BASIC AND CLINICAL DERMATOLOGY
Series Editors ALAN R. SHALITA, M.D.
Distinguished Teaching Professor and Chairman Department of Dermatology SUNY Downstate Medical Center Brooklyn, New York

DAVID A. NORRIS, M.D.
Director of Research Professor of Dermatology The University of Colorado Health Sciences Center Denver, Colorado

1. Cutaneous Investigation in Health and Disease: Noninvasive Methods and Instrumentation, edited by Jean-Luc Lévêque 2. Irritant Contact Dermatitis, edited by Edward M. Jackson and Ronald Goldner 3. Fundamentals of Dermatology: A Study Guide, Franklin S. Glickman and Alan R. Shalita 4. Aging Skin: Properties and Functional Changes, edited by Jean-Luc Lévêque and Pierre G. Agache 5. Retinoids: Progress in Research and Clinical Applications, edited by Maria A. Livrea and Lester Packer 6. Clinical Photomedicine, edited by Henry W. Lim and Nicholas A. Soter 7. Cutaneous Antifungal Agents: Selected Compounds in Clinical Practice and Development, edited by John W. Rippon and Robert A. Fromtling 8. Oxidative Stress in Dermatology, edited by Jürgen Fuchs and Lester Packer 9. Connective Tissue Diseases of the Skin, edited by Charles M. Lapière and Thomas Krieg 10. Epidermal Growth Factors and Cytokines, edited by Thomas A. Luger and Thomas Schwarz 11. Skin Changes and Diseases in Pregnancy, edited by Marwali Harahap and Robert C. Wallach 12. Fungal Disease: Biology, Immunology, and Diagnosis, edited by Paul H. Jacobs and Lexie Nall 13. Immunomodulatory and Cytotoxic Agents in Dermatology, edited by Charles J. McDonald 14. Cutaneous Infection and Therapy, edited by Raza Aly, Karl R. Beutner, and Howard I. Maibach

15. Tissue Augmentation in Clinical Practice: Procedures and Techniques, edited by Arnold William Klein 16. Psoriasis: Third Edition, Revised and Expanded, edited by Henry H. Roenigk, Jr., and Howard I. Maibach 17. Surgical Techniques for Cutaneous Scar Revision, edited by Marwali Harahap 18. Drug Therapy in Dermatology, edited by Larry E. Millikan 19. Scarless Wound Healing, edited by Hari G. Garg and Michael T. Longaker 20. Cosmetic Surgery: An Interdisciplinary Approach, edited by Rhoda S. Narins 21. Topical Absorption of Dermatological Products, edited by Robert L. Bronaugh and Howard I. Maibach 22. Glycolic Acid Peels, edited by Ronald Moy, Debra Luftman, and Lenore S. Kakita 23. Innovative Techniques in Skin Surgery, edited by Marwali Harahap 24. Safe Liposuction and Fat Transfer, edited by Rhoda S. Narins 25. Pyschocutaneous Medicine, edited by John Y. M. Koo and Chai Sue Lee 26. Skin, Hair, and Nails: Structure and Function, edited Bo Forslind and Magnus Lindberg 27. Itch: Basic Mechanisms and Therapy, edited Gil Yosipovitch, Malcolm W. Greaves, Alan B. Fleischer, and Francis McGlone 28. Photoaging, edited by Darrell S. Rigel, Robert A. Weiss, Henry W. Lim, and Jeffrey S. Dover 29. Vitiligo: Problems and Solutions, edited by Torello Lotti and Jana Hercogova 30. Photodamaged Skin, edited by David J. Goldberg 31. Ambulatory Phlebectomy, Second Edition, Stefano Ricci, Mihael Georgiev, and Mitchel P. Goldman 32. Cutaneous Lymphomas, edited by Gunter Burg and Werner Kempf 33. Principles and Practices in Cutaneous Laser Surgery, edited by Arielle Kauvar and George Hruza 34. Wound Healing, edited by Anna Falabella and Robert Kirsner 35. Phototherapy and Photochemotherapy for Skin Disease, Third Edition, Warwick L. Morison

Ambulatory Phlebectomy
Second Edition

Stefano Ricci
Ambulatorio Flebologico Rome, Italy

Mihael Georgiev
University of Ferrara, Italy

Mitchel P. Goldman
University of California, San Diego and La Jolla SpaMD, California, U.S.A.

Published in 2005 by Taylor & Francis Group 6000 Broken Sound Parkway NW, Suite 300 Boca Raton, FL 33487-2742 © 2005 by Taylor & Francis Group, LLC No claim to original U.S. Government works Printed in the United States of America on acid-free paper 10 9 8 7 6 5 4 3 2 1 International Standard Book Number-10: 0-8247-5909-5 (Hardcover) International Standard Book Number-13: 978-0-8247-5909-4 (Hardcover) This book contains information obtained from authentic and highly regarded sources. Reprinted material is quoted with permission, and sources are indicated. A wide variety of references are listed. Reasonable efforts have been made to publish reliable data and information, but the author and the publisher cannot assume responsibility for the validity of all materials or for the consequences of their use. No part of this book may be reprinted, reproduced, transmitted, or utilized in any form by any electronic, mechanical, or other means, now known or hereafter invented, including photocopying, microfilming, and recording, or in any information storage or retrieval system, without written permission from the publishers. For permission to photocopy or use material electronically from this work, please access www.copyright.com (http://www.copyright.com/) or contact the Copyright Clearance Center, Inc. (CCC) 222 Rosewood Drive, Danvers, MA 01923, 978-750-8400. CCC is a not-for-profit organization that provides licenses and registration for a variety of users. For organizations that have been granted a photocopy license by the CCC, a separate system of payment has been arranged. Trademark Notice: Product or corporate names may be trademarks or registered trademarks, and are used only for identification and explanation without intent to infringe.

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. . . . . . Ramelet xv xix xxiii Acknowledgments . . . . Definition and Indications . . . . . . . . . . . . . . . . . . . . . . . 20 Combined Collateral and Saphenous Varicosities . . . . . . . . . . . . . . . Robert Muller Preface . . . . . . . Robert Muller . . xxv Introduction to the Second Edition . . . . . . . . Interview of Dr. . . . . . . . . . . . . . . . . . A. . . . . . . . . . . . . . . . . . . 22 Perforating Veins . . . . . . . . . . . . . . . . . . . . . . 17 Collateral Veins and Varicosities . 11 Great Saphenous Vein . . . . . . 3 Anatomical Bases of Ambulatory Phlebectomy . . . . . 5 General Organization of the Superficial Venous System . . . . . . . . . . . . . . A. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 Indications . . . . . 5 Great Saphenous Vein Compartment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xxxiii Robert Muller Who Discovered Saphenous Vein Incontinence? . . . . . . . . . 20 Autonomous Collateral Varicosities . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11 Small Saphenous Vein . . . . . . . . . . . . . . . . . . . 24 vii xli 2. . xxix Stefano Ricci History of Ambulatory Phlebectomy . . . . . . Stefano Ricci Part I: General Considerations 1.Contents Foreword . . . . . . . . . . . .

. . . . . . . . . 61 Groin Examination . 29 Posterior Thigh . . . . . . 57 Medical History . . . . . . . 58 Doppler Orthostatic Reflux Test . . . . . . . . . . . 71 References . . . . . 32 Anterior and Lateral Knee . . . . 37 Lateral Leg . . . . . . . 30 Anterior Thigh . 43 Surgical Anatomy of Venous Leg Telangiectasia . 57 Clinical Examination . . . . . . . . . 53 Segmental GSV Involvement . . . . . . . . . . Examination of the Patient with Varicose Veins . 37 Foot . . 36 Anterior Leg . . . . 27 Medial Thigh . . 57 Physical Examination . . . . . . . . . 64 Interpretation and Pitfalls of Doppler Reflux Testing . . . . . . . 53 Anatomical Arrangement of the GSV and Related Varicose Patterns . . . 32 Medial Knee . . . . 37 Posterior Leg . . . . . . . 54 Patterns of ASV Involvement . . . . . . . 45 Appendix A: Atlas of Varicose Vein Patterns . 54 Patterns of SSV Involvement . 56 Patterns Involving Both GSV and SSV . . .viii Contents Topographic Description . . . . 42 Nerves and Lymphatics . 27 Upper Thigh . . . 40 Deep Veins of the Lower Limb . . 47 Primary Varicose Veins Circuits . . . . 63 Popliteal Examination . 47 Patterns of Saphenous Vein Involvement in Varicose Vein Disease . 44 References . . 69 Evaluation of the Leg Pump Function . . . . . . . . . . . 32 Knee . 56 3. . 73 . . . . . . . . . 61 Method . . . . . . . . . . . . . . . . . . 33 Popliteal Area . . 64 Additional Investigation . 30 Lateral Thigh . . . . . 53 Patterns of GSV Involvement . . . . . . . . . . 67 Color-Duplex Ultrasound Examination . 34 Medial Leg .

. . . . 78 Patient Consent . . . . . . 113 Graefe Iris Forceps . . . 121 Progression of Phlebectomy . . . . 75 Symptomatic Varicose Veins (CEAP 3 – 6) . . . . . 113 Instruments . . . . . . . . . . . . . . . . . . . . . . . . 102 91 97 References . . . . . . . . . . . . 114 Toothed Clamps . 107 Phlebectomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Staging of Surgery . 109 Incision . . . 98 Traditional Technique . . 121 Dissection . 121 Traction . . .Contents ix 4. . . . . . . . 109 Vein Retrieval. . . . . . . . 113 Hooks . 99 Preparations and Dosage . . . . . 104 8. . 133 . 79 References . . . . . . . . . . . . . . . . . . . . . . . . 130 End Division . 116 Technique . . . . . . . Position of Patient During Surgery . . . . Pre-Operative Marking . . . . . . 99 Technique . . . Preparations. . . 79 5. . . . . 76 75 Patient’s General Health Conditions . . . . . . . . . . . . Dosage. . . . . . . . . 133 Side Branch Division . . . . . . . . . Hooking. . 116 Vein Avulsion . . . . . . . . 125 Vein Division . . . . . . . . . . . 7. . . . . . . . . . . . . . 78 Infectious Disease . . . . Selection of Patients for Office Varicose Vein Surgery . . . . . 9. . . . . . 102 Local Infiltration Anesthesia . . . . . . . Anesthesia . . . . . . . . 98 Preparations and Dosage . . . . . 130 PV Division . . . . . . . . . 75 Asymptomatic Varicose Veins (CEAP 1– 2) . . . . . . . 76 Modifying the Procedure . . . . 102 Pre-Operative Anesthesia . 98 Tumescent Technique . . . 81 Part II: Technique of Phlebectomy 6. . . . . . . . . . . . . and Exteriorization . . . . . . . and Techniques . . Varicose Vein and Leg Conditions .

145 Bandaging . . 138 Great Saphenous Vein . . . 159 Staging . . . . . . 136 Shin . . 140 Lipodermatosclerosis . . . . . . . . . . . 139 Small Saphenous Vein . . . . . . . . 144 Reference . . . . . . . . . 162 Position of Patient . 157 13. 135 Foot . 135 Vein Fragility . . . . . . . . . . . 163 . . . . . . .x Contents Technical Difficulties . . . . . . . . . . 146 Adhesive Bandage . . Small Saphenous Vein Phlebectomy . . 144 10. . . . . 135 Varicose Clusters . . 162 Technique . . 162 Incisions . 153 Post-Operative Management . . . . . Post-Operative Medication and Bandaging . . 140 Varicose Veins Recurrent After Traditional Surgery . . . . . . . . . . . . . Patient Discharge . . . 152 Post-Operative Management and Follow-Up . . 141 Venous Leg Telangiectasia . . . . . . . . . . . . . . . . . 162 Pre-Operative Marking . . . . . . . . . . . . Follow-Up . 138 Knee . 153 Further Compression . . . . . 138 Thigh . . . . 156 Patients in Need of Special Care . . . . 140 Superficial Thrombophlebitis . . . 159 Diagnostic Work-Up . . . . . . . . . . . . 143 Hand . . . . . . . 155 12. . 140 Thin Skin . . . . . . . . 153 Between Phlebectomy Sessions . . . . . . . . . . . . 146 Removable Bandages . . . 155 Type and Duration of Compression . . . . . . . . . . 151 Reference . 145 Medication . . . . . . 139 Varicose Veins Recurrent After Sclerotherapy . 153 After the Last Operation . . 142 Periorbital Veins . 147 11. . . . 162 Starting the Phlebectomy . 162 Anesthesia . . . . . . . . . . . . . . . .

. . . . . . . . . . . . . . . . . 171 xi Post-Operative Compression . . . . 169 Atypical Popliteal Terminations of the SSV . 168 Proximal Progression . . . . Post-Operative Compression . . . . . 198 GSV Stripping . . 187 Saphenofemoral Junction Incompetence . . 202 . . . . . . 184 Errors of Bandaging . . 189 Preservation of an Incompetent GSV/Saphenopopliteal Junction . . . 179 Degree of Compression . 187 Indications . . . . . . . . . . . Division. . . . 189 Alternative Treatments for GSV Incompetence . 173 References . . . . . 168 Saphenopopliteal Division and Ligation . . 188 GSV Dilatation . . . . . . . . . . . 177 Protective Skin Underwrapping . . 169 Higher Popliteal Incision . . 194 Instruments . 184 Insufficient Compression . . . . . . 182 Testing the Bandage . 183 Removable Bandage . . . . . . . . . . . . . . . . 185 References . . . 185 15. 178 Extension of the Bandage . . 177 Local Compression Pads . 184 Compression Stockings . . . . . . 197 Technique . . . . . . . . . . . . .Contents Distal Progression . 191 Programing the Operation . . . . 178 Adhesive Bandage . . 178 Materials . . . . 194 Patient Position and Skin Preparation . . . . . . 183 Difficult Areas . . . and Groin to Knee Stripping of the GSV: An Office Procedure . . . . . . . . 191 Pre-Operative Marking . . . High Ligation. 177 Protective Pads . . 174 Part III: Selected Phlebological Techniques 14. . . . . . 192 Anesthesia . . . . . 184 Excessive Compression . 190 Choice of Stripping Technique . . . 179 Technique of Application . . 198 Ligation and Division of the SFJ . . . . . . . . . . . . . . . 171 Advantages of SSV Phlebectomy . . . . 194 Surgical Anatomy of the SFJ . . . . . .

. . . . . . . . . . . . . . . . . 238 Setting Up a Varicose Vein Surgery Practice . . . . . . . . . . . . . . . 241 Alternative Applications of Phlebectomy . . . . 228 17. . . . . . 217 Local Complications . 241 High Ligation and Division of the Greater Saphenous Vein . . Complications and Untoward Sequela of Ambulatory Phlebectomy . . . 207 Complications . . . 223 Pulmonary Embolism . . . . . 208 References . . . 217 Toxic Reactions . . 228 References . . . 224 Telangiectatic Matting . . . . . . 226 Blister Formation . . . . . . . . . . . . . . . . . . . . . 218 Hematoma . . 209 Part IV: Conclusions 16. . . . . . . . . . 222 Lymphorrhea . . . 225 Complications of Compression Bandage . . . . . . 219 Wound Infection . . . . . 241 Phlebectomy . . . . . 223 Vein Thrombosis . 223 Persisting Edema . . . . 241 Who Should Perform Office Varicose Vein Surgery? . . 235 References . . . . . . . . 215 Complications of Anesthesia . . 223 Nerve Damage . . 225 Hypertrophic and Pigmented Scars . . . 228 Contact Dermatitis . . . 218 Hemorrhage at Home . . . . . . . 231 18. . . . . . . Advantages of Ambulatory Phlebectomy and Office Varicose Vein Surgery . . . . . . 234 . . Psychological Aspects Reference . . 242 19. . . . . 215 Allergic Reactions . . . . 222 Lymphocele . . . . . . . . . 226 Excessive Compression . 225 Rare Complications . . 218 Late Reactions . . . . . . . . . . . . 220 Lymphatic Disruption . . . . . . . . . . . . . . . . . . . . . . . . . 218 Complications of Phlebectomy . . . . . . . . .xii Contents Post-Operative Bandage . . . . . . . . . . . . . . . .

. . . 245 Bureaucratic and Accreditation Requirements . . 248 Materials for Bandaging . 244 Emergency Measures . 243 Anesthesia . 250 Marking Solution . . . . . . . . . . . 261 Introduction . 250 Emergency Equipment . . . . 244 Operator’s Experience . . 247 Surgical Instruments . . . . . . . . . 251 Part V: Advanced Techniques 20. 250 Medication Material . . . . . Autologous Vein Transplantation for Correction of Dermal Atrophic Changes . . 248 Materials for Anesthesia . . . 255 Technique . . . . . 247 Specific Instruments for Phlebectomy (Single Set) . . . . . . . . 259 Treatment of the Great Saphenous Vein with Endoluminal Laser or Radiofrequency Closure Mitchel P. . . . . . . . . . . . . . . . . 266 Animal Studies . 245 Equipment and Materials . . 248 Syringes . 247 Room Equipment . . 244 Post-Operative Management . . . . . . . Goldman and Robert A. . . . . . . . . . . Weiss History of Vein Obliteration . . . . . . . . . 245 Operating Room . 250 Material for Local Anesthesia (MPG) . . . . . . 244 Type of Surgical Procedure . . . . . . . 263 RF Technology . . . . . . . . . 249 Other Materials . 256 References . 250 Examination Equipment . . . . 249 Compression Bandages . . . .Contents xiii Safety in Office Surgery . . . . 250 References . . . . 249 Additional Localized Pressure . . . . . 249 Compression Stockings . . . . 268 Histology . 242 Pre-Operative Management . . . . . . . . . . 268 21. . . 245 The Free-Standing Surgical Office . 251 Bibliography . 248 Needles . . . . . . . . . . . 261 . . . .

. . . . . . . . . . . . . . Varicose Vein Surgery Suggestions Following Surgery . . . . . . . . . . . . . . . . . . . 313 . . . 323 3. . . . . . . . . . . . . . . . . . . . . . . 277 Closure of the GSV with Endoluminal Laser Ablation . . . 274 Technique for Closure with AP (Video CD) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Index . . 277 Follow-Up Care . . . . . . . . . . . . . . . . . . . 305 . . . . . . . . . 287 References . . . 2. . . . . . . . . . . . . 271 Side-Effects . . . . . . . 6. . . . . . . . Explanation Card for the Patient . . 7. . . . . . . . . 270 RF Closure with AP . . . . . . . . . . . 274 Technique of Closure Without Phlebectomy (Video CD) . . . . . . . . . . . 297 . . . . . . . . . . Instructions for Patients Affected by Chronic Venous Insufficiency . . . . . . . . . . . . . . . 309 . . . . Consent for Ambulatory Phlebectomy. . . . . . . . . . . . . Endovenous Closure with Laser or Radiofrequency. . 325 . . . . . . . . . . . . . . . . . . . . . . . . . . . 283 22. . Operative Report for Endoluminal Laser Closure . Ambulatory Phlebectomy of Recurrent Varicose Veins . Operative Report for Endoluminal Radiofrequency Closure . . . . . 301 . . . . . . . . . . . . 317 . . 283 References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 311 . . . . . . . . . . . . . . . . . . . . . Administration of Anesthetics. 270 RF Closure Without AP . . . . . . . Post-Operative Explanation Card for the Patient . . . . . . . . . . . . . . . 9. . . . . . . . . . . . 282 Summary . . Duplex Evaluation Forms . . 307 . 321 . 10. . . . . . . . . . 278 Technique for Closure Using Endoluminal Laser (Video CD) . . . . . . . . .xiv Contents Clinical Experience . . 5. . . 8. . . . . . . . . Ambulatory Phlebectomy Operative Report . . . . . . . . . . . . . . . . and the Rendering of Other Medical Services . . . . . . . . 4. 293 Part VI: Appendices 1. . . . . . . . . Nursing Instructions . .

wrong theories have inspired therapeutic acts that were salutary or disastrous. Do believe only on what you can verify personally. as much as we go back in history. Those who try to abolish them are heretics. paradoxically. However. Dogmas provide security. Doubt must shake-up every doctrine. fighting against a metaphysical anguish. the same ideas along the centuries were copied. are adventurers with the need to advance knowledge. changes the “Future” into the “Past.” the dream into a victorious reality or into a defeat. that become illusory. Hippocrates was a great revolutionary. repeated. inspired the bleeding which was salutary for pulmonary edema due to heart failure but disastrous in other patients. The scholastic. This is why. It is the “acquired knowledge. symbolically. the Asclepiades medical treatises that were the dogmas dominating all medical schools of that time: everything must be rediscussed.” fully submitted to different interpretations. and recalled. opposes with doubts the comfort of stability of the so-called acquired verities. fixed the knowledge. Men are extraordinarily lazy. This is the base of science. he refused traditional knowledge and burned. Even if accepted in a general consensus it needs constant revision. It is Hippocrates’ glorious merit to tear up medicine from religion. causing exhaustion or even death. The total immobilization of operated patients helped xv .Foreword Robert Muller The “Present. In places far away from each other in time and space. These same men. their spirit.” inexorably. This reality should not be mistaken with truth. Great Spirit’s enemy. followed by ´ Hippocrates and Ambroise Pare. destiny’s irony stated that Hippocratic writings would be sacred and they became dogmas themselves and a cause of stagnation. “Humoral” theory. there is always a conflict between religion and science. The history of medicine shows us a peculiar aspect of its evolution. From the beginning of his teachings. So.

In the 6th and 7th centuries. cited by Plutarch in the “Vitae Parallelae. lasting for 14 centuries. lazy river. once. and wisdom. These absolute decrees had no sense and were based only on incompetence and ignorance. AP ended by a compression that permitted immediate walking. but predisposed them to deep veins thrombosis and pulmonary embolism. In opposition to the doctrine. in 107 BC. Ambulatory phlebectomy (AP) of the 2nd century BC was less dangerous than that of the 8th century ACE. as the suppression . It is interesting to recall that in those times. Ideas evolved along a long. like in Marius. This was absurd and harmful for the patients. At present. the famous surgeons of Constantinople. I remember that in 1950 my teacher. honesty. Immobility caused blood circulation stasis and that same thrombosis that it ought to prevent. to refrain from giving advice regarding fields that are closely related. But as the humoral theory was strongly believed. It was thought that blood impurities caused nearly all the diseases. favored the total immobilization of varicose operated patients. needed centuries. AP was performed with success long before Christ. No idea of blood circulation was present. chief of the dermatologic department in Berne (Switzerland). if he ´ ignores them. The circulation was completely ignored and this nonsense became dogma. as he was ashamed to exhibit his ugly and ridiculous varicose veins. A false or wrong theory is rapidly rejected. a “reasonable” amount of impure blood was evacuated (which was absurd).xvi Foreword in recovering body and mind. particularly phlebology. we must compare it with the other contemporary doctrines—it is the horizontal comparison—or with the development of historic times—it is the vertical comparison. Horizontal comparison is done nearly in real time. it was believed that veins carried blood and arteries air. At Hippocrates’ times it was slow. Let us take the example of Ambroise Pare who is cited for his modesty. The same great ´ Ambroise Pare shared this knowledge in the 16th century. History proceeds at an irregular speed. the uncle of Julius Caesar. He preferred to show the more virile and honorable scars. Professor Robert. Aetius of Amida and Paul of Egina. History is filled with such notions damaging patients and harming medicine’s progression. It is humanly difficult or even impossible for a chief or a “Mandarin” very qualified in a particular field. the practice showed that an exaggerated hemorrhage harmed the patient. before the cauterization. When studying a doctrine. In spite of the lack of pathophysiologic data. mass media takes only a few hours to extend worldwide those experiences that. Two centuries after Marius’ operation. he did not give up pontificating that the cause of varicose veins was the “melancholic blood”: “Pregnant women often develop varicose veins. Time flew slowly. following the diffusion of knowledge. used to state preemptorily that we should not touch the varicose veins of men over 60 or women over 40 and of subjects having experienced a deep veins thrombosis.” Marius was concerned about frivolity. the famous Aulus Cornelius Celsus first described a true AP.

I had the luck of meeting extremely good pupils. as those varicose veins are untreatable. and even perversions.Foreword xvii of the menstrual blood evacuation fattens this blood. It is better not to deal with. it was improved vastly. . Some of them enhanced the diffusion of AP so that now all over the world patients can benefit from a simple surgical treatment of their varicose veins.” I dare think about the solidity of both the doctrine and the execution of the AP technique. deviations. After 1957. but the main principles had to resist strong oppositions. AP went through the trial of vertical comparison (50 contemporary years worth several past centuries) and horizontal comparison (worldwide extension by the media). In opposition to winds and tides.

.

Preface

During the last century, great saphenous vein (GSV) ligation and stripping (L&S) has been (and still is) the most common operation for varicose veins to the point of becoming synonymous with varicose vein surgery. This has occurred despite evidence that the “prefabricated” stripping operation, based on textbook anatomy, poorly matched the clinical variability of varicose vein disease. In fact, L&S is appropriate and successful in some cases only, because in many others it leaves the collateral varicose veins untreated. There are cases where it is not even indicated, because 20 –30% of the limbs with varicose veins may not have an incompetent GSV (1 –3). Though possible on an outpatient basis under local anesthesia, L&S of the GSV is almost always performed under general or regional anesthesia. The inadequacy of the stripping operation noted in the 1940 –1950s stimulated the development of sclerotherapy by Sigg in Switzerland (4), Tournay in France (5), Fegan in Ireland (6), and Orbach in the United States (7). Though some schools propose sclerotherapy as an alternative to the stripping operation, the optimal use of sclerotherapy is to complement the treatment of the collateral varicose veins not removed by the stripping operation. Sclerotherapy is a versatile office procedure. Any varicose vein, including telangiectasia, can theoretically be injected. In expert hands, treatment is safe and results excellent. However, long-term results of sclerotherapy are conditioned by a variable rate of recanalization in treated veins (8 – 15). In the mid-1950s, Robert Muller, a Swiss dermatologist, developed a technique for varicose vein avulsion through multiple stab incisions and called it “la phlebectomie ambulatoire.” Dr. Muller designed his own instruments and reported that his procedure was appropriate for treating all varicose veins with the exception of an incompetent saphenofemoral junction (16 –20). This technique permits removal of any varicose vein—except telangiectasia and the proximal portion of the GSV with the saphenofemoral junction—in an office setting
xix

xx

Preface

under local anesthesia. The Muller technique is referred to in English literature as “stab avulsion,” “office phlebectomy,” and “ambulatory stab avulsion phlebectomy.” It is only within the last decade that physicians recognized that it represents a major improvement in varicose vein surgery. This technique achieves the long-term results of surgical treatment with less inconvenience, lower cost, and better cosmesis as compared to traditional surgical treatment or combination surgery/sclerotherapy. However, over 30 years after its introduction and despite recent interest, ambulatory phlebectomy is still discussed more than practiced. This may be due to the lack of a textbook that describes the technique in detail. Our goal is to fill this gap. We believe that, especially for a manual technique, “details make the master”; we learned this from our teachers and from the experience of the colleagues who visit our practice. Although the description of ambulatory phlebectomy techniques is essential, it is more important to determine the proper method of treatment for each type of varicose vein. This statement is controversial because the technique can be employed in two different—and in a sense, opposite—ways. The first is to employ it complementary to traditional surgery for the removal of the collateral varicose veins left after the stripping operation. The second is for removal of all varicose veins, thus limiting traditional surgery to only high ligation and division of the GSV. Although the objectives of varicose vein surgery can be achieved by both approaches, we propose the latter choice, which is described in this text. With ambulatory phlebectomy one cannot treat all varicose conditions; venous telangiectasia are best treated with sclerotherapy, and GSV incompetence with high ligation, division; and endoluminal laser or radio frequency ablation. To provide a complete practical guide for office-based surgical treatment of varicose veins, our technique for L&S of the GSV is also described. This book is not a textbook of phlebology. The physiology, pathology, investigation, and diagnosis of the venous disorders of the lower limb, as well as the available wide range of nonsurgical, surgical, and sclerotherapy procedures are not discussed here. Those who need or wish to improve their knowledge on these and other topics should turn to other sources, some of which are listed below. The treatment of venous disease in the USA has been undergoing a rapid evolution during the past decade. This was primarily stimulated by the popularization of sclerotherapy for the treatment of varicose and telangiectatic leg veins. However, it soon became apparent that many veins, especially those larger than 6 –8 mm in diameter and those with reflux from various junctions were better treated with surgical techniques. This led to an improvement and enhanced cosmesis of the traditional L&S procedures. In addition, the American physician has once again borrowed concepts developed by our European colleagues to modify the stripping part of the surgical procedure into one of stab avulsion or ambulatory phlebectomy. It is therefore fitting that a textbook on this technique be made available for the English-speaking physician.

Preface

xxi

We hope this text is useful for those who wish to include ambulatory phlebectomy in their phlebological practice. The techniques described here are personal. However, we have attempted to separate the essential points from the many personal details, which in our hands are useful, but not mandatory. We tried to create a text that might trigger an “imaginary movie” in the reader’s mind; it is the reader who will judge how we succeeded. Stefano Ricci Mihael Georgiev Mitchel P. Goldman

REFERENCES
1. Schwartz SI. Yearbook of Surgery. Chicago: Yearbook Medical Publishers, 1979 2. Goren G, Yellin AE. Primary varicose veins: topographic and hemodynamic correlations, J Cardiovasc Surg 1990; 31:672 – 677. 3. Hanrahan LM, Kechejian GJ, Cordts PR et al. Patterns of venous insufficiency in patients with varicose veins. Arch Surg 1991; 126:687 – 691. 4. Sigg K. The treatment of varicosities and accompanying complications. Angiology 1952; 3:355. 5. Tournay R et al. La Sclerose des Varices. 4th ed. Paris: Expansion Scientifique Francaise, 1985. 6. Fegan WG. Continuous compression technique of injecting varicose veins. Lancet 1963; 2:109. 7. Orbach EJ. A new approach to the sclerotherapy of varicose veins. Angiology 1950; 1:302. 8. Chant ADB, Jones HO, Weddell JM. Varicose veins: a comparison of surgery and injection/compression sclerotherapy. Lancet 1972; 2:118 – 1191. 9. Beresford SAA, Chant ADB, Jones HO, Piachaud D, Weddell JM. Varicose veins: a comparison of surgery and injection/sclerotherapy. Five-year follow-up. Lancet 1978, 1:921– 924. 10. Doran FSA, White M. A clinical trial designed to discover if the primary treatment of varicose veins should be Fegan’s method or by an operation. Br J Surg 1975; 62:72– 76. 11. Jakobsen B. The value of different forms of treatment for varicose veins. Br J Surg 1979; 66:182– 184. 12. Hobbs JT. Surgery and sclerotherapy in the treatment of varicose veins. Arch Surg 1974; 109:793 –796. 13. Hobbs JT. Surgery of sclerotherapy for varicose veins; 10-year results of a random study. In: Tesi M, Dormandy J, eds. Superficial and Deep Venous Disease of the Lower Limbs. Turin, 1984, Edizione Minerva Medica, pp. 243 – 246. 14. Einarsson E. Compression sclerotherapy of varicose veins. In: Eklof B, Gjores JE, Thulesius O, Bergqvist D, eds. Controversies in the Management of Venous Disorders. London: Butterworth, 1989:203 – 211. 15. Neglen P. Treatment of varicosities of saphenous origin: comparison of ligation, selective excision, and sclerotherapy. In: Bergan JJ, Goldman MP, eds. Varicose

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Preface Veins and Telangiectasias: Diagnosis and Treatment. St. Louis: Medical, Publishing, Inc., 1993:148 – 165. Gilliet F. Die ambulante Phlebektomie. Schweiz Rundsch Med (Praxis) 1980; 69:1398– 1404. Muller R. Die ambulante Phlebektomie netzformiger in der Angiologie: Die Kniekehle. Bern, Switzerland: Hans Huber, 1975:116 – 118. Muller R. La phlebectomie ambulatoire. Phlebol 1978; 31:273– 278. Muller R. La phlebectomie ambulatoire. Helv Chir Acta 1987; 54:555 –558. Muller R. Traitement des varices par la phlebectomie ambulatoire. Phlebol 1966; 19:277.

16. 17. 18. 19. 20.

BIBLIOGRAPHY
Bergan JJ and Kistner RL. Atlas of Venous Surgery. Philadelphia: W. B. Saunders Company, 1992. Bergan JJ, Goldman MP, Weiss RA. Varicose Veins and Telangiectasias: Diagnosis and Treatment. 2nd ed. St. Louis: Quality Medical Publishing, Inc., 1998. Browse NL, Burnand KG, Lea Thomas M. Diseases of the Veins: Pathology, Diagnosis and Treatment. London: Edward Arnold, 1988. Goldman MP, Bergan JJ. Sclerotherapy: Treatment of Varicose and Telangiectatic Leg Veins. 3rd ed. St. Louis: Mosby, 2001. Nicholaides AN, Sumner DS. Investigations of Patients with Deep Venous Thrombosis and Chronic Venous Insufficiency. London: Med-Orion Publishing Company, 1991. Tibbs DJ. Varicose Veins and Related Disorders. London: Butterworth Heinemann, 1992.

Interview of Dr. Robert Muller
A. A. Ramelet

ˆ Dr. Robert Muller was born in Neuchatel (Switzerland) on September 2, 1919. ˆ After his medical studies in the Universities of Neuchatel, Bern, and Lausanne, he served as a resident in both psychiatry and gynecology in Lausanne, followed ˆ by surgery and internal medicine in Neuchatel. He finally settled into dermatology, obtaining his title of specialist in dermatology in Bern as he was working in the Department of Dermatology (Professor Robert) as a senior resident. His thesis was dedicated to the rate of healing 20 years after syphilitic treatment with neosalvarsan and bismuth (the magna therapia sterilisans as described by Ehrlich). He discovered that all the patients who could be controlled were healthy and Wasserman negative. ˆ He settled down in private practice in Neuchatel in 1951, practicing both dermatology and phlebology. Teaching these fields in the local nursing school, he developed ambulatory phlebectomy between 1951 and 1955, creating a phlebological team in 1960, including a surgeon, a radiologist, and himself as a “dermato-phlebologist.” He treated innumerable patients, all of whom were convinced of the superiority of phlebectomy. These qualities contributed to Dr. Muller’s growing international fame. Dr. Muller worked hard to introduce his technique to the medical community. He suffered from lack of understanding of the technique coupled with great skepticism and ridicule. He courageously ignored this scoffing while steadily convincing more and more disciples. Physicians were received very generously ˆ in Neuchatel or Dr. Muller would instruct increasingly successful conferences throughout France, Italy, Netherland, Denmark, Austria, Yugoslavia, Iran, Brazil, and Argentina. He also produced films and videos. He retired in 1994, as a 75-year-old active phlebologist, honored by many national and international scientific societies. Dr. Muller had a rich personal life as well. He married his wife Simone in 1944, just before the end of his studies. Simone was a French national and her
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Interview of Dr. Robert Muller

brother was active in the Resistance. As such, she was in danger and marriage was hastily arranged to avoid her returning back to France during the war. They had four children; three of them are presently alive. As a result, Dr. Muller is an enthusiastic grandfather of nine granddaughters and grandsons. Dr. Muller served as a physician to the Swiss army and had a reputation as a fine sportsman. Unfortunately, he had to renounce his sporting activities because of a damaged knee. Dr. Muller then developed a passion for the garden and is still very busy attending 300 roses. Dr. Muller has always been fascinated with the history of medicine. As a humanist he discovered that ambulatory phlebectomy was already performed during Roman times, in particular by Celsus. He relinquished giving his name to his technique in deference to the ancients. Some other physicians, who pretend to have invented phlebectomy, do not demonstrate this same humility. ˆ I shall never forget Dr. Muller’s hospitality in Neuchatel. I visited him in 1977 with the task of developing ambulatory phlebectomy at the Department of Dermatology, University of Lausanne. In Dr. Muller’s office, each patient was first welcomed by Mrs. Muller with her smiling reassuring face and quiet authority. She had a strong effect on the patient who would enter the operating room totally in trust due to her reassuring manner. As I observed, Dr. Muller operated in a quite simple, sterile, and highly economical outpatient setting. An excellent teacher, he demonstrated all his tricks with humor and precision, operating very quickly and effectively. He spent still more time inviting me to a delicious fish meal with a fine local wine while generously providing further explanation and instructions. In much the same way, many disciples benefited from the remarkable hospitality of Dr. and Mrs. Muller. Each of us will never forget their reception, their kindness and respect to each patient. The Mullers now live happily in their house ˆ in Neuchatel, cultivating their garden and roses, surrounded by their family and friends. With great gratitude, let all of us proclaim our respect and affection.

Acknowledgments

Dr: Robert Muller

Dr: Lidio Ricci

At the Congress of Phlebology in Strasbourg (France), 1970, my father, Dr. Lidio Ricci, a sclerotherapist with surgical experience, heard a certain Dr. Muller presenting a paper about a strange method of ambulatory avulsion of varicose veins through stab incisions. During the presentation most of the audience laughed at the speaker, and some protested, especially for the “unorthodox” way of performing the operation: no surgical gloves, the instruments held in his mouth (!). Back home my father told us: “I saw a guy who has for us the thing we need. He is either crazy or a genius!” Without losing time, Lidio Ricci went to visit Dr. Muller’s practice in ˆ Neuchatel (Switzerland), took notes of everything, and, after preparing himself for a start with the new method, invited Muller to his practice in Rome to give him a hand for the treatment of the first few cases. This happened on May 1, 1971, and that was the beginning of our experience in ambulatory phlebectomy.
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England. and described worldwide. It is. Switzerland. Italy. With this book we are trying exactly the . dogmas. It is my father’s merit to have appreciated immediately and early the importance and potential of Muller’s technique. “It turned to be a complete disaster. until 1986 under the direction of Lidio Ricci. did not change the original idea of Muller that “one should cure safely and with good cosmetic results the legs of all varicose patients. division. he was nominated Honorary Member of the Swiss Society of Phlebology.xxvi Acknowledgments At about the same time. While all this demonstrates that the importance of ambulatory phlebectomy is already universally recognized. more than 260 physicians from France.” It is only recently that Muller was able to see the fruit of his “craziness. President of the French Society of Phlebology. Venezuela. Israel. In 1966. my brother. because we used to think that such a simple and efficacious method would be immediately copied and practiced by those who would come in touch with it.” Despite this official hostility. and economic technique. safe. Michele. During all these years. without even discussing the method. especially by the academic world. and has been object of several publications and at least two editorials. the technique was first ignored and later adversed. Raymond Tournay. which.” In January 1992.” and many of these have in turn taught the technique to others: success greatly deserved for this extremely modest person. invited Muller to present his technique at the Society’s Meeting in Paris. often imitated. It is my personal opinion that only a physician without a formal surgical training (Muller is a dermatologist) could invent such a practical. presented under different names. His technique is already recognized. of course. At this point. and myths a surgeon usually has. introduced in our practice the office high ligation. To our great surprise. are the basis of this book. These 20 years of experience. Germany. it took almost 20 years for this to happen. however. Since then. “Surgeons and phlebologists submerged me in an ocean of criticism and sarcasm. because of the absence of all traditions. we were able to treat surgically any varicose case in a completely office setting. thus allowing us to practice it and gain experience 20 years ahead of the beginning of its large diffusion. we added to our experience many details and some original personal solutions too. simple. USA. cited. During the first years of our experience our attitude was rather egoistic. and even “improved” or reinvented by the use of “personal” techniques and instruments. and groin-to-knee stripping of the greater saphenous vein (GSV) under local anesthesia according to the technique he learned from Crosetti (a surgeon who worked at that time with Muller). who never refused—and still does not—to listen to and counsel the colleagues who contact him. efficacious. and other countries ˆ have visited what could be called the “Neuchatel school. But to imitate or to try to reinvent a product simply means to admit its importance and superiority.” Muller himself recalls. colleagues proved rather conservative and reluctant to apply the new method. But this ‘accident’ only stimulated the further development of the method.

Acknowledgments xxvii opposite: to share our experience in such detail. to have the sensation of a physical presence in our practice. we will have at least in part paid a debt to R. as to permit the reader. who would have seen with satisfaction the development of the work he started. Stefano Ricci . and to Lidio Ricci. If we succeed in this. if possible. Muller. whom we owe so much.

.

Its purpose was to educate phlebologists through the American edition (1995). but: . This teaching has a medico-legal implication. but a procedure well founded in the tenets of cost-effective. That is to say. may add new information to the previous edition. The technique has expanded to other surgical procedures and now is used not only like an ambulatory method. In fact. safe surgery. . many aspects remain unchanged. xxix . The fundamental rules can be left out. nearly every physician involved in the treatment of varicose veins (phlebologist) knows something about ambulatory phlebectomy (AP) and its general indications. The concern for surgery done with limited or no hospitalization. We believe that many patients now know that varicose veins may be removed without visible scars and the need for hospitalization. though phlebectomy did not change. many honors. followed by a Portuguese translation (1998) and an Italian one (1999). the technique per se is the same and cannot be reinvented. and for economies in medical administration have enhanced Muller’s procedure. This book’s first edition represented the first textbook devoted solely to this subject. A new edition of Ambulatory Phlebectomy may be viewed as a simple reprint or. in part by providing the basis for AP not to be considered as a strange surgical procedure.Introduction to the Second Edition At present. at the opposite extreme. from 1995 to today. Teaching the latest advances in surgical treatments of varicose veins is important and advantageous for both doctors and patients. The fact that many Phlebologist’s have “reinvented” this procedure after Muller (sometimes giving their name to it) is the true confirmation of its validity: many imitators. the world around phlebectomy has. In our case we are half-way.

Asia. Surgeons are generally more concerned about the saphenous stem than about collaterals. may be treated subsequently by sclerotherapy. New treatments have been suggested to be associated to AP. patient mobilization. in part. better would be a supplementary incision than skin damage. and the USA dermatologists are more interested in AP. Collateral varices. Spain. The Netherlands. which are instead fundamental to achieve a good result. In fact Muller’s technique is the ideal surgical method as it is easily reproducible. Prolonged searching for a varicose vein in a difficult site. causes visible scars. Switzerland. an easy technique may be badly performed. and use of local anesthesia allows one to compare it to a common dentistry procedure. where ambulatory means “in an ambulatory setting. absence of post-operative complications.xxx Introduction to the Second Edition . simplicity. . Limiting attention to the saphenous stem causes poor attention to varicose veins (always due to collateral veins) that should be appropriately completely removed to avoid a subsequent “reactivation” of those tracts left behind. . although prompt. . Its employment in association with a traditional saphenectomy procedure is useful and appropriate. and England. . but will be the first to reappear when a retrograde flow develops again. besides. postoperative compression is done on an atonic leg making hemostasis less effective. who operate by quality and economy (day surgery.” Its execution. its characteristics by not being performed under local anesthesia. In fact. TECHNIQUE EXPANSION AP was created to be a typical ambulatory technique. LEAVING OUT FUNDAMENTAL RULES Phlebectomy phases are well known: they are simple and easily performed by all. nevertheless is not immediate because of the spinal or general anesthesia. whose demanding and boring avulsion is often impossible in a commonly busy operative session. surgeons and angiologists are. However. short hospital stay). In France. Austria. Australia. angiologists). Moreover. . Germany. collateral vein phlebectomy may be so trivial that poor attention may result to those (boring) details. In fact these may initially disappear after the saphenectomy. Latin America. and up to those surgeons practicing phlebology. Duplex evaluation has enhanced the approach of single patient’s pathology. in Italy. often done with gross instruments. Incisions should be as small as possible relative to the treated vein diameter (generally one-fifth of the diameter). AP consequently had a prevailing diffusion up to those phlebologists who operate in an ambulatory setting and have limited surgical experience (dermatologists. but alters.

when the Doppler was still to come into use. . when personally done (or supervised) by the phlebologist. the last proximal incision in the site where the varicose vein enters the incompetent saphenous vein. bleeding. and hematomas. clinically performed. Infiltrating (tumescent) anesthesia limits neural damage. Same is the case for the saphenous stem when it breaks down during the saphenectomy and must be retrieved back. malformations. on “flair. Keeping graduated elastic compression for 2 months improves the cosmetic result in some patients. deep thrombosis. Duplex ultrasound may be applied to phlebectomy in searching for deep placed venous tracts (eco-phlebectomy). may be used for introducing the catheter in the saphenous lumen.Introduction to the Second Edition xxxi . At present. New adhesive acrylic bands. DUPLEX EVALUATION During 1960s.” and a few simple maneuvers (Trendelenburg. NEW TREATMENTS New techniques of obliteration of the saphenous vein by heat—“closure” that employs radiofrequency or lasers that causes the blood vaporization and/or vein wall heating—may take advantage of collateral AP. It is the case for many reticular varices or telangiectasia. bruising. and so on. as an integration of AP. . thromboses. and Schwartz). especially at the thigh. detecting the incompetent points. duplex ultrasound allows a patient’s disease approach to be specific for that patients needs. Apart from mapping integration with morphologic and hemodynamic details. When fully explored. Today phlebologists have supplementary ears (Doppler) and eyes (ultrasound) to understand the venous system. In particular. thereby eliminating the puncture or retrieval of the saphenous stem. Perthes. that may be placed directly over the skin. selection of healthy veins. assessing the pathologic anatomy. infections. the introduction of a sclerosing foam has made sclerotherapy a more effective and rapid treatment . re-entry perforators. followed by immediate ambulation (possible only with tumescent anesthesia) avoids hematomas. based on experience. where fatty tissue may hide the varicose vein. the presence and the volume of reflux. postoperative bleeding. it was enough for the patient to be “Muller positive” (visible varicose veins. deep vein potency) to have an indication for surgery. the single subject may be submitted to one of the different current therapeutic choices appearing more appropriate in his case. The main step was mapping. A firm post-operative compression. avoid many cutaneous problems associated with tight bandaging (blisters and abrasions). Where venous diameters do not allow AP. sclerotherapy may be used.

In association with AP. Stefano Ricci Mihael Georgiev Mitchel P. sclerotherapy may also be used to treat the saphenous stem abolishing the reflux re-entry by collateral veins. The saphenous vein is then submitted only to the physiological centripetal flow. Goldman . so that its sclerosis becomes more effective. From these statements this new Edition finds its justification.xxxii Introduction to the Second Edition for varicose veins and enhance AP.

and the experimentation tend to produce novelty and continuously question the truths. Egypt. If I must choose between the two. Doubt is a sin for religion. it became a widespread dogma only in the 11th century. and all over the world. The submission of medicine to religion turned out to be beneficial for providing care to the poor and for idealizing the medical art. Unfortunately. xxxiii . those systems sterilized research. this subjection to religion was an obstacle to the scientific progress. The great Greek doctors have saturated medicine by systems inspired a priori to contemporary philosophies. but essential for science. “The” truth is fixed and complete by definition from God. medicine being initially run by the magicians became sacred. whereas it is an absolute necessity for science. under the influence of religion. The oath of Hippocrates was reserved to few medical schools and not universally known. Aristotele’s. “Plato is my friend. whereas medicine depends on science that is evolutionary and progressive: the doubt. Greece. the curiosity. The power of treating and healing moved from the witch-doctor’s to the priest’s hands. Europe. in the name of the infallible philosophy. Hippocrates’.” Despite this sentence. As Aristotele said. Religion was deemed to possess the truth. but also Truth is my friend. These innovations are dangerous for religion. and Galeno’s fans followed for 2000 years the spirit constructions instead of the facts of reality. A further danger also threatened the practice of medicine in ancient times: the attempt to freeze in a doctrine the experiences of men. even if geniuses. I choose the Truth.History of Ambulatory Phlebectomy Robert Muller PRELIMINARY NOTE In Mesopotamia. Considered as inviolable verities and accepted as dogmas. The doctor shall not submit to revelation-based religious dogmas nor lay dogmas based on the absolute and consequently exaggerated texts of the great geniuses.

He underlines the patient’s courage in standing the terrible pains of the operation. slightly bigger than the leg. but not still a phlebectomy. without ties. and writer from Greece. In spite of being a devout Ugonot. although ignoring the Latin and Greek language.xxxiv History of Ambulatory Phlebectomy In the 16th century. However. Marius refused: “I believe—he said—that the improvement is not worth the pain. we can deduce that in 2nd century ACE in Rome varices were not simply incised. as learned from the Hippocratic texts. Unfortunately he was not a doctor. but were excised. He was a sage. He was the most clever of Renaissance surgeons and the craftsman of the surgery renaissance. we observe that it was not a matter of healing an ulcer. an aesthetic reason. Interestingly. philolosopher. uncle of Julius Caesar. at the time of his second consulship (107 BCE). who wrote “Parallel Lives.” In spite of the report of his sobriety. Concerning the patient’s motivation. excitement. while palpating in the area of Boyd’s perforator the proximal end of a long and sinuous varicose vein. tying the patient so that both legs could be treated in a single session. in a medallion in the lower left side. and on the right. the God Aesculap. allthough never touching the dangerous black spot. but of eliminating horrible varices. we can observe the image of a malleolar ulcer . Hippocrates thought that the bad blood that “fed” the ulcer should be evacuated. that it was a currently performed operation. It was a phlebotomy. translated by Littre. his illness considered nonvirile and ridiculous. PLUTARCH Plutarch lived from 50 to 125 ACE. the chapter of ulcers revealed the necessity of incising the proximal varicose vein at different levels when an ulcer is threatening. a longitudinal extra fascial tributary of the great saphenous vein. HIPPOCRATIC TEXTS ` In Hippocratic texts (dating back 2000 years ago). that it was performed without anesthesia. in the middle there is an enormous leg. but impassive and silent. he used religion only to love and respect his patients. ´ Ambroise Pare developed his genius at “the university of battlefields”.” Here he described the varicose vein operation of Caius Marius. cries. consequently he reports only few details. a Roman general and consul. a compressive bandage was applied and the patient was invited to immediate deambulation. This sculpture is the practical witness of the ancient Greek doctors’ interest for the ulcer –varices relationship. Marius was embarassed of exhibiting varicose veins to his soldiers under the tunic. when the surgeon asked to treat the other leg. . On the magnificent marble exvoto found in a temple near Athens Partenos.

the doctors were liberated slaves or strangers. He lived during Tiberius between 56 BCE and 7. military art. The Greeks did not easily read the Latin language. Burning the wound edges. . they were upset that a nondoctor could be better updated than most of them and did not forgive him his intelligence or his competence. by separating them with hooks (hamulus) will be easily avoided. it is more advisable to excise them (utilius est eximere). philosophy. the wound edges . but the first to be printed in Florence in 1478. when cauterization has been completed. The cauterization is preferred when the vein is straight. or even 40. . . rhetoric. Unfortunately this encyclopedia has disappeared. common-sensed sage. nearly always from Greece. detailed. the one who created Latin termonology. and exact way. remedies are applied that are employed for burns (. rich and extremely meticulous. jurisprudence and . This is not likely as in 1st century BCE in Rome. He wrote in a remarkable style (he was named the Cicero of Medicine) a human’s knowledge encyclopedia. quo adusta sanatur). . In the 31st chapter. This book disappeared. we should have recourse to it also if. this is moderately touched by a red-hot iron with a thin and blunt tip. Guerino from Verona found a manuscript. all along the vein. if the varices are winding. a contemporary of Christ. Hooks are placed at a four finger distance each other. was lost and forgotten. Excision instead is done as following. It is the work of a talented. After skin division as in the former way. He was a Roman. medicamentum. I will therefore say that all the varices becoming harmful must be repressed by the fire or suppressed by the instrument. “De Artibus. even today.” probably between 30 and 35 years BCE. the future Pope Nicolas V. in 1426. especially surgery. It was the last ancient text to be discovered. We can read in the translation by M. At the opposite. . During Quattrocento. in spite of the present obliquities. the vein is isolated and has a medium volume. a 10th century dated copy. Celsus was the first Latin author. This is so well documented and precise so as to induce many authors to think. medicine (the 7th book). with the exception of the 7th book. inside the church of Saint Ambrogio in Milan. intelligent. precise.History of Ambulatory Phlebectomy xxxv AULUS CORNELIUS CELSUS He first described ambulatory phlebectomy in a complete. The surgical instruments found in Pompei correspond exactly to those described by him. and ´ in 1443 it was found by Thomas de Sezanne. The Roman patricians considered the practice of medicine. Here is the way of making cauterization: teguments are incised and after the vein has been dissected. he deals with leg diseases. des Etanges: The lower limbs are submitted to varices that are not difficult to eliminate . This is the reason for the low success of this book. . Celsus achieved in this way a sensational revenge. at the point of forming a kind of circumvolutions and plaits. with an inexhaustible scientific and philosophical culture that concerns agriculture. ACE. as absolutely unbecoming of their nobility. that Celsus was a doctor.

