References

Surgery of great saphenous vein recurrences: the presence of diffuse varicose veins without a draining residual saphenous trunk is a factor of poor prognosis for long-term results

J Phlebology 2002 ;2: 90-6
D. CRETON
Denis Creton, MD, EC A Paré, rue A Paré, 54100 F, Nancy, France; téléphone: 33 3 83 95 54 00; fax:33 3 83 95 54 23

ABSTRACT

Objectives: To assess long-term results of complete ablation of saphenous trunks and varicose veins during re-do surgery for recurrent great saphenous veins. To study the evolution of superficial venous disease after suppression of every residual principal or accessory saphenous trunk.

Methods: Re-do surgery for a recurrent varicofemoral junction (RVFJ) (new communication between the femoral vein and varices in the groin) was carried out as well as stripping the residual insufficient saphenous trunk and complete removal of varicose veins. Out of 170 extremities treated on 137 patients, follow-up data based on physical and ultrasound examinations were obtained for 119 extremities on 100 patients.

Results: An average 4.9 year-follow up shows that no varicose veins or incompetent superficial veins could be observed for 27.7% of extremities. For 45.3% of extremities, diffuse varicose veins without reflux between the deep and superficial system could be observed, usually (p=0.001) between 2 contiguous areas. For 26.8% of extremities, varicose veins and a new site of incompetence had been growing between the deep and superficial venous system (for 5 extremities, there was formation of another RVFJ). Recurrent varicose veins were significantly associated with the preoperative presence of diffuse varicose veins without residual insufficient saphenous trunk (p=0.015) and a higher number of phlebectomy incisions during re-do surgery (p =0.02).

Conclusions: In the case of surgery of great saphenous vein recurrences the presence of diffuse varicose veins without a draining residual trunk is a factor of poor prognosis for long-term results. With no saphenous trunk left, after complete removal of varicose veins, only 27.7% of the cases will not show any recurrences at five years follow up. The presence of a major varicose vein network in patients with no residual saphenous trunk indicates a poor prognosis and probably suggests the presence of a non draining superficial venous system.

INTRODUCTION

Spontaneous evolution of varicose vein disease is still controversial. Classically the start-point could be an insufficient sapheno femoral or sapheno popliteal junction but it could be an isolated insufficient tributary [1]. The origin of lower limb venous reflux appears to be a local or multifocal process [2]. Actually the most important cause may involve a genetic lack or dysfunction of endothelial peptidic receptor [3-5]. In the case of insufficient great saphenous vein it is now clear that the flush ligation stripping is the best way to have a good result. Nevertheless, the rate of recurrences requiring re-do surgery after primary surgical treatment of varicose veins is between 20% and 30% [6, 7]. Many recurrences result from a lack of removal concerning the saphenous trunk, the varicose veins or the communications between deep and superficial venous system. But some other recurrences may result from the suppression of a venous way (e.g. iatrogenic or post-thromboses stenosis of the femoral vein). Some authors [8] have demonstrated that varicose vein surgery could generate new varicose veins especially when leaving a non draining residual trunk, which means leaving a saphenous trunk that cannot drain into the deep venous system either by a residual junction when the flux is upwards or by a re-entry perforator when there is a reflux. Few series have studied the evolution of a saphenous system deprived of any saphenous trunks or tributaries. In order to study this special hemodynamic situation we have chosen to assess the long-term results obtained after a complete removal of the saphenous trunk and varicose veins in the case of re-do varicose vein surgery located on the great saphenous area, leaving a type of non draining great saphenous system.

METHODS

Patients

Between 1992 and 1994 a total of 137 consecutive patients (170 extremities) underwent a re-do surgery consisting at the same time in a re-operation for recurrent saphenofemoral incompetence, complete ablation of varicose veins and stripping the residual saphenous trunks . All these patients had been previously operated on with a flush ligation and stripping the great saphenous vein but no documentation or post-operative records were available to say nothing of data about pre and post operative exams. These patients were showing clinically documented recurrent varicose veins which were retrospectively classified from clinical records as C2, C3, or C4 in accordance with the CEAP criteria. Patients showing previous deep venous thrombosis or clinical signs of deep venous insufficiency were excluded. Patients with insufficient short saphenous vein were excluded. Each of them underwent a Doppler ultrasonography (done by the same technician) before the procedure and one month later. The postoperative imaging was done to confirm that the varicose veins as well as the residual trunk had been completely removed. Preoperative marking was performed with the use of a Doppler ultrasound study of the femoral region (Hitachi EUB 555 [7.5 Mhz] transducer; Ecoscan, Les Ulis, France; and Esaote AU 530 [10 Mhz] transducer; Biomedica, Leperreux, France).

