Varicose Vein Surgery Treatment & Management

Surgical removal or obliteration of varicose veins is often for cosmetic reasons alone. Noncosmetic indications include treatment of symptomatic varicosities (eg, pain, fatigability, heaviness, recurrent superficial thrombophlebitis, bleeding) and treatment of venous hypertension after skin or subcutaneous tissue changes (eg, lipodermatosclerosis, atrophie blanche, ulceration, or hyperpigmentation) have developed. ^[27]

Conservative treatment with stockings and external compression is an acceptable alternative to surgery, but worsening cutaneous findings or symptoms despite these measures usually warrant intervention. Nonetheless, a patient's desire for surgical management over conservative treatment or for cosmetic purposes alone are both reasonable relative indications for surgery.

Patients with venous outflow obstruction should not have their varicosities ablated, because they are important bypass pathways that allow blood to flow around the obstruction.

Those patients who cannot remain active enough to reduce the risk of postoperative deep vein thrombosis (DVT) should not undergo surgery.

Surgery during pregnancy is contraindicated because many varicose veins of pregnancy spontaneously regress after delivery.

Management of varicose veins has evolved over the centuries and will continue to do so. Less invasive techniques continue to be refined, but it is always necessary to compare the long-term efficacy of such techniques with that of of surgical saphenectomy.

Guidelines for the management of lower-extremity varicose veins have been published by the Society for Vascular Surgery (SVS), the American Venous Forum (AVF), and the American Vein and Lymphatic Society (AVLS). ^[28] (See Guidelines.)

Surgical treatment of varicose veins has been under development for more than 2000 years, but until the present era, relatively little weight was given to the cosmetic outcome of treatment. Current therapies are becoming less invasive and yielding improved recovery, but there remains a need for long-term outcome data. Therapies aim to remove the superficial venous system through either surgery, endovenous ablation, or sclerotherapy. ^[29]

In 90% of cases where venous hypertension is from superficial and perforator vein reflux, removal or obliteration of the great saphenous vein (GSV) alone can resolve the venous hypertension. ^{[6, 30]} In the remaining 10%, however, additional treatment to the incompetent perforator veins may be needed. Additionally, if severe deep venous incompetence exists, treatment of the GSV alone usually does not resolve the venous hypertension.

In both these cases, additional interventions with subfascial endoscopic perforating vein surgery (SEPS), perforator vein ablation, and/or venous reconstruction can be attempted, but these details are not further discussed in this article.

For now, the authors will discuss the procedures to remove or obliterate the superficial venous system, proceeding from most invasive to least invasive. Historical perspectives, advantages, and disadvantages to each technique will also be addressed. However, before any intervention, duplex ultrasonography (DUS) should always be used to map all major reflux pathways, and a skin marker should be used to mark all surface vessels to be removed.

Open techniques

The Rindfleisch-Friedel procedure of the early 1900s involved one incision to the level of the deep fascia that wrapped around the leg six times, creating a spiral gutter that brought into view a large number of superficial veins, each one of which was ligated. This wound was left open to heal by granulation. The Linton procedure, introduced in the late 1930s, used a large linear medial leg incision that brought into view all the superficial and perforator veins of the leg. Incompetent superficial veins were removed, and perforating veins were interrupted. ^[31]

In the late 1800s, Trendelenburg introduced a midthigh ligation of the GSV. The outcomes were variable, and this procedure was later modified by Trendelenburg's student Perthes, who advocated a groin incision and a ligation of the GSV at the saphenofemoral junction (SFJ).

Later, even better outcomes were found if saphenectomy (removal of the GSV) with ligation at the SFJ was performed in place of ligation alone. In a randomized trial, two thirds of patients treated with ligation without saphenectomy could be expected to need reintervention within 5 years for recurrent reflux, either from recanalization or from collateral formation around the ligated GSV. ^{[31, 32, 33]}

Excision of GSV

Surgical removal of the GSV has evolved from large open incisions to less invasive stripping. Original methods of stripping used different devices and variations of techniques. The Mayo stripper was an extraluminal ring that cut the tributaries as it was passed along the vein. The Babcock device was an intraluminal stripper with an acorn-shaped head that pleated up the vein as it pulled the vessel loose from its attachments. The Keller device was an internal wire used to pull the vein through itself, as is done today with perforation-invagination (PIN) strippers.

