(Adapted from Perrin M. Insuffisance veineuse superficielle: notions fondamentales. EMC (Elsevier Masson SAS, Paris), Techniques chirurgicales – Chirurgie vasculaire, 43-161-A, 2007.)

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

Technical Information

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

• Saphenous trunk stripping is most frequently performed using the endoluminal technique, with invagination or pin stripping, and is credited with causing fewer neurologic complications (Figs 10.2 and 10.3).

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

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

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

Figure 10.2 Invagination stripping. 1. Vein is catheterized from the ankle to the groin. 2. A thread is fixed on the stripper. 3. The rigid stripper is pulled up from the ankle to the groin. 4. The thread is fixed on the vein at the groin. 5. Pull on the thread allows the removal of the vein by the invagination technique.

(Adapted from Perrin M. Chirurgie à ciel ouvert de l’insuffisance veineuse superficielle. Principes. Techniques. Résultats. EMC (Elsevier Masson SAS, Paris), Techniques chirurgicales – Chirurgie vasculaire, 43-161-B, 2007).

Figure 10.3 Pin-stripping. 1. The great saphenous vein is catheterized from the groin to the upper third of the lower leg with the pin-stripper. 2-3. The pin-stripper distal extremity is pushed through the vein wall and the skin. 4-5. A thread is passed through the pin-stripper eyelet. Then the thread is interlocked with the vein; the tie must be done on the thread and not on the pin-stripper. 6. Both stripper and invaginated vein are extracted through the distal incision.

Conventional surgery variants

Saphenous Trunk Stripping with Preservation of Saphenofemoral Confluence, with or without Incompetent Tributary Phlebectomy and/or Incompetent Perforator Interruption

Non-flush ligation at the SFJ and/or SPJ was, until recently, described as a technical mistake responsible for in situ recurrence in all cases as reflux through the incompetent terminal valve persisted. But preoperative ultrasound investigations have proved that in GSV varices the terminal valve is competent in approximately half the patients.^11,¹²

In this situation it looks obvious that high flush tie is not recommended as tributaries of the saphenofemoral confluence can drain in a physiologic way into the common femoral vein. Besides neovascularization, elimination of normal physiologic reflux is the main cause of recurrence after flush ligation,¹³ but rarely identified after confluence conservation.¹⁴

When the terminal valve is incompetent, non-flush ligation was thought to promote recurrence, as previously stated (Fig. 10.4). However, one prospective study has demonstrated that this concept is wrong. In this large series neither postoperative outcome nor clinical and diagnostic evaluation found a difference in terms of recurrence if the terminal valve was competent or not.¹⁴

Figure 10.4 Terminal incompetent valve and high ligation of the saphenofemoral junction. A, Terminal incompetent valve responsible for femoro-saphenous reflux. B, Following incorrect high ligation of the saphenofemoral junction, leaving a stump of the GSV termination the reflux persists through the terminal valve. The terminal valves of the tributaries ending in the stump progressively become incompetent, and consequently the tributaries refluxive.

The explanation for this may be that suppression of the reservoir represented by an incompetent saphenous trunk and tributaries allows the terminal valve to recover its competence.

Cryostripping

The only difference with cryostripping in comparison to classical surgery is the ablation modality of the saphenous trunk. After HL, the saphenous trunk is catheterized downward with the cryoprobe until reaching the lower limit of the vein to be stripped. The generator is activated and when the vein is attached to the cryoprobe (by freezing to it) the vein is broken off easily. No distal ligation is needed and the vein attached to the probe is progressively pulled up and extracted through the groin incision (Fig. 10.5).

Figure 10.5 Cryo stripping. 1. The saphenous trunk is catheterized downwards with the cryoprobe until the lower limit of the vein to be stripped. 2-3. While still applying the freezing, the stripper is progressively pulled out by traction from bottom to top. The GSV remains attached to the cryoprobe.

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

Surgery with saphenous trunk preservation

This is less invasive than other procedures, including vein stripping. The most aggressive part of vein stripping is the trunk excision. Besides, supporters claim that the preserved saphenous trunk might be used as an arterial substitute either for coronary surgery or as a bypass in femorocrural obliteration. Unfortunately there are no data on the real need for, or value of, the saphenous trunk as an arterial substitute after such surgery. Another argument in favor is the preservation of venous flow drainage, as ablation of the superficial system enhances varicose vein recurrence. The different procedures are depicted in Figure 10.6.

Figure 10.6 Schema of the trunk preserving procedures.

Isolated flush ligation or limited resection

Isolated flush ligation or limited resection of the SFJ and/or SPJ is termed in Western Europe ‘crossectomie’. This procedure is rarely performed as an isolated procedure since older studies demonstrated very poor outcome after these procedures.

SFJ and/or SPJ ligation plus incompetent tributary phlebectomy with or without incompetent perforator interruption

Suppression of leak points between the DVS and the SVS combined with reservoir ablation is supposed to restore competence of the saphenous trunk.¹⁵^–¹⁸ This procedure was promoted during the last two decades but is presently rarely performed, probably because the myth of compulsory HL has been discredited on account of its lack of clinical efficacy.

SFJ wrapping or valvuloplasty plus incompetent tributary phlebectomy with or without incompetent perforator interruption

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

SFJ Wrapping

The hemodynamic principle here is that by wrapping the SFJ using an external stenting technique (instead of the HL described above), the supposed restoration of competence to the valve restores valvular function (Fig. 10.7).¹⁹^–²¹

Figure 10.7 SFJ wrapping. A, Venocuff II devices. B, Schema of the SFJ wrapping. The Venocuff II is around the terminal valve. In dotted line a the removed lateral accessory vein. C, Schema of the valve before and after Venocuff application. D, Angioscopic control after Venocuff application.

(Courtesy of Dr Lane.)

The upholders of this method underlined that the terminal or subterminal valve has to be assessed carefully by B-flow ultrasound preoperatively, as only selected valves can benefit from wrapping. These would be valves that are not irreversibly damaged and can have their competence restored with a decrease in their diameter.

