closure. They reported five patients with post-

operative paresthesia of the saphenous nerve and one with a cutaneous burn

for an overall complication rate of 23%. One patient (3.8%) had total recurrence

of the GSV. One patient (3.8%) could not be treated due to a technical failure.

Eight patients (30.8%) had closure of the GSV but with persistent reflux of the

SFJ. Fifty percent of patients had closure of both the GSV and the SFJ. They

had a total of 88% of patients with a totally occluded GSV.

The probable reasons for the increase in adverse effects were their use of a

spinal anesthesia instead of the recommended tumescent anesthesia. In addition,

they treated all patients from the ankle proximally, which exposed the GSV

within the calf to heat from the RF catheter. Their mean operating time was

67 min (range 25–120 min).

Another report describes two episodes of DVT in 29 patients treated with

the RF Closure (27). Here, the surgeons treated the patient with a groin incision

and passage of the catheter from the groin downward. The authors do not report

the type of anesthesia used or the length of vein treated. It is presumed that

patients were not ambulatory and treated under general anesthesia.

The important information to come out of a review of various treatments of

the GSV is that the use of tumescent anesthesia in awake patients who can ambu-

late immediately after the procedure is important in preventing skin burns and

Table 21.4 Post-Operative Duplex Evaluation

Veins closed 29/42 (69%)

Veins open without reflux 9/42 (21%)

Veins open with reflux 4/42 (9%)

Recurrent veins 3/42 (7%)

Recurrent symptoms 1/42 (2%)

Note: Time after VNUS Closure procedure of last

evaluation: 8 legs at 24 months; 8 legs at 18 months;

7 legs at 12 months; 8 legs at 9 months; 11 legs at

6 months; 8 patient legs unavailable for 6-month

evaluation.


DVT. Treatment when limited to the GSV segment above the knee is also import-

ant in preventing paresthesia to the saphenous nerve.

SIDE-EFFECTS

In our experience using tumescent anesthesia in awake patients, two patients have

developed focal numbness 4 cm in diameter on the lower medial leg. These

resolved within 6 months. Since adopting the principles outlined earlier of tumes-

cent anesthesia with moving the catheter rapidly from any points of sharp pain, no

paresthesias have been noted. No skin injury or thrombus has been observed in

any of our patients.

TECHNIQUE OF CLOSURE WITHOUT PHLEBECTOMY (VIDEO CD)

The patient undergoes the same diagnostic process as previously outlined. Pre-

sently, patients with reflux in the greater or lesser saphenous vein are candidates

if the vein size does not exceed 1.2 mm. Reflux may originate at the junction

itself as this region may be safely treated. After eliciting a detailed history as

with all the other venous procedures, and describing alternative procedures such

as ligation and stripping in detail, the patient signs the appropriate consent form

(Fig. 21.3).

The procedure begins with the vein to be treated marked on the skin using

duplex ultrasound. An appropriate entry point is selected. This is usually just

below where reflux is no longer seen in the GSV or where the vein becomes

too small to cannulate with a 16 gage introducer set. For the majority of patients

in our series, this is at a point just above or below the knee along the course of the

GSV. Before proceeding, the patient’s feet are wrapped in warm material or

socks to minimize vasoconstriction, a heating pad is placed under the thigh

and a small amount of 2% nitrol paste is rubbed onto the intended entry point

to minimize vasoconstriction during the initial cannulation process.

The patient is then prepped and draped after which 0.1 cc of 1% lidocaine

without epinephrine is injected at the pre-marked site. As detailed, with duplex

guidance, a 16 gage needle is inserted through the skin and guided into the saphe-

nous vein. When venous return is noted through the attached syringe, the Closure

catheter may at this point be placed directly through the needle into the vein.

Because this permits some slow leakage of blood around the Closure catheter

during the procedure, we prefer to insert a sheath through which the Closure cath-

eter is then advanced. Others prefer gaining entry via a venous cut-down or

pulling of the vein close to the surface with an AP hook. Our technique requires

one needle puncture only and is more likely to result in better cosmesis.

In order to place the sheath, a guidewire must be first inserted through the

16 gage needle initially inserted into the skin. The guidewire is passed �5 cm

into the GSV. The sheath is then threaded along the guidewire, piercing the

skin; its progress is followed by duplex until it is seen firmly placed within the


Figure 21.3 Consent form for Closure procedure.


lumen of the GSV. After establishing the intraluminal placement of the sheath,

the guidewire is carefully withdrawn.

The Closure catheter, with a diluted heparin solution slowly running

through a central lumen, is now inserted through the sheath. Its progress up

the GSV is monitored by duplex. If the catheter gets hung-up on a valve or

slight bend of the GSV, no additional force is used or perforation will occur.

Rather the catheter is twisted or external pressure is applied to the leg to

change the shape of the GSV. Sometimes the patient must rotate the leg.

Once the Closure catheter is in place, tumescent anesthesia (consisting of

0.25–0.5% lidocaine neutralized to pH 7 with sodium bicarbonate) is injected

between the skin and the cannulated GSV. Tumescent anesthesia volume is typi-

cally 60–120 cc for the course of the vein along the thigh. Duplex monitoring of

the anesthesia injection at the SFJ is recommended as the shape of the SFJ is

changed from the round “hook” to a straighter path.

The leg is then wrapped with a short stretch bandage from the ankle up to the

mid-thigh. This is to minimize blood return from the GSV, further diminish the size

of the GSV and reduce the possibility of heating blood rather than vein wall. When

the leg wrapping has not been tight enough, we have observed a much higher like-

lihood of a small coagulum building up at the electrodes of the Closure catheter.

Once the leg is wrapped, the final check of the position of the catheter is

made with duplex. The tip is positioned with the electrodes deployed. The tips

of the electrodes are placed so that they align with the base of the terminal

valve cusps. Once positioned, an impedance and temperature check is performed

to make sure the catheter is functioning properly. Impedance of the vein wall

should be between 200 and 350 ohms, and the thermocouple should transmit a

baseline temperature of 33–378C.

The RF is then applied; the physician monitors the temperature and impedance.

Within 15 s, the target temperature of 858C should be reached. If this does not occur,

the catheter has been mistakenly advanced too far into the CFV. Impedance would

most likely rise quickly and the RF generator shutdown automatically.

After target temperature is achieved, one waits for 30 s and then slow with-

drawal of the catheter begins. The first 4 cm are treated over 3 min but then the

catheter is advanced at a rate of 2.5 cm/min. If the patient experiences a sudden

sharp pain, the catheter is pulled 1 mm past that point, quickly to minimize the

possibility of nerve injury. If a sharp drop in temperature occurs during pull-

back, it most likely represents a large branch point or perforator, and the catheter

is temporarily held in place for 5–10 s until 858C is reached again.

When the catheter has been pulled back to the introducer sheath site, impe-

dance will suddenly rise and the RF generator cuts off. Duplex ultrasound of the

SFJ should reveal no flow except the superficial epigastric emptying into the

CMV. The GSV should be more echogenic with thicker appearing walls. If

flow is seen in the GSV, the procedure may be repeated assuming the Closure

catheter can be advanced past the treated distal segment. If one cannot pass the

catheter easily, no repeat treatment is performed, as vein perforation would be

the most likely outcome of such an attempt.


TECHNIQUE FOR CLOSURE WITH AP (VIDEO CD)

After establishing incompetence of the SFJ with duplex and/or Doppler exami-

nations, the patient is asked to stand and the locations of all varicose veins

are highlighted with a marking pen. The location of the GSV (that is usually not

visible) is marked with either Doppler or duplex control. The patient then lies on

the examining table in the operative position and all varicose veins are transillumi-

nated and marked with another marking pen. Confirmation of the location of the

GSV in the mid-thigh is obtained in the operative position with duplex or Doppler.

The patient is then taken to the operating theater, the leg is prepped

with TechnicareTM solution and sterile drapes are placed allowing exposure of

the varicose veins including the SFJ and medial thigh. The table is placed in

308 Trendelenburg position. Tumescent anesthesia is then given as previously

described through a 21 gage spinal needle. Intravenous midazolam (2–3 mg) is

sometimes given through a hep-lock to alleviate patient apprehension. Tumescent

anesthesia is given along the entire course of the varicose veins as well as around

the GSV, both above the facial sheath as well as circumferentially around the

GSV within its facial sheath. Typically, 750–1000 mL of 0.1% lidocaine with

1 : 100,000 epinephrine is used averaging between 5 and 10 mg/kg of lidocaine.

A 2–3 mm incision is then made with an 11 blade medial to the GSV in

the mid-thigh typically 20 cm distal to the SFJ. A #3 or #4 Muller hook is used

to grasp the GSV and bring it through the incision. This “blind” retrieval of the

GSV is usually accomplished in ,1 min. Hemostats are placed across the

exposed GSV and it is ligated. The proximal portion is then opened with two

toothed hemostats. The Closure catheter is then placed into the vein and its tip posi-

tioned to within 1–2 cm of the SFJ. Correct tip placement is confirmed by measur-

ing the length of the catheter and with duplex ultrasound. A slow heparin drip is

then started and the catheter withdrawn slowly as described earlier.

After the entire proximal GSV is treated, the distal stump is ligated with a

#3/0 Vicryl suture. The distal GSV and varicose veins are then removed through

a series of 2 mm incisions with a standard AP technique.

At the conclusion of the surgery, the entire leg is wrapped in a short-stretch

compression bandage over copious padding over the varicose veins removed

through phlebectomy. No incisions are closed at all. The open 2 mm incisions

allow for drainage of the anesthetic solution over 24 h minimizing bruising.

The patient is seen the next day and the compression bandage is removed. The

leg is checked for hematoma or other adverse sequelae. All incisions are

covered with antibacterial ointment and a band-aid, and a 30–40 mm/Hg

graduated stocking is applied. The stocking is left on 24 h a day for 1 week.

