References

Hypotheses on the aetiology or recurrences of the varices of the great saphenous system : anatomical study of 211 patients

In: Negus D., Jantet G., Colleridge-Smith PD., eds, Plebology 95, Supl. 1, London, Springer- Verlag, 1995 : 164 -168
D. CRETON
EC. Ambroise Paré, rue Ambroise Paré, 54100 F-NANCY

INTRODUCTION

Surgical treatment of great saphenous reflux leads to a high percentage of recurrence, assessed as being between 20% and 25%, with extremes at 7% [1] and 65% [2]. Treatment of these recurrences represents approximately 20% [3] of all varicose surgery. Preoperative Doppler scans and the intraoperative anatomical study of our inguinal operations on great saphenous recurrence has led us to submit a hemodynamic hypothesis with regard to long saphenous recurrence.

PATIENTS AND METHOD

Between 1992 and 1994, with 2149 varicose exeresis on 1889 patients, we operated on 419 varicose recurrences (19.4%). Out of these, we only studied great saphenous recurrence that involved the previous crossectomy for inguinal reflux: 211 cases.

Residual high reflux

We studied the anatomical feed type for residual high reflux, and its hemodynamic importance.

1°) major femoral-varicose junction, labelled C+.

For these residual refluxes issuing from a former crossectomy stump, we created the following labelling system based on the type of the junction and the type of the reflux:

  • C+ 1 intact long saphenofemoral junction.
  • C+ 2 junctions by a single residual branch from the previous crossectomy.
  • C+ 3 junctions by a bifurcated residual branch from the previous crossectomy.
  • C+ 4 junctions by a trifurcated residual branch.
  • C+ 5 junctions by a quadrifurcated residual branch.
  • C+ 6 re-permeableness of the saphenofemoral junction on a bad ligation of the arch.
  • C+ 9 refluxes by thigh perforators located at least 15 cm from the stump.
  • C+ 10 refluxes by a voluminous juxta-inguinal branch (double saphenofemoral junction).
2°) minor femoral-varicose junction, neoangiogenesis on the femoral stump, labelled :
  • C0 7 for inguinal angiogenesis on the femoral stump.
  • C0 8 for refluxes fed by pudental veins.
  • C0 11 for refluxes fed by sub-cutaneous abdominal veins.

Residual varix in the thigh

We studied the type of residual varix in the thigh.

1°) flow-back residual saphenous vein of at least 3 mm in diameter, and longer than 15 cm (S+). These were labelled :
  • S+ 1 when they were directly connected to the source of the reflux on the femoral vein.
  • S+ 2 when there was a femoral-saphenous neojunction (with large tortuous veins) of between 2 and 10 cm.
  • S+ 3 when they were isolated further down with no visible connection with the deep venous system.
  • S+ 4 when they were fed by a pudental vein.
  • S+ 5 when they were fed by a thigh perforator.
2°) diffuse varices, not systematised, labelled S0.

The importance of the recurrence, globally assessed on the basis of its clinical tolerance, is judged in terms of the number of years between the two operations. In order to understand the pathological role of the various anatomical criteria of the recurrence, and their hemodynamic importance, we studied the relationships between these different factors.

RESULTS

The origin of the reflux

  • Exploration of the previous crossectomy allowed us to discover 137 major refluxes: 35 intact saphenofemoral junction (C +), 19 of which were in continuity with the long saphenous vein. 52% were refluxes on an intact saphenofemoral junction or on a voluminous single residual branch; the others were refluxes found on the lower triburary of the bifurcation of the residual trunk. A little less than half of these refluxes communicate with a residual saphenous vein.
  • 15 upper thigh perforators (C+ 9) (C+ 10) were responsible for reflux, one of them being voluminous (C+ 10) and located 5 cm below the crossectomy stump, corresponding to the junction of a second saphenous vein that had not been recognised during the first operation.
  • Minor refluxes were observed on 47 occasions: microscopic femoral-varicose neojunction or neoangiogenesis (C0 7). No stump of this type was connected to the residual saphenous vein.
  • On 12 occasions, a minor reflux issued from genito-crural varices (C0 8).
  • 1 minor reflux (C0 11) came from sub-cutaneous abdominal tributaries.

The type of residual saphenous vein Table I

Table I

  • Correlation between the type of inguinal reflux C and the type of residual saphenous vein S
  • In 93 cases we found diffuse varices (S0) with no saphenous trunk at thigh level: in 55% of the cases they were linked to a major reflux on the residual femoral-varicose junction (C+) and in 31% of cases they are linked to a minor reflux (C0 7) of microscopic femoral-varicose neojunction type.
  • In 118 cases, the residual saphenous vein had a diameter of between 3 and 15 mm and a length of between 15 and 70 cm. 60 saphenous veins (S+ 1) communicated with the femoral via a residual branch of the saphenofemoral junction.
  • 16 saphenous vein (S+ ) communicate with the femoral vein via winding macro vessels of between 2 and 10 cm, ensuring the junction between the saphenous vein and the femoral vein in two ways :

in 8 cases by major reflux on a residual tributary (C+)

in 8 cases by minor reflux of angiogenetic type.