He states that you must be radical: eliminate all the varices. as far as the christian occidental world is concerned. A lot of courage was needed to stand such a treatment. reigned as soverign over the Medieval scholastic medicine. personal translation). to the occidental world for their rebirth. since after his death every serious anatomical or physiological research was dismissed by the thought that whatever could be said had been said by Galenus. CLAUDIUS GALENUS In spite of his Latin name. So we must speak about phlebectomy according to Celsus and not of Celsus.xxxvi History of Ambulatory Phlebectomy are grasped with the hooks. born in Pergamus in 130 and died in Rome in 200. he knew how to change a limp subcutaneous cord into a stiff rod. and when all varices are in this way ascertained. he used an adhesive and compressive medication that allowed walking. He contributed greatly. than varices. AETIUS OF AMIDA AND PAUL FROM AEGINA From Galenus to Renaissance. the wound lips are approached and a sticky poultice is applied (emplastrum glutinans). Celsus did not invent this treatment. . then the scalpel is used to entirely isolate the vein from the surrounding parts taking care not to injure it. together with Aristotele. He treated the varices by the technique described by Celsus. Finally. This obscurity was fortunately cleared by flashes of geniality. although done by large incisions. We can notice that Celsus described in detail sclerosing thermocoagulation and ambulatory phlebectomy. ameliorated. Men preferred to have scars. he was a Greek. This done. Then we proceed to the nearest hook where the same maneuver is done (‘where the vein is attracted and eradicated’. pers and translation). He was the last giant of Greek–Roman antiquity medicine. He was devoted to scientific research and contributed to the development of anatomy. which showed virility. unfortunately. the vein is cut in the point where the hook is lifted. trad. medicine degraded for more than a thousand years. it easy to detect due to the tension applied to the hook’. They collected. a period corresponding to one-quarter of the history of humanity. they submitted them to experience the criticism and transmitted them. to medicine decadence. and the leg being freed from all the varices. Pulling the vein. He represents the apex of the Greek medicine. blunt hooks are slipped under the vessel. particularly in the Roman Oriental Empire from 500 to 1500 and in the Islam Empire. saved. ndr. and translated the writings of the ancient Greek and Latin authors. avulsing them with the hook. while keeping them separated as told before. To understand the varices direction. Monotheist. which were ridiculous. He wrote more than 500 works. simply lift the hook (‘when the vein is pulled.

according to Celsus. Actually we deduce that the deep vein is obstructed at the tourniquet level and the avulsion of the superficial vein. was followed by a long agony in science. also in living subjects. He passed two strings under the varice. the Tours Council proclaimed: “The Church abhors blood. When the Church wanted to bring down an anatomist. . disregarded deity worship and probably was the first to dissect the human body in the dead and. Authorized by his sovereign (Alexander). a thousand years later. a famous doctor of Alexandria’s school. He drew out a practical curious conclusion. isolated the vein. Celsus did not avulse the varices higher than the knee. although varicose. Aetius and Paul. Aetius stressed their compression with bandages. In 3rd century BCE. conveyed the nutritional blood. This bed resting became a fixed dogma for more than 1400 years. This was done. but their writings confirm complete scientific research stagnation. Those acts horrified the world. after a century. totally different from the actual one. and took off the ties. he seems to have dissected some dead condemned and war prisoners. but unfortunately he prescribed convalescent bed resting with elevation of the limb over the head. Paul from Aegina placed a tourniquet at the thigh and invited the patient to walk. he marked it for avulsion. The other famous doctor charged with human vivisection was Erisitratus from Chio. MIDDLE AGES The fall of the Roman Western Empire in 476 and. it used to charge him with this awful crime. If he observed a distal dilatation of the varice. Then Paul reclined the patient and placed a second tourniquet behind the knee. This partial avulsion of the GSV at the thigh is exactly the same that Trendelenburg will perform 1200 years later.” The same taboo reigned in China (dissection was permitted in 1916). being adverse to cadaveric dissection and human blood manipulation. He believed. He evacuated all the blood that was felt necessary. is avoided. Aetius and Paul from Aegina obtained a practical progress. will ligate the greater saphenous vein at the thigh. and Islamic religions.History of Ambulatory Phlebectomy xxxvii Aetius of Amida (502 – 575) and Paul from Aegina (607 –690) were both Greek doctors living in Costantinople and concerned with varices. He carried out what we call a Perthes –Delbet test. till below the second Dodd perforator. This horror for blood has a historical base. Erophilous of Calcedonia. then separated them and incised the vessel. of the Eastern Empire. As a humoralist he made the vein bleed just to eliminate the impurities. In 1163. He incised the skin over the varice between the ties. above others. The Church. in 1453. that arteries carried air (Hippocrates pneuma). in the Hindu. Paul did not remove the proximal part of GSV as it may injure the stem of vessel that. the famous Flemish anatomist from Montpellier and. Arabic. then he ligated the vein tying the strings and removed the vessel between. with Berengarius from Carpi and with Vesalius (1514 – 1564). prohibited all anatomical and physiological research. born in 310 BCE. he thought. according to Galenus.

Arabs did not develop important progresses. experimental research. ` Ambroise Pare (1510 –1590) He was the most clever surgeon of the Renaissance. the sublime goal of the soul ascent to God. During 13th century a muslim from Fez. It is for this (wrong) reason that Vesalius was condemned to death by the Inquisition. although ignoring it. He died during his travel from a shipwreck. he inspired to Albucasis. according to the Believers. as he was the personal physician of the king of Spain. Guy de Chauliac really treated Laura from Noves. towards those illuminated and tolerant calyphs. He deserved celebrity status for having stated that the medicine base is that of anatomy. Maroc. Guy de Chauliac (1300– 1368) ´ He was born in the Gevaudan region. excellent spirits with the disinterested researches of Science. and even common sense. eight centuries before Mayo. son of a surgeon– barber –healer. He was a sincere but liberal Uguenot. in 1366. Both philosophy and generally science disappeared in a most sterile decline. the GSV stripping. These two great surgeons rediscovered the treatment described by Celsus. followed by cauterization or avulsion. As an anecdote we remind the tremendous hate he was submitted to by the poet Petrarca (born in Arezzo in 1304). the first humanist of the renaissance. who collected and translated the tradition and the Greek –Roman texts. but did recognize the great evolution of the ancient thought towards the truth. RENAISSANCE The renaissance and our world culture holds an endless gratitude of debt towards Islam. Guy de Chauliac was a traveler. objection. and towards their doctors (often Jews and Christians). He ignored Latin and Greek . He clearly described multiple ligation of the varices and also. but particularly medicine did as a consequence of the lack of doubt.xxxviii History of Ambulatory Phlebectomy particularly. said: “Men must glorify God with the means that they have to disposal: modest spirits with pity and charity. but could not cure her from pestis. Two years before his death the dissection was officially admitted in Montpellier. He recommended multiple serial incisions of varices. even if his penalty was changed into a pilgrimage to Jerusalem. but studied by human dissection either on books. from Padova. he was Christian. The bright Greek – Roman –Byzantine inheritance disappeared forgotten in the scholastic march.” Albucasis (1013 –1106) He was Muslim and has been the greatest surgeon of Andalusia kingdom.

Aetius in the 6th century. . Surgery took care only of removing the blood reflux in the varicose GSV: Celsus in the 1st century. He modestly recalled that a young French surgeon –barber (Alois Carsena from Nice) had already tried to tie arteries. THE PIONEERS OF AMBULATORY PHLEBECTOMY REVIVAL My master at the dermatologic clinic of Bern University gave me two fundamental dogmas: (1) never treat the varices of an old phlebitic patient and (2) never treat the varices of men aged more than 60 or of women aged more than 40. Alois. Moore in 1896 and DeTakats in 1930 operated in an ambulatory setting. ambulatory and radical phlebectomy was forgotten after Celsus. till the knee. He has the great merit of having adopted arterial ligation. at the junction. Jean-Louis Petit (1674 – 1750) He was the first director of Paris Surgery Academy. He nearly revived ambulatory phlebectomy. Concerning varices.History of Ambulatory Phlebectomy xxxix languages. Moore in 1906 and Babcock in 1907. he reinvented the technique of Paul from Aegyna. Paul from Aegyna in the 7th century and Trendelenburg in 1890. ´ Ambroise Pare was concerned about avoiding ugly scars (one of the principles of aesthetic surgery). He invented. Schiassi in 1908 added to the junctional ligation the distal sclerotherapy. Finally. Islam had preciously preserved those Greek –Roman (ligation) and oriental (analgesia) customs. or Alohim. It is better not to get involved. as the pregnancy varices are not curable”. That is why pregnant women often develop varices. learned arterial ligation with cutgut and analgesic inhalation (narcosis) during his captivity in Algeri. The blood often concentrates melancholy humours. He was a participant of the radical excision school. designed. and made up a kind of hooks and mini-strippers that allowed leg and thigh varices avulsion. till the high thigh. till the mid-thigh. They develop in those subjects that complain a melancholy disposition and over-indulge in tasty meat. His “university” was the battlefield. opposed to the amputation stumps cauterization by boiling hot oil or white-hot iron. even if he wrote about the pathogenesis: “The cause of varices is melancholy blood. He treated pertinently the varices etiology: whatever interfered with blood progression to the heart. In conclusion. MODERN TIMES Jean Scultetus (1595 –1645) He was a German surgeon of the 17th century. which was how he escaped from the pernicious scholastics. as the abolition of menstrual blood evacuation encrusts their blood. Half of the beds of our clinic were occupied by complications of chronic venous disease. described.

. I then decided to eliminate the injection and to treat the vein directly. J. Obviously. Germany. In spite of this official hostility. Tournay invited me to Paris to present my technique to the French Society of Phlebology. at low risk and at low cost all of the varices.P. Venezuela. Knowing that in Germany. In 1956. From that time. which then became 0.5 mm after the hook introduction. Dortu) asked me to teach him the technique. I began to do the same using local anesthesia. and other countries.xl History of Ambulatory Phlebectomy In 1951. to avoid this occurrence I started to take off not only the thrombus but also the wall of the affected vein. ambulatory phlebectomy was defined and achievable in any medical office: marking (mapping). Italy. I felt the disappointment (for my pride) and the satisfaction (for the important roots of my technique) to find that 2000 years earlier some colleagues had solved in the same way. simply by slightly modifying an instrument. after which I could only bury myself together with my invention. patients were immobilized. I quickly realized that the vein wall was rapidly became fragile and it was difficult to remove without breaking it. many of them have subsequently taught the technique to others. the incision. or the bandage. the method started to diffuse and to be accepted. asepsis. with great success. I began my activity as a private dermatologist. Israel. In 2 years time I focused all the details concerning the doctrine. Everybody agreed that it was a ridiculous method. In 1967. and England thrombus evacuation followed by compression and ambulation was the treatment employed. local anesthesia. Sclerotherapy gave good results although recurrences were the rule. Crossetti) when the GSV had reflux to the sapehnofemoral junction. heparinized. Switzerland. We had learned that in Bruxelles Dr. the word “phlebitis” gave rise to general panic. After a while. Ryckaert was easily and for a long time performing the groin to knee saphenectomy in an ambulatory setting. the technique. treated with cold poultices. multiple longitudinal incisions (3 mm. In those times. excision of the whole varicose vein together with perforators and tributaries. Trendelenburg tilt. more than 260 doctors from France. The patient would be recommended to the surgeon (Dr. high compressive bandage. under local anesthesia. after visiting him. It is in this moment that I revived ambulatory phlebectomy. physiology. Our team was now able (1960) to excise effectively. In 1964. UK. Dr. the anatomy. however. As the vein recanalized and thrombosis recurred. immediate and vigorous ambulation. and the instruments. the same problems. I was doing the same procedure 3 days after sclerotherapy. a young colleague (Dr. anesthesia knowledge have nowadays changed the general situation. have visited my office. USA. aesthetically. It was a total fiasco. Austria. The ways of vanity are subtle: many colleagues could not resist the temptation to claim not only the revival but also the discovery of ambulatory phlebectomy. we immediately adopted this method. created by the casual breakage of a forceps).

In 1836. this can be temporarily stopped by the digital compression over the saphenous trunk at the thigh during the passage from horizontal to standing position. ligation and section of the saphenous vein is named the Trendelenburg operation.” Over time he carried on his “experiments” concerning radical treatment of varicose veins as a chief surgeon of Ravenna hospital (1820) and Venice hospital (from 1822).” The author describes the phenomenon of downward filling of the varicose bed through the incompetent saphenous trunk. xli . Tommaso Rima published in the “Giornale per servire i progressi della Patologia e della Materia Medica” (Journal for Serving the Progresses of Pathology and Medical Matter) a memory titled “On the near cause of varicose veins to inferior limbs.” Rima is a military surgeon. one year before the birth of Trendelenburg (1844 – 1924). and to the meaningful historical changes in the surgical practice (antisepsis and anesthesia). Friedrich Trendelenburg published a fundamental paper entitled “Ligation of the greater saphenous vein in varicose veins of the leg. to the absolute need of finding a possible solution to varicose vein disease.Who Discovered Saphenous Vein Incontinence? Stefano Ricci In 1890. till his death in 1843. He had the chance (1808) to observe a veteran operating with a “Home method. From that historical moment on. to the good management of his reputation. above all. As a consequence some benefit will follow from the “ligation and section of saphenous vein at the junction of the lower and the middle third of the thigh” proximally to leg varicose veins. The true merit of this surgeon is connected to his skill in scientific diffusion of his observation. a very skillful and quick surgeon: he needed only few minutes to do the operation so that anesthesia was useless (according to him). and on their radical treatment. He was. even if subsequently widely modified.

but could also cause fatal embolism and septicemia. the blood flows down for the gravity law to fill the veins.” He made the patient sit on a chair. at that time the most important medical society of the world. Thomas even describes a “Rima method. but probably indirect (and inaccurate). and . Schede.” that he used in two cases with “worst than ever” results.” On this basis. Venice was still administered by the Austro-Hungarian Empire and publications issued there were not isolated from the German academic world. positioned over the operating table. Velpeau. By the way. In fact. frustrating the proper credit to Rima. who is never cited by his distinguished colleague. as a consequence. which is an extraordinary result for those times when hospital infections were frequent. that causes gravity in the column up downward. it was not enough to put a tourniquet “as far as the veins are most distended only when the patient stands up. Only two patients died in this series. because “the natural circulation order inverted. was not consulted in Germany. Pare. it also created some problems regarding the comprehension of varicose vein pathophysiology until the discovery that the blood in the varicose veins took the downward direction instead of towards the heart. Rima performed excisions (41 cases) of few centimeters of the saphenous trunk above the knee to interrupt the blood column weighing down. Bonnet. Fricke. However. Gagnabe. Madelung.xlii Who Discovered Saphenous Vein Incontinence? “We thought to be able since then to prove by reasoning and facts (the near cause of varicose veins) to consist of an inverted movement of blood in the great saphena. in his paper on Liverpool Medico-Chirurgical Journal in 1896 where he suggests the ligation of the saphenous vein at the saphenofemoral junction (“below the saphenous opening”). By this means valves are paralyzed. although crediting a wrong date (1857) and a noncorresponding technique (excision of varicose veins). Evidently Trendelenburg knew how to better use the media of that time to communicate and diffuse information throughout the scientific world. exhausted in various ways the vein tunicae. so presenting more apt to operation. Perhaps it is possible that Rima’s paper was issued in an obscure journal and not known to the German medical society. it is curious that Thelwell Thomas refers to Rima. contributed to obliteration of venous trunks. post-operative thrombophlebitis. We suspect here a real knowledge of the Italian author.” but failing to recognize the valvular absence and hydrostatic pressure not only limited to the saphenous length. Galen. at the beginning of the 19th century. and that. Avicenna. Rima too cites Home and refers to his observation (however. from the center distally. Varicose vein surgery done in the times by Celsus. Paul ´ from Aegyna. but also dependent on the distance from the heart. Trendelenburg instead cites Edward Home (1799) as the supporter of the saphenous ligation below the knee for “removing the pressure in the blood column included in the common trunk. not scientifically explained) that to make the vein easier to operate on.” If William Harvey’s discovery (1628) of blood circulation revealed that the blood circulated in a centripetal direction. while recovering. even in an epidemic form.

It would answer the same purpose as the pressure of my thumb. the patient was in the erect posture.Who Discovered Saphenous Vein Incontinence? xliii others. It is noteworthy that in Germany antisepsis and. the famous test described by Trendelenburg 44 years later. while the saphena major was of enormous diameter. To Lister we also owe the development of resorbable sterile sutures (catgut treated with phenolic acid. so that valves were evidently good for nothing. consisted essentially of varicose vein avulsion with distal and proximal ligation. I can understand that a ligature upon the vena saphena under these circumstances. But if. but still it is not to be supposed that the good thus obtained would be permanent. the valves being of no use. I removed the pressure from the vein. Trendelenburg’s success is probably due to all of this. With catgut. the asepsis (von Bergmann. on taking off the bandage. without any knowledge of saphenous reflux. overall. or that it would be sufficient to counterbalance the chance of mischief resulting from the operation. otherwise subjected to the infection lottery and. the incision could be sutured completely. could employ it for a therapeutic purpose. the patient being in the erect posture. that was cut short and buried in the tissues. If I put on a bandage. To whom then do we credit the discovery of saphenous reflux? When we work out these “placings” we always have the risk of ignoring other authors who contributed to the evolution of saphenous reflux. A few years later. and only from the capillary vessels. 1891) were adopted much more rapidly than elsewhere. 1867) would efficiently enter (with some initial resistance) the surgical art. lowering the infection risks. and squeezed the blood out of the veins below. 1869) to substitute those made of silk. So writes Benjamin Brodie (1846): I had a patient in whom there was an unusually large cluster of varicose veins on the inside of the leg. whose ends needed to be left long out of the wound for suture removal. that the cluster of veins below filled very slowly. consequently. but few did understand and fix that mechanism and. the blood rushes downwards by its own weight. I found. in fact. although not in surgical function (but instead in antisurgical purpose). and filled the varicose cluster below almost instantaneously. consequently without any hemodynamic explanation. anti-sepsis (Lister. and then put my thumb on the vena saphena above. so as to stop the circulation through it. successively. changing the pessimistic vision of surgeons like Brodie. would to a great degree lessen the inconvenience arising from the distention of the varicose veins below. We have the impression. radically changing the prognosis of those poor patients. that many did realize the importance of blood coming up from downward. contrary to the course of the circulation. Here is perfectly described. .

others sent them for post-operative sclerotherapy (big tour going on).” However. others interrupted them by ligatures (big scars –big surgeons). When I was a student. and in a few cases he applied it to the vena saphena minor. 1846:157. N. this anecdote is referred mostly to underline the operation’s risks. It became time to pay attention to the “periphery. Although the saphenous hemodynamics ought to be respected and corrected (even if less “furiously” than before). we can clearly see how these dates speak with evidence and allow an objective and possible universal vision. Lectures illustrative of various Subjects in Pathology and Surgery: On Varicose Veins and Ulcers of the Legs. for the purpose of undergoing the operation. considering superficial varicose veins as the consequence rather than a cause of the disease. Simposi Clinici CIBA. Benjamin Brodie.: Valvole venose e flusso centrifugo del sangue. varicose veins could be gently and cosmetically treated.1968. A nationalist vision of these primacies always inspired history writers. In conclusion. BIBLIOGRAPHY Belloni L. Brodie the description of the clinical test (1846). He performed this operation in a great number of cases.4. and leaning over the back of a chair. according to the repeated fatal outcome of patients of the same Home. After the discovery of saphenous reflux as a cause of varices. The latest advance is in duplex ultrasound. where the veins of the leg were varicose. While waiting for further indications. This has changed craftsmanship into a science. and so on. to the vena saphena major. attention was directed for the most part to treatment of the saphenous vein. and Trendelenburg the skill in scientific divulgation and the diffuse therapeutic application (1890). London: Longmans. Rima with the comprehension of valvular incompetence with a cavo-iliac-femoro-saphenous reflux and its practical application (1836). it is possible that on this subject some other author could raise a compatriot contribution. nothing was more common than to see a patient with varicose veins standing on a table. allowing simple cosmetic treatment.xliv Who Discovered Saphenous Vein Incontinence? Brodie also tells about Home: “Sir Edward Home recommended the application of a ligature. we can credit Home (1799) with the basic idea.Vol 5. patients accepted to be operated only when grossly affected. Results were ugly. caused by inflammation: “There are indeed no circumstances here to justify the performance of a dangerous operation” he wrote. Consequently. Varicose vein treatment greatly improved but we still have not found the definite solution. . Some surgeons did not treat them (they will disappear spontaneously).” This led to the Mueller procedure.

Trendelenburg F.fasc XIV pag 1 – 36. Rutkow IM. Missoury: Mosby Year Book. Giornale per servire ai progressi della Patologia e della Materia Medica. Goldman MP. Louis. 1836. Surgery: An Illustrated History. 1993.Who Discovered Saphenous Vein Incontinence? xlv ` Rima T. 1993. Rose. Diagnosis and treatment. Sulla causa prossima delle varici alle estremita inferiori e sulla loro cura radicaleMemoria letta all’ateneo di Venezia 1836. . Historical development of varicose vein surgery. Operative treatment of varicose veins of the lower extremity by ligature and division of the internal saphena vein at the saphenous opening—Liverpool Medico-Chirurgical Journal 1896. Thelwall Thomas W. Louis. Varicose veins and telangectasias. Ueber die Unterbindung der Vena saphena magna bei unterschenkelvaricen)—Beitrage zur klinischen Chirurgie 1890. 16:278. Page 128 – 129 In: Bergan JJ. Missoury: QMP. 7:195. Appendice. St. S.

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Part I: General Considerations .

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6. like the GSV and the small saphenous vein (SSV). subcutaneous extrafascial varicose collaterals. dilated veins on other parts of the body. and face. varicose veins in lipodermatosclerotic areas. 5. INDICATIONS Varicose veins of any size—except telangiectasia—and at any site—except for the proximal end of the great saphenous vein (GSV) and its junction with the common femoral vein (sapheno femoral junction.5 – 4 mm in length). patients with widespread varicosities. These do not require skin sutures and are followed by hemostatic compression and immediate ambulation. SFJ)—can be removed by AP. varicose veins recanalized after one or more sclerosing treatments or thrombophlebitis. dorsal hand. lower leg hemorrhagic varicose “blebs”. under local anesthesia. that is. and deeply situated superficial truncal varicose veins that lie anterior to the aponeurotic fascia or are covered by a layer of the latter. abdominal wall. Muller to his technique of ambulatory varicose vein avulsion through multiple stab incisions (0. The technique of AP is particularly efficacious in several cases that are difficult to treat by traditional surgical techniques: 1. 9. 7. 4.1 Definition and Indications “Ambulatory phlebectomy” (AP) is the term given by R. varicose side branches of the GSV and the SSV in limbs with competent saphenous trunks. patients in early stages of varicose vein disease with isolated or shortsegment varicose veins. 2. varicose veins on the dorsal foot. These include small reticular (dermal) varicosities. 8. 3. the superficial fascia. varicose veins residual or recurrent after traditional surgical operations. 3 .

Therefore. Despite the potential for wide application. Telangiectasia can also be partially destroyed (“scraped out”). Nevertheless. so that practically all types of varicose veins can be treated in an office setting. . Telangiectasia cannot be directly avulsed by AP. AP is employed in different ways and to different extent by different physicians.4 Ricci. which consist of many small and thin-walled vessels and the muscular (gastrocnemius) calf veins that are inaccessible under local anesthesia. We employ it for the removal of all varicose veins except for the SFJ and telangiectasia. sclerotherapy is necessary for the elimination of residual telangiectasia. However. and Goldman The incompetent SFJ can be ligated and divided or treated with endoluminal radiofrequency or laser closure under local anesthesia in the office. its indications depend on the surgeon’s experience. The only exceptions are some types of recurrent varicose cavernoma in the groin (secondary to SFJ ligation or to thrombotic occlusion of the GSV). Georgiev. areas of dense telangiectatic “flares” fed by a larger incompetent superficial or perforating vein benefit from the avulsion of the latter.

This chapter describes the veins of the lower limb in a method useful to those who practice phlebology. and perforating (crossing the aponeurotic fascia to connect the superficial to the deep) according to their location relative to the deep (aponeurotic) fascia. 2. 2. superficial veins do not usually have accompanying arteries. permits safe removal of diseased superficial veins. The valves direct blood flow to the heart from superficial to deep veins and prevent reflux of blood in the opposite direction. These two larger vessels empty into deep veins 5 . as well as the large total capacity of the venous system.90% of the limb’s blood flow is carried by the deep veins. In this chapter. venous anatomy is described with special reference to the superficial venous system. described in 1574 –1603 by Hieronimus Fabritius d’Acquapendente in Padua.2 Anatomical Bases of Ambulatory Phlebectomy The anatomic description of veins as taught in medical school is not useful in everyday practice. Normally. GENERAL ORGANIZATION OF THE SUPERFICIAL VENOUS SYSTEM Unlike deep veins that accompany and are named after their matching arteries. Veins of the lower limb can be divided into three types: superficial. A varicose vein is a dilat0ed superficial vein that has lost its valvular function in which blood flow is bi-directional. but are organized in a series of subcutaneous channels that drain into two major and deeper superficial veins: the great saphenous vein (GSV) (Fig.2) (1). deep. The vein’s most characteristic features are its valves. . This fact.1) and the small saphenous vein (SSV) (Fig. The description is related to varicose vein disease and ultrasound vein imaging with reference to varicose vein surgery and the technique of stab avulsion phlebectomy.

anterior crural vein. F. Boyd’s perforator. posteromedial thigh vein. In addition to these two “classical” junctions. which may fill the incompetent GSV and other varicose veins even when the SFJ is competent [Fig. anterolateral thigh vein. 1. SSV. SFJ. and gluteal areas through abdominal and pelvic anastomoses. and the saphenopopliteal junction (SPJ) in the popliteal fossa. above-knee perforator. Dodd’s perforator(s).6 Ricci. great saphenous vein. 2. respectively. However. ACV. femoral vein. PMV. superficial veins bypass the SFJ and drain into the iliac and caval veins via numerous anastomotic branches of the abdominal wall and the pudendal. their constant (named) tributaries. PA.1 The great saphenous vein system. abdominal and suprapubic anastomoses.1 and 2. P. These branches are a potential source of “extrafemoral” reflux. GSV. The subcutaneous space in which all superficial veins run is divided by a fascia. perforating veins (from below): the (three) Cockett’s perforators.2. this classical description is not sufficient and may be even misleading for clinical practice because of the following anatomical and clinical considerations. PAV. In addition to the aforementioned junctions and pelvic/abdominal anastomoses. 2. and Goldman Figure 2. through the saphenofemoral junction (SFJ) in the groin. AA.4(b) and (c)]. Georgiev. The GSV. called superficial or membranous. and major perforators are illustrated in Figs. posterior arch (Leonardo) vein. pelvic (pudendal and gluteal) anastomoses. in two layers or . the 24 cm perforator. superficial veins anastomize with deep veins through more than 140 perforating veins (PVs) distributed along the entire length of the limb (2). saphenofemoral junction. ALV. perineal.

Deeper superficial trunks that run into the intrafascial compartments can be examined and mapped adequately only with the help of ultrasound (duplex) . is a marker for distinguishing the two levels of superficial veins. intersaphenous thigh anastomosis. reflux is deviated distally to the varicose SSV via the incompetent Giacomini vein (GIA). The two major collectors (GSV and SSV) lie into the deep compartment of the subcutaneous space and are covered by the superficial fascia. MC.2 The small saphenous vein.Anatomical Bases of AP 7 Figure 2. small saphenous vein. and are easily avulsed by ambulatory phlebectomy (AP). The distinction between the two levels of superficial veins is of clinical and surgical significance. popliteal vein.3 Transfer (cross-over) of reflux between the varicose segments of two different veins. saphenopopliteal junction. 2. Figure 2. deep and superficial. the superficial veins are arranged in two layers. SPJ. mid-calf perforating vein. whereas all other superficial veins (tributaries or collaterals of the saphenous) run subcutaneously into the superficial compartment. SSV. perforating vein. Accordingly. Thus the superficial fascia. PV. which is barely mentioned in standard textbooks. P. compartments: deep and superficial. Only the proximal portion of the GSV is incompetent. which are divided by the superficial fascia (3). 3. Subcutaneous collaterals can be mapped for operation by means of clinical examination alone.

1 and 2. the variations are more frequent than the rule (3). and Goldman Figure 2. They may be present at different depths. often have double segments (i. 56% proved to be collaterals. are present in many variants. (b) Reflux originates from the incompetent SFJ and from incompetent collaterals. 5.25% of the limbs (Tables 2. Even the saphenous veins. imaging.. This is because of superficial collateral veins (CVs) being involved in varicose disease more often than saphenous veins. more than one vein is found where one expects a single channel). Similar findings have been reported by others (6). and may be treated by alternative techniques as axial stripping or endovascular obliteration. with competent SFJ. (c) Collateral (pelvic/PA and/or abdominal/AA) reflux only. because all superficial veins have variants. and/or abdominal wall anastomoses. Despite the opinion that varicose veins constitute a “saphenous” system disease. Superficial venous anatomy should be considered in statistical terms.8 Ricci. In many cases. Georgiev. (d) Reflux originates from incompetent thigh (Dodd’s) PV while the proximal GSV portion is competent. 4.2) (4).4 Origin of reflux in the varicose GSV trunk. (a) Reflux originates from the incompetent SFJ. which is even more variable. The latter were present in 84% of the limbs and were the only varicose veins in . and their junctions may vary in site (SPJ) and anatomy (SFJ and SPJ). which are anatomically better defined. pelvic (PA). In a series of 279 limbs with PVVs.e. . This anatomical variability corresponds to a clinical one. They are difficult to avulse by AP. they are not.

Anatomical Bases of AP 9 Table 2. of an anatomical vein becomes varicose (Table 2.4). are not necessarily involved in varicose vein disease. Sometimes. It is difficult to find two limbs with identical varicose veins. of veins Percentage of total 44 21 35 100 Saphenous trunks (GSV and SSV) Named collaterals (ALV þ PMV þ ACV þ PAV) Unnamed collaterals Total 187 88 149 424 Note: 49% of the limbs had varicose veins of one type only and 51% had a combination of more than one type. varicosis is a polymorphic disease. of limbs 162 34 25 10 88 21 14 32 21 149 71 72 77 Percentage of all limbs 58 12 9 4 32 8 5 11 8 53 25 26 28 Type of varicose vein GSV GSV alone SSV SSV alone Named collaterals (total) ALV (thigh) PMV (thigh) ACV (leg) PAV (leg) Unnamed (atypical) varicosities (total) Atypical varicosities alone Single collaterals Diffuse networks Note: 49% of the limbs had only one type varicose veins and 51% had a combination of more than one type. operations based on standard anatomy consisting of total (“anatomical”) removal of a single vein. . Usually only a portion. which are classical anatomical and surgical reference points. In many cases. are often inadequate—they remove competent (healthy) portions of some veins.3). there is cross-over reflux from the varicose portion of one vein to another vein via connecting (anastomotic) collateral varicose veins (CVVs) (Fig.2 Varicose Vein Distribution in 279 Limbs No. The main anatomical saphenous junctions (SFJ and SPJ). not the entire length. Therefore. while leaving other varicose veins untreated. GSV or SSV stripping.1 Number and Type of Different Varicose Veins No. 6. the most proximal deep to superficial reflux point (“escape” or “leak” point) may be a Table 2. that is. Therefore. 7. 2.

the SFJ was competent in 38% of cases (29% and 46%.4 Extension of Reflux in the Varicose GSV: 162 Limbs No. which may be competent [Fig. only the most proximal reflux (leak) point(s) were determined. SFJ or SPJ ligation should not be performed for anatomical reasons alone. that is. In one series.3 Groin reflux points (total) SJF reflux Pudendal (pelvic) reflux Anterolateral or abdominal collateral of the SFJ (limbs with competent GSV) Thigh perforators Knee perforator (total) SPJ or popliteal perforator Other knee perforators Below knee perforators Total 218 151 39 28 55 57 37 20 9 339 Note: For each varicose vein (reflux pathway). Therefore. CV or PV different from the main (anatomical) saphenous junctions.4) (4.10 Ricci. of limbs Percentage of all limbs Most proximal reflux level Groin SJF alone SFJ þ collateral (pelvic and/or abdominal reflux) Thigh Knee or below Distal extension of reflux Malleolus (total reflux) Mid-calf Above or below knee 139 129/139 ¼ 93% 10/139 ¼ 7% 18 5 72 49 41 86 11 3 45 30 25 .3 and 2.4(a – d)]. In two series of 509 limbs with PVVs. then the main junctions must also be incompetent. 151 (69%) corresponded to the SFJ. and Goldman Number and Level of Proximal Reflux Points Number Percentage of total 64 45 11 8 16 17 11 6 3 100 Table 2.5). and 28 (13%) to abdominal or anterolateral collaterals of the SFJ. out of 218 reflux points in the groin. Incompetent perforators distal to the latter were not considered. assuming that if the veins that drain into these junctions are varicose. 2. The most proximal reflux point was a Table 2. Georgiev. respectively) (Tables 2. 39 (18%) to pelvic anastomoses.

In over 40% of cases. sometimes so deep as to lie adjacent to the aponeurotic (deep or fibrous) fascia. On contrast venogram and ultrasound scans.Anatomical Bases of AP 11 thigh perforator in 20% of the limbs. The GSV usually has a thick wall that permits it to be used as an arterial bypass conduit. and operating on varicose veins must emphasize the specific varicose pattern of the individual case. Great Saphenous Vein Compartment On the medial aspect of the lower limb. in 10% of cases. examining. the GSV may appear as a Figure 2. It lies deep to the superficial (membranous) fascia.5 The GSV lies into the interfascial space (saphenous compartment) enclosed between the leaves of the superficial fascia and the deep (aponeurotic) fascia. the superficial and deep (aponeurotic) fasciae form a space called “GSV compartment. there is a second vein in the compartment called anterior ASV. Other times it can be so superficial as to resemble a CV. 2. Great Saphenous Vein The GSV begins anterior to the medial malleolus and ascends along the medial aspect of the tibia and thigh to empty into the common femoral vein (CFV) in the groin. The entire length of the GSV is in the compartment. lateral to the GSV.5 mm (range 1 – 7 mm) (8). and leg perforator in 3%. The average diameter of a normal GSV is 3. in the upper thigh.3) (4). planning treatment. knee perforator (including the SPJ) in 20%. For these reasons.” in which lie the GSV and the anterior accessory saphenous vein (ASV) described in this section (Fig. [The junction of the GSV with the CFV (SFJ) is described in detail in Chapter 15].5 –4. with the SFJ incompetent in 54% of the limbs (Table 2. .5 of the compartment with the two veins) (7).

Figure 2.2) (4. the GSV is almost always accompanied by two parallel CVs of smaller caliber. the GSV is often so deep that its hooking through stab incision may be difficult. In fact. If the surgeon is unaware of the existence of two distinct parallel veins.5). hooking. Identification and precise marking of these variants prior to surgery is important if precise and thorough varicose vein removal is to be obtained. the GSV is embedded in a compact (fibrous) subcutaneous tissue. (b) Bayonet type varicosities developed from the posterior accessory saphenous vein (PAS). (a) Double varicose GSV.6 Varicose patterns of a double GSV. but is the only site of varicose changes in 12% of the limbs (Table 2. (c) Double incompetent GSV marked for stripping. an extraluminal stripper may be necessary (see Chapter 15).12 Ricci.) (10). . 2. these parallel CVs lie subcutaneously. and in 52% a combination of single and double segments (9). in its middle third. with competent distal GSV portion. the classical endoluminal stripping is likely to remove only one (sometimes even the competent) channel. some of which are illustrated in Fig. Georgiev. However. and exteriorizing difficult. For the removal of that portion of the GSV. These veins run anterior and posterior to the GSV and give rise to different clinical varicose vein patterns (10). (Redrawn from Dortu J. while the main GSV trunk lies into the saphenous compartment. In the thigh. In the lower leg and at the knee.6. which may make its retrieval. The GSV is involved in varicose disease in about 60% of cases (58% and 64% in two series of total 509 limbs). and Goldman totally double (sometimes even triple) vessel.

Anatomical Bases of AP 13 Often only a portion of the GSV is dilated and incompetent (Fig. 2. (b) The situation after GSV stripping. GSV ligation and stripping should be carefully evaluated case by case. the saphenous compartment appears as an “Egyptian eye. Ultrasound identification of the GSV: The GSV is identified and distinguished from parallel running collaterals by its position in the saphenous compartment.7 Errors in varicose vein diagnosis: CVV mistaken for GSV.5. the superficial fascia the superior eyelid.” in which the saphenous lumen is the iris.4). the largest varicose veins often develop from the CVs and not from the GSV trunk (Fig. In the thigh.10). This may lead to stripping of a competent GSV. keeping in mind that it is not infrequent to find reflux in normal-looking GSVs in healthy. and the aponeurotic fascia the inferior eyelid (Fig. 46%. is erroneously diagnosed as an incompetent GSV. asymptomatic legs. on a transverse scan.” . and 55% in four different series of total 849 limbs) (4.3. to specific ultrasound “identification signs. Figure 2. 51%. which runs parallel to a competent GSV and is drained by the latter. 2. 2.” The “eye” sign. (a) An independent CVV. This position gives rise.8 of eye) (11). Table 2. In about 50% of cases. The CVV has lost its main drainage channel and distends further to become larger than before surgery. so that its total stripping is often unnecessary (Table 2.4). only the proximal portion of the GSV is incompetent (44%. In 79% of cases. The condition is often described by the patient as “worse after surgery.7). Therefore. under the superficial fascia. the varicose GSV is accompanied by CVVs (4). In these cases.9.

called “anterior accessory saphenous” Figure 2. Anterior accessory saphenous vein: In the proximal third of the GSV compartment there is often a second vein. and Goldman Figure 2. that in some cases in this area the GSV is absent or hypoplastic. and the laminae of the superficial fascia.9 Transverse scan of the medial aspect of the leg just below the knee. The GSV lies into the interfasial (saphenous) compartment and appears as the iris of an “eye.8 (a) Transverse scan of the GSV in the thigh. This sign allows one to demonstrate. 2. the GSV is distinguished from other closely running veins by its position in the angle formed by the tibia and the medial gastrocnemius muscle (Fig. tibia (T). Georgiev. when the angle is empty. . In these cases. The GSV (the round spot in the square) lies in a triangle formed by the medial head of the gastrocnemius muscle (GCM). Below the knee the fascial sheets are often so close to each other that the interfascial compartment may be difficult to recognize.9 of sign) (12). The tibia –gastrocnemius sign. (b) Longitudinal scan of the saphenous compartment. note that the superficial fascia often has more than one distinct layers.14 Ricci.” which has the superficial fascia as its upper eyelid and the aponeurotic fascia as its inferior eyelid.

beside its alignment with the deep vessels.10) (13).11). (ASV). The ASV is recognized and distinguished from the GSV by its alignment with the deep (femoral) vessels on a transverse ultrasound scan (“alignment sign. both GSV and ASV are present in the proximal portion of the interfascial compartment. the diameter of the ASV is inferior Figure 2.10 Transverse scan of the upper thigh. Note that the ASV is aligned with the axial femoral vessels (artery and vein). and femoral vein (4). In these cases. In 41% of cases. 2. 2. ASV (2). . Sometimes the superficial fascia divides the saphenous compartment so that both GSV (left) and ASV (right) have their own “eye”. which runs lateral to the GSV (3). the ASV has its own eye (Fig.11 Transverse scan of the upper thigh. showing the relationships between the GSV (1).Anatomical Bases of AP 15 Figure 2. femoral artery (3).” Fig. Sometimes.

4 vs.12 with patterns) (15). or divides in more scattered subcutaneous branches (11%). then the vein pierces the superficial fascia to continue distally as a subcutaneous collateral(s) in anterolateral (72%) or medial/anterior (11%) direction. Type B: The GSV trunk is double for a certain length. Type C: The GSV trunk is present in all its length. with both branches lying into the saphenous compartment. These patterns and their prevalence as determined in a series of 610 consecutive limbs with and without varicose veins are as follows (Fig. (a) Type A. it may give rise to what Tibbs (16) calls “concealed” or “straight through” form of incompetence. This is the second most Figure 2. .16 Ricci. and Goldman to that of the GSV (2. (d) Type D. (c) Type C. Type A: Full size GSV trunk. This is the rare case (1%) of truly double GSV. Georgiev. Proximally the ASV joins the GSV close to the SFJ and only rarely (3%) terminates directly into the femoral vein. When such GSV becomes incompetent.0 mm). (b) Type B.14). 4. The ultrasound markers of GSV identification allow to distinguish several patterns of relationship between the GSV and its side branching collaterals (3. In 6% of cases. the ASV does not leave the interfascial compartment. but there is also a large (or even larger) subcutaneous collateral.12 Ultrasound markers of GSV identification. The average length of the ASV from its proximal junction is 16 cm (7 –30). when the diseased GSV is not visible and barely palpable because of its subfascial position. present in all its length in the saphenous compartment. but joins distally the main GSV trunk (3). This pattern is found in 52% of cases. 2. and (e) Type E. with no large subcutaneous side branches.12.

as in types A or C. while leaving in place the incompetent ASV. Type E: Single full size GSV is present only in the proximal part of the saphenous compartment. the SPJ is also present. which is described in Chapter 13. the proximal (transfascial) portion is usually a single vessel without important collaterals (12). and is also embedded into an interfascial compartment. the interfascial SSV compartment is typically of a triangular shape and is delimited by the medial and lateral heads of the gastrocnemius muscle and the superficial fascia that stretches over the intermuscular groove (Fig. This pattern was found in 16% of cases. Small Saphenous Vein The SSV begins behind the lateral malleolus and ascends up the posterior aspect of calf to empty into the popliteal vein in the popliteal fossa. In most cases. there are two veins instead of one: the GSV and the ASV. This occurs in 41% of the limbs. 2. In some of these cases only an intermediate segment of the GSV is missing. This is probably the most common varicose vein pattern and is one reason for limiting the GSV stripping to the proximal part of the GSV only (short or groin-to-knee stripping). . Despite this interfascial position. Type D: In the proximal portion of the saphenous compartment. 2. as the ASV is often (14%) involved in varicose vein disease. On a transverse ultrasound scan. Whereas the distal portion of the SSV has many collaterals and anastomoses with the superficial and deep veins of the leg.14). while distal to this point the GSV itself is barely visible or absent (hypoplastic). In 26% of cases. 2. the SSV extends proximally into the thigh. In varicose limbs with this pattern. the SSV merges with the gastrocnemius vein before joining the popliteal vein (Fig. whereas the proximal (thigh) and distal (lower leg) portions are present. This allows for prompt identification of the SSV and its distinction from parallel running subcutaneous collaterals (Fig. which corresponds typically to the space between the popliteal crease (which corresponds to the knee joint) and the proximal 5 cm. Failure to recognize this prior to surgery may lead to removal of a normal GSV. while distally the reflux is deviated along the subcutaneous side branch(es). large subcutaneous side branches may or may not be present. often only the proximal portion of the GSV is incompetent.Anatomical Bases of AP 17 common pattern and accounts for 26% of cases.1 mm) (19). the GSV pierces the superficial fascia to continue downwards outside the compartment as a subcutaneous collateral. the SSV joins the popliteal vein at the SPJ. At a certain point. Like the GSV it is rather thick-walled (average diameter of 3.13) (3). This pattern is of clinical importance. respectively. Thigh extension of the SSV: In about 50% of cases.15) (20). the varicose SSV can be avulsed by stab phlebectomy. In one-third of these cases.

whereas in the remaining two-thirds of cases the SSV extends proximally into the thigh without having connection to the popliteal vein. The SSV is situated in the groove between the medial (M) and lateral (L) heads of the gastrocnemius muscle. . and Goldman Figure 2. The laminae of the superficial fascia are also evident between the saphenous compartment and the skin. in a compartment formed by a duplication of the deep (aponeurotic) fascia. GCV running parallel but deeper to the SSV and the saphenous compartment. Georgiev.13 Transverse scan of the posterior aspect of the upper calf. or may continue proximal under the superficial fascia of the thigh as a “femoropopliteal Figure 2. The SSV may connect to the GSV in the thigh via an oblique anastomotic vein (Giacomini vein).18 Ricci.14 A CV of the SSV is shown on longitudinal scan to pierce the fascia covering the saphenous compartment and become subcutaneous.

40%. in 42% of cases. this is the only termination. one-third of the latter have also a standard SPJ. the SSV may continue up into the thigh and terminate as follows: into the Giacomini vein (GIA. 4%. gluteal anastomoses). as it may transfer reflux from the incompetent GSV into the SSV and its varicose collaterals. vein” to join deep veins at variable locations up to the groin. .) (21). or divide into many muscular branches of the thigh (Fig. into the femoropopliteal vein (FP.15 In 26% of cases. (Figures from HM Hoffman and J Staubesand. half of these have also a standard SPJ.16 Proximal termination of the SSV. PA. the FP vein may end into a thigh perforator (TPV.16) (21 – 24). The thigh anastomosis between the GSV and the SSV is of particular clinical interest. or in substitution of the latter. low termination (below the knee joint. popliteal artery. Figure 2. standard termination (saphenopopliteal junction) within 5 – 6 cm proximal from the knee joint.Anatomical Bases of AP 19 Figure 2. 2%). intersaphenous thigh anastomosis). in 44% of cases. L. the SSV merges with a GCV before joining the PV. SPJ. “high SSV termination”). In addition. or split in two or more branches that may reach the gluteal area (GA. 2. in 12% of cases. posterior subcutaneous thigh vein).

easier to avulse through stab incisions than the saphenous trunks. A separate discussion of the CV is. Therefore.13). as the SSV incompetence may be difficult to diagnose with a clinical examination alone. Georgiev. the varicose side branches of the SSV anastomize with the GSV and its collaterals [Fig. but without stripping the latter—may give better results than GSV stripping alone (14). In normal conditions the caliber of the CV is very small.e. nonsaphenous) veins.4(b) and (c)]. CVV avulsion—with or without high ligation of the GSV. Exteriorization of the often thick-walled saphenous trunks of similar caliber requires larger incisions. 15%. of great practical importance. In many cases. but also independently via numerous (. 9%.100) PVs that are distributed along the entire length of the lower limb. however. but most are unnamed. which are richly interconnected by shorter transverse (“anastomotic”) veins (Fig. that is.20 Ricci. they may dilate to even a few centimeters.4%. They are also thin-walled. in many cases.17). When the SSV is varicose. CVVs develop either in combination with saphenous vein incompetence or independently.10. but when varicose. Collateral Veins and Varicosities As mentioned earlier. and Goldman The SSV is involved in varicose disease in about 15% of cases (7. Autonomous Collateral Varicosities This term is used here to describe CVVs that develop in limbs with competent saphenous veins (and thus are functionally or hemodynamically “autonomous” or “independent”). The understanding of CV anatomy and their involvement in varicose disease—topics largely ignored in the past—was stimulated and became possible by the practice of AP and Doppler ultrasound (8). 2.13).1). 2. The independence of many CVV from the GSV is confirmed . The CVs drain into deep veins. because of the subfascial position of the vein. the superficial venous system is built of a network of subcutaneous channels called “collateral” (i.9. The individual variability of the CV networks is so great that their detailed anatomical description is impossible. Some of the CV are rather constant side branches of the GSV and have names (Fig. not only via saphenous veins. The superficial CV network consists of many longitudinally and obliquely oriented long channels (“drainage” veins). The CV are subcutaneous and therefore. because it is from them that most varicosities develop.5.. Proximally they also drain via anastomotic veins of the abdominal wall and perineal and gluteal areas. and it is therefore often possible to avulse a CVV 5 –7 mm in diameter through a 1 mm stab incision. So-called “recurrent” (after stripping) varicose veins are usually CVVs. 21% in five different series of total 2142 limbs with PVVs (4. On the other hand. dilatation and incompetence is limited in 46% of cases to its proximal portion (42% and 50% in two series of total 269 limbs) (7. These collaterals are often diagnosed erroneously as GSV disease. 2. in limbs with competent saphenous veins. 20%.

2. Though more superficial than saphenous trunks. in which case both are removed. with the stripper passed into the GSV and kept in situ. transverse (anastomotic) veins. longitudinal (drainage) veins. It is often possible. the origin of reflux may be the SFJ or SPJ (of which the CVV is a branch).18(a) and (b)]. if there is no (or negligible) transfer of reflux between the two systems. 2. A. CVV may be confused with the latter when they descend along the course of the saphenous veins. while the main saphenous junctions (SFJ and SPJ) remain competent [Fig. (Of course. L. Autonomous CVV may be filled from incompetent perforating. the CVV may be autonomous even in the presence of saphenous vein incompetence.18(c)]. Alternatively. because in such cases high ligation and stripping of the normal GSV or SSV is not necessary.) Finally.Anatomical Bases of AP 21 Figure 2. In these cases. .17 General organization of the superficial collateral (nonsaphenous) veins. it is not uncommon that both the saphenous trunk—single or double—and the CVV parallel to it be incompetent. to avulse the varices without encountering the stripper (14). duplex scan will readily distinguish between the two. by surgical experience. abdominal or pelvic veins. while distal the saphenous trunk remains competent [Fig. This is important. showing the saphenous vein in its interfascial compartment and the CV in the subcutaneous space outside the saphenous compartment.

