Ambulatory phlebectomy (AP) is a common, minor, office-based procedure using a specially designed hook inserted through a minute stab incision to avulse and completely remove superficial varicose veins. AP is generally well tolerated and results in a high degree of patient satisfaction. Advantages of AP include short surgical time, ability to be performed under local tumescent anesthesia, low recurrence rate compared to sclerotherapy, minimally obtrusive scars and dyschro-mia compared to other methods, and immediate post-operative ambulation, which helps prevent vascular complications.1–4
Indications
Superficial varicose venous tributaries of the great •saphenous vein (GSV) or small saphenous vein (SSV), perforator veins, and reticular varicose veins when distended, visible, and palpable on the sur-face of the skin (Fig. 21.1 and 21.2(a))Preferred for varicosities greater than 4 mm in •diameter and flesh-colored (which are thicker wall and more resistant to treatment with sclerotherapy)Large tortuous distal veins (which are difficult to •treat with endovascular procedures)
Contraindications
Infection in the treatment area•Severe arterial occlusive disease•Bleeding tendency or coagulopathy•Allergy to local anesthetics•Severe peripheral edema or severe lymphedema•Seriously ill patients (i.e., cardiovascularly compro-•mised, etc.)Very elderly patients•
Relative Contraindications
Recent deep vein thrombosis•Hypercoagulable states•Pregnancy•Untreated or poorly managed diabetes mellitus•
Clinical Examination and Patient History
Before stripping any vessels or performing extensive phlebectomies, a preoperative evaluation must be completed. The deep venous system should be inter-rogated, and any source of venous hypertension needs to be identified by using duplex ultrasound.1
Chapter 21Ambulatory Phlebectomy
Marisa Pongprutthipan, Girish Munavalli, and Simon Yoo
136 M. Pongprutthipan et al.
If reflux is demonstrated at the saphenofemoral or saphenopopliteal junctions, procedures such as endo-vascular radiofrequency, endovascular laser, or liga-tion and short stripping should be performed.3,5 This will decrease venous pressure, prevent recurrence, reduce the size of the superficial veins, and ease the phlebectomy procedure. AP can be done concurrently or several weeks after endovenous ablation.
Webril, Kerlix, Ace Wrap, Coban, Comprilan) 13. If needed, suturing material (needle holder, suture
material, suture scissors and Adson forceps)
To avoid any possible injury to superficial neurovascu-lar structures, use caution when treating deeper super-ficial veins along the common femoral artery, superficial femoral artery, popliteal artery, anterior and posterior tibial artery, and superficial nerve supplies of the lower limb below the knees (the superficial pero-neal nerve and saphenous nerve) (Fig. 21.2(b)). If inad-vertently hooked, patients will experience sharp burning pain radiating proximally or distally. Special attention should be paid to difficult anatomical zones such as the ankles, feet, and knees where injuries to the superficial cutaneous nerves are common. Injury to the sensory cutaneous nerves may cause paresthesia and dysesthesia. In most cases, this is only temporary and resolves within 2–3 weeks. However, there are case reports of foot drop that may or may not resolve over time, depending on the extent of nerve damage.
Technique (Fig. 21.3)
1. Venous Marking: Accurate and comprehensive venous marking on the skin with an indelible marker should be done while the patient is standing (Fig. 21.4). Marking should be done in a consistent, standardized way, so as to highlight straight and tortuous segments. The choice of marking pen is important, as even the most tough markings can easily wear off during the procedure as the area is exposed to surgical prep washes and interoperative blood and oozing. Marking is a critical aspect of the procedure, allowing the surgeon to quickly locate the desired venous segments. The standing position increases venous hydrostatic pressure, making them easily visible. Mapping may be done via visual inspection and palpation. An intense point light
Fig. 21.1 Varicose veins. The bulging veins on the calf of an African-American female in her 40 s. AP would be preferred to sclerotherapy due to the size of the vessels and high probability of postsclerotherapy hyperpigmentation
13721 Ambulatory Phlebectomy
Tab
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138 M. Pongprutthipan et al.
source can be used to transilluminate the skin, making it much easier to visualize less superficial segments of the vein.
2. Anesthesia: Tumescent anesthesia is a safe and easy technique for use with AP. The technique involves infiltration of the subcutaneous fat compartment by using an irrigation pump with a 0.05–0.1% prepara-tion of lidocaine with epinephrine1,6 (Table 21.2). Advantages of tumescent anesthesia include elimination of multiple needle sticks, rapid-onset of anesthesia, and an extensive anesthetic field. Additionally, the temporary turgor and hydrodis-section of surrounding adventitia can facilitate vein identification and extraction, reduce blood loss, diminish bruising, shorten postoperative recovery, and allow for greater postoperative comfort.7
3. Incisions: When the patient is in the supine position, the vein may shift from the initial markings. Confirm the vein location with transepidermal illumination or Doppler ultrasound mapping. This will allow better vein visualization, fewer incisions, and less operative time. Depending on vein size, incision lengths vary from 0.5 to 4 mm, or as long as the
diameter of the hook curvature. Place incisions just lateral to the targeted vein, and parallel to the long axis of the extremity following tension lines. This allows approximation of the wound edge with the force of a circumferentially placed compression dressing. Incisions are made by a needle for small varicose veins or a scalpel for larger ones. Horizontal stab incisions, following the relaxed skin tension lines, are preferred around the knees and ankles. Incision through marking ink should be avoided to prevent tattooing the skin. Avoid stretching or trau-matizing the wound edge. The interval between incisions varies from 3 to 5 cm depending on the patient’s veins. Verify the location of subsequent incisions by simply pulling the vein gently to observe depression of the skin along the venous course.