FOLLOW-UP CARE

Class 2 compression hosiery is worn for 3 days with the percutaneous closure

technique and 7 days with the Closure and Phlebectomy techniques. Patients

will note some bruising from the tumescent anesthesia. Anesthesia of the


treated portion of the leg may persist for 8–24 h. To gain experience, we rec-

ommend that for the initial cases, one should re-evaluate the treated veins at

3 days by duplex ultrasound. This will allow correlation of results with the

pull-back rate or any difficulty encountered during the procedure. Once comfor-

table with the procedure, the physician may want to see the patient for a duplex

ultrasound follow-up study at 6 weeks. At that time, any open segments can be

treated by duplex-guided sclerotherapy. It has been our experience that when

closed at 6 weeks, the GSV will remain closed, fibrosed, and almost indistin-

guishable from surrounding tissue at 6 months in all cases. Symptom reduction

is rapid with many patients experiencing relief at 3 days but some not until

6 weeks. Clinical improvement in appearance of varicosities is typically seen

within 6 weeks as well (Fig. 21.4). Although the patient instructions after the

Closure technique are very straightforward including 3 days of compression,

they are still provided with an instruction sheet (Fig. 21.5).

CLOSURE OF THE GSV WITH ENDOLUMINAL LASER ABLATION

Endovenous laser treatment (EVLTTM) allows delivery of laser energy directly

into the blood vessel lumen in order to produce endothelial and vein wall

damage with subsequent fibrosis (Fig. 21.6). It is presumed that destruction of

the GSV with laser is a function of thermal destruction. The presumed target

for lasers with 810, 940, 980, and 1064 nm wavelengths is intravascular red

blood cell absorption of laser energy. However, thermal damage with resorption

of the GSV has also been seen in veins emptied of blood. Therefore, direct

thermal effects on the vein wall probably also occur. The extent of thermal injury

to tissue is strongly dependent on the amount and duration of heat the tissue is

exposed to. Moritz and Henriques (28) investigated the time–temperature

response for tissue exposed to up to 708C. They found that skin can withstand

temperature rises for very short exposure times and that the response appears

to be logarithmic as the exposure times become shorter. For example, an increase

in body temperature to 588C will produce cell destruction if the exposure is

.10 s. Tissues, however, can withstand temperatures up to 708C if the duration

of the exposure is maintained ,1 s. Thus, any tissue injury from brief exposure to

temperatures ,508C would be expected to be reversible.

One in vitro study model has predicted that thermal gas production by laser

heating of blood in a 6 mm tube results in 6 mm of thermal damage (29). These

authors used a 940 nm diode laser with multiple 15 J, 1 s pulses to treat the GSV.

A median of 80 pulses (range 22–116) were applied along the treated vein every

5–7 mm. Histologic examination of one excised vein demonstrated thermal

damage along the entire treated vein with evidence of perforations at the point

of laser application described as “explosive-like” photodisruption of the vein

wall. This produced the homogeneous thrombotic occlusion of the vessel. As a

940 nm laser beam can only penetrate 0.3 mm in blood (30), the formation of

steam bubbles is the probable mechanism of action.


Another possibility for the mechanism of action of EVLT is similar to RF

closure, collagen contraction. Collagen has been noted to contract at about 508C,

whereas necrosis occurs between 708C and 1008C (22). Weather collagen con-

traction, thermal damage, or a combination of the two effects is responsible for

destruction and resorption of the GSV is unknown.

Figure 21.4 Two cases of before and after VNUS Closure. Latino woman with large

varicosities for 20 years and mild changes of chronic venous insufficiency with major

reflux originating at the SFJ, before. Two weeks after RF occlusion of the GSV along

with AP of the veins below the knee. The symptoms and signs of pain, fatigue, and

edema resolved totally. Young woman, aged 28, with recent onset of small varicosities

traced to reflux at the SFJ occurring during her second pregnancy—immediately before

treatment. Six weeks after treatment showing complete clearance. Only two punctures

were necessary for the accompanying AP of small side branches of the incompetent

GSV. Treatment resulted in rapid alleviation of symptoms of leg fatigue.


Initial reports have shown this technique with an 810 nm diode laser to

have excellent short-term efficacy in the treatment of the incompetent GSV,

with 96% or higher occlusion at 9 months with a ,1% incidence of transient par-

esthsia (31,32). Although most patients experience some degree of post-operative

ecchymosis and discomfort, no other major or minor complications have been

reported.

The lack of significant heating of perivenous tissues probably explains the

low complication rate found and argues well for the continued lack of significant

complications.

Our patients treated with EVLT with an 810 nm diode laser have shown an

increase in post-treatment purpura and tenderness. Most of our patients do not

return to complete functional normality for 2–3 days as opposed to the 1 day

“down-time” with RF closure of the GSV. As the anesthetic and access tech-

niques for the two procedures are identical, we believe that nonspecific

Figure 21.5 Post-operative patient instructions for Closure.


perivascular thermal damage is the probable cause for this increased tenderness.

In addition, recent studies suggest that pulsed 810 nm diode laser treatment with

its increased risk for perforation of the vein as opposed to continuous treatment

which does not have intermittent vein perforations may be responsible for the

increased symptoms with EVLT vs. RF treatment (Fig. 21.7) (29,33). In fact,

trying to vary the fluence and treating with a continuous laser pull-back vs.

pulsed pull-back has not resulted in an elimination of vein perforation (34).

We await longer-term results from patients already treated with EVLT and

additional refinement and evaluation of this promising new technique.

A longer-wavelength such as 940 nm has been hypothesized to penetrate

deeper into the vein wall with resulting increased efficacy. A report of 280

patients with 350 treated limbs with 18 month follow-up demonstrated complete

closure in 96% (35). Twenty vein segments were examined histologically. Veins

Figure 21.6 EVLT photo.


were treated with 1 s duration pulses at 12 J. Perforations were not present. When

the fluence was increased to 15 J with 1.2 and 1.3 s pulses, microperforations did

occur and were said to be self-sealing. The author suggests that his use of tumes-

cent anesthesia as well as the aforementioned laser parameters is responsible for

the lack of significant perforations and enhanced efficacy.

Three studies have evaluated a 1064 nm Nd:YAG endolumenal laser

(36–38). In one study (36), the lateral saphenous goat vein was used. Occlusion

was more likely when fluence exceeded 84 J/cm2. More importantly, treated

vessels were not perforated even with a fluence of 224 J/cm2. A diffusing fiber

was also used to obtain circumferential damage.

A clinical study using an endolumenal 1064 nm Nd:YAG laser in the treat-

ment of incompetent GSV in 151 men and women with 252 treated limbs was

also reported (37). Unfortunately, the surgeons also ligated the SFJ which did

not allow for a determination of the efficacy of SFJ ablation. Spinal anesthesia

was used and the laser was used at 10–15 W of energy with 10 s pulses with

manual retraction of the laser fiber at a rate of 10 s/cm. Skin overlying the

treated vein was cooled with cold water. Unfortunately, this resulted in super-

ficial burns in 4.8% of patients, paresthesia in 36.5%, superficial phlebitis in

1.6%, and localized hematomas in 0.8%.

In an attempt to bypass absorption of hemoglobin, we have been involved in

the development of a 1320 nm endolumenal laser. At this wavelength, tissue water

is the target and the presence or absence of red blood cells within the vessels is

unimportant. In addition, we utilize a mechanical catheter drawback system and

a diffusing laser fiber to provide uniform heating of the vessel. Studies in the

porcine GSV demonstrate full thickness thermal damage at 5 W with the

1320 nm laser and 20 W with the 1064 nm laser (38). Clinical studies have demon-

strated 100% efficacy without evidence of vessel perforation with use of the

1320 nm Nd:YAG intravascular laser in the first 30 patients with 6 month

follow-up (at the time of this writing). Clinical results as well as post-operative

adverse sequelae are identical to that seen with VNUS Closure treatment.

TECHNIQUE FOR CLOSURE USING ENDOLUMINALLASER (VIDEO CD)

The patient is evaluated and marked in an identical manner as with RF closure of

the GSV. Anesthesia is given along the vein in an identical manner as with RF

Figure 21.7 Vein perf with EVLT.


closure. The only difference between the two procedures is that with EVLT a

600 mm laser fiber is inserted into the vein within a protective sheath so that

only the distal 2–3 mm of laser fiber exits from the sheath. A helium neon

aiming beam that is continuously illuminated when the laser is on insures that

the laser fiber is outside of the sheath. If the laser fiber retracts within the

sheath, thermal destruction of the sheath occurs (Fig. 21.8). A Steri-strip was

placed on the fiber at the entrance of the protective sheath to mark its length.

Correct placement of the laser fiber tip 2 cm distal to the SFJ is confirmed

through catheter length measurement, duplex examination, and viewing the

He : Ne aiming beam through the skin. To prevent perforation of the GSV, using

the laser in a continuous firing mode with slow withdrawal at a rate of 1 cm/s is

advocated. It was found that this technique minimizes pain and maintains efficacy

of treatment. The remaining portion of the procedure is identical to RF closure.

SUMMARY

A new technique for endovenous occlusion using RF ablation catheters or endo-

luminal laser offers a less invasive alternative to ligation and stripping as well as a

safer alternative to duplex-guided sclerotherapy of saphenous trunks and junc-

tions. Initial clinical experience in several hundred patients shows a high

degree of success with minimal side-effects, most of which can be prevented

or minimized with minor modifications of the technique. In the near future,

many venous ablative procedures involving saphenous trunks may be replaced

or supplemented by this technique.

REFERENCES

1. Home E. On the coagulation by heat of the fluid blood in an aneurismal tumour. Philos

Trans MDCCCXXVI:189–201.

Figure 21.8 Sheath destroyed by EVLT.


2. Chapman HT. On Treatment of Ulcers on the Leg, Without Confinement, With an

Inquiry into the Best Mode of Effecting the Permanent Cure of Varicose Veins.

Cincinnati: Electric Publishing Office, 1853:148–152.

3. Conti G. Sulla cura eradicativa delle varici, emorroidi e varicocele secondo il metodo

del prof. Palasciano. Stabilimento Tipografico di Gaetano Gioja: Napoli, 1854.

4. Jakobsen BH. The value of different forms of treatment for varicose veins. Br J Surg

1979; 66:182–184.

5. Munn SR, Morton JB, Macbeth W et al. To strip or not to strip the long saphenous

vein? A varicose veins trial. Br J Surg 1981; 68:426–428.

6. McMullin GM, Coleridge Smith PD, Scurr JH. Objective assessment of high ligation

without stripping the long saphenous vein. Br J Surg 1991; 78:1139–1142.

7. Rutherford RB, Sawyer JD, Jones DN. The fate of residual saphenous vein after partial

removal or ligation. J Vasc Surg 1990; 12:426–428.