All the patients showed a residual stump in the area of the sapheno femoral junction and a reflux exceeding 1 second, calculated during the pumping of the calf muscle. A recurrent varico-femoral junction (RVFJ) (new communication between the femoral vein and varices or superficial veins) provided a connection between the femoral vein and an insufficient residual saphenous trunk or accessory saphenous trunk. The definition of residual trunk was, indifferently the right trunk in its anatomical subfascial position [9] or an accessory saphenous trunk. The presence of insufficient perforators was determined as well as the assessment for short saphenous incompetence. The patients who had undergone a re-do procedure showed one of the following anatomical types of recurrence (figure 1) : type 1, presence of a saphenous trunk with a direct connection to the femoral vein by means of a residual stump (junction or collateral of the intact sapheno femoral junction); type 2, presence of a saphenous trunk with an indirect connection to the femoral vein by means of newly formed vessels in the groin; type 3, presence of an isolated saphenous trunk with the proximal end not connected to the incompetent residual stump; and type 4, presence of a residual stump associated with diffuse varicose veins. The first three types showed a residual saphenous or accessory trunk whereas type 4 showed only diffused varicose veins. Considering the very low rate of C3/C4, the absence of C5/C6 and the absence of clinical sign and history of deep venous thrombosis routine assessment for deep-vein insufficiency was not carried out

Surgical technique

Surgical procedures were performed under loco regional anesthesia with a femoral nerve block, injection of 50% lidocaine solution to extend the area of anesthesia to the residual varicose veins, and, if requested by the patient, an injection of midazolam and alfentanil for sedation and pain control. It was a always unilateral procedure. Eighty-two percent of patients chose to be treated as outpatients and were discharged from the recovery room on the same day. The other, the decision of resting in the clinic was taken by the patient. The operation was carried out using a lateral approach to expose the stump like previously described [10]. After initial suture ligation of the stump flush with the femoral vein, if present, the trunk (or trunk collateral of the residual great saphenous vein) was pre-tied for stripping. Obliteration of the stump was achieved by burying it with a back-and-forth suture laying the stump over the adventitia of the femoral vein. A partitioning was achieved by interposition of an ePTFE patch (W.L. Gore & Associates, Flagstaff, Arizona, USA). Incompetent residual saphenous trunks and collateral trunks were stripped with a Pin-Stripper (Tüscher, Berne, Switzerland). Varicose veins were removed with Muller avulsion hooks inserted through phlebectomy incisions. The number of phlebectomy incisions was recorded for each operation. No SEPS were performed. Insufficient perforators connected with the varicose network were removed by means of phlebectomies. Postoperative compression was achieved by applying double class II stockings for 3 days followed by single class II elastic compression for 1 month. Injection sclerotherapy was not proposed for any patients but chosen by only 25, and compliance was poor.

Follow up study

All the patients who had undergone re-do surgery for recurrent varicose veins since 1997 were contacted and asked to fill in a questionnaire ; they were also submitted to a follow-up evaluation including physical examination and Doppler ultrasound study. The assessed extremities of the patients who had undergone this evaluation were initially classified into 2 categories (figure 2): type A, absence of varicose veins, (equivalent to category C0, C1 of the CEAP classification) and type B, presence of varicose veins (C2 of the CEAP classification) ; then the extremities with type B results were divided into 2 subgroups :

  • first, type B1, presence of visible or palpable varicose veins, exceeding 3 mm in diameter, but no reflux from the deep to the superficial veins (i.e. no reflux when performing Valsalva maneuvres and when compressing and decompressing the calf). The presence of a single varicose vein, even a few centimeters long, in any area—perineal, inguinal, femoral, lower leg, or popliteal—was considered as evidence of ongoing varicose disease in that area.
  • second, type B2 : presence of varicose veins and of another incompetent connection between the deep and superficial network with reflux during calf compression and decompression (incompetent femoral perforating vein or incompetent short saphenous vein). A new RVFJ was systematically sought for on the anterior aspect of the femoral vein.