4. Hooking and Extraction: Vessels are grasped by either using a hook or using fine hemostats to elevate the vein. Hooks should be inserted very gently to grasp veins 2–3 mm in depth to avoid unnecessary trauma to the wound margins and avoid injury to the deep structures. Ultrasound may be used to guide hooking especially for deeper or subtle veins.
Fig. 21.2 Relevant anatomical structures: (a) veins and (b) nerves (Illustration by Alice Y. Chen)
13921 Ambulatory Phlebectomy
The authors typically use blunt dissection with the blunt end of the Varady hook to release the vein from the surrounding dermis prior to inserting the hooked end of the instrument. Due to the availabil-ity of a variety of hooks, it is recommended that the surgeon try each to determine which fits his style best. Different hooks have different advantages; for
example, the Ramelet hook is more pointed and smaller in size, thus easier in tight spaces. Once the vein or its adventitia are hooked, the vein should come out easily through the stab incision. If the effort is met with resistance or requires a lot of traction, it is possible that another structure has been hooked; remove the hook and reattempt.
Fig. 21.3 AP techniques: (a) incision, (b) and (c) hooking, (d) and (e) venous extraction, and (f) vein separation from surrounding tissue using the spatula component of Varady’s hook (Illustration by Alice Y. Chen)
140 M. Pongprutthipan et al.
Separation of the vein from the surrounding adven-titia may be necessary by using iris scissors or the spatula component of a phlebectomy hook such as the Varady. Veins are exteriorized by the phlebec-tomy hook. The exteriorized vein is then clamped proximally and distally and cut in between. A gentle rolling motion of the clamp in the same or opposite direction pulls and frees the vein from its surround-ing tissue (Fig. 21.5). Dissection of the vein from its adventitia should be done at the skin level to avoid injury to the unseen structures. Lack of subcutane-ous tissue in the anterior of the knee and dorsum of the foot may cause difficulty when extracting the vein. Do not forcibly pull the vein. Instead, either locate and ligate the perforator, or make a larger incision. Perforators may be identified by their per-pendicular course and by evaluating patient discom-fort when retracted.2 Hemostasis is achieved by
applying gentle pressure over the incision site and by placing the patient in Trendelenburg position to reduce the venous hydrostatic pressure. Venous liga-tion is not necessary, as stretching of the vein causes rapid hemostasis most likely due to an increase in exposed endothelial sites for platelet aggregation.8 If the vein is difficult to compress, ligation may be performed in areas such as the inner thigh.
Special attention should be paid to difficult anato-mical zones such as:
Below the knee: The saphenous nerve is particu-•larly prone to injury. If this nerve is injured, the patient may experience shooting pain radiating into the foot.Pretibial area: This area contains many lymphatic •vessels. Accidental trauma to lymphatic vessels will cause lymphatic pseudocysts and swelling may follow.6
Popliteal fossa: The skin is very soft and easily •torn. Be very gentle when handling the wound edge, especially with the elderly.Ankle and foot: Superficial sensory cutaneous •nerves and vascular structures may be easily injured on the ankle and foot. Multiple attempts or traumatized manipulation in the wound may produce swelling, hematomas, and nerve dam-age. If a sensory cutaneous nerve is avulsed, paresthesia and dysesthesia may follow. In most cases, this is temporary.
5. Incision Closure: Cleanse the area postoperatively (i.e., with 0.9% normal saline solution or hydrogen peroxide), and apply antibiotic ointment to the puncture sites. Spontaneous wound healing facili-tated by sterile adhesive tape to approximate wound
Fig. 21.4 AP markings. A water-resistant, indelible marker is used to clearly mark the varicose veins while the patient is standing
Table 21.2 Tumescent anesthesia preparation (0.05% lidocaine)In 1 L of 0.9% normal saline solution: Lidocaine 500 mg (50 ml of 1% lidocaine solution) Epinephrine 1 mg (1 ml of 1:1,000 solution) Sodium bicarbonate 12.5 mg (12.5 ml of an 8.4%
NaHCO3 solution)
Fig. 21.5 Avulsed vein segment
14121 Ambulatory Phlebectomy
edges is preferred by most surgeons. This sponta-neous healing allows blood and anesthetic fluid to drain. Sutures may be required if the surgical inci-sion is longer than 3 mm, or if the incision is near the foot and ankle, which is subject to potential bleeding and wound dehiscence. In some cases, steristrips can be used to facilitate epidermal skin approximation, while allowing for mild drainage to continue.
