Historical Background

Ambulatory phlebectomy (AP) is a minor surgical procedure designed to remove varicose vein clusters located close to the skin surface. Originally performed in ancient Rome, the technique was published by Robert Muller in 1966.¹ In many office-based venous surgery practices in the United States, AP is performed with the use of local tumescent anesthesia. The six basic features of the technique are as follows:

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

Etiology and Natural History of Disease

Bulging varicose veins on the surface of the skin can originate from different sources. Identification of these sources is important because the source influences the treatment plan. Varicosities on the medial aspect of the thigh and calf are usually the result of great saphenous vein (GSV) incompetence. To minimize the chance for recurrence, the incompetent GSV must be eliminated from the circulation. This concept has been substantiated in several prospective randomized clinical trials involving patients who were treated with or without saphenectomy by conventional vein stripping.^2–5 The recurrence rates for limbs without saphenectomy were much higher than those for limbs with saphenectomy. Of course, now thermal ablation techniques with either radiofrequency or laser have proved to be the methods of choice for eliminating the GSV from the circulation.^6,7

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

In cases where no “feeding source” is found, phlebectomy of the varicosities may be all that is required. Labropoulos et al.⁸ have shown that varicose veins may result from a primary vein wall defect and that reflux may be confined to superficial tributaries throughout the lower limb. Without great and small saphenous trunk incompetence, perforator and deep vein incompetence, or proximal obstruction, their data suggest that reflux can develop in any vein without an apparent feeding source. This is often the case when bulging reticular veins are seen along the course of the lateral leg. This lateral subdermic complex and its vein of Albanese are often dilated and bulging in elderly patients. The underlying source of venous hypertension is usually perigeniculate perforating veins, not easily identifiable with duplex imaging. AP using an 18-gauge needle stab incision and a small crochet hook for exteriorization of the vein is an excellent procedure for this clinical problem.

Patient Selection

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

Prior to placing the patient in the supine position on the operating table, the veins of interest must be marked in the standing position with an indelible marker. Marking is performed in the standing position because hydrostatic pressure is elevated and the pressurized veins become visible and palpable. Bulging veins literally disappear when patients lie supine because the venous pressure drops to near 0 mm Hg.

Endovascular Instrumentation

AP is not truly endovascular in the purist sense; rather, it is a common and perfect adjunct to an endovascular procedure. The following are tools needed to perform AP:

Imaging

We prefer mapping these veins using visual inspection and palpation; other investigators might prefer transillumination mapping using specialized vein lights.⁹ Ultrasound-guided vein hooking is useful for deeper veins.

Hemostasis and Anticoagulation

Avulsion of venous segments treated by AP is relatively hemostatic when tumescent anesthesia is used. Hemostasis is augmented by applying gentle pressure over the incision site. The epinephrine in the anesthetic preparation enhances the hemostasis process through vasoconstriction. When extracting larger veins with the stab-avulsion technique, significant force may be required and some minor bleeding may be encountered. Placing the patient in the Trendelenburg position may also help control bleeding if there is more than usual.

Klein¹⁰ has shown through clinical studies that a dose of 35 mg/kg of dilute lidocaine solution is well tolerated and safe. Infiltrating solutions should contain epinephrine in appropriate concentrations to induce vasoconstriction and more gradual absorption of lidocaine into the bloodstream.

Infections are rare after liposuction and venous procedures with tumescent anesthesia and are usually confined to the incision site.¹¹ The reason for the low rate of infection is not clear, although there are reports of lidocaine concentration–dependent bacteriostatic and bactericidal activity. Pathogens commonly found on the skin may be sensitive to this activity.¹²

Compression bandage: Careful application of the postoperative dressing cannot be overstated because improper dressing placement can lead to bleeding and hematoma, blistering, nerve injury, and ischemia. The limb is wrapped circumferentially from foot to groin with a bulky compression dressing that is removed after 48 hours. The dressing should be applied with graduated pressure; the amount of pressure should decrease as one proceeds from foot to groin. It is critical to place extra padding over the lateral fibular head to avoid pressure-induced injury to the deep that is superficial peroneal nerves.