Valvuloplasty or Valve Repair

Valvuloplasty is another way to restore either terminal or subterminal valves. Repair is made by using either the assistance of external valvuloplasty angioscopy ²² or a direct surgical approach.²³^–²⁵

Ambulatory phlebectomy

Muller described this technique in 1956 and published it 10 years later.²⁶ The method consists of extracting VVs in an outpatient setting under local anesthesia using small punctures and hooks, The procedure is described in detail elsewhere,²⁷^–²⁹ but it is worth mentioning here that phlebectomy is performed by using fine-pointed blades, mini-incisions, and crochet hooks or other specialized phlebectomy hooks (Fig. 10.8).

Figure 10.8 Grasping of previously marked varicosities. A, The incision is a 2- to 3-mm stab made with a no. 11 blade. B, After the varicosity is exteriorized, it is divided and each end is carefully avulsed to remove as much varix as possible. C, With the limb elevated 30 degrees, 2-mm cutaneous incisions can be made, the varicosity can be brought to the surface by the hook technique, and after division of the vein each end can be avulsed selectively. Placement of subsequent incisions depends on the length of varicosity excised. D, This photograph, taken 10 days after surgery, shows the location of a distal medial calf incision through which the great saphenous vein has been stripped from the groin to this level.

Muller used this procedure in isolation or in combination with trunk stripping to avulse tributary varices, as reported in 1996.³⁰

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

Figure 10.9 Intraoperative view of the transilluminated powered phlebectomy procedure. Note the subcutaneous transillumination.

Varices phlebectomy

Varices phlebectomy with conservation of the refluxing saphenous trunk is named in French ‘ablation sélective des varices sous anesthésie locale’ (ASVAL; selective ablation of varices under local anesthetic).³¹ This process gathers and unifies techniques of phlebectomy that were previously scattered and insufficiently systematized and is based on the demonstrated fact that varicose disease most often begins at lower leg level (see above). According to ASVAL principles, the suppression of varicose reservoirs (especially extra fascial varicose clusters) can – at least to a certain extent – improve or restore to normal (centripetal) the reflux in saphenous trunks, thus preserving them.³²

CHIVA method

CHIVA is the acronym of the French ‘Cure Conservatrice et Hémodynamique de l’Insuffisance Veineuse en Ambulatoire’.³³ The pathophysiological basis of CHIVA relates to a ‘hemodynamicocentric model’ of venous insufficiency (VI).³⁴

According to CHIVA all the VI symptoms are due to an obstacle to the flow and/or valvular incompetence which increases the transmural pressure (TMP). Excessive TMP dilates the veins (varices) and impairs drainage (edema, lipodermatosclerosis, and ulcer) (Fig. 10.10). The hemodynamic diagnosis consists of checking and, correcting the VI causes in order to normalize the TMP and, consequently, its clinical symptoms. According to the VI hemodynamic pattern, CHIVA involves fractioning the hydrostatic pressure, disconnecting the shunts, and preserving the draining veins in order to cure all the symptoms of VI at the same time and avoid recurrence. Open Deviated Shunts Type II (varices + segmental saphenous trunk reflux) and Closed Shunts Type III (varices + segmental saphenous trunk reflux + SFJ reflux (SFJR)) are frequent patterns of VI due to superficial valve incompetence. In these specific cases CHIVA divides the refluxing tributaries at their junction with the saphenous trunk. These divisions result in trunk reflux suppression and varices ‘remodeling’ to normal size while the drainage is preserved in order to avoid short-term side effects and long-term recurrences (in the case of Shunt III SFJR, redo due to a trunk re-entry) (Figs 10.11–10.14).

Figure 10.10 Hemodynamic CHIVA Model for Venous Insufficiency: varices and trophic changes are

symptoms of different causes. CHIVA involves correcting all the patterns of shunts in order to cure the varices and the trophic disorders at the same time without phlebectomy. EVP external venous pressure, IVP intravenous pressure, TMP transmural venous pressure.

Figure 10.11 Types of ‘private circulation’ or veno-venous shunts according to CHIVA nomenclature. Type I shunt with reentry on the saphenous trunk, and variations. N1 deep vein network; N2 superficial vein surrounded by the superficial fascia (GSV, SSV, proximal part of the accessory anterior saphenous vein, Giacomini vein); N3 superficial venous system not surrounded by the superficial fascia.

(Courtesy of Dr Franceschi.)

Figure 10.12 Types of ‘private circulation’ or veno-venous shunts according to CHIVA nomenclature.

Type II shunt without reflux from the deep circulation, with compartmental regurgitation N2>N4>N2> or N2>N3>N2. N1 deep vein network; N2 superficial vein surrounded by the superficial fascia (GSV, SSV, proximal part of the accessory anterior saphenous vein, Giacomini vein); N3 superficial venous system not surrounded by the superficial fascia; N4 superficial communicant vein longitudinal (N4L)

(Courtesy of Dr Franceschi.)

Figure 10.13 Types of ‘private circulation’ or veno-venous shunts according to CHIVA nomenclature. Type III shunt with re-entry located on an extrasaphenous perforator, and variations. N1 deep vein network; N2 superficial vein surrounded by the superficial fascia (GSV, SSV, proximal part of the accessory anterior saphenous vein, Giacomini vein); N3 superficial venous system not surrounded by the superficial fascia; N4 superficial communicant vein longitudinal (N4L) or transversal (N4T).

(Courtesy of Dr Franceschi.)

Figure 10.14 Types of ‘private circulation’ or veno-venous shunts according to CHIVA nomenclature. Type IV shunt with reflux from the pelvic circulation. N1 deep vein network; N2 superficial vein surrounded by the superficial fascia (GSV, SSV, proximal part of the accessory anterior saphenous vein, Giacomini vein); N3 superficial venous system not surrounded by the superficial fascia.

(Courtesy of Dr Franceschi.)