Currently, the technique of PIN stripping begins with a 2- to 3-cm incision made at the groin crease. The femoral vein and the SFJ are exposed with dissection, and all tributaries of the SFJ must be identified and flush-ligated to minimize the incidence of reflux recurrence.

After ligation and division of the junction, the stripping instrument (usually a stiff but flexible length of wire or plastic) is passed into the GSV at the groin and threaded through the incompetent vein distally to the level of the upper calf. The stripper is brought out through a small (≤ 5 mm) incision approximately 1 cm from the tibial tuberosity at the knee. An inverting head is attached to the stripper at the groin and is secured to the proximal end of the vein.

The vessel is then inverted into itself, tearing away from each tributary and perforator as the stripper is pulled downward through the leg and out through the incision in the upper calf (see the image below). If desired, a long epinephrine-soaked gauze or ligature may be secured to the stripper before invagination, allowing hemostatic packing to be pulled into place after stripping is complete.

An older technique of stripping to the ankle (rather than to just the knee) has fallen into disfavor because of a high incidence of complications, including damage to the saphenous nerve, which is closely associated with the vein below the knee. ^[4]

Excision of SSV

Removal of the small saphenous vein (SSV) is complicated by the variable local anatomy and the risk of injury to the popliteal vein and peroneal nerve. The saphenopopliteal junction (SPJ) must be located by duplex examination before the dissection is begun, and adequate direct visualization of the SPJ is essential.

After ligation and division of the SPJ, the stripping instrument (often a more rigid stripper that facilitates navigation) is passed downward into the distal calf, where it is brought out through a small (2- to 4-mm) incision. The stripper is secured to the proximal end of the vein, which is invaginated into itself as it is pulled downward from knee to ankle and withdrawn from below.

Stab phlebectomy

Performed by Galen as early as the second century, stab phlebectomy (also referred to as ambulatory phlebectomy) came back into modern favor during the 1960s and has increased in popularity ever since. This procedure is extremely useful for the treatment of residual vein clusters after saphenectomy and for removal of nontruncal tributaries when the saphenous vein is competent.

A microincision is made over the vessel with a tiny blade or a large needle, a phlebectomy hook is introduced into the microincision, and the vein is delivered through the incision. With traction, as long a segment as possible is pulled out of the body until the vein breaks or cannot be pulled any further. Another microincision is made and the process is begun again and repeated along the entire length of the vein to be extracted. Short segments of veins can be removed through tiny incisions without ligatures, and skin closure is not necessary. ^[4]

Endovascular techniques

Endovenous laser treatment

A laser fiber produces endoluminal heat that destroys the vascular endothelium. In endovenous laser treatment of varicose veins, a Seldinger technique is used to advance a long catheter along the entire length of the truncal varicosity to be ablated (usually the GSV). A bare laser fiber is passed through the catheter until the end protrudes from the tip of the catheter by approximately 2 cm, and the laser fiber tip is positioned at the SFJ just distal to the subterminal valve. The position is confirmed by means of ultrasonography (US) and the use of the laser guide light.

Under US guidance, tumescent solution with a local anesthetic is injected around the entire length of the vessel, separating it from its fascial sheath. This serves to insulate the vessel and prevent heat from damaging adjacent structures, including nerves and skin, as well as to provide pain control.

Firm pressure is applied to collapse the vein around the laser fiber, and the laser is fired, generating heat that leads to intraluminal steam bubbles and irreversible endothelial damage and thrombosis. The fiber and catheter are withdrawn approximately 2 mm, and the laser is fired again. This process is repeated along the entire course of the vessel. ^{[34, 29]}

A single-center study by Baraldi et al (N = 4895; 3818 women, 1077 men; mean age, 51.4 y) assessed 5500 procedures in which a combination of endovenous laser ablation and foam sclerotherapy (see below) was employed to treat chronic venous insufficiency secondary to varicose veins and saphenous trunk incompetence. ^[35]  The closure rates for saphenous veins and tributaries were 99.1% at 30 days, 98.3% at 1 year, and 97.9% at 4 years. The authors found the combined procedure to be safe and to yield acceptable long-term outcomes, with only minor adverse effects; however they noted the need for further prospective randomized studies to confirm the role of this approach.