(d. (a) Reflux from groin anastomoses with competent SFJ. (f) Large anterolateral varicosities with competent GSV. (b) Reflux from incompetent thigh perforator (TPV).1 – 2. The most frequent combination is that of partial (proximal) or total GSV dilatation and incompetence with one or more distal varicose side branches (Fig.e) Large collateral bilateral varicose veins with pelvic reflux via pudendal anastomoses and competent SFJs and GSVs. there are several possible combinations between collateral and truncal (saphenous) varicosities. The latter usually originate from the area of Boyd’s PV below the medial knee. which are described separately.2).22 Ricci. pelvic anastomoses. Georgiev. and Goldman Combined Collateral and Saphenous Varicosities This is the most common varicose pattern that is present in . According to the anatomic position and functional role of the CV segment involved. PA. These combinations give rise to specific clinical varicose vein patterns. Figure 2.18 Origin of reflux in CVV. (c) Reflux originates from an incompetent SFJ and continues along the varicose anterolateral thigh vein (ALV). while the GSV is competent.50% of cases (Table 2. .19). but may arise at any point along the GSV. 2.

Anatomical Bases of AP 23 Figure 2.21).18 Continued. A particular combination is that of a . In the latter scenario. 2. Sometimes. 2. in these cases. the proximal reflux point may be either a combination of incompetent main junctions (SFJ/SPJ) plus collateral reflux or collateral reflux only with competent SFJ or SPJ (Fig.20). high ligation of the GSV/SSV may not be necessary. Another possible combination is for the CVV to bypass a competent middle saphenous vein segment and transmit reflux between proximal and distal incompetent segments (Fig. the CVV may lie proximally to the incompetent portion of the GSV (or SSV).

PVs are not regularly distributed along the limb’s surface.24 Ricci. and Goldman Figure 2. which spares normally functioning superficial veins. long vessels with an oblique course terminating in muscular branches (“indirect” PV). but increase in density from proximal to distal in a 1:2:8 proportion between . In most cases. 2. Perforating Veins PVs connect superficial to deep veins crossing (“perforating”) the aponeurotic fascia.19 Common type of advanced varicose vein disease of the GSV system. Georgiev.35(b)]. More than 150 PVs have been described. some are shorter and almost perpendicular (“direct” PV). Recognition and mapping of these clinical variants permits precise surgery. most of which are valveless and some of which permit reverse (deep to superficial) one-way flow]. a typical example is that of a varicose Giacomini vein transferring reflux from the proximal GSV to the SSV [Figs. 2. varicose veins present as combination of GSV incompetence and CVVs. this latter group are fairly constant and named (Figs.1 and 2. 60% of which accompany an artery (2).2). varicose collateral transferring reflux from the proximal varicose segment of one vein to a distal varicose segment of another vein.3 and 2. Most PVs are tiny. They have valves that direct flow from the superficial to the deep veins [exceptions are the PV of the foot.

(a) Combined (collateral and truncal) varicose veins with partial (distal) truncal involvement and competent main junction. time-consuming. despite its small surface area (27). Normally. and unreliable. . Thus. The most proximal leak point of a varicose vein is rather easy to detect with Doppler ultrasound. given their small caliber and the extreme abundance of venous anastomoses. flow through the PV is minimal.20 Varicose veins with collateral origin of reflux. a PV permits flow from deep to superficial veins termed escape or leak points. but the detection of all leak points is difficult. thigh.Anatomical Bases of AP 25 Figure 2. When incompetent. but in the varicose limb incompetent PV rarely enlarge. CVV. and foot. Attempts to ascribe a major role to some PV in pathologic conditions have been attempted. leg. great saphenous vein. GSV. Their caliber usually remains smaller than that of varicose superficial veins.30% of all perforators are in foot. Detection is improved with duplex imaging and further enhanced with venography/varicography. collateral varicose veins. While determining the most proximal leak point of a varicose vein is important (because the latter should be avulsed as close as possible to it) . (b) Clinical presentation.

flow in it is mainly inward during ambulation (15. flow in any incompetent lower leg perforator is directed mainly inward so that the latter (called also “re-entry perforator”) drains retrograde saphenous flow into the competent deep veins.26 Ricci. these are hemodynamically and clinically significant only when there is concomitant deep vein incompetence (17). retrograde flow becomes physiologic (inand upward) as it reaches the competent deep veins via a re-entry perforator (PV). it becomes physiologic Figure 2. 2. Georgiev. Furthermore.22 Flow in perforating veins. because proximal occlusion of the saphenous trunk normalizes the pathological high ambulatory pressure in the perforator (16 – 18). even when the latter is incompetent. during ambulation.16). When deep veins are competent and saphenous vein incompetence co-exists with lower leg perforator incompetence. the pathologic significance of an incompetent PV cannot be considered out of context to varicose vein disease. Reflux originates at the incompetent SFJ and bypasses a competent GSV portion via CVV. the former appears to be of major pathological significance. and Goldman (Tables 2.21 Combined (collateral and truncal) varicose veins with partial truncal involvement. . In these conditions. When outward flow of an incompetent PV reaches a competent superficial vein.3 and 2. At the end of the incompetent GSV portion. the importance of all other (distal) leak points is probably overestimated. Figure 2. While about 45% of limbs with PVVs have multiple incompetent perforators.28). where flow becomes physiologic (upward) (Fig.4).22) (27. at least when the limb has competent deep veins.

thigh extension of the SSV) may be difficult to determine unless a duplex scan or a venogram is performed. others are transverse anastomotic channels. At the end of an incompetent superficial segment. Here. Some are longitudinal channels that run along the thigh either parallel to the GSV and ASV or divergent from these.Anatomical Bases of AP 27 (Fig. the ASV. with foot perforators. 2. The anatomy of the SFJ is described in detail in Chapter 15. flow becomes physiologic as blood reaches either a deep vein through a re-entry perforator or a competent superficial vein (Fig. TOPOGRAPHIC DESCRIPTION The extension of a varicose vein is determined both by clinical examination and by extension of its reflux. Thus. deep and/or superficial valvular incompetence must be present for outward perforator flow to become clinically important (27). however.23). we describe the most common types of varicose veins that may develop in different areas of the lower limb and the possible origin and propagation of their reflux. In other words. In 41% of limbs. the total number of superficial and perforating veins is very high. what matters is not the detailed description of all anatomical anastomoses. SSV. along the posterior. 2. physiologic outward flow does not induce varicose veins.28). every superficial vein has many proximal anastomoses with both the superficial and deep veins. avulsion of the varicose vein automatically disconnects the incompetent PV (26. when outward perforator flow reaches an incompetent varicose vein. a varicose vein may originate from a competent superficial vein and have no real escape point from the deep venous system. . In other words. CV in this area form a complex network. The varicose GSV may be dilated as to bulge at its termination in the groin. Sometimes. While superficial reflux is easy to trace with Doppler ultrasound. and lateral aspects of thigh. the number of possible (different) varicose vein patterns is large. In clinical practice. On the contrary. Anatomically. In fact. it causes high pressure in the latter and ultimately distends it. medial.23). In this section. there is a second vein in the intrafascial saphenous compartment. but the identification of those which are incompetent. 2. ASV. The GSV terminates in this area and its proximal branches (up to 12 collaterals) of the SFJ have been described (Fig. The most proximal reflux (escape) point is usually an incompetent PV or main junction (SFJ or SPJ). anterior.24). Because any of these superficial veins may become varicose. it is the reflux pathway—the origin and propagation of reflux—that is of clinical interest. the exact origin of reflux from deep veins and the exact involvement of the veins lying into the intrafascial saphenous compartments (GSV. Upper Thigh Varicose veins in the upper thigh are usually located on the medial and anterior aspect (4).

that is. PMV. suprapubic anastomoses. GIA. P. great saphenous vein.28 Ricci. and CV may originate from the incompetent SFJ and/or incompetent extrafemoral (pelvic or abdominal) anastomoses [Fig. subcutaneous saphenous collateral veins. ALV. abdominal wall anastomoses. reflux into the GSV. which connect longitudinal veins.4(b) and (c)]. pelvic anastomoses (pudendal and gluteal veins). SC. deep vein.23 Flow in perforating veins. deep and/or superficial axial incompetence is also necessary. In a series of 279 limbs with PVV. Figure 2. Giacomini vein (intersaphenous thigh anastomosis). it is drained upward. PA. For outward flow to become clinically important. These CVs anastomize freely with each other and proximally with veins of the abdominal wall and pelvis. Thus. anterolateral thigh vein. GSV. Georgiev. Dodd’s perforator(s). pudendal reflux in 39 limbs (14%). AA. perforating veins. (Redrawn from Dortu J. 2. becomes physiologic. When outward flow in an incompetent perforator (PV) reaches a competent superficial vein (PAV). DP. and abdominal or collateral of the SFJ reflux in 28 . ASV. and Goldman Figure 2.) (10).24 Superficial vein topography: upper and medial thigh. SA. posteromedial thigh vein. SFJ incompetence was found in 151 limbs (54%). DV.

Therefore. et al. the GSV may course inward or outward lying at different depths in different segments of the thigh. 2. where they function as a natural bypass of the obstructed deep veins and drain limb blood flow into the caval veins via extrafemoral (pelvic and abdominal) anastomoses. it is often difficult to follow in its entire length with palpation and percussion alone. unpublished data. as there are often one or two parallel veins that run anterior and posterior to the GSV. The thigh portion of the GSV is covered by the superficial fascia. For these reasons. careful Doppler examination with a superficial. which can only . (Georgiev M. and transverse (anastomotic) CVs (Fig.) Medial Thigh The medial thigh is crossed by the GSV and longitudinal. One or more of these collateral channels may be involved in the varicose disease. while the main GSV trunk lies deep to them under the superficial fascia (10). but are often missed (bypassed) by internal strippers. Sometimes. extrafemoral (pelvic or abdominal) reflux was found in 53 limbs (68%). Sometimes. Sometimes. which is. 2. therefore.1). CVV of the groin are not rare in PVV and are common finding in women with pelvic (ovarian) varices. Most varicose veins of the thigh develop in this area. determining the presence—and especially the course and extent—of reflux in the GSV may be difficult and unreliable with clinical examination alone and must be confirmed by Doppler or duplex ultrasound. In this case. which are varicose. the GSV may be very superficial and thus easy to examine clinically. even when dilated and incompetent. Often only a saccular dilatation (usually at the site of Dodd’s PV) is palpable. oblique. Duplex scan of this area is mandatory if one is to distinguish between GSV and ASV incompetence. in a series of 78 limbs with recurrent varicose veins. only the proximal portion of the main GSV trunk is incompetent and reflux is then deviated along one of the subcutaneous CVs.24).Anatomical Bases of AP 29 (10%) (5). It has two constant perforators: the mid-thigh perforator in Hunter’s canal and the above-knee perforator(s) [Dodd’s perforator(s)] (Fig. which is usually deep and may even lie adjacent to the deep fascia.. They are regularly found in cases of chronic postthrombotic occlusion of the common femoral and external iliac veins. When varicose. 2. many groin collaterals become visible and palpable. of great practical interest for the phlebologist. These variants are evident during GSV stripping with the external stripper. Here.6(b)] (10). a superficial varicose vein should not be assumed automatically to be the GSV. This specific and quite common varicose pattern is termed a “bayonet” type varicosity [Fig. narrow-focused high frequency (8 – 10 mHz) probe allows one to determine exact reflux patterns to separate incompetent and competent branches. However. They are also commonly found in recurrent (post-stripping) varicose veins. the distal (competent) portion of the GSV (below the cross-over of reflux into the bayonet) need not be stripped.

Reflux in them may originate from the incompetent SFJ or pelvic/abdominal anastomoses [Fig. 2.21] or independent (autonomous) [Fig. Independent dilatation of this system occurs through incompetent PVs that connect the lateral venous system directly to the deep femoral or popliteal veins (31. 2. or from incompetent thigh perforator(s) (saphenous or not) [Fig.16(a)]. Reflux in the varicose GSV may originate in the groin.4) [Figs. from an incompetent SFJ and/or extrafemoral (pelvic/abdominal) anastomose (86%).30 Ricci. 2.19. and leg or the anterior/posterior aspect of thigh. and Goldman pass through one of the multiple channels. The posterior thigh CVV may extend to the leg. the posteromedial thigh vein (PMV). 2. They transverse the lateral thigh and calf. but usually extend beyond the medial thigh to continue along the medial aspect of knee. 2. usually the most direct one. 2. Sometimes. in which case they transfer reflux to varicose veins in the respective areas or to the SSV (Fig. empty into the SSV in the popliteal fossa.2) (5). and leg. but not necessarily the varicose one. 2.16(b)].26) (41). The aforementioned varicose variants are sometimes difficult to assess in detail by clinical and Doppler examination alone. This system may become varicose alone or in association with other larger varicose veins.6(b). Lateral Thigh The most common varicose vein on the lateral aspect of thigh is the lateral subdermal plexus (reticular vein). often having complex communications at the lateral knee. which course just beneath the dermis.32). A particular varicose pattern is present when varicose veins of the posterior thigh are filled by upward reflux from the incompetent SPJ (Fig. or from a mid-thigh (Dodd’s) perforator (11%) in one series (Table 2. The lateral subdermic venous system consists of veins that are the size of reticular veins. Georgiev. 2. The PMV often continues distally as a Giacomini vein. and also have anastomoses to the GSV. Posterior Thigh The CVs of the posterior thigh have perforators that connect to the deep femoral vein. but their diagnosis is easy with duplex scan.17(a) and (b)].4(a – d). or transfer reflux from an incompetent GSV to an incompetent SSV or vice versa (varicose Giacomini vein) (Fig. which was varicose in 5% of the limbs in one series (Table 2. Reflux in posterior thigh CVV originates from the incompetent SFJ. to join the SSV in the popliteal fossa. 2. 2 –4 mm in diameter. knee. from an incompetent thigh perforator.25).20] (5). or thigh intersaphenous anastomosis. 2. CVV in the medial thigh may be branches of the varicose GSV or ASV [Figs. It is proposed that reflux through these lateral knee perforator veins into the lateral venous system accounts for the vast majority of painful telangiectatic groups on the lateral . 2.3). which accompanies venous telangiectasias of the lateral thigh and leg. or from incompetent pudendal/gluteal anastomosis. CVV appear as localized clusters. The latter has a constant side branch in this area.

posteromedial thigh vein. Giacomini vein (intersaphenous thigh anastomosis). PMV. GIA. P. FP. perforating veins. (c) Duplex scan of incompetent posterolateral thigh perforator causing back flow from the deep femoral vein into the posterolateral varicose veins. gluteal anastomoses. great saphenous vein. femoropopliteal vein (posterior subcutaneous thigh vein). GA. lateral subdermal plexus (reticular) vein. which may terminate into posterior perforator (P) or split in two or more thigh/gluteal branches (GA).25 (a) Superficial vein topography: posterior thigh. GSV. . posterolateral varicose vein. (b) Clinical appearance. L. PL.Anatomical Bases of AP 31 Figure 2. perforating vein. P.

2. an incompetent anterior thigh perforator situated at any level along the thigh. Medial Knee At knee level. Knee The knee area is characterized by an extremely rich superficial anastomotic collateral venous network and by the presence of many PVs.5 see if adequate). In addition. embedded in a compact subcutaneous tissue and covered by the .28). (b) Longitudinal scan showing the dilated thigh extension of the SSV (FPV) transmitting reflux to the thigh varicose veins. the GSV passes along its medial aspect and the SSV terminates (or transits) in the popliteal fossa. The main GSV channel is deeper. 2. the GSV is almost constantly accompanied by two superficial and parallel CVs that run anterior and posterior to it (10). Larger varicosities in this area are usually branches of the varicose anterolateral thigh vein (discussed later) (Fig. PV. whereas the GSV remains normal and competent (Fig. which originates at the saphenopopliteal junction and proceeds upward along the thigh extention of the SSV.26 (a) Varicose veins of the posterior thigh filled by a “paradoxical” upward reflux. Anterior Thigh Varicose veins of the anterior thigh develop mostly from the branches of the incompetent ASV. Georgiev. half of the thigh and upper calf (33). 2. The ASV was found varicose in 8% and 14% of the limbs in two series (Table 2. and Goldman Figure 2.32 Ricci.27). popliteal vein. veins of the abdominal wall. A grossly dilated ASV may originate from an incompetent SFJ.2) (3.1 and 2.5). or a combination of these. Reflux in them may originate from an incompetent SFJ. and also from the GSV (Figs.

L.29).30). At the upper end of the knee there is a constant perforator that connects the GSV to the superficial femoral vein. This makes its retrieval often difficult. anterolateral thigh vein.27 Superficial vein topography: lateral thigh. Figure 2. anastomotic veins. AA. GSV. superficial fascia. anterior accessory saphenous vein. subcutaneous saphenous collateral veins. A. 2. ASV. great saphenous vein. . anterolateral thigh vein. Varicose veins in this area may be branches of the incompetent GSV. perforating veins. abdominal wall anastomoses. The skin (especially over the patella) is thick and the subcutaneous tissues rather compact and fibrous. suprapubic anastomoses. P. lateral subdermal (reticular) plexus. and transversely oriented superficial veins that form a rich network.30). ALV. or may have local origin from an incompetent knee perforator (Fig. 2. obliquely. Infiltration anesthesia in the area just anterior to the head of fibula may reach the peroneal motor nerve and cause “drop-foot” for the duration of anesthesia (Fig.Anatomical Bases of AP 33 Figure 2. 2. SC. Anterior and Lateral Knee This area contains longitudinally. ALV.28 Superficial vein topography: anterior thigh. Many varicose collaterals transit here or originate from the knee portion of the GSV or from an incompetent knee perforator (Fig. CVVs of the thigh. so that phlebectomy may be time-consuming. SA.

are all clustered in relatively little space. Popliteal Area Deep anatomy of the popliteal fossa is complex. great saphenous vein. SC. BPV. the description of veins in the popliteal area with reference to their involvement in varicose vein disease and the technique of stab avulsion phlebectomy is much simpler. ACV. posterior knee anastomoses. anterior knee anastomoses. the short saphenous vein. superficial peroneal nerve. SC. In about one-third of cases. subcutaneous saphenous collateral veins. However. anterior knee anastomoses.29 Superficial vein topography: medial knee and leg. The SSF usually joins the popliteal vein in the segment that extends from the knee joint proximally for $5 cm. deep peroneal nerve. AK. Georgiev. DPN. PAV. (The skin projection of the knee joint corresponds to the popliteal crease. common peroneal nerve. and Goldman Figure 2.) The termination of the SSV may differ from this standard type in up to 50% of cases (21). AK. CPN. GSV. SPN. great saphenous vein. PK. Cockett’s perforating veins. motor and sensory nerves. Boyd’s perforating vein.30 Superficial vein topography: anterior knee. anterior crural vein. In addition to its junction with the popliteal vein . posterior arch (Leonardo) vein. GSV. the muscular (gastrocnemius and soleus) arteries and veins. The popliteal artery and vein(s). additional (up to eight) popliteal PVs. the SSV and the gastrocnemius vein merge just before the SPJ. it terminates above or just below this segment.34 Ricci. like tendons. Figure 2. CPV. subcutaneous saphenous collateral veins. In some cases. and collaterals of the aforementioned vessels plus nonvascular structures.

small saphenous vein. It may originate from a proper incompetent popliteal perforator (which often presents as a very large sacciform vein). sometimes joins the SPJ). 2. Dodd popliteal area vein is close to the SSV. For this reason. They may be side branches of the SSV. PA.Anatomical Bases of AP 35 (SPJ). and other (nonpopliteal) knee perforator incompetence in 7% of limbs in one series (Table 2. A.7). originate from the GSV or other varicose thigh collaterals. but superficial and lateral to it. SPJ or popliteal perforator incompetence was found in 13% of limbs. popliteal vein. or may share the SPJ with the SSV (Fig. P. or may join the GSV via the Giacomini vein (Fig.31 Superficial vein topography: popliteal area. causing unsightly scars. so that attention must be paid during phlebectomy to avoid nerve damage. G. . muscular (gastrocnemius) calf veins. 2. or an incompetent popliteal perforator (up to eight popliteal perforating veins have been described). Figure 2. great saphenous vein. S. popliteal area vein (Dodd) (collateral channel of posterior leg with proper popliteal perforator. CVVs different from the popliteal area vein may also develop in the popliteal area. Veins that terminate in the popliteal fossa (especially the SSV and the popliteal area vein) may lie in close proximity to the sural (sensory) nerve and its branches. the SSV may continue up the thigh as femoropopliteal vein. we prefer to use Graefe forceps instead of hooks in this area. As points of origin of varicose veins (most proximal leak points). GSV.35). SPJ. intersaphenous leg anastomosis.3) (4). FP. saphenopopliteal junction. The skin over the popliteal area is soft and delicate. M.31) (34. The varicose SSV can usually be palpated in the popliteal area over the point where it courses anteriorly to approximate the popliteal vein (for more detail see Chapter 13). careless manipulation may lacerate it. femoropopliteal vein (thigh extension of the SSV). Giacomini vein (intersaphenous thigh anastomosis).

It runs along the medial aspect of tibia and is covered with a layer of the superficial fascia. but a superficial CV. (A readily visible varicose vein in this area is usually not the GSV. 2. and the PAV. Most often the leg portion of the GSV is competent and the varicose veins are collaterals that are conveniently removed by stab phlebectomy. many GSV side branches depart from this area and are better illustrated in separate groups.29). and Goldman Medial Leg The medial aspect of leg is the most important area in phlebology. 2. by the posterior arch vein (PAV). because most varicose veins and most stasis changes occur in this area. four or even more separate varicose veins in this area. lies posterior and almost parallel to the GSV. especially in advanced cases of varicose vein disease. The GSV begins anterior to the medial malleolus where it is usually visible and palpable. Posterior group.1 and 2. few of which are direct (Figs. CVs of the posterior and anterior leg. It is recognized by its subcutaneous position outside the interfascial saphenous compartment. superficial medial collaterals.1 and 2. by many other collateral and perforating veins. Fortunately. it is not rare to find. There are many unnamed superficial veins on the medial aspect of leg. Inferior collaterals may be double or triple subcutaneous collaterals. 4. parallel to the GSV.28). parallel to the GSV trunk or anastomoses with thigh CVs. its palpation is difficult and its avulsion by stab phlebectomy time-consuming. In the upper end of the medial leg. Inferior group. 2. Anterior collaterals are the anastomotic veins of the anterior knee and the anterior accessory leg vein (discussed later). the lower leg portion of the GSV is rarely incompetent and varicose and its stripping is seldom necessary. Reflux in the varicose veins of the medial aspect of leg may originate from the incompetent proximal GSV. Anterior group. 2. the PAV was varicose in 8% of the limbs (13% if only the limbs with incompetent GSV are considered) (5). 1. It is crossed by the GSV. The area of this perforator is an important superficial venous “crossroad” (Fig. 3. The only named CV of the medial leg. and its connection to the posterior tibial vein by four direct.) The saphenous (sensory) nerve lies close to the GSV. Care must be taken not to damage it when manipulating the GSV trunk. In one series of 279 limbs with PVV. anastomotic channels with the SSV. Georgiev. the “posterior arch” or Leonardo vein (PAV). This consists of anastomotic channels with the SSV and CVs of the popliteal area and posterior leg. Superior collaterals may be double or triple subcutaneous collaterals.36 Ricci. from the incompetent proximal portion of the . the GSV is connected to the deep (posterior tibial) vein by a constant (Boyd’s) PV. Superior group. constant PVs: the (three) Cockett perforators plus the 24 cm perforator (Figs. For this reason.29).

32). The skin in this area is thick and the subcutaneous tissues compact. For this reason. prior to hooking and exteriorizing the proximal part of the SSV. which makes its avulsion time-consuming. or leg perforator(s) or a combination of these. Anterior Leg A constant branch of the GSV.33). Posterior Leg There are two types of veins on the posterior aspect of the leg: the SSV and CVs. veins in this area may be visible—and considered unsightly by the patient—even when competent and not varicose. Few additional collaterals are often found over the tibia. The SSV begins behind the lateral malleolus and ascends the posterior aspect of the leg to join the popliteal vein in the popliteal fossa. The distal part of the SSV. SSV. may be embedded in compact fibrous tissue. or popliteal area vein. Varicose veins in this area are usually branches of the incompetent GSV. These often lie close to sensory nerves and lymphatics that may be damaged during the operation. lateral thigh vein (lateral subdermal plexus). Therefore. Fortunately. but may also originate from an incompetent local (lateral or paraperoneal) PV. The veins may be embedded in the membranous fascia and their avulsion. Near the level between the lower and medial third of the leg it perforates the deep fascia and lies in a compartment formed by a duplication of the deep (aponeurotic) fascia. so that its total avulsion is seldom necessary (17. as with the GSV. The sural (sensory) nerve lies close to the SSV.Anatomical Bases of AP 37 SSV. The SSV is covered by the superficial fascia for its entire length. though superficial to the deep fascia.25). 2. 2. the anterior crural vein (ACV) crosses the tibia obliquely from the dorsal foot to the area of Boyd’s perforator. Lateral Leg Varicose veins of the lateral leg may be branches of the anterolateral thigh vein. therefore. knee. especially in its distal portion. . from incompetent thigh. The medial leg varicose veins often transfer reflux between the GSV and SSV. GSV. but may also originate from incompetent tibial perforators (Figs. it is necessary to perforate and dissect the aponeurotic fascia. the presence of varicose veins on the proximal aspect of leg does not automatically imply proximal GSV incompetence. As the subcutaneous tissues over the tibia are thin. in most cases only the proximal portion of the SSV is incompetent and dilated. It was varicose in 11% of cases in one series (20% if only the limbs with incompetent GSV are considered) (5). occasionally vein and nerve lie so close to each other that it may be difficult or even impossible to separate them without damaging the nerve (40).4 and 2. and may become very large when varicose. time-consuming (Fig.

ALV. ACV. AK. R. transverse (anastomotic) collateral veins. L. which lies superficial to the SSV and may be confused with it.34). PP. This vein is extrafascial and usually lateral to the SSV and has a proper popliteal perforator. retromalleolar collaterals. The SSV is connected to the deep veins by a few large and direct PVs. anterior knee anastomoses. anterior crural vein(s). 2. Most of the collaterals on the posterior aspect of leg are short (transverse or oblique) anastomotic branches that connect the SSV with the GSV and its branches (intersaphenic anastomoses) or with other lateral and medial leg veins (Fig. BPV.38 Ricci. 2. great saphenous vein. because it may run along the subfascial portion of the SSV (difficult to palpate) or along some of the deep (muscular) veins of the calf . Boyd’s perforating vein. and Goldman Figure 2. it has been called by Dodd popliteal area vein (34). which are illustrated in Figs. Reflux in the SSV and varicose veins on the posterior aspect of leg may have different origins and may be difficult to trace by clinical and Doppler examination.7. paraperoneal perforating veins.32 Superficial vein topography: anterior leg.33 Superficial vein topography: lateral leg.2 and 2. but most often is independent and may develop in legs with competent SSV. A. small saphenous vein. SSV. anterolateral thigh vein. lateral subdermal plexus vein. GSV. There is sometimes a varicose vein on the posterior aspect of the leg. It may co-exist with SSV incompetence and may even share a common popliteal junction with the SSV. Figure 2. Georgiev.

R. 2. PAV via transverse (anastomotic) collaterals [Fig. 4. A. but also from the muscular (gastrocnemius and soleus) veins of the calf. Distally they join the SSV and/or the collateral superficial veins via the soleus and gastrocnemius perforators [Fig. Reflux in them is difficult to localize and differentiate from popliteal (deep) or SSV reflux. they are not palpable and difficult to identify by Doppler examination.35(a – e)]. M.35(d)]. PA. 3.35(b) and (c)] (21). duplex scan has the advantage of permitting a repeatable visualization and determination of the direction of flow in each of these vessels. 2. Reflux may originate from: 1. P. muscular (gastrocnemius) calf veins. Proximally they join the popliteal vein close to the SPJ (and may even share the latter with the SSV). Bassi’s perforator.3. retromalleolar SSV collaterals. BP. (difficult to distinguish from the SSV) [Fig.Anatomical Bases of AP 39 Figure 2. Incompetent posterior leg perforators: These originate not only from the axial (tibial posterior) deep leg veins. 2. intersaphenous leg anastomoses. posterior leg perforators. 2. While venogram gives an excellent general view of the region.35(e)]. 2. Incompetent SPJ and/or popliteal perforator(s) [Fig. mid-calf (gastrocnemius point) perforating vein. MC. 2. These veins have an oblique course. S. Because the muscular veins lie deep and almost parallel to the SSV. Incompetent superficial veins of the thigh: GSV via the Giacomini vein or veins of the posterior aspect of thigh (femoropopliteal vein) [Figs. unless a duplex scan or a venogram is performed. Incompetent superficial leg veins: GSV. popliteal area vein (posterior subcutaneous leg vein). small saphenous vein. 2. .34 Superficial vein topography: posterior leg.35(a)].

The dorsal venous arch is formed by continuations of the GSV and SSV and is covered by the superficial fascia (Fig. Georgiev. and also from an incompetent posterior leg perforator (data not shown). 1991. Others argue that these veins are often responsible for the development of varicose veins on the posterior aspect of leg and for the impairment of calf muscle pump function (35). (d) incompetent GSV or medial leg perforator(s) via intersaphenous leg anastomoses (A).37). 2. (c) posterior thigh perforator (high termination) or posterior subcutaneous thigh veins via the femoropopliteal vein (F. (b) incompetent GSV via the Giacomini vein (G). thereby allowing safe removal of any varicose foot vein. P. dilatation of these veins is most often an aging phenomenon (4).40 Ricci. all veins freely communicate with each other. . often of post-thrombotic origin. posterior subcutaneous thigh vein). they must be excised according to one of the available specific techniques (24. It is thick-walled and rarely enlarges to become grossly varicose. 103:13.36(a) and (b)]. Foot Superficial veins of the foot can be divided into two types: the dorsal venous arch and the CVs [Fig. popliteal vein. In the resulting rich network. According to some authors. and Goldman Figure 2. Approximately one-third of all perforators are located in foot. and may feed varicose veins to the medial and lower third of the leg. A peculiar characteristic of foot veins is the great abundance of perforators and venous anastomoses. Lettre chirurgicale. Muscular calf veins cannot be avulsed by stab phlebectomy.35 Origin of reflux in the varicose short saphenous vein. if necessary. (Modified from J Van der Stricht. There is some controversy regarding the role muscular calf veins may play in varicose disease.) Reflux in the varicose SSV (S) may originate from: (a) incompetent SPJ (standard type SSV).25). In our experience. Varicographie et Phlebographie dynamique. It is connected to the deep (plantar) veins by thick-walled perimalleolar and transmetatarsal perforators. (e) incompetent muscular (gastrocnemius) calf vein(s) (M). 2. isolated gastrocnemius or soleus vein incompetence is rare. Avulsion of the dorsal venous arch is rarely indicated.

posterior arch vein. ACV. collateral veins of dorsal foot.33). (b) Lateral foot. collateral veins of dorsal foot. C. retromalleolar collaterals of the SSV. They form a network that has many perforators and anastomoses with the dorsal venous arch and with the most distal portion of the GSV and its anterior leg collaterals. SSV. dorsal venous arch. Figure 2. GSV.36 Superficial vein topography: the foot. these often become varicose when the distal portion of the SSV is incompetent (Fig. . outside the superficial fascia.37 Transverse scan of the foot portion of the GSV. R. D. thin-walled and lie subcutaneously. anterior crural vein.Anatomical Bases of AP 41 Figure 2. C. 2. great saphenous vein. D. A fascial (superficial fascia) layer separates the GSV (left) from the subcutaneous collateral veins also at foot level. (a) Medial foot. dorsal venous arch. small saphenous vein. In the lateral retromalleolar fossa there are many collaterals of the SSV. The dorsal foot CVs are a continuation of collateral leg veins. PAV.

deep blood flow passes through a single vessel: the popliteal vein (which is often double) and the CFV. sensory nerves. Thus. DVI)— causes impairment of calf pump function. it is important for long-term prognosis.42 Ricci. Short segment damage of one of these veins can therefore be compensated by the remaining collateral (deep) veins. and even tendons lie very close to each other. the superficial and the deep femoral veins. damage to these veins (especially if extensive) causes severe impairment of venous pump function. it is important that patients with suspected deep venous pathology undergo a thorough investigation. veins. For this reason. they are the major transport vessels of the leg and their permanent (usually post-thrombotic) damage—chronic obstruction of valvular incompetence (deep venous insufficiency.) There are many deep venous channels in the leg (usually two for each artery). but most will ultimately develop classic post-thrombotic syndrome with chronic edema. DEEP VEINS OF THE LOWER LIMB Deep veins accompany corresponding arteries under the deep fascia and normally drain . dermatitis. Though DVI does not influence the decision to operate on varicose veins. (Other types of deep venous pathology are congenital aplasia and extrinsic compression syndromes. Patients with DVI must be told that their . Patients with mixed deep and superficial venous insufficiency benefit from varicose vein avulsion (17. lifelong compression is the only treatment available. Deep venous thrombosis may cause enlargement of some superficial veins that may become varicose in appearance. Therefore.27). because great care must be taken not to damage nerves (or even tendons). and at least two major deep channels in the thigh. thus. Exceptions are the dilated but competent superficial veins in limbs with DVI. phlebectomy in this area is difficult and time-consuming. They may also benefit from correction of co-existent superficial venous insufficiency (38). which are beyond the scope of this text. On the contrary. and Goldman The CVs on the dorsal foot may enlarge and become grossly varicose. and consequently lead to only moderate clinical symptoms. but nevertheless remain competent. DVI may co-exist with varicose veins and may also play a role in their development. pigmentation.90% of the limb’s blood flow. However. Georgiev. On the dorsal foot there is only a thin layer of subcutaneous tissue. and cutaneous ulceration. For most of these patients. most of the varicose veins of the foot develop in fact from the CVs. varicose veins are avulsed regardless of the presence of DVI. therefore. lipodermatosclerosis. Such normally functioning superficial veins are easily identified by Doppler ultrasound and should not be avulsed. because a small percentage of them may benefit from the available techniques of reconstructive deep vein surgery. Some limbs may tolerate considerable impairment of venous pump function and develop relatively few (and mild) symptoms. in the popliteal fossa and in the groin. with the classic symptoms of acute deep venous thrombosis and its chronic sequalae—the post-thrombotic syndrome.

(a) Telangiectasia along the course of an incompetent GSV. B. S. which may rupture causing hemorrhage). Figure 2. isolated telangiectasia (not related to larger vein incompetence). Except for the isolated type. more important. so that lifelong compression therapy is mandatory (see Appendix A). These telangiectasia are usually spider (star) shaped and may be the only symptom of GSV incompetence. NERVES AND LYMPHATICS Cutaneous (sensory) nerves and lymphatic vessels lie in close relationship with superficial veins. lymphocele. cart-wheel telangiectasia of lateral thigh. spider (star) shaped telangiectasia with superficial (F) or perforating (P) feeding vein. lateral subdermal plexus (reticular) vein.Anatomical Bases of AP 43 deep vein pathology makes varicose vein recurrence (and. Consequently.38 Venous leg telangiectasia. L. the development of stasis changes) more likely. . (b) Different types of telangiectasia. bleb type (large blue telangiectasia. C. all other types of telangiectasia may benefit from phlebectomy of the feeding veins. sensory nerve damage. I.

this GSV is not visible or palpable and measures only 3 – 3. Lymphatic damage is most likely to occur in the Boyd perforator area below the medial aspect of knee and the area along the anterior aspect of tibia (39).44 Ricci.39 Telangiectatic flare of lower leg in 23-year-old patient. which is incompetent from its junction with the femoral vein in the groin to the enlarged perforator situated in the middle of the flare. lymphedema are potential complications of varicose vein surgery (4). not directly connected to an incompetent larger vein. that is.5 mm in diameter all along its course. filling with retrograde flow appropriately Figure 2.0 mm in diameter. and Goldman lymphorrhea and. Despite being incompetent. more rarely. Some of these tiny vessels are isolated. They may appear at any site of the lower limb and are best treated by sclerotherapy. along the distal portion of the GSV and especially along the distal part (sometimes the entire length) of the SSV.1 – 1. Georgiev. The flare is filled by retrograde flow into the GSV. others— especially those which appear as a dense telangiectatic network—may be connected to an incompetent vein. Sensory nerves lie close to dorsal foot veins. so that the only “symptom” of GSV incompetence is the telangiectatic flare. . SURGICAL ANATOMY OF VENOUS LEG TELANGIECTASIA Leg telangiectasia measure 0. and it is in these areas that nerve damage most frequently occurs.

we consider this “cosmetic frontier” of stab phlebectomy most rewarding. Ann R Coll Surg Eng 1979. Ultrasound anatomy of the superficial veins of the lower limb. 2. flow in the reticular vein is upward and the latter becomes a feeding vein. while leaving the reticular vein untreated. Confirmation of this “ambiguity” is the observation that it is often possible.1 mm pointed (n. Vellin A. and may be the only symptom of saphenous trunk incompetence [Fig. Personally. J Cardiovasc Surg 1990.1) Muller hook (for vein hooking and exteriorizing). 1987. L’anatomie du systeme veineux de l’extremite inferieure en relation avec la pathologie variqueuse.39). it is usually still possible to detect a reflux point by Doppler ultrasound (Fig. IV European-American Symposium on Venous Diseases. Folia Angiol 1961. Occasionally. 2. it may also be deep and perpendicular to the skin surface (i. Georgiev M. 4. DC. 61:198. 3. Goren G. 8:240. in these cases. The long saphenous vein compartment. because the avulsion of feeding veins by stab phlebectomy usually attenuates the telangiectasia (which may disappear completely) facilitating sclerotherapy of the remaining vessels. However. Phlebology 1997.. Stuttgart: Georg Thieme Verlag. The relationship between this type of telangiectasia and the larger (reticular) vein is ambiguous. May R. There is not always such a clear relationship between telangiectatic and reticular (feeding) veins. Common types of telangiectasia are those of cartwheel or radiating pattern on the lateral thigh [Fig. 2. which thus behaves as a drainage and not feeding vein. 2. permits avulsion of the feeding veins with scars that become virtually invisible after a few weeks.e. 12:107– 111. It is this second type of telangiectasia that is of surgical interest. the feeding vein is usually of small (1 – 3 mm diameter) caliber [Fig.38(b)].38(a)]. 6. The surgical anatomy of the superficial and perforating veins of the lower limb. 7. 5. Ricci S. 31:672. Primary varicose veins: topographic and hemodynamic considerations. on the contrary. a telangiectatic flare may be “fed” directly by an incompetent saphenous trunk. March 31 – April 2. The feeding vein may be visible (when superficial) and its reflux is easily detected by an 8 – 10 mHz Doppler probe. In such case. In the recumbent position. Georgiev M. Thompson H. flow may be downward. from the telangiectasia to the reticular vein. to obtain excellent and long-lasting results by sclerotherapy of the telangiectasia alone. Nissl R.Anatomical Bases of AP 45 called a “feeding” vein.38(b)]. In the upright position. Washington. Surgery of the Veins of the Leg and Pelvis. because the use of a hypodermic needle or blood lancet (for the incisions) and a 0. 2. Ricci S. Limborgh J van. 1979. tiny perforator) and thus impossible to see or palpate. Primary varicose veins: a topographic study. J Vasc Technol 2002. 26(3):183– 199. Caggiati A. . However. that is. REFERENCES 1.

3:273. 1 – 4. Staubesand J. Frequence et extension de l’insuffisance primitive de la saphene externe. Koyano K. J Vasc Surg 1986. Leopold PW et al. The clinical implication and therapeutical consequences of the observed hemodynamic patterns. 27. Berry SM. 16. 156:69. Phlebologie 1989. Muenchen: Urban & Schwarzenberg. Echoanatomical patterns of the long saphenous vein in patients with primary varices and in healthy subjects. Bailly M. and Goldman 8. Belcaro G. 20:225– 233. Nasso C. Oxford: Butterworth Heinemann. Myers K. In: Enciclopedie Medico-Chirurgicale. Staubesand J. Lefebre-Vilardebo. Perforating Veins. Caggiati A. J Vasc Surg 2003. . Partsch H. 14:54 – 58. 14:59–64. Zukowski AJ. Flebologia 1997. Phlebology 2001. 2:886. Berlin E et al. Determination of “good” saphenous veins for use in in situ bypass grafts by real-time B-mode imaging. Bassi Gl. diagnosis and office surgery. Chang BB. Cornu-Thenard A. Haemodynamic significance of incompetent calf perforating veins. Dortu J. 37:558– 563. Tibbs D. Eriksson I. Ricci S. J Vasc Surg 1985. 103:615. 25. Almgren B. eds.46 Ricci. ´ ´ 11. Echoanatomy of the long saphenous vein in the knee region: proposal for a classification in five anatomical patterns. 9. 24. Georgiev M. Georgiev M. Thulesius O. Bailly M. Gioeres JE. Hoffman HM. 18. ´ 20. 1992. 8:117 –119. 78:625. 12:184. Phlebology 1999. 23. with preservation of the main great saphenous trunk. Perforating Veins. Sakaguchi SH. Surgery 1988. In: May R. J Vasc Technol 1987. Selective stripping operation based on Doppler ultrasonic findings for primary varicose veins of the lower extremity. Georgiev. 12. Die venoesen abflussverhaeltnisse des musculus triceps surae. Blood flow in perforating veins of the lower extremity. Ricci S. Ballo M. The femoropopliteal vein: ultrasound anatomy. 28. Does a double saphenous vein exist? Phlebology 1999. 22. 21. 15. Szendro G et al. 11:145.” Int Angiol 2001. Varicose Veins and Related Disorders. 17. 16:111–116. Anatomie clinique des collaterales variqueuses (varicoses essentielles). 26:137. Acta Chir Scand 1990. Ricci S. Dermatol Surg 1996. Shah DM. Belcaro G. Cavezzi A. The lesser saphenous vein: an under-utilized arterial bypass conduit. 20:164. 26. 19. 48:321 – 327. Lemasle Ph. 13. 22:57– 62. Phlebologie 1991. In: May R. 42:553. Tamisier D. Paris: 43-161-B. Baud JM. Cartographie CHIVA. Ecografia venosa ed esperienza CHIVA. 1981. 29. 1981. Caggiati A. Staubesand J. The anatomy of the greater saphenous venous system. Bjordal R. Kupinski AM. Georgiev M. Circulation patterns in incompetent perforating veins of the calf in venous disfunction. Myers K. ´ ´ Confrontation echo-chirurgicale de la termination de la saphene externe dans le ` cadre de la chirurgie d’exerese. Nicolaides AN. 10. Giacomini’s observations “on the superficial veins of the abdominal limb and principally the external saphenous. 14. J Vasc Technol 1988. Large J. Surgical treatment of saphenous varices. Phlebologie 1995. Sussmann B. Ibrahim IM et al. Uhl JF. Partsch H. deep and perforating veins of limbs with varicose veins. Phlebologie 1973. Br J Surg 1991. Valvular incompetence in superficial. eds. Muenchen: Urgan & Schwarzenberg.

Phlebology ’85. Phlebologie 1980. The enigma of the gastrocnemius vein. Rinaldi B. this was done by total stripping of the GSV or SSV. J Dermatol Surg Oncol 1992. Hobbs JT. Inc. they are visible and easily marked for operation by clinical examination alone. the anterior ASV. and the thigh intersaphenous anastomosis (Giacomini’s vein) (Fig. They are not visible and may not be palpable even when dilated and incompetent. “custom-made” stripping of only the incompetent segment has been proposed. 1986:172. J Cardiovasc Surg 1981. 39. When the interfascial veins are incompetent and transmit reflux to the varicose veins. 52:350. Because of their superficial position. On the contrary. Weiss MA. Ltd.. 40. more recently. APPENDIX A: ATLAS OF VARICOSE VEIN PATTERNS PATTERNS OF SAPHENOUS VEIN INVOLVEMENT IN VARICOSE VEIN DISEASE Varicose veins develop from subcutaneous saphenous collaterals. Georgiev M. Weiss RA. Surgery 1977. Thomas ML et al. Doppler ultrasound findings in reticular veins of the thighs. but can be thoroughly visualized and marked precisely under ultrasound (duplex) guidance. 32. Vieira G. Varicose Veins and Telangiectasias: Diagnosis and Treatment. Beeman S et al. 3:19. Lymphatic disruption in varicose vein surgery. 1993:389– 406. Burnand KG. 33. St. Gross WS. Painful telangiectasias: diagnosis and treatment.Anatomical Bases of AP 47 30. The preoperative duplex examination. 41. 38. eds. Weiss RA. Phlebectasia within the sural nerve. Thiery L. the SSV and its thigh extension. the interfascial superficial veins lay in the saphenous compartments and are covered by the superficial fascia. Bergan JJ. 37. Localized vascular dilatations of the human skin—capillary microscopy and related studies. A1). 35. 82:9. Jantet G. 36. The varicose tributaries of the popliteal vein. In: Negus D. Dermatol Surg 1998. In: Bergan JJ. Goldman MP. Am Heart J 1949. Br J Surg 1965. Walsh JC. 24:433– 440. there are also surgeons who demonstrated that in some patients. Weiss MA. L’importance de la saphene externe en phatologie. The relative importance of incompetent communicating veins in the production of varicose veins and venous ulcers. However. 31. Pelzer RH. J Dermatol Surg Oncol 1994. 37:106– 111. Phlebology 1988. Thiery L. 20:65. London: John Libbey & Co. Redisch W. Da Luz NW. 22:213. A novel operative technique. Louis: Quality Medical Publishing. Verta MJ et al. 33:271. O’Donnel TF. Traditionally. 82:257. eds. Femoral reflux is oblished by great saphenous vein stripping (abst). 34. Later on short groin to knee stripping of the GSV became the standard treatment and. best functional and cosmetic results are obtained when both the varicose veins and incompetent segments of the saphenous truncs are removed. These interfascial veins include the GSV. Surgery 1977. van Bellen B. 18:62. it is possible to avulse the subcutaneous varicose collateral . Dodd H.

Giacomini vein. GSV. retrograde flow pathway. obtaining satisfactory results. What are the criteria for sparing the incompetent saphenous truncs? In the Figure A2. TE. or perforators connecting the subcutaneous varicose collaterals to the deep veins (G. only. Primary varicose vein circles are typically composed of a proximal deep-to-superficial leak (reflux) point. great saphenous vein. or small perforators and collaterals (A. Boyd’s perforator). This approach spares the saphenous veins and is often called “conservative” varicose vein surgery. The first one is to obtain same functional and cosmetic results with a minimal surgery. Its rationale is the fact that it is not rare to find incompetent but small calibre saphenous truncs in people without varicose veins and without signs or symptoms of venous insufficiency. Downward flow may re-enter into the deep veins through perforators connecting the saphenous truncs with the deep veins (B. a large named perforator (D. ASV. . pelvic collaterals). “Conservative” surgery is performed basically for two reasons. GIA. gastrocnemius perforator. small saphenous vein. P. Downward flow may involve the saphenous truncs (S) and/or subcutaneous varicose collaterals (V). abdominal collaterals.48 Ricci. Georgiev. The second is to preserve veins that may serve as an arterial bypass conduit. SSV. and Goldman Figure A1. The source of proximal reflux could be a main saphenous junction (J). anterior accessory saphenous vein. C. Cockett’s perforators). and distal (perforator) re-entry point. Dodd’s perforator). thigh extention of the SSV.

(b) “h” type: there is a subcutaneous collateral.Anatomical Bases of AP 49 Figure A3. (c) “S” type: a middle portion of the GSV is “substituted” by a subcutaneous collateral. but have their both endings (proximal reflux point and distal re-entry point) connected only to the saphenous trunc. (a) “I” type: the GSV is present as a main intrafascial trunc along its entire length. Anatomic types of the GSV with respect to the compartment enclosed between the superficial and deep (aponeurotic) fasciae. as shown in transverse ultrasound scan (right). the extrafascial position of the collateral (ouside the intrafascial csaphenous compartment) is easily appreciated on transverse ultrasound scan (right). Varicose veins have no direct connection with the deep veins. running parallel and superficial to the main saphenous trunc (left). where there is not a clearly visible vein in the interfascial saphenous compartment. Figure A4. .

Varicose patterns of the different IhS anatomic types. Georgiev. (a) The most common type. This last pattern is important to recognize. (i) GSV incompetence with competent terminal (saphenofemoral) valve and secondary (collateral) proximal relfux source. (e) Groin-to-midthigh incompetence. ( j) Segmental GSV incompetence with the midthigh (Dodd’s) perforator as most proximal reflux source. and Goldman Figure A5. (d) Groin-to-above knee incompetence. in which case. the incompetent saphenous trunc is usually not visible. (c) Groin-tomidcalf incompetence. (b) Total GSV incompetence. (f) Only short segment from the groin down (left). the leg portion of the GSV may be competent (left) or incompetent but very small (right).50 Ricci. Figure A6. (a) In the “I” type. . whereas the main intrafascial saphenous trunc is competent and (d) both the collateral and the saphenous are incompetent. Patterns of segmental GSV involvement. avulsion of the varicose cluster could be tried as first surgical approach (right). the visible enlarged straight vein in the thigh and knee region is the subcutaneous extrafascial vein. before (right) and after (left) avulsion of the varicose vein only. varicose vein avulsion without ligation of the saphenofemoral junction may be sufficient and restore practically normal pattern of physiologic upward flow (right). (g) Small caliber GSV with a varicose cluster as the only clinical expression (left). otherwise one of the two veins may be missed at surgery. from groin to below the knee. The “h” type gives rise to two different varicose patterns: (c) only the superficial collateral is involved. (h) Same as (g) but with the distal GSV portion competent. (b) In the “S” type. in such cases.