8. Sarin S, Scurr JH, Coleridge Smith PD. Assessment of stripping the long saphenous

vein in the treatment of primary varicose veins. Br J Surg 1992; 79:889–893.

9. Olgin JE, Kalman JM, Chin M, Stillson C, Maguire M, Ursel P et al. Electrophysio-

logical effects of long, linear atrial lesions placed under intracardiac ultrasound

guidance. Circulation 1997; 96(8):2715–2721.

10. Van Cleef JF. La “nouvelle electrocoagulation” en phlebologie. Phlebologie (Fr)

1987; 40(2):423–426.

11. Gradman WS. Venoscopic obliteration of variceal tributaries using monopolar

electrocautery. Preliminary report. J Dermatol Surg Oncol 1994; 20(7):482–485.

12. Cragg AH, Galliani CA, Rysavy JA, Castaneda-Zuniga WR, Amplatz K. Endovascu-

lar diathermic vessel occlusion. Radiology 1982; 144(2):303–308.

13. Haines DE. The biophysics of radiofrequency catheter ablation in the heart: the import-

ance of temperature monitoring. Pacing Clin Electrophysiol 1993; 16(3 Pt 2):586–591.

14. Haines DE, Verow AF. Observations on electrode-tissue interface temperature and

effect on electrical impedance during radiofrequency ablation of ventricular myocar-

dium. Circulation 1990; 82(3):1034–1038.

15. Lavergne T, Sebag C, Ollitrault J, Chouari S, Copie X, Le HJ et al. Radio-

frequency ablation: physical bases and principles. Arch Mal Coeur Vaiss 1996;

89(Spec No 1):57–63.

16. Weiss RA, Goldman MP. Controlled radiofrequency-mediated endovenous shrinkage

and occlusion. In: Goldman MP, Weiss RA, Bergan JJ, eds. Varicose Veins and

Telangiectasia: Diagnosis and Treatment. 2nd ed. St. Louis: Quality Medical Publish-

ing Inc., 1999:217–224.

17. Weiss RA. RF-mediated endovenous occlusion. In: Weiss RA, Feied CF, Weiss MA,

eds. Vein Diagnosis and Treatment. New York: McGraw-Hill, 2001:211–221.

18. Weiss RA, Weiss MA. Controlled radiofrequency occlusion using a unique radio-

frequency catheter under duplex guidance to eliminate saphenous varicose vein

reflux: a 2-year follow-up. Dermatol Surg 2002; 28:38–42.

19. Weiss RA, Goldman MP, Weiss MA. Transillumination Mapping Prior to Ambulatory

Phlebectomy. Dermatol Surg 1998; 24:447–450.

20. Smith S, Goldman MP. Tumescent anesthesia in ambulatory phlebectomy. Dermatol

Surg 1998; 24:453–456.

21. Goldman MP. Closure of the greater saphenous vein with endoluminal radiofrequency

thermal heating of the vein wall in combination with ambulatory phlebectomy: pre-

liminary 6-month follow-up. Dermatol Surg 2000; 26:452–456.


22. Goldman MP, Amiry S. Closure of the greater saphenous vein with endoluminal

radiofrequency thermal heating of the vein wall in combination with ambulatory

phlebectomy: 50 patients with more than 6 months follow-up. Dermatol Surg 2002;

28:29–31.

23. Chandler JG, Pichot O, Sessa C et al. Defining the role of extended saphenofemoral

junction ligation: a prospective comparative study. Vascular Surgery 2000;

34:201–214.

24. Manfrini S, Gasbarro V, Danielsson G et al. Endovenous management of saphenous

vein reflux. J Vasc Surg 2000; 32:330–342.

25. Kabnick LS, Merchant RF. Twelve and twenty-four month follow-up after endovas-

cular obliteration of saphenous vein reflux—a report from the multi-center registry.

J Phlebol 2001; 1:17–24.

26. Sybrandy JEM, Wittens CHA. Initial experience in endovenous treatment of saphe-

nous vein reflux. J Vasc Surg 2002; 36:1207–1212.

27. Komenaka IK, Nguyen ET. Is there an increased risk for DVT with the VNUS closure

procedure? J Vasc Surg 2002; 36:1311.

28. Moritz AR, Henriques EC Jr. Studies of thermal injury II: the relative importance of

time and surface temperature in the causation of cutaneous bums. Am J Pathol 1947;

23:695–720.

29. Proebstle TM, Lehr HA, Kargl A, Espinosa-Klein C et al. Endovenous treatment of

the greater saphenous vein with a 940-nm diode laser: thrombotic occlusion after

endoluminal thermal damage by laser-generated steam bubbles. J Vasc Surg 2002;

35:729–736.

30. Roggan A, Friebel M, Dorschel K et al. Optical properties of circulating human blood

in the wavelength range 400–2500 nm. J Biomed Opt 1999; 50:523–529.

31. Min RJ, Zimmet SE, Isaacs MN, Forrestal MD. Endovenous laser treatment of the

incompetent greater saphenous vein. J Vasc Interv Radiol 2001; 12:1167–1171.

32. Navarro L, Min RJ, Bone C. Endovenous laser: a new minimally invasive method of

treatment for varicose veins—preliminary observations using an 810-nm diode laser.

Dermatol Surg 2001; 27:117–122.

33. Weiss RA. Comparison of endovenous radiofrequency versus 810 nm diode laser

occlusion of large veins in an animal model. Dermatol Surg 2002; 28:56–61.

34. Goldman MP. Endovenous laser treatment of the greater saphenous vein at 810 nm.

Laser Surg Med 2002; (suppl 14):121.

35. Bush RG. Regarding “endovenous treatment of the greater saphenous vein with a

940-nm diode laser: thrombolytic occlusion after endolumenal thermal damage by

laser generated steam bubbles.” J Vasc Surg 2003; 36:242.

36. Parente EJ, Rosenblatt M. Endovenous; laser treatment to promote venous occlusion.

Lasers Surg Med 2003; 33:115–118.

37. Chang C-J, Chua J-J. Endovenous laser photocoagulation (EVLP) for varicose veins.

Lasers Surg Med 2002; 31:257–262.

38. Goldman MP, Detwiler SP. Endovenous 1064-nm and 1320-nm Nd:YAG laser treat-

ment of the porcine greater saphenous vein. Cos Dermatol 2003; 16:25–28.


22

Ambulatory Phlebectomy ofRecurrent Varicose Veins

Recurrent varicose veins are an important part of phlebological work [18% rate at

3 years, 48% at 10 years, and 77% at 34 years, according to a recent research (1);

from 4% to 52%, according to different authors (2)]. They can evolve during the

patient’s entire life and appear several years after successful treatment. Their

appearance arises from a retrograde flow fed by a source detectable at different

levels, according to Perrin’s classification (3):

. No source

. Abdominopelvic

. Saphenofemoral junction (SFJ)

. Thigh perforators

. Saphenopopliteal junction (SPJ)

. Popliteal perforators

. Gastrocnemious perforators

. Leg perforators

Causes may be surgical, technique, tactique, strategy, and residual varices,

or nonsurgical, angiogenesis, evolution, and appearance in different sites.

No matter what the cause if for the development of new veins, the patient

appears to be either deceived or desperate. The difficulty for the phlebologist is

the patient’s certain lack of confidence in the procedure or worst, the surgeon. If

the primary operation was done by the same phlebologist, some embarrassment

will be present; otherwise the operation must have been done “unsuccessfully” by

a colleague. Nevertheless, recurrent varicose vein treatment gives rise to a won-

derful opportunity to demonstrate proper ambulatory phlebectomy as the ideal

treatment.

In fact, the saphenous tributary veins in these cases are generally removed

and the recurrent varicose veins arise entirely from more superficial veins. These

287

veins are much more evident, but also easier to remove. (Different is the case of

groin recurrence with saphenous conservation.)

Of course, the true problem comes from the inadequate treatment from the

source of the reflux. If it is due to a perforator vein, its interruption and possible

ligation during the phlebectomy is generally sufficient in removing all the con-

nected varicose veins. If the recurrence is secondary to re-anastamosis of the

SF or SP junctions, usually [67% according to Stonebridge (4)] surgical revision

is necessary. Surgery is required in the presence of a saphenous stump, a sign of

insufficient junction dissection, or in the presence of a large vein connected to the

junction (85%) (1), while the detection of a re-anastamosis formed by multiple

tiny veins or capillaries does not require operative repair (10%) (1).

Surgical revision of the SFJ is a demanding operation, performed in scar

tissue full of venous tracts and is not manageable in an ambulatory setting.

Some authors still prefer to perform this surgery under local anesthesia (2) in a

more structured environment, more suitable for surgery on large deep vessels.

This operation usually requires the lateral dissection of the femoral vein up to

SFJ dissection and section/ligation.

Although good results have been reported [73% in Ref. (2)], re-recurrences

are not rare [28% in Ref. (2) and 40% in Ref. (5)]. These are caused by unknown

pathologic and/or genetic factors and are called neo-vasculogenesis. Following

the experience of one of the authors (SR), a simplified management of recurrence

at the SFJ is possible. This experience is based on a limited experience, both in

number (32) and in follow-up (oldest cases date of 1999), but the general prin-

ciples appear to be useful.

The typical case of recurrence secondary to junction re-canalization after

saphenectomy, has superficial varicosities, which converge in the groin region

to meet the neo-junction (Fig. 22.1). The varicose veins run above the superficial

fascia; they travel below the fascia only in close proximity (5–10 cm) to the groin

crease [Fig. 22.2(a–c)]. The varicose veins, even when grossly dilated, are easily

removed by phlebectomy until the penetration point below the superficial fascia,

where only ultrasound may visualize them.

It is possible then to insert into an exposed varicose vein (Fig. 22.3), an

endovenous catheter (Fig. 22.4), and inject 2–3 cc of polidocanol foam at 1%,

gently pushing the agent toward the junction (Fig. 22.5). The sclerosing foam,

more than a sclerosing solution has a long lasting “filling” effect into the entire

vascular bed. The exposed vein may then be pulled out till breaking (the foam

stops the bleeding) or tied. If a saphenous vein stem is still present at the thigh

(if the saphenectomy was not performed during the initial operation), it is poss-

ible to do the same procedure in distal direction (Fig. 22.6).