  • 25 saphenous vein (S+ 3), often lower down the thigh, did not communicate with any source of reflux. There was no visible contact between the residual saphenous vein and the femoral vein at the level of the previous crossectomy. 16 were accompanied by major refluxes (C+) and 9 by minor refluxes (C0 7).
  • 10 saphenous vein were fed by genitofemoral pudental varices.
  • 7 were fed by upper thigh perforators.

Relationship between the type of reflux and the type of saphenaous vein

Table II

The relationships were, in order of frequency :

  • residual reflux + residual saphenous vein C+ / S+= 85 (43%)
  • residual reflux + diffuse varix C+ / S0=52 (26%)
  • absence of inguinal reflux + diffuse varix C0 / S0 =34 (17%)
  • absence of inguinal reflux + residual saphenous vein C0 / S+ =26 (13%)

Preferentially, C+ will be related to S+ (62%), and C0 will be related to S0 (57%).

Relationship between the type of and the recurrence time until the second operation

Table III

Delay between the first operation and the reoperation for the recurrence

The time between the operation and recurrence varied between 1 and 41 years; analysis of the cumulative frequency curves for re-operated patients shows that they are similar for the different recurrence parameters, taking time lag into account.

50% of patients with a C0 S+ type underwent a second operation 9 years later, and 75% 15 years later.

50% of patients with a C+ S+ type underwent a second operation 10 years later, and 75% 20 years later.

50% of patients with a C0 S0 type underwent a second operation 11 years later, and 75% 19 years later.

50% of patients with a C+ S0 type underwent a second operation 13 years later, and 75% 19 years later.

DISCUSSION

This study leads to the hypothesis that there are two types of recurrence: 1) recurrence of hemodynamic type, where the residual inguinal reflux and the residual saphenous vein accepting the reflux are tangled together. 2) Angiogenetic-type recurrences where the refluxes are minor. Indeed, the persistence of a major inguinal reflux is accompanied, in 62% of cases, by a saphenous vein accepting the reflux, and the persistence of a flow-back residual saphenous vein is accompanied by a major inguinal reflux in 76% of cases.

For recurrences of hemodynamic type, there are two hypotheses: either residual inguinal reflux develops and deteriorates the residual saphenous vein, or it is the reflux in the residual saphenous vein which, by suction, worsens and develops the residual inguinal reflux.

Among the 41 residual saphenous vein without any direct connection with the reflux (S+ 2, S+ 3), 58% are associated with a major reflux and 41% with a minor reflux, whilst among the macroscopic femoral-saphenous neojunctions (S+ 2), the proportion is the same. Among the major residual refluxes there are twice as few femoral-saphenous junctions as there are isolated saphenous vein (6% as against 12%), which shows that angiogenetic phenomena are independent of phenomena of pressure. If the saphenous vein has been completely removed, in 55% of cases it is fed by a major inguinal reflux, and in 31% of cases by a minor reflux (C0 7) Table I. In residual saphenous vein directly connected to the inguinal reflux, major residual refluxes are more frequent. 21% are connected to intactsaphenous junction, and 4% to tributaries with weak flow. Residual saphenous vein which develop a macroscopic femoral-saphenous neojunction (S+ 2) are connected to medium-sized inguinal refluxes, whilst isolated residual saphenous vein (S+ 3) are connected to major or very major refluxes, which shows that angiogenesis is a phenomenon that develops independently of any pressure effects.

Whilst the study of the time between the two operations is not the same as the time needed for recurrence to occur, it is nevertheless an objective way of comparing the different types of recurrence. One must, however, take into account the lower clinical tolerance of certain forms of recurrence. If, in the case of a residual inguinal reflux one also leaves a saphenous vein, one reduces the interval by 3 years. If, despite a good crossectomy, one leaves a saphenous vein, one reduces the interval by 2 years; this shows how important a residual saphenous vein can be with regard to recurrence. On the other hand, and very curiously, if one leaves an inguinal reflux and a residual saphenous vein, the time between operations is actually increased, and if, with regard to a complete saphenoctomy one performs a full crossectomy, the interval is reduced to 2 years. This discrepancy can be explained by the fact that these two types of recrecidivation, without saphenous vein and with minor reflux, are of angiogenetic type, and are certainly less well tolerated, clinically speaking, due to the unaesthetic and often painful varicose diffusion.

CONCLUSION

This study shows the major role of the residual saphenous vein in the pathology of recurrence; an important role where the phenomena of the reservoirs accepting the subjacent reflux are entangled with the phenomena of upward suction of the reflux. These hemodynamic-type recurrence are often due to surgical error; they are surprisingly well tolerated over time.

Angiogenesis or microscopic femoral-saphenous neojunction do not appear to be influenced by the effects of pressure; it is a cicatrisation phenomenon independent of reflux pressures. These types of recurrence are clinically less well tolerated, and surgical treatment should be performed under the least traumatic conditions possible.

REFERENCES

  1. RILVINS S. The surgical cure of primary varicose vein. Br. J. Surg. 1975 ; 62 : 913-17
  2. ROYLE JP. Recurrent varicose vein . World J. Surg . 1986 ; 10 : 944-53
  3. DAVIES GC. The Lothian surgical audit . Medical Audit News 1991; 1 : 26-7
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