Anatomical Bases of AP 51 absence of evidence-based criteria. small calibre saphenous veins. segmental incompetence (with long segments competent). we propose the following list of “common sense” criteria: 1. 2. .

rather subjective and personal. very slow retrograde filling of varicose veins during Trendelenburg test. The earlier-listed criteria are. The drawings in this atlas (section) illustrate some basic varicose vein patterns involving the interfascial superficial veins. however. Figure A7. ASV anatomy. presence of a competent terminal (saphenofemoral) valve. 4. in the position of the ASV. 6. (a) Absence of the ASV (48%). is present in the upper thigh. (b) Presence of both ASV and GSV (41%). . 5. Georgiev. with a large posterior collateral of the saphenofemoral junction. because no data are available to help predict the long-term fate of the spared saphenous trunc. veins that could be potential bypass conduits (without grossly dilated or hypoplastic segments). and Goldman 3. (d) Often the posterior collateral joins directly the SSV as Giacomini’s thigh intersaphenous anastomosis. (c) Only one vein.52 Ricci. presence of a competent (iliofemoral) valve proximal to the saphenofemoral junction.

a normally functioning GSV is preserved (right). main trunc plus one or more parallel subcutaneous collaterals (“h” type). with a subcutaneous vein bypassing the missing segment (“S” type). These three types of arrangements give rise to specific varicose patterns. Varicose patterns involving the ASV. (a) Anterior and lateral thigh and leg varicose veins. A4: a fulllength main trunc (“I” type). then proceeds along the incompetent saphenous and/or varicose collaterals. A5. Varicose veins may also exist without a proximal deep-to-superficial reflux and/or without a re-entry perforator (Fig. which are illustrated in Fig. and main trunc absent in the middle third. and finally re-enters distally into the deep veins through one or more re-entry points (distal or re-entry perforators) (Fig. with preservation of the saphenofemoral junction. Figure A8. (d) Incompetence of both ASV and GSV.Anatomical Bases of AP 53 Primary Varicose Veins Circuits Primary varicose veins present reflux (downward flow) that typically starts from a proximal deep-to-superficial leaking point(s) (incompetent major junction and/or perforators). (c) Only the ASV is incompetent (left). A2). but such patterns are not considered in the present section. Patterns of GSV Involvement Anatomical Arrangement of the GSV and Related Varicose Patterns The GSV has three basic anatomic arrangements illustrated in Fig. after avulsion of the ASV and the varicose collaterals. A3). (b) Medial varicose veins. .

and the proximal reflux point is a secondary (pelvic and abdominal) source [Fig. If only the saphenofemoral (terminal) valve is incompetent. A6(i)] or a more distal incompetent saphenous perforator [Fig. Avulsin the varicose collateral only may be considered also when the GSV is of very small calibre [Fig.54 Ricci. A6(j)]. the GSV may not be stripped at all. A6(g) and (h)]. A7. but only the varicose collaterals avulsed [Fig. there are different varicose vein patterns. (a) Only the proximal portion of the SSV is incompetent and dilated. A6(a)]. illustrated in Fig. while the distal portion is either competent (left) or incompetent but of very small calibre (right). In a personal series of 172 normal limbs. Varicose patterns involving the SSV. Patterns of ASV Involvement The anatomical arrangements of the anterior ASV are shown in Fig. Sometimes the terminal (saphenofemoral) valve is competent. or incompetent but very small [Fig. (c) The thigh extension of the SSV is present in $50% of cases and may transmit reflux from the gluteal and muscular veins of the posterior thigh toward the SSV. and Goldman Segmental GSV Involvement According to the length of the incompetent GSV portion. A6. The frequency of this pattern is the rationale for changing the standard GSV treatment from full length to short (groin to below the knee) stripping. In 48% of cases. the ASV was present in 41% of cases. . there was no ASV Figure A9. A7(b)]. The most common is with the GSV incompetent from the groin to just below the knee. (d) The thigh extension of the SSV may transmit upward (“paradoxical”) reflux from the saphenopopliteal junction toward varicose veins of the posterior thigh. with the segment distal to this point competent. anterior and parallel to the GSV [Fig. Georgiev. A6(f )]. (b) Total SSV incompetence.

and in 11%. restoring normal function to the Giacomini anastomosis (right). with a possible treatment the stripping of the incompetent GSV portion and avulsion of the varicose collaterals. (b) Competent Giacomini vein tranfering reflux from the saphenopopliteal junction (left) to the GSV and the varicose collaterals (center). but in the position of the ASV instead of GSV. . A7(a)]. The ASV may be involved several varicose vein patterns presented in Fig. it is possible to avuls only the veins with downward flow. A8. the GSV appears to be missing. (a) Incompetent Giacomini vein transferring reflux from the GSV to the SSV. The most common one is with varicose veins on the anterior and on the lateral thigh and leg. there was only one vein in the upper thigh. In this last arrangement.Anatomical Bases of AP 55 [Fig. Varicose veins along the course of the GSV are also quite Figure A10. Varicose patterns involving both GSV and SSV via the intersaphenous anastomoses. A7(c) and (d)]. but there is often a large Giacomini vein joining in proximity of the saphenofemoral junction [Fig. (c) Leg intersaphenous anastomosis transferring reflux from the GSV to the SSV (left). (d) Leg intersaphenous anastomosis transferring reflux from the SSV to the GSV. without interruption of the SSV (right).

A10. The most common of these patterns are presented in Fig. both ASV and GSV are incompetent. Georgiev. . one or more thigh (Giacomini) or leg intersaphenous anastomotic veins are involved. Sometimes. Patterns of SSV Involvement Some typical varicose patterns involving the SSV and its thigh extension are shown in Fig. a rationale approach would be to remove only the ASV and spare the GSV. Patterns Involving Both GSV and SSV When both GSV and SSV are involved in varicose vein disease. The nonawareness of all these possibilities may lead to incomplete surgery or to the removal of the wrong (competent) vein only. and Goldman common. A9. If only the ASV is incompetent and the GSV not.56 Ricci.

The examination of patients with varicose veins is described here with reference to the technique of ambulatory phlebectomy and is therefore limited to accurate varicose vein mapping necessary to formulate an adequate treatment plan. which may cause or enhance the symptoms and signs of venous insufficiency. orthopedic. If deep vein thrombosis (DVT) is suspected. which must be explained to patients prior to their consent to surgery. This information is provided by clinical examination. hepatic. calf pump function. CLINICAL EXAMINATION Medical History Directed medical history provides important information that is useful to diagnosis. further testing and treatment. dermatologic. and is also important for understanding the patient’s expectations of treatment. The discussion of all aspects of venous diagnostics is beyond the scope of this book. but a detailed diagnosis may require the employment of several clinical and laboratory investigation techniques. but also information regarding deep and perforating vein function. but also by orthopedic or other disorders. Patients are 57 . This is important because a thorough diagnosis may include not only the origin and extension of reflux in the varicose veins. Doppler ultrasound. and other pathologies. These may be caused not only by varicose veins. or duplex ultrasound. cardiac. neurologic. Symptoms referred by the patient must be carefully evaluated. and so on. it must be ruled out or diagnosed and adequately treated before planning varicose vein surgery.3 Examination of the Patient with Varicose Veins Varicose veins are recognized and reported by patients themselves.

A history of recurrent thrombophlebitis anticipates difficult vein avulsion because of perivenous adherences. diseases and medications are discussed. because the decision if.58 Ricci. which may be due to phlebitis. Painful sites. In the presence of stasis changes—edema. when inflammation has subsided. Previous treatments must also be discussed in detail. and how to operate is primarily based on it. but also about other limb structures. the better. the examination room should not be too cold as cold air can cause vasoconstriction. It should be treated immediately with compression bandage or stocking and—in the presence of large thrombi—with thrombectomy. Georgiev. if it is clear which veins have been surgically removed. as these may lead to changes in the treatment plan or contraindicate office surgery. dermatitis. Palpation is the most important clinical test and provides information not only about the veins. 4% were not satisfied with the treatment because of persistence of symptoms that were later diagnosed as lumbar spine pathology (1). “Recurrent” varicose veins after surgery are better classified. We therefore request that patients stand when placed into the examination room. The longer they are standing. the patient’s general medical condition. the type. . size. palpation permits an appreciation of soft-tissue consistency and fascial defects. and Goldman often concerned more with the discomfort attributed to the varicose veins than with the varicose veins themselves. Venous trunks that do not bulge and are missed by observation are more readily palpated. However. and consistency of the varicose veins is best appreciated. Physical Examination Physical examination is the most important part of a patient’s evaluation. Observation gives information about the type and distribution of varicose veins. In this case. In the supine position. When standing. In addition. lipodermatosclerosis. Finally. In a recent report of a series of 413 consecutive patients treated for varicose veins with surgery and sclerotherapy. Patients who wear elastic stockings (or bandages) should be examined after 10 –15 min in a standing position without compression. so that the varicose veins are fully distended. and ulceration— surgery is postponed until these heal under compression therapy. Veins recanalized after sclerotherapy may be more difficult to evaluate because of irregular caliber and wall thickness. in some cases the opportunity to remove the affected varicose segment may be difficult to evaluate for weeks or months. The patient is next examined by palpation and percussion (Schwarz test). varicose vein surgery is performed as soon as possible. when. Superficial (thrombo)phlebitis is a common finding in patients with varicose veins and is often the event that brings the patient to the doctor. Veins in areas with chronic edema or lipodermatosclerosis are difficult to evaluate by palpation and must be re-examined after healing of edema under compression therapy. the presence and degree of stasis changes or superficial thrombophlebitis.

which produces an impulse that can be detected by the other hand at a variable distance along the same vein or its branches. important information is obtained in all these cases with the help of the Doppler ultrasound. or inflammation of other leg structures (joints. Posterior tibial and dorsal pedal arterial pulses must be palpated and. tendons. superficial thrombophlebitis. etc. which.Examination of the Patient 59 lymphangitis. however. which makes it difficult to recognize the impulse of the vein. in the initial stages of varicose disease. whereas the other hand taps over a distal part of the same vein (or a collateral). even transfascial segments of veins [thigh portion of the GSV. may produce an impulse free of “noise.” With some experience. For the detection of the thigh portion of the great saphenous vein (GSV). at maximum filling. For this purpose. The detecting hand lies flat with minimum pressure over the presumable course of the proximal segment of the vein. which makes the impulse perception difficult. may not expand further with tapping. 3. Tapping may also cause limb movement. Tapping in the standing patient—especially on a weight-bearing limb— may be difficult to interpret. 3. then holding the leg firmly with the tapping hand and pressing against the vein with the thumb (or other fingers) without lifting it. Fortunately. is not reliable in assessing valvular incompetence. with widespread varicosities. The latter is the simplest instrument that gives the greatest amount of useful information and is part of the routine examination in our practices. and so on.). In this position. proximal portion of the small saphenous vein (SSV)] may be at least partially traced by percussion (Fig. are also evaluated by palpation. . if necessary. SSV incompetence. recurrent varicose veins after surgery or sclerotherapy. the patients lean with their buttocks against the edge of the examination table. performing the percussion test with the patient in a semisitting position enhances the performance of the test and permits tracing veins that are otherwise not detectable in the standing position. with the foot rested on the platform and the limb flexed and externally rotated for optimal groin exposure. This is especially true for obese patients and for veins with thick and rigid walls. tapping causes greater blood displacement and vein wall movement.1). Percussion is the most sensible test and assists tracing the course of superficial veins that are otherwise not visible or palpable. tapping at knee level is most efficacious. These are usually veins recanalized after thrombophlebitis or sclerotherapy. ankle blood pressure measured to rule out occlusive arterial disease. This test. The well-known clinical tests for the study of valvular incompetence— Trendelenburg (Fig.2) and Perthes—are less reliable and difficult to interpret in obese patients and those with deeply situated superficial trunks. In our experience. The entire limb is thus relaxed and the veins sufficiently—but not maximally— filled. Percussion (tapping) on a vein with one hand causes blood displacement and vein wall movement. If tapping causes excessive movement of the perivenous tissues.

1 Percussion (tapping) test. Georgiev. . over the proximal (a) or distal (b) segment of a superficial vein.60 Ricci. The receiving hand lies flat. and Goldman Figure 3. without much pressure. Percussion test may be performed in standing (a) or sitting (b) position. whereas the other hand is producing the wave impulse by tapping or pressing repeatedly on the other end of the vein.

after emptying the varicosities by leg elevation. or pulsed devices may be employed. (b) Release of compression causes rapid filling. whereas deep veins are recognized by auscultation together with or next . bi-directional. DOPPLER ORTHOSTATIC REFLUX TEST Doppler ultrasound is the phlebologist’s stethoscope and permits auscultation of blood flow. Method Doppler ultrasound is performed with the patient standing and the weight borne on the opposite leg (Fig. Superficial veins may be conveniently marked in a few points during clinical examination to facilitate placement of the probe. avoiding time consuming and less reliable clinical tests.Examination of the Patient 61 Figure 3. Nondirectional. The Doppler probe is placed over a proximal portion of a vein at a 458 angle. Deep veins may also be evaluated in certain locations. The Doppler ultrasound confirms or detects the origin and extent of reflux in superficial veins of any size. 3. The device is best employed by the surgeon himself. Atypical origins and/or reflux are also easily detected.2 Selective occlusion (Trendelenburg) test. (a) Compression of the GSV after emptying at the SFJ. Selective occlusion and release of the proximal portion of the GSV. demonstrates the incompetence of the SFJ and the velocity of retrograde filling.3). continuous wave (CW ).

(a) Examination of the CFV and GSV in the groin. a very precise and . it is essential that the examined limb be relaxed. retrograde filling may be difficult and the reflux signal shorter and more difficult to interpret. The exact reflux pathway can be determined by digital compression of the investigated vein distal to the probe. if the vein is incompetent. Flow signal upon release of compression indicates reflux. (b) Examination of the popliteal vein and SSV in the popliteal fossa. Georgiev. no signal is heard upon release of compression. For an optimal reflux signal. With a high-frequency (10 mHz) probe. Origin and endpoint of reflux in a superficial vein is determined by moving the probe cephalad and downward along the vein while repeatedly compressing and releasing the leg distally. the weight borne on the opposite leg. it is concluded that the vein is the only incompetent channel between the probe and the point of compression. The probe is placed over the proximal portion of the examined vein and adjusted to obtain a maximum flow signal upon distal compression/release of the limb by the other hand. The Valsalva maneuver may be less reliable because it depends on patient’s performance.62 Ricci.3 Doppler orthostatic reflux test is performed with the leg relaxed. and may not detect reflux in distal perforators or in patients who have a competent femoroiliac valve. Compression is then suddenly released. and Goldman Figure 3. to the adjacent arteries. Cephalad (physiologic) flow is auscultated by increasing its velocity with manual compression (squeezing) of the limb distal to the probe. if reflux is completely abolished. uncomfortable for the standing patient. If the vein is competent. otherwise. a long signal of reflux flow is heard.

3. duplex scan or varicogram must be performed. but not calf level. one must remember that in about 40% of patients the ASV is present lateral and parallel to the GSV. The latter may join the deep veins much higher than the most proximal palpable point of the varicose vein and may have a long oblique subfascial segment. If reflux is completely abolished by digital compression of the GSV at knee level. (On the contrary. saphenofemoral junction (SFJ). accessory saphenous vein (ASV). if more detailed information is desired. and reflux may originate in the collaterals (abdominal.1 cm apart. because reflux much shorter than the distance between the probe (auscultation point) and the site of release may not be detected. Though the ASV might be detected with the hand-held Doppler by the surgeon who is aware of it. Groin Examination In the groin the GSV. especially in the early stages of varicose vein disease (Fig. it is concluded that there is at least one competent valve in the femoroiliac segment. with or without GSV incompetence. there is some evidence that in such cases varicose vein disease may have a more aggressive course (2). If no reflux is detected in the CFV (but there is reflux in the GSV). failure to abolish reflux means that there are incompetent high collaterals or deep veins. retrograde flow depends on the incompetence of the second (more distant) valve. In these cases. pudendal) of the SFJ. The CFV is auscultated just medial to the common femoral artery and may be followed above the SFJ [Fig. If. Another important detail that will be disclosed only by duplex scan is the frequent case of GSV (or ASV) incompetence with a competent saphenofemoral valve. for example.3(a)]. . While the latter condition is normally present in 30– 40% of the population. CW Doppler may still identify the highest level of reflux. In these cases.Examination of the Patient 63 detailed superficial reflux mapping can be obtained. as well as parallel veins . on the contrary. can be individually investigated. it is concluded that the thigh portion of the GSV is incompetent. but will not identify the vessel.4). This pattern has been described in up to 40% of patients with GSV incompetence. reflux in the CFV is detected up to the highest auscultation point. 3. but is also not necessary for planning a phlebectomy. and the common femoral vein (CFV) can be investigated. In examining the groin.) Reflux in a collateral varicose vein sometimes originates from incompetent “indirect” thigh perforators. The level at which compression/release is performed is also important. pelvic and abdominal anastomoses. detection of all incompetent distal perforators is less reliable. it is best examined with the duplex scan. a competent valve may not be present. segments of the same vein. short segment GSV reflux—from groin to Dodd’s perforator—will be detected by compression/release at middle thigh level. Veins already identified by clinical examination are easily examined for presence of reflux and the latter traced to its origin (most proximal reflux point).

). If more detailed information is desired.3(b)]. The popliteal vein is auscultated together with the popliteal artery and is therefore easily separated from the SSV in most cases. indicates that there are deeply situated incompetent veins (double popliteal vein. and the popliteal vein can be investigated [Fig. and Goldman Popliteal Examination In the popliteal area. The presence and identification of reflux in the SSV presents little difficulty when the latter is palpable. GSV stripping may not be necessary. if the incompetent SSV is the only runoff channel of the incompetent popliteal vein. Though obviously varicose. rapid filling of collateral varicosities upon release of digital GSV compression. when the small dermal reticular veins assume a varicose appearance. 3.4). deep leg veins. while repeatedly compressing and releasing the leg distally. saphenopopliteal junction (SPJ). as well. and so on. they invariably lose their valvular function demonstrating reflux (3. However. such veins may be competent. An important exception is a varicose vein secondary to deep vein incompetence (usually of post-thrombotic origin). additional testing (duplex scan. the mere presence of Doppler detectable GSV reflux may not be sufficient reason to strip the vein. compression of the SSV will abolish reflux in the popliteal vein. while deep vein (usually popliteal) reflux is invariably . that is. clinical and Doppler findings concur in most cases. Even in limbs with varicose veins. etc. Abolition of reflux in the popliteal vein by digital compression of the incompetent SSV is not sufficient to rule out popliteal vein incompetence. The level of a “standard” SPJ (within 5 –6 cm from the knee joint) can be localized to $2 cm precision. The highest reflux point indicates the level of the incompetent SPJ. The presence of reflux in the popliteal area in the absence of palpable SSV or other varicose veins. which are the bases of clinical decision making. Interpretation and Pitfalls of Doppler Reflux Testing Doppler findings must be interpreted in the light of medical history and clinical examination. the SSV. as well as failure to abolish reflux with digital compression along the course of the SSV. The origin of reflux in the SSV is investigated by moving the probe cephalad along the vein.64 Ricci. muscular calf veins. Even in those with purely cosmetic varicose veins. Georgiev.4). 3. If there are no other clinical signs of GSV incompetence. venogram) must be performed (Fig. The priority of clinical examination is evidenced by the fact that it is not unusual to detect reflux in normal sized GSV or other veins of asymptomatic limbs with no clinical signs of venous disease (reflux of no clinical significance). which cannot be identified by CW Doppler ultrasound. but a higher origin of reflux (incompetent femoropopliteal vein or posterior thigh perforator) is difficult to examine with Doppler alone and requires duplex scan or venogram. dilated and palpable vein.

Longitudinal (sagittal) scan (e) showing the small sapheneous vein (SSV). gastrocnemius artery. and d courtesy G. anterior accessory saphenous vein. Belcaro.) . small saphenous vein (incompetent). (c) Color flow examination of the mid-thigh portion of the GSV showing a “bayonet” type varicose vein with the GSV trunk competent distally to the origin of the bayonet (arrow). the SSV laterally and the GCV medially. common femoral artery. PA. GSV. and popliteal vein (PV). SSV. M. gastrocnemius vein (GCV).D. Giacomini vein (incompetent). Transversal scan (f) showing the SSV (incompetent) and gastrocnemius vein (competent) joining the popliteal vein at the same level. CFV. PV. ASV. greater sapheneous vein. b. (a) Color flow examination of popliteal fossa. popliteal vein (incompetent).4 Duplex and color flow examination yields information that is difficult or impossible to obtain by clinical and Doppler examinations alone. (b) Color flow examination of the SFJ showing that both GSV and ASV are incompetent. B1. B2.Examination of the Patient 65 Figure 3. popliteal artery. c. (d) Duplex scan of popliteal fossa. (a. G. Scanning in different planes is essential for obtaining threedimensional information. transverse view. GCA. CFA. common femoral vein. longitudinal view.

there are some in which the nondirectional Doppler signal may be erroneously interpreted. downward flow in the varicose vein becomes cephalad as it reaches the competent parallel vein. In this case. a nondirectional CW Doppler device is sufficient. While this is true in almost all cases. Such competent varicose veins are easily recognized by Doppler and need not be removed.66 Ricci. and Goldman Figure 3. Such “paradoxical” phenomena occur when the examined superficial vein (in our experience most often the middle third of the GSV) is competent and functions as a main drainage channel for a parallel incompetent vein. present. and distal release triggers—at the same time—centrifugal flow in the former and centripetal flow . This happens when distal release triggers cephalad (physiologic) flow instead of reflux in the auscultated superficial vein. It is widely accepted that for reflux examination. Georgiev.4 Continued.

Examination of the Patient 67 Figure 3.5). 3. If not correctly interpreted. Directional Dopplers demonstrate this “paradoxical” flow pattern. ADDITIONAL INVESTIGATION The routine examination described in this chapter is largely sufficient for planning varicose vein avulsion. It permits a correct diagnosis in a large majority . this finding may lead to incorrect diagnosis of GSV incompetence.4 Continued. in the latter (Fig.

Georgiev.68 Ricci. and Goldman Figure 3. .4 Continued.

their junctions with the popliteal. A wide range of noninvasive and invasive investigation techniques are available. the reflux flow in the varicose collateral (VC) becomes physiologic (upward). according to Nicolaides) (5). and so on—additional laboratory investigations may permit more precise diagnosis.5 Pitfalls of nondirectional Doppler. or other imaging techniques). and posterior leg). Of these. recurrent varicose veins (especially in the groin. suspected occlusion/incompetence of veins not accessible to the CW Doppler examination. it will be heard upon release of digital compression. . These permit morphologic and flow pattern studies of veins not accessible to clinical and Doppler examination (duplex scan. When the examiner listens to flow in the GSV. popliteal fossa.5 mHz) transducer permits visualization of superficial veins. and evaluation of the venous pump function (plethysmography. necessity to evaluate the venous calf pump function. of patients with varicose veins (92%. Color-Duplex Ultrasound Examination B-mode ultrasound imaging with a high-frequency (usually 7.Examination of the Patient 69 Figure 3. giving the erroneous impression of reflux in the GSV. In particular situations—discordance between clinical and Doppler examination. ambulatory venous pressure). venography. Reaching the competent GSV. the single most useful instrument for venous investigation—after the CW Doppler—is the color-duplex scanner (combined B-mode imaging Doppler and color-Doppler ultrasound).

and muscular veins of the calf.and post-operative records with treatment evaluation. frequently found in the early stages of varicose vein disease. This is done with the patient standing and the maneuvers for Doppler reflux testing already described. veins recanalized after thrombophlebitis. For . and we now employ and recommend it as a routine examination. Our use of B-mode and duplex scanning during examination of varicose veins and the information provided by such testing may be summarized as follows: . Deep vein incompetence can be confirmed or diagnosed by direct examination of the deep veins for reflux. is basically the same as with the hand-held Doppler test. may not need to be removed. depending on whether the flow is towards or away from the probe. up and down along the leg. Visualizing incompetent superficial veins permits measuring their diameter. may be studied in detail. “Borderline” or “ambiguous” cases of GSV reflux. obese limbs. deep veins can also be visualized along their entire length. very thin (hypoplastic) GSV or SSV. duplex scanning allows hard-copy documentation to compare pre. though incompetent. . Georgiev. The technique of duplex examination. Veins are best examined with the transducer horizontal with respect to the limb axis (transverse scan). in which flow may be evoked and detected by the Doppler or color flow capabilities of the scanner. This allows immediate recognition of the vein as a round anechogenic (dark) image. vein segments situated under the superficial fascia. This allows precise separation of the intrafascial (saphenous) trunks from their subcutaneous side branches. that is. Duplex scanners also permit a flow study of each visualized vein by Doppler.70 Ricci. Suspected DVT may be easily confirmed or ruled out. The use of ultrasound imaging immediately prior to phlebectomy for more detailed varicose vein mapping is discussed in Chapter 6. which may assist surgical planning. patient’s position and maneuvers for the detection of venous flow and reflux. . Color duplex allows direct visual representation of flow. In addition to its diagnostic use. Superficial veins that are difficult (or impossible) to palpate (i. always in a transverse position. . For example. or sclerotherapy) can be immediately visualized.e. The availability of color-duplex ultrasound has enabled us to add important details to our clinical and Doppler examination. thus simplifying the clinical examination itself. and Goldman femoral. with a change of color from red to blue. especially for pre-operative varicose vein marking.. In normal sized (not obese) limbs. Veins can be followed along their entire course by moving the transducer. Collateral reflux in the groin can be differentiated from a competent SFJ sparing an unnecessary GSV ligation and division. . The position of the veins with respect to the superficial fascia is readily appreciated. Failure to completely obliterate the vein by compression (with the transducer) and an absence of respiratory flow indicates (thrombotic) occlusion of the examined vein.

apparently normal valves are seen.1. . In some cases the same information may be obtained—though sometimes to a different extent—by several different examination techniques. . In many of these cases. The GSV and ASV can be examined separately and their involvement in varicose vein disease determined with precision. Therefore. the muscular calf veins. We believe that for optimal cost-effectiveness. Some of the most popular methods of investigation and their respective areas of application are presented in Table 3. This reinforced the need for continuing compression therapy to prevent stasis changes. we postulate that these patients often evolve to permanent incompetence. early intervention and supportive conservative techniques can be prescribed. and the superficial collateral veins can be individually checked for valvular incompetence. surgical revision of the area of the SFJ may be unnecessary.” and in selected cases this may lead to GSV-sparing surgery. Our use of strain-gage and photoplethysmography are limited to documenting normal venous pump function in patients with stasis changes (edema. the clinical significance and prognostic value of such ultrasound findings are not yet clear (we are unaware of conclusive data regarding the natural history of borderline GSV incompetence). so that “limited” or “intermittent” GSV incompetence may be postulated. dermatitis) in legs with normally functioning deep and superficial veins. the SSV. This is especially useful in the popliteal fossa and posterior leg. superficial vein incompetence might be detected by clinical. if recurrent reflux in the groin originates from one or more tiny collaterals. For example. They are also useful for post-operative follow-up testing of patients with DVT. However. For example. these investigations are of little help to AP and will not be discussed in detail. can be studied in detail.Examination of the Patient 71 . However. Evaluation of the Leg Pump Function In addition to vein imaging and flow studies. when the popliteal vein. Doppler. there are cases in which slight compression with the transducer or a change in leg position may abolish the reflux at the SFJ. Complex patterns of venous reflux that are often found in the advanced stages of varicose vein disease or in limbs with deep vein incompetence. several noninvasive plethysmographic techniques are available to evaluate venous pump function. example. information should be collected by the simplest . . The decision to operate on the GSV is based on clinical symptoms as discussed in Chapter 15. Varicose veins recurrent after surgery may be studied for appropriate phlebectomy. or duplex examination. in order to document persistent impairment of venous leg pump function. The reflux originating from the incompetent SFJ may be distinguished from the one that originates from the “second valve.

and Goldman Note: “à ” indicates (information) partial and/or more difficult to obtain. “Ãà ” indicates (information) more detailed and/or easy to obtain. .72 Table 3. Georgiev.1 Routine examination Clinical examination Doppler examination Duplex scan Plethysmography à à Ãà à Ãà Ãà Ãà Ãà à Ãà Ãà Ãà à à à à à à Ãà Ãà Ãà à à Methods of Investigation and Areas of Application Additional investigation Ambulatory venous pressure Venogram à Medical history Varicose veins Symptoms of venous insufficiency Ãà Superficial vein incompetence à Ãà Ãà Ãà à Perforating vein incompetence Deep vein incompetence Deep vein occlusion Venous pump function Occlusive arterial disease Ãà Ricci.

8. Bergan JJ. 4. 3. J Dermatol Surg Oncol 1991. Edinburgh: Churchill Livingstone. Nicolaides AN. For a further discussion of the different methods of investigation. Tourbier H. Landes Co. St. Louis: Medical Publishing Inc. 11. 10. Phlebol u Proktol 1988. Van Bemmelen JS. Doppler ultrasound findings in reticular veins of the thigh subdermic lateral venous system and implications for sclerotherapy. Weiss RA. Phlebologie: ’89 London: John Libbey Eurotext Ltd. the reader is referred to other sources (5 – 11). 1991:108– 157. Stemmer R. 17:818. Nicolaides AN. 5. Zimmerman H. Fernandes e Fernandes J. 1981. this becomes meaningful only if interpreted in light of the clinical examination. Noninvasive examination of the patient before sclerotherapy. 1992. Though sophisticated equipment may give extremely detailed diagnostic information. In: Goldman MP. 7. London: Med-Orion Publishing Company. REFERENCES 1.Examination of the Patient 73 possible method. Weiss MA. Tretbar LL. In: Nicolaides AN. 2. 9. The origin of reflux in incompetent blue reticular/telangiectasia veins. Doppler ultrasound in the investigation of venous insufficiency. .und Seitenastvaricosis der Vena saphena magna und parva. Hubner K. Laboratory evaluation of varicose veins. In Bergan JJ. Quantitative Measurement of Venous Incompetence. The out-patient therapy of trunk varicosis of the greater saphenous vein by means of ligation and sclerotherapy: a contribution from a German phlebology practice. 19:947 – 951. V. Sumner DS. Van Bemmelen JS.. 1982. Investigation of patients with deep vein thrombosis and chronic venous insufficiency. 1989:95– 96. Fronek HS. J Dermatol Surg Oncol 1993. Investigation of Vascular Disorders. Goldman MP. Louis: Mosby Yearbook. St. Louis: The C. Weindorf N. Sumner DS. Vao JST. Mosby Company. Bernstein EF.. Varicose Veins and Telangiectasias: Diagnosis and Treatment. Sophisticated and costly examinations should not be employed for collecting data obtainable by simpler methods. 1982. eds. 1993:73– 84. 1991. on which the decision to operate is still ultimately based. Moderne hamodinamisch orientierte Richtlinien fur die Sklerosierung die Stamm. G. In: Davy A. Noninvasive Diagnostic Techniques in Varicose Disease. Sclerotherapy Treatment of Varicose and Telangiectatic Leg Veins. 6.. New York: Churchill Livingstone. Phlebography of the Lower Limb. Lea Thomas M. Austin: R. 17:83. St. Schultz-Ehrenburg U. eds. eds.

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Patients with uncomplicated. varicose vein disease invariably progresses to more severe forms. patients’ general health conditions. and prophylactic reasons. Recurrent varicose groin cavernoma [after sephenofemoral junction (SFJ) division] should also not be operated in the office. Asymptomatic Varicose Veins (CEAP 1– 2) Varicose veins are removed for cosmetic. In its natural course. Many patients suffer these chronic complications simply because they did not get proper treatment in time. The incompetent SFJ must be ligated and divided as an office procedure as described in Chapter 15. exclusion criteria are related primarily to the patients’ general health.2). there are a few exceptions. Though any varicose vein can be avulsed by AP. As most varicose veins can be treated by AP. with about one-third of patients with large and/or widespread varicosities developing one or more complications like superficial thrombophlebitis. and ulceration (1. These are the muscular (gastrocnemial) calf veins. the type of varicose vein disease is diagnosed and the treatment program discussed. symptomatic. asymptomatic varicose veins should be encouraged to remove them early to slow down the progression of the disease and prevent its complications. VARICOSE VEIN AND LEG CONDITIONS At the patient’s initial visit. lipodermatosclerosis. dermatitis. skin pigmentation. Another important reason to treat asymptomatic varicose veins is that 75 . and consent. which cannot be removed by office phlebectomy. A distinction between purely “cosmetic” and “clinically significant” varicose veins is not always easy to make.4 Selection of Patients for Office Varicose Vein Surgery The selection of patients for ambulatory phlebectomy (AP)—and office varicose vein surgery in general—is based on the type of varicose vein.

4. dermatitis. Georgiev. and Goldman phlebectomy is easier to perform. that is. This is because vein avulsion is difficult in lipodermatosclerotic skin.1). recurrent DVT may be difficult to recognize even by duplex ultrasound. only healthy patients or patients with well-controlled systemic disease should be operated in . symptomatic or complicated varicose veins must be not only encouraged. However. Only then can the local varicose veins be adequately evaluated and removed. Some of these patients are operated on only after adequate leg preparation. varicose veins in the upper leg and thigh may be avulsed before complete softening of lower leg lipodermatosclerosis. This is done in cases of stasis changes—recurrent or chronic edema. It is therefore important to obtain a detailed medical history and appropriate laboratory examinations from all patients with indications for phlebectomy. some selection is mandatory. until adequate venous outflow becomes clinically evident. Varicose vein surgery is not attempted until symptoms of deep vein occlusion disappear. this is another important reason to postpone varicose vein surgery until edema is stable and eliminated by compression therapy. there have been no reports of serious untoward reactions or complications with Muller’s technique. including many who are considered “at risk” for general anesthesia or traditional surgery. but also strongly advised to have them treated. however. lipodermatosclerosis. Generally. Acute superficial thrombophlebitis is treated first by thrombectomy and compression bandage that is worn until local symptoms disappear—usually from 1 to 3 months—then the varicose vein can be adequately evaluated and removed. in 40 years. AP is a very limited surgery that utilizes a low dosage of local anesthesia (LA) so that it is possible to operate—with very few exceptions—on practically all patients. In limbs with chronic edema. Moreover. but may require months to a year of compression therapy. at least for defensive reasons. This may enhance the healing of the latter under compression therapy. Symptomatic Varicose Veins (CEAP 3– 6) Patients with large.76 Ricci. and its functional and cosmetic results are best when patients are operated in the early stages of varicose vein disease. Acute deep vein thrombosis (DVT) is treated with compression therapy and anticoagulation. before the development of the aforementioned complications. PATIENT’S GENERAL HEALTH CONDITIONS Varicose vein surgery is an elective procedure and patients must be—and usually are—in good health. Lipodermatosclerosis invariably yields to compression bandage. considering the high level of personal responsibility in private practice. Sometimes. or leg ulcer (Fig.

(d) six months after compression treatment. . (b) five weeks after treatment with adhesive bandage followed by 30 – 40 mm/Hg below-knee graduated compression stocking. It is at this point that the varicose veins can be adequately appreciated and removed. or ulcer—surgery is postponed until the stasis changes heal under compression bandage. There are no signs of inflammation. lipodermatosclerosis. (c) chronic leg edema with acute stasis dermatitis.Office Varicose Vein Surgery 77 Figure 4. dermatitis. Pressure with the finger demonstrates the previously indurated lower leg to be soft. Regression of edema allows the varicose vein to be clearly seen.1 In case of stasis changes—recurrent or chronic leg edema. (a) Chronic leg edema that hides the varicose veins.

Examples are the hepatitis B and C (HepB and HepC) and human immune deficiency virus (HIV) positive patients. 5. but the procedure is modified in order to reduce its impact on the patient’s general conditions. uncontrolled diabetes. that is. unless specific allergy is excluded by careful evaluation. it is advisable not to schedule the operation during the hot season. phlebectomies of even more limited extension may be performed in order to further reduce the dosage of LA and patient stress. it is the latter who should decide which patients are not operable in an office setting. but in the presence of an anesthesiologist. high blood pressure. For example. Infectious Disease A problem is presented by carriers of blood-borne infectious viruses. On the contrary. operating on whom carries a risk of contamination. as inadequate patient compliance with post-operative compression may cause poor cosmetic result. Another argument for pre-operative screening for blood-borne infections is that such practice makes it impossible for the carriers to claim they have contracted the virus in our office. congestive heart disease. 3. systemic cancer of any type. and Goldman the office. Therefore. Elderly patients who live alone and are not self-sufficient. or delayed in order to permit better evaluation of patient’s physical and psychological conditions. though HepB and HepC screening is accepted . Examples of patients who may be excluded are: 1. Modifying the Procedure In certain cases the patient is not rejected. Patients with history of untoward reactions to LA. diabetes compensated. AP is postponed until a chronic disease is brought under control. Patients who are unable to walk for at least 20 min four times a day. 2. anemia cured. Patients with specific heart disorders. if the patient is concerned with the cosmetic outcome. However. high blood pressure lowered. infectious disease. immunodeficiency. 4. coronary heart disease. Georgiev. In other cases. like clinically significant arrythmia or symptomatic coronary artery disease. and so on. but are of an emotional nature. Patients in poor health. in selected cases.78 Ricci. or multisystem disease. for example. LA without epinephrine may be preferred. and so on. If phlebectomy is performed not by the solo practitioner alone. impaired blood coagulation. It must be kept in mind that most problems that may arise are not due to the procedure itself. Phlebectomy may also be postponed for climatic reasons. severe anemia. glaucoma. in patients with diabetes. age is not a contraindication if the patient’s health is satisfactory. If staff members are vaccinated against HB—and this is strongly advised—operating HB carriers poses only the problem of avoiding office contamination.

. Eklof B.Office Varicose Vein Surgery 79 as a routine practice. Bergqvist D. Widmer LK. 1978. After a thorough explanation of the treatment procedure. Vasu Surg 1996. Bergan JJ. The time needed to complete the check is a good test for the patient’s acceptance of the procedure. Switzerland: Hans Huber Publishers. in case of doubts. they may opt for more traditional or in-hospital treatment. Peripheral venous disorders: prevalence and socio-medical important observations in 4529 apparently healthy persons. we do not ask patients for immediate consent or appointment for surgery. 30:5 – 11. ¨ 2. PATIENT CONSENT Informed patient consent is obviously mandatory prior to the operation. Classification and grading of chronic venous disease in the lower limbs: a consensus statement. An example of patient consent form is found in Appendix 2. Basle Study III. Goldman MP et al. for the well-known emotional reasons that do not allow a rational medical approach to the problem. REFERENCES 1. Bern. but first give them a request form for routine laboratory evaluations. Eriksson I. HIV screening is not. Beebe HG. It is to be hoped that in the future a more rational approach to HIV screening becomes possible.

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2). or.5 Staging of Surgery The surgical treatment that we describe is a “true” ambulatory procedure. we usually avulse the GSV portion first between the Dodd and Boyd perforators. emergency facilities. Phlebectomy sessions are performed 2– 5 days apart. performed in an office setting. we start operating from the distal part of the limb and proceed proximally.1). so that it is preferable to limit the extent of veins to avulse in a single session. There are. and also limbs with such a widespread disease that more than three (or more) sessions are needed. In some difficult areas. As a rule. and may be compared to a dental procedure. phlebectomy may be time-consuming. 5. In cases of widespread varicosities. and patient selection). In these cases. such as foot. The extent of the single phlebectomy is programed to limit anesthesia and operative time to $1 h. performing these during separate sessions. with grossly enlarged (. the best way to achieve maximum safety is to divide vein avulsion into several operations of limited extent. but with some more attentive cautions (laboratory exams. of course. cases of isolated varicose veins that are avulsed completely in a single session. weekly. Safety in office surgery cannot be overestimated.1 cm diameter) thigh GSV. next divide and strip the remaining thigh portion of the GSV. It is usually possible to divide varicosities in well-defined areas to be operated on in separate sessions (Fig. and very large and widespread leg varicosities (Fig. Exceptions to this practice are some cases of extremely large varicose veins. A typical case of greater saphenous vein (GSV) incompetence with few varicose leg collaterals usually requires two 1 – 2 sessions: one for the leg varicosities and one for GSV ligation and groin to knee stripping. and only then avulse the leg 81 . if the patient prefers. 5. does not require the presence of an anesthesiologist. This regimen does not require hospitalization. If sclerotherapy is planned on smaller veins we advise a 6 week hiatus. not even for few hours. which is.

82 Ricci. (g) Six days after the last phlebectomy. Left leg marked for phlebectomy. (e) Ten days after GSV ligation and stripping (July 10). The distal varicose veins are removed first and treatment proceeds upwards. The patient does not have groin bandage anymore (band-aids are still visible over the groin incision). (a) Widespread bilateral varicose veins with incompetent saphenofemoral junction (SFJ) on the right leg. June 24). the patient is marked for the last operation (July 14). (f) Four days after the first phlebectomy on the left leg. the patient is now marked for GSV ligation and division (July 1). . (c) Two days after the first phlebectomy (June 26). Georgiev. (b) Preoperative marking of the right leg (SFJ not marked. and Goldman Figure 5.1 Organization of multi-session phlebectomy. (d) Three days after the second phlebectomy.

Staging of Surgery 83 Figure 5.1 Continued. .

Georgiev. and Goldman .84 Ricci.

Second. Another exception are some cases of lower leg lipodermatosclerosis. when the veins proximal to the dermatosclerotic zone may be avulsed first. and it is less likely that large thrombi form in the veins left for the next session. Starting at the first session. while the rest of the limb has been kept bandaged to prevent thrombosis in the remaining varicose veins. However. compression pads are placed over the veins left for the next session(s). when GSV stripping or endoluminal laser or radiofrequency (RF) closure is necessary. This simplifies each session and avoids formation of large thrombi in the veins left for the next operation. (c) Large and widespread leg varicose veins with GSV incompetence. divided and ligated at knee level. . at this point lower leg varicosities are better assessed and avulsed more easily. The grossly enlarged parts of the GSV are removed and this greatly facilitates the next operation. it is left for the last session. Operating in this order causes less bleeding during surgery.2 Starting the operations from the middle third of the limb. GSV stripping is the “major” procedure and is better performed last. GSV stripping or closure is simplified when all distal varicose veins have been removed. In these cases. While this approach may lead to the same end result. Third. it is useful to have checked in advance (with lower dosage) the patient’s tolerance to local anesthesia. we usually start operating from the middle third of the limb. Muller himself has the proximal portion of the GSV stripped first. There are several reasons for leaving GSV high ligation and stripping or endoluminal laser or RF closure for the last session. First. This behavior may also hide some varicose veins that could be better removed immediately. (This may not hold for the simpler and less invasive endoluminal RF or laser closure procedures). thus simplifying subsequent procedures. (a) Saccular dilatations of the GSV at the knee. Except for the earlier listed exceptions. (b) Site and extension of the first phlebectomy. there is less bleeding. and evaluates the leg for eventual phlebectomy a few months later. when the patient is already “prepared” by previous operations. makes phlebectomies easier to perform. In case of extremely large and/or widespread varicose veins. the day of the first session (October 21). leaving a proximal GSV segment of various length for the last session (see Chapter 15). in order to enhance the healing of the lower leg under compression therapy. and the limb is bandaged from foot to groin. more time is needed to complete the treatment. The largest varicosities have been removed. phlebectomy almost always involves the GSV trunk.Staging of Surgery 85 varicosities. and the remaining GSV trunk. which can be divided at various levels (between Boyd’s and Dodd’s perforators). The lower leg varicosities are marked for phlebectomy. as more than double the amount of anesthesia is necessary for treating the GSV than for the average phlebectomy. while the GSV will be divided and ligated at the groin 2 days later. Figure 5. is easily pulled out from the groin incision. treating the GSV first causes resolution of many distal veins. (d) Two days later (October 23). some authors (MPG) do exactly the opposite.

complications are rare and correspondingly insignificant. 5. it is better not to end phlebectomy with division and ligation of a large trunk. 3. After a few days the vein is avulsed without difficulty. thrombus may form at the site of the ligature. A low dose of local anesthesia is employed. Patients “at risk” because of advanced age. which limits potential untoward (toxic) reactions to the anesthetic. Reduction of surgical time (per session) allows more precision. In these cases. However. alternating operations on both sides. The practice of performing varicose vein avulsion in several separate sessions is often criticized by authors who advocate ambulatory varicose vein surgery in a single session. Dividing the operation into two or more sessions has the following advantages: 1. 4. however. and Goldman When possible.86 Ricci. poor general health. so that total compression time is not prolonged by multi-session avulsion. Bilateral varicose veins may be treated at the same time. if needed. the previously operated sites are often completely healed and little further compression is needed. . In these cases thorough vein avulsion in single session would require more time or a quicker surgical procedure with the risk of neglecting details of minor or purely cosmetic significance. If a large vein is ligated. If the vein ruptures under traction. this approach is particularly indicated in situations like: 1. especially in cases of very widespread varicosities. difficult ambulation. Seeing the patient with such frequency permits detailed evaluation of previously operated sites and. Immediate discharge of the patient. With operations of so limited extent. the thrombus is easily squeezed out through the incision. of little importance because symptomatic inflammatory reactions rarely occur if proper compression is used. Exaggerated individual reactions are usually revealed at the first session (which therefore 2. 2. which permits operation in an office setting. This is. At the time of the last operation. Patients with exaggerated emotional reactions. extension of phlebectomy and dose of anesthesia may be further reduced. increasing the number of sessions. In addition to the aforementioned advantages. 6. obesity. allows modification of local compression to enhance healing. cardiac or pulmonary disease. the latter is not possible in all cases in an ambulatory setting. Georgiev. and patients otherwise not operable may be operated upon. There is major stress to the patient and general anesthesia may be required necessitating the use of a “day hospital” rather than an office base. and so on.

. that is. bandaging. Despite these inconveniences. it is less convenient for patients who travel a long distance to reach the office. For some patients attending the operation is major cause of stress. Increased stress. giving inhalation sedation/analgesia. There are. disadvantages of multi-session vein avulsion. While this is compensated by the fact that the patient does not lose much time at each session and can resume activities immediately. reassuring the patient. performing shorter operations. giving more anesthesia. and so on. 3. with subsequent sessions modified as necessary. in our experience there is a net advantage in favor of multi-session vein avulsion. of course. 2. and this is repeated before each session. The most obvious is that patient must attend the office more times. and increasing the interval between sessions.Staging of Surgery 87 should be as short and simple as possible). 1. It is more time-consuming for the surgeon. who must repeat the same procedures many times: anesthesia.

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Part II: Technique of Phlebectomy .

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which are performed as described in Chapter 3. Marking is guided by observation. palpation. the more precise and thorough the marking. Patients who wear compression bandage or hosiery may need to remain in the standing position without compression for 15– 20 min to allow sufficient distention of the superficial veins. Marking is therefore best performed by the surgeon. The latter will not get wiped-off by the common surgical skin disinfectants and will remain visible for a few days. Observation of the latter is further improved by skin translucidation with an alcoholic disinfectant. 91 . percussion. the better the result of stab phlebectomy. We routinely perform duplex imaging immediately prior to surgery to assist pre-operative marking. it eventually fades completely and never permanently stains the skin. Marking is performed with the patient standing. reflux is traced with Doppler ultrasound to check the precision of marking and to detect any segments missed by clinical examination alone. The permanganate solution is not irritating and allergic reactions to it have not been reported. Adequate illumination is essential. the knee of the limb to mark is slightly flexed and the weight borne on the opposite leg. 6. except for the smaller dermal varicose veins that are better observed in the recumbent position. Veins are marked with a cotton swab dipped in a 7. All visible varicose veins are marked first. Sufficient time must be set apart for the procedure: a minute more spent for marking is well worth it. As for clinical examination. Finally. Doppler and Duplex ultrasound.5% (saturated) water solution of KMnO4 . Careful palpation and percussion will often disclose some nonvisible varicose segments and permit their marking. The patient stands on an examination platform to permit easy observation by the examining physician.6 Pre-Operative Marking Pre-operative varicose vein marking is an important part of the procedure. The few minutes spent visualizing the marked veins are worth the details obtained.1). These are usually veins more deeply situated and covered by a layer of the fibrous fascia: the proximal portion of the great and small saphenous veins is those most frequently marked with the help of the Doppler (Fig.

1 Pre-operative marking. (c) Three weeks after last treatment session. and thus more easy to retrieve. (b) A dotted line marks the competent distal portion of the GSV. and Goldman Figure 6. Georgiev. where the GSV is more dilated and palpable. . (a) Prior to marking. Transverse sign marks the site above the knee.92 Ricci.

and is especially useful in patients with deeply situated superficial veins. not necessary because it is the varicose veins that are avulsed by stab phlebectomy. with the SSV continuing into the posterior thigh muscles as the femoropopliteal or Giacomini vein. An incompetent popliteal fossa perforator can be distinguished from the SPJ. The size of the marking sign roughly corresponds to the size of the varicose veins. however. The most prominent varicose sites. and the skin wiped with alcohol for better visualization of the smaller varicose veins. can also be diagnosed. the individual veins can be tested for reflux. Pathologically dilated perforating veins (PVs). Double (or even triple) segments. can also be diagnosed. Vein diameter. An example of such veins are the pelvic anastomoses at the root of medial thigh and the small dermal (“reticular”) varicose veins that typically accompany telangiectasias. the competent segments may also be marked with a different (dotted) line. Nonpalpable. being . 6. This helps localize the points where the vein is easier to hook. If duplex capability is available. which are also marked. This is especially important in the presence of a very large ASV that joins the GSV or the common femoral vein. The patient is then placed in the recumbent position. as well as the sites of side branch confluence. thus facilitating vein disconnection (Fig. are more difficult (but also less important) to mark. When only a part of an anatomical vein is varicose. Complex patterns of the SPJ. incompetent subcutaneous “feeder” veins can be detected in areas of dense telangiectatic flares. The PVs are not necessarily given special attention.2). as well as the sites more easily palpated. gastrocnemius vein(s) joining the small saphenous instead of the popliteal vein. the examination is being performed by the surgeon with the patient standing.1). or side branch and/or incompetent perforator confluence. Precise mapping of all incompetent PVs is. are also marked with a circular sign. . as this may allow more precise surgery with maximum sparing of normally functioning veins (Fig. and fascial defects are marked with a separate (transverse) sign. when related to larger varicose veins. 6. This prevents the ASV from being confused at operation with the GSV itself (Fig. that is. whereas most perforators.Pre-Operative Marking 93 In this situation. The absence of SPJ. In the popliteal fossa. including those of the Cockett group. 6. The signs are useful because in these sites the vein is more easily retrieved and side branch and/or perforator disconnections are more easily performed. the level and type of saphenopopliteal junction (SPJ) can be determined. the size of the great saphenous vein (GSV) and location of the collaterals of the saphenofemoral junction (SFJ) are determined. The areas of telangiectatic flare.5 mHz) transducer is employed for optimal imaging of the superficial veins and their junctions.1 mm in diameter. These sites correspond to either a saccular dilatation. sites of saccular dilatations. are also visualized and marked. and its relation to the superficial fascia are noted. are relatively easy to localize (for eventual ligation). distance of the vein from the skin surface.2). A high-frequency (7. In the groin.