Investigations to be Done Before VV Surgery

A thorough physical examination is important; it allows the clinical class (using the CEAP classification system) to be identified. Both symptom type and severity must be carefully recorded.

Systematic DUS prior to surgery for varicose veins is crucial. From a classification standpoint, DUS is used to complete CEAP sections E, A and P. In practical terms, it allows creation of a precise map that will be very useful during surgery (Fig. 10.15).

Figure 10.15 Surgery preoperative mapping A, Incompetent SFJ and GSV until half-way down the thigh (line —— • ——). Below GSV is competent and a medial-posterior tributary is refluxing, draining in lower leg reentry perforators. B, SFJ and GSV competent (continuous line in blue). Refluxing non-saphenous veins (dotted line in black). C, SFJ and GSV proximal part competent (continuous line in blue). Incompetent femoral canal perforator feeding the GSV (continuous line in black). D, SFJ and GSV competent (continuous line in blue). Incompetent anterior accessory great saphenous vein (dotted line in black). E, SPJ and proximal SSV incompetent (continuous line in black) as well as SSV tributary (dotted line in black). Competent distal SSV (not mapped). F, Incompetent SSV not connected with the popliteal vein but with the GSV.

(Courtesy of Dr Creton.)

This examination is required and is sufficient in clinical practice for primary and isolated superficial VI (SVI). For secondary SVI or SVI associated with abnormalities other than associated perforator incompetence, complementary tests should be performed depending on the clinical context.

The assessment performed in preparation for surgical treatment of varicose veins should provide answers to the following questions:

• Are the symptoms described by the patient connected with his/her varicose veins?

• Are there signs that can be used to classify the varicose veins into the category of complicated varicose veins (significant edema, skin changes, hemorrhage, superficial thrombophlebitis)?

• Are the varicose veins primary, secondary or congenital?

• Where are the leaks between the DVS and SVS (junctions and perforating veins)?

• Which veins are varicose (GSV: trunk, tributaries; SSV: trunk, tributaries; other non-saphenous veins)?

• What is the DVS status?

• Is there an associated disease that may affect the therapeutic indication?

• Is surgical treatment the best option?

• If the surgeon has made up his/her mind, have the anatomical variations been identified?

• What does the patient expect from surgery?

Patient’s Information

The information to be given depends, of course on the technique scheduled, but in all cases the following information must be provided:

• Advantages and disadvantages of the different surgical methods must be explained, as well as the postoperative course (return to normal activity, convalescence duration) and possible complications.

• Whether the surgery will be performed on an ambulatory basis or not.

• How much the patient will be charged.

In addition, a written document is handed over to the patient (Appendix 10.1).

Anesthesia and Hospitalization

Anesthesia

Regardless of the technique used, surgery may be performed under local anesthesia (LA). Tumescent anesthesia is strongly recommended for all patients. This innovation has revolutionized surgery of varicose veins.^35,³⁶

The addition of epinephrine (adrenaline) does decrease ecchymosis, and Goldman has shown that in appropriate concentrations, epinephrine is safe when used in a tumescent anesthetic technique during ambulatory phlebectomy. It does reduce the incidence of hematoma and hyperpigmentation.^37,³⁸

Hospitalization

Surgery for varicose veins is increasingly performed on an ambulatory basis. Only in elderly patients undergoing classical surgery or those characterized by a particular social or pathological context are hospitalized for 24 hours. Hospitalization is therefore determined by the patient’s desires, local traditions or socioeconomic conditions.

Postoperative Care and Convalescence

Drug treatment

After classical surgery minor analgesics may be proposed on the day of the procedure, which may be supplemented with anti-inflammatory treatment for 8 days. Tumescent anesthesia usually provides adequate pain control which lasts for 1 to 2 days. Any patient complaining of pain must be evaluated to determine the cause. Postoperative antithrombotic prophylaxis with low molecular weight heparin (LMWH) is indicated in at-risk patients (history of thromboembolic disease, positive family case history, known thrombophilia, etc.). Ambulatory phlebectomy or other mini-invasive techniques (ASVAL, CHIVA) performed under the same conditions do not require antithrombotic prophylaxis due to the absence of perioperative muscle atony and immediate mobilization of the patient at the end of the procedure.

Postoperative elastic compression

Such treatment should be systematically initiated on the day of the procedure. It has been credited with analgesic effects, prevents edema and most likely the occurrence of thromboembolic complications that may affect the SVS and DVS. Depending on the case and customary practice, stockings or bandages are used. This compression is usually prescribed for 1 to 2 weeks in the absence of skin changes.

For ambulatory phlebectomy and other mini invasive techniques, the duration of elastic compression (with bandages and then stockings) is usually 1 week. Poorly applied compression may lead to complications.

Recovery and convalescence

Recovery depends on the surgery performed and the level of patient activity: from 2 weeks for extensive excisional surgery to a maximum of a few days for so-called conservative surgery. The norm is rising with movement on the day of the procedure, depending on the procedure performed – with mini invasive and LA procedure immobility time is shortened. Exercise time is progressively increased during recovery. In principle, surgeons should provide patients with a document showing all postoperative instructions (Appendix 10.1).

Surgical Complications ^39,⁴⁰

Perioperative complications

Perioperative complications associated with surgery are exceptional when it is performed by a qualified operator. However, vascular injuries from damage to the principal arterial and venous trunks or nerves have been reported mainly after conventional surgery, sometimes with dramatic consequences. Lastly, anesthesia, regardless of its mode of delivery, may cause accidents, but tumescent LA provides fewer complications.

Postoperative complications

Postoperative complications may be cutaneous, vascular, lymphatic, neurological or of a more general nature.

Neurologic complications

Neurologic complications ⁴¹^–⁴³ are more frequent after trunk stripping, are mainly associated with perioperative injury and, rarely, when elastic compression is applied to patients under general anesthesia. Lesions to the motor nerves are extremely rare but may be permanent. In contrast, lesions to superficial sensory nerves, estimated at between 10% and 40%, lead to disorders such as anesthesia, paresthesia, dysesthesia and, more rarely, neuralgia. The patient often only becomes aware of these neurological disorders a few days after the procedure and they usually disappear within a few weeks, sometimes after several months. They are rarely permanent.