This early experience shows that it is not convenient to extract the varicose

vein until the limit of its passage below the fascia, as it is better to isolate a dilated

and straight vein tract, although at some distance from the groin, to facilitate the

catheter’s introduction. Alternatively, if the catheter is inserted very close to the

skin, it may not pass through and the injection may be impossible. In case of a


leak in the vein wall, a suture is placed on the vein’s wall around the catheter. The

suture can be employed successively for tying the vessel after the procedure.

The sclerosis of these veins is generally very effective as their walls are

dysplastic in nature and, in particular, because the absence of blood flow as a con-

sequence of the removal of drainage by the distal varicose veins. Post-operative

ultrasound examination demonstrating noncompressibility of the varicose veins

Figure 22.1 Recurrences typically appear with superficial bulging varices. At some

distance from the groin, they become deeper passing below the hypodermic fascia.

Right leg pre-operative mapping: varices “disappear” at 10 cm from the groin ending in

a sub-fascial saphenous stamp. Left leg nonmarked: varices end in a sub-fascial cavernoma

at 3 cm from the groin.

AP of Recurrent Varicose Veins 289

Figure 22.2 Usual pattern in recurrences. (a) At the groin, a residual saphenous stump or

a cavernoma or a neo-vessel is found below the saphenous fascia, clinically invisible. (b)

GSV residual tracts are detected below the saphenous fascia. (c) The most of the varicose

network is evidenced over the fascia.

Figure 22.3 The phlebectomy of the superficial varices (dotted line) stops at the point

where they get below the fascia (black line).


Figure 22.4 A veno-cath is introduced in the last extracted varice to access to the deeper

groin veins.

Figure 22.5 Foam sclerosing agent (polidocanol 1%, 1/4 foam–air ratio) is introduced

without forcing into the catheter. The foam is gently pushed upward to fill the system.


Figure 22.6 If the saphenous vein was not, or only partially, stripped, foam sclero-

therapy through the catheter procedure may be used also in distal direction.

Figure 22.7 US imaging at 7 days follow-up of the groin cavernoma. No open lumen is

present.


confirms the effect of this procedure (Fig. 22.7). Sometimes, a portion of the vein

may still appear permeable (compressible), but has an absence of blood flow.

These vein segments may require a subsequent ultrasound guided sclerotherapy

treatment. In each case, the effects of treatment is easily followed by ultrasound

and simply corrected by further injections.

It is possible that the effects of treatment are conditioned by the anatomical

picture, the treatment of micro-vein cases being more effective than the big stump

cases. The described procedure may be practiced as a complement to phlebec-

tomy simplifying an otherwise complicated operation. An unsatisfactory result

will have a very slow and measurable evolution that can always be corrected,

if necessary, by a traditional surgery.

REFERENCES

1. Fischer R, Linde N, Duff C. Cure and reappearance of symptoms of varicose veins after

stripping operation—a 34 year follow-up. J Phlebology 2001; 1:49–60.

2. Creton D. Surgery for recurrent sapheno-femoral incompetence using expanded

polytetrafluroethylene patch interposition in front of the femoral vein: long term

outcome in 119 extremities. Phlebology 2002; 16:93–97.

3. Perrin M. Classification des recidives variqueuses apres chirurgie: un document de

travail preliminaire. Phlebologie 1998; 51:423–430.

4. Stonebridge PA, Chalmers N, Beggs I, Bradbury AW, Ruckley CW. Recurrent varicose

veins: a varicography analysis leading to a new practical classification. Br J Surg 1995;

82:60–62.

5. Earnshow JJ, Davies K, Harradine K, Heather BP. Preliminary results of PTFE patch

saphenoplasty to prevent neovascularisation leading to recurrent varicose veins.

Phlebology 1998; 13:10–13.


Part VI: Appendices

Appendix 1

Instructions for Patients Affectedby Chronic Venous Insufficiency

Leg veins transport blood from the foot upward to the heart. Healthy veins have

valves which prevent blood from flowing downward. It is the rhythmic move-

ments of the foot—flexion and extension—that drive blood up. Therefore,

good venous circulation depends on two factors: (1) healthy veins with normal

valves and (2) muscular exercise.

These two elements build the “muscular-venous leg pump.” If the “pump”

does not function properly, movement of blood up the leg becomes difficult, and

consequently blood tends to stagnate. In such cases, accumulation of fluid may

occur beginning at the ankle and extending up the thigh. Vein dilation, leg

swelling and induration, skin redness, inflammation, itching, and brown or

white discoloration develop and with time skin ulceration may occur. Such

ulcers may stay open for many months or even years, then heal only to reopen.

Some do not heal at all without prolonged bed rest.

You have a chronic venous disorder. Some leg veins may be obstructed

whereas others are dilated, some valves are destroyed, and consequently blood

flows down rather than up. This explains why your leg starts swelling in the

morning, and increases during the day.

Some of the diseased veins may be eliminated (surgically or by scler-

otherapy), but there are also other veins which cannot be treated. Reconstruc-

tive vein surgery is experimental. It is tried sometimes, but no standard

operation has been developed. Therefore, no treatment exists which can com-

pletely and permanently heal your leg. For this reason, continued care is indis-

pensable to maintain your leg in optimal condition. This care consists of:

(1) regular use of elastic support stockings and (2) an appropriate lifestyle

which includes the suggestions discussed later. Ultimately, it is your responsi-

bility to take care of your legs.

297

If your leg is in very poor condition, healing may require a few months (or

even more than a year) of professional bandaging and considerable changes in

your life. Once healing is achieved, it is usually possible to maintain your leg

in an acceptable condition by adhering to a few simple rules.

To maintain your leg in good condition, you must not allow swelling to

occur. Therefore, it is indispensable to wear the prescribed elastic support

bandage or below-knee medically approved graduated compression stocking

daily, and every evening make sure that the calf is soft and the leg is not swollen.

1. Put on the stocking (or bandage) early in the morning, before starting

your daily activities; because in some legs swelling may start a few

minutes after assuming an upright position. You may have additional

benefit if, after putting on the stocking, you lay down, raise your leg

and move the foot repeatedly up and down for a few minutes.

2. Avoid prolonged standing or sitting without moving the legs. During

long trips (car, train, and airplane), move your feet up and down often

and, when possible, get up for a walk.

3. Make it a habit to take long walks. Walking with an elastic support

stocking is an important exercise for the venous circulation. The

elastic support stocking alone does not pump blood upwards, but

does so only during leg movement. Leg movement during usual

daily activities is of limited value when compared with long,

regular pace walking.

4. Make it a habit to keep your legs higher than the rest of the body a few

times a day; keep your knees flexed, as full-knee extension obstructs

venous circulation. Some activities; i.e., reading, may well be done

lying down with the legs raised.

5. If necessary, lose weight and maintain your optimal body weight.

Being overweight makes it much more difficult to keep your legs in

good condition.

6. Avoid lifting and carrying weights of .20 pounds.

7. If you smoke, know that smoking damages not only your heart and

lungs, but also your legs. The best thing to do is to stop smoking.

8. Keep your feet and toenails clean. Wear comfortable shoes and avoid

high heels. Avoid activities which risk leg trauma.

9. If you have dry skin, use an appropriate skin moisturizing cream reg-

ularly. Do not use medicated products without consulting a physician.

Many topical preparations may damage the sensitive skin of your leg.

10. Check your leg every evening for swelling. If leg compression and

lifestyle are adequate, your leg should not be swollen in the evening.

11. If you do not have gastritis (heartburn), make it a habit to sleep with

your legs slightly elevated (�6 in.). Place suitable support under the

foot of the bed so that you may comfortably change position; you

need not keep your legs fully extended.

298 Appendix 1

12. Keep a spare stocking (or bandage) on hand to avoid going without

the needed elastic support. Replace the old support stocking when

it wears out and loses its efficacy. With proper care, good quality

elastic support hose will last up to 6 months.

13. Should symptoms like swelling, itching, redness or pain occur, or you

traumatize the leg, contact us immediately. Even a trivial or small

wound, if not promptly and adequately treated, may lead to serious

consequences.

Appendix 1 299

Appendix 2

Consent for Ambulatory Phlebectomy,Endovenous Closure with Laser orRadiofrequency, Administration of

Anesthetics, and the Renderingof Other Medical Services

PATIENT NAME:

DATE: TIME:

A) AUTHORIZATION FOR VEIN SURGERY

I hereby authorize and/or associates to extract

or interrupt diseased veins for the purpose of attempting to improve the sympto-

matology and/or appearance of my legs.

B) ALTERNATIVES

I understand that alternative treatments for varicose veins exist, includ-

ing conservative treatments (elastic stockings), sclerotherapy (injection of scler-

osing agents into diseased veins), stripping, and vein ligation.

C) RISKS

The nature of the procedure to be performed has been explained to me,

and I understand that among the known risks are bruising, swelling of the leg,

transitory pigmentation, scarring, dermatitis, nerve pain, accumulation of

localized lymphatic fluid, and secondary telangiectasias (spider veins). These

301

adverse events are almost always temporary in nature but may persist for 2–6

months.

I am aware that in addition to the minor risks specifically described earlier,

there are other risks that may accompany any surgical procedures, such as loss of

blood, infection, inflammation in the venous systems with formation of a throm-

bus (clot), post-operative bleeding, and nerve trauma, which may lead to tempor-

ary numbness.

D) ANESTHESIA

I consent to the administration of anesthesia, to be administered by

or under his/her direction. I am aware that

risks are involved with the administration of local anesthesia, such as allergic

or toxic reactions to the anesthetic and cardiac arrest.

E) PROPOSED TREATMENT RESULTS

I know that the practice of medicine and surgery is not an exact science,

and, therefore, reputable practitioners cannot guarantee results. No guarantee or

assurance has been given by anyone, as to the results that may be obtained.

I have had sufficient opportunity to discuss my condition and proposed

treatment with and all of my questions

have been answered to my satisfaction. I believe that I have adequate knowledge

on which to base an informed consent to the proposed treatment.

I hereby authorize to perform

any other treatment which may be deemed necessary, should he/she encounter

an unhealthy or unforeseen condition during the course of the procedure.

F) COOPERATION

I agree to keep and staff

informed of any changes in my permanent address and I agree to cooperate

with them in my after care.

G) PHOTOGRAPHS

I consent to be photographed before, during, and after the treatment.

These photographs shall remain the property of

and may be published in scientific journals and/or shown for scientific reasons.