CFV. all varicose veins are marked prior to the first operation. When more than one operation is planned. Georgiev.2 Incompetent GSV and ASV trunks at the saphenofemoral junction in the groin. GSV. For this reason it is advisable to check the position of the vein with the patient sitting—or even in a semirecumbent position—and the limb flexed in maximal external rotation (a position similar to that used for GSV high ligation and stripping) (see Chapter 15). marking a deeply positioned thigh segment of the GSV may “move” (usually anteriorly) when the patient changes the position from standing to recumbent. great saphenous vein.94 Ricci. In a very obese patient. common femoral vein. and Goldman Figure 6. This is done to permit a general view of the work . and may thus not correspond to the skin projection of the GSV in the recumbent position. detected by color flow imaging.

One may chose between many of these models. that is. extent. . Some are reported in Appendix 10. if not marked. and order for the separate sessions. residual varicose veins may be difficult to identify later on. because of the favorable hemodynamic conditions created by the first operation(s) and the effect of post-operative compression. Another reason for marking all the varicose veins prior to the first surgical session is that. to better determine the site.Pre-Operative Marking 95 to be done and its optimal subdivision. The drawn map is referred on a stylized leg model as a graphic reference of the anatomical and hemodynamic condition.

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Perhaps the only indication for modification of LIA procedure is the strongly emotional patient who expressly requests other types of anesthesia. For use in the free-standing surgical practice. and spinal to general. AP can be.5%. Emotional stress due to a more complex hospital-like procedure. These include: 1. Side effects and delays in full recovery after surgery due to the administration of anesthetics and pre-medication drugs. requires the assistance of specialized personnel. which. Further refinements brought a reduction in lidocaine concentration from the initial 1% to 0. LIA remains the standard of care. However. In these cases we found that optimal solution is LIA and intravenous sedation/ analgesia with short-acting drugs (like midazolam). 4. performed under a vast range of different types of anesthesia. Keeping the dosage of anesthetic as low as possible and avoiding preoperative medications keep the LIA procedure on the safest side. 3. and nowadays often is.7 Anesthesia At its inception. from loco-regional. 2. 97 . ambulatory phlebectomy (AP) was performed strictly under local infiltration anesthesia (LIA) with lidocaine. Temporary loss of motor function of the limb with problems in fitting the post-operative bandage and impossibility of immediate ambulation. The presence and assistance of highly specialized personnel. these techniques have major disadvantages when compared with LIA. of course. The latter dosage proved sufficient and allowed for a more extensive surgery without exceeding the recommended maximum dosage.

the 0. An exception is GSV high ligation with groin to knee stripping for which 320 mg may be necessary (see Chapter 8). obtaining 20 mL of neutralized 0. refrigerate the anesthetic solution in order to reduce pain. About 0.5 mL of LIA per linear centimeter is sufficient. many authors. but lower (5) or higher (6 – 8) concentrations are employed by others.000 epinephrine in saline. the earliermentioned concentration must be prepared by dilution of a commercial solution. The description of both traditional and tumescent techniques for LIA as practiced by us is as follows. We dilute 4 mL of 2% mepivacaine/1:100.07 – 0.000 epinephrine solution.4% anesthetic solution and achieves limited tumescence along the course of the veins targeted for avulsion. It is performed with 0. we warm up the saline and bicarbonate solutions at $508C and then add the anesthetic. and Goldman PREPARATIONS. This is performed with a large amount of strongly diluted (0. This is performed with 0. which is 550 mg (or 7 mg/kg) (8). but this practice is not validated by objective studies. Georgiev. as suggested in a recent report (4). To obtain $378C. 2.98 Ricci. on the contrary.4% sodium bicarbonate.) In our experience.000 epinephrine solution (available in Italy in 20 mL vials) with 12 mL of saline and 4 mL of 1. This is less than one-third the recommended maximum dosage for mepivacaine. This solution is injected at body temperature (378C) instead of room temperature for further reduction of pain. though larger amounts may be necessary if a larger and/or deeper infiltration is needed (i.1– 0. Tumescent technique.1%) anesthetic solution and achieves major tumescence along the veins targeted for avulsion. Traditional technique.. neutralized with 40 –60 mg/L of sodium bicarbonate to reduce pain of injection (1– 3). However. However.4% mepivacaine/1:500.4% mepivacaine (or other suitable local anesthetic) with 1:500. We employ an average 20 –40 mL (80 – 160 mg mepivacaine) for each session and limit the extension of phlebectomy accordingly. multiple. If not available. AND TECHNIQUES Currently LIA is practiced basically in two ways: 1. tortuous. Usually 20 mL of 0. In absence of comparative studies that indicate the clear superiority of one of these techniques upon the other. or deeper varicose veins).4% solution proved to be the lowest efficacious concentration. Traditional Technique Preparations and Dosage LIA is applied exclusively along the course of the marked varicose veins. (Curiously. it is not clear how refrigerated solution can reduce pain. .e. DOSAGE.4% solution is sufficient for a 20– 40 cm long strip (vein). the preference of the specific technique depends on operator’s experience. for large.

000 Sodium bicarbonate 1. the anesthetic effect actually improved until a threshold of $0. gradual elevations in plasma lidocaine levels were seen. This gave way to questioning and then exceeding the published maximal doses for lidocaine when given for local infiltration. In a recent study it was found that during phlebectomy under LIA with !600 mg lidocaine (8 – 15 mg/kg) (18 patients).6 mg/mL with a maximum of 1.1.04% was reached. For this reason.4% Saline. The dilution of lidocaine had a surprising effect. Early consultation with surgical colleagues convinced us not to use epinephrine for concerns of toxicity given the large volumes of anesthetic sometimes used. Further documentation and now years of safe use have made it the standard for anesthesia in liposuction surgery (Table 7. Jeffrey Klein.2). It was then recognized that when lidocaine was given in this dilution via a subcutaneous route. As the concentration was lowered. intravascular lidocaine levels averaged 0. Subsequent to the findings of this study we have reintroduced epinephrine into Table 7. or may be an effect of the anesthetic technique. we examined the complications found in our cases to determine whether this form of anesthesia put patients at any greater risk. concerns arose over the blood levels of lidocaine that patients were being exposed to. It began with simple local anesthesia and dilution to allow larger areas to be anesthetized without exceeding the published maximal dose of lidocaine for local infiltration. warmed at $378C 4 mL 4 mL 12 mL .Anesthesia 99 there is evidence that even dosages larger than the latter are safe. Tumescent Technique Preparations and Dosage The development of tumescent anesthesia is generally credited to Dr. The induction of any anesthesia should have safety as its primary concern. The latter is still less than one-half the concentration considered neurologically toxic (4 –12 mg/L) and less than one-twelfth the one considered toxic to the cardiovascular system (24 mg/L) (10). This may reflect only some lack of operator skill. however.8 mg/mL in one patient only. We discovered a higher than expected rate post-operative hematoma formation. a dermatologist looking for ways to improve the technique of liposuction. only slow. poor post-operative care. The preparation of the anesthetic solution employed by us is illustrated in Table 7.1 Preparation of the Anesthetic Solution: Dosage for One Syringe (20 mL) of Anesthesia Mepivacaine 2% with epinephrine 1:100. The anesthetic fluid used did not contain epinephrine. After large volumes of dilute anesthetic were administered.

This is thought to occur partly because of the dilute nature of the solution and also due to the prolonged vasoconstrictive effects seen with epinephrine. The anesthetic effect is long-lasting and return of sensation occurs slowly. including scalp surgery and hair transplantation.000. and slight elevation of superficial veins toward the dermis. only a few needle punctures are required to completely anesthetize even long segments of veins. facelifts. and Goldman Preparation of Tumescent Anesthetic Solution: 0.000 epinephrine diluted 1:10 with . vessels are more “open”.4) Table 7. A complete discussion on the safety of tumescent anesthesia with lidocaine is found in Chapter 16. The tumescent swelling may provide an internal compression of the limb and the affected vessels. amounts are slowly absorbed and peak levels are achieved much later than would be expected with “typical” local infiltration.100 Ricci. More importantly. Duplex images of vein position upon instillation of tumescent fluid show a decrease in vein diameter. LIA is applied exclusively along the course of the marked varicose veins. Its application to phlebectomy takes advantage of the ease of use and adds several benefits not found with LIA. dramatic peak in plasma lidocaine concentration is likely to occur without the use of epinephrine. and simple excisional surgery.000 final concentration) 12. Studies of liposuction cases using lidocaine and epinephrine have shown that when very dilute lidocaine is infiltrated into the subcutaneous space. Tumescent anesthesia has been applied to a variety of surgical procedures. anesthesia wanes more quickly. 1:1. and the possibility of exceeding the toxic level of lidocaine (5 meq/dL) is increased. as long as the needle tip is not kept in one position for a prolonged period of time. it may be a crucial component of the tumescent technique by limiting lidocaine absorption. This may decrease the incidence of hematoma formation. dermabrasion. a small amount of perivenular clear space (c/w hydrodissection). With large volumes instilled and longer needles used. Thus. Thus. It is customary when infiltrating local anesthetic to draw back with the syringe to insure that the needle tip is not intravascular. mastectomy.9% Normal saline 2% Lidocaine Epinephrine Sodium bicarbonate 8. The tumescence or firmness of the tissue seems to aid in “hooking” of the vein. It is performed with 1% lidocaine with 1:100.2 0.1% Lidocaine 950 mL 50 mL 1 mL (1 mg. The dilute nature of the infiltrating fluid in the tumescent technique allows some inadvertent intravascular administration without consequences.5 mL (final solution pH 7.45% the anesthetic fluid. Georgiev. Without epinephrine. and lidocaine enters the bloodstream more rapidly. there is no concern for substantial intravenous lidocaine/epinephrine administration. This contributes to the low post-operative pain reported in our series. a more sudden.

therefore limiting its toxicity (3. The benefits of the tumescent technique are most likely due to extensive diffusion throughout subcutaneous and adipose tissues through the use of large volumes of fluid. Initial clinical stages of lidocaine toxicity are lightheadedness. Inc. This is because other anesthetic agents are more likely than lidocaine to produce cardiovascular toxicity (13). This solution is injected at body temperature (378C) instead of room temperature for further reduction of pain (4). However. lidocaine toxicity can occur with rapid intravascular injection of concentrated solutions. Objective toxicity occurs with doses of 5 –9 mg/mL seen as nausea. “For normal healthy adults. vomiting. We employ on average 250 –1000 mL for each session. Utilizing this quantity of anesthesia is essentially an adaptation of the tumescent technique that has been previously described by Klein for liposuction surgery (10). Although a diluted lidocaine mixture is extremely safe.. we prefer lidocaine as the drug of choice for dermatologic surgery and tumescent anesthesia. the Physicians’ Desk Reference and the Xylocaine (lidocaine hydrochloride. and muscular fasciculations. A mechanical effect from the pressure generated by engorging fatty tissue with the anesthetic solution may also result in enhanced anesthesia. euphoria. supplemental post-operative analgesia is usually not necessary. . dermabrasion. A complete discussion on the potential toxicity of rapid infiltration of dilute lidocaine is found in Chapter 16. Although different anesthetic solutions such as bupivacaine or etidocaine can be utilized. Westboro. tremors. neither the initial manufacturer of lidocaine nor the United States Food and Drug Administration has data to support this recommended maximal safe dosage (11).Anesthesia 101 bacteriostatic in saline. and softtissue reconstruction (12). For nerve blocks and LIA. The anesthetic effect of this dilute lidocaine mixture in subcutaneous fat has been shown to persist for up to 16 h post-operatively. Both volume and pressure result in a thorough permeation of even the smallest capillaries and nerve endings (11).14). lidocaine toxicity may occur when plasma concentrations exceed 5 meq/mL. This would be equivalent to 2000 mg in a 57 kg (125 lb) patient and 2500 mg in a 73 kg (160 lb) patient (11). Therefore. the individual maximum recommended dose of lidocaine HCl with epinephrine should not exceed 7 mg/kg of body weight. Klein has estimated that the maximal safe dosage of lidocaine using the tumescent technique is 35 mg/kg. The use of tumescent anesthesia requires less total milligrams of lidocaine to achieve the same or better anesthesia. it is recommended that the maximum total dose not exceed 500 mg” (15). MA) package inserts state. excitement. restlessness. Although the tumescent technique was originally developed for the use in liposuction surgery. However. and/or drowsiness that appear with levels of 3 –6 mg/mL. He has shown that the use of diluted lidocaine delays absorption. tinnitus. blurred vision. psychosis. Astra Pharmaceutical Products. Klein recommends a maximum dose of 35 mg/kg when the tumescent technique is employed in liposuction surgery (11). and in general. its use has been expanded for scalp surgery. confusion.

With the traditional technique.5 –3 mg usually is sufficient to limit pre-operative anxiety. The skin is prepared with a suitable surgical disinfectant. that is. respiratory arrest.102 Ricci. individual reaction is evaluated during the first injection. When using the tumescent technique. Though infiltration of warmed LIA is almost painless. The patient must be informed before of the first injection in order to avoid “surprise” and possible defensive reaction. Here. Georgiev. beta-adrenergic receptor blockers. conversing with the patient in a warm and interested manner is of great help and has a positive psychological effect. and procainamide (18 – 24). intravenous medazolam 2.40 Â 20 mm2). Therefore. phenytoin. Patients with liver disease have a decreased metabolism of lidocaine (16). This needle exerts moderate resistance to injection so that infiltration is slow and less painful. injection is inevitably faster and more painful. Perception of pain and reaction to it vary from patient to patient. Several drug interactions can occur to decrease either lidocaine metabolism or hepatic flow. It also permits optimal control of the injected amount and maximum spare of anesthetic. The most commonly associated drugs with these interactions include cimetidine. we use an infiltration pump set to the maximum tolerated infiltration rate with a spinal needle of 22 or 25 gage. The patient is placed in slight Trendelenburg position (head-down foot-up tilt) to avoid emotional vagal reactions. Local Infiltration Anesthesia The pain of LIA injection is due more to infiltration than needle puncture. coma. it is important to perform it in the most painless and comfortable manner. With larger needles. 0. and infiltration is then slowed or accelerated as needed. and there is also waste of anesthetic. amounts larger than necessary are injected. we recommend that appropriate respiratory and cardiac monitoring be performed. and terminating in cardiac standstill (11). . and Goldman Doses over 8 – 12 mg/mL may lead to seizures. it is still the most uncomfortable part of the procedure and also the one with which the invasive part of the treatment begins. which no medication can match. LIA injection is therefore less unpleasant when needles are small and infiltration slow. we perform LIA with a 20 mL excentric cone disposable syringe and 2 cm long 27 gage needle (Terumo 27 gage. Diseases or drugs that decrease lidocaine metabolism may accentuate the development for lidocaine toxicity. Technique Pre-Operative Anesthesia Perioperative analgesia is not necessary in the vast majority of patients. greater amounts of anesthetic are used. cardiorespiratory depression. as this will reassure patients and make them more relaxed and cooperative for the rest of the operation. In the anxious patient. Lidocaine metabolism may be diminished indirectly by diseases that diminish hepatic perfusion such as heart disease (17). For this purpose. When utilizing this form of conscious sedation.

If the needle is in the perivenous space. the anesthetic solution may spread for many centimeters further along the vein. which is longer than the needle’s length. the small diameter of the needle. so that fewer injections are needed. 7. in the groin. and the slow rate of injection make an accidental intra-arterial or venous injection of large amounts of LIA unlikely. large perforators. operation at the saphenofemoral or saphenopopliteal junctions. as seen by blanching beyond the injection site (“A”).and subdermal) infiltration around the vessel is sufficient unless there are deep trunks (e.. that is. a longitudinal wheal and/or bleaching results are clearly visible (Fig. we start injecting from the middle (or from a bi-trifurcation) and then proceed alternatively in both (or more) Figure 7. Moreover. Correct position is recognized by wheal formation. Aspiration to check for intravenous position of the needle is usually unnecessary.Anesthesia 103 Superficial (intra. On the contrary.1 Anesthesia with epinephrine-containing solutions causes vasospasm evidenced as skin blanching over the marked vessel. its continuous movement. the next injection is made at the end of the wheal. thigh portion of the GSV). When infiltrating a long and straight segment. If infiltration is performed in the perivenous cleavage plane. LIA often dissects the latter infiltrating a tunnel that may extend a few centimeters beyond the tip of the needle. Injection begins immediately after the insertion of the tip of the needle and proceeds as the latter is pushed forward.1).g. aspiration is performed when deep (perpendicular) infiltration is needed. In such case. in which case deeper infiltration may be necessary. .

one must be able to recognize promptly and treat adequately any untoward reaction should it appear. Unlike other local anesthetics. and medial knee—areas where injection should be slower—and is practically painless in the groin. 305:617 – 618. 16:842. Arditti J. ankle. Bourbon JH et al. and it has been shown that systemic concentrations of the anesthetic during LIA for phlebectomy are many times lower than maximal. diabetes. Sodium bicarbonate attenuates pain on skin infiltration with lidocaine. 15:1081. In this way. cardiac arrhythmias. and pain of infiltration is also reduced. Chen SE. with or without epinephrine. It is therefore more suitable than other local anesthetics for use without epinephrine. L’anesthesie locale au cours de la phlebectomie ambulatoire selon la methode de R. Neutralized lidocaine with epinephrine for local anesthesia.9). Davidson JAH. Cole GW et al. deviations in the course of the marked veins. Klein JA. At the dosage employed by us. for example. 5. It has been calculated that more than one million APs have been performed in Europe without a single major accident (5. and Goldman directions. In other cases. Stewart JH. Ilieff P. arterial hypertension. Stewart JH. 4. 2. J Dermatol Surg Oncol 1989. However.8. it is useful to test the degree of anesthesia with a second series of injections and inject more if needed. It is advisable to keep a sterile syringe with some LIA ready in case supplementary infiltration is needed during surgery. Cole GW. Anesth Analg 1987. but causes even some vasoconstriction. Phlebologie 1990. Mushlin P. Injections are thus made from points already anesthetized to adjacent and still sensible areas. Vidal Michel JP. J Dermatol Surg Oncol 1990. mepivacaine does not cause vasodilation. mepivacaine may be employed without epinephrine. REFERENCES 1. Warming lignocaine to reduce pain associated with injection. glaucoma. However. errors in marking. Morris R. LIA is effective almost immediately and lasts 1–2 h. coronary heart disease. 18:640. because of insufficient dosage. 6. and so on.104 Ricci. Injection is more painful on the foot. . McKay W.6. However. Muller. 43:305– 315. Not all areas of the limb are equally sensible to LIA infiltration. and advanced occlusive arterial disease. adverse reactions to LIA are exceptionally rare and mild. Office varicose vein surgery. At the end of infiltration the anesthetized skin appears pale because of epinephrine-induced vasoconstriction. Br Med J 1992. Adverse reactions to LIA and their diagnosis and treatment are discussed in Chapter 17. Georgiev. J Dermatol Surg Oncol 1992. bad diffusion of LIA due to cicatrix tissue. Boom SJ. 3. This is because adverse reactions to LIA are dose-dependent. unexpected collaterals. in such case. one must also expect— besides more bleeding—major and more rapid mepivacaine absorption and shorter duration of LIA. Neutralized lidocaine with epinephrine for local anesthesia. 66:572. needle insertion is not averted by the patient. hyperthyroidism.

12. Increased toxicity and reduced clearance of lidocaine by cimetidine. 17:21S-28S. N Engl J Med 1980. Ricci S. 98:174– 177. Eur J Clin Pharmacol 1974. Bax NDS. Reduction in lidocaine clearance during continuous infusion and by coadministration of propranolol. Klein JA. 7:455 – 459. Shand DS. Use of tumescent technique for scalp surgery. Br J Pharmacol 1984. Tumescent technique for regional anesthesia permits lidocaine doses of 35 mg/kg for liposuction. 33:133 – 138. 21. 96:592 – 594. 24. Louis: CV Mosby. Adjepon-Yamoah KK. Lillis P. Br Med J 1976. Muller R. 202:908 – 909. J Dermatol Surg Oncol 1992. 13. The reduction of lidocaine clearance by dl propranolol: an example of hemodynamic drug interaction. Prescott LF. Handbook of Local Anesthesia. Ann Intern Med 1982. 14. Klein JA. 8:439– 450. 1:939– 941. 18. Wilkinson GR et al. licensed by Astra Pharma. Carbocaina: description leaflet. 17. 31:273 – 278. 1993:662. 2d ed. 19. 14:1124 –1132. Branch RA. Georgiev M. Sasahara AA. 15. Greenblatt DJ. Phlebologie 1970.Anesthesia 105 7. St. Knapp AB et al. Feely J. Office varicose vein surgery under local anesthesia. Effects of b-adrenoceptor antagonists on the pharmacokinetics of lignocaine. 303:373– 376. Karlsson E. Milano. Al-Asady S et al. Central nervous system toxicity induced by lidocaine: report of a case in a patient with liver disease. 10. 11. Wilkinson GR. Collste R. dermabrasion and soft tissue reconstruction. J Dermatol Surg Oncol 1990. Impaired lidocaine metabolism with patients with myocardial infarction and cardiac failure. J Dermatol Surg Oncol 1988. Carstens G. Tucker GT. Byers JM III. The cimetidine– lidocaine interaction. Clin Pharmacol Ther 1983. Conrad KA. 18:130 – 135. Klein JA. Ochs HR. Finley PR et al. 18:55. 184:515 –519. La phlebectomie ambulatoire. 16:248 – 263. Malamed S. McAllister CR et al. Astra Dental SpA. 22. The tumescent technique for liposuction surgery. 1986:44. Coleman WP.. Dermatol Clin 1990. J Dermatol Surg Oncol 1992. . Physicians’ Desk Reference. Rowlins MD. 47th ed. J Pharmacol Exp Ther 1973. 16. Montvale. 20. Lidocaine elimination: effects of metoprolol and of propranolol. 8. Plasma levels of lidocaine during combined treatment with phenytoin and procainamide. Selden R. Talbot RG. 23. Sweden. 9. Anesthesia for liposuction in dermatologic surgery. Ann Intern Med 1983. New Jersey: Medical Economics. J Am Med Assoc 1967. Inc.

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the limb may be further elevated by means of thick pads.). elderly patients. pronounced dorsal kyphosis. cervical spine pathology. This is done to avoid excessive bleeding and emotional vagal reactions. 107 .. according to the presumable blood pressure in the varicose veins. If necessary. the area to be operated on is chosen in a way that the patient should not have to Figure 8. etc.1 Supine position with one knee flexed for exposure of medial aspects of thigh and leg. The skin is prepared again with surgical disinfectant and a sterile drape of suitable size is placed under the limb. When possible. Phlebectomy is best performed on a horizontal plane. but a higher one should also be available in case the patient is unable to keep the head flat on the table (i.e. foot-up tilt) of various degrees. The head is placed on a flat pillow.8 Position of Patient During Surgery The patient is operated in mild Trendelenburg position (head-down.

The latter is easy to maintain. In the prone position.2). while the other leg may rest on the table with the knee slightly flexed. anterolateral. and anteromedial aspects of the leg are operated with the patient in supine position (Fig. the limb may be wrapped in the drape and the latter opened in the new position. 8.1). the patient has to change position completely. Anterior. and Goldman Figure 8. We place the patient in a semiprone position with the inferior leg straight on the table and the superior leg flexed with the knee rested on the table (Fig. so care should be taken to insure maximum comfort and relaxation of the patient. If.2 Lateral position for exposure of posterolateral and posteromedial aspects of thigh and leg. Limited rotation of the limb does not present problems. but other positions may not. on the contrary.108 Ricci. Lateral position may be difficult to maintain. one can operate on the posterolateral aspect of the superior and posteromedial aspect of the inferior leg. 8. . Georgiev. In this position. change position during surgery. a support pad under the ankle makes it more easy to maintain the leg in position.

9 Phlebectomy INCISION The incisions are the most characteristic feature of Muller’s technique. During the operation many of the smaller stab incisions may enlarge. A series of different instruments are used for the incision: a hypodermic needle (18 gage). which cannot be introduced and maneuvered through an incision . Japan) superior to the common blades. This is true for normal skin.4 –5 mm long.. Fortunately. incisions retract to their original size.2 mm diameter) hypodermic needle (Terumo blood transfusion 18 gage needle) results in a 1 mm large semicircular incision. or a common number 11 scalpel blade (Fig. which limits its penetration and makes it operate as a blood lancet. the smaller the risk of adverse sequelae. we found the carbon – steel blades (Feather Safety Razor Co. Medical Division. hypertrophic or keloid scars: the smaller the incision. with compression. Puncture with an 18 gage (1. and even more for skin that tends to form reddish. Ltd. Therefore. brown. even when enlarged by subsequent 109 . 9. one should make the smallest possible incisions. The latter may be held with a forceps close to the tip. Not all commercially available number 11 blades have well-sharpened tips. their use prolongs the time of the operation without increased cosmetic benefit. but in our experience. Muller himself calls a 2 mm incision “large” and a 3 mm one “enormous. a blood lancet.1). This enlargement is primarily due to stretching of cutaneous elastic fibers. even if vein avulsion becomes more time consuming..) Needle incision. There are techniques described as “stab avulsion” that use common hemostatic forceps. The latter is even smaller when the skin is so elastic as to get dissected rather than cut by the tip of the needle.” This “obsession” with the size of the incisions is based on the observation of the scars: the difference between a practically invisible scar and an unsightly scar could be no more than 1 mm. (Even smaller needles are used by some authors. at the end of surgery.

and thus not readily noticed. This permits better eye control of the depth (and size) of the incision. . causing a larger than desired incision. malleoli. so that the progression of blade penetration is controlled. it is necessary to hold up a skin fold and incise on it in order to avoid damage to deeper structures. 18 gage hypodermic needle. The cutting edge of the blade is held up and the skin is kept stretched to become tense (Fig. will result almost always—and often in a few weeks—in a practically invisible scar. like those made with needle. but once perforated may yield abruptly.1 mm tip) to hook the vein.1 Instruments for skin incision. It is advisable to press firmly with the top of the third finger against the skin. the skin is very resistant to puncture. They tend to be perceived as common and not surgical scars. are all of the same size and shape. With these small (up to 1 mm) incisions we use a number 1 Muller hook (0. Incisions made with blood lancet have similar characteristics. the scalpel is held as a pencil and the skin is incised with vertical pressure only (as with a blood lancet). tibia. Georgiev. 9.110 Ricci. given the shape of the lancet permits penetration only to a fixed depth (1 – 2 mm) so that deeper structures cannot be accidentally damaged. and number 11 surgical blade. manipulation and passage of the vein. Even when visible.2). Sometimes. such scars are usually round and not linear. When incising close to a bony surface (knee. and. From left to right: blood lancet. and foot). When a number 11 blade is used. and Goldman Figure 9.

the incisions—especially the smaller—usually have an excellent cosmetic outcome. We make such incisions with a number 11 carbon– steel scalpel blade. The skin is held tight. . the thickness of the vein wall. an adherent vein may require larger incisions and thorough dissection before its avulsion or it will continuously rupture. Small dermal veins (usually mixed with telangiectasia) are invariably avulsed through incisions made by a puncture with hypodermic needle or blood lancet. or lose time with a “fruitless” incision in order to spare an additional one. CVVs). as this may result in unsightly scarring. so that it is better to make one more incision rather than risk to leave segments of vein not avulsed.Phlebectomy 111 Figure 9. is still palpable as a hard cord through the skin. 9. it is better to lengthen it. For larger varicose veins or for thick-walled veins (saphenous trunks) incisions larger than 1 mm are necessary. The size of the incision depends on the size of the varicose vein.2 Technique of microincision with number 11 scalpel blade. and its adherence to the perivenous tissues. It is amazing how often a 6– 7 mm diameter varicose vein may be avulsed through a 1 mm incision (Fig. may need no more than a needle or lancet incision (such as collateral varicose veins. the cutting edge of the blade up for better visual control of the depth and size of incision. However. It is also better to avoid excessive trauma to the edges of the incision or to lacerate the skin. when an incision is inadequate. Even larger varicose veins. kept in traction. These incisions are vertically oriented to prevent inadvertent lymphatic damage except for areas—like the popliteal fossa and the anterior knee—where skin tension lines are too obviously horizontal and thus the incisions are oriented accordingly. we prefer to make one incision at a time and place the next one at the most distant point where the vein. The incision is made by puncture. when thin walled and without perivenous adherence.3). Therefore. Unlike Muller who makes all the incisions together and at a regular distance (3 – 5 cm) from each other.

and Goldman .112 Ricci. Georgiev.

so that many different types of hooks are now available (Varady. (a) Posterolateral thigh varicose vein. This perforator typically connects the posterolateral superficial thigh veins to the deep femoral vein. Double marking (arrow) indicates the point where phlebectomy was started.2 mm) needle. 9. and second needle puncture is made a few centimeters proximally. needle punctures).3 Avulsion of larger varicose veins through needle puncture. (g) The segment between the two incisions has been avulsed through the second incision.e. (e) Hooking the varicose vein with number 1 Muller hook. 5 – 6 mm diameter. Ramelet. AND EXTERIORIZATION Vein hooking and exteriorization are the most specific phlebectomy maneuvers and permit varicose vein avulsion through 1– 3 mm stab incisions. and fine-pointed toothed clamps (Fig. VEIN RETRIEVAL. Graefe iris forceps. Oesch. HOOKING. whereas toothed clamps (hemostatic forceps) require incisions over 3 mm long. (d) Needle puncture with 18 gage (1. (f) Grasping the vein with mosquito clamp.Phlebectomy 113 Figure 9.).1 mm long (i. Hooks After the introduction of the Muller hook during the 1970s. etc. . including simple punctures Figure 9.4). which is shown in the next photographs. Note how the needle puncture dilates to allow the passage of a much larger vein. Villavicencio.3 Continued. which measures 5 – 6 mm in diameter. The purpose of the hook is to operate through very small incisions. The circular sign marks the incompetent perforator at the origin of the varicose vein.. Scars from previous “classical” varicose vein surgery. Trauchessec. The vein is next put under traction until a loop is exteriorized and divided. Instruments Three types of instruments are employed for vein retrieval and hooking: hooks of different size and shape. Dortu. Small size hooks allow the operation to proceed through stab incisions . (c) Pre-operative marking. (h) Exteriorization of the incompetent perforator at the proximal end of phlebectomy. (b) B-mode scan of the perforator. Note how the first incision has retracted to almost its original size (about 1 mm). many authors designed their own hooks. Graefe forceps require incisions 1 –2 mm long.

features available only with the addition of lefthanded hooks. Our (MG and SR) preference is due to the fact that.2 mm diameter) in middle for comparison. The type used for phlebectomy has a right-angled point (Graefe iridectomy forceps number 35-367-10. less curved variants are available. to free the vein from its perivenous attachments. some hooks have larger points and need larger incisions to operate. Martin. Another advantage is that.7). to clean the exteriorized vein from its investments and separate the two branches of the venous loop.5 mm. that is. in fact. as a small hook (only one branch) or as a large hook (closed. to grasp the vein.5 –9. because of its small size. 4. Graefe forceps permits better definition of the type or structure touched and hooked. before or after its exteriorization. we prefer it to hooks for phlebectomy of larger varicose veins. 5.114 Ricci. can . with a 18 –19 gage hypodermic needle or blood lancet (Figs. but are not suitable for phlebectomy. 3. It can be used for the following (Fig. 9. and with both hands. Though Muller himself has abandoned the use of the Graefe forceps in favor of his series of hooks. However. unlike hooks. Graefe Iris Forceps Muller developed his method of phlebectomy with the small toothed ophthalmologic forceps. and Goldman Figure 9. 2. 9. Georgiev. forceps. when incisions are made with a number 11 scalpel blade and are larger than 1.4 Muller hook (number 1) on right and Graefe forceps on left with 18 gage needle (1.8): 1. both branches). Germany). the Graefe forceps is a versatile instrument that combines at least five different functions. for hooking in two directions (clockwise and counterclockwise). as a dissector.

Kistener RL. eds. (c) Appearance of the vein on the hook. Surgical procedures for varicose veins: axial stripping and stab avulsion. W. (Reproduced with permission from Ramelet AA. (a) Overall appearance. 1992. (b) Magnified view of specially designed curved end. Figure 9.A. Saunders. Muller phlebectomy. Atlas of Venous Surgery.Phlebectomy 115 Figure 9.) (a) Two different sized hooks. 17:814 – 816. J Dermatol Surg Oncol 1991. In: Bergan JJ. (b) Magnification of tips. Ramelet. (Reproduced with permission from Bergan JJ.B.5 A phlebectomy hook designed by A.) .6 Four sizes of Muller hooks.

like the proximal portion of the small saphenous vein (SSV) or the thigh portion of the GSV. Saunders. Fig. teased out and avulsed through needle or lancet punctures. Technique Small dermal varicosities are hooked.116 Ricci. this maneuver will tease out the vein.2 – 3 mm. but may also be used to grasp the veins through skin incisions (see Chapter 13. (a) Overall appearance.14).) be considered an extension of the fingers. As a result a stump (or two) of various lengths come out of the incision and are clamped. 1992. eds. the hook is rotated in a clockwise direction to hook the vein. Toothed Clamps Fine-pointed toothed clamps (Halsted mosquito clamp or Debakey hemostatic forceps) are used mainly for traction on the exteriorized veins. and avulsed. If this maneuver is “fruitless. Georgiev. whereas hooks are rather an extension of the hand.7 Oesch hooks in various sizes. This can only be done with incisions . Surgical procedures for varicose veins: axial stripping and stab avulsion. 13. if the vein does not come out. teased out. W. breaking it at the same time. (b) Magnified view of specially designed “grasping” end. Once introduced into the incision.” that is. and Goldman Figure 9. In many cases. and is employed for deeply and/or subfascially located trunks. In: Bergan JJ.B. Kistener RL. 9. When only the perivascular . the hook is maneuvered gently until the vein is hooked. (Reproduced with permission from Bergan JJ. and then pulled out of the incision with abrupt movement.9). Atlas of Venous Surgery. with the use of number 1 Muller hook (Fig.

(c) Hooking with one branch of the Graefe forceps. (d) The exteriorized vein wall is grasped with mosquito clamp. especially if the skin is elastic and does not lacerate during the passage of the vein. but thin-walled CVVs can be successfully avulsed through needle/lancet incision. the vein can be teased out and avulsed. In these cases. The vein wall is recognized by its white color.10).Phlebectomy 117 Figure 9. . most larger varicose veins are avulsed through scalpel blade incisions 2– 3 mm long. Some larger. (e) A loop is now completely exteriorized. we use the Graefe iris forceps and proceed as follows (illustrated in Fig. At this point. and with both hands. it is clamped with a mosquito clamp and kept in traction while the hooking maneuver is repeated until a venous loop is exteriorized. 9.8 Graefe iris forceps can be used as a bi-directional hook in clockwise (a) and counterclockwise (b) directions. Either single branch or both branches together (closed) may be used for hooking. However. connective tissue is hooked.

Georgiev.118 Ricci. and Goldman .

. In many cases. and clamped with mosquito forceps for further traction. (e) Once hooked. Figure 9. and exteriorizing with the Muller sharp hook (number 1 TF). hooking.Phlebectomy 119 Figure 9. (a) Needle puncture is sufficient for extraction of small varicosities and for operating with the number 1 Muller hook.9 Continued. One or both branches of the forceps are introduced through the incision and passed first in both directions along the vein in order to dissect it from surrounding tissues. (b) The hook is inserted into the incision with its point down. The forceps is then passed under the vein and the latter hooked with rotatory movement of the wrist (in clockwise or counterclockwise direction). this maneuver will break the vein and tease out one or both ends (f). the hook may be maneuvered gently until the vein or its investments are hooked and exteriorized. the vein is pulled out with an abrupt upward movement. (g) If the earlier described maneuver fails. and then rotated in a clockwise direction (c) until the vein is hooked (d).9 Serial diagrams illustrating varicose vein retrieval.

At this point. if the vein is hooked. Once exteriorized. In this case. The hooked vein gives a precise and specific sensation of an elastic. The pulling and rotating maneuver brings the tip of the forceps closer to the skin surface. it comes out of the skin opening. the vein is pulled out with alternative rotatory movement of the forceps’ tip (similar to windshield wiper motion). it is clamped with the hemostatic forceps and kept in traction with the left hand. Georgiev. . the perivascular connective tissue is hooked and teased out without the vein. the vein is clamped with the hemostatic forceps and the perivascular tissue is dissected with the Graefe forceps until a loop is completely defined. and. At times. and Goldman Figure 9. Once hooked.120 Ricci. while the Graefe forceps repeats the initial maneuver until the vein is hooked and pulled out. rubber-like structure. and is recognized by its white. lustrous appearance.9 Continued. the vein can be pulled out and avulsed.

Small dermal varicosities are fragile and break easily upon traction. it is pulled out by alternating rotatory movement of the forceps’ tip. clamped with a mosquito forceps (i).Phlebectomy 121 VEIN AVULSION Dissection Veins are pulled out more easily when they are separated from the surrounding connective tissue. other times. (b) The forceps is passed under the vein and the latter hooked with clockwise (or counterclockwise) rotation of the wrist. (a) One or both branches of the Graefe forceps are introduced through the skin incision and passed along the vein to create a cleavage plane. 9. Sometimes a complete venous loop comes out (d –f). 9. similar to windshield wiper motion. fine-pointed 9 –10 cm mosquito clamps may be employed. Further dissection may be achieved with a blunt probe passed along the perivenous cleavage plane around the entire circumference of the vein (Fig. the exteriorized vein is first “peeled off ” with the scalpel or with the tip of the Graefe forceps (Fig.10 Serial diagrams illustrating vein retrieval. (c) Once the vein is hooked. nontoothed. the vein stretches and becomes tense under traction. Therefore.11). only the investments of the vein are exteriorized (g and h). Traction Varicose veins are avulsed by traction maneuvers as illustrated in Fig.12. and exteriorization with the Graefe forceps. When adequately dissected from its attachments. . and put in traction until a complete loop is exteriorized (j). but for larger varicose veins. the latter grasp better and permit stronger traction without breaking the vein.11). 12 –14 cm toothed clamps (hemostatic forceps) are preferred. For traction on very small dermal varicosities. Therefore. 9. It can be palpated as a hard cord for a variable length under the skin. they must be clamped close to the skin opening and pulled gently or twisted Figure 9. hooking.

Georgiev.10 Continued.122 Ricci. and Goldman Figure 9. .

a small vein is resistant to traction. these veins often break and are therefore removed piecemeal. and its two segments are avulsed separately. abrupt pulling may break the vein. attention must be paid to not leave behind nonavulsed segments. which is the way larger varicosities are avulsed. While pulling the vein with one . it is better not to break it. but hook it and tease it out from a separate incision. it is pulled with to-and-fro rocking and circular motions. This minimizes excessive post-treatment inflammation. however.10 Continued. Linear traction is alternated with “to-and-fro” rocking and circular movements. If. When a loop of a larger varicose vein is exteriorized. Despite careful manipulation. it must be held with the clamp close to the skin opening to minimize breaking and pulled slowly with a progressively increasing force.Phlebectomy 123 Figure 9. The loop is then doubly clamped and divided. To tease out the vein. on the forceps. These alternating traction movements permit detachment from perivenous tissue.

124 Ricci. Georgiev.10 Continued. and Goldman Figure 9. .

retrieval and hooking the vein from the first incision may be difficult so that it is often more convenient to start phlebectomy from a site of side branch confluence or where the vein is readily accessible. that .11 Diagrams illustrating dissecting maneuvers. (b) Dissecting the vein from its attachments along the perivenous cleavage plane by repeatedly passing a blunt probe along the vein. but which end to start with is not important. Progression of Phlebectomy The marked vein must be avulsed in all its length. to-and-fro traction on the skin over the vein with the other hand facilitates further detachment of the vein from the perivenous tissues. even longer segments may be avulsed from a single incision. hand. In cases of varicose clusters or meandering veins. All these maneuvers may free 10 or even more centimeters of the vein. We usually begin from the distal end of a varicose vein and proceed proximally.Phlebectomy 125 Figure 9. (a) Stripping the vein off its connective tissue investments with Graefe forceps. However.

126 Ricci. and Goldman . Georgiev.

more superficial or bulging.Phlebectomy 127 Figure 9. and its both ends avulsed separately.12 Continued.12 Diagrams illustrating traction maneuvers. Further detachment may be achieved by countertraction on the skin with the other hand (h). it may rupture. Before this happens. To-and-fro rocking movements (d and e) and circular movements (f and g) help free gradually the perivenous attachments all around the vein. 9. When resistance to traction increases and the vein does not yield any more. then divided (a). is. The exteriorized loop is put under traction. and pulled with slow. or twisted on the forceps (c) until it yields. The vein is held close to the wound opening (otherwise it breaks easily). progressive linear traction (b). the next incision is made. as far as possible Figure 9. . and proceed from that point in both directions (illustrated in Fig.13).

The segment between the two incisions is pulled out through the second incision. traction on it is released and it is exteriorized through the new incision. Georgiev. according to the resistance of the vein and its subcutaneous attachments. and Goldman Figure 9.10 cm. the vein breaks upon traction. if. however. In many cases. and therefore pulls the overlying skin. The Graefe forceps (or a hook) is introduced into the new incision. while the free end of the vein is kept under traction. it is retrieved and hooked again from a new incision. Once the vein is hooked. along the palpable vein cord. . The next incision can now be made and the procedure repeated as many times as needed until the entire length of the previously marked varicose vein is avulsed. the latter is easily recognized as a hard cord and hooked and exteriorized through the new incision.12 Continued. The distance between incisions varies from 1 to . usually where the vein has not been dissected from the subcutaneous tissues. long segments—even the entire length—of the vein may be avulsed undivided.128 Ricci.

and avulsed (c) through the new incision (d).13 Serial diagrams illustrating progression of phlebectomy through the second incision. hooked. exteriorized (b). Next incision is placed over the most distant point where the vein is still palpable.Phlebectomy 129 Figure 9. . (a) The free end of the vein is kept under traction so that the vein is palpated as a hard cord for a variable distance under the skin. The vein is easily recognized as a hard cord.

The residual stump retracts and usually does not bleed. If the vein begins from a large perforator. Georgiev. . They are part of a superficial venous network connected by perforating veins (PVs) to the deep (subfascial) veins. as the upper thigh. however. digital compression for a few seconds will stop the bleeding. 9. where a compression bandage may not be sufficient to stop bleeding. must be divided in order to avulse the marked varicose veins (Fig. because— especially when superficial—these may cause granuloma formation. this is best ligated. The general rule is to avoid ligatures as much as possible. Small dermal veins without well-defined proximal connections are teased out until they break or are pulled to maximal stretch and cut at the skin opening. the vein is divided in different ways according to the type of proximal ending. ligatures are used for large PVs and in obese patients or in areas. If the vein begins from a small incompetent perforator. the latter is put under traction and/or torsion and divided. Vein Division Varicose veins are not “solitary” trunks. Vicryl or Dexon suture. as well as both ends of the varicose vein itself.130 Ricci. especially at the upper thigh where compression may be inadequate to prevent bleeding (otherwise—though very rarely—hemorrhage or hematoma formation may follow). the varicose vein is pulled to maximal stretch and divided close to the skin opening.14). if it bleeds. These side branches and PVs increase in density distally along the limb.13 Continued. End Division At its distal end. left in place (or removed at the next session) is ligated with #3-0 catgut. The proximal segment of a large vein. All of these anastomotic veins. followed by digital pressure for a few seconds to prevent bleeding. At its proximal end. and Goldman Figure 9.

14 Diagrams illustrating vein division. a few minutes of digital pressure prevents bleeding (e). Keeping the vein under traction. (h) Side branches may rupture upon traction of the main trunk. Side branches (k and l).Phlebectomy 131 Figure 9. longer varicose vein segments (!20 cm) can be avulsed through only two incisions. or twisted until they break (d). but may also cause the main trunk to break (i). This way. (c) Small perforators are either put under traction and divided. may be divided by needle puncture. . (If a large incompetent proximal segment is left in place to be avulsed at the next session. of course. or teasing it out until it breaks (b). Terminal (distal or proximal) disconnection is performed by pulling the vein to maximal stretch and dividing it at the skin opening (a). it is. the latter may be exteriorized and divided. Larger incompetent perforators are best ligated (f and g). (j) If the incision has been made close to side branch confluence. it is transformed into a hard cord that can be divided by needle puncture without skin incision. ligated). as well as the main trunk (m).

and Goldman Figure 9.132 Ricci. Georgiev. .14 Continued.

Though phlebectomy could be performed without vein ligature.15). are better ligated. The saphenofemoral and saphenopopliteal junctions are. or is pulled to maximal stretch and divided at (or below) the skin opening without ligature. its side branches are also pulled. pulling the perforator beyond its stretching capacity causes discomfort to the patient. Some of them will break under traction without impeding varicose vein avulsion. Characteristically. If an incision is made exactly over a perforator. PV Division PVs are usually not given special attention. one has to rely only on the compression bandage for prevention of bleeding. 9. as well as those in the medial and upper thigh.Phlebectomy 133 Figure 9. most of them rupture upon traction and do not impede varicose vein avulsion. Side Branch Division While pulling the vein. the latter may be recognized by its T-shape junction when the superficial vein is exteriorized (Fig. otherwise. the perforator is put under torsion until it breaks.14 Continued. For vein ligation. of course. we use #3 catgut suture or #2-0 or #0 Vicryl or Dexon suture. always ligated. but some are strong . In these cases. Digital pressure is immediately applied and maintained for a few minutes to prevent bleeding. large incompetent perforators of the “direct” type.

the latter may be exteriorized and divided. In addition to superficial side branches. Georgiev. Side branches (and perforators as well) can be disconnected by traction and/or torsion until they break. This may be done during GSV stripping. it is possible to avulse longer (!20 cm) segments of a vein with only two incisions (avoiding the third incision . divided through the skin incisions. The needle is held close to the tip. and divide veins by puncture without skin incision or exposure of the vessel. the vein to divide must be kept in traction.134 Ricci. Their pulling may cause discomfort to the patient because there is no anesthesia along the side branches. and Goldman Figure 9. If incisions are placed over side branch confluences. To do this. and also to cut a varicose vein away from the point it is clamped. Side branch division enhances vein avulsion and permits longer varicose vein segments to be avulsed with fewer incisions and less discomfort to the patient. like a pencil. or to divide the vein between two incisions. they counteract traction and prevent it to be transmitted at a longer distance along the main vein. For these reasons. The skin is punctured and the tense collateral is recognized as a hard cord and cut with the needle’s tip. because many collaterals break upon traction or can be divided by needle puncture without a skin incision. perforators and even the main varicose trunk may also be divided by needle puncture. In this last case. Large needles (number 18 or 19) are easier to use as blades. However. to divide the GSV at the knee. It is possible to divide a vein using a hypodermic needle as a blade. it is advisable to divide them. but smaller needles may also be employed. enough to cause the varicose vein to break instead of breaking themselves.15 Isolation of the Boyd (below knee) PV. it is not necessary to make an incision over every vein bifurcation. Moreover. The beveled tip of a hypodermic needle has sharp cutting edges that allow it to be used as a microblade. or divided by needle puncture without skin incision.

with fewer incisions and less discomfort to the patient. 9. Good pre-operative marking—with the patient in the recumbent position—is essential for this purpose. Varicose Clusters Sometimes. Vein section by needle puncture permits side branch disconnection without excessive traction and rupture. hooking. varicose veins are arranged in clusters or complex patterns. but must still be minimized. so that the sites where the vein has not been avulsed appear indurated.Phlebectomy 135 in the middle). more incisions are needed and the vein has to be avulsed piecemeal. 9. some veins are fragile and rupture with the slightest traction. In these cases. and conditions of the varicose veins and surrounding tissues. Usually this damage is insignificant. “blind” avulsion far from the incision may damage nerves and lymphatics. However. When a vein is avulsed. This is recognized after the removal of the bandage (here we avulse the residual veins free of charge).17). some vein segments may remain in place. However. It is often possible to “scratch out” the residual piece through the old incision and thus avoid making additional incisions over the remaining segment. localization. phlebectomy may be difficult and even discouraging to the inexperienced operator. Examples of veins that not only rupture easily but also form complex networks are some reticular (dermal) varicosities. very abundant venous material may be avulsed from a rather limited area (Fig. the latter is divided in the middle by needle and the two segments are teased out separately. Keeping the vein in traction from both ends. We find this procedure very useful and use it routinely. but short segments of the vein may be left in place.16). it is important to remove them thoroughly. . The more experienced the operator. the less frequently this occurs (Fig. As their removal is requested mainly for cosmetic reasons. and avulsion have to be modified accordingly. The difficulties depend on the type. In such cases. which often accompany telangiectasia. phlebectomy is more difficult and the maneuvers of retrieval. despite careful marking and thorough avulsion. which may make marking difficult. long segments of varicose veins are easily avulsed through a few stab incisions. Vein Fragility Optimally. TECHNICAL DIFFICULTIES Despite its apparent simplicity. In some areas. However. Careful dissection and gentle pulling may permit avulsion of longer segments. the empty tunnel along its course can usually be palpated as a skin depression.

(a) Varicose clusters over the right knee. (c) Three weeks after phlebectomy. in a number of cases foot varices need to be treated. Foot Although a simple dilatation may be due to blood overflow and may recover after proximal varicose correction. Over 100 consecutive cases. Georgiev. one of the authors (SR) found that 12 required foot phlebectomy. in continuity .136 Ricci. (b) Large number of veins avulsed from a limited area. Generally foot dorsal veins. and Goldman Figure 9. bilaterally in two cases.16 Complex patterns of varicose veins.