Data from all these patients were recorded and compiled. Statistical analyses using ?2 tests were made to evaluate the relation between recurrence of varicose veins after re-do surgery and location in the extremity (contiguous and noncontiguous areas) and the relations between recurrence and patients’ ages, the number of pregnancies in female patients, the types of recurrence before re-do surgery, and the number of phlebectomy incisions during re-do surgery. A P value less than 0.05 was considered to represent statistical significance

RESULTS

Between 1997 and 1999, in the context of this follow-up study, 100 patients were examined (90 women and 10 men; mean age 53.5, ranging from 26 to 72). Female patients had undergone an average of 2.5 pregnancies before re-do varicose vein surgery. No patients were pregnant after re-do surgery. No patients had vulvar veins suggesting the presence of ovarian vein incompetence. The average period of time between re-do surgery and follow-up is 4.9 years (ranging from 3 to 7 years). A total of 119 extremities (61 right legs and 58 left legs) were examined. For 98 extremities, re-do procedure had never been performed before ; for the 21 left, two to four previous re-do surgery had already been performed. Before re-do surgery, 34 of the extremities had been classified with a type 1 recurrence, 23 with a type 2, 4 with a type 3, and 58 with a type 4. The average number of phlebectomy incisions was 39.9 (ranging from 5 to 92). For 33 extremities (27.7%), the follow-up examinations showed no varicose veins or incompetent veins (type A findings) ; 86 extremities showed new varicose veins, 54 extremities of them (45.3%) with type B1 findings and 32 of them (26.8%) with type B2 findings. In this last group 5 cases showed a new RVFJ. The follow-up examinations showed no saphenous trunk.

Table 1 shows the locations of new varicose veins according to the type of follow-up findings. Statistical analysis revealed that recurrence of varicose veins after re-do surgery was less likely to appear in two noncontiguous areas (groin versus lower leg, p=0.023) than in two contiguous areas (groin versus thigh, p=0.001; thigh versus lower leg, p=0.001). The presence of varicose veins in contiguous areas (thigh and lower leg) was linked to the presence of varicose veins in the groin (p=0.002 when groin varicose veins were present and p=0.012 when they were absent).

In the follow-up examinations (type A findings), no correlations could be established between the absence of varicose veins and, either the patients’ ages (p=0.221) or the number of previous pregnancies (p=0.883). Conversely, the presence of varicose veins after re-do surgery at follow-up (types B1 and B2) was significantly associated with both type 4 preoperative recurrence (p=0.015) and a greater number of phlebectomy incisions during re-do surgery (p=0.02) (Table 2).

Patients who showed a residual insufficient saphenous trunk before re-do (type 2, 3) were significantly correlated with patients with good result showing no varicose veins at the follow up examinations (type A) (Table 2).

Out of the 81 patients with type B1 or B2 findings after re-do surgery, ten of them had undergone another re-do procedure. These procedures involved a perforating vein of the popliteal fossa (2 patients), an incompetent short saphenous vein (1 patient), an incompetent perforating vein in the thigh (1 patient), and phlebectomy incisions (6 patients).

DISCUSSION

Echo-Doppler examination at follow up has not revealed any new residual saphenous trunk or extra-fascial collateral trunk, which means that the total removal of these trunks is efficient ; however it cannot stop the growing of new varicose veins. The patients who showed a residual saphenous trunk before redo had probably a missed saphenous trunk. Retrospectively the differentiation between a normal subfascial trunk, an accessory extra-fascial trunk and a bifid saphenous trunk [11] is difficult to establish. The complete removal of the superficial venous system (trunk, tributaries and varicose veins) in the area of the great saphenous vein could not prevent the new development of varicose veins from happening in this area.