H) INFORMED CONSENT

I certify that I have read the above consent for surgery permit. It has been

fully explained to me and I fully understand the above consent for surgery permit.

I fully understand the inherent potential risks, complications, and results of both

the surgical procedure and necessary anesthetic which were made known, and I

accept full responsibility for these or any other complications that may arise or

302 Appendix 2

result during the surgical procedure(s), which is to be performed at my request

according to this consent and surgical permit.

PLEASE INITIAL EACH PARAGRAPH AND SIGN BELOW.

Patient Relationship

(or Legal Guardian) to Patient

Patient Name (please print)

Witness Date

I certify that I have informed the patient of the available alternative(s) with

respect to the proposed surgical procedure, and of the inherent potential surgical

risks, complications, and results that may occur as a result of said procedure.

Signature of Doctor Date

Appendix 2 303

Appendix 3

Varicose Vein SurgerySuggestions Following Surgery

ACTIVITY

Your physical activity after surgery will determined by how your legs feel. In

general, you will be able to walk, sit, drive a car, and pursue normal physical activity.

In the early days after surgery, your legs may tire. If they do, sit down and elevate

your legs above the level of your heart if possible. Vigorous activity such as jogging,

bicycling, or aerobics should be avoided for 7 to 10 days following surgery.

BANDAGES

The pressure bandages are designed to decrease swelling and increase the rate of

healing. They should be left in place for 24 hours. When they are removed,

(usually in our office), unroll the elastic bandages and roll them up once again.

Use scissors to cut off the heavy gauze bandages. Should any of the surgical

wounds remain open and drain fluid, cover them with a Band-Aid and a

non-prescriptive antibiotic ointment such as Polysoporin or Bacitracin.

On the second day after your surgery, the bulky dressings will be removed

and you will be fitted in a graduated support stocking. The stocking should be

worn 24 hours a day for a one week. The stocking is then worn during the day

and left off at night and with bathing for an additional 2 to 3 weeks, as rec-

ommended by your physician.

DISCOLORATION

Bruising is common and occurs with any procedure. It will follow the pathway of

the removed veins and become more apparent 2 to 3 days after surgery. Lumps

305

may also be present where veins were removed. These will go away in a few

weeks.

PAIN MEDICATION

Modern varicose vein surgery is remarkably pain free although it remains an

uncomfortable procedure. This discomfort can usually be relieved with Tylenol

or Extra Strength Tylenol, 1 to 2 tablets every 4 to 6 hours. Should you need

stronger pain medication, please call our office.

BATHING & SHOWERING

After the bulky surgical dressings are removed, you may shower. Be sure that the

surgical wounds are thoroughly dried after bathing to decrease the chances of

developing a wound infection.

OFFICE RETURN VISIT

Please schedule a follow-up appointment for 2 to 3 weeks after surgery. If you

should have questions or concerns prior to that appointment, please call our

office.

Patient Survey Give: Patient Signature

306 Appendix 3

Appendix 4

Nursing Instructions

Title of procedure: ambulatory phlebectomy

Time required to complete procedure: 30–60 min

Supplies needed to perform procedure: phlebectomy hooks (Muller,

Ramlet, Vardey, and other), venous probes, hemostats (large and

medium size) #6, hemostats (distal tooth) #2, #11 blade, needle

holder, straight iris scissors, tissue forceps, 4 � 4 gauze (large pack),

kling bandage, short stretch elastic bandages, 30–40 mm graduated

compression stocking

Anesthesia: 1:10 dilution of 1% lidocaine with epinephrine, diluted with

normal saline, (lidocaine 0.1%, epinephrine 0.75 mg/L). The solution

is mixed in a 500 or 1000 mL bag of normal saline. The liter bag is

warmed prior to infiltration to achieve a temperature of 37–408C. Infil-

tration is accomplished with #25 and/or #20 gage spinal needle with a

Klein infusion pump at settings ranging from three to nine

Number of people required to perform procedure: 2

Minimum qualification of employee performing procedure: medical

assistant

PROCEDURE

1. All informed consents are explained to the patient, and payment

received.

2. The patient is then photographed after the physician marks the veins

to be treated.

3. Patient is then placed on surgery table and entire area (leg) is prepped

with Hibiclens or another antiseptic solution. An absorbent chuck is

placed beneath the patient’s leg and sterile drapes are placed to

expose the vein which will be excised.

307

4. Physician will then infiltrate diluted anesthetic solution along the

course of the entire vein which will be excised.

5. #11 blade will be used to make a 2–3 mm linear incision, to get at the

proximal aspect of the vein.

6. Physician will then utilize blunt probe to undermine incision site.

7. Physician will then insert phlebectomy hook to grasp vein and pull it

out of the wound.

8. Assistant/physician will then clamp vein, proximal and distal, with

hemostat and sever connection between hemostats with iris scissors.

9. Physician will extract portion of distal and proximal vein through

incision with tug.

10. Alternatively, phlebectomy probe may be inserted into entire course

of vein.

11. This procedure is repeated until entire vein is removed.

12. Incision sites are not closed to allow anesthetic fluid to leak out.

13. Entire treated leg and incision sites are cleansed with hydrogen

peroxide.

14. Absorbent 4 � 4 gauze pads placed along course of vein and affixed

with roll of kling gauze.

15. Short stretch elastic bandage is wrapped on to treated leg starting at

the foot and continuing 4–6 cm above last phlebectomy incision.

A 30–40 mm/Hg graduated compression stocking is given to the

patient, which will be applied to the treated leg, the next day after

the compression bandage is removed.

16. Post-operative care is explained.

17. Sample of vein tissue is to be sent for pathology.

308 Appendix 4

Appendix 5

Ambulatory PhlebectomyOperative Report

Patient Name:

Date of Surgery:

Physician:

Assistant:

Anesthesia: 1% xylocaine with Epinephrine 1:100,000, diluted 1:10

with normal saline. Total of ml Pre-operative

anesthesia: Versed mg IVP

Diagnosis:

Surgical Procedure:

Operative Time:

Alternative therapies were discussed with patient prior to obtaining written and

verbal consent for surgery after explanation of the risks of bleeding, infection,

scarring and consequences of no treatment.

PROCEDURE: Vaices were identified both visually, with transillumination and

with Doppier Ultrasound. Cutaneous Marking was performed. The patient was

309

placed in a slight Trendelenburg position. Surgical asepsis was obtained using

Hibiclens solution. Microincisions were made using a #11

blade. A #2, #3 and #4 blunt hook was used to Grasp the vein.

Varicose vein(s) was/were extracted measuring cm in length

and mm in diameter.

Absorbant pads were placed over the microincisions. Elastic compression

bandages and/or stockings were applied including a selective compressive

dressing of the varicose vein for 7 days.

Estimated blood loss was . The patient tolerated the procedure

well. Postoperative care was reviewed. Follow-up appointment was scheduled

for 24 hours and in one week.

Comments:

Physician Signature Date

310 Appendix 5

Appendix 6

Operative Report for EndoluminalRadiofrequency Closure

MARYLAND LASER, SKIN AND VEIN INSTITUTE, LLCNAME DIAGNOSIS: Incompetent great

saphenous vein from incompetent

saphenofemoral junction.

DATE PROCEDURE: Endovenous closure of

greater saphenous vein from

saphenofemoral junction.

PHYSICIAN: PROCEDURE TIME: hrs.

ASSISTANTS: PRE-OP MEDS: Valium 10 mg, lnderal

20 mg po

ANESTHESIA:

0.2% Lidocaine with Epinephrine, cc total along the course of the greater

saphenous vein in a tumescent technique.

OPERATIVE REPORT:

The patient was informed of the risks and benefits of the above-mentioned pro-

cedure, as well as alternative forms of treatment including no treatment. Sterile

preparation and adequate anesthesia was obtained as described above.

311

A 16 gauge needle puncture was performed at the level of the . A guide

wire was placed through the 16 gauge needle. The needle was withdrawn and a

tapered 6 French sealed catheter was threaded along the guidewire. Then the

VNUS endoluminal Closure catheter was inserted through the 6 French catheter

under Duplex guidance. The tip of the catheter was placed under Duplex visual-

ization at the sapheno-femoral junction. The catheter was inserted for a distance

of cm. At this time the tumescent anesthesia was placed overlying the

vein under Duplex guidance. The VNUS radio-frequency machine was activated.

The electrodes were expanded and an Impedence check showed impedence of

130 Ohms.

The catheter was pulled back over_minutes for a pull-back rate of 2.0 cm per

minute. During the pullback period, the temperature was maintained at 908Cranging between 788 & 928 averaging approximately 908C. Average energy uti-

lized was approximately 2.5 watts. At the end of the pullback the Duplex ultra-

sound showed total occlusion and closure of the greater saphenous vein from

the saphenofemoral junction distally to the .

The patient tolerated the procedure well and without complications. At the

conclusion of surgery a bulky gauze pad dressing was placed under a graduated

compression stockings. The patient was ambulatory immediately following the

procedure ensuring that proper hemostasis had been obtained.

ESTIMATED BLOOD LOSS: 5 cc

DISPOSITION: The patient will return in 6 weeks for follow-up

Duplex ultrasound.

PHYSICIAN DATE

312 Appendix 6

Appendix 7

Operative Report for EndoluminalLaser Closure

Patient Name:

Procedure Time: minutes

Date of Surgery:

PREOPERATIVE DIAGNOSIS:

Painful (729.5) varicose veins (454.9) with saphenofemoral incompetence and

multiple clusters of varicose veins tributary to the saphenous system,

r left r right r both r lower extremity

POSTOPERATIVE DIAGNOSIS:

Painful (729.5) varicose veins (454.9) with saphenofemoral incompetence and

multiple clusters of varicose veins tributary to the saphenous system,

r left r right r both r lower extremity

OPERATION PERFORMED:

1 Endovenous closure of the r left r right greater

saphenous vein(s) from the saphenofemoral junction distally (37720).

2 Selective catheter placement, venous system; first order branch (36011).

313

3 Transcatheter occlusion or embolization, percutaneous, any method,

non-central nervous system, non-head, non-neck (37204).

4 Transcatheter therapy, embolization, any method, radiological, supervision

and interpretation.

5 Removal of multiple clusters of varicose veins (37785),

r left r Right r both lower extremity.