Venous thromboembolic complications

Local anesthesia and early mobilization have certainly reduced the frequency of such complications. Analysis of two prospective series with systematic DUS examination showed that, after ancillary surgery, DVT and pulmonary embolism were, respectively, 0.4 to 5.3% and 0.2 to 0%,^44,⁴⁵ demonstrating that most of the DVTs were distal and asymptomatic. It should, however, be noted that in the first series the patients (n = 377), who were treated by HL + saphenous trunk stripping + tributary phlebectomy and/or ligation of the perforating veins, were operated on under general anesthesia followed by early mobilization and postoperative compression, but patients at risk for DVT were not systematically given preventive anticoagulation. In the second series various open surgery procedures were performed, but under LA. Although no randomized controlled trials (RCTs) comparing the two modes of anesthesia are presently available, it appears that venous thromboembolic complications are more frequent with general anesthesia.

In practice, on the slightest suspicion, the patient must be reassured and a venous DUS and/or lung scan urgently requested to diagnose or exclude possible deep vein thrombosis (DVT) and/or pulmonary embolism.

Cosmetic complications

Cosmetic complications appear later. Unsightly scars are rare if the operator respects the accepted rules for cutaneous incisions. Aggravation of pre-existing telangectasias, occurrence of a neotelangiectatic network (‘matting’) or of pigmentation, particularly on the medial aspect of the thigh, are not uncommon along the pathway of the stripping. The following cutaneous complications have also been reported along the line of incision:

• Localized hypertrichosis

• Scleroderma-like dermatitis

• Vitiligo.

These complications may also occur near phlebectomy incisions.

Redo Surgery

The modality and indication for repeat surgery will be discussed later. Nevertheless it must be underlined that redo-surgery, particularly at the SFJ and SPJ, generates a complication rate higher than primary surgery.

Post Surgical Follow-up

Follow-up, whatever the VV operative treatment undertaken, is strongly recommended and must be understood both by patient and physician. One must keep in mind that varices are a chronic and progressive disease and in most cases surgery cannot completely cure the patient. Postoperative DUS allows one to assess the presence of persistent reflux, and treatment may prevent further recurrence, although no RCT is available to recommend this practise.

Results from Surgery

Outcome is difficult to evaluate, owing on the one hand to the various anatomic and physiologic lesions or disorders, and on the other hand to symptoms and clinical signs that differ from one patient to another. These facts help to explain why there is no universally appropriate classification available for VVs.

Certain evaluations only take into consideration the investigation results (DUS, plethysmography, etc.) while others also include evaluation of the symptoms (persistence or disappearance) and/or signs (presence or absence of varicose veins). Lastly, pre- and postoperative patient quality of life (QoL) can be an interesting evaluation tool.

In a comprehensive review including 118 references the authors’ conclusions were ⁴⁶ that surgical treatment seems to:

• relieve symptoms and improve disease-related QoL

• have a role in the secondary prevention of venous ulcer

• provide a cosmetic improvement, which is almost certainly operator-dependent

• be associated, as said above, with minor complications that are relatively common and major neurosensory or vascular complications that are very rare

• be associated with a definite but variable risk of recurrence.

Some prospective RCTs, comparing the various surgical techniques themselves or comparing chemical or thermal ablation with surgery, are available, but for most there is no long-term follow-up.

Surgery without preservation of the saphenous trunk

Conventional surgery

Numerous publications on this technique are available; this procedure has been used almost exclusively for a century.

Natural Evolution of the Disease Versus Conventional Surgery

A set of 149 patients with uncomplicated but symptomatic VVs, who had chosen 6 months earlier whether or not to be treated, were assessed by a questionnaire.⁴⁷ Surgery significantly reduced the total number of symptoms reported by the patients at follow-up (P < 0.02). However, none of the symptoms reported during specific activities were significantly lessened by surgery compared with no treatment.

Conservative Treatment Versus Conventional Surgery

Two RCTs have been conducted, one concerning symptomatic patients with non-complicated varicose veins, the other one in patients with venous ulcers. The outcome is displayed in Table 10.1.⁴⁸^–⁵²