(b) Ten days after phlebectomy it became evident that there is another varicose vein originating from an incompetent below-knee perforator. with leg collateral veins.Phlebectomy 137 Figure 9. If larger incisions are made and the Graefe forceps is used instead of a hook. Touching or manipulating a sensory nerve is usually painful or causes an “electric shock” . it is often necessary to pull up a skin fold to make the incision and hook the vein. they are often accompanied by sensory nerves. Moreover. This vein is now marked for avulsion. The missed vein runs close and parallel to the one marked and avulsed. If a number 1 Muller hook is used. Because the subcutaneous layer is very thin. making retrieval difficult. laying under a fascial shelter (Figure Saphenous eye of the foot). but shrink in Trendelenburg position. (a) Preoperative varicose vein marking in patient with long-standing varicose veins and stasis changes of lower leg. it is preferable to grasp—not hook—the vein with the forceps. CVVs on the dorsal foot may become very large in the upright position. so one has to make sure that the exteriorized cord-like white structure is a vein and not a nerve.17 Complex varicose vein patterns may cause incomplete avulsion. Nerves and veins may be difficult to distinguish. while dorsal marginal and arch veins. are those most involved in varicose veins (75%). The black dotted line indicates the course of the varicose veins avulsed at the first phlebectomy. Manipulation must therefore be delicate in order to avoid nerve damage. it is better to hook only part of the vein or its perivascular tissue. are more rarely involved. Due to their great elasticity. in continuity with the saphenous veins.

so that their removal is often requested for cosmetic reasons. bleeding after vein disconnection is often quite strong. Thigh Thigh varicose veins may be independent from the GSV. but compact layer of subcutaneous connective tissue and are difficult to hook. and Goldman sensation. A skin fold should be pulled up with the left hand. causing unsightly scars. In the popliteal area. the skin is.138 Ricci. Georgiev. the search must go deeper. even when not grossly varicose. If reflux in them originates from an incompetent thigh perforator. These veins are embedded into a thin. and the vein searched and hooked delicately in order to avoid trauma to the periosteal tissue or damaging the tiny sensory nerves that often accompany the veins. larger incisions may be necessary and the vein has to be thoroughly dissected from the surrounding tissue prior to hooking and avulsion. on the contrary. The probe is felt through the skin. Knee The skin over the anterior aspect of the knee is particularly thick. but ceases promptly after a few minutes of digital compression. the traction needed is stronger and some risks are higher. and scars tend to be more visible. These veins may be more easily removed by introducing a metallic probe into the lumen of the vein to retrieve it through a more proximal extracted vein. Shin The veins over the tibia may become visible and unsightly. and the subcutaneous connective tissue. whereas nerves are less yielding and obviously do not have a lumen. Phlebectomy is more difficult when treating the dorsal marginal and arch veins. but does not lead to appreciable loss of sensitivity. the rupture of which causes burning pain. Careless manipulation may lacerate the incisions. As a consequence the incision must be larger. fibrous and compact. which facilitates venous wall identification. thin and delicate. The vein can also be better recognized by filling it with blood (by squeezing the foot proximally and distally). The area is rich in tiny sensory nerves. Therefore. These veins are not superficial and failure to avulse them will be immediately noticed by the patient. These veins are very thick walled and run under the connective fascia similar to the saphenous veins. the latter is often fragile and must be carefully isolated and ligated because the compressive bandage—especially in obese thighs—may not be sufficient to prevent bleeding with hemorrhage or .” Another sign is that collateral foot veins usually yield upon traction without much resistance or pain so that long segments are easily avulsed through a single incision. Owing to the very rich vascularization in the foot. or by a longitudinal incision that allows better exposure of the vein “lumen.

Alternatively. a probe can be introduced inside the lumen through a more distally extracted vein. the vein often presents more superficial segments or bulging and palpable spots. and it is in these sites that it is more easily retrieved and hooked. The varicose thigh branches of the GSV are ligated as close to the GSV trunk as possible. there are no indications to strip it. The distal portion of the GSV—below the Boyd perforator—is invariably embedded in a compact fibrous tissue and covered by layers of fibrous fascia. They are avulsed as high as possible and disconnected proximally by twisting. The saphenous (sensory) nerve runs close to the distal portion of the GSV and may be easily damaged. ligated. which may take many weeks or even months. in most cases it is competent. which must be disconnected. This may require larger incisions. bruising or hematoma may cause skin discoloration. otherwise the saphenous trunk may break upon traction. distal (knee and leg) GSV segments are often avulsed by phlebectomy. side branch and perforator confluence. Alternatively. which invariably stops bleeding. the distal portion of the GSV is better left in place and not avulsed. Incompetent pudendal varicose veins are usually of small caliber. of course. sclerotherapy can be more easily performed. the technique of SSV phlebectomy differs from that of the superficial CVVs. It may therefore be difficult to retrieve and exteriorize. it assists in localizing the deep and sometimes nonapparent location of the saphenous vein. and can be spared. not enlarged and without varicose side branches. an occasional large vein may be. to disappear. Great Saphenous Vein While we ligate the SFJ and strip the thigh portion of the GSV through the groin incision (see Chapter 15) or close the GSV with endoluminal laser or radiofrequency closure (Chapter 21).Phlebectomy 139 hematoma formation. once the feeding incompetent varicose vein is removed. The probe will assist the surgeon to the location of the saphenous vein helping its retrieval. Therefore. However. like in SSV and foot vein phlebectomy. In this area. Many . the GSV is put under traction and its deeper and nonpalpable portions are more easily recognized as a hard cord and hooked from the next incision. of course. and manipulation must stop in case of pain or an “electric shock” sensation. Because of these difficulties. Once exteriorized. It also may have many side branches. When a duplex ultrasound is available. it is difficult to hook and exteriorize. fortunately. Unlike its side branches. while the latter is left in place if. the vein must be delicately hooked (or grasped) and dissected. and is described in detail in Chapter 13. Small Saphenous Vein Owing to its subfascial course. which correspond to sacular dilatations. the GSV lies deeper and is covered by a fascial layer that encloses it within a relatively restricted space that prevents varicose formation. therefore.

Varicose Veins Recurrent After Sclerotherapy Varicose veins recurrent after sclerotherapy may present segments of different diameter and consistency that may be difficult to evaluate and mark by clinical examination alone. lipodermatosclerosis. then the recanalized vein may be adherent to surrounding tissues. If not adequately treated. and in such cases. Some segments may be stiff and their caliber may appear much smaller than it really is. Veins around the scars are adherent and break easily upon traction. some segments may stay in place and later recanalize with varicose vein recurrence. Georgiev. that is. Lipodermatosclerosis As previously mentioned. leg ulcer. lipodermatosclerosis is best treated with graduated compression with phlebectomy performed only after adequate cutaneous softening. In this case. superficial thrombophlebitis is first treated by thrombectomy and compression. in cases with diffuse perivenous and venous wall calcifications. If phlebectomy is performed too early. . Varicose Veins Recurrent After Traditional Surgery The areas of surgical scars are also difficult to operate through. In the presence of thick perivenous fibrous investment. However. phlebectomy is unexpectedly difficult. such segments may become very adherent to the surrounding tissue and be extremely difficult to avulse. dermatitis. and Goldman patients who need varicose vein surgery have one or more local complications like phlebitis. Supplementary anesthesia is often needed because of poor diffusion in the fibrous tissue. when little improvement is expected by compression treatment. and removal may be incomplete. a segment of the GSV or other varicose veins left in place develop thrombophlebitis. If the sclerotherapy-induced inflammatory reaction has involved the outer layer of the vein and the perivenous tissue (excessive dosage of sclerosant or insufficient compression). diffusion of anesthesia may be inadequate and supplementary anesthetic injections may be necessary.140 Ricci. veins sclerosed or recanalized after sclerotherapy. and all these conditions make phlebectomy more difficult. Superficial Thrombophlebitis As previously mentioned. the vein may be difficult to dissect and avulse. more and larger incisions may be necessary. Occasionally. Patients with long-standing varicose veins sometimes develop extensive perivenous adherence as a result of recurrent subclinical phlebitis. neurogranulomas. paresthesia. chronic edema. Larger incisions and thorough dissection are necessary to avulse the thrombosed segments. or signs of previous treatments like surgical scars.

Sclerotherapy may be useful for treating residual varicose veins. However.Phlebectomy 141 phlebectomy can be performed in the lipodermatosclerotic area. at best only pieces of veins are avulsed (Fig. (b) This is in contrast with phlebectomy in early stages of varicose vein disease: virtually no blood loss. In this case. Such skin may easily lacerate during phlebectomy. combined with compression therapy. but heals promptly under compression therapy. long segment avulsed through few minimal incisions.18 (a) Phlebectomy within a lipodermatosclerotic area is a difficult procedure. Thin Skin In some patients the skin of the lower leg may be thinned and fragile because of age or prolonged steroid treatment. followed by clinical improvement.18). the resulting damage to multiple vein segments. causes significant obliteration of the abnormal varicose venous network. . Only small pieces of veins are avulsed. Bleeding is common. Figure 9. 9.

(c) Technique of subdermal scratching with 0. This procedure invariably reduces the number and size of associated telangiectasia. and Goldman Venous Leg Telangiectasia Venous leg telangiectasia are tiny superficial vessels. 9.19(a. 0. Some bruising in the upper left angle of photogram. further destruction of telangiectasia may be Figure 9. 0. They may appear alone or associated with larger (1– 4 mm diameter) incompetent dermal (“reticular”) veins. P. b)]. with the number 1 Muller hook. . but need further treatment (sclerotherapy) to completely disappear. (d) Directions of scratching. Georgiev. In addition.142 Ricci.1 – 1 mm diameter. Telangiectasia have been greatly reduced in number and size. We first avulse the larger veins through needle puncture incisions. Further destruction of telangiectasia may be achieved by subdermal scratching of areas of dense telangiectatic flares. point of entry of the hook. (e) Telangiectatic flare crossed by an incompetent dermal (reticular) vein. but some of the tiny red telangiectasias are still visible. (a) Some large blue telangiectasia ($1 mm diameter) may be—at least partially—avulsed. Even some large blue telangiectasia. (b) Two days after phlebectomy.1 Muller hook.5 –1 mm diameter. Post of the blue telangiectasia has been avulsed. Needle puncture points are clearly visible. (f) Five days after avulsion of the reticular vein and scratching of the telangiectatic flare. can be directly avulsed or at least partially destroyed [Fig.19 Treatment of venous leg telangiectasias.

20– 30 to 30 – 40 mm/Hg (Class I– II) as needed. Hereford.19 Continued. However. Skin incisions are made by needles and the finest hooks are used. Sclerotherapy may start as soon as 1 – 3 weeks after phlebectomy. All our patients wear elastic stockings. if these sclerosing solutions are too mild.Phlebectomy 143 Figure 9. 9. The discussion of sclerotherapy is beyond the scope of this book. Only one or two skin incisions are needed for the whole procedure. incision). Bleeding is uncommon as the venous pressure is usually low. They are very thin and delicate and sometimes difficult to identify because of a spasm reaction to trauma (anesthesia. . d)]. and.19(c. England). The dangerous site is the temporal because of the proximity of motor branches of the facial nerve. We inject telangiectasia with 72% glycerin or with sodium salicylate. at 0.D. for the entire duration of treatment.5% polidocanol (Aethoxysklerol. Germany). with 0.T. achieved during phlebectomy. These two last agents may be used in a foam form (1:3 or 1:4 with air. unless a Valsalva-like activity is made. Compression is applied directly after the avulsion and maintained for 10 min. Our technique for sclerotherapy of telangiectasia is described in detail elsewhere (1). by “scratching” areas of dense telangiectatic “flares” with number 1 Muller hook. as illustrated in [Fig. Kreussler.5% or 0. Periorbital Veins Their avulsion is requested for cosmetic purposes only. most of which have to be destroyed by sclerotherapy if the best possible cosmetic result is to be achieved. respectively). but may be found in many excellent sources. phlebectomy cannot completely eliminate telangiectasia. or with sodium tetradecyl sulfate (S. Limited.25%.

it is often necessary to pull up a skin fold to make the incision and hook the vein. For this reason the extent of the phlebectomy should be limited and the manipulation is particularly delicate. Their avulsion is easy. Louis: Mosby. Georgiev.144 Ricci. Small nerve branches run superficially below and around the veins. Bergan JJ. eds. Goldman MP. If their damage is limited the consequences are inconsistent. and Goldman Hand Hand veins may become cosmetically upsetting by aging. 2001. They are superficial and often mobile in the subcutaneous space and. Sclerotherapy Treatment of Varicose and Telangiectatic Leg Veins. like in the foot. as a consequence of the skin atrophy. 3rd ed. . but patients must be aware of the potential for sensory impairment. REFERENCE 1. St.

Any residual bleeding is stopped by digital pressure. adherence at the incision sites may form between skin and subcutaneous tissues. we apply the tape with overlapping in a zig-zag pattern. the edges of larger—greater than 3 mm— incisions are approximated with 5-O Vicryl dermal suture and then closed with band-aids or surgical tape. this way. 145 . This is more likely to occur at sites of vein ligature from retraction of the ligated vein that pulls on the perivenous tissues. and the skin is pulled up abruptly a few times until the adherent subcutaneous layers are detached. and. To avoid this. If necessary. if needed. a hook or one branch of Graefe forceps is introduced through the incision. the skin edges may retract and form a depressed scar. when removing them. Incisions are not sutured but closed with simple band-aid or surgical tape. followed by dry gauze. Sometimes. A skin adhesive is applied first to the skin to increase the adherence of the tape dressing. If this occurs. no attempt is made to approximate their edges further. pulling the first one detaches them all. On the contrary. Any fibrous and/or adipose tissue extending from the incisions is torn off or cut to insure optimal wound closure and to prevent bacterial migration from the skin surface into the surgical wound. When the incisions are small. the skin is cleansed with saline or hydrogen peroxide to remove blood residue and Hibiclens solution as an antiseptic.10 Post-Operative Medication and Bandaging MEDICATION At the end of surgery. the Trendelenburg tilt of the table is increased. the elasticity of the tape is sufficient to insure optimal wound closure.

. Joints and bone prominence are protected by protective cotton wool or rubber pads fixed also with underwrap. then the adhesive bandage is applied. and allow comfortable ambulation. In addition. the limb must be prepared with some “lining. then local gauze or cotton pads are placed over the operative sites to enhance local compression to absorb any bleeding. This consists of overlapping layers of Figure 10.146 Ricci. hematoma formation above the upper end of a postoperative bandage that was too short. it produces an analgesic effect. Georgiev. avoid post-surgical edema. and Goldman BANDAGING Adhesive Bandage The purpose of the adhesive compression bandage is to prevent bleeding.1 One week after phlebectomy. Before applying the adhesive bandage. making systemic analgesic medication unnecessary in a large majority of patients. These are fixed with a few more layers of underwrap.” The skin is first protected by a few layers of thin polyurethane underwrap or absorbent gauze.

erosions and pain. . it is mandatory to acquire skill in applying adhesive compression bandages prior to engaging in phlebectomy. if additional compression is needed. the patient must put a bandage or graduated elastic stocking over the foot and lower leg to prevent a tourniquet effect from the bandage. edema. It must be realized that it is the compression bandage that makes ambulatory phlebectomy possible. both distally and proximally.2). although rare. In such cases. Once the leg is bandaged. and taken off during the night. Removable Bandages After 5 min of walking with the adhesive bandage alone. never by “bad luck” (or by the patient). the adhesive bandage was applied proximally for several centimeters directly on skin contact to obtain a firm anchorage of the whole bandage and prevent slipping during ambulation.Medication and Bandaging 147 8 –10 cm large elastic adhesive bandage. The possibility of such bleeding. it is usually noticed during the first few minutes while in the upright position. This bandage is to be worn during the day. caused by the excessive glue adhesion to the skin. At present we perform the same anchorage using bandages with acrylic glue. and hematoma formation (Fig. As a rule. $10 cm beyond the operated area to avoid bruising. a short. In other words. when the foot and lower leg may be left without adhesive bandage. and if this change of position does not cause dizziness. more layers are applied. In this case. An exception is made in purely “cosmetic” cases without edema. The purpose of this removable bandage is to give supplementary compression and avoid foot swelling. The adhesion is lower but sufficient while the harm to the skin has nearly disappeared. the technique of leg bandaging is described separately and in detail in Chapter 14. the patient is put back in Trendelenburg position and the bandage is partially (or completely) removed. the operating table is returned to horizontal position so that the patient may gradually resume an upright position. A few minutes of walking in the operating room is necessary to test the bandages. Because of its importance. the compressive bandage includes the foot to prevent pedal edema. Bleeding is always caused by inadequate bandaging.1). in upright position. In the past. in the recumbent position. Bleeding must not occur. It must not be applied at maximum stretch. The bandages must not cause pain or obstruct normal walking. This very helpful detail was frequently followed by blister. Before applying the adhesive bandage. the patient is invited to sit with the legs off the table. and skin lesions at the moment of bandage removal. however. to step down. must be explained to the patient in advance to avoid a potentially frightening experience. Local compression is reinforced and/or more layers of adhesive bandages are applied as needed (Fig. 10. 10.or mediumstretch bandage or graduated stocking is applied from foot to knee (or thigh). The adhesive bandage must extend. If compression is inadequate to prevent bleeding.

148 Ricci. and (c) the bandage is reapplied. (b) the compression pads soaked with blood are replaced with new pads.2 In case of bleeding: (a) the bandage is partially removed. Georgiev. . and Goldman Figure 10.

Such “late bleeding” is probably due to insufficient muscular contraction during the first few minutes of walking. according to the type of surgery and the patient’s conditions. but still may rarely occur. . If only dermal (reticular) varicosities have been removed. Bleeding with the patients already dressed—or out of the office—is extremely rare and very unpleasant to both the patients and everybody around them. With the leg so bandaged. It is exceptionally rare for a patient to be in the office for a longer time period. an 18– 21 or 30– 40 mm/Hg graduated stocking (compression Class I– II) may be applied instead of bandages. It is to be avoided at any cost.Medication and Bandaging 149 especially if there is no adhesive bandage on the foot. the patient leaves the operating room and walks in the hallway or recovery room for 5– 30 min. later on. the patient starts walking more vigorously and venous pressure may reach a “critical” threshold and cause bleeding. which is initially absorbed by the lining pads and comes out later.

.

Information regarding the post-operative period is given orally and in a written form. should the need arise.11 Patient Discharge In the beginning. but with an accompanying person. Elderly or anxious patients. etc. are advised not to come alone.. a patient was admitted to the hospital during the day after the operation. they are advised to sit on the front seat with the leg only slightly flexed in the groin and knee. though many patients do not feel the need to take it. as they may not yet feel the leg fully efficient with the bandage. because of the pressure and traction exercised by the bandage. as well as those operated on for the first time. if needed. However. the patient must be seen before the scheduled appointment or even at home (which is. In our experience such calls are not frequent. the patient can leave the office. Tylenol with codeine. It is mandatory to be personally available on call so that the patient may contact the surgeon at any time. We recommend routinely calling each patient in the evening after surgery to answer any additional questions they might have and encourage proper post-operative care. Upon resuming normal walking. This was an older lady. piroxicam.) is prescribed. left home alone. in our experience exceptionally rare). Though it is possible for the patients to drive—as practiced during the 1920s in Chicago by De Taketz (1)—they are advised not to do so immediately after surgery. Once. and it is usually possible to reassure the patient—or give instructions—on the telephone. who started bleeding a few hours 151 . so that the bandage may adapt to the limb’s shape. the written instructions given to every patient are reproduced in Appendix 1. Anti-inflammatory/analgesic medication (e. patients familiar with the procedure often choose to come alone.g. They must be therefore encouraged to relax the leg and ambulate vigorously. 20 mg. patients tend to keep the operated leg stiff. If the patients go home by car.

94:1194. then call us”—but instead ran out of her home crying for help. Caught by panic. Georgiev. de Taketz G. so that her neighbors called an ambulance and brought her to the nearest hospital. J Am Med Assoc 1930. Ambulatory ligation of the saphenous vein. as well as avoiding office surgery on patients who live alone and are not self-sufficient. she was unable to follow the instructions—“lay down. elevate the leg.152 Ricci. REFERENCE 1. . This “unique” case emphasizes the importance of giving detailed instructions prior to discharging the patient. and Goldman after surgery.

153 . MI) adhesive remover. The adhesive bandage is then reapplied directly over the underwrap. 12. and can be removed immediately or later. The limb is then examined by observation and palpation. It is cut longitudinally and delicately detached from the skin. residual vein segments are palpated as painless fluctuating spots or cords. so that the leg may be directly examined. any residual adhesive material is wiped off with Detachol (Ferndale Laboratories. or may be due to the bandage rather than to the phlebectomy itself. some bruising is normal and has no clinical significance. the adhesive bandage and compression pads applied at the previous session are removed. Inc. whereas the protective underwrap and band-aids are left in place (Fig.5% hydrocortisone lotion is applied prior to the application of the new compression bandage (or stocking). the underwrap is also removed. Ferndale. After the Last Operation The post-operative adhesive bandage (POB) is removed completely 5– 7 days after the last operation.. however.12 Post-Operative Management and Follow-Up POST-OPERATIVE MANAGEMENT Between Phlebectomy Sessions When further phlebectomy or sclerotherapy sessions are scheduled within 1 week. in a recumbent and upright position. absorbent powder and/or a 2. if there is induration. local compression pads are reapplied. Bruising may be completely absent. If the skin is irritated. If there is any pain or bleeding. Failure to completely remove the marked varicose veins may also sometimes be appreciated early.1). without local compression pads.

the leg will be bandaged again (October 1). Note the extent of vein avulsion with second operation. (b) two days later.1 Management between phlebectomy sessions. (a) On the day of the first phlebectomy (September 29). but the band-aids are left in place (October 1). and protective underwrap (blue) are removed. Georgiev. . and Goldman Figure 12. (c) after finishing the second phlebectomy.154 Ricci. local compression (cotton) pads. the adhesive bandage.

The choice depends on the limb’s condition and necessity of sclerotherapy. upon the removal of the POB. with or without compression padding. The general rule is that some compression is applied to all limbs while the signs and symptoms of surgery persist. If. If there is only localized induration. inadequate or too short a time for compression is probably responsible for many cases of persistent skin discoloration. adequate compression—bandage or stocking—is continued indefinitely. high compression. At the other extreme are limbs with very large and/or widespread varicose veins. the segment involved is compressed by a ring of adhesive bandage. so that further bandaging may seem unnecessary. However. Stronger compression bandages may thus become necessary again—and for a longer period of time—until all local symptoms disappear. especially if there is pain. while the limb itself has not yet healed from trauma of surgery. extensive bruising. compression may be continued by four means: adhesive bandages. or tender spots. In cases of edema-free limbs with only dermal varicosities. of course. and local edema. the patient applies an additional graduated compression stocking or bandage. and telangiectatic matting around the scars and along the operative sites. it may not be sufficient to protect the limb from the action of the force of gravity. These should be worn for at least 2 months or until local tenderness disappears. scar hyperpigmentation. Continuing compression is also important for cosmetic reasons. usually 1 or 2 more weeks. During the day. stockings or Class I 20 –30 mm/Hg stockings. This depends on the underlying disease and the conditions of the limb prior to surgery and upon removal of the POB. hematomas. a Class I 20 – 30 mm/Hg graduated stocking (pantyhose) may be sufficient. without extensive bruising. Class II – III 30 – 40. Sometimes. chronic edema. the entire leg must be bandaged. if only a Class I graduated compression stocking is prescribed. local inflammation. that is. symptomatic post-thrombotic deep vein incompetence. the limb is in excellent condition. the underlying disease. removable bandages. In such cases. These patients must have adhesive compression bandages until most symptoms disappear. and discomfort may appear. hematomas. inflammation. Type and Duration of Compression After removal of the POB. The guidelines for employing different types of compression are outlined as follows. In these cases.Management and Follow-Up 155 Further Compression The duration and type of further compression are decided individually and may vary considerably from one patient to another. this may be due to the action of the POB. The importance of continuing compression beyond the first week after surgery must not be underestimated. 36 –46 mm/Hg. a short-stretch adhesive bandage . warrants lifelong compression treatment. This segmental adhesive bandage is kept in place for a few days or a week. If there is extensive induration and/or edema. and tenderness.

which will only increase the symptoms and delay healing. This varies individually and may take. Two months after phlebectomy.. in some cases.e. Though 10– 20 mm/Hg stockings are easy to use. The stockings are worn until all signs of surgery and/or sclerotherapy disappear. If the leg is relatively asymptomatic. Though for some . The follow-up program is decided individually and varies from patient to patient. because the stocking may not only be insufficient to control the symptoms. this will only aggravate the symptoms the stocking was supposed to control. and Goldman is preferred. Patients are reassured that these red spots will disappear with time. in case of pain. 10 – 20 mm/Hg or 20 –30 mm/Hg stockings may be employed as needed. so that their use requires some skill. FOLLOW-UP Adequate follow-up is important for the successful management of patients with venous disorders. These visits are important and useful to both patient and surgeon. the patient may find it difficult to apply the bandage alone. follow-up visits are scheduled at 2 and/or 12 months after surgery. The patient must be therefore adequately instructed by a staff member on stocking application. It is important not to replace bandages with high compression stockings if pain is still present at the operated sites. Patients must be told that surgery is limited to the elimination of the clinically evident varicose veins. the bandage may be replaced by light-weight compression stockings. Georgiev. Once most symptoms—especially pain—disappear. All patients are advised to come back for a check-up 6– 12 months later (though many—especially those with no problems—will not come). which are preferred by many—especially female—patients. A tubular plastic bandage (i. One stocking is kept in place during the night. This is because. and thus give up bandaging. a double layer of graduated compression stockings is worn during the day. while the patient may benefit from the early diagnosis of an eventual varicose vein recurrence or other symptoms related to venous insufficiency. How to put on and remove compression stockings is described in Chapter 13.156 Ricci. 12 –18 months for complete resolution. If symptoms are mild. the patient may apply a removable bandage for daytime use only. Surgeons have the opportunity to check the results of their work. and the patient applies the other stocking over it during the day. Scars still may be erythematous or not visible. higher compression (20–30 mm/Hg to 30–40 mm/Hg) stockings are difficult to put on and take off. the functional and cosmetic results of surgery can be appreciated. If the patient fails to put it on. For patients who do not need continuous treatment and control. Tubigrip) under the removable bandage remains on the leg at night. but also painful to put on. or for $2 months.

Continuous daytime compression is limited almost always to the leg (below-knee support) and can be obtained basically in two ways. Though varicose vein surgery is certainly of benefit in these cases. it does not cure the underlying deep vein incompetence (or occlusion) and thus does not restore a physiologic vein flow pattern. Lower leg stasis changes must be completely healed under the compression bandage. and replace them with 20– 30 mm/Hg graduated stockings when out. Patients are less likely to neglect their legs. who need lifelong adequate compression to prevent the recurrence of varicose veins and/or symptoms of venous insufficiency. it is not always so. and may blame the physician. all patients are advised to use regularly light-weight graduated pantyhose (or below-knee stockings for the male patients). by short. Optimal compression may be achieved by different means according to the patient’s and doctor’s preference.Management and Follow-Up 157 patients this may result in a definitive cure. Insisting on these concepts is important and useful to both patient and surgeon. Patients in Need of Special Care For some patients. To give these patients the illusion that varicose vein removal “cured” their legs—and fail to provide further assistance—is irresponsible. no matter what the initial treatment. as this is the best way to counteract the force of gravity. A typical example is patients with post-thrombotic syndrome. This may be preferred by many. Therefore. Though the removal of clinically evident varicose veins probably slows down disease progression. First. they may wear the bandages only at home. These patients should be seen more frequently. For older . the general recommendation to use light-weight graduated compression stockings is not sufficient. Some—especially elderly—patients find this program optimal to maintain their legs symptom-free. Patients who disappear for 10 years and only then report back often have their legs in poor condition. as varicose veins are a chronic and progressive disorder. one is to wear high compression (30 – 40 mm/Hg or 40 – 50 mm/Hg) below-knee stockings instead of bandages. other veins may dilate and become varicose. and prevent the development of varicose veins and symptoms of venous insufficiency. before stockings are applied. Secondly. then more compression is needed. These patients need lifelong compression treatment and must be controlled in the office as often as needed. If patients pass much time at home. No matter what type of compression is chosen.or medium-stretch bandages applied by the patient every morning and removed in the evening. especially young patients. its efficacy is checked by the patient every evening: if there is pitting tibial edema. there are cases in which. and surgeons may—with a few simple treatments over many years—maintain the patients’ legs and their own reputation in good condition. Major and continuous compression is necessary to control the signs and symptoms of venous insufficiency.

. two lower compression (10 – 20 mm/Hg) stockings put one over the other may have the same effect. Georgiev. Leg conditions of patients with chronic and surgically incurable venous disease depend on the patients’ knowledge of the nature of the disease and the ability to manage it. and Goldman patients who are unable to put on high compression stockings. We find it useful to provide selected patients with written instructions on how to maintain their legs in good condition (see Appendix 1).158 Ricci.

The dilated and incompetent SSV is almost invariably accompanied by collateral varicose veins.1).13 Small Saphenous Vein Phlebectomy The varicose small saphenous vein (SSV). phlebectomy of the SSV is more difficult than that of the epifascial collateral veins and differs in some aspects from the general description of phlebectomy in Chapter 9. 13. The difficulties particular to this vein are due primarily to two anatomical features: 1. at least in some points 159 . to a point that occasionally may make it impossible to separate vein from nerve. treated by most authors by the traditional ligation and stripping operation. can also be avulsed—and in our opinion advantageously—by ambulatory phlebectomy (AP) (1. due to its subfascial course. SSV incompetence is probably the most frequently missed diagnosis in varicose vein disease.5 mm (average 3. However. but when the vein is incompetent and dilated. The SSV is enveloped into a duplication of the aponeurotic fascia and is therefore subfascial. see Chapter 3). The vein is in fact accessible to phlebectomy from its origin behind the lateral malleolus. With some experience. may not be visible. It is therefore described separately in this chapter. Quite often only the latter are clinically evident. It is therefore important to investigate the SSV for dilatation and incompetence in every patient with varicose vein and/or venous disease.7– 4. the dilated SSV can be appreciated by manual examination (palpation and percussion. 2.1 mm) (3). whereas the SSV. to its termination in the popliteal fossa. The distal portion (and sometimes the entire length) of the SSV lies in close approximation with the sural sensitive nerve. DIAGNOSTIC WORK-UP The diameter of the normal SSV is 1. For this reason. it usually exceeds 6 mm and may reach !10 mm.2). even when grossly dilated (Fig.

.1 The dilated and incompetent SSV is almost invariably accompanied by collateral varicose veins. although the SSV itself is not. confirming the retrograde filling through the incompetent saphenopopliteal junction. (b) Anterior view of the same leg. due to its subfascial course. B. distal end of the incompetent portion. level of saphenopopliteal junction. (c) The anterior and medial varicose veins remain empty while the saphenopopliteal junction is kept obliterated by digital pressure (and rapidly fill upon release). (a) Preoperative marking of the incompetent segment of the SSV. and Goldman Figure 13. A. often only the collateral varicose veins are visible. Georgiev.160 Ricci. C. uppermost palpable point.

and in the popliteal fossa.Small Saphenous Vein Phlebectomy 161 Figure 13. that is. 1992. a double SSV segment. popliteal area vein. popliteal fossa (competent). Torino. even the experienced operator may remove a long varicose vein but still miss a second one. Note how in this case two gastrocnemius veins terminate into the SSV instead of directly into the popliteal vein. In the absence of precise anatomical diagnosis. gastrocnemius veins (incompetent). visualize and localize the saphenopopliteal junction (SPJ).2 Duplex scan of the popliteal fossa. or even the SSV itself. PV. (From Belcaro GV: Vene. pre-operative duplex scanning of this area is extremely useful. short saphenous vein (incompetent). SSV. 13.2). It allows one to obtain information not accessible to clinical and Doppler examination. and varicose collateral. Double SSV segments. . where the overlaying connective tissue layers are less tight. Edizioni Minerva Medica. as well as large popliteal perforators (popliteal area vein). and detect unanomalous termination of the gastrocnemius veins into the SSV (Fig. GCV. reveal other sources of reflux in the popliteal or muscular calf veins that may superimpose with SSV reflux (and thus be confused with the latter by Doppler examination alone). Such anatomic and functional details (complex reflux patterns) are impossible to appreciate by clinical and Doppler examination alone. Doppler reflux examination confirms the presence and extent of reflux. However. may also be diagnosed and properly treated. that is.) where it is more dilated.

is horizontal within skin tension lines. lateral. In the popliteal fossa. All varicose veins and the incompetent portion of the SSV are marked. Varicose collaterals on the medial. two points are marked with a transverse sign: the uppermost palpable point and the uppermost reflux point as determined by Doppler and/or duplex examination [Fig. In these sites. the SSV is more easily retrieved and hooked. . If the great saphenous vein (GSV) has to be removed too. which may prove to be time consuming. The order is not important. then deeper infiltration of the anesthetic is given into the popliteal fossa and along the proximal portion of the SSV. and Goldman STAGING The SSV is always avulsed in a single session. TECHNIQUE Incisions The incisions are vertical and longer (2 –4 mm) than usual. as well as the sites of side branch confluence. and hematoma formation. Only the uppermost (popliteal) incision. the leg in nonweight-bearing position. 13. ANESTHESIA Total SSV avulsion can be usually performed with as little as 40 mL of anesthetic solution.3). To start the operation. Superficial infiltration is performed first. If they are avulsed together with the SSV. especially if fed directly by the incompetent SSV. or anterior aspect of the leg may be avulsed at a separate session(s). so that the patient may keep the leg relaxed (Fig. Georgiev. 3 –5 mm. and usually 1 –1. the first incision is made as described subsequently and the vein exteriorized.5 h is scheduled for this operation. and some of the operative sites could be moved out of sight. this is done after avulsion of the SSV. 13. increasing the risk of bleeding. are usually avulsed together with the SSV. then the next incision is made along the course of the vein proximally. POSITION OF PATIENT The patient is placed in prone Trendelenburg position. with a support under the ankle. PRE-OPERATIVE MARKING The SSV is marked with the patient standing. the patient must change position during surgery. It is of utmost importance to mark with a separate (transverse) sign the sites where the SSV is more easily palpable.162 Ricci. Varicose collaterals on the posterior aspect of calf and leg.1(a)]. and the knee slightly flexed.

5(a)]. . (c) Endoluminal probe (blunt needle).4 Instruments for ambulatory phlebectomy of the SSV. It is embedded into a Figure 13. then the vein is first hooked in its extrafascial portion. As a rule. If the SSV is to be totally removed. (b) Toothed clamp (12 to 14 cm). and an endoluminal probe (Fig. (d) Endoluminal probe (curved tip). the patient is in the prone Trendelenburg position with a support pad under the ankle. even this distal portion is not easy to retrieve and hook.4).Small Saphenous Vein Phlebectomy 163 Figure 13.3 Position for phlebectomy of the SSV. toothed clamp. the operation is started from the distal point of the segment to remove [Fig. Starting the Phlebectomy Few instruments are necessary for this operation: Graefe forceps. 13. (a) Graefe iridectomy forceps. Nevertheless. 13.

(e) If the previous maneuver fails. preferably over a saccular dilatation for easier hooking. (d) Piercing the overlying fascia with to-and-fro longitudinal rocking action (or rotary movement) with the tip of the Graefe forceps. the SSV trunk becomes tense and easier to identify and hook from a separate incision after perforating the overlying fascial layer. This is done by introducing the closed mosquito (or Graefe).5 The technique of phlebectomy of the SSV. its retrieval is greatly enhanced by the use of an endoluminal probe. (a) As a rule the operation is started from the distal (extrafascial) portion of the SSV. (f) If hooking of the SSV trunk proves difficult or causes an “electric shock” sensation due to touching the accompanying nerve. Georgiev. Continued . then opening and closing it repeatedly until the vein is grasped. (c) With the side branch kept under traction. pushing it deep until it stops. (b) In the presence of a large varicose side branch. and Goldman Figure 13. Once the SSV trunk is hooked and exteriorized. 11 scalpel blade. the fascia may be hooked with one branch of the Graefe forceps and cut with the point of the no. the vein may be grasped with a toothed clamp. it is convenient to start operating by hooking the side branch.164 Ricci. forceps. The resulting incision is then enlarged bluntly with the tip of the Graefe forceps.

5 Continued For this purpose the probe is inserted into the SSV and the SSV is hooked with the Graefe forceps (g) or grasped with the toothed clamp (h) together with the probe. Continued .Small Saphenous Vein Phlebectomy 165 Figure 13.

166 Ricci. ( j) The free end of the SSV is avulsed and the procedure repeated until the entire length of the SSV is exteriorized from the uppermost (popliteal) incision.5 Continued (i) The probe is then pulled out. leaving the SSV trunk in the forceps. Georgiev. . and Goldman Figure 13.

ligated with #3-0 catgut or Vicryl suture (k). the SSV trunk should be manipulated with the Graefe forceps only ¨ and toothed clamp. If only the proximal—subfascial—portion of the SSV is to be removed. If the SSV cannot be hooked without causing electric shock sensation. A side .Small Saphenous Vein Phlebectomy 167 Figure 13. it can be separated and left in place. Occasionally it may be impossible to separate the vein from the nerve. a short distal incompetent SSV segment may be of little clinical significance. but its manipulation may be followed by a loss of sensitivity. the first incision is placed over a palpable point of the SSV or a side branch. manipulation must stop and then start again.5 Continued The SSV is pulled up until it yields. In this case. compact fibrous connective tissue layer and often lies close to the sural nerve. because of the risk of nerve damage. For this reason. If during the search and manipulation of the SSV trunk the patient feels an “electric shock” sensation. pulled abruptly. or divided percutaneously by needle. and never hooked with a Muller hook. Sometimes the nerve is exteriorized together with the vein. it must be tried again from a new (more proximal) incision. and in such case it might be advisable to leave the distal portion of the SSV in place rather than damage the sural nerve. and divided (l). force from its perivenous tissue. which may last from days to weeks.

Proximal Progression To proceed proximally. 13. pushed deep until it stops. Bologna 40068.5(g) and (h)]. through the previously prepared fascial incision together with the probe [Fig. Chirurgica SpA. and cut with the point of number 11 scalpel blade [Fig.5(e)].168 Ricci. so that it can be palpated under the skin as a hard cord. the SSV may be grasped with either the Graefe or the hemostatic forceps. 13. then the distal segment of the SSV is avulsed first.4). the next incision is performed at a distance of 5 –15 cm. bleeding is prevented by a few minutes of digital pressure.5(i)]. 13. With the probe inside. The probe is then pulled out. The next incision is placed over a point where the cord is still palpable (the cord in fact “fades” at a certain distance). leaving only the vein in the forceps [Fig. and. and closed again repeatedly until the vein is grasped. Italy) (see Fig. and Goldman branch is usually easier to hook. and the fascia is pierced or cut and dissected as described.5(b) and (c)]. may put tension on the SSV trunk to facilitate its retrieval and hooking [Fig. This can be done by a to-and-fro longitudinal rocking action (or rotary movement) of the tip of the Graefe forceps [Fig. 13. it is double clamped and divided. If the hooking maneuver is fruitless. then the fascia is hooked with one branch of the Graefe forceps. and the vein is hooked and extracted through the new incision. Instead. The procedure is repeated until the entire marked segment is completely exteriorized. Owing to its deep position. the vein is easily localized and hooked with the Graefe forceps. followed by avulsion of the proximal portion. The vein is then divided at its lowest end without ligating the residual distal stump. its perivascular connective tissue or upper wall is hooked. The probe is inserted into the free end of the SSV and pushed upwards. If the incision is not at the most distal end of the portion to be avulsed. Once the loop is exteriorized. 13. The resulting incision is then enlarged bluntly with the tip of the Graefe forceps.5(d)]. 13. exteriorized through the skin incision. or grasped with either the Graefe or the hemostatic forceps. and pulled out. 13. it is necessary to pierce the overlying fascia. the free end of the distal SSV segment is kept under traction. San Lazzaro di Savena. Georgiev. Distal Progression When phlebectomy needs to be continued distally. SSV retrieval through the new incision is facilitated by the use of an endoluminal probe (blunt needle type probe or our specially designed probe. In this scenario. Prior to hooking the subfascial portion of the SSV.5(f )] and grasped with the toothed clamp until a loop is exteriorized. the SSV is rarely hooked completely. The portion of the SSV between the two incisions is then pulled out from the proximal incision and the procedure is repeated as many times as needed until the entire . then opened. It is then pulled out [Fig. the forceps are introduced closed. If this maneuver fails. kept in traction. Sonda BD 14700-16.

In four limbs (22%) no stump was found. the distal part is avulsed completely with traction on the vein and skin (and disconnection of the collaterals. if any).6(a)]. the stump was 1. At this point. which is often avulsed through two incisions only: one in the popliteal fossa and one at the gastrocnemius point (mid-calf perforator). it is usually possible to palpate them when they are under traction. considered adequate by authors who practice traditional surgery (5–8). point usually corresponds to the site where the varicose SSV bends anteriorly to approach the popliteal vein. This palpable. 13.7 and 13. 13. This study demonstrated that high (not flush) ligation of the SSV in the popliteal fossa. which corresponds to the knee joint (see Fig. Once a loop is exteriorized. as the varicose SSV is almost always elongated. or even bulging. where the overlying connective tissue layers are less tight and resistant. However. In 12 cases (67%). whereas in the remaining 14 limbs there was a short stump. when . Higher Popliteal Incision The standard type SSV may join the popliteal vein at—or close to—the level of the uppermost palpable point [Figs. The use of the endoluminal probe allows one to reduce the number of incisions. In fact. If there are collaterals.” it often tends to form this bulging angle in the popliteal fossa.5( j–l)]. almost parallel to the popliteal vein. and divide them by needle puncture. freed of its perivenous investments and ligated as high as possible with #3-0 absorbable suture and divided [Figs. the terminal portion of the SSV is pulled until it yields (1–2 cm). facilitating avulsion. The exact site of saphenopopliteal ligation was investigated by duplex scan in 18 limbs with “standard” type SSV and SPJ within 5 cm proximal to the popliteal crease.M. respectively (Fig.6). The SSV is retrieved from the popliteal incision with the help of an endoluminal probe and is avulsed as previously described. 13. especially over the proximal portion of the SSV. 13. 13. running subfascially. but cannot become sinusoid because of its tight fascial “envelope. If the duplex scan has shown that a competent gastrocnemius vein terminates into the SSV. personal communication. then the SSV may be ligated below this termination. so that it yields and stretches upon traction.0–2. to avoid interruption of physiologic gastrocnemius vein drainage (see Fig. especially if they are accurately marked.5 cm long and in two cases (11%) 3.2). so that incision at this point will allow optimal saphenopopliteal ligation [see Fig. 13. at (or close to) the popliteal crease. Typically. The proximal half of the SSV typically has only few side branches and perforators. 13.4 and 4 cm.5( j]). 1992).8(a)]. Often there is no branching between the gastrocnemius point and the SPJ (4) (J Staubesand and H. Saphenopopliteal Division and Ligation The horizontal popliteal incision is usually performed at the uppermost palpable point of the SSV. the proximal portion is elongated.7). is also achievable by AP. Hoffman.Small Saphenous Vein Phlebectomy 169 length of the SSV is exteriorized from the uppermost (popliteal) incision [Fig.

170 Ricci. and Goldman Figure 13. For this purpose. with the help of the endoluminal probe [Fig. . Georgiev.8(c)]. 13.4 cm) stump. the endoluminal probe is pushed upwards into the SSV. it may be possible to make the incision higher than the uppermost palpable point and obtain higher SSV ligation. 13. an incision over the latter may result in low SSV ligation with a longer residual stump [Figs. With this maneuver.6 Postoperative duplex scan of the popliteal fossa to determine the level of saphenopopliteal ligation. (A courtesy PL Antiganni.8(c) and (d)].) the SSV joins the popliteal vein !3 cm higher than the uppermost palpable point [Fig. MD. (b) longer (1. (a) Minimal (shorter than 1 cm) stump. it is usually possible to make the popliteal incision within 3 cm distally to the SPJ when the latter is situated up to 5 – 6 cm proximal to the popliteal crease. Here. 13.6(b) and 13. and the incision is made at the uppermost point where the probe’s tip is still felt close to the skin surface [Fig. 13.8(b)].6(a)].

whereas the small thigh branches are torn off without ligature. 13. or pantyhose is . However.Small Saphenous Vein Phlebectomy 171 Figure 13. they are treated as follows: the Giacomini vein is traced with Doppler and/or duplex scan and avulsed (in these cases. 30 – 40 mm/Hg graduated below-knee stocking. or divides into many small thigh branches. It is then usually replaced with a below-knee adhesive bandage for one more week. In these patients. The femoropopliteal vein is ligated as high as possible.7 X-ray film of the knee joint. a compression adhesive above-knee bandage is applied and kept in place for 1 week. the GSV is invariably incompetent and is also removed) (Fig. rarely there is no connection between the SSV and the popliteal vein. After that. POST-OPERATIVE COMPRESSION After closure of the wounds with tapes. or continues deep into the posterior thigh as the femoropopliteal vein. MD.9). removable bandages. the main SSV trunk joins the GSV via the intersaphenous thigh anastomosis (Giacomini vein). If these terminations are incompetent. The marker placed over the popliteal crease shows that the popliteal crease corresponds to the knee joint. (Courtesy G Izzo.) Atypical Popliteal Terminations of the SSV The standard type SSV with termination within 5 –6 cm proximal to the popliteal crease is the one most frequently encountered.

8 Continued. .172 Ricci. Georgiev. and Goldman Figure 13.

to extract the SSV through a higher incision. Complications are . with the help of the endoluminal probe. it is sometimes possible to palpate the vein higher than the popliteal crease and exteriorize the SSV through a higher incision to ligate it closer to its junction with the popliteal vein.5 cm away from the popliteal crease and only 1 cm below the level of the saphenopopliteal junction (SPJ). 3. some specific advantages over the traditional surgical or sclerotherapy methods of treatment. While sclerotherapy is followed by a high recanalization rate (9). (c) With the endoluminal probe pushed upward into the SSV. (b) Saphenopopliteal junction higher than the uppermost palpable point.10). On these figures the uppermost palpable point coincides with the popliteal crease (dotted line). ADVANTAGES OF SSV PHLEBECTOMY In addition to the general advantages of AP. after exteriorizing the SSV from the incision over the uppermost palpable point at the popliteal crease (P). SSV phlebectomy has. (a) Saphenopopliteal junction situated at the level of the uppermost palpable point. as evidenced by a recent review of over 120 articles on the topics (2). and traditional surgical techniques are considered difficult and less gratifying (than GSV stripping) by many (7.Small Saphenous Vein Phlebectomy 173 Figure 13.8 Different levels of the saphenopopliteal junction. worn by the patient until all signs of surgery disappear or at least for 2 months. This may be because of the thorough removal of the collateral varicosities and an extre¨ mely low complication rate. in our opinion. in an office setting. AP permits removal of the varicose SSV under local anesthesia (LA). with many contradictory opinions regarding the choice of treatment. Post-operative management is discussed in detail in Chapters 10– 18. AP can produce excellent results. where the uppermost incision is usually made and the SSV is more easily retrieved. three of which needed traditional surgical revision (1). it was possible. In this case an incision over the joint is likely to leave a longer residual SSV stump. (d) Higher popliteal incision. Muller reports only five cases of popliteal recurrence. at low cost and with excellent cosmetic results. The SSV is a rather “controversial” vessel.8. In this patient. In this case an incision over the joint allows optimal (highest possible) ligation of the SSV.

Georgiev M. 18:61. 3. Fischer R. infrequent.174 Ricci. 14:129. 44:687. Traitement de la saphene externe variqueuse per la phlebectomie ambulatoire. Dorignaux JP. . Hobbs JT. Wo in der Fossa poplitea soll man die Vena saphena parva beim Stripping ligieren? Phlebol u Proktol 1985. 2. whenever possible. Br Med J 1980. 5. Die venosen Abflussverhaltnisse des Musculus triceps surae. 4. 6. Thomas ML. Staubesand J. J Vasc Technol 1987. 7. and are represented by sural nerve damage with loss of sensitivity or paresthesia. Chirurgie der Bein. mild. 33:281. Stuttgart: Geog Thieme Verlag. even this is largely avoided by limiting the operation. manipulation of the sural nerve is felt by the patient and can be therefore avoided. May R. Browse NL. 1988.und Beckenvenen. Burnand KG. Phlebologie 1980. Sclerotherapy of the popliteal junction in primary varicose veins (abstr). to the proximal portion of the SSV. Ledant P et al. Preoperative venography to ensure accurate saphenopopliteal vein ligation. 11:145. Carbone D et al. Schultz-Ehrenburg U. Muller R. Hoffman HM. Georgiev.9 Long segment of the Giacomini vein (GCV) avulsed during phlebectomy of the short saphenous vein. J Dermatol Surg Oncol 1993. However. Phlebologie 1991. Ricci S. 9. Diseases of the Veins. La phlebographie saphene externe selective. under LA. and Goldman Figure 13. 10. London: Edward Arnold. 1974. REFERENCES ¨ 1. Phlebologie 1991. The lesser saphenous vein: an underutilized arterial bypass conduit (abstr). 8. Van der Stricht J. Kupinski AM et al. 1:1578. 20:164. J Dermatol Surg Oncol 1992. 19:456. Stab avulsion of the short saphenous vein: technique and duplex evaluation. In addition.

Part III: Selected Phlebological Techniques .

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as well as the properties and use of some basic materials. antiexudative. it exercises strong analgesic action. In fact.. These rules. and analgesic effects in the tunnel remaining after vein avulsion. (Mueller Sports Medicine. Inc. PROTECTIVE SKIN UNDERWRAPPING Before applying the compression bandage. the skin must be protected with an underwrap such as a Mueller wrap. Prairie du Sac. which is a thin polyurethane foam bandage. However. LOCAL COMPRESSION PADS The scope of local compression pads is to achieve maximal hemostatic. WI 53578. Its purpose is to protect the skin from the edges of the local compression pads and the glue of adhesive bandages. The post-operative bandage (POB) is composed of five parts: (i) protective skin underwrapping. bruising. USA). general compression 177 . and allow comfortable ambulation. are illustrated in this chapter. there are some basic rules to respect if a bandage is to function properly. (iv) adhesive bandage. (ii) local compression pads. and transverse linear skin pigmentations may occur and persist for many months.14 Post-Operative Compression The scope of post-operative compression is to insure hemostasis. In addition. If the protective underwrap is not used. blistering. and (v) removable bandage. Techniques and materials for bandaging may vary. (iii) protective pads. making analgesic medication unnecessary in a large majority of patients. avoiding excessive general compression of the limb. with skill being more important than materials: the experienced phlebologist is able to perform an adequate compression bandage with many different—and even “improper”—materials. avoid postsurgical edema. Bandaging is an art.

5 –8 cm wide bandages may fit the foot and ankle better. but in very small legs. Such a bandage exercises the highest pressure in upright position and during walking (high working pressure). The size of the pads depends on the circumference of the limb and the size and localization of the avulsed veins. The reader is referred to them for further information. its action due not as much to the pressure exercised by the bandage as to its resistance to leg expansion during ambulation. and tendons. but to the underwrap that is easily cut before removal. Georgiev. or other relatively hard material commercially available. it does not compress as much (low resting pressure). while in the recumbent position. Materials We prefer short-stretch lengthwise (one-way) elastic bandages. elastic bandages conform to the shape of the joints and are more comfortable. It is therefore advisable to protect the earlier-mentioned areas with 5 mm thick (“three-dimensional”) foam rubber (or cotton wool) strips. which is beyond the scope of this text (2 –4). during the night—in the recumbent position—will not produce excessive compression. and. Bandages of 10 cm width are suitable. larger pads are necessary. and Goldman alone—even when excessive and poorly tolerated by the patient—may not be sufficient at the operated sites. nerves. On the medial aspect of the limb and on the thigh. ADHESIVE BANDAGE The adhesive bandage is the most important part of the POB (Fig. the bandage may traumatize skin.1). In short. it will have a high working pressure and low resting pressure. they may cause skin bruising and blistering. gauze strips. Both compression and protective pads are fixed with a few loops of underwrap. There are numerous papers that describe the use of compression therapy on the lower extremities in great detail. 7. however. foam rubber. when the limb is “empty” of blood. the bandage must have a short stretch. It will allow normal ambulation while exercising adequate compression. PROTECTIVE PADS On joints and bone prominences (shin. Compression pads should not have hard edges and should be placed as a continuum.178 Ricci. this way the adhesive bandage will not stick to the pads. at ankle and knee (two-way stretch). dorsum of foot). which inhibits normal ambulation. To achieve this. These pads may increase local compression by up to 50% (1). . otherwise. 14. Local compression is obtained by compression pads made of cotton wool. causing pain. A properly applied bandage will remain in place without losing its efficacy for several days.