6 Intraoperative ultrasound monitoring (76986).

PREOP MEDICATIONS: Versed Other

SURGEON:

ASSISTANT:

ANESTHESIA: r Tumescent r General r Laryngeal

Mask

r Other

ESTIMATED BLOOD LOSS: Nil.

COMPLICATIONS: None

PATIENT CONSENT:

The patient was informed of the risks, benefits, and possible complications of

the procedure as planned. Alternative forms of treatment were discussed,

including no treatment at all. The patient verbalized understanding of the risks,

benefits and possible complications and agreed to proceed. Informed consent

was obtained, and the patient was taken to the operating suite.

DESCRIPTION OF PROCEDURE:

With the patient supine on the operating table milligrams of Versed was

given intravenously. After adequate skin preparation and draping, tumescent

anesthesia was instilled. This consisted of 0.1% lidocaine with epinephrine and

a total of milliliters was given. This was instilled in and around the course

of the greater saphenous vein to be treated and in the region of the multiple

clusters of varicose veins.

The ultrasound scanner was brought to the operating table. Visualization was

obtained with the 7.5 to 9.0 megahertz probes at a frame rate of 12 frames per

314 Appendix 7

second. The receptor angle was 26 degrees, and adequate visualization of the

saphenous vein, the femoral vein, and the saphenofemoral junction was

obtained. Access to the saphenous vein was gained through a 3 millimeter

incision in the mid-thigh over the greater saphenous vein which was grasped

with #3 or #4 Mueller hook and an intraluminal cannula was placed. Monitoring

of the catheter placements was accomplished.

The endolominal catheter was then inserted and the laser activated. This

insertion and eventual location was monitored with the ultrasound as well as

externally by visualization of the Helium:Neon aiming beam. The catheter was

placed precisely just distal to the saphenofemoral junction, and the sheath

removed. The laser was then activated at 1320 nanometers, 5.0 watts at 30 hertz

and 167 millijoules, continuous mode. Pullback rate was approximately

1.0 millimeter per second for a total of seconds required to treat

centimeters of the proximal portion of the greater saphenous vein,

and seconds to treat centimeters to treat the distal portion of the

greater saphenous vein. A 3-0 vicryl absorbable suture was placed around the

free ends of the vein to ensure complete ligation.

Varicose clusters were treated by the stab avulsion technique using a series of

2 millimeter incisions and removal of the veins with #2 and #3 Mueller hooks

and appropriate clamps. A total of approximately centimeters of varicose

veins were removed in this fashion through cutaneous incisions.

The patient tolerated the entire procedure will. The instrument, needle and

sponge counts were reported to be correct. A bulky gauze dressing was placed

under graduated short-stretch bandaging. The patient was ambulatory

immediately and was discharged in stable condition to the postoperative area.

FOLLOW-UP INSTRUCTIONS:

The patient will return in 1 day and 7 days for follow-up, bandaging changes and

placement of a graduated compression stocking.

, MD

Surgeon’s name Surgeon’s signature Date

Appendix 7 315

Appendix 8

Explanation Card for the Patient

TREATMENT OF VARICOSE VEINS BYAMBULATORY PHLEBECTOMY

The most effective treatment for eliminating both large and small varicose veins,

either causing symptoms or simply bringing cosmetic problems, is their surgical

removal in the office, using local anesthesia (the same used by your dentist).

The operation is called Ambulatory phlebectomy (AP).

After this procedure, the patient goes home and continues normal everyday

life, the only limitation being a bandage and/or compression stocking on the leg.

The varicose veins are removed by special small instruments through

small holes (�1–2 mm of diameter), made on the skin by needles or special

pointed blades, along the course of the varicose vein. The wounds are so small

that often after 2 months they are hardly visible and at 6 months no signs of

surgery can be found.

At the end of the procedure, the operated leg is tightly bandaged, and the

patient gets up and walks in the waiting room, for verifying that all is going

right. After half-an-hour patient is ready for going home. Not only will the

patient not need to lay down and rest, but also walking and being active

through the whole day is encouraged.

Sometimes, a leg has an extended network of varicose veins. In those cases,

the operation is not done in a single session, but sub-divided into two or even

three sessions. In this case, the patient has to come more than once, but after many

years of experience, we can assure you that several short procedures achieve a

more accurate and complete treatment, with less anesthesia amount as well as

being less boring and worrisome for the patient, compared with a single long

and (sometime) stressful session.

The saphenous vein too may be removed by this method (local anesthesia,

immediate walking, and going home). However, in this case, a slightly bigger

incision is needed at the groin (3 cm) that will be invisible after a few months.

317

If more sessions are foreseen, they will be done 2–3 days apart, so that

compression is not excessively prolonged (1–2 weeks). Between the sessions,

everyday life can be continued.

One to seven days after the last session, all bandages are removed and

changed with moderate graduated compression stockings that are worn for 1–2

months until complete healing occurs. This moderate compression period helps

to obtain the complete resolution of all the traces of the operation.

Removing all the varicose veins does not mean that the problem is solved

for your entire life. At times, varicose veins may reappear. These are related to

familial (genetic) and individual tendency, job and physical activity, body

weight, pregnancies, and other less defined factors such as the wearing of tight

clothing and/or high healed shoes, taking estrogen supplements, and the like.

It is for these reasons that once a year it is suggested to check the venous

circulation in our center. In fact, it is possible that after sometime (years), a revi-

sion must be performed, for removing veins that have reappeared. These varicose

veins will be related to veins that are different from those removed in the past.

AP operation is very simple as it is carried out on the surface, directly under

the skin, and does not concern “dangerous” structures. The compression bandage

ensures minimal blood loss. Before the office discharge, an accurate post-operative

check-up will confirm that everything is all right. A telephone call is always

available even for simple advice.

A little pain may be felt at the end of the effect of the anesthesia. Walking

and other activities are usually the best medicine for this discomfort, however,

analgesics like Tylenol may be taken if necessary.

Serious complications, possible in any kind of surgery, have not happened

in our 20–30 years of experience.

Even if rarely occurring, inconveniences are nevertheless possible (blister

formation, wound infection, visible scars, bruising or hematomas along the

course of the removed varicose vein, and loss of sensibility in small areas).

Most of the times, they are trivial events that soon disappear without any

problems.

Before the procedure, laboratory examinations, and in some patients an

electrocardiogram, are requested to check the general state of the patient’s

health. This will confirm that the treatment can be performed safely in our surgi-

cal center.

The capillary dilatations or telangiectasia that remain after the procedure or

that appear in the treated areas may be tended by sclerosing injections, which will

be carried out after few weeks, as the bruising disappears.

COMMENTARY

This card is given to all the patients who need to undergo an AP with a map of the

varicose veins where the specific treatment is outlined (see the drawing). In our

experience, it has a calming effect and may remind the patients of some concepts

318 Appendix 8

of the procedure’s simplicity that they may have misunderstood during the

“horrifying” visit.

Sometimes, patients prefer not to read it but to entrust its lecture to their

husbands or wives. However, it is always favorable to the AP operator that all

the explanations have been offered in a written form. Moreover, the explanation

card may be read by family physician, by cardiologists, by other relatives and

friends and providing positive marketing of your practice.

Appendix 8 319

Appendix 9

Post-Operative Explanation Cardfor the Patient

POST-OPERATIVE INSTRUCTIONS

Local anesthesia lasts from 2 to 8 h after the procedure. Tumescent anesthesia

usually lasts 6–8 h with higher concentrations of local anesthesia lasting up to

2 h. Generally, the operative site does not ache; however, if there is some pain,

giving discomfort, the prescribed analgesic medications (Tylenol) will solve

the problem.

After the procedure it is required to walk actively, the faster the better. It is

advised not to sit down for a long period (�2 h). Getting in the car to return home

is OK as long as the ride is not longer than 1 h. For longer car rides to return

home, it is appropriate to stop every 30–45 min and walk for 10 min. During

the day, a nice walk will be useful for “breaking up” little pains or discomforts.

Normal daily activities may be resumed (stand, drive, sit, etc.) on the first

operative day, always taking in mind that the more you move, the better you

will feel.

In rare cases, after a few hours, getting up from sitting or lying position,

blood pressure may be low as reflected by dizziness. This event is of short dur-

ation and is overcome by lying down again for a short time then sitting up slowly.

If blood stains appear on the bandage (which is rare) after the discharge

from the office, the best thing to do is to lie down and raise the leg: in this

way every blood loss will stop automatically. The inconvenience will solve

simply waiting until the blood dries up. However, it is advisable to call the avail-

able phone numbers marked on this card. If blood traces appear .6 h after the

operation, usually a slow infiltration of blood stained anesthesia solution

through the bandage is the cause. In this case nothing needs to be done.

Sometimes the foot or the ankle may swell. The elastic band or the stocking

that has been placed over the adhesive bandage is there to avoid this event. In

321

case of swelling, it will be enough to tighten the elastic bandage on foot and ankle

and walk actively. When wearing the elastic band, this must be removed at night

and repositioned the next morning. As it is elastic, it must be adequately

stretched, starting at the ankle, going on with four turns on the foot (covering

the heel), and continuing until just below the knee. The adhesive bandage

placed after the operation must not be touched.

Read all these instructions again.

Phone numbers to call in case of trouble or simply for asking an advise.

COMMENTARY

At the beginning of our experience with AP, these things were told to the patient

at the moment of office discharge. A few patients did not understand or remember

some of the concepts, and when something happened (foot swelling, bleeding,

pain, etc.) they would say that nothing had been told to them.

To avoid this event, we began to write down all the points to be remem-

bered. It is curious that in our long experience even with written instruction

some patients do not follow our recommendations. They simply do not read it

when they have no troubles. When they have troubles, they do not remember

to read the papers. For this reason, it is wise to insist for that instructions are con-

sidered by both the patient and the accompanying relatives.