Table 10.1 Conservative treatment versus conventional surgery

Type of Procedure	Article	Conclusion
Uncomplicated symptomatic VVs HL+S versus conservative treatment	Michaels JA, et al. Randomized clinical trial comparing surgery with conservative treatment for uncomplicated varicose veins. Br J Surg 2006;93:175	246 patients Uncomplicated symptomatic VVs (C₂S) Conservative treatment (lifestyle advice) versus HL+S
		F-U 2 years After surgery Health-related QoL better Symptoms improvement (pain and edema feeling) Cosmetic improvement
	Ratcliffe J et al. Cost effectiveness analysis of surgery versus conservative treatment for uncomplicated varicose veins in a randomized control trial. Br J Surg 2006;93:182	246 patients Uncomplicated VVs (C₂S) Conservative treatment (lifestyle advice) versus HL+S
		F-U 2 years After surgery Modest health benefit for relatively little NHS cost (United Kingdom)
Venous ulcer HL+S and compression versus compression	Barwell JR, Davies CE, Deacon J Harvey K, et al. Comparison of surgery and compression with compression alone in chronic venous ulceration (ESCHAR study): randomized control trial. Lancet 2004;363:1854	500 extremities HL+S and compression versus compression Venous ulcer healing (C₆) F-U 24 weeks No difference between the 2 groups
		Ulcer recurrence prevention F-U 1 year Less ulcer recurrence in the surgical group. P < 0.0001
	Guest M, Smith JJ, Tripuraneni G, Howard A, Madden P, Greenhalgh RM, Davies AH. Randomized clinical trial of varicose vein surgery with compression versus compression alone for the treatment of venous ulceration. Phlebology 2003;18:130-6;363 Ulcer	76 patients Ulcer healing F-U 26 weeksCompression (n = 39) versus HL+S and compression (n = 37). Surgery gives no additional benefit to compression therapy from the point of view of healing rate and quality of life generic questionnaire (SF 36) and disease specific questionnaire (CXVUQ)
	Gohel MS, Barwell JR, Earnshaw JJ, et al. Randomized clinical trial of compression + surgery versus compression alone in chronic venous ulceration. (ESCHAR study)-haemodynamic and anatomic changes. Br J Surg 2005;92:291	Venous ulcer Compression (n = 112) versus HL+S+ compression (n = 102)
		F-U 1 year Saphenous surgery abolished deep reflux in 10 of 22 legs with segmental reflux and 3 of 17 with axial reflux. P = 0.175 A significant hemodynamic benefit was obtained despite co-existent deep reflux; residual saphenous reflux was common
	Gohel MS, Barwell JR,Taylor M, et al. Long term results of compression therapy alone versus compression plus surgery in chronic venous ulceration (ESCHAR): randomized controlled trial. BMJ 2007;335:83	Venous ulcer recurrence (500 legs) HL+S and compression versus compression At 4-years F-U – In patients with isolated superficial reflux surgery + compression is better than compression P < 0.01 – In patients with superficial reflux combined with segmental deep reflux surgery is better than compression P = 0.04 – In patients with superficial reflux combined with axial deep reflux no difference between the 2 groups P = ns At 3-years F-U the surgical group experienced a greater proportion of ulcer free-time P = 0.007

F-U, follow-up; HL, high ligation; NHS, National Health Service; QoL, quality of life; S, saphenous stripping.

Outcome of conventional surgery in observational studies

Only two prospective observational studies will be analyzed here. The patients had been treated at centers highly skilled in venous surgery, investigated in depth pre- and postoperatively by USD and there was no patient loss at 5 years follow-up.^53,⁵⁴

In the first one including 93 patients (113 extremities C_2-6) the recurrence rate according to the REVAS (recurrent varices after surgery) definition ⁵⁵ was 25% (28/113), of which 72% were symptomatic (20/28). Nevertheless the clinical score was an improvement on the preoperative one (P < 0.001). The main cause of REVAS was neovascularization at the SFJ.

In the second series, which included 92 patients (127 extremities: C₂ = 58; C₃ = 11; C₄ = 34; C₅ = 5; C₆ = 19); all patients were assessed postoperatively to identify incorrect surgery. The REVAS rate was 47% and mainly related to neovascularization at the SFJ or/and SPJ, but only two ulcers recurred (2/19 = 10.5%). Clinical recurrence was more likely in limbs with worse preoperative venous function assessed by air plethysmography (APG) and reflux present at three or more sites. After surgery correction to normal venous filling index was less frequent in limbs with recurrence. Gradual deterioration in APG measures of reflux was identified in 66% at 5 years. Unfortunately no correlation was established between long-term DUS and APG anomalies and patient satisfaction or symptoms severity.

RCTs on Conventional Surgery Versus Other Operative Treatment

The results of these trials are shown in Table 10.2^56,⁵⁷(HL+ conventional stripping vs HL+ cryostripping), Table 10.3⁵⁸^–⁶⁴ (HL+S vs radiofrequency ablation (RFA)), Table 10.4⁶⁵^–⁶⁸ (HL+S vs endovenous laser ablation (EVLA)), Table 10.5^16,^17,⁶⁹^–⁷¹ (HL+S vs surgery preserving the GSV), and Table 10.6⁷²^–⁷⁴ (HL+S vs foam sclerotherapy).

Table 10.2 RCTs of HL+ conventional stripping versus HL+ cryostripping

Type of Procedure	Article	Conclusion
HL + S (conventional) versus HL + cryostripping	Menyhei G et al. Conventional stripping versus cryostripping: a prospective randomised trial to compare improvement in quality of life and complications. Eur J Vasc Endovasc Surg 2008;35:218	HL + S (n = 80) versus HL+ cryostripping (n = 79)
		F-U 6 months No difference in terms of postoperative pain and outcome Less bruising with cryostripping P = 0.01
	Taco MAL et al. A randomized trial of cryo-stripping versus conventional stripping of the great saphenous vein. J Vasc Surg 2009;49:403	HL + S (n = 245) versus HL+ cryostripping (n = 249)
		F-U 6 months Cryostripping has no benefits over conventional stripping.

F-U, follow-up; HL, high ligation; S, saphenous stripping.