Distally. patients apply a removable bandage or graduated compression stocking during the day and night to avoid a tourniquet effect. It is applied in 8-shaped loops over foot and ankle. it will be difficult to apply it with an even and desired pressure. for example. and inflammatory reactions. A 10 cm wide one-way stretch bandage is adequate in most cases.) is applied directly to the skin to insure that the bandage stays in place. provided there is no underlying disease causing leg edema. Extension of the Bandage Local compression pads must be applied for at least 5– 10 cm beyond the operated zones to avoid bruising. Each loop overlaps the preceding one $50% so that a double-layer bandage is made. When the lower leg has not been operated on. Only the uppermost border of the bandage ($1 in. Technique of Application The bandage is applied with the patient in recumbent position.1 Adhesive compression below-knee bandage. hematoma. The surgical part is bandaged first. If. then the bandage is continued distally and proximally . The adhesive bandage is applied after covering the skin with protective underwrap and protective pads over ankle and shin.Post-Operative Compression 179 Figure 14. then in spiral loops over the rest of the leg. The quality of adhesive bandages is important. In these cases. it can be left without adhesive bandage. the adhesive is too sticky and much force is required to unroll the bandage. edema. the compression bandage starts at the bases of toes to prevent pedal edema.

Before application. preferably 7 m long 10 cm wide bandage. without stretching it to its maximal extension. but unrolled over the leg to insure even pressure in all points. constant tension. 14. The second bandage. The bandage must conform to the limb’s shape. . so they are not stretched during application. it is first crossed over the tibia. The result is a 10 m long. it is kept close to the skin and unrolled around it with slight. the rest of the leg with spiral loops (loops 6 – 10). each 5 m long.2). foot and ankle are bandaged with figure 8-shaped loops and 7. (a) Long-stretch strong elastic bandage with one.and downward along the leg. When applying the bandage.5 – 8 cm wide bandage. almost inelastic bandage. (b) Short-stretch compression bandage according to Karl Sigg.2 Techniques of applying removable elastic compressive bandage. It is comfortable to the patient and exerts very high pressure during ambulation.180 Ricci. 8 or 10 cm wide. 4 – 6 layers. are employed. then applied with spiral loops up. 10 or 12 cm wide. and Goldman (Fig. the bandages must be rolled stretched. whereas the rest of the limb with spiral loops and 10 cm wide bandage. Foot and ankle are bandaged with 8-shaped loops (loops 1 – 5). Two bandages. whereas is well-tolerated in the recumbent position. This avoids excessive tension and rubbing during maximal joint movement. in order to better shape the bandage around the joints. Georgiev. is applied from ankle to below the knee. The foot is flexed at a right angle with the knee slightly flexed. The first bandage. Figure 14. is applied over foot and ankle only and terminates just below the calf. Patients who are going to bandage themselves must have adequate instruction and given an illustrated guide.

Post-Operative Compression 181 Figure 14. .2 Continued.

less adhesive and must be kept in place by a loop of the usual adhesive bandage applied over it. however. or more layers are applied: the more the layers. otherwise. Both edges must be pulled with the same force. which sticks to itself.2 Continued. Degree of Compression The bandage must prevent edema formation during the day and must not excessively compress the leg at night. Rarely a patient may be allergic to the glue of the adhesive bandage. These two types of bandages are.e. If maximal compression is desired. compressive “laces” may form. This way. and Goldman Figure 14. the more rigid and compressive the bandage is. . otherwise. Proximally. a greater width of each loop is overlapped. or of “cohesive” bandage..182 Ricci. the loops applied directly to the skin must be made with a nonallergic (i. acrylic) adhesive. in such cases. the entire limb is covered by two layers of bandage. it may slip or roll down. the bandage must continue beyond the protective underwrap and stick directly to the skin. but not the skin. Applying the bandage under the same tension results—due to the conical shape of the limb—in gradually decreasing pressure from distal to proximal (Laplace’s Law). and the latter becomes less elastic. Georgiev. Each loop overlaps the preceding one $50%.

toes. as follows: the central part of the adhesive strip is placed on the posterior aspect of the thigh. start the bandage high proximally than necessary. as this may cause excessive compression in the recumbent position. . and the skin of forefoot must remain warm. This discoloration must disappear after a few steps (sign of adequate venous outflow). the bandage takes its final shape with ambulation. In such cases. It is of great help to bandage one’s own leg. Testing the Bandage A good bandage is readily recognized by its perfect stay on the leg. Bandaging is usually mastered by treating patients with chronic edema and stasis changes. applying the first loop without tension. there are several ways to keep the upper edge of the bandage in place. ankle. For small. and wear these for several days. apply a “fish-bone” bandage. In the obese. the upper edge of the bandage may roll down. it is preferable to cut the bandage and apply it again in the desired direction. Difficult Areas On the foot. Such bandaging does not allow the foot to swell. though feeling the compression. conically shaped thigh. In obese. The foot and ankle should be bandaged with overlapping loops of slightest tension. However. mild compression may be sufficient. so that the bandage becomes more rigid. edematous limbs. gradually increase tension while proceeding distally. When compression is adequate. not by stretching the bandage to its maximal extension. The patient. especially the first toe. Secondly. which is done after great saphenous vein (GSV) stripping and is described in Chapter 15. with large varicose veins. and knee it may be difficult. forming compressive painful rings that leave the upper thigh noncompressed. The foot does not tolerate excessive compression. made of oblique separate loops. Then. even with figure 8-shaped loops. In these cases. a two-way stretch elastic bandage is preferable to a oneway stretch elastic bandage. Proper bandage tension is learned by experience. must not feel pain or discomfort. whereas both ends are applied obliquely in an anterior – superior direction crossed on the anterior aspect of the thigh. but less compressive. stronger compression is needed.Post-Operative Compression 183 All patients do not require the same compression. but is well-tolerated in the recumbent position. and must be able to walk normally. to follow the shape of the limb while maintaining both edges of the bandage under the same tension. First. it is helpful to see the bandaged patients daily in order to insure adequate compression. become mildly cyanotic. irrespective of the material used. edema-free limbs with small dermal varicosities. The latter is obtained by applying more bandage layers. For the beginner. Another method is to fix the bandage on the hip and lower abdomen. both with adhesive and removable bandages.

and Goldman REMOVABLE BANDAGE The removable bandage is applied by the patient every morning over the adhesive one. In addition.) The removable bandage is applied without much tension and the patient must be adequately instructed and given an illustrated leaflet explaining how to put it on. Georgiev. numbness. or blistering. Excessive Compression Excessive compression may not be tolerated by the patient. Edema and/or hematoma may follow. except for cases of limb anesthesia (diabetic neuropathy. Though of little importance. pain may occur at the operated sites. it may traumatize the skin. excessive compression causes such a severe pain that the patient seeks help much before any ischemic damage occurs. secondary to excessive pressure. it is sufficient to apply the removable bandage tighter on the foot. arterial ischemia. . skin abrasion. causing pain. if the bandage is comfortable during the night. or tendons through anoxia. At times. sensory nerves. such lesions may cause severe pain and inhibit adequate ambulation. Moreover. especially when over the shin and dorsal foot. the removable bandage “fixes” the freshly applied adhesive one and prevents it from yielding.184 Ricci. Insufficient Compression If the bandage is too loose. Short-stretch (semirigid) bandages are preferable. the patient may not complain during the day. ERRORS OF BANDAGING The most frequent inconvenience is edema of dorsal foot caused by inadequate compression of the foot. It provides additional compression during the day. but cannot tolerate compression during the night. The alleged danger of compression bandages. On the knee. causing discomfort or pain that requires additional weeks of compression bandaging. and removed every evening. the bandage may cause rubbing with bruising. but medium or long-stretch (elastic) bandages may be employed as well. as these are also tolerated in the upright position. Except for cases of severe arterial occlusive disease. Here. it might be insufficient during the day. This is because the compression necessary when standing may not be tolerated when lying down. is a commonplace. or even skin necrosis. the compression bandage is unlikely to exceed arterial pressure. (The removable bandage may not be necessary if the adhesive bandage is “personalized” by applying more layers. In other words. Should this occur. etc.).

4. Partsch H. so that compression is extended to the entire limb. a Class I pantyhose is sufficient. Stemmer R. Compression therapy of the legs: a review. 67:122. but. such stockings are more difficult to put on and remove. After removal of adhesive bandage. putting on a Class II–III stocking is painful. The patient must be trained on their application and removal in the office. The stocking should not be pulled at the top. In: Bergan JJ. A foot slip (provided by the manufacturer) is then put on. Prior to using these stockings. 2–5 days later. . slipped on and spread over the leg with the flat of the hand using rubber gloves. Compression treatment of lower extremities. then its distal end is worked over the heel. 17:799– 805. Furderer C. increasing the difficulty in applying it. Goddard M. Stockings are applied over the adhesive bandage mostly in cosmetic treatments. 31:355 – 365. Raj TB. skin lesions and tender spots must heal under the compression bandage. they must be put on for the first time in the office by a staff member. where minimal compression is sufficient. After removal of the adhesive bandage. The Dermatologist 1980. the latter can glide easily over it.. 3. When only dermal (reticular) varicosities have been avulsed. with the flat of the hand. Makin GS. J Dermatol Surg Oncol 1991. Tazalaar DJ. To remove it. In most of these cases. The stockings are then put over the bandage. the stocking is held at the upper edge and pulled down inside out. Compression sclerotherapy. 1993:103 – 122. compression stockings may be employed for post-operative compression.Post-Operative Compression 185 COMPRESSION STOCKINGS Instead of removable bandages. Class II single compression stockings may be used. This is because if the leg is still aching. eds. the patient continues to wear the Class II or I pantyhose until the signs of phlebectomy disappear. Goldman MP. in cases of larger varicose veins. St. Varicose Veins and Telangiectasias: Diagnosis and Treatment. Neumann HAM. Louis: Quality Medical Publishing Inc. Marescaux J. 2. REFERENCES 1. They should not be prescribed as if they were an oral medicine. the adhesive bandage is put only on the operated segment of the limb. With this technique. Unlike Class I pantyhose. How long do compression bandages maintain their pressure during ambulatory treatment of varicose veins? Br J Surg 1980. Therefore. over the adhesive bandage or after its removal. and removed. particularly with compression stockings. It is of great help to wear an ordinary nylon stocking under the compression stocking.

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as stripping the GSV regardless of its involvement in the varicose vein disease was widespread. patients on whom the GSV ligation was indicated: The cases of varicosities of the leg in the domain of the great saphenous vein can be separated into two different groups. 187 . utilization of the GSV as an arterial graft led to “pleas” to save the GSV (2). Division. It was thus well established. Only the last-named group. that only some patients with varicose veins may benefit from the GSV division. however. Trendelenburg drew attention to the importance of the incompetent great saphenous vein (GSV) in varicose vein disease.15 High Ligation. Such practice was further questioned by studies demonstrating that the GSV trunk may be competent in $40% of the varicose patients (3. there are those in which the trunk of the saphenous is likewise markedly dilated and varicose. while the trunk shows no changes of any sort. e.n. Recently. that is. will be considered in the following discourse (GSV ligation. removal of the GSV was necessary in all patients with varicose veins. on the other hand. This is how he described. There are cases in which the varicose deterioration is limited to the branches of the great saphenous vein. the cases of simultaneous varicose dilatation of the trunk and the branches of the saphenous.4). early. the opposite was taught and practiced. and Groin to Knee Stripping of the GSV: An Office Procedure INDICATIONS At the end of the last century. and. and by surgical experience demonstrating satisfactory results by varicose vein removal without the GSV stripping at 3 year (5) and 5 year (6) follow-up. In the following century.) (1). in 1890.

188

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Although the aforementioned studies report excellent long-term results with ligation of the saphenofemoral junction (SFJ) followed by ambulatory phlebectomy (AP), additional studies performed with more than a mere clinical examination and patient opinion disclose persisted reflux in up to 50% of patients treated in this manner (7 – 9). In addition, if one strips the GSV from the SFJ to the knee there is a decreased incidence of reflux recurrence, as cited in numerous studies (7 – 10). Finally, in assessing whether the GSV has potential as use as vascular conduit is also of great importance. Corcos et al. (11) have found that virtually all of the lower extremity veins have evidence of histopathological damage when major varicose veins are present. They demonstrated that peripheral venous biopsy of the dorsal vein of the foot revealed parietal lesions of various types and grades in patients who had varicose veins. The normal dorsal vein of the foot had lesions similar to those found histologically in the varicose veins. This suggests that peripheral veins in patients who have varicose veins may not be suitable as vascular conduits. This finding has been partly corroborated by Marin et al. (12) who studied the relationship between the histologic condition of the GSV at the time of grafting and subsequent stenosis of vein grafts. Here, Marin et al. concluded that when the GSVs had thick or calcified walls, or a hypercellular intima, there was an increased risk of developing intragraft lesions which could lead to graft failure. These veins did not have grossly apparent disease as noted by inspection or palpation. Unfortunately, the authors did not know whether the patients had co-existing varicose veins. In an effort to assess potential vascular graft conduits preoperatively, Davies et al. (13) demonstrated that preoperative assessment of vein wall compliance can be used to predict vein grafts at risk for failure. These studies have led to a more detailed assessment of the GSV for its potential as a useful vascular conduit with duplex scanning (14,15). These latter two studies provide the best evidence that stripping of the GSV should be selective, most likely to the knee. AP and/or sclerotherapy should be used to eradicate and/or obliterate other varicose veins, with the GSV distal to the knee being preserved for potential use as a vascular conduit, if necessary. In our opinion, GSV high ligation and stripping to the knee is indicated by the simultaneous presence of two symptoms: 1. 2. Incompetent SFJ and GSV trunk. Dilated GSV.

Saphenofemoral Junction Incompetence The detection of a retrograde flux by Doppler at the SFJ is not decisive for a terminal valve incompetence. The Doppler device is so sensitive that it may detect reflux of little clinical significance which occurs or fluxes originated by incompetent junction communicating veins, with competent ostial valve (30% of cases) (Chapter 2). Therefore, the mere presence of an otherwise normal and

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nonsymptomatic GSV reflux does not automatically indicate the necessity to operate on the GSV. An equivocal clinical/noninvasive examination must be supplemented with duplex ultrasound evaluation. The reader is referred to two excellent texts on venous Doppler (16) and duplex testing (17) for further reading. GSV Dilatation The average diameter of the normal GSV is 3.5– 4.5 mm (range 1– 7 mm) (18). A grossly dilated (.1 cm) GSV is readily appreciated by palpation and percussion even in the obese patient, but even a competent GSV may be clinically detectable in some patients. In most cases, the GSV is not dilated along its entire length, but has only a few focal saccular dilatations. In any case, the entire course of the GSV should be traced by Duplex in order to verify calibers at different levels, the depth and the effective incompetence, having always in mind the US “eye sign.” It is not rare to find that the reflux spills out from the saphenous stem into a more superficial collateral vein (CV), the saphenous vein being in part competent (see Chapter 2, the Atlas). In these patients, there is no need to remove the normal part of the GSV (as previously discussed). Moreover, the saphenous vein may be partly hypoplasic (absent), the flux being completely shunted on the collateral (see Chapter 2, the Atlas). Preservation of an Incompetent GSV/Saphenopopliteal Junction In a certain number of cases, we consider GSV incompetence to be of little clinical significance and do not recommend ligation and stripping. The common denominators in these cases is an incompetent but not dilated GSV. Duplex examination of the SFJ allows the detection of cases of “borderline” or even “intermittent” GSV reflux due to valve closure delay. In these cases there is reflux, but apparently normal valves are also seen. Slight compression with the transducer—without obliterating the GSV but only slightly narrowing its lumen— may abolish the reflux. (Although the pragmatic value of such finding is unclear, in few selected cases we were able to observe restoration of normal flow pattern at the SFJ, after avulsion of the varicose collaterals but leaving the proximal GSV portion in place.) Sometimes the terminal valve is competent, whereas the retrograde flow comes from incompetent collaterals emptying into the saphenous stem. However, the earlier described situation may not be sufficient for leaving the incompetent GSV in place, unless one or more of the following conditions are also present. . Few and small leg varicosities without symptoms. . Competence of the ostial valve at the Valsalva maneuver. . Presence of a re-entry perforator centered on the saphenous stem (usually Boyd or Paratibial perforator), able to efficiently empty the refluxing volume, once the collateral varices have been removed.

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.

. .

.

.

. . . .

Slow filling of the varicose veins upon release of proximal compression (Trendelenburg test) corresponding to a duplex signal of low velocity retrograde flow. Presence of a competent femoroiliac valve proximal to the SFJ; this valve prevents abdominal reflux into the GSV. Large incompetent mid-thigh perforator with dilatation of the GSV only distal to it (in these cases, the perforator is considered to be a more important reflux source than the SFJ, and the GSV is removed distal to the perforator). Reflux in a collateral of the SFJ (typically an anterior accesory saphenous vein) with competent pre-ostial valve and GSV trunk (in this case, avulsion and high ligation of the collateral varicosity is sufficient). Reflux from the saphenous stem to a CV of the thigh, with a competent distal saphenous stem. If the refluxing collateral emergence is high, only the collateral may be eliminated. A short proximal tract of incompetent saphenous stem will be left, deserving conservative treatment. Very young patients. Here, one cannot predict if the disease is going to progress toward important dilatation of the GSV. Very old patients, in which minimal surgery may be functionally adequate. Presence of nonsymptomatic GSV reflux in the opposite leg, which may also suggest little clinical significance. Patient with chronic ischemic cardiac and/or peripheral arterial disease, in whom the other GSV has been stopped.

It may appear from this description that the decision to leave the GSV is somewhat complex and confusing. The use of duplex examination possibly done by the same surgeon may greatly help in dealing all these different aspects. However, the alternative is indiscriminate removal of all incompetent GSVs even if only partly involved. The decision not to operate on the GSV is greatly facilitated by varicose vein surgery based on phlebectomy. This implies simple and easily repeatable surgical procedures. This advantage allows one to leave rather than to remove the GSV, which can be easily removed later, should it become necessary.

ALTERNATIVE TREATMENTS FOR GSV INCOMPETENCE It has been our practice so far to either divide and strip the GSV or leave it in place. This all-or-nothing attitude simplifies decision-making and is also based on consistent evidence that removal of all dilated and varicose veins with interruption of all sources of deep to superficial reflux has been shown to give the best functional and cosmetic results (19). However, some alternative treatments do exist and may give comparable long-term results. The only such treatment we occasionally perform is GSV division and ligation alone, usually when minimal

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surgery is considered more convenient, that is, patients in advanced age or chronic systemic disease. We have no experience with other alternative surgical procedures like SFJ valve repair (20,21), ligation of the SFJ and ligation of the GSV trunk just below each incompetent perforator (CHIVA) (22), or GSV avulsion by phlebectomy without division of the SFJ and its collaterals (23 – 25). Choice of Stripping Technique Three different stripping methods are known: The Babcock technique, which strips the vein on the outer side in distal direction of the vein, using an olive stripper inserted inside the vein and fixed to it (26). The invaginating technique, according to Keller (24), is performed with a suture or a wire passed inside the vein: the vessel is inserted in its own lumen and pulled out by traction in “glove finger” way. Mayo performs this procedure with stripper with a ring at the tip. The vein is introduced through the ring; this is pushed distally in the sudcutaneous tissue of the thigh by dissecting the vessel (24). When using local infiltration anesthesia (LIA), where only a limited strip of skin is involved, it is necessary to use that technique, of the three, that produces the least traction on the collaterals during saphenous extraction. Those veins translate the traction to surrounding tissues that are not, anesthetised, causing pain. The technique of Babcock is the most traumatic in this sense and cannot be employed. The invagination technique is much more “friendly,” although keeping traction on the collaterals is important to allow interruption of the CVs by small phlebectomy counter incisions, according to Oesch (25). Furthermore, it requires a certain “open vein” manipulation (sound introduction, counterincision and distal recovery, skilled ligation of invaginating stump, etc). This makes it not suitable for operation under local anesthesia (LA). Mayo’s technique, modified by the use of rings with sharp cutting edges, is performed on a “closed” vein without manipulation, and allows excision of the collaterals without any traction (28). In this way, LIA is sufficient and effective. Mayo’s modified technique seems best for the demands of our method for treating varicose veins and is the one that we are going to describe in this chapter. A different type of anesthesia (truncal, spinal, and general) is best for treating varicose veins with the other techniques of stripping. However, our experience suggests that this method has value for its ease, execution rapidity, cleanliness of operating field, and effectiveness, particularly if an ambulatory practice is foreseen. PROGRAMING THE OPERATION The GSV is involved in the varicose syndrome in $60% of the cases. The reflux spills out from the saphenous stem at a variable height, mostly below the knee. Phlebectomy deals with superficial (collateral) varices, whereas the saphenous stem varicose veins require stripping techniques.

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Only the incompetent saphenous tract is usually avulsed, whereas the healthy saphenous part is basically conserved. In fact, there is no reason or right for eliminating a well-functioning part of a vein. Therefore, removal or closure of only the incompetent portion of the GSV is performed. This requires accurate duplex mapping of GSV incompetence. If the incompetence occurs along the entire GSV that is dilated [usually .7 mm in diameter to the mid-calf (20% of cases) or even to the foot (in up to 10% of patients)], the vein is removed through phlebectomy and/or stripping and/or an endolumenal closure technique. If the extension of the disease is limited, the whole procedure (saphenectomy and phlebectomy) is performed in a single procedure, otherwise we prefer to perform CV phlebectomy 3 – 5 days before the saphenectomy. We avoid operating on the GSV during patient’s menstrual cycle for hygienic rather than surgical reasons (this limitation does not apply to phlebectomy in general). The decision to strip the GSV must be made prior to operating on the collateral varicose veins. This is because if the distal varicosities are removed first, the diameter of the GSV may reduce and the reflux disappears (lacking the re-entry point) although the incompetence persists. The GSV is stripped from its junction with the femoral vein down to the most distal point where it is dilated and incompetent, which in most cases does not go beyond the Boyd (below-knee) perforator. If necessary, the GSV distal to the Boyd perforator is avulsed by phlebectomy. In easy cases, during phlebectomy even the saphenous stem may be avulsed in a proximal direction over the knee, making the consequent saphenectomy shorter and quicker [Fig. 15.1(b)]. When previously performed, ligation of the GSV at the knee may give rise to formation of a thrombus of limited extension. The post-operative compression bandage and anti-inflammatory medication may avoid or reduce the consequent local inflammation. Occasionally, when the GSV is stripped by phlebectomy, the remaining GSV trunk may be completely obliterated up to the groin. In this case, it is not operated on, but kept under compression bandage (like after sclerotherapy) until it turns into a fibrotic cord, and the patient is evaluated 6 –12 months later. PRE-OPERATIVE MARKING The GSV is marked with the patient standing, its course followed by palpation, percussion, and Doppler and/or duplex ultrasound. Its course is then checked again with the patient sitting and the marking adjusted as needed (in the obese patient, the markings may “move” from standing to recumbent position). Pre-operative duplex scanning of the SFJ provide helpful details of the anatomy we are going to operate on (number and site of collaterals, diameter and shape of the junction, possible anomalies, and lymph nodes). The evaluation of the thigh portion of the GSV allows more precise marking of saccular dilatations, GSV duplication, and side branch and/or perforator confluence. This is useful in planning supplementary anesthesia at the sites of GSV branching.

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Figure 15.1 At the time of the stripping operation, all leg varicosities and the middle portion of the GSV have been usually avulsed. (a) Leg varicose veins with GSV incompetence, marked for phlebectomy (May 13). (b) Four days after phlebectomy. The middle portion of the GSV has been removed from mid-thigh to knee and the patient is positioned for high ligation and stripping of the remaining proximal GSV segment (May 19). (c) Removal of the post-operative bandage 6 days after GSV stripping (May 25). No bruising or hematoma formation.

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The groin crease must also be marked from the point the femoral pulse is palpated to the insertion of the abductor’s tendon. This is done with the patient standing and/or sitting, because in the recumbent position it may be impossible to appreciate the groin crease [Fig. 15.2(d)]. ANESTHESIA Anesthetic solution of 60 –90 mL (240 –450 mg of mepivacaine with epinephrine) or 60– 180 mL (1:10 dilution of 1% lidocaine) is employed, with 10 mL kept aside for supplementary anesthesia, if necessary. For groin infiltration 20 mL, for the skin and superficial layers 10 mL, and for deep tissues 10 mL are used. Test suction is always performed during deep infiltration to avoid accidental intravascular injection. For the infiltration along the marked vein, 40–100 mL is then employed first superficial then deeper. The saphenous vein running in an anatomical space is limited by a connective fascia (saphenous fascia) (see Chapter 2); the infiltrating anesthesia must necessarily involve this same space for obtaining an effective anesthesia. By US it is possible to verify the effective infiltration of this area especially in obese or “difficult” patients. Wider areas are infiltrated in the upper third of the thigh, where there are constant collaterals and possibly more pain receptors in the perivenous tissue (Fig. 15.3). PATIENT POSITION AND SKIN PREPARATION The operation is performed according to classical surgical standards regarding patient and surgeon preparation. The patient is operated in supine Trendelenburg position, with the knee and hip flexed and the limb externally rotated for optimal exposure of groin and medial thigh (Fig. 15.3). If the patient has difficulty in maintaining this position, a support pad under the knee may help. The groin must be shaved, preferably 2– 3 days before surgery. Male patients are advised to remove the hair from the thigh to avoid pain when the post-operative adhesive bandage is removed. Female patients cover genitalia with tanga-type disposable bikini, while male genitalia are covered with a drape and taped to the opposite side. Patients are asked to keep their arms under the head during the operation, to avoid involuntary touching of the sterile area. When using pulse-oximetry, it is wise to position it out of the patients’ view to avoid anxiety reactions. INSTRUMENTS The surgical instruments employed are common and nonspecific, except for the Mayo and Corcos extraluminal phleboextractors (strippers) and Graefe iris forceps. The set includes the following: . . two 20/30 mm retractors (Richardson-Easmann or Goelet); two standard 14 cm 2 Â 3 teeth dissecting forceps;

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Figure 15.2 Patient preparation for GSV stripping. (a) Removing the adhesive bandage placed after previous phlebectomy. (b) Thick cotton strip placed over the GSV for additional (local) compression. (c) The GSV marking is checked again by percussion test. Impulse is given by quickly pressing the GSV distally with the thumb of the right hand, while the wave is received at the groin by the left hand. (d) The GSV is marked again. The groin crease is marked in the standing position, because it may be difficult to localize it later in the recumbent position. (e) B-mode scan is performed to check the marking and localize the major side branches of the GSV. (f) Marking is now completed with side branches indicated by transverse signs.

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Figure 15.2

Continued.

. . . . . . .

one 14 cm Mayo dissecting scissors; three curved toothed 13 cm Halsted hemostatic forceps; three straight toothed 13 cm Halsted hemostatic forceps; two curved nontoothed 12 cm Halsted hemostatic forceps; two curved 14 cm Kocher hemostatic forceps; one 15 cm Lahey (Mixter or Meeker) forceps; one Graefe iris forceps (for phlebectomy);

Figure 15.3

The area of LA is larger in the upper thigh.

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. . . . . .

one regular 14 cm Hegar-Baumgartner needle holder; one number 15 scalpel blade with holder; two Mayo external anular strippers, 6 and 8 mm diameter; two 50 cm Corcos external strippers, 6 and 8 mm diameter; Vicryl #3-0 without needle; Vicryl #3-0 with needle.

SURGICAL ANATOMY OF THE SFJ At the groin (as in its entire course until the foot), the GSV lies beneath two fatty layers and a fibrousfascia (fascia superficialis), the so-called “saphenous compartment” (27). As it approaches the femoral vein, it receives several tributaries (Fig. 15.4). These vary in number and position, and may directly join the femoral vein instead of the GSV. The tributaries are usually easily recognized because of their small caliber. However, a very large ASV or posteromedial thigh vein joining the GSV close to the femoral vein (or joining the femoral vein directly) may be confused with the GSV. In this instance, it is not uncommon for only one of the veins to be ligated, while the other is missed. The presence of two large veins (instead of one) that join the femoral vein together or separately can be confirmed by duplex scan, which also determines the presence of reflux in each of the veins separately (Fig. 15.5).

Figure 15.4 The SFJ, Dotted line: common femoral vein GSV, great saphenous vein; AL, anterolateral thigh vein; PM, posteromedial thigh vein; SI, superficial iliac vein; SE, superficial epigastric vein; SP, superficial pudendal vein. The diagram shows a “typical” SFJ with two distal (AL and PM) and three proximal (SI,SE, and SP) collaterals. However, less than three as well as more than ten collaterals may be encountered here.

great saphenous vein. This centers it over the marked GSV termination. The incision is made exactly over the (previously marked) groin crease. ASV. Georgiev.5 Longitudinal and transversal color flow imaging of the saphenofemoral junction. anterior accessory saphenous vein. which could be performed by a solo operator without general surgical training. and Goldman Figure 15. who is able to cope with any eventual complication that might occur during groin dissection. GSV division must be performed with an assistant and by a surgeon with adequate general (or vascular) surgical training. A 3 cm incision is sufficient. between the point of palpation of the femoral pulse and the abductor tendons. 15. GSV. common femoral vein. . and CFV. Belcaro) The groin tributaries and collaterals anastomize freely with each other demonstrating why even a correct ligation of both saphenous and CVs cannot eliminate all potential sources of groin reflux (Fig.6). except in very obese patients where a 4 –5 cm incision may be necessary. showing both GSV and ASV incompetent.198 Ricci. TECHNIQUE Ligation and Division of the SFJ Unlike phlebectomy. (Courtesy of G.

If the dissection is particularly difficult. 15. 15. the GSV may be retrieved a few centimeters distally from the incision level. over the medial aspect of the thigh. while the other hand checks. Some adjunctive anesthesia may be added simply by dripping the solution into the open wound. Once the GSV is divided [Fig. The latter is divided with scissors and retracted to expose the second layer of subcutaneous fat and the second connective tissue fascia.7(c)]. bringing into view the dilated GSV.6 Intraoperative finding of a collateral (COL) of the SFJ. rather than simply moving laterally. The GSV is sometimes embedded in a dense adherent fibrous and lymphatic tissue (especially where there is a history of thrombophlebitis or sclerotherapy). In this case. and C). With the vein kept in traction. and Stripping of GSV 199 Figure 15. The GSV is then doubly clamped with the curved Halsted forceps. the lower . In this case. The subcutaneous fat is retracted until the layers of the superficial fascia are exposed. The collateral (in this case. 15. Division. its distal portion is put repeatedly under strong traction. the superficial iliac vein) divides into three branches (A.Ligation. Before dividing the vein.B. which illustrates why groin reflux—retrograde flow from A to B and C—may not be abolished even with flush saphenofemoral ligation. it is grasped with the dissecting forceps and pulled up until its inferior wall is visible [Fig. The latter is then divided and retracted.7(a)]. its exposure and dissection may be difficult and time consuming. The edges of the skin incision are pulled up apart from each other with the dissecting forceps (the operator holds the lower and the assistant the upper edge) and the residual dermal and subdermal connective tissues are divided with scissors until there is enough space for retractor insertion. the presence and direction of skin traction. the GSV must be searched laterally. the supporting tissues are bluntly dissected with Mayo scissors until the latter is passed under the vein [Fig. it is better to start dissecting from more superficial layers. If during dissection the abductor tendons are exposed.7(b)]. This maneuver may cause discomfort that disappears promptly once the perivenous tissues are dissected and retract. Once the GSV is retrieved.

The proximal stump is pulled gently and freed of its investments [Fig. retractor is placed over the distal stump. Freeing the GSV. it is grasped with the dissecting forceps and pulled up until its inferior wall is visualized. (e) The GSV stump is clamped proximally to the insertion of the collateral. (i) The GSV is ligated at its junction with the femoral vein. (k) Second transfixed ligature is placed just distal to the first one. (d) The proximal GSV stump is pulled gently and dissected from its attachments.200 Ricci. (a) Once the GSV is retrieved.8). Georgiev. divided. the collaterals of the SFJ are exposed and pulled . (b) The GSV is freed from surrounding tissue with Mayo scissors passed under the vein.7 Serial diagrams illustrating GSV high ligation and division. exposing the collaterals of the SFJ. (c) The GSV is doubly clamped and divided. Sometimes the pudendal artery crosses the GSV anteriorly. and ligated. 15. and the latter is also clamped. and Goldman Figure 15. in which case we do not divide the artery but pass the GSV stump in front of it (Fig. thus excluding the latter from the operating field. The procedure is repeated (f) until all collaterals are divided and ligated and the SFJ exposed (g).7(d)]. 15.

and Stripping of GSV 201 Figure 15. Division. .Ligation.7 Continued.

The GSV is dissected and freed of its perivascular adhesions distally as much as possible (usually 5 – 10 cm). the first collateral is clamped at $1 cm distance from the GSV trunk. If the CVs have a low insertion. 15. The procedure is then repeated for the remaining collaterals until the SFJ (white line) and lateral aspects of the femoral vein are exposed [Fig. 15. the latter divided between the GSV and the forceps and only its distal end is ligated [Fig. the GSV put under strong traction and the inferior edge of the groin incision maximally retracted. into the surgical site. they may not be exposed but still hooked with a finger and divided.7(g)]. Georgiev. Distal to the ligature. ligated. Careful inspection of the field for bleeding completes this part of the procedure. As a rule. Once isolated. 15. The trunk is then clamped proximally to the insertion of the collateral. . The SFJ is ligated with #3-0 resorbable suture. Each collateral is pulled gently into the wound until it breaks or is ligated [Fig.8 (a) If the pudendal artery crosses anteriorly to the GSV it is left intact by passing the GSV stump in front of it (b). It is better to leave a short stump rather than strangle the femoral vein [Fig. a second transfixed suture is placed and the GSV stump is trimmed at $1 cm beyond the second ligature [Fig.7(f)]. and Goldman Figure 15.7(i)].7(e)].202 Ricci. GSV Stripping The superior retractor is removed. At times.7(h)].9(a)]. Their division releases the GSV to stretch and exteriorize further. and divided [Fig. 15. We do not expose the femoral vein above and below the SFJ and consider such maneuver unnecessary and potentially harmful (angiogenetic stimulus). 6– 10 cm of CV can be removed as in a standard phlebectomy. 15. the anterolateral and posteromedial thigh collaterals are pulled into the wound. 15. paying attention not to include part of the femoral vein into the ligature.

15. 15. and (4) poor alignment of the stripper to the vein axis (obese patient). This maneuver may break some tiny collaterals. Occasionally. which causes poor diffusion of anesthesia into the fibrous scar tissue. The remaining portion of the vein is then avulsed either by phlebectomy or by passing the stripper through the new incision. (3) very large saccular dilatation of the GSV. the vein is secured with two clamps and put under strong traction. 15. and a way out in proximity of the cutting edge [Fig 15. the remaining portion.9(b)]. all collaterals and perforators.9(d)]. with an immediate relief of discomfort. but will usually cut.9(c)] and slowly pushed down along the vein [Fig. while the other operator keeps the vein under traction with one hand.9(h)]. sometimes the cutting stripper may cut the GSV (12% of a casuistic on 100 consecutive cases) (30). while the Mayo stripper is rotated with the ring down [Fig. or may be left off if . The Corcos stripper is used exactly as Mayo’s. hook and exteriorize the vein and free it from its fibrous adhesions. the other close to the skin incision).9(g)]. and Stripping of GSV 203 The GSV is clamped as distal as possible and its upper end ligated with a long suture that serves to pass the vein into the 8 mm ring of the Mayo stripper [Fig. but a large and strong collateral (or perforator) will stop the progression of the stripper [Fig. creating a channel along the stripper’s rod.9(p)]. Also a vein dilatation. Division. 15.9(f)]. If the patient feels pain during the instrument’s progression. 15. with a way in (for the syringe) at the handle [Fig. Sometimes dissection is difficult and painful. or a calcification of the wall may stop the sound’s advancement.9(i)] or by pressing it against the cutting edge of the Corcos stripper [Fig. Passed through the ring. must be avulsed through a separate incision(s). by pressure and to-and-fro rotating movement. additional anesthesia may be given at the stripper’s tip or over the previously marked site of branch confluence. 15.9(o)]. whose dissecting end is a cylinder with a sharp cutting edge (28) [Fig. either by needle puncture [Fig. If there is pain during progression of the stripper. especially if there are perivenous adherences from phlebitis or previous sclerotherapy. some more anesthetic can be injected in the exact site of pain. it can be divided now. the Mayo annular stripper is replaced with the Corcos 6 mm stripper (8 mm stripper is used only for very large veins). 15. About one-third of the procedures require this adjunctive anesthesia. To overcome possible occasional discomfort during the dissection we have modified the Corcos stripper (30). thus dissecting and freeing the GSV down to the point it has been ligated at the previous operation or freed in the phlebectomy phase [Fig.Ligation. In case the GSV breaks. The Mayo stripper is held with two hands by one of the operators (one hand at the holder. 15. This may occur for a number of reasons: (1) vein fragility. However. derived from a similar instrument suggested by Thompson (29). 15.9(e)].9( j)]. (2) large collateral that joins the GSV at an acute angle (the stripper may follow the collateral and cut the GSV trunk). If the GSV has not been divided at the knee level during a preceding operation. When this happens. 15. large diameter collateral. if long enough. it may be preferable (to avoid discomfort) to make an incision over the point of stripper blockage. and with the other hand exerts counter pressure on the skin over the stripper’s tip [Fig. so avoiding a counter incision.

and Goldman .204 Ricci. Georgiev.

a gauze pad is rolled a few times from knee up to groin over the tunnel left after GSV stripping. This maneuver usually puts one or more of the distal collaterals (anterolateral and posteromedial thigh veins) in evidence. If the GSV has been ligated and divided during the preceding operation. followed by subcuticular buried closure [Fig.10). In 1970. (f) The Mayo (ring) stripper may break some collaterals. (k) Sometimes the Corcos stripper may cut the GSV instead of its side branches. which are also divided and ligated. (b) The end of the GSV is ligated with long suture and passed through the ring of a Mayo stripper. (d) The stripper is now pushed down along the GSV.9(m)]. but a large collateral will stop its advancement. The Corcos stripper is available with a 6 and 8 mm diameter cylinder. The groin wound is closed with continuous intradermal suture with #3-0 Vicryl. Since then. (g) When this occurs. has a cylinder with a cutting edge. (h) Pushed down with a to-and-fro rotating movement. (e) The advancement of the stripper and the traction it exerts on the saphenous side branches may be visible from traction on the skin.Ligation. due to the presence of large side branches. The above-described technique was introduced by Crosetti in Neuchatel (Switzerland) for the purpose of removing the proximal portion of the GSV in patients treated by Muller with phlebectomy (31). the only substantial difference between the original technique and the one we perform now is the introduction of the Corcos stripper. Division. the remaining GSV portion has to be avulsed by phlebectomy maneuvers through additional incision(s). the stripper has cut the GSV and the latter had to be avulsed through few separate incisions. so that any residual blood and/or coagula are expressed through the groin incision [Fig. After extraction of the GSV. it can be divided now either by needle puncture (i). Ricci learned the technique from Crosetti. (m) Expression of coagula from groin incision. 15. . the assistant applies a few layers of underwrap and adhesive compression bandage along the thigh (Fig. or by pressing it against the cutting edge of the cylinder stripper ( j). (c) The stripper is rotated with the ring pointed down. This bandage applied before the closure of the groin wound substantially decreases the incidence of thigh hematoma and even bruising.9 Serial diagrams illustrating stripping of the GSV. the Mayo stripper (left) is replaced by the Corcos stripper (right) which. 15. further modified by canalization for target anesthesia. M. Figure 15. In this case. intraoperative echography may be very useful. In case of difficulty in finding the saphenous stem. If the GSV has not been divided at knee level during the preceding operation. Immediately. and Stripping of GSV 205 very short and devoid of collaterals [Fig.9(n)] with band-aids covering the wound after a skin adhesive is applied. (l) Removal of the residual GSV trunk after its rupture. instead of a ring. while the GSV itself is kept in traction. (n) The groin wound is closed with continuous intradermal suture with #3-0 catgut absorbable suture. 15. Note how in this case. 15. the Corcos stripper will usually cut all collaterals and perforators and dissect the GSV down to the end point of the operation.9(m)]. (a) The free end of the distal GSV segment is put under traction and dissected from perivascular tissues. thus avoiding an incision at knee level. Dissection of the GSV from the surrounding tissue may be enhanced by exerting counterpressure on the skin over the stripper’s tip. it is now pulled out from the groin incision.

9 Continued. . and Goldman Figure 15. Georgiev.206 Ricci.

10(c)]. 15. The leg is also bandaged as needed and the patient invited to walk for about a 30 min in the office. A 1 cm thick 5 Â 10 cm gauze pad is placed over the groin incision [Fig. and lateral thigh [Fig.9 Continued. then rolled down over the groin to make a double loop around the medial. Next. and the patient is discharged. where it overlaps the groin bandage. Division. First.Ligation. POST-OPERATIVE BANDAGE The groin is bandaged first [Fig. posterior.10(d)].10(a)]. the thigh is bandaged with a second adhesive bandage (Fig. and Stripping of GSV 207 Figure 15. The compression adhesive bandage is then applied in spiral overlapping loops from below the lowest operated point up to the groin. 15. then compression cotton wool pads are applied over the tunnel of the GSV and secured with a few more layers of underwrap. 15. 15. 15.10(e)].10(b)] and secured with a 10 cm wide acrylic adhesive elastic bandage applied as follows: The bandage is started from the iliac crest [Fig.11). then crossed over the groin and terminated over the suprapubic area [Fig. 15. The inferior border of the groin bandage overlaps the annular mid-thigh bandage. Patient will come back to the office a week later for the removal of the adhesive . Analgesic is prescribed during the evening after surgery. a few layers of underwrap are applied.

(a) Mid-thigh adhesive bandage is applied even before suturing the groin wound.10 Post-operative groin bandage. COMPLICATIONS The procedure described earlier is simple and safe. The successive management of the operated patient does not differ from that after phlebectomy in general and is discussed in detail in Chapter 12. then crossed over the groin and secured over the suprapubic area (e). A 10 cm wide elastic adhesive bandage is applied over the iliac crest (c). Georgiev. bandage. rolled down over the groin to make a double loop around the upper thigh (d).208 Ricci. and Goldman Figure 15. Our average complication rate is illustrated well by a series of 141 consecutive operations of GSV stripping. No major complication has occurred in more than 20 years in our practice. (b) After closure of the groin wound. . a thick gauze pad is placed over the groin incision.

Uber die Unterbindung der Vena saphena magna bei Unterschenkelvarizen. without other complications. performed in 1990: Three cases of groin hematoma.11 Finished full-length thigh bandage. and Stripping of GSV 209 Figure 15.1) has her left limb bandaged after GSV ligation and stripping. Trendelenburg F. Angiology 1971. 15. Division. Inc. 1987. Beitrage zur Klinische Chirurgie 1890. Texas: Silvergirl.Ligation. 22:428. 2. A further study over 100 consecutive case made in 1997 registered a single case of hematoma at the middle third of the thigh conservatively treated (30). . 3. Primary varicose veins: a topographic study. REFERENCES 1. Mar 31 –Apr 2. Plea to save the thigh segment of the saphenous vein. 1986). 7:199. (Cited in English from: Laufman H. This patient (shown on Fig. Austin. Washington DC. IV European-American Symposium on Venous Diseases. Georgiev M. one case of groin wound infection. and one of groin lymphocele occurred (32). The Veins. Demos NJ.

20. Ricci S. 2:886. History of stripping. 1991.. 7:20– 22. 14. Peruzzi G. Veith FJ.210 Ricci. 10. Austin: R. Phlebology ’92. NY Med J 1907. Pugh N et al. 15. 1:859. 103(6):615– 619. 16. An assessment of the long saphenous vein for potential use as a vascular conduit after varicose vein surgery. Large J. 1989. 79:1019 – 1021. 12. The role of surgery in treatment of varicose veins and venous telangiectasias. External valvuloplasty of the sapheno-femoral junction versus high ligation or disconnection. Selective stripping operation based on Doppler ultrasonic findings for primary varicose veins of the lower extremities. 35. Bergan JJ. Primary varicose veins: topographic and hemodynamic considerations. Br J Surg 1992. Scurr JH. Davies AH. 1988. 51:761 –772. 86:1553. 18:836– 840. Goren G. 24. Scurr JH. In: Raymond-Martimbeau P. 1992:1081 – 1082. K. Fligelstone L. Zummo M. Bergan JJ. 11. Hammerstein J. Groin-to-knee downward stripping of the long saphenous vein. Pedersen P. 6. Romeo V et al. St. Acta Phlebologica 2001. and Goldman 4. Surgery 1988. Landes Co. Paris: John Libbey Eurotext. Etude critique sur 218 cas. Precy-sous-Thil: Editions de l’Armancon. Pin-stripping. Phlebologie 1996. 31:672. Barabas AP. 7. Macchi C. Sarin S. Should we strip the long saphenous vein? A randomized controlled trial. Oesh A. Baird W. 5. 1992. In: Goldman MP. Cederlund et al. Louis: Mosby Year Book. 8. 13. 25:177– 182. 18:407– 415. Dortu JA. ed. Magee TR. Coleridge-Smith PD. Surgical treatment of saphenous varices with preservation of the main great saphenous trunk. 19. McMullin GM. De Anna D. Corcos L. Prescott R. Sclerotherapy. Schultz-Ehrenburg U. Eur J Vasc Surg 1990. J Vasc Surg 1993. 78:1139– 1142. 18. Babcock WW. Marin ML. 22. Peripheral venous biopsy: significance. 12:184. Van Bemmelen JS. A new operation for extirpation of varicose veins. Corcos L. Ann Chir 1997. 4:271 – 274. Phlebology 1989. Objective assessment of high ligation without stripping the long saphenous vein. Godwin RJ. 21. Schattauer Verlag. Coleridge-Smith PD. Procacci T. MacFarlin R. Belcaro GV. Yellin A. ´ 25. Determination of a “good” saphenous vein for use in in situ bypass grafts by real-time B-mode imaging. Phlebologie (D) 1996. Plication of the saphenofemoral junction. Vol. Cure conservatrice et hemodynamique de l’insufficiance veineuse en ambulatoire. Carolan G. Stugggart-New York: F. Franceschi C. Hubner HI. Reflux Diagnosis with Doppler Ultrasound. Vein compliance: the preoperative indicator of vein morphology and of veins at risk of vascular stenosis. Constancias-Dortu J. 4:361 – 364. Sakaguchi S. J Cardiovasc Surg 1990. 18:296. J Vasc Surg 1985. eds. Phlebology 1992. . 26. ´ 23. VASA 1989. Long saphenous vein-saving surgery for varicose veins. Panetta TF et al. J Vasc Surg 1993. Comparison of preliminary results between two groups of patients. Br J Surg 1991. 25:2 –10. limitations. Berry S et al. A long-term follow-up. Saphenous vein biopsy: a predictor of vein graft failure. Peruzzi G. 9. Traitment des varices des membres inferieurs par la ´ phlebectolie ambulatoure. Quantative Measurement of Venous Incompetence. G. 17. indications and clinical applications. Conrad P. Georgiev. Koyano K. Are varicose veins and coronary artery bypass surgery compatible? Lancet 1985. J Vasc Technol 1988.

31. Phlebology 1989. Phlebology 1997. The Lancet 1950. 18:55. Corcos L. The long saphenous vein compartment. and Stripping of GSV 211 27. Structure and use of the external phlebo-extractor. 4:275. 52:61– 68. 29. Ricci S. Saphenectomie par stripper externe. ´ ´ 30. Caggiati Ricci. 28. Division. A modified Mayo vein stripper. Muller R. Proceedings of the 8th International and 19th Brazilian Congress of Angiology 439. Georgiev M. Phlebologie 1999. 1972. . Thompson W. 32. 29:173. Crosetti JP. Office varicose vein surgery under local anesthesia. J Dermatol Surg Oncol 1992.Ligation. Ricci S. 12:107– 111. Traitement radical ambulatoire des varices.

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Part IV: Conclusions .

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The type and incidence of untoward reactions during AP are illustrated in Tables 16. 1990). more than one million of such operations have been performed in Europe without a single major complication reported (R. warmed (378C) solution and injecting slowly. but resolve spontaneously and completely in a relatively short time). These complications are discussed in further detail in relation to the different phases of phlebectomy. there are untoward reactions with ambulatory phlebectomy (AP). as employed for AP. has not caused major complications (see Chapter 7). only a few need to be seen before their scheduled return to the clinic.2. Muller. Inappropriate initiation of emergency treatment 215 . personal communication.3 with a review reported by Ramelet in 1997 (1).16 Complications and Untoward Sequela of Ambulatory Phlebectomy As with any surgical procedure. and by employing neutralized. It is largely avoided by the Trendelenburg position. All of these maneuvers help to reduce pain. It is important to recognize emotional reactions as such and not to confuse them with toxic or allergic reactions. Transitory malaise is usually due to emotionally induced hypotension. 16. these are less frequent than with the traditional varicose vein surgery. It has been calculated that since the introduction of AP. and 16. Undesired reactions may be divided into two types: true complications (events that require professional assistance and may leave sequela) and minor inconveniences (which cause some nuisance to the patient. However. by distracting patient’s attention.1. Although $5% of the operated patients may call to complain (or simply to be reassured). COMPLICATIONS OF ANESTHESIA Local infiltration anesthesia (LIA).