322 Appendix 9

Appendix 10

Duplex Evaluation Forms

323

324 Appendix 10

Index

Absorbent gauze, 146

Accreditation requirements

office varicose vein surgery,

245–246

Activity

after varicose vein surgery, 305

ACV. see anterior crural vein (ACV)

Adhesive bandage, 146–147

allergy to, 227

Adhesive compression below-knee

bandage, 179

Aetius of Amida, xxxii–xxxiii

Albucasis, xxxiv

Allergy

to adhesive bandage, 227

to anesthesia, 217

Ambulatory phlebectomy (AP)

advantages of, 235–238

anatomical basis of, 5–79

anesthetic complications,

215–218

complications of, 215–228, 216

compression bandage

complications, 226–228

consent for, 301–303

defined, 3–4

history, xxix–xxxvi

indications for, 3–4

LIA, 97

nursing instructions, 307–308

operative report, 309–310

patient explanation card,

317–319

pioneers, xxxv–xxxvi

psychological aspects, 231–238

rare complications, 225–226

technique for closure, 277

American Society of

Anesthesiologists (ASA)

physical status classification,

242, 243

Anesthesia, 97–104. see also local

infiltration anesthesia (LIA)

allergic reactions, 217



late reactions, 218

local

for office varicose vein

surgery, 250

local complications, 218

office varicose vein

surgery, 244


surgery, 248

preoperative, 102

SSV phlebectomy, 162

toxic reactions, 217

tumescent

side effects, 274

Aneurismal sac

internal view of, 264

325

Anterior

topography

thigh, 32

Anterior accessory saphenous vein

(ASV), 14–15, 14–17, 48

anatomy, 52

incompetent

color flow imaging, 94

patterns, 54–55

varicose patterns, 53

Anterior crural vein (ACV), 37

Anterior knee

superficial vein topography, 34

topography, 33

Anterior leg


topography, 37

Anterior thigh

topography, 32

lateral knee, 33

Anxiety

patient discharge, 151

AP. see ambulatory phlebectomy (AP)

Aristotle, xxix

Arterial aneurysm

endoluminal obliteration, 262

ASA. see American Society of

Anesthesiologists (ASA)

ASV. see anterior accessory

saphenous vein (ASV)

Asymptomatic varicose veins


75–76

Autologous vein transplantation

dermal atrophic changes,

255–259

technique, 256–259

Autonomous collateral varicosities,

20–21

Babcock technique, 191

Bandage

adhesive, 146–147

adhesive compression

below-knee, 179

compression, 147

with bleeding, 148


pressure


removable, 147–149

removable elastic compressive

application techniques,

180–182

Bandaging materials


surgery, 249

Bathing


Battery

invention of, 262

Berengarius from Carpi, xxxiii

Blisters

with compression bandage,

226–228

Blood lancet

for incision, 109, 110

Blood vessels

electrocoagulation of, 262

B-mode ultrasound imaging,

69–70

Boyd perforator, 139

isolation of, 134

Bruises, 139

Calf

transverse scan, 18

Celsus, Aulus Cornelius,

xxxi–xxxii, 261–262

CFV. see common femoral

vein (CFV)

Chronic venous insufficiency

patient instructions, 297–299

Closure catheter, 267

clinical experience, 270

Closure technique

consent form, 275

with endoluminal laser,

282–283

followup care, 277–278

postoperative patient instructions

for, 280

without phlebectomy, 274

Closure with ambulatory

phlebectomy

technique for, 277

326 Index

Codeine

tylenol with, 151

Collateral varicose veins (CVV), 9, 20

groin, 29

posterior thigh

reflux, 30

reflux origin, 22

Collateral veins (CV)

dorsal foot, 41

of SSV, 18

superficial, 8

organization of, 21

Color-Duplex ultrasound

examination, 69–71

Combined collateral and saphenous

varicosities, 22–24

Combined varicose veins, 26

Common femoral vein (CFV)

Doppler orthostatic reflux test, 63

Competent Giacomini vein

transferring reflux from

saphenopopliteal junction

to GSV, 55

Compression. see postoperative

compression

Compression bandage, 147

with bleeding, 148


excessive compression, 226


surgery, 249

Compression hosiery, 277–278

Compression stockings, 156

for office varicose vein surgery,

249–250

Compressive adhesive bandage

GSV, 207–208

Consent form

closure technique, 275

Contact dermatitis

with compression bandage, 228

Conti, Gaetano, 262

Corcos stripper

GSV, 203–305, 205–207

Custom made stripping, 47

CV. see collateral veins (CV)

CVV. see collateral varicose

veins (CVV)

de Chauliac, Guy, xxxiv

Deep vein thrombosis (DVT),

57, 76

with phlebectomy, 224

Deep venous insufficiency

(DVI), 42

Dermatome, 258

Diazepam


Discoloration

after varicose vein surgery,

305–306

Doctor-patient relationship, 233

Dodd popliteal area vein, 35

Doppler orthostatic reflux test,

61–63

groin examination, 63–64

GSV, 63

interpretation, 64–67

method, 61–62

pitfalls, 64–67, 69

popliteal area, 64

Dorsal foot collateral veins, 41

Dorsal venous arch, 40

Double great saphenous vein


DVI. see deep venous

insufficiency (DVI)

DVT. see deep vein

thrombosis (DVT)

Edema


Elderly

patient discharge, 151

Electric shock, 137–138, 167

Electrocoagulation

GSV, 262

Emergency equipment


surgery, 250

Endoluminal laser

closure technique, 282–283

GSV, 261–284

Endoluminal laser closure

operative report for, 313–315

Endoluminal obliteration

arterial aneurysm, 262

Index 327

Endoluminal probe

for ambulatory SSV

phlebectomy, 163

Endoluminal RF closure

operative report for, 311–312

Endoluminal strippers

vs. extraluminal strippers, 237

Endovenous closure with laser or

radiofrequency


Endovenous laser treatment (EVLT),

278, 281, 282

destroying sheath, 283

Endovenous RF ablation

consent form, 275

Endovenous RF occlusion

CEAP class description after, 271

Epinephrine


Equipment and materials


247–248

Erisitratus from Chio, xxxiii

Erophilous of Calcedonia, xxxiii

EVLT. see endovenous laser

treatment (EVLT)

Examination equipment

for office varicose vein surgery, 250

Eye sign, 13

Fear, 231–233

Feeding vein, 45

Femoropopliteal vein


Foam sclerotherapy

for recurrent varicose veins, 292

Foot

GSV

transverse scan, 41

phlebectomy complications,

136–138


topography, 40–42

Foot care

patient instructions, 298

Fragile veins


Freestanding surgical office, 245–250

Galeno, xxix

Galenus, Claudius, xxxii

Gauze

absorbent, 146

Giacomini vein, 18, 24, 35, 48


long segment of, 174


saphenopopliteal junction to

GSV, 55

varicose, 30

Glutamate receptors, 5

Graefe forceps, 114–116, 117,

137, 145

ambulatory SSV phlebectomy, 163

dissection with, 121

distal progression, 168

proximal progression, 168–169

SSV phlebectomy, 168

vein avulsion, 128

vein hooking, 121–124

vein hooking with, 121–124

vein stripping, 125

Great saphenous vein (GSV), 3, 6,

11–13, 35, 48

advanced varicose disease, 24

anatomical arrangement, 53

anatomic types of, 49

anterior group, 36

bayonet type varicosity, 29

dilatation, 190

division



double


electrocoagulation of, 262

endoluminal laser ablation,

261–284, 278–282

foot

transverse scan, 41

h type, 53

incompetence

alternative treatments for,

190–191

incompetent


preservation of, 189–190

328 Index

inferior group, 36

I type, 53

ligation and division

performed by, 241–242

ligation and stripping, 187–209,

200–201, 205–207

anesthesia for, 194


division, 200–201

full-length thigh bandage, 209

indications for, 187–190

instruments, 194–195

patient position, 194

patient preparation for, 195–196

postoperative bandage, 207–208

preoperative marking, 192–193

programming operation,

191–192

pudendal artery crossing

anteriorly, 200, 202

saphenofemoral junction

incompetence, 188–189

skin preparation, 194


location of, 7

lower leg, 36

marked, 193

patterns, 53, 54

phlebectomy complications, 139

posterior group, 36

radiofrequency closure, 261–284

reflux origin, 8

RF occlusion, 279

segmental

involvement, 54

segmental involvement, 50

S type, 53

superior group, 36

and SVV

patterns, 56

via intersaphenous

anastomoses, 55

tapping, 59

thigh, 14, 29

ultrasound identification of, 13–14, 16

varicose

patterns, 53

reflux, 30

Groin

CVV, 29

Doppler orthostatic reflux

test, 63–64

preoperative marking, 93

Groin cavernoma

US imaging, 292

Groin-to-knee stripping, 17

GSV. see great saphenous

vein (GSV)

Halsted forceps

clamping GSV, 199

H anatomic type

varicose patterns of, 50

Hand


Harvey, William, xxxviii

Hematoma, 139

above postoperative

bandage, 146

with phlebectomy, 218–219, 219

Hemorrhage


Hepatitis B, 78

Hepatitis C, 78

Hippocrates, xxix

Hippocratic texts, xxx

HIV. see human immunodeficiency

virus (HIV)

Home, Everard, xl, 262

Hooks, 113–114

Hosiery

compression, 277–278

Human immunodeficiency

virus (HIV), 79

Hypertrophic scars


Hypodermic needle

for incision, 109, 110

Incompetent anterior accessory

saphenous vein

trunks


Incompetent Giacomini vein

transferring reflux from GSV

to SSV, 55

Index 329

Incompetent great saphenous vein


trunks


Incompetent posterior leg

perforators, 39

Incompetent saphenopopliteal

junction


Infectious disease

office varicose vein

surgery, 78–79

Informed consent, 79

office varicose vein surgery, 79

Instruments

for ambulatory SSV phlebectomy, 163

Interfacial veins, 47

Invaginating technique, 191

Klein, Jeffrey, 99

Knee

anterior


topography, 33

GSV, 12

medial


topography, 32–33


topography, 32–35

Knee joint

X-ray of, 171

Lateral leg


topography, 37

Lateral subdermal plexus

(reticular vein), 30

Lateral subdermal venous system, 30

Lateral thigh

topography, 30–32

Leg

anterior


topography, 37

artist’s design of, 265

edema, 77

GSV, 12

lateral


topography, 37

lower

deep veins, 42–43

GSV, 36

telangiectatic flare, 44

medial

topography, 36–37

posterior


topography, 37–40


transverse scan, 14

Leg intersaphenous anastomosis


GSV to SSV, 55

transferring reflux from SSV

to GSV, 55

Leg pump function

evaluation, 71–73

Leonardo vein, 36

LIA. see local infiltration

anesthesia (LIA)

