Ambulatory Phlebectomy for Varicose Veins Periprocedural Care

Updated: Sep 24, 2018
  • Author: Albert-Adrien Ramelet, MD; Chief Editor: Dirk M Elston, MD  more...
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Periprocedural Care

Preprocedural Planning

Detailed vein examination and ultrasonography (US) are obligatory before treatment is administered. Careful attention must be paid to the patient's medical history and general status, and any contraindications for local anesthesia or the surgical procedure itself must be identified.

Hematologic or other laboratory investigations are not typically normally required, unless indicated by previous disorders revealed by the patient history. If previous episodes of venous thrombosis have occurred, testing for a factor V Leiden mutation, a prothrombin 20210 mutation, or both is recommended; these patients are poor surgical candidates.

The integrity of the deep venous system and the proper function of the calf muscle pump should be ensured. In addition, preoperative clinical and US examinations are essential to detect and map all types of varicosities and their origins. Duplex US mapping of the source of reverse flow or reflux is typically performed, especially with the high availability of highly portable and high-resolution US 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.



Ambulatory phlebectomy requires a small number of surgical instruments. A No. 11 scalpel or an 18-gauge needle is used to make microincisions. Multiple mosquito forceps are used to grasp the veins as they are extracted.

Ambulatory phlebectomy hooks (see the image below) include the classic Muller hook, which most resembles a crochet hook with a blunt tip and a straight shaft that is designed to be placed under the veins and pulled out from below. The Oesch hook, which is available in three sizes, is characterized by a massive squared-off grip and is designed with a small barb at the tip to pierce the vein from the lateral aspect and elevate it.

Various hooks are used in ambulatory phlebectomy ( Various hooks are used in ambulatory phlebectomy (eg, Ramelet, Muller, Oesch, and Varady hooks).

The Ramelet hook, which is available in two sizes, is a small, fine hook. The smaller of the two is designed to remove reticular or medium-sized truncal varicose veins. The larger one has a thicker stem that is useful in large truncal and perforating veins. The cylindrical grip permits gentle rolling of the hook between the fingers, which diminishes the amount of rotation of the wrists and minimizes wrist and hand stress during the procedure.

The shaft of the Ramelet hook is short and allows precise and close work, as well as moderate traction. The hook angulation facilitates vein dissection, while the sharp tip grips the vein by the perivenous collagen bundles and tunica externa, allowing them to be lifted from above. (This approach limits damage to the surrounding tissues and lymphatics.)


Patient Preparation

Premedication is rarely required. Generally, it should be avoided as much as possible because it may hinder immediate postoperative walking, which is the best means of preventing potential vascular complications.

The varicose veins are carefully identified with an indelible marking pen or surgical marker with the patient standing. The patient is then placed supine for further marking. Cutaneous transillumination may be helpful in marking the veins for removal and, particularly, in detecting shifts in position of the veins when the patient moves from a standing position to a supine position.

The most common anesthetic approach for phlebectomy is large-volume administration of low-concentration lidocaine in a technique known as tumescent anesthesia. Tumescent anesthesia is very different from local anesthetic injection at points along a vein or a field block. In the tumescent technique, as much as 600 mL of 0.1% lidocaine with 1:1,000,000 epinephrine is injected in order to push the vein closer to the skin and cause vasoconstriction of skin capillaries to minimize postoperative bleeding (see the image below). [14, 15]

Tumescent anesthesia placed subcutaneously pushes Tumescent anesthesia placed subcutaneously pushes vein closer to skin for easier removal.

Subcutaneous infusion of 0.1% lidocaine with 1:1,000,000 epinephrine in a concentration of 35 mg/kg is considered safe. The maximum plasma levels reached 11-15 hours postoperatively are well below the toxic level (ie, 5 mg/mL). Compared with conventional local anesthesia, tumescent anesthesia produces a delay in achieving the peak serum lidocaine level and does not produce as high a level. This allows coverage for removal of long vein segments. The solution is pumped into the subcutaneous area of the leg to elevate the veins closer to the skin surface.

The use of tumescent anesthesia offers the following major advantages:

  • Decreased pain with injection
  • Low toxicity
  • Predissection of the vein from surrounding tissue
  • Perioperative capillary compression effect for improved hemostasis and less postoperative bruising
  • Pushing the vein to be removed closer to the skin
  • Postoperative rinsing and cleansing effect as the solution slowly drains from the punctures
  • Long-lasting anesthetic properties that reduce patient discomfort well into the postoperative day

The anesthetic can be infused below the vein, just under the dermis, by using a peristaltic pump or a series of large syringes. The authors primarily use the peristaltic pump because it reduces the time needed to infuse the anesthetic by 75%.

To minimize the pain that accompanies the injection of a normally acidic anesthetic solution, commercial lidocaine-epinephrine solutions can be buffered to a near-neutral pH by adding 1 mL of an 8.4% sodium bicarbonate solution to every 10 mL of lidocaine solution used. In a prospective study that included 101 patients undergoing ambulatory Muller phlebectomy for varicose veins, Krasznai et al found that the use of 1.4% sodium bicarbonate to alkalinize the tumescent anesthesia solution yielded significantly greater patient comfort during anesthetic injection. [16]

When lidocaine is used without epinephrine, the recommended dose is as high as 4.5 mg/kg (not to exceed 300 mg). The addition of epinephrine slows the absorption of lidocaine and permits the use of a dose as high as 7 mg/kg (not to exceed 500 mg) in a single session.

Allergic and toxic reactions are rare, but intravenous (IV) perfusion solutions, resuscitation equipment, epinephrine, injectable steroids, and IV diazepam should be readily available.


Monitoring & Follow-up

At 6 weeks after surgery, the success of the procedure and the need for additional sclerotherapy or laser procedures for residual small veins are assessed.