Table 10.3 RCTs (except Kianifard article) HL+S versus RFA

Type of Procedure	Article	Conclusion
HL+S versus RFA	Hinchliffe RJ, et al. A prospective randomised controlled trial of VNUS Closure versus surgery for the treatment of recurrent long saphenous varicose veins. Eur J Vasc Endovasc Surg 2006;31:212	16 patients presenting REVAS with persistent GSV trunk RF VNUS Closure bipolar catheter versus redo-groin surgery + S.
		F-U 10 days With RF Procedure shorter P = 0.02 Less post-operative pain. P = 0.02 Less bruising P = 0.03
	Kianifard B, et al. Radiofrequency ablation (VNUS Closure) does not cause neo-vascularisation at the groin at one year: results of a case controlled study. Surgeon 2006;4:71	55 patients treated by VNUS closure bipolar catheter versus HL+S (control group)
		F-U 1 year Absence of neovascularization after RFA 11% after conventional surgery P = 0.028
	Lurie F et al. Prospective randomized study of endovenous radiofrequency obliteration (Closure procedure) versus ligation and stripping in a selected patient population (EVOLVES Study). J Vasc Surg 2003;38:207	86 patients VNUS Closure bipolar catheter versus HL+S
		F-U 4 months With RFA Return to normal activity shorter P = 0.02 Return to work shorter P = 0.05 Better health-related QoL
	Lurie F et al. Prospective randomized study of 65 endovenous radiofrequency obliteration (Closure) versus ligation and vein stripping (EVOLVeS) Two-year follow-up. Eur J Vasc Endovasc Surg 2005;29:67	65 patients VNUS Closure bipolar catheter versus HL+S
		F-U 2 years With RFA Clinical and DUS results at least equal to those after HL+S Better health-related QoL
	Rautio T, et al. Endovenous obliteration versus conventional stripping operating in the treatment of primary varicose veins: a randomized controlled trial with comparison of the costs. J Vasc Surg 2002;35:958	VNUS Closure bipolar catheter (n = 15) versus HL+S (n = 13)
		F-U 2 months Less post-operative pain P = 0.017–0.036 Shorter convalescence. P < 0.001 Cost-saving for society in employed patients
	Perala J et al. Radiofrequency endovenous obliteration versus stripping of the long saphenous vein in the management of primary varicose veins: 3-year outcome of a randomized study. Ann Vasc Surg 2005;19:1	VNUS Closure bipolar catheter (n = 15) versus HL+S (n = 13) F-U 3 years No difference in terms of clinical result
	Subramonia S, Lees T. Radiofrequency ablation vs conventional surgery for varicose veins-a comparison of treatment costs in a randomized trials. Eur J Vasc Endovasc Surg 2009;39:104	VNUS closure bipolar catheter versus HL (n = 47) vs HL+S (n = 41) RFA was more expensive but return to work was earlier P = 0.006

F-U, follow-up; GSV, great saphenous vein; HL, high ligation; QoL, quality of life; RFA, radiofrequency ablation; S, saphenous stripping.

Table 10.4 RCTs of HL+S versus EVLA

Type of Procedure	Article	Conclusion
HL+ S versus EVLA	Darwood RJ, et al. Randomized clinical trial comparing endovenous laser ablation with surgery for the treatment of primary great saphenous veins. Br J Surg 2008;95:294	810-nm laser diode stepwise withdrawal (n = 42) and continuous withdrawal (n = 29) versus conventional surgery (n = 32)
		F-U 3 months Abolition of reflux and improvement in disease specific QoL comparable Earlier return to normal activity with EVLA P = 0.005
	De Medeiros et al. Comparison of endovenous treatment with an 810-nm laser versus conventional stripping of the great saphenous vein in patients with primary varicose veins. Dermatol Surg 2005;31:1685	810-nm laser diode sequential withdrawal (n = 20) versus conventional surgery (n = 20)
		F-U 9 months (mean) Post operative pain comparable Fewer swellings and less bruising after EVLA. P ? More benefits with EVLA. P?
	Kalteis M, Berger I, Messie-Werndl S, et al. High ligation combined with stripping and endovenous laser ablation of the great saphenous vein: early results of a randomized controlled study. J Vasc Surg 2008;47:822	810-nm laser diode sequential withdrawal + HL (n = 47) versus conventional surgery (n = 48)
		F-U 4 month Hematomas smaller with EVLA. P = 0.001 EVLA was associated with a longer period of time until return to work P = 0.054 No difference in terms of health related QoL (CIVIQ)
	Rassmussen et al. Randomized trial comparing endovenous laser ablation of the great saphenous vein with ligation and stripping in patients with varicose veins: short-term results. J Vasc Surg 2007;46:308	980-nm laser diode pulse mode (n = 62) versus conventional surgery (n = 59)
		F-U 6 months Short-term efficacy and safety are similar. Except for slightly increased postoperative pain and bruising in HL+S group no differences were found
EVLA versus cryostripping	Disselhoff BCVM, der Kinderen DJ, Moll FL. Is there a risk for lymphatic complications after endovenous laser treatment versus cryostripping of the great saphenous vein? A prospective study. Phlebology 2008;23:10-4	810-nm laser diode withdrawal mode not mentioned 17 EVLA (n = 17) vs cryostripping (n = 16)
		F-U 6 months One complication lymphedema after cryostripping
	Disselhoff BCVM, der Kinderen DJ, Kelder JC, Moll FL. Randomized clinical trial comparing endovenous laser with cryostripping for great saphenous varicose veins. Br J Surg 2008;95:1232-8	810-nm laser diode withdrawal mode not mentioned EVLA (n = 46) versus cryostripping (n = 46)
		F-U 2 years With EVLA less postoperative pain P = 0.003 Return to normal activity shorter P = 0.002 Clinical and hemodynamic outcome no difference
	Disselhoff BCVM, Buskens E, Kelder JC, der Kinderen DJ, Moll FL. Randomized comparison of Costs and Cost-effectiveness of cryostripping and Endovenous Laser ablation for Varicose veins: 2-year results. Eur J Vasc Endovasc Surg 2009;37:357-63	810-nm laser diode withdrawal mode not mentioned 60 EVLA (n = 60) versus cryostripping (n = 60)
		F-U 2 yearsOutpatient cryostripping less costly and more effective P = ns

EVLA, endovenous laser ablation; F-U, follow-up; HL, high ligation; QoL, quality of life; S, saphenous stripping.