6. Dressing Compression Bandage: After applying absorbent sterile dressings to the incision site, a com-pression bandage is applied to prevent bleeding and hematoma. Careful precautions must be observed to avoid ischemic nerve damage and blistering.
Apply extra padding over the lateral fibular head •to avoid foot drop from a pressure-induced injury to the deep and superficial peroneal nerves.Wrap the leg circumferentially from foot to •groin, first with inelastic compression dressing and then with an elastic compression dressing. This dressing helps to promote hemostasis, to reduce swelling of the foot and leg, and to pro-mote wound healing.Take heed of patient’s complaints, such as pain, •numbness, and tightness, to guide assessments and complication prevention. These complaints can herald nerve compression.Observe the patient for at least 15 min after the •three-layer compression bandage is in place.Encourage ambulation of all patients while •still in the office to help mold the pressure wrap, generate normal function of the calf muscle pump, and minimize potential thromboembolic complications.
Postoperative Instructions
Patients should return to the office 2 days after the procedure for dressing removal and follow-up. Consideration of a duplex ultrasound to exclude the presence of deep venous thrombosis may be performed. Some ecchymosis or some minor leakage of blood and anesthetic fluid from the open wound is expected near the treated areas. After the compression bandage is removed, class II (20–30 mmHg) graduated compression stockings are indicated during daytime hours for 2 weeks.
Alternative Treatment Methods
Sclerotherapy is the alternative treatment for truncal varicosities or perforators especially in thin-walled venules. It may be performed 4–6 weeks after AP to clear up residual, smaller caliber vessels. Endovascular laser and endovascular radiofrequency may be combined with AP for maximal removal of GSV branches from the saphenofemoral junction, or deeper GSV and SSV.
Complications
Proper patient evaluation selection and operator expe-rience are the most important elements to prevent com-plications. The most common postoperative event is hematoma or ecchymosis (Table 21.3), which resolve within 2–3 weeks. The majority of neurologic compli-cations is temporary and usually resolves within a few months.
Pearls
Use of tumescent anesthesia is key to an easy, •successful procedure.Prevent recurrence by evaluating for venous reflux.•
Table 21.3 Complications of Ambulatory Phlebectomy6,8
Minimize the size and number of incisions and •decrease operative time by mapping veins with transepidermal illumination (venoscope) or Doppler ultrasound.9
Avoid complications such as swelling, hematoma, •and nerve damage by exercising caution when the procedure is performed around the knee, ankle, or foot.Correct GSV and axial vein reflux by combining •AP with saphenofemoral ligation or endovenous ablation prior to AP. This will reduce the vein size and make it easier to remove.
Manage patient expectations by educating patients •about recurrence and possible complications.
Conclusion
Ambulatory phlebectomy is a simple, minor surgical procedure for complete removal of large superficial varicose veins. By combining AP with endovenous abla-tion or PIN stripping, complete removal of all varicose veins can be accomplished in-office. With proper and
Fig. 21.6 Seroma: (a) an ultrasound probe is placed on the seroma on the right thigh of a patient 1-week post-op from AP, (b) the duplex ultrasound image shows the seroma fluid collection under the skin, and (c) an 18-G needle is being used to drain the seroma. The clear fluid being drained from the seroma can be seen at the hub of the needle.
14321 Ambulatory Phlebectomy
careful operation, AP is safe, effective, and achieves successful cosmetic results.
References
1. Almeida JI, Raines JK. Ambulatory phlebectomy in the office. Perspect Vasc Surg Endovasc Ther. 2008;20(4): 348-355.
2. Ricci S. Ambulatory phlebectomy. Principles and evolution of the method. Dermatol Surg. 1998;24:459-464.
3. Sadick NS. Advances in the treatment of varicose veins: ambulatory phlebectomy, foam sclerotherapy, endo-vascular laser, and radiofrequency closure. Dermatol Clin. 2005;23(3):443–455.
4. Ramelet AA. Phlebectomy. Technique, indications and com-plications. Int Angiol. 2002;21:46-51.
5. Weiss RA, Dover JS. Leg vein management: sclerotherapy, ambulatory phlebectomy, and laser surgery. Semin Cutan Med Surg. 2002;21:76-103.
6. Olivencia JA. Pitfalls in ambulatory phlebectomy. Dermatol Surg. 1999;25:722-725.
7. Cohn MS, Seiger E, Goldman S. Ambulatory phlebectomy using the tumescent technique for local anesthesia. Dermatol Surg. 1995;21:315-318.
8. Olivencia JA. Complications of ambulatory phlebectomy. Review of 1,000 consecutive cases. Dermatol Surg. 1997;23: 51-54.