Radiofrequency ablation

In radiofrequency ablation (RFA) of varicose veins, radiofrequency (RF) thermal energy is delivered directly to the vessel wall, causing protein denaturation, collagenous contraction, and immediate closure of the vessel. Unlike the endovenous laser fiber, the RF catheter actually comes into contact with the lumen walls.

An introducer sheath is inserted into the proposed vein of treatment (again, usually the GSV). A special RF catheter is passed through the sheath and along the vein until the active tip is at the SFJ just distal to the subterminal valve. As with the endovenous laser, tumescent local anesthetic is injected.

Metal fingers at the tip of the RF catheter are deployed until they make contact with the vessel endothelium. RF energy is delivered both in and around the vessel to be treated. Thermal sensors record the temperature within the vessel and deliver just enough energy to ensure endothelial ablation. The RF catheter is withdrawn a short distance, and the process is repeated all along the length of the vein to be treated.

Subramonia and Lees found that in comparison with conventional high ligation and stripping, RFA of GSV varicosities took longer to perform, but patients returned to their normal activities significantly earlier and had significantly less postoperative pain. ^[36]

In a study comparing  endovenous microwave ablation and RFA in 287 patients (295 limbs) with lower-limb varicose veins, Yang et al found that whereas the two modalities were similar with respect to efficacy and short-term effects, RFA required a longer procedural time and was more expensive. ^[37]

Cyanoacrylate

Endovenous treatment of varicose veins with N-butyl cyanoacrylate is receiving increasing interest and has shown promising midterm results. ^{[38, 39, 40]}  This and other nonthermal ablation techniques may cause less postprocedural pain than thermal ablation and may pose a smaller risk of nerve injury. ^[41]

Minimally invasive techniques

Cutaneous electrodesiccation

This is an old technique involving electrical cautery for destruction of small vessels. Because of the disfiguring cutaneous injury, it is rarely used today.

Sclerotherapy

Chemical sclerosis of varicose veins has waxed and waned in popularity since the late 1800s. Modern sclerosants with an acceptable risk profile became widely available in the 1930s, and since that time, their use has expanded. Initially, sclerotherapy was used as a surgical adjunct after saphenectomy to treat residual varicosities, reticular veins, or telangiectasias. Currently, it is being used to treat the GSV and main tributaries.

Under US guidance, a sclerosing substance is injected into abnormal vessels to produce endothelial destruction that is followed by formation of a fibrotic cord and eventual reabsorption of all vascular tissue layers (see the image below).

Local treatment of the superficial manifestations of venous insufficiency will always fail if the underlying high points of reflux have not been found and treated. Even when the patient appears to have only primary telangiectasias and the initial treatment seems to be successful, recurrences will be seen very quickly if unrecognized reflux exists in larger subsurface vessels.

Caution must be exercised in the use of sclerosing agents. Inadvertent injection into an arteriovenous malformation (AVM) or directly into an unrecognized artery can cause extensive tissue loss or loss of the entire limb. Inadvertent injection of concentrated sclerosants into the deep system can cause DVT, pulmonary embolism (PE), and death.

The most commonly used sclerosants today are polidocanol and sodium tetradecyl sulfate. Both are known as detergent sclerosants because they are amphiphilic substances, inactive in dilute solution but biologically active when they form micelles. These agents are preferred because they have a low incidence of allergic reactions, produce a low incidence of staining and other adverse cutaneous effects, and are relatively forgiving if extravasated. Polidocanol, the most forgiving sclerosing agent, was originally developed as a local anesthetic agent.