Table 10.5 RCTs of HL+S versus surgery preserving the GSV

Type of Procedure	Article	Conclusion
HL+S+ Perforator ligation versus HL + tributary phlebectomy +/– perforator ligation	Campanello M, et al. Standard stripping versus long saphenous vein saving surgery for primary varicose veins: a prospective, randomized study with the patients as their own controls. Phlebology 1996;11:45	HL + tributary phlebectomy+ perforator ligation (n = 18 group 1) versus HL+ stripping + tributary phlebectomy + perforator ligation (n = 18 group 2) Post operative course Less subjective post operative discomfort
		F-U 4 years No difference in terms of clinical outcome and plethysmography GSV compressible and patent when preserved
	Dwerryhouses et al. Stripping the long saphenous vein reduces the rate of reoperation for recurrent varicose veins. J Vasc Surg 1999;29:589 Winterborn RJ, et al. Causes of varicose vein recurrence: late results of a randomized controlled trial of stripping the long saphenous vein. J Vasc Surg 2004;40:34	HL + tributary phlebectomy (n = 58) versus HL+ stripping + tributary phlebectomy (n = 52)
		At F-U 5 and 11 years No difference in terms of recurrence but in the group with preservation of the saphenous trunk redo surgery was performed more frequently P = 0.012
HL+S versus CHIVA	Carandinas et al. Stripping versus haemodynamic correction (CHIVA): a long term randomised trial. Eur J Vasc Endovasc Surg 2008;35:230-7	HL+S (n = 75) versus CHIVA (n = 75)
		10 years F-U With CHIVA Less recurrence P = 0.04
	Parés JO, Juan J, Tellez R, Mata A, Moreno C, Quer FX et al. Varicose vein surgery. Stripping versus the CHIVA method : a randomized controlled trial. Ann Surg 2010;251:624-31	501 patients C2-C6 randomized in 3 groups – HL+ Stripping with clinic marking (S-CM group n =167) – HL+ stripping with duplex marking (S-DM group n = 167) versus CHIVA group n = 167)
		5 years F-U CHIVA > HL+ stripping in terms of recurrence P < 0.001

F-U, follow-up; HL, high ligation; S, saphenous stripping

Table 10.6 RCTs of HL+S versus foam sclerotherapy

Type of Procedure	Article	Conclusion
CA + HL versus HL+S	Bountouroglou DG, Azzam M, Kakkos SK, et al. Ultrasound-guided foam sclerotherapy combined with sapheno-femoral ligation compared to surgical treatment of varicose veins: early results of a randomised controlled trial. Eur J Vasc Endovasc Surg 2006;31:93	Liquid sclerotherapy + HL (n = 30) versus HL+S (n = 30)
		F-U 3 months Early recanalization in 13% after CA treated by complementary injection
		CA+HL less expansive, more rapid return to normal activities P < 0.0001
		No difference in term of complication and occlusion
	Abela R, Liamis A, Prionidis I, et al. Reverse foam sclerotherapy of the great saphenous vein with sapheno-femoral ligation compared to standard and invagination stripping: a prospective clinical series. Eur J Vasc Endovasc Surg 2008;36:485	HL+ reverse foam sclerotherapy (n = 30), HL + cryostripping (n = 30), HL+S (n = 30)
		HL+ reverse foam sclerotherapy less post operative complication and better patient satisfaction
CA versus HL+S	Figueiredo M, Araujo S, Barros N Jr, Miranda F Jr. Results of surgical treatment compared with ultrasoundguided foam sclerotherapy in patients with varicose veins: a prospective randomised study. Eur J Vasc Endovasc Surg 2009;38:758	Foam sclerotherapy (n = 27) 1–3 sessions 10 mL/session vs HL+S (n = 29) in C₅ patients
CA versus HL+S		F-U 6 months Vein obliteration AC 78%, HL+S 90%. P = ns related to the small number of patients included

CA, chemical ablation; F-U, follow-up; HL, high ligation; S, saphenous stripping.

Classical surgery variants

Saphenous trunk stripping with preservation of the saphenofemoral confluence +/− incompetent tributaries phlebectomy +/− incompetent perforator interruption

A retrospective cohort study of 151 patients (175 lower limbs C₁ = 1.5%, C₂ = 82.1%, C₃ = 6.7%, and C_4-6 = 9.7%) were treated as mentioned above knowing that 68.1% were symptomatic. The preoperative DSU showed that both saphenofemoral confluence (SFC) and saphenous trunk were incompetent. At a mean of 24.4 months postoperatively (median 27.3 months, range 8 to 34.8), persistent SFC reflux was observed in only two cases (1.8%) and a SFC neovascularization in one case (0.9%). Recurrence of VVs appeared in seven cases (6.3%) but in conjunction with SFC reflux in only one case. Post treatment 83.9% of limbs were converted to CEAP clinical class 0 to 1 and significant symptom improvement was observed in 91.3% of cases with an esthetic benefit in 95.5%.¹⁴

There is no RCT comparing this method to other operative treatments.

Cryostripping

Table 10.2 shows the outcome of the RCTs comparing cryostripping with conventional surgery.^56,⁵⁷

Surgery with saphenous trunk preservation

Isolated flush ligation or limited resection of the SFJ and/or SPJ

Various observational studies as well as RCTs have demonstrated that this procedure results in a poor outcome in the long term.

SFJ and/or SPJ ligation plus incompetent tributaries phlebectomy with or without incompetent perforator interruption

In addition to observational studies, two RCTs are available that include patients presenting with SFC and saphenous trunk incompetence (see Table 10.5).^16,^17,⁶⁹ It is not clear whether this procedure provides better results than the ASVAL method (see below).

Apart from in one study,¹⁶ the quality of the preserved saphenous trunk to be used as an arterial substitute has never been assessed in depth.

SFJ wrapping or valvuloplasty plus incompetent tributaries phlebectomy with or without incompetent perforator interruption

Some observational studies have been reported claiming both good clinical and hemodynamic results for this procedure.^21,²² Again, it is not known whether this procedure produces better results than ASVAL nor whether the quality of the preserved saphenous trunk is suitable for use as an arterial substitute.

Ambulatory phlebectomy

The results from Muller’s technique of ambulatory phlebectomy are difficult to assess as it is used either as an isolated procedure or in combination with any kind of trunk ablation, including the different stripping modalities.

