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Ambulatory Phlebectomy for Varicose Veins

  • Author: Albert-Adrien Ramelet, MD; Chief Editor: Dirk M Elston, MD  more...
 
Updated: Jun 23, 2016
 

Background

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.[1] The incidence of varicose veins is estimated to be 25% of the white population. The incidence is higher with age and with female hormonal environment.

Histologic specimens of removed varicose vein typically demonstrate features of veins that have had a dynamic response to venous hypertension. Varicose veins are dilated and tortuous veins with significantly larger wall areas and higher amounts of collagen. They have a higher content of smooth muscle and elastin.

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.

Ambulatory phlebectomy permits removal of incompetent veins below the saphenofemoral and saphenopopliteal junctions, not including the proximal great or small saphenous veins. The junctions themselves cannot be treated with simple phlebectomy, because junctional reflux must be addressed with endovenous ablation methods, which allow saphenous reflux to be treated.

Cornelius Celsus first described phlebectomy in 45 CE. The earliest phlebectomy hooks were described in 1545 in the Textbook of Surgery authored by WH 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.[2, 3, 4] Dr Albert-Adrien Ramelet, one of Dr Muller's students and a former president of the Swiss Society of Phlebology, further advanced the technique for smaller reticular veins with his own hooks.[5, 6, 7] Today, the technique is practiced by thousands of phlebologists around the world.

For patient education resources, see Varicose Veins.

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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 small 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 means of ambulatory phlebectomy, but some large branch varicosities may rarely be treated by means of endovenous ablation. Ambulatory phlebectomy is best for tortuous varicosities. Radiofrequency ablation (RFA) 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. The physician's assessment of the thickness of the vein wall can be the determining factor in the decision to use ambulatory phlebectomy or foam sclerotherapy, with the latter procedure being reserved for thinner-walled veins.

Clinical practice guidelines published by the European Society of Vascular Surgery in 2015 state that phlebectomy can be considered either as an adjunctive treatment in association with stripping or endovenous ablation of the main refluxing truncal vein or as the sole treatment of varicose veins.[8]

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Contraindications

The main contraindication for ambulatory phlebectomy is reflux at the saphenofemoral or saphenopopliteal junction. These junctions must be treated by other means, such as endovenous RFA or endovenous laser ablation (EVLA).

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Technical Considerations

Veins that may be removed by means of ambulatory phlebectomy include major tributaries such as the anterolateral vein, pudendal vein, and branches of the saphenous vein around and below the knee (see the image below). Perforators and reticular veins may also be addressed, rarely including small reticular veins associated with telangiectasias.

This vein on calf represents major varicose tribut This vein on calf represents major varicose tributary of small saphenous vein that was removed by means of ambulatory phlebectomy.

See Superficial Venous Insufficiency: Varicose Veins and Venous Ulcers, a Critical Images slideshow, to help identify the common risk factors and features of this condition and its management options.

Skin incisions as small as 1 mm or needle punctures with an 18-gauge or larger needle 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 via endovenous ablation.

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, and this leads to relatively high recurrence rates. With ambulatory phlebectomy, the small size of the skin incision or puncture usually results in little or no scarring. This procedure, only performed with local anesthesia, leads to greatly reduced surgical risks as compared with traditional surgery for truncal (axial)reticular varicose veins and incompetent perforators.

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Outcomes

Long-term results after phlebectomy are excellent when the procedure is performed for the appropriate indications.

The main indication is an incompetent primary or secondary branch of the great or small saphenous vein. Long-term success rates of 90% or greater are reported. Long-term success is typically associated with the elimination of high-grade junctional reflux before or immediately prior to phlebectomy. It is common practice to perform endovenous ablation of saphenous reflux and then perform ambulatory phlebectomy of varicose branches arising from the saphenous system.

A randomized trial involving 50 patients undergoing EVLA for great saphenous vein insufficiency, in which 25 underwent ambulatory phlebectomy concomitantly with EVLA and 25 underwent EVLA alone with subsequent phlebectomy as needed a minimum of 6 weeks later, found that the former approach yielded better results with regard to disease severity and quality of life.[9]

The AVULS (Ambulatory Varicosity avUlsion Later or Synchronized) trial, in which 101 patients undergoing endovenous truncal ablation received either simultaneous phlebectomy (n=51) or delayed varicosity treatment (n=50), found that the patients in the simultaneous group had improved clinical outcomes and less need for further procedures, as well as early improvements in quality of life.[10]

As with any therapy, new varicose veins may develop over time, and patients must be informed about the likely evolution and progression of venous insufficiency and the associated genetic predisposition.

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Contributor Information and Disclosures
Author

Albert-Adrien Ramelet, MD Specialist in Dermatology and Angiology, Switzerland

Disclosure: Nothing to disclose.

Coauthor(s)

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 Society for Dermatologic Surgery, American Society for Laser Medicine and Surgery, MedChi The Maryland State Medical Society

Disclosure: Received honoraria from Angiodynamics for speaking and teaching; Received intellectual property rights from CoolTouch Corp for consulting; Received grant/research funds from Cynosure for independent contractor; Received grant/research funds from Palomar for independent contractor.

Specialty Editor Board

David F Butler, MD Section Chief of Dermatology, Central Texas Veterans Healthcare System; Professor of Dermatology, Texas A&M University College of Medicine; Founding Chair, Department of Dermatology, Scott and White Clinic

David F Butler, MD is a member of the following medical societies: American Medical Association, Alpha Omega Alpha, Association of Military Dermatologists, American Academy of Dermatology, American Society for Dermatologic Surgery, American Society for MOHS Surgery, Phi Beta Kappa

Disclosure: Nothing to disclose.