Deep peroneal nerve injury is quite serious because it is a motor nerve. A patient who develops a foot drop after venous surgery will have a decreased quality of life—a common source of litigation.

All patients are encouraged to ambulate immediately after the procedure to minimize thromboembolic complications.

Operative Steps

Tumescent anesthesia (Fig. 9-1): Tumescent anesthesia allows large areas of the body to be anesthetized with minimal effect on intravascular fluid status, avoidance of general anesthesia, and short postoperative recovery. Tumescent anesthesia provides a safe, easy-to-administer technique for use with AP. The technique of tumescent anesthesia involves infiltration of the subdermal compartment with generous volumes of a 0.1% solution of lidocaine with epinephrine. The anesthetic preparation is administered subdermally under pressure. The doctor pushes the fluid until a characteristic peau-d’orange effect is visualized on the skin. The tumescent fluid hydrodissects the subcutaneous fat from the venous tissue as it enters, thus facilitating vein extraction afterward.

Fig 9–1

Incisions (Figs. 9-2 and 9-3): The most popular instruments for creating incisions are No. 11 scalpel blades, 18-gauge needles, and 15-degree ophthalmologic Beaver blades. Incision length should correspond to vein size but is usually in the range of 1 to 3 mm. The author removes small varicose veins through an 18-gauge needle hole, while larger veins require slightly larger incisions made with a No. 11 scalpel blade.

Fig 9–2

Fig 9–3

Widening of incisions with a hemostat is tempting but should be avoided because this traumatizes wound margins and may lead to increased pigmentation in the postoperative scar. There have been anecdotal reports of “tattooing” the skin when the incision is placed through the indelible ink mark made preoperatively, which is why many operators circle the veins.

The incisions are oriented vertically because this allows wound edges to close solely with the force of a circumferentially placed compression dressing. That is, the dressing approximates the wound edges without the need for sutures or adhesive tapes. Horizontal incisions are preferred around the knees and ankles.

Hooking and extraction (Fig. 9-4): Hooking the target vein through the small incision is the next step. There are multiple instruments available—some are medical and others are manufactured for crochet. The latest available device is disposable and mounts the blade and hook on the same instrument.

Fig 9–4

Using a hook of choice, the vein is exteriorized from the wound. Hooks need not be introduced into the wound deeper than 2 to 3 mm, and they should be inserted gently and deliberately to avoid unnecessary trauma to the wound margins. Gentle probing and “searching” for the target vein with the hook are routinely necessary and should be done with great care. Once a segment of vein is exteriorized from the wound, it is grasped with fine hemostatic clamps (Fig. 9-5). With the use of gentle traction in a circular motion, the vein is teased out of the wound (Fig. 9-6).

Fig 9–5

Fig 9–6

With experience, one learns to distinguish between the vein wall, which is elastic, and the connective perivenous tissue, which is not elastic. Dissection of the vein from its perivenous investments greatly facilitates its extraction. Perivenous tissue issuing from the wound is excised at the skin level. This tissue should never be forcefully pulled out of the wound.

When traction is applied to the vein, the skin juxtaposed to the incision site will momentarily depress downward. Attention to this detail gives the operator an idea of where to place the next incision. The depression represents the point at which the vein will avulse. The next incision is made near the area of depressed skin, and the process is repeated sequentially until all of the venous bulges have been addressed. Although all bulges should be marked preoperatively, not all of the marks need to be incised if the operator takes care in identifying the skin depressions described earlier. It is very rewarding when a large segment is removed from a single site (Fig. 9-7). On balance, in some cases only small fragments of varicose veins are encountered that can make the operation quite tedious; this frequently cannot be avoided.

Fig 9–7

If vein exteriorization proves difficult, it is better to make larger incisions rather than induce ischemia at the wound edges from excessive stretching. For the number of incisions to be reduced, the incisions should be made one at a time (Fig. 9-8). If avulsion proves difficult and the vein breaks, it is more convenient to make more incisions than to waste time trying to retrieve more vein from the same incision (Fig. 9-9).