Hook phlebectomy or powered phlebectomy

According to the RCTs there is no evident benefit in using powered phlebectomy (Tables 10.6 and 10.7).⁷⁵^–⁷⁷

Table 10.7 RCTs of hook phlebectomy versus powered phlebectomy

Type of Procedure	Article	Conclusion
Hook phlebectomy versus Trivex	Aremu M, Mahendran B, Butcher W, et al. Prospective randomized controlled trial: conventional versus powered phlebectomy. J Vasc Surg 2004;39:88	No difference in terms of patient satisfaction and cosmetic result
	Scavée V, Lesceu O, Theys S, et al. Hook phlebectomy versus transilluminated powered phlebectomy for varicose veins surgery. Early results. Eur J Vasc Surg 2003;25:473
	Ray-Chaudury SB, Huq Z, Souter RG, McWhinnie D. A randomized controlled trial comparing transilluminated powered phlebectomy with hook avulsions: an adjunct to day surgery. One Day Surg 2003;13:24	No difference in postoperative pain

Trivex (InaVein LLC, Lexington, Mass.)

Varices phlebectomy with conservation of the refluxing saphenous trunk

A retrospective study was undertaken of 303 lower extremities (221 patients), all presenting with saphenous trunk (ST) reflux of more than 0.5 seconds (GSV, 85.8%; SSV, 11.9%; and GSV and SSV, 2.3%), that had been treated according to the ASVAL method. The ST reflux was shown to be reduced to less than 0.5 seconds in 69.6%, 69.2%, 68.7%, 68.0%, and 66.3% of limbs, respectively, after 6 months, 1, 2, 3, and 4 years of follow-up. Symptoms improved or disappeared in 84.2%, 84.2%, 83.4%, 81.4%, and 78.0% of limbs at each annual check-up until year 4. Freedom of varices recurrence was 95.5%, 94.6%, 91.5%, and 88.5%, respectively, at 1, 2, 3, and 4 years.

When, preoperatively, reflux in the saphenous trunk extended from its termination to the malleolus, the elimination of the ST reflux was less frequent (47.6% vs 70.3%; P < .05).³¹

CHIVA method

A great number of observational studies, mostly retrospective by Italian and Catalonian teams, have been reported. Their analyses are sometimes difficult for other practitioners to understand, owing to the use of the specific CHIVA terminology and the modification of the technique itself, but CHIVA protagonists are happy with this method if the preoperative hemodynamic shunt type (CHIVA language) has been correctly identified. Two long-term RCTs are available that supports its use (see Table 10.6).⁷¹

Indications for Surgery

In absence of long-term follow-up RCTs evaluating the different treatment methods including surgery, only weak recommendations according to Guyatt ⁷⁷ can be stated. Nevertheless, it appears that surgery is presently giving way to minimally invasive procedures; that is to say chemical and thermal ablation. In Europe, surgery with preservation of the saphenous trunk (including ASVAL and CHIVA) has some supporters.

Indications according to etiology

Only primary varices will be considered – post-thrombotic or congenital varices are a specific problem that will not be developed in this chapter. The systematic use of DUS, including routine investigation of the deep vein combined with other examinations, prevents the wrong indication of VV treatment in post-thrombotic syndrome.

Indications according to the clinical presentation

Clinical presentation may sometimes influence the indication.

Pregnancy

In women, pregnancy may influence the indication. It has been established that the REVAS risk after GSV conventional surgery in a woman who has already had a child is higher in subsequent pregnancies.⁷⁹ If an operative treatment is decided upon then a less invasive procedure is recommended, such as combining it with chemical or thermal ablation in order to avoid open surgery at the groin.

Association of VV with another disease

Obesity

Given the understanding that postoperative complications are higher in obese people following SFJ surgery, open surgery at the groin is not recommended.

Peripheral Arterial Occlusive Disease and Coronary Disease

The treatment of varicose veins in the presence of peripheral arterial occlusive disease (PAOD) or coronary disease (CD) tends toward being conservative, particularly because of the potential need for a vein graft. In this situation, if VVs need to be treated then surgery preserving the saphenous trunk is recommended providing the saphenous vein is suitable for use as a replacement conduit. Nevertheless, a vein that cannot be used as a graft should be treated and the practitioner must not forget that the association of severe VVs and PAOD increases the risk of ulcer.

Lymphedema

If operative treatment is needed, chemical and thermal ablation are less dangerous than surgical techniques, the aim being not to damage the lymphatics.

Indications according to the CEAP class

In the C₂ class (non-complicated VVs) there is no argument that favors surgery to other operative treatments. In complicated VVs, particularly in C₆ patients, only RCTs comparing classical surgery to conservative treatment are available,⁵⁰^–⁵² apart from one small series involving treatment with CHIVA.⁷⁹ That does not demonstrate that classical surgery provides a better outcome in patients presenting with venous ulcer, as observational studies with thermal and clinical ablation include C₆ patients.⁸¹

Indications according to anatomic and physiopathologic anomaly

Reflux at the SFJ and/or at the SPJ

In theory, with major reflux at the SFJ or SPJ (particularly when the terminal valve is incompetent and the terminal portion of the saphenous trunk very enlarged), classical surgery is the best option as HL+S are supposed to solve the problems. This recommendation was stated by Cappelli but no data support it.¹² However, patients with an incompetent terminal valve treated with preservation of the SFJ had a good outcome in the Pittaluga’s series.¹⁴ Furthermore, outcome in patients treated using thermal ablation by RF with preservation of the SFJ was as good as after classical surgery at 5 years.^53,^54,⁸² In any case, SFJ has been examined at a median follow-up of 25 months by DUS and the most common finding in the groin was an open, competent SFJ with a greater than 5-cm patent terminal GSV segment conducting prograde tributary flow through the SFJ (82%) (Fig. 10.16).⁸³

Figure 10.16 DUS. Physiological drainage of the superficial epigastric vein in the stump of the SFJ after radiofrequency ablation.

(From Perrin M. Traitement chirurgical endovasculaire des varices des membres inférieurs. Techniques et résultats. EMC (Elsevier Masson SAS, Paris), Techniques chirurgicales – Chirurgie vasculaire, 43-161-C, 2007).

Knowing that neovascularization at the groin is frequent and the major cause of recurrence at the SFJ after HL ^13,^54,^83,⁸⁴ (Fig. 10.17), whatever the pathophysiology, is inconclusive; there is no RCT comparing saphenous trunk stripping with and without HL.