eMedicine Specialties > Dermatology > Surgical

Varicose Veins Treated With Ambulatory Phlebectomy

Author: Robert Weiss, MD, Associate Professor, Department of Dermatology, Johns Hopkins University School of Medicine
Coauthor(s): Albert-Adrien Ramelet, MD, Specialist in Dermatology and Angiology
Contributor Information and Disclosures

Updated: Aug 30, 2007

Introduction

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 as junctional reflux must be addressed by endovenous ablation methods or rarely by surgical ligation and stripping. Veins that may be removed by ambulatory phlebectomy primarily include major tributaries; perforators; and reticular veins, including small reticular veins associated with telangiectasias.
 
Skin incisions or needle punctures as small as 1 mm are used to extract veins with a phlebectomy hook. The procedure is well tolerated by patients and produces good cosmetic results. Long-term results 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.

In contrast to traditional venous ligation, the small size of the skin incision or puncture usually results in little or no scarring. Performed with the patient under local anesthesia, ambulatory phlebectomy leads to greatly reduced surgical risks compared with traditional surgery for truncal (axial), reticular varicose veins and incompetent perforators. In contrast, for these larger veins, sclerotherapy involves risks including intra-arterial injection, iatrogenic phlebitis, deep vein thrombosis and pulmonary embolism, skin necrosis, and most of all, residual hyperpigmentation.

History of the Procedure

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. 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. Today the technique is practiced by thousands of phlebologists around the world.

Pathophysiology

Venous insufficiency is caused by a refluxing circuit that results from failure of the primary valves at the saphenofemoral junction typically leads to superficial varicose veins. Varicose veins that branch off an incompetent saphenous vein are called branch veins or secondary varicosities. 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.

Presentation

Detailed general and phlebologic examination is mandatory before any phlebologic treatment is 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. Also, 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. Important sources of reflux (eg, saphenofemoral or saphenopopliteal junctions) should be corrected before any effort is made to address end-branch disease.

Indications

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 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

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.

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References
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References

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Further Reading

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Keywords

stab avulsion of varicose veins, phlebectomy hooks, venous insufficiency, reflux circuit,  superficial varicose veins, varicose branches, venous valve failure, stasis dermatitis, superficial phlebitis, hook avulsion of varicose veins

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Contributor Information and Disclosures

Author

Robert Weiss, MD, Associate Professor, Department of Dermatology, Johns Hopkins University School of Medicine
Robert Weiss, MD is a member of the following medical societies: American Academy of Cosmetic Surgery, American Academy of Dermatology, American College of Phlebology, American Dermatological Association, American Society for Dermatologic Surgery, American Society for Laser Medicine and Surgery, and MedChi
Disclosure: Nothing to disclose.

Coauthor(s)

Albert-Adrien Ramelet, MD, Specialist in Dermatology and Angiology
Disclosure: Nothing to disclose.

Medical Editor

Désirée Ratner, MD, Director of Dermatologic Surgery, George Henry Fox Assistant Clinical Professor, Department of Dermatology, Columbia Presbyterian Medical Center, New York Presbyterian Hospital
Désirée Ratner, MD is a member of the following medical societies: American Academy of Dermatology, American College of Mohs Micrographic Surgery and Cutaneous Oncology, American Medical Association, American Society for Dermatologic Surgery, and Phi Beta Kappa
Disclosure: Nothing to disclose.

Pharmacy Editor

David F Butler, MD, Professor of Dermatology, Texas A&M University College of Medicine; Director, Division of Dermatology, Scott and White Clinic; Director Dermatology Residency Training Program, Scott and White Clinic
David F Butler, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Dermatology, American Medical Association, American Society for Dermatologic Surgery, American Society for MOHS Surgery, Association of Military Dermatologists, and Phi Beta Kappa
Disclosure: Nothing to disclose.

Managing Editor

John G Albertini, MD, Consulting Staff, Dermatologic Surgery, The Skin Surgery Center
John G Albertini, MD is a member of the following medical societies: American Academy of Dermatology and American College of Mohs Micrographic Surgery and Cutaneous Oncology
Disclosure: Nothing to disclose.

CME Editor

Glen H Crawford, MD, Assistant Clinical Professor, Department of Dermatology, University of Pennsylvania School of Medicine; Chief, Division of Dermatology, The Pennsylvania Hospital
Glen H Crawford, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Dermatology, American Medical Association, Phi Beta Kappa, and Society of USAF Flight Surgeons
Disclosure: Nothing to disclose.

Chief Editor

Dirk M Elston, MD, Director, Department of Dermatology, Geisinger Medical Center
Dirk M Elston, MD is a member of the following medical societies: American Academy of Dermatology
Disclosure: Nothing to disclose.

 
 
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