Fig 9–8

Fig 9–9

Areas where there is minimal subcutaneous fat or inflammatory changes can make the procedure more difficult. Typically, the operator will struggle around the knee, pretibial areas, and dorsum of the feet because these areas do not harbor much fat. Areas involved with previous superficial thrombophlebitis or previous surgery have more fibrosis.

Varicose veins sometimes act as outflow tracts for perforating veins; therefore, avulsion of varicose veins can disconnect underlying perforators. A perforator may be recognized by its perpendicular course and by the fact that the patient reports discomfort when traction is applied to the varicosity. The perforator is pulled until it yields, and then avulsed. Bleeding is controlled with digital compression.

Whether to close or not close wounds is a matter of judgment. The wounds may be left open or closed with simple sutures or adhesive tape. Most venous surgeons leave the wounds open and allow spontaneous healing. This technique results in little or no scarring and also has the advantage of allowing drainage of blood and anesthetic fluid into the overlying compressive dressing, obviating the formation of hematomas.

A single suture to close wounds near the foot and ankle may be required because of the elevated venous pressure at these locations in the upright position. Frequent ambulation will aid in decreasing ambulatory venous pressure in these dependent locations. Adhesive tapes are associated with a high incidence of skin blistering; therefore, these must be used with caution.¹³

After 10 minutes of postoperative observation, patients ambulate from the office, with a three-layer compression bandage in place. Minimal postoperative discomfort is the norm, but if it is more intense, it can usually be easily managed with nonsteroidal antiinflammatory agents.

Patients return to the office on postoperative day 2 for dressing removal and for duplex ultrasound to exclude the presence of deep venous thrombosis. Some ecchymosis is to be expected near the treated areas; this rarely results in permanent discoloration of the skin. Some minor leakage of blood and tumescent anesthesia may also drain from the open wounds. Regular adhesive bandages will usually control this satisfactorily. After the compression bandage is removed, patients wear graduated compression stockings (20 to 30 mm Hg) for 2 weeks during the daytime.

Indurated areas are commonly seen at AP incision sites and usually defervesce without incident over a period of several weeks. Firm subcutaneous inflammatory nodules may occasionally form directly under the incision sites; these, too, are self-limiting after several months.

Pearls and Pitfalls

Avoiding nontarget tissues: The venous surgeon must have a thorough command of neurovascular anatomy to avoid injury to nontarget tissues such as arteries and nerves. If the treating physician heeds several important suggestions, complications will rarely be encountered. Knowledge of the course of the common femoral artery, superficial femoral artery, popliteal artery, and anterior and posterior tibial arteries will keep the surgeon from injuring these structures while probing to exteriorize a varicose vein. It would be very difficult, although not impossible, to injure the profunda femoris or peroneal arteries during AP. As stated earlier, the hook rarely needs to plunge deeper than 3 mm to contact the target vein.

The saphenous and sural nerves are particularly prone to injury below the knee because of their proximity to the GSV and SSV. If the saphenous or sural nerves are displaced by the hook, the patient will usually complain of shooting pain into the foot. This is a sign for the surgeon to gently release the structure and replace it in situ. Occasionally, hair-sized sensory cutaneous nerves are encountered and inadvertently avulsed during the course of AP. Patients will experience sharp pain that usually dissipates after 2 to 5 minutes without treatment. If this occurs in the ankle and foot area, chances are that the patient will develop postoperative paresthesias or areas of dysesthesia that in most cases will be temporary.¹⁴

The femoral, obturator, sciatic, tibial, and peroneal (common, deep, and superficial) nerves are deep and generally not disturbed in the hands of a competent surgeon.

Foot: The skin of the foot is thin and fibrotic. Further, there is minimal subcutaneous fat, less protection against trauma of the skin, and important underlying tissues such as tendons, tendon sheaths, and joints. There are more small nerve branches that can be damaged by the hook. As in the popliteal space, there is greater risk of injuring an artery.