John G Albertini, MD Private Practice, The Skin Surgery Center; Clinical Associate Professor (Volunteer), Department of Plastic and Reconstructive Surgery, Wake Forest University School of Medicine; President-Elect, American College of Mohs Surgery

John G Albertini, MD is a member of the following medical societies: American Academy of Dermatology, American College of Mohs Surgery

Disclosure: Received grant/research funds from Genentech for investigator.

Chief Editor

Dirk M Elston, MD Professor and Chairman, Department of Dermatology and Dermatologic Surgery, Medical University of South Carolina College of Medicine

Dirk M Elston, MD is a member of the following medical societies: American Academy of Dermatology

Disclosure: Nothing to disclose.

Additional Contributors

Desiree Ratner, MD Director, Comprehensive Skin Cancer Center, Continuum Cancer Centers of New York; Director of Dermatologic Surgery, Beth Israel Medical Center and St Luke's and Roosevelt Hospitals; Professor of Clinical Dermatology, Columbia University College of Physicians and Surgeons

Desiree Ratner, MD is a member of the following medical societies: American Academy of Dermatology, American College of Mohs Surgery, American Medical Association, American Society for Dermatologic Surgery, Phi Beta Kappa

Disclosure: Nothing to disclose.

References
  1. Mowatt-Larssen E. Management of secondary varicosities. Semin Vasc Surg. 2010 Jun. 23(2):107-12. [Medline].

  2. Muller R. [Ambulatory phlebectomy]. Ther Umsch. 1992 Jul. 49(7):447-50. [Medline].

  3. Muller R. [Treatment of foot varices by ambulatory phlebectomy]. Phlebologie. 1990 Apr-Jun. 43(2):317-8. [Medline].

  4. Muller R. [Treatment of varicose external saphenous vein by ambulatory phlebectomy]. Phlebologie. 1991 Jul-Oct. 44(3):687-92. [Medline].

  5. Ramelet AA. Complications of ambulatory phlebectomy. Dermatol Surg. 1997 Oct. 23(10):947-54. [Medline].

  6. Ramelet AA. Phlebectomy. Technique, indications and complications. Int Angiol. 2002 Jun. 21(2 Suppl 1):46-51. [Medline].

  7. Ramelet AA, Perrin M, Kern P, Bounameaux H. Phlebology. 5th ed. Paris, France: Elsevier Science; 2008.

  8. [Guideline] Wittens C, Davies AH, Bækgaard N, et al, European Society for Vascular Surgery. Editor's Choice - Management of Chronic Venous Disease: Clinical Practice Guidelines of the European Society for Vascular Surgery (ESVS). Eur J Vasc Endovasc Surg. 2015 Jun. 49 (6):678-737. [Medline]. [Full Text].

  9. El-Sheikha J, Nandhra S, Carradice D, et al. Clinical outcomes and quality of life 5 years after a randomized trial of concomitant or sequential phlebectomy following endovenous laser ablation for varicose veins. Br J Surg. 2014 Aug. 101(9):1093-7. [Medline].

  10. Lane TR, Kelleher D, Shepherd AC, Franklin IJ, Davies AH. Ambulatory varicosity avulsion later or synchronized (AVULS): a randomized clinical trial. Ann Surg. 2015 Apr. 261 (4):654-61. [Medline].

  11. Cohn MS, Seiger E, Goldman S. Ambulatory phlebectomy using the tumescent technique for local anesthesia. Dermatol Surg. 1995 Apr. 21(4):315-8. [Medline].

  12. Smith SR, Goldman MP. Tumescent anesthesia in ambulatory phlebectomy. Dermatol Surg. 1998 Apr. 24(4):453-6. [Medline].

  13. Krasznai AG, Sigterman TA, Willems CE, Dekkers P, Snoeijs MG, Wittens CH, et al. Prospective study of a single treatment strategy for local tumescent anesthesia in Muller phlebectomy. Ann Vasc Surg. 2015 Apr. 29 (3):586-93. [Medline].

  14. Hubmer MG, Koch H, Haas FM, Horn M, Sankin O, Scharnagl E. Necrotizing fasciitis after ambulatory phlebectomy performed with use of tumescent anesthesia. J Vasc Surg. 2004 Jan. 39(1):263-5. [Medline].

  15. Fays-Michel S, Vieu C, Trechot P, Mazet J, Cuny JF, Barbaud A. [Cutaneous necrosis following ambulatory phlebectomy: the role of sodium bicarbonate used in local anaesthesia]. Ann Dermatol Venereol. 2007 Jan. 134(1):76-7. [Medline].

  16. Elvy M. Post ambulatory phlebectomy: chronic peripheral lymphocoele. Phlebology. 2010 Jun. 25(3):158-60. [Medline].

 
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Tumescent anesthesia placed subcutaneously pushes vein closer to skin for easier removal.
Various hooks are used in ambulatory phlebectomy (eg, Ramelet, Muller, Oesch, and Varady hooks).
Before and 2 months after ambulatory phlebectomy. Reflux at saphenofemoral junction was treated with radiofrequency endoluminal ablation during same procedure.
This vein on calf represents major varicose tributary of small saphenous vein that was removed by means of ambulatory phlebectomy.
Extraction of veins by means of ambulatory phlebectomy.
 
 
 
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