If we consider that the « no varicose veins » result criteria are the same in this study as in Cappelli’s [8], long-term results of a complete truncular and varicosis ablation are not better than those obtained with the CHIVA method where a saphenous draining residual trunk is left, (27% of the patients without varicose veins at follow up versus 41.2% with the CHIVA method). The spreading of the varicose network and the progression of new vessels without reflux from deep to superficial veins can be considered as either signs of severe varicose disease or hemodynamic consequences of a permanently stable, non draining saphenous vein system. Residual varicose veins or a non draining residual saphenous trunk could induce new-vessel formation with progression, a process that stabilizes with the appearance of a re-entry communicating vein (inguinal neovascularization). The poor prognosis of the diffused varicose veins may correspond to a final non draining saphenous system. Complete removal of varicose veins during surgery may reduce the risk of creation of a non draining superficial venous system.

Actually, re-do surgery for incompetence of the GSV is a challenge. Three years after a first operation Fischer [12] mentioned 18% of recurrences, after 10 years 48% and after 34 years 77%. But in this study they were considered as recurrence only if the patient experienced or confirmed them as such. The long-term results obtained with our technique (on an average 4.9 year- follow-up period) were similar: 27.7% of extremities had no varicose veins and 45.3% of extremities showed small isolated varicose veins requiring only sclerotherapy or phlebectomy. Only 26.8% showed a theoretically re-expected treatment (short saphenous, perforators). Saphenectomy and complete resection of varicose veins from the thigh are key factors in the successful management of RVFJ. Extensive resection of varicose veins during re-do surgery is probably another reason for the good long-term results obtained.

The correlation between a greater number of incisions during re-do surgery (which is directly related to the extent of the varicose network) and recurrence of varicose veins after such surgery, suggests (Table 2) that varicose disease is sometimes serious and progressive. The same comment can be made for recurrence after re do surgery and type 4 recurrence.

For patients of our series : the fact that non refluxing superficial new vessels were more common between 2 contiguous areas than between 2 noncontiguous areas suggests that new-vessel formation is an ongoing progressive process. The appearance of these new vessels in the inguinal region probably corresponds to the development of new drainage routes to the deep venous system. Hydrostatic pressure in these vessels may account for contiguous proximal-to-distal development, resulting in a higher rate of varicose vein occurrence in the thigh and lower leg in patients with varicose veins in the groin. Turton [13] has demonstrated the occurrence of new reflux after stripping procedures in previously normal superficial veins in 19.6% of the cases. Dysfunction may be induced by changes in the hemodynamic organization of the superficial venous system.

In this study, the sex ratio (90 % of women) and the mean number of pregnancies by female patient could have influenced the varicose vein evolution. But, if the female patients' mean age at the time of re-do surgery (48.5) and the absence of new pregnancies after this surgery are taken into consideration, it is very unlikely that the hormonal impregnation could have had an impact on the results. In fact, in the follow-up examinations it has not been actually possible to establish any correlation between the absence of varicose veins and the number of previous pregnancies (p=0.883). Moreover, this possible risk factor has the same impact on the female patients with diffuse varicose veins and on those with draining trunks. Besides, our study, in which all the female patients have had a previous great saphenous striping, shows a pregnancy frequency that is quite similar to the one observed in the Labropoulos’s study concerning 100 randomly selected women (2.2) with the same saphenous reflux [14].

To summarize, the good long-term results obtained are probably due to the elimination of venous reflux, extensive excision of varicose veins and residual saphenous trunks. The carrying out of recurrent surgery is rather tricky since the necessary ablation of residual saphenous trunks may render the superficial venous draining all the more difficult. Nevertheless for recurrent surgery where the saphenous trunk has already been removed, a complete ablation of the varicose vein system seems to be inevitable in order to lessen the long-term occurrence of new varicose veins. Too important a resection can be worse than an insufficient one. More studies will be necessary to demonstrate that accurate adaptation of the venous resection to the hemodynamic dysfunction can improve the long term follow up

ACKNOWLEDGEMENTS

This study was supported by the Swiss Society of Phlebology. Statistical analyses were carried out by F. Kohler PR, Spieao, Medical University of Nancy, Nancy, France.

