Ambulatory Phlebectomy for Treatment of Varicose Veins 

Ambulatory phlebectomy permits removal of incompetent veins below the saphenofemoral and saphenopopliteal junctions, not including the proximal great or short saphenous veins. The junctions themselves cannot be treated with simple phlebectomy because junctional reflux must be addressed by endovenous ablation methods, which allow saphenous reflux to be addressed. Veins that may be removed by ambulatory phlebectomy include major tributaries such as the anterolateral vein, pudendal vein, and branches of the saphenous vein around and below the knee. Perforators and reticular veins may also be addressed, with rarely including small reticular veins associated with telangiectasias.

Skin incisions as small as 1 mm or needle punctures using an 18-gauge needle or larger are used to extract veins with a phlebectomy hook. The procedure is well tolerated by patients under local anesthesia and typically produces good cosmetic results. Long-term results from the authors’ experience are excellent as long as the most proximal source of reflux is eliminated by endovenous ablation techniques. In contrast to sclerotherapy of large varicose veins, ambulatory phlebectomy minimizes the risks of intra-arterial injection, skin necrosis, and residual hyperpigmentation. The source vein is extracted by the procedure.

Traditional venous ligation is no longer considered an acceptable method because the vein is interrupted rather than removed, leading to relatively high recurrence rates. With ambulatory phlebectomy, the small size of the skin incision or puncture usually results in little or no scarring. Only performed under local anesthesia, ambulatory phlebectomy leads to greatly reduced surgical risks compared with traditional surgery for truncal (axial), reticular varicose veins and incompetent perforators.

See the image below.

Cornelius Celsus first described phlebectomy in 45 CE. The earliest phlebectomy hooks were described in 1545, as illustrated in the Textbook of Surgery authored by W.H. Ryff. Dr Robert Muller, a Swiss dermatologist in private practice in Neuchâtel, Switzerland, rediscovered the technique in 1956. He developed his own technique and instruments and taught the technique to hundreds of physicians.^{[1, 2, 3]} Dr A.A. Ramelet, former president of the Swiss Society of Phlebology, was one of Dr Muller's students who further advanced the technique for smaller reticular veins with his own hooks.^{[4, 5, 6]} Today the technique is practiced by thousands of phlebologists around the world.

The incidence of varicose veins is estimated to be 25% of the white population.

Frequency

Incidence is higher with age and with female hormonal environment.

Venous insufficiency is caused by a refluxing circuit that results from failure of the primary valves at the saphenofemoral junction and typically leads to superficial varicose veins. Varicose veins that branch off an incompetent saphenous vein are called branch veins or secondary varicosities.^[7] The typical signs and symptoms of venous insufficiency, including ankle edema, stasis dermatitis, and possibly ulceration, may occur when varicose veins are untreated. The most important aspect of pathophysiology is the origin point of reflux and its elimination. Only then can branch varicosities be treated.

Detailed vein and ultrasonography examination is obligatory prior to treatment being administered. Careful attention must be paid to the patient's medical history and to the general state of the patient, and any contraindications to local anesthesia or the surgical procedure itself must be identified.

The integrity of the deep venous system and the proper function of the calf muscle pump should be ensured. In addition, preoperative clinical and ultrasonographic examinations are essential to detect and map all types of the varicosities and their origins. Duplex ultrasonography mapping of the source of reverse flow or reflux is typically performed, especially with the high availability of highly portable and high-resolution ultrasonography devices. Important sources of reflux (eg, saphenofemoral or saphenopopliteal junctions) should be corrected before any effort is made to address end-branch disease with ambulatory phlebectomy.

Although any branch varicosity can be removed by means of hook extraction, inexperienced physicians should be careful to avoid the popliteal fold, the dorsum of the foot, and the prepatellar and pretibial areas. These regions are more susceptible to injury, and they contain veins that can be more difficult to extract.

Veins most readily treated with phlebectomy include branch varicosities of the great and short saphenous veins, pudendal veins in the groin, and reticular varices in the popliteal fold or lateral part of the thigh. Phlebectomy can also be used as an immediate treatment for small segments of superficial phlebitis because the intravascular coagulum is expressed and the involved vein segment can be extracted through the same incision.

Large, tortuous distal branch varicosities are typically treated by using ambulatory phlebectomy but some large branch varicosities may be rarely treated by endovenous ablation techniques. Ambulatory phlebectomy is best for tortuous varicosities. Radiofrequency ablation catheters or optical laser fibers cannot easily be passed along a tortuous vein. Large, tortuous varicosities can also be treated by foam sclerotherapy in which a detergent sclerosant, such as 1-3% sodium tetradecyl sulfate, is agitated with air. Physician assessment of the thickness of the vein wall can be the determining factor in terms of use of ambulatory phlebectomy versus foam sclerotherapy, the latter being reserved for thinner-walled veins.

Contraindications to ambulatory phlebectomy are reflux at the saphenofemoral or saphenopopliteal junctions. These junctions must be treated by other means such as endovenous radiofrequency or laser ablation.