Other agents that have fallen out of favor include sodium morrhuate, associated with a relatively high incidence of anaphylaxis. Ethanolamine oleate, a weak detergent, is excessively soluble, decreasing its ability to denature cell surface proteins. Hypertonic saline in a 20% or 23.4% solution can be used as a sclerosing agent, but, because of dilutional effects with injection, it is difficult to achieve adequate sclerosis of large vessels without exceeding a tolerable salt load. If extravasated, it almost invariably causes significant necrosis.

The addition of foam with the sclerosing agents has allowed reduction of the amount of sclerosing agent injected, as well as improved efficacy. ^[42] Foam pushes blood out of the vein, decreasing dilution and increasing contact of the sclerosant with the endothelium. Homemade foam is usually air-agitated in saline. Because of the theoretical risks of air embolism, commercially available foam consists mostly of carbon dioxide. Varisolve (known as Varithena in the United States) is one such product, using carbon dioxide foam and polidocanol sclerosant (see the image below). ^{[15, 29]}

In the US, sodium tetradecyl sulfate, sodium morrhuate, and ethanolamine oleate were all developed before the establishment of the US Food and Drug Administration (FDA). These agents have never been submitted to the FDA for approval, but they are available in the United States as grandfathered agents. In November 2013, Varithena (Biocompatibles, Oxford, CT) was approved by the FDA for clinical use in the United States. ^[43]

After treatment of large varicose veins by any method, a 30- to 40-mm Hg gradient compression stocking is applied, and patients are instructed to maintain or increase their normal activity levels. Most practitioners also recommend the use of gradient compression stockings even after treatment of spider veins and smaller tributary veins.

O'Hare et al found that compression bandaging for 24 hours, followed by use of thromboembolus-deterrent stockings for the remainder of 14 days, gave results comparable to compression bandaging for 5 days. In a randomized trial in patients undergoing foam sclerotherapy for primary uncomplicated varicose veins, no significant difference was noted in vein occlusion, phlebitis, skin discoloration, or pain at 2 and 6 weeks with the two techniques. ^[44]

Ace wraps and other long-stretch bandages should not be used. These elastic bandages fail to maintain adequate compression for more than a few hours. They often slip or are misapplied by patients, with a resulting tourniquet effect that causes distal swelling and increases the risk of DVT.

Guidelines for the use of compression therapy after invasive treatment of superficial veins of the lower extremities have been published (see Guidelines).

Activity is particularly important after treatment by any technique because all modalities of treatment for varicose disease have the potential to increase the risk of DVT. Activity is a strong protective factor against venous stasis. Activity is so important that most venous specialists will not treat a patient who is unable to remain active following treatment.

A correct diagnosis of superficial venous insufficiency is essential. Veins should be treated only if they are incompetent and if a normal collateral pathway exits. Removal of a saphenous vein with a competent termination will not aid in the management of nontruncal tributary varices.

In the setting of deep system obstruction, varicosities are hemodynamically helpful because they provide a bypass pathway for venous return. Hemodynamically helpful varices must not be removed or sclerosed. Ablation of these varicosities will cause rapid onset of pain and swelling of the extremity, eventually followed by the development of new varicose bypass pathways.

The most annoying minor complications of any venous surgery are dysesthesias from injury to the sural nerve or the saphenous nerve. Subcutaneous hematoma is a common complication, regardless of the treatment technique used. It is easily managed with warm compress, nonsteroidal anti-inflammatory drugs (NSAIDs), or aspiration if necessary.

At the SFJ, accidental treatment of the femoral vein by inappropriate RF or laser catheter placement, spread of sclerosant (not visualizing progression with US), and inappropriate surgical ligation can all lead to endothelial damage at the deep vein, causing DVT formation with the potential for PE and even death. ^[34]

Other complications, such as postoperative infection and arterial injury, are less common and may be kept to a minimum through strict attention to good technique.

Endovenous treatment techniques (with RF and laser therapy) have the potential of excessive tissue heating, which can lead to skin burns. This problem can be avoided if sufficient volumes of tumescent anesthetic are injected to elevate the skin away from the vein. ^[34]