REFERENCES

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Table 1

es and locations of recurrent varicose veins (n=86 extremities) at long-term follow-up after patch interposition to treat recurrent saphenofemoral incompetence with complete removal of varicose veins and incompetent residual saphenous trunk

SSV indicates short saphenous vein; RSSV, recurrent short saphenous vein; PPF, perforator in popliteal fossa; RPPF, recurrent perforator in popliteal fossa; TP, thigh perforator; LP, leg perforators and RVFJ, recurrent varicofemoral junction (new communication between the femoral vein and varices in the groin). Type B1 indicates presence of visible or palpable varicose veins, exceeding 3 mm in diameter, but no reflux from the deep to the superficial veins and type B2, presence of varicose veins and of another incompetent connection between the deep and superficial network.

Type (nb./% of limbs) & location   Nb. of recurrent veins
B1 (54/62.7) 
Varicose veins and varicosities 38
Groin 22
Thigh 57
Lower leg 67
Thigh or lower leg 81
Popliteal fossa 4
B2 (32/35.5) 
Popliteal fossa 2 SSV, 1 RSSV, 4 PPF, 1 RPPF
Thigh 8 TP
Lower leg 10 LP
Groin, Thigh, Lower leg 2 2RVFJ, 1RVFJ+ TP, 1 RVFJ+RSSV
Groin 1 RJFV

Table 2

Relation between types of varicose vein recurrence assessed preoperatively and presence and absence of varicose veins at follow-up after re-do surgery, and relation between recurrence after re-do surgery and number of phlebectomy incisions made during re-do surgery

  • type 1 : indicates presence of a saphenous trunk with a direct connection to the femoral vein by means of a residual stump (junction or collateral of the intact sapheno femoral junction)
  • type 2 : presence of a saphenous trunk with an indirect connection to the femoral vein by means of newly formed vessels in the groin
  • type 3 : presence of an isolated saphenous trunk with the proximal end not connected to the incompetent residual stump
  • type 4 : presence of a residual stump associated with diffuse varicose veins

At follow-up, type A indicates absence of varicose veins, type B1, presence of visible or palpable varicose veins, exceeding 3 mm in diameter, but no reflux from the deep to the superficial veins and type B2, presence of varicose veins and of another incompetent connection between the deep and superficial network.

  Type of recurrence and % of all recurrences  
  Type 1 Type 2 Type 3 Type 4 NNb. of incisions
5 year follow up           
Varicose veins present (type B1 or B2) 29 12,7 2,3 5,58* 40,12†
cose veins absent (type A) 27,3 36,4 6,1 30,3 33†

* p=0.015 for the difference between the percentage of varicose veins recurrences (type B1 or B2) after re-do surgery in extremities with type 4 recurrence compared with the other 3 types of recurrences. (type 1, 2, 3) (figure 1).
† p=0.02 for the difference between the number of phlebectomy incisions performed during re-do surgery on patients with varicose veins at follow-up

Figure 1

Classification des types anatomiques de récidives opérées

Classification of the anatomical types of recurrences :

  • type 1 : saphenous trunk with a direct connection to the femoral vein by means of a residual stump (junction or collateral of the intact sapheno femoral junction)
  • type 2 : saphenous trunk with an indirect connection to the femoral vein by means of newly formed vessels in the groin
  • type 3 : isolated saphenous trunk with the proximal end not connected to the incompetent residual stump
  • type 4 : residual stump associated with diffuse varicose veins

Figure 2

Classification des résultats à 5 ans

Classification of the results at follow-up :

  • type A : absence of varicose veins, (C0, C1 of the CEAP classification)
  • type B1 : presence of visible or palpable varicose veins, exceeding 3 mm in diameter, but no reflux from the deep to the superficial veins (i.e. no reflux when performing Valsalva maneuvres and when compressing and decompressing the calf) (C2 of the CEAP classification)
  • type B2 : presence of varicose veins and of another incompetent connection between the deep and superficial network (C2 of the CEAP classification)

 

 

 

 

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