(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).