Lidocaine, 97



surgery, 248, 250

toxicity, 101–102, 217

Limbs

postoperative examination, 153

Lipodermatosclerosis, 76, 140–141

Local anesthesia


surgery, 250

Local infiltration anesthesia (LIA)

ambulatory phlebectomy, 97


dosage, 98–104

preparation, 98–104

solution preparation, 99

technique, 98–104, 102–103

traditional technique, 98–99

preparation and dosage, 98–99

tumescent solution

preparation, 100

tumescent technique, 98–102

preparation and dosage, 98–102

330 Index

Lower leg

deep veins, 42–43

GSV, 36

telangiectatic flare, 44

Lymphatics, 43–44

Lymphocele


Lymphorrhea


Marionette lines

autologous vein

transplantation, 257

Marking solution


surgery, 250

Mayo’s technique, 191

Mayo stripper

GSV, 203, 205–207

Medial knee


topography, 32–33

Medial leg

topography, 36–37

Medial thigh

topography, 29–30

Medication material


surgery, 250

Mepivacaine, 107–108

for GSV ligation, 194


Methylparabens


Middle Ages, xxxiii–xxxiv

Modern Times, xxxv

Muller hook, 113–114, 114,

116, 119–120, 137

sizes of, 115

with venous leg telangiectasia,

142–143

Muller’s technique

incision, 109

Multi-session phlebectomy, 82–84

Nasolabial groove

autologous vein

transplantation, 257

Needle puncture, 114

Needles


surgery, 248–249

Nerve damage


Nerves, 43–44

Oesch hooks

sizes of, 116

Office varicose vein surgery


anesthesia, 244

emergency measures, 245

freestanding surgical office,

245–250

general health, 76–79

operator’s experience, 244

patient consent, 79

patient selection for, 242–243

postoperative management, 244

preoperative management,

243–244

procedure modification, 78

procedure type, 244

safety in, 242–243

selection for, 75–79

varicose vein and leg conditions,

75–76

Operating room


Pain medication


Palpation, 58–59

Pare, Ambroise, xxx, xxxiv–xxxv

Patient discharge, 151–152

anxiety, 151

elderly, 151

Patient instructions

foot care, 298

postoperative

for closure technique, 280

sleeping, 298

smoking, 298

walking, 298

Patient position

during surgery, 107–108

Index 331

Patient postoperative explanation

card, 321–322

Paul from Aegina, xxxii–xxxiii

PAV. see posterior arch vein (PAV)

Percussion test, 58–59, 60

Percutaneous closure


Perforating veins (PV), 24–27, 130

flow in, 26, 28

Periorbital veins, 143

Perthes test, 59

Petit, Jean-Louis, xxxv

Phlebectomy, 109–144. see also

ambulatory phlebectomy;

small saphenous vein (SSV),

phlebectomy

alternative applications of, 242


incision, 109–111

instruments, 109, 110

within lipodermatosclerotic area, 141

multi-session, 82–84

performed by, 241

progression of, 129–130

small saphenous vein, 159–173

technical difficulties, 135–144

Phlebectomy hook, 115

Pigmented scars


Piroxicam, 151

Plutarch, xxx

PMV. see posteromedial thigh

vein (PMV)

POB. see postoperative adhesive

bandage (POB)

Polidocanol, 143

Popliteal area


topography, 34–35

Popliteal artery, 19

Popliteal fossa

deep anatomy, 34


65–68

duplex scan, 161

groin, 42

postoperative duplex scan, 170


Popliteal vein


Posterior arch vein (PAV), 36

Posterior leg


topography, 37–40

Posterior thigh

topography, 30

varicose veins, 32

Posterior thigh collateral varicose

veins

reflux, 30

Posteromedial thigh vein (PMV), 30

Postoperative adhesive bandage

(POB), 153

compression after removal of,

155–156

part of, 177

Postoperative bandaging, 146–149

Postoperative compression,

177–185

adhesive bandage, 178–183

application technique, 179–182

bandage extension, 179

bandaging errors, 184

compression stockings, 185

degree of compression, 182–183

difficult areas, 183–184

excessive compression, 184

insufficient compression, 184

local compression pads, 177–178

protective pads, 178

protective skin

underwrapping, 177

removable bandage, 184

testing bandage, 183

Postoperative followup, 156–158

special care, 157–158

Postoperative groin bandage, 208

Postoperative management,

153–156

after last operation, 153–154

further compression, 155

between phlebectomy sessions,

153, 154

Postoperative medication, 145

Postoperative patient instructions

for closure technique, 280

332 Index

Preoperative anesthesia, 102

Preoperative marking, 91–95, 92

Pressure bandage


Primary varicose veins

circles, 48

circuits, 53

reflux, 53

Proximal reflux points, 10

Pulmonary embolism

with phlebectomy, 224–225

PV. see perforating veins (PV)

Radiofrequency ablation

animal studies, 268

histology, 268–270, 269

patient characteristics, 271

postoperative duplex

evaluation, 273

technology, 266–268

treatment complications, 272

Radiofrequency closure

with AP, 271–272

without AP, 270

Recurrent varicose veins

AP, 287–293

foam sclerosing agent, 291

with superficial bulging

varices, 289

usual pattern, 290

veno-cath, 291

Red-hot iron, 262

Reentry perforator, 26

Reflux

extension of, 10

transfer, 7

Removable bandage, 147–149

Removable elastic compressive

bandage

application techniques,

180–182

Renaissance, xxxiv

Reticular vein, 30

Retromalleolar fossa

SSV collaterals, 41

Return office visit


Rima, Tommaso, xxxvii

Safety


242–243

S anatomic type

varicose patterns of, 50

Saphenofemoral junction (SFJ),

6, 9

collateral intraoperative

finding, 199

division of, 198–202


test, 63, 65

ligation of, 198–202

surgical anatomy of, 197–198

Saphenopopliteal junction (SPJ),

6, 8, 9, 161


test, 64

levels of, 173

Saphenous compartment

appearing as Egyptian eye, 13

Saphenous veins

incontinence discovery,

xxxvii

varicose vein disease,

47–56

Scalpel blade

for incision, 109, 110, 111

Schwarz test, 58–59

Sclerotherapy, 237, 268

foam

for recurrent varicose

veins, 292

Segmental great saphenous vein

involvement, 54

Selective occlusion (Trendelenburg)

test, 61

Sensory nerves, 137–138

SFJ. see saphenofemoral

junction (SFJ)

Shin


Showering


Skin necrosis

with anesthesia, 218

Sleeping


Index 333

Small saphenous vein (SSV), 3, 5,

7, 34, 35, 48

anatomy of, 17–20


64, 65

location of, 7

pattern, 56

phlebectomy, 159–173


anesthesia, 162

atypical popliteal

terminations, 171

beginning, 163–164


diagnosis, 159–161

Graefe forceps, 163, 168

higher popliteal incision,

169–170

incisions, 162–163

patient position, 162, 163

postoperative compression,

171–173


saphenopopliteal division and

ligation, 169

staging, 162

technique, 162–176,

164–167

preoperative marking of, 160

proximal termination of, 19

reflux

posterior leg, 38

tapping, 59

thigh extension of, 17–20, 48

Smoking


Sodium metabisulfite


Sodium salicylate, 143

Sodium tetradecyl sulfate, 143

SPJ. see saphenopopliteal

junction (SPJ)

SSV. see small saphenous

vein (SSV)

Stockings

compression, 156

for office varicose vein surgery,

249–250


Superficial collateral veins, 8

organization of, 21

Superficial thrombophlebitis, 58,

76, 140

Superficial veins

topography, 28, 31, 33

Superficial venous system

organization, 5–27

Surgical instruments


247–248

Surgical office

freestanding, 245–250

Surgical staging, 81–87

Symptomatic varicose veins


Syringes

with chopped up vein, 258


surgery, 248

Tapping test, 59, 60

Telangiectatic matting


Thigh

anterior

lateral knee

topography, 33

GSV, 14, 29

lateral

topography, 30–32

medial

topography, 29–30

phlebectomy complications,

138–139

posterior

topography, 30

varicose veins, 32

transverse scan, 15

upper

topographic description,

27–29

Thin skin, 141

Thrombophlebitis

superficial, 58, 76, 140

Tibia-gastrocnemius sign, 14

Toothed clamps, 116

for ambulatory SSV

phlebectomy, 163

334 Index

Transitory malaise

with local infiltration anesthesia,

215–216

Traumatic dermal defect, 259

Trendelenburg, Friedrich, xxxvii

Trendelenburg test, 59, 61

Tumescent anesthesia

side effects, 274

Tylenol with codeine, 151

Ultrasound imaging

B-mode, 69–70

color-Duplex, 69–71

Upper thigh

topographic description, 27–29

Valves, 5

Valvular incompetence, 59

Varicose clusters

with phlebectomy, 135, 136

Varicose Giacomini vein, 30

Varicose great saphenous vein

reflux, 30

Varicose short saphenous vein

reflux origin, 40

Varicose veins. see also recurrent

varicose veins

ambulatory venous pressure, 72

avulsion, 137

multi-sessions, 86–87

clinical examination, 57–58, 72

collateral, 9, 20

with collateral origin of reflux, 25

combined, 26

complex patterns of, 136, 137

deep veins, 49

diagnostic errors, 13

distribution of, 9

Doppler examination, 72

duplex scan, 72

examination of, 57–73, 72

medical history, 57–58, 72

number of, 9

physical examination, 58–59

plethysmography, 72

previous treatment, 58

recurring after sclerotherapy, 140

recurring after traditional

surgery, 140

saphenous trunk, 49

surgery

suggestion following, 305–306

surgery practice

setting up, 241–250

symptomatic


symptoms, 57–58

topographic description, 27–42

types of, 9

venogram, 72

Vasoconstriction, 104

Vasospasm, 103

Vein

avulsion, 121–135

dissection, 121

Graefe forceps, 128

phlebectomy progression,

125–126

traction, 121–125, 127

division, 130–135, 131–133

end division, 130–133

PV division, 133

side branch division, 133–135

extraction, 256

hooking with

Graefe forceps, 121–124

obliteration

history of, 261–262

retrieval, hooking and

exteriorization, 113–135

instruments, 113–144


vein division, 130–135

stripping

Graefe forceps, 125

thrombosis


Venous leg telangiectasia, 43


surgical anatomy of, 44–45

treatment, 142–143

Vesalius, xxxiii

Volta, Alessandro, 262

Walking


Wound infection


Index 335

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Ambulatory Phlebectomy

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