Eyelid: AP of the periocular vein avoids the concerns regarding thrombotic phenomena within ocular, orbital, or cerebral veins possibly associated with periocular vein sclerotherapy. Weiss and Ramelet¹⁵ reported excellent results on 10 patients who underwent removal of periocular reticular blue veins via AP. A single puncture with an 18-gauge needle sufficed in most cases. It is important to attempt to remove the entire segment, as partial resection may lead to recurrence. The use of postoperative compression for 10 minutes reduces the incidence of bruising. The puncture sites typically disappear quickly without scarring.

Hands: In general, inquiries about hand vein treatment come from elderly women who find them unsightly. Often, they have had prior facelift surgery and worry that their hands need rejuvenation to complement the face. Our initial consultation stresses the importance of hand veins for reasons of intravenous access; furthermore, removal of these veins may require central venous access should the patient be hospitalized in the future. If attempts to dissuade the patient fail, we recommend AP as the procedure of choice for hand vein removal. AP is identical to leg vein treatment and closely resembles treating the dorsum of foot because of the thin skin overlying the area. Results have been excellent.

Complications

Complications from AP in experienced hands are rare and, when they do occur, are minor.¹⁶ A multicenter study performed in France evaluated 36,000 phlebectomies. The most frequently encountered complications were telangiectasias (1.5%), blister formation (1%), phlebitis (0.05%), hyperpigmentation (0.03%), postoperative bleeding (0.03%), temporary nerve damage (0.05%), and permanent nerve damage (0.02%).

At the Miami Vein Center, we have performed more than 5000 AP procedures in the office environment, and complications have been limited to hyperpigmentation, telangiectatic matting, seroma, transient paresthesia, superficial phlebitis, blistering, and “missed veins” requiring repeat treatment. Each of these complications occurred in less than 0.5% of cases.

Comparative Effectiveness of Existing Treatments

We do not look at AP as a solitary procedure but rather as part of our armada in the treatment of venous disease. We usually perform endovenous thermal ablation of the saphenous trunk in the same setting as AP because bulging varicose veins are usually in continuity with a refluxing axial vein such as the GSV. Other operators delay AP until 4 weeks following endovenous ablation. The argument for this strategy is to allow the bed of varicosities distal to a refluxing axial vein to shrink in size and number. Then, fewer incisions will be required for vein removal at the time of AP.

It is important to note that Monahan reported during the follow-up period that complete resolution of visible varicose veins was seen in only 13% of limbs after saphenous ablation alone.¹⁷ Therefore, about 90% of patients require another intervention after saphenous ablation to fully eradicate their visible varicose veins. This has also been our experience.

If the patient returns in the postoperative period and points out veins that were missed during AP, a redo procedure is generally not required. Sclerotherapy, with or without ultrasound guidance, can be performed 4 to 6 weeks postoperatively to “clean-up” any missed veins. If redo phlebectomy is required, we permit 3 months to elapse; this allows the inflammatory response to subside at the original AP sites.

AP versus TriVex: In a published prospective comparative randomized trial comparing AP with the new technique of transillumination powered phlebectomy (TriVex), there was no difference in operating time. Although an incision ratio of 7 : 1 favored TriVex, there was no perceived cosmetic benefit between the patient groups. There was a higher number of recurrences in the TriVex group (21.2%) compared with the AP group (6.2%) at 52 weeks postoperatively. Assessment of pain scores showed no difference between groups.¹⁸

AP versus compression sclerotherapy: There is one randomized controlled trial on recurrence rates and other complications after sclerotherapy and AP. One year after sclerotherapy, 25% of varicose veins had recurred versus only 2% recurrence after phlebectomy. After 2 years, the difference in recurrence was even larger: 38% recurrence in the sclerotherapy group and only 2% in the AP group.¹⁹

Conclusion

AP is elegant by its mere simplicity. It is effective and safe with acceptable cosmetic results (Fig. 9-10). AP is a perfect complement to endovenous thermal ablation of the saphenous veins. With this combination, patients can expect all varicose veins to vanish following a 1-hour procedure that used only local anesthesia in the comfort of a physician’s office.

Fig 9–10 A, Before. B, After.