1%) (0. and Goldman Table 16.6%) (3.9%) (0.6%) (2. foot-up tilt.1%) (1.216 Ricci.3%) (1.3 Cases (4) Complications of AP in 4000 Consecutive 214 183 145 110 15 6 5 4 4 (5.2%) (0.8%) (4. emotional fainting in our experience is more frequent with these . Georgiev.3%) Table 16. and reassure the patient.3%) (1. All that is needed for emotionally induced hypotension or malaise is to stop injecting.4%) (2.6%) (1.8%) (0.8%) (0. increase the head-down.4%) (7. and pre-operative marking.2%) (8.4%) (4.1%) Blister formation Pigmentation (transitory) Telangiectasia matting Localized superficial phlebitis Temporary dysesthesia Lymphocele Extensive superficial phlebitis Delayed bleeding Hematoma will only enhance the patient’s anxiety and worsen the situation.2 Complications of AP in 1000 Patients (2953 Operations) Treated by Muller from 1965 to 1975 (3) Hemorrhage at home Hematoma Lymphocele Nerve damage Persistent pedal edema (more months) Infection Superficial thrombophlebitis Discolored scars Persistent pain (2 months) Blister Eczema Keloid Minor malaise during anesthesia 11 17 18 46 13 18 4 72 2 84 26 3 5 (1.5%) Table 16.3%) (0.2%) (0.6%) (0. Most patients “at risk” for emotional reactions are identified in advance. during the orthostatic clinical.4%) (0.7%) (1.6%) (0.1%) (0. ultrasound examination.1 Complications of AP in 320 Consecutive Patients (852 Operations) Performed in Our Office in 1990 (2) Hemorrhage at home Hematoma Lymphocele Nerve damage Persistent pedal edema (5 months after surgery) 1 1 5 3 1 (0.3%) (0.

The average dosage of lidocaine (which is metabolized like mepivacaine) for phlebectomy is 10 mg with a maximum of 20 mg for GSV stripping. oxygen must be immediately supplied. If bronchospasm occurs. found in only one patient. The average dosage of mepivacaine for phlebectomy is 2 mg/kg with a maximum of 6 mg/kg for great saphenous vein (GSV) stripping. have been reported (15 – 22). Despite the low risk of allergenicity to lidocaine. The amide class of anesthetics has a very low risk of allergic reactions (6 – 11). and less than one-thirty-sixth the cardiotoxic concentrations.12 – 14). with important cardiac arrhythmias and blocks. including anaphylaxis. that is. With dosages of 3– 15 mg/kg (average 8. to keep the allergic risk as low as possible. rapid absorption from the injected site. coronary heart disease. If there is only a cutaneous rash. most patients have already had local anesthesia (usually for dental procedures) which has established their allergic history. multiple allergic reactions. lidocainemia was found to be an average of 0. Allergy is most likely caused by methylparabens or sodium metabisulfite that is used as a preservative in the anesthetic solutions (6. one should use single dose vials of anesthetic without preservatives. uncontrolled hypertension. which is less than one-sixth the neurotoxic concentration. intravenous diphenhydramine and/or cortisone may be sufficient. They occur from accidental intravascular injection of the anesthetic agent. In the case of a suspected allergic reaction. the injection must be stopped immediately. Allergic Reactions With the local anesthetics now in use. Blood concentrations of lidocaine were checked in a series of 50 patients treated by AP (23). low absorption rate due to superficial infiltration. was still less than one-half the concentration considered neurotoxic (4 – 12 mg/mL) and less than one-twelfth the one considered cardiotoxic (24 mg/mL). They are largely avoided by using a low dosage of anesthesia. Patients with confirmed allergy to local anesthesia are excluded. Toxic Reactions Toxic reactions are either neurologic or cardiovascular. or in the oversensitive patient. beta-blocker medication. and the presence of epinephrine to further decrease the systemic absorption of the anesthetic agent.6 mg/mL. allergy is exceptionally rare and is due in most cases to the psychogenic or vasovagal reactions (5). IV cortisone plus inhalatory beta-mimetic drug (salbutamol. Fortunately. Alupent) is given.8 mg/mL. and IV cortisone and epinephrine are given. A peak value of 1. and so on.7 mg/kg). If anaphylactic shock occurs.Complications and Untoward Sequela of AP 217 procedures than with anesthesia and phlebectomy performed in the Trendelenburg position.7. Therefore. . hypokalemia. It is also important to consider excluding patients at risk.

tremor or convulsions. Respiratory depression may require assisted respiration. The patient revealed a history of prolonged anesthesia following dental procedure lasting up to 1 week. Bleeding is avoided by placing the patient in the Trendelenburg position.218 Ricci. may occasionally reach the motor branch of the external sciatic-popliteal nerve with consequent foot drop. Toxic reactions to epinephrine. are unlikely at the dosage employed (20 – 100 mL of 1:500. and/or ephedrine as needed. We do not have an explanation for this phenomenon. one must not forget that they might occur.000. AP is virtually a “bloodless” procedure. Should these occur. oxygen must be supplied. In these conditions. which may persist for 24 – 48 h after surgery. such as anxiety. IV atropine. the availability of emergency and resuscitation equipment and drugs. It might be a rebound effect of epinephrine injections. Georgiev. close to the head of the fibula.000 solution). and hypertension. Although allergic and toxic reactions are extremely rare and may never happen in many years of busy practice. 1 week after the procedure in the area anesthetized with 20 mL of 2% lidocaine with epinephrine 1:100. Local Complications Anesthesia on the anterolateral aspect of the knee. and/or respiratory depression. but may also have an emotionally based hypotensive reaction. is necessary for an office where varicose vein surgery is performed (see Chapter 19). and Goldman A neurotoxic reaction includes cortical excitement symptoms. such as sweating. Her twin sister had a similar response to local anesthetics. tachycardia. COMPLICATIONS OF PHLEBECTOMY Hematoma Significant hematoma formation is rare. Full thickness skin necrosis. The procedure performed in the controlateral leg with lidocaine without epinephrine was uneventful and suggest an exaggerated response to epinephrine. Therefore. . Late Reactions A small number of patients report (especially after higher dosage of anesthesia) symptomatic orthostatic hypotension. Cardiovascular toxic reactions include arterial hypotension and bradycardia. as well as the ability to use them. they must be promptly recognized and adequately treated. was described (25). tremor. Convulsions are treated by intravenous diazepam. and should this happen. Hypotension and bradycardia require accentuated Trendelenburg position. Even a minor impairment of foot dorsiflexion may create ambulation problems. The effect of anesthesia ceases in $2 – 3 h. IV sedation (diazepam) and/or anti-hypertensive medication may be indicated.

Provided bleeding during phlebectomy has been treated adequately (digital pressure.2).1 Blood collection inside the tunnel resulting from the saphenous stem avulsion (one week post operation). unexpected hematoma formation may occur in patients with impaired blood coagulation (Fig. Occasionally. For this reason. post-operative bleeding indicates that the compression bandage is inadequate.1). Hematoma is more likely to occur in the groin or in the patients with obese limbs and over an incompetent perforator that has not been ligated. it is important to keep the patient under observation in the office for at Figure 16. and by digital compression of all bleeding sites and ligation of any large perforator or collateral. They may explain some fat tissues indurations or even inflammation lasting more than a week. ligation of large incompetent perforators). . After the operation. 16. Hemorrhage at Home Although groin hemorrhage is avoided by careful ligation of all divided vessels. Bleeding usually occurs within the first few minutes after surgery. 16. Limited nonvisible hematomas taking place in the fat tissue tunnel resulting from the venous avulsion are more frequent. bleeding from distal incisions is prevented primarily by the compression bandage. Finally. a large hematoma has to be evacuated to accelerate healing. where effective local compression is more difficult to achieve. Hematoma usually requires no other treatment than locally enhanced and longer lasting compression to hasten reabsorption. bleeding is avoided by the compression bandage.Complications and Untoward Sequela of AP 219 by peripheral vasoconstriction (epinephrine and emotionally induced). or the formation of subcutaneous cord-like reactions with (rare) retraction of the skin (Fig. Longitudinal (left) and transversal (right) scans show how a cord-like induration may appear.

Only after. a collection of blood may not stain the bandage spontaneously. and Goldman Figure 16. If bleeding is noticed. . Bleeding is also checked by vigorously squeezing the bandaged leg with both hands. patients must walk and step up and down on a platform. with only the adhesive bandage applied (Fig. . Wound Infection Wound infection is rare and promptly responds to antibiotic medication (Fig. 16. but will be brought to the surface by such squeezing. Several factors determine the very low rate and benign nature of such infections: . least half-an-hour after the operation. it is certain that there is no bleeding in the removable stocking or bandage applied. .4). Sometimes. minimal incisions and tissue trauma.220 Ricci. the patient is placed in the Trendelenburg position and the bandage reapplied.3).2 Extensive hematoma formation after phlebectomy of patient on (unreported) oral anti-coagulant medication. surgery limited to the extrafascial compartment. and the patient discharged. During the office observation period. Georgiev. absence of (or very limited) hematoma formation. 16.

4 Wound infection. .3 Bleeding usually occurs within the first few minutes after phlebectomy.Complications and Untoward Sequela of AP 221 Figure 16. therefore. it is important to keep the patient under observation in the office for at least half-an-hour after the operation. Figure 16.

anti-edema and anti-inflammatory effects of the compression bandage. . it presents as local pain starting during the third post-operative day in an otherwise uneventful follow-up. by needle aspiration. Wound infection is usually limited to one or two contiguous incisions and not to the whole area of the procedure. The patients can wear their own clothes. This may be minimized by keeping incisions small and vertically oriented. . all the usual rules of the hospital operating room are not applied in the office surgical setting.5). absence of drug-resistant hospital acquired infections. Recently. The anterolateral tibial area is most prone to develop lymphatic damage due to the propensity of the lymphatic system being just beneath the epidermis.3%) following aspiration has been demonstrated to be very effective in treating this condition. Prophylactic antibiotic medication is not necessary prior to. and the operating room is not sterile. and Goldman . Usually. They may be asymptomatic.5 Lymphocele over tibia 5 days after phlebectomy. one or several times. it is possible to break them by digital pressure. The wound will be more visible than the normal incisions. Local compression is needed until symptoms disappear. Figure 16. but may also cause local inflammation and pain. or after surgery.222 Ricci. An immediate pus evacuation and a local and general antibiotic medication for the following 5 days will stop the infection. the operator does not change shoes. Sometimes. during. but the result will be still satisfactory at 2 months. 16. Although skin preparation and draping are similar to any surgical procedure. the injection of a small amount of sclerosing foam at low concentration (0. but they may need to be evacuated. Georgiev. Lymphatic Disruption Lymphocele Small lymphatic collections occasionally occur over the operated sites (Fig.

but ceases once the lymphatic vessel has been identified and pushed back under the skin. However. whereas nerve trauma may be followed by temporary loss of sensation. Although rare. A small nerve is occasionally hooked and avulsed without significant sequela at the foot dorsal area. In one case. especially to the sural nerve. This complication. an annoying or painful hyperesthesia due to granuloma formation at the site of nerve disruption or trauma may occur. a lymphatic vessel may exteriorize from an incision. is more likely to occur when the vein dissection is difficult and traumatic to the perivenous tissues. Division of a larger nerve causes permanent loss of skin sensitivity. when the normal outflow is decreased or stopped. causing lymphorrhea. Nerve Damage Sensory nerve damage occurs most often along the distal segments of the GSV and short saphenous veins. we had to surgically remove a 5 mm painful granuloma from a phlebectomy scar in the Boyd area 3 years after phlebectomy. because manipulation of the nerve is painful (electric shock sensation) and thus largely avoidable. nerve damage does occasionally occur because veins and sensory nerves may occur in close approximation. Immediate disappearance of symptoms followed. due to the absence of space between the skin and the fascia. This is more likely to happen when there are extensive perivenous adherences that may occur in limbs. local infiltration with corticosteroids may help. An empty vein may also appear similar to a nerve. Because these segments are not routinely removed. The use of low dosage LIA further decreases this complication. Nerve damage is more likely to occur when dissection is particularly difficult because of perivenous adherences (previous surgery. which does not stop with compression bandaging alone. the incidence of nerve damage is lower than with total stripping operations. which have had repeated superficial thrombophlebitis or have been treated by sclerotherapy and/or traditional stripping techniques. causing the latter to be mistaken for a vein.Complications and Untoward Sequela of AP 223 Lymphorrhea Rarely. Vein Thrombosis Superficial thrombophlebitis may occur in veins adjacent to those avulsed even if normal. It is largely prevented . In this case. veins and nerves being in great proximity (24). The posterior ankle and inferior calf are the most likely locations to induce nerve damage. because of its close apposition to the GSV and its tributaries. sclerotherapy. Persisting Edema Very rarely varicose vein surgery may be followed by lymphatic edema that may persist for many months. as well as lymphatic disruption. phlebitis).

absent in Asians and Africans. Leiden’s mutation of clotting factor V is the most common cause of familial thrombophilia. In this case. Although thrombosis rarely occurs in the deep venous system after AP. Figure 16. Georgiev. The popliteal and femoral veins were partially closed (Fig. and Goldman by adequate compression. a 70 years lady with a lymphoma in remission phase. hereditary or acquired. Should it occur. Clinically manifested deep vein thrombosis is extremely rare having occurred in our practice only in a recent case. the patient was admitted to the hospital and had a negative lung scan. Pulmonary Embolism Clinically manifested pulmonary embolism has never occurred in our practice. our attention must be directed on suspecting early symptoms and consequent early anticoagulating therapy with low-molecular weight heparin at curative dosage. Clotting abnormalities. prompt resolution occurs with compression and anti-inflammatory medication. the thrombosis partially recanalized.6 Transversal scan at the groin level showing a partial obstruction of the Femoral Vein along the deep side: deep vein thrombosys appearing at the seventh post-operative day. . a diagnosis of viral pulmonary infection was made. should be considered when analyzing the history of patients. can occur. Curiously. due to circulating thrombophilic factors.224 Ricci.6). This experience is exceptional but shows that in any case one must be aware that what is impossible to occur. The thrombosis appeared during the seventh post-operative day (she had also a short stripping) as a popliteal pain. a complete iliac-femoral thrombosis occurred. 16. At 6 months follow-up. However. which is present in 5% of the European population. the leg never became swollen as it was compressed from the beginning. we believe that immediate and sustained compression therapy and immediate ambulation prevents this from occurring. In the rare patient where it was clinically suspected. Although establishing anticoagulation and continuing “heavy” compression.

scars may persist as red.5% to 9%. In AP. Rare Complications A case of lipoidic necrobiosis and a case of granuloma due to talc powder have been described. along the area where a varicose vein had been avulsed. red telangiectasia may appear along the operated sites. with very clear skin. In some subjects. In the patient with defective skin healing.Complications and Untoward Sequela of AP 225 Telangiectatic Matting In a few patients (from 0. the red phase of the scars may last for a long time. Treatment can be attempted by sclerotherapy or laser. Telangiectatic matting may tend to fade in a few months and may be related to excessive inflammation from aggressive phlebectomy and/or inadequate compression. and also of sclerotherapy and traditional venous surgery. It is the “worst” complication of AP. 16. Hormonal influence may be suspected. We have never seen true keloids to occur. . brown. a case of vitiligo has been reported (26). according to different authors) (1). locally enhanced and prolonged compression may prevent the formation of unsightly scars. or the unwanted creation of areas of difficult akin drainage. but only after waiting for 6 –9 months to allow for spontaneous resolution. Hypertrophic and Pigmented Scars In a few patients. it is particularly annoying as far as the esthetic result is generally very good. although an occasional patient has developed a hypertrophic scar.7 Red-brownish spots over needle puncture incisions 5 months after phlebectomy. appearing sometime Figure 16. Recently.7). new tiny. or white spots (Fig.

If blister rupture exposes the underlying skin. or incisions or avulsion (Kobner’s phenomenon). This is most common around the knee and posterior thigh. (b) Blisters causing brown pigmentations. and Goldman after an uneventful phlebectomy. with pain. Figure 16. It is due to excessive skin tension or friction between bandage and skin. (a) Blisters.). may cause trauma to skin. numbness. Excessive ankle compression. which may take many months to disappear. may cause pedal edema. Blister Formation Blister formation occasionally occurs. especially over bony prominences (shin. An auto immunization mechanism is considered. It may also cause transverse hyperpigmented stripes. combined with insufficient foot compression.8 Blister formation due to traction of the band-aids and the friction exercised by the bandage. . sensory nerves. an occlusive hydrocolloid dressing is applied under the compression bandage.226 Ricci. It is very painful. but heals promptly once the blisters are punctured and the bandage properly reapplied. dorsum of foot. etc. Georgiev. and tendons. secondary to the trauma of anesthesia. which may take many months to disappear. COMPLICATIONS OF COMPRESSION BANDAGE Excessive Compression Excessive local compression and inadequate protection padding. or even skin necrosis (see Chapter 14).

(No allergy to the adhesive bandage applied directly on the skin at the groin and upper thigh.Complications and Untoward Sequela of AP 227 Figure 16.) .9 Allergy to the adhesive bandage over the site of direct contact with the skin.10 Allergy with blister formation and sloughing to the band-aids used to cover the stab incisions 48 h after GSV stripping with multiple phlebectomies. Figure 16.

Schatz M. Local anesthetic agents and regional anesthesia of the face. deJong RH. J Allergy Clin Immunol 1979. Arch Otolaryngol Head Neck Surg 1986. 7. Office varicose vein surgery under local anesthesia. 63:387– 394. J Dermatol Surg Oncol 1992. 16. Eriksson E. 239:1166 –1168. 5:185– 188. 6. 15.9 and 16. Dermatol Surg 1997. . Charles C. 31:273. Kennedy KS. 18. Gill C. Ann Emerg Med 1983. 16. Georgiev M. 3. alternative compression materials must be employed at direct contact to the skin. 23:947– 954. 19. Oral Surg 1980. Aldrete JA. Vassallo HG. Patterson R. 112:671 – 673. Complications of ambulatory phlebectomy: a review of 4000 consecutive cases. Local anesthesia. J Am Med Assoc 1978. Allergic hypersensitivity to lidocaine hydrochloride.8). Anaphylactic reaction to lidocaine. that is.B. acrylic adhesive bandage or glue. Dupont DC. Covino BG. 11. Fregert S. deJong RH. 12:25 – 31. Assessment of allergy to local anesthetic. 5. Contact Dermatitis 1979. Nelson HS. Complications of ambulatory phlebectomy. Thelin I. Thomas. 1976. Dental drugs and anaphylactic reactions: report of a case.. 8:28– 33. Contact allergy to lidocaine. Blackmon BB. 18:55. Incaudo G. 10. Georgiev. Sensitivity to lidocaine. Chest 1983. Promisloff RA. La phlebectomie ambulatoire. Administration of local anesthesia to patients with a history of adverse reactions. 12:316– 318. Death from ARDS and cardiovascular collapse following lidocaine administration. Anaesth Intens Care 1979. Ill. 9. Int J Dermatol 1980. Local Anesthetics. Phlebologie 1978. 61:339 – 345. Contact Dermatitis Cutaneous reactions may range from skin irritation to allergic contact dermatitis (Figs. 7:73 – 74. New York: Grune & Stratton. Clin Plast Surg 1985. Baker JD. Olivencia JA. Thomas RM. 2nd ed. 1980. Michaelides PL. Toxic effects of local anesthetics. Fellner MJ. and Goldman Blister formation may be followed by skin discoloration. 17:161 – 165. 2nd ed. J Assoc Military Dermatol 1982. 2. Chin TM. J Allergy Clin Immunol 1978. Philadelphia: W. 12. Swanson JG.10). Springfield.228 Ricci. 1977. Tegner E. Muller R. DeShago RD. 19:147 –148. 4. Saunders. 14. Ricci S. 17. 50:30– 32. which may take many months to disappear (Fig. In these patients. Am J Cos Surg 2000. Cave RH. 83:585. 16. Ramelet A-A. 13. Local Anesthetics: Mechanisms of Action and Clinical Use. 8. An approach to the patient with a history of local anesthesia hypersensitivity: experience with 90 patients. REFERENCES 1. Illustrated Handbook of Local Anesthesia.

53:223 – 228. Survenue ` ´ ´ d’une vitiligo apres phlebectomie ambulatoire. Allergic reaction to lidocaine: a case report. A rare complication of local anesthetic: case report and literature review. 111:101– 102. Dermatol Surg 1996. Fischer MM. Phlebologie 2002. Olivencia JA. 23. L’snesthesie locale au cours de la phlebectomie ambulatoire selon la methode de R. Ricci S. 43:305. Br Dent J 1975. Kockaert MA. de Roos KP. Lancet 1971. ´ ´ 24. Arditti J. Ambulatory phlebectomy. appreciation du risque per dosage de la lidocainemie. Lechner T. Br J Anaesth 1982. 1:1245– 1246. Phlebologie 1990. 54:893– 894. 21. Lidocaine hypersensitivity. 55:275 – 277. Bourbon JH et al. 22.Complications and Untoward Sequela of AP 229 20. Pennington JC. Phlebectomie des varices du pied. Vidal-Michel JP. Phlebologie 2000. Ravindranthan N. Bullens-Goessens YIJM. 26. . 22:53 –55. Muller. 25. Allergy to local anesthesia. Neumann HAM.

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patients may be divided into four groups. The surgeon should be aware of this and also find the best approach to all patients and situations in order to both win the patient’s confidence and deliver optimal care. or if a relative or friend has described phlebectomy in positive terms. and judge the procedure objectively. discomfort). these patients are not the majority. These patients ask reasonable questions. during. for leg ulcer or phlebitis). One should not deny or minimize some inconveniences (bandaging. but explain that these are largely overweighed by the benefits of the procedure. withstand inconveniences. Comparing it to the common fear of the dentist is pertinent. and so on. Unfortunately.17 Psychological Aspects Patients who undergo ambulatory phlebectomy (AP) or any surgical procedure are more or less anxious about it and experience a certain degree of fear prior to. Surgeons must be firm in their ideas. which produces dissatisfaction with the results. Reassured by the first phlebectomy. and even after the operation. but know that surgery is necessary. These patients are oversensitive to pain. They have fears. This requires a rapid recognition of individual patient nuances to help identify patients who are not compatible to outpatient surgery.. they come back for the next operation with less fear. Patient fear is normal and should be treated with comprehension and support. but comprise $30% of the population. According to their behavior. It is important to explain in detail with simple words what will be done and why it should be done. have a negative attitude to many situations.” patients everybody would like to treat. but also reassuring in order to obtain and maintain the patient’s confidence. The latter is easier to obtain if the patient has already been treated (i. Group 2: These patients are able to manage their fear and anxiety only with continuous exteriorization and support. collaborate with office staff. They endlessly repeat the same 231 .e. Group 1: These are the “normals.

saving a great deal of trouble to the doctor. They often become strong advertisers for AP. If continuously distracted.232 Ricci. are the most difficult to manage. Wenner defines them “infantile or regressed” (1). Once operated. and so on. the results are rewarding. how much time is left. difficulties or complications. Those who eventually get operated are a tough test for the doctor’s patience and ability. Though operating on them may be quite demanding (as the operator must continuously capture their attention). They are unwilling to accept the minimal temporary discomfort to gain a long-term benefit. these patients are often enthusiastic about the procedure and the results. Group 4: This group consists of anxious and doubtful patients. and Goldman questions. they often forget pre-operative instructions and do not follow the prescribed rules. Despite an ideal first phlebectomy. During the operation. even though the procedure was smooth and painless. About 50% of patients belong to this group. they start telling everybody (the patients waiting for the operation included) how much they suffered. Often underweight. moan continuously even if there is no pain. upon entering the waiting room. they call every touch or minimal discomfort pain. that is. in continuous need for reassurance and encouragement. and are often unsatisfied with the result. talking about arguments of interest to them. and so on. the operation proceeds normally. are there any problems. They could be considered an exaggerated version of Group 2. and eager to communicate their sensations to others. they behave like those of Group 1. Once the “big trial” has been overcome. but are prone to become anxious about what is being done at any new situation. Once bandaged. the sound of closure of the clamp. Georgiev. these patients come back for the next operation with the classical statement: “This time I am more afraid than the previous time. traction upon a vein. Group 3: These patients. Many such patients will not consent to surgery. if properly entertained and distracted. They are uncertain of everything. Often. fear everything. complain or even panic at any minimal sensation. These are often overweight and insecure patients who need constant commiseration and make of their “suffering” a means of capturing other’s attention. $10%. such as. Often these are well-instructed persons in whom. sometimes in bad condition. such as. which gives them self-gratification. however. and ask the surgeon to stop operating. anxiety sweeps intelligence away. they do not come for follow-up visits until many years later. they may have vagal reactions triggered by .” These are extroverted characters who need to continually “manifest” their fears and sensations. and usually consult many specialists even for trivial and insignificant pathology.

Create a pleasant environment. Avoid starting treatment with a difficult or complicated phlebectomy. Such ability is difficult to teach. in addition to clinical and surgical ability. and the same concepts must be repeated many times. because of their negative attitude. . and even secretary is. the operator. This “burden” may be—and should be— shared by the office staff. Many of these patients are “constitutionally” difficult—or impossible—to satisfy. Some suggestions on how to improve the doctor – patient relationship and the patient’s comfort with phlebectomy are as follows: . Many of them have had previous treatments with poor results. provided their confidence is obtained and realistic goals of treatment are agreed upon. too. but because of the relation they manage to establish with the doctor. They do so not as much for a specific phlebological problem (the proposed solution of which they still have doubts about). It is mastered by experience and self-confidence. If good transference is achieved. of course. Treat patients friendly and make every effort to show an efficient office organization.Psychological Aspects 233 a simple orthostatic clinical or ultrasound examination. The choice and training of the nurse. may in turn get conditioned by the patient with the result of not being able to deliver the best possible care. therefore. a capacity to adapt their behavior to the individual patient’s character. underlining the negative aspects of treatment may help dissuade such patients of being treated. The above-described “classification” is. and instead of conditioning patient’s behavior. who may assume the role of the “good one” as opposed to the “bad one. but this is more difficult than with the patients of Group 2. . . Assure the presence of an assistant. Moreover. Consider utilizing self-administered inhalation sedation –analgesia with nitrous oxide/oxygen for the extremely anxious or oversensitive patient. Great patience is necessary. assistant. whose role in patient support cannot be over emphasized. It is possible to treat such patients successfully. with friendliness or firmness. . Practitioners engaged in office surgery under local anesthesia need. If it becomes clear that reasonable goals of treatment are difficult to agree upon. these patients may often come for a visit or counsel. an oversimplification. Supply pleasant background music. . but gives an idea of the most common personality types and problems encountered in everyday practice.” that is. of primary importance. . often for problems not related to phlebology. doctors themselves belong to one of the cited groups.

SpA. Aspetti Psicosomatici in Flebologia. Supply telephone number(s) and assure 24 h availability should any problems arise. Wenner L. Georgiev. Give simple written instructions that permit the patient to manage eventual minor inconveniences. . REFERENCE 1.234 Ricci. . 1979. and Goldman After surgery: . Napoli: Fratelli Conte Editori.

235 9. 3. Sclerotherapy alone (1. few ideas stand up to the judgment of time. 1. 7. in particular. GSV stripping with sclerotherapy of the collateral varicose veins (CVV) (10).” when a colleague promptly enjoys destroying it. Cryostripping of the GSV (16). 8. 10.2). Cryosclerosis of the GSV (15). Ambulatory phlebectomy (AP) of the CVV with/without stripping of the proximal portion of the GSV (13). GSV division with intraoperatory sclerotherapy (11). proving the exact opposite. 4.18 Advantages of Ambulatory Phlebectomy and Office Varicose Vein Surgery In medicine. a patient with an incompetent great saphenous vein (GSV) and few varicose leg collaterals. . 5.” and varicose vein surgery. Surgery represents a field most appropriate for such “cultural massacre. 6. One has just proclaimed an “important truth. GSV stripping with eventual phlebectomy of CVV (12). 2. Total GSV stripping with/without subfascial or epifascial perforator ligation (3 –8). Phlebectomy of the CVV and of the GSV trunk up to the groin.” Indeed. even when thoroughly studied with the modern investigation techniques and supplied with a precise diagnosis. seems to offer the best possibilities for this “game. Total GSV and lesser saphenous vein stripping (9). without flush ligation and division of the groin collaterals of the GSV (14). may be advised to consider the following wide range of different—and even opposite— treatments.

17. The following discussion is limited to the advantages of AP as compared to traditional surgical and sclerotherapy methods of varicose vein removal and/or destruction. With so many different procedures. Some of these methods are obsolete. which further complicates our evaluation of treatment techniques. acceptable long-term results may be achieved. Therefore. Restoration of the competence of the saphenofemoral valve (18). Radiofrequency ClosureTM of the GSV with/without sclerotherapy or phlebectomy of distal veins (21 –27). The disease is one that manifests such diverse conditions and symptoms that no (single) method can be suited to all cases” (3). varicose veins excision. perforator division. and follow-up visits with eventual further treatments are given.” Conservative techniques aim at restoring valvular competence or interrupting deep to superficial and/or downward flow without removal or destruction of the incompetent superficial veins. An example is the excellent results achieved by GSV stripping in patients without CVV. 13. The earlier-mentioned operations (or groups of operations) may be classified as “conservative. A detailed discussion of each method of varicose vein treatment is beyond the scope of this book. 15. the great variety of treatments is partly justified by the variety of clinical forms of varicose vein disease. If correctly applied. but almost all of these techniques are still performed. Foam sclerotherapy of the GSV (33 –38). In fact. any treatment may give satisfactory results in selected cases. 16. cooperation. Step-by-step division of the incompetent perforators with/without sclerotherapy (19). rather than on the type of varicose vein pathology. “There are many operations in use at the present time for the relief of varicose veins. Endovenous laser treatment of the GSV with a variety of laser wavelengths (28 –32). High ligation and division of the GSV with ligature of the GSV trunk distal to all incompetent perforators (20). others experimental or practiced by only a few physicians. Georgiev. 14. 12. Ablative techniques aim at interrupting deep to superficial flow.236 Ricci. Varicose vein disease may progress regardless of the initial treatment. regardless of the initial treatment when adequate patient education. and Goldman 11. An example is a patient treated by sclerotherapy . High ligation and division of the GSV alone (17). Most physicians agree that the best cosmetic and functional results are obtained by ablative techniques.” or “ablative. These remove or destroy all varicose veins and interrupt all sources of pathological (deep to superficial) reflux (39). as well as removing or destroying all incompetent varicose veins. These goals have been traditionally achieved by the stripping operation. As Charles Mayo stated in 1906. the choice of the type of treatment often depends on the doctor’s experience. and sclerotherapy.

the technique is mostly utilized for the chemical destruction of the varicose veins left by the stripping operation and for small caliber veins. excellent immediate and long-term results. In a 1988 survey. . Varicosities left by the stripping operation should be removed through additional incisions (often leaving unsightly scars). . . . it is not indicated at all as 20 – 50% of the patients with varicose veins may have a competent GSV (40.” as the distal portion of the GSV is competent in over 25% of the cases. AP combines many of the advantages of both methods and minimizes their drawbacks. does not require complex and expensive equipment. However. the stripping operation is still the most frequently performed varicose vein operation (3–6). causes minimal trauma and stress to the patient. The endoluminal stripper is largely preferred to the extraluminal. only 10 practiced varicose vein surgery on an ambulatory basis. and is even more efficacious. . is extremely safe. This operation may also be insufficient as it leaves CVV untreated. Sclerotherapy is an office procedure that does not require anesthesia or interruption of a patient’s work or social activities.AP and Office Varicose Vein Surgery 237 alone who may improve or maintain the good results of the first treatment by adequate patient education.42). Though possible on an outpatient basis and under local anesthesia (LA) or regional anesthesia. can be associated with other treatments. Introduced almost 100 years ago. excellent cosmetic results. it is still performed mainly under general anesthesia. . . . is suitable for the removal of any varicose vein in any site of the lower limb (except for the saphenofemoral junction). Repeated treatments—or subsequent surgery— are often needed to maintain acceptable cosmetic and physiologic results. treated by sclerotherapy. Though sufficient in some cases. or even by operations more complex than the stripping operation itself. Some specific advantages of AP are: . can be easily repeated. out of 30 Italian Centers of Vascular Surgery. and only on selected patients (43). This combined approach exploits the advantages and reduces the drawbacks of the two methods (10. its long-term results are conditioned by a high rate of recanalization. reduces inconveniences. and thus at a considerable cost. and further treatment(s). collaboration. . and in other cases. the one of stripping/phlebectomy/sclerotherapy also enhances treatment. The inadequacy of the stripping operation—and of the classical surgical approach in general—stimulated the development of sclerotherapy. is simple to perform.11). a complete stripping operation from groin to ankle is often “excessive. Although some schools advocated the employment of sclerotherapy as an alternative to surgery in all varicose vein patients. Like the combination stripping/sclerotherapy. because it may allow total stripping of the GSV with only two incisions.

Linton RR. 9. and Goldman . Babcock WW. Surg Gynecol Obstet 1906. 2:399. AP leaves a “clean field” because of the lack of extensive dissection and scarring. Myers TT. at a lower cost. B. 6. Saunders Company. Heinemann Ltd. Results and technique of stripping operation for varicose veins. Philadelphia: W. Frileux C. Use of new marking ink to delineate varices. 10. Atlas of Venous Surgery. Muller R. It is a “custom-made” procedure adaptable to individual patients. 7. La role de la saphene externe dans les varices essentielles. Kistner RL. Nabatoff RA. 109:793. Hobbs JT. Br Med J 1956. Gillot C. A new operation for the extirpation of varicose veins of the leg. 52:563. 2. 4. Surgery and sclerotherapy in the treatment of varicose veins. London: W. Unlike traditional surgery. Mayo CH. 13. which often makes subsequent operation(s) more difficult because of extensive scarring. Cockett FB. Treatment of varicose veins. and without interruption of the patient’s work or social activities. Georgiev M. when needed. adherence. Kistner RL. . Pillot-Bienayme P. Phlebologie 1973. 86:153. The communicating veins of the lower leg and the operative technique of their ligation. Berlin: Springer Verlag. by GSV division. REFERENCES 1. It allows early treatment of cases previously considered unsuitable for surgery. 31:273. This assumes additional importance in delivering optimal care for a progressive and chronic condition like varicose veins. Ricci S.238 Ricci. La phlebectomie ambulatoire. 1992. At the same time—complemented. with less inconvenience. 1967. 2:385. 1976. . 3. with the long-term results of surgery. Diagnosis and surgery of high pressure venous leaks in the leg. Sigg K. J Dermatol Surg Oncol 1992. 8. A random trial. 163:87. 26:143. Fegan GW. 11. Office varicose vein surgery under local anesthesia. In: Bergan JJ. better cosmetic results. Varizen Ulcus Cruris und Thrombose. Saphenous interruption and sclerotherapy. J Am Med Assoc 1957. Georgiev. can be employed for the removal of veins in locations other than the lower limbs. and poor anatomical definition. low-cost procedure (office treatment). and/or sclerotherapy of the residual telangiectasia—AP allows one to treat even the most complicated cases of varicose veins in an office setting. Ann Surg 1938. Arch Surg 1974. 18:55. 5. Phlebologie 1978. AP is not a “textbook operation” devised to treat an anatomical (abstract) vessel. Importance of adequate excision of all incompetent perforator vessels in the surgical treatment of varicose veins. high ligation and stripping under LA. 12. 107:582. NY J Med 1952. NY Med J 1907. eds. Varicose Veins Compression Sclerotherapy.

31. eds. 18. Milleret R. Manfrini S. 35:729– 736. Forrestal MD. Phlebologie 1989. 21. Vein Diagnosis and Treatment. 42:579. 7:126 – 128. Min RJ. New treatment options for venous disease: a minimally invasive alternative treatment for patients with superficial venous insufficiency. Navarro L. 46:123. 27. Phlebology 1991. 28:29–31. 32:330 – 342. 24. Goldman MP. Controlled radiofrequency-mediated endovenous shrinkage and occlusion. Isaacs MN. Chandler JG. . Pichot O. J Vasc Surg 2000. Belcaro G. J Mal Vasc 1991. 6:159. Dermatol Surg 2001. Christopoulos D. 2nd ed. Weiss RA. Espinosa-Klein C et al. Phlebologie 1989. 30. Proebstle TM. Sessa C et al. 34:201 – 214. Uber die Unterbindung der Vena saphena magna bei Unterschenkelvarizen.AP and Office Varicose Vein Surgery 239 14. 32:941 – 953. In: Goldman MP. Weiss RA. Trendelenburg F. Plication of the saphenofemoral junction: effects on incompetence after two years. 50(2):181– 188. Treatment of superficial venous incompetence with the SAVAS technique. Cabrera Garcia-Olmedo JR. 29.: St. 42:573. Treatment of primary venous insufficiency by endovenous saphenous vein obliteration. Varicose Veins and Telangiectasia: Diagnosis and Treatment. Lasers Surg Med 2002. RF-mediated endovenous occlusion. Endovenous laser: a new minimally invasive method of treatment for varicose veins—preliminary observations using an 810-nm diode laser. Sessa C et al. 17. Endoluminal laser treatment of the greater saphenous vein at 810 nm. 26:452 – 456. J Vasc Interv Radiol 2001. Weiss MA. Goldman MP. 1999:217 – 224. Besset JF. Precy-sous-Thil: Editions de l’Armancon. Closure of the greater saphenous vein with endoluminal radiofrequency thermal heating of the vein wall in combination with ambulatory phlebectomy: 50 patients with more than 6-month follow-up. 33. 12:1167– 1171. 25. 27:117 – 122. Belcaro G. 15. Quality Medical Publishing Inc. New York: McGraw-Hill. Closure of the greater saphenous vein with endoluminal radiofrequency thermal heating of the vein wall in combination with ambulatory phlebectomy: preliminary 6-month follow-up. Min RJ. 1988. Goldman MP. Dermatol Surg 2002. 16:23. Endovenous management of saphenous vein reflux. ´ ´ ´ Elargissement des limites de la schlerotherapie:noveaux produits sclerosants ´ Phlebologie 1997. 19. Garcia-Olmedo Dominguez MA. 22. (suppl 14):121. Concervatrice et hemodynamique de l’insufficiance veineuse en ambulatoire. Bergan JJ. Cabrera Garrido JR. Feied CF. Zimmet SE. Dortu J. 23. Vasdekis S. 32. Mon experience de la cryochirurgie des varices. Louis. Scope Phlebol Lymphol 2000. Endovenous laser treatment of the incompetent greater saphenous vein. Mon experience de la cryochirurgie. Goldman MP. 26. Dermatol Surg 2000. Pichot O. 2001: 211 – 221. eds. 16. Chandler JG. 20. 28. Bone C. Beitrage zur klinischen Chirurgie 1890. In: Weiss RA. Weiss RA. Phlebologie 1993. Danielsson G et al. J Vasc Surg 2002. Danielsson G. Gasbarro V. Franceschi C. J Vasc Surg 2000. J Vasc Surg 2000. Amiry S. Lehr HA. 7:195. La crossectomie sus-fasciale au cours de la phlebectomie ambulatoire du complexe saphenien interne a la cuisse. Kargl A. Defining the role of extended saphenofemoral junction ligation: a prospective comparative study. Endovenous treatment of the greater saphenous vein with a 940-nm diode laser: thrombotic occlusion after endoluminal thermal damage by laser-generated steam bubbles.

Louis: Mosby Year Book. Aust NZ J Phlebol 1999. Esclerosis venosa con espuma: foam medical system. 6:127 (Ital). Cavezzi A. 43. Georgiev. Piccolo GR. La chirurgia ambulatoriale delle varici.240 Ricci. 50(3):351 – 353. Quad Med Chir 1990. Nouvelle technique d’obtention de la sclero-mousse. Un an de pratique quotidienne de la sclerotherapie (veines reticulaires ´ ´ ´ et teleangiectasies) par mousse de polidocanol: faisabilite. Mingo-Garcia J. 39. Monfreux A. and Goldman ´ ` ´ 34. resultats. 3(2). 1991. The role of surgery in treatment of varicose veins and venous telangiectasias. Yearbook of Surgery. Arch Surg 1991. complications ´ Phlebologie 1997. The role of sclerosing foam in ultrasound guided sclerotherapy of the saphenous veins and of recurrent varicose veins: our personal experience. Mannelli MP. 1979. Primary varicose veins: topographic and hemodynamic correlations. Goren G. Patterns of venous insufficiency in patients with varicose veins. ´ 38. 36. Henriet JP. Kechejian GJ. Chicago: Yearbook Medical Publishers. Dedonato A. Yellin AE. 41. 31:672 – 677. Hanrahan LM. 7:29 –31. Revista ´ Espanola de Medicina y Cirugia Cosmetica 1999. Bergan JJ. 53(1):129. Tessari L. 37. 50(3):355– 360. Schwartz SI. 42. Phlebologie 2000. ´ ´ 35. Sclerotherapy: Treatment of Varicose and Telangiectatic Leg Veins. . 126:687– 691. Frullini A. St. J Cardiovasc Surg 1990. In: Goldman MP. Cordts PR et al. 40. Traitement sclerosant des troncs saphenies et leurs collaterales de gros ´ ´ calibre par le methode MUS Phlebologie 1997.

that is. 3. as the same 241 . thorough knowledge and ability in applying compression—adhesive and nonadhesive—bandages. Besides the specific manual skill. yields the best results in the hands of the experienced phlebologist. and pathology. to practice phlebectomy successfully. the physician routinely involved in treatment of venous diseases. phlebectomy is best learned under the supervision of an experienced surgeon. High Ligation and Division of the Greater Saphenous Vein Unlike phlebectomy (which may be performed by a “beginner” without general surgical training). thorough knowledge of venous anatomy. high ligation and division of the great saphenous vein (GSV) must be performed by an expert surgeon. While in the hospital. in the office. the junior surgeon can always obtain help from a senior colleague.” Therefore.19 Setting Up a Varicose Vein Surgery Practice WHO SHOULD PERFORM OFFICE VARICOSE VEIN SURGERY? Phlebectomy Phlebectomy maneuvers are simple enough to be performed by a physician with manual dexterity without general surgical training. in fact. manual ability. the surgeon should possess: 1. it can be “learned” by any physician. This is because the operator must be able to cope with the potential hazards of groin dissection. Although it cannot be “performed” by every physician. it is the operator him/herself who is “captain of the ship. This is important not only for learning the technique. The technique. physiology. but also for acquiring experience prior to initiating a completely autonomous activity. 2. As with any manual skill.

A surgeon performs GSV ligation and stripping. as well as enhanced safety. to a point that it is hardly recognizable as the original Muller’s technique. Georgiev. from patient selection and pre-operative management.” especially by surgeons who perform traditional stripping operations. Besides these “active” aspects. The most appropriate types of patients are Class I or Class II as categorized by the American Society of Anesthesiologists (ASA) physical status classification (see Table 19. Patients chosen for outpatient surgery must be generally healthy. and the risks of anesthesia. the hospital operation has the major risks of pulmonary embolism. or by a team of phlebologists and surgeons. spinal. . Most of these aspects have been discussed to some extent elsewhere in this text. With newer methods of eliminating reflux from the saphenofemoral junction (SFJ) including endoluminal radiofrequency or laser closure of the GSV. Muller’s office. the job may be done either by a single operator (with adequate surgical experience). such as the availability of adequate emergency equipment (and the ability to use it). was organized on a team basis. phlebectomy has been modified and “reinvented. one must keep in mind that safety cannot be overemphasized. In addition to physical requirements for outpatient surgery. to complete the traditional stripping operation. It can. patients must also be psychologically suitable. of course. and are summarized in this chapter under separate headings. Alternative Applications of Phlebectomy Phlebectomy is best performed in the office under local infiltration anesthesia (LIA). low cost. and no interruption of patient’s work. be performed under regional. Instead. safety measures also involve a number of “passive” or defensive aspects. and post-operative management. such as repeatable office procedure. although the avulsion maneuvers are the same. the entire procedure can now be performed in an office setting under local anesthesia (LA).242 Ricci. Proper patient selection is critical in insuring both optimal surgical results. in fact. to the type of anesthesia utilized and procedure being performed. The matter is rather complex and involves professional behavior in all of its phases. and Muller himself the phlebectomy of the remaining varicose veins. the technique loses many of its advantages. However. sensory nerve damage. Their expectations must be realistic. or general anesthesia in the hospital. This is without any advantage in terms of complications. SAFETY IN OFFICE SURGERY In organizing a free-standing surgical office. and Goldman patient may need phlebectomy and GSV division. in addition to conforming to all bureaucratic and accreditation requirements. Criteria for assessing a patient’s fitness for anesthesia have been well described. Indeed.1).

detailed diagnosis. However. The intensity of patient monitoring depends on the complexity of the surgery and the patient’s general health. patient monitoring during the procedure is helpful and may be considered standard of care in some communities.1 Class 1 Class 2 Class 3 Class 4 Class 5 ASA’s Physical Status Classification (1– 3) Healthy patient Patient with mild systemic disease. medications taken regularly or intermittently. such as marked hypertension. results of previous surgeries. diet-controlled diabetes Patient with severe systemic disease. It is recommended that an appropriate routine pre-operative laboratory evaluation be performed. and partial thromboplastin time. if such monitoring devices induce complacency or divert the surgeon’s attention from the patient. The most useful tests include a complete blood count. Physical examination should be directed towards the cardiopulmonary status of the patient. Although not absolutely necessary. Continuous electrocardiographic monitoring and automatic periodic blood pressure measurements may also be important in selected patients. Each patient should have a pre-operative evaluation appropriate to their physical state. asthma. In addition. cardiac arrhythmia. History should be directed towards uncovering previous adverse drug reactions. with the earliermentioned recommendations serving only to provide useful guidelines. prothrombin time. routine blood chemistries. Patients who are taking thyroid supplementation should have thyroid hormone levels evaluated. Pre-Operative Management An optimal phlebectomy procedure begins with a thorough diagnostic work-up leading to a precise. moderate obesity.Varicose Vein Surgery Practice 243 Table 19. a history of hypertension. they may work to the patient’s detriment. morbid obesity. such as mild hypertension. and kidney or liver disease. Continuous monitoring of a patient’s arterial oxygen saturation by a pulse oximeter has become an accepted standard for respiratory monitoring of patients under deep intravenous or nitrous oxide sedation or general anesthesia. Precise anatomical definition is . insulin-dependent diabetes Incapacitating systemic disease Moribund patient Patients who are excessively apprehensive and those with “a remarkably low pain threshold” are best dealt with under general anesthesia. we recommend a serological test for human immunodeficiency virus and hepatitis B and C surface antigen. Continuous verbal communication between the patient and surgeon is sufficient for most procedures done under LA. and/or any associated complications. not incapacitating. It is up to the individual physician and ambulatory surgical facility to determine appropriate standards of operation. including tumescent anesthesia.

However. but have been performed only in the hospital. Type of Surgical Procedure The type of operation performed in the office is important. the procedures performed must be proportionate to the experience of the surgeon. In addition. the junior surgeon can obtain help at any time from a senior colleague. . that is. Office surgery should be limited to anesthesia type I and II patients. Borderline cases should be considered for office surgery only after a specialists’ explicit agreement.244 Ricci. Post-Operative Management Adequate written patient instructions are mandatory. the surgical procedure(s) should be more limited than usual. patients in good health or with well-controlled systemic disease (Table 19. This is not possible in the office. Operations that are technically correct. Operator’s Experience While in the hospital. The surgeon (or assistant) must be available to answer patient questions and concerns 24 h a day after the procedure. In other words. In these patients. we recommend multiple. speedier surgery with a decreased likelihood for hematoma formation. there is no need to monitor the patient’s vital functions (unless it is considered standard of care in your community). This is well illustrated by the experience of two masters of the past. as exclusion factors are related more to a patient’s general health rather than type of venous disorder. whereas in 1957. This enhanced accuracy allows for a smoother. only office-tested operations should be performed in the office. the patient must be carefully observed during anesthesia for any untoward reaction. and in selected cases.1). modified or further reduced as needed. Patient selection is equally important. and Goldman mandatory for an office surgical procedure. With the type and dosage of anesthesia used for AP. should not be performed in the office. During the 1920s in Chicago. Georgiev. permitting patients to drive themselves back home immediately after surgery (4). Myers recommended keeping 500 – 1000 mL of blood available for transfusion if needed after GSV stripping (5). short procedures that produce minimal stress to the patient. A warm and caring attitude with psychological support from the staff is important to minimize emotional distress that remains the most common “complication” of ambulatory phlebectomy (AP). Anesthesia Recommended dosage of anesthesia must never be exceeded. Therefore. de Takatz routinely performed ambulatory ligation and division of the GSV under LIA.

Bureaucratic and Accreditation Requirements In planning and organizing a surgical unit. However. Finally. ephedrine or mephentermine (for persisting hypotension). hydrocortisone. foot-up tilt (Trendelenburg) position. they are not to be expected to be totally efficient in providing . though not necessary for giving anesthesia. the decision regarding what equipment to purchase is left to the individual operator. IV fluids and emergency drugs: epinephrine. then two operating rooms instead of one will greatly enhance efficiency and permit one to perform almost twice as many operations as when a single room is utilized. A 12 Â 15 square foot operating room is sufficient and will also provide space for a stock of the necessary materials.Varicose Vein Surgery Practice 245 Emergency Measures The office and staff must be adequately equipped and prepared to cope with an emergency situation. blood pressure cuff. stethoscope. 2. ambu bag with a variety of airways. oxygen source. While patient safety depends primarily on the procedure itself. We find diffuse overhead fluorescent type illumination adequate and do not use special surgical lighting. 3. If the practice is busy and phlebectomy organized as teamwork. Therefore. The room must be adequately ventilated and have either windows for outdoor light or emergency lighting. comply with all local laws and regulations. and labetalol or hydralazine (for high blood pressure). may enhance the efficiency of the office and also take some of the professional and legal burden off the surgeon. an anesthesiologist gives anesthesia and an assistant (or nurse) does the post-operative bandaging. In the absence of specific mandatory standards for freestanding surgical suites. 4. the presence of an anesthesiologist. diazepam. atropine. one must. while bureaucratic regulations may augment costs. Additional equipment may include a defibrillator and cardiac/blood pressure monitor. this should not be neglected. that is. The operating table must permit head-down. public (and peer) opinion tends to identify safety with the availability of emergency facilities with reference to those present in a well-equipped hospital. The minimum emergency equipment and drugs may include the following: 1. THE FREE-STANDING SURGICAL OFFICE Operating Room Office varicose vein surgery does not require a sophisticated operating room or equipment. of course.

But. manually and/or with DOPPLER ultrasound DUPLEX ultrasonography YES YES NO NO YES NO YES YES NO NO Cutaneous marking was performed using . (AAAHC.. it is to be expected that pressure will grow toward enforcement of higher standards of care and safety. as those provided by the Accreditation Association for Ambulatory Health Care. Inc. Illinois 600773702) have been developed with the scope of assisting the surgeon in organizing an efficient. The patient was placed in a Trendelenburg position. . OPERATIVE REPORT AMBULATORY PHLEBECTOMY Name of patient: Date of birth: Physician: Date performed: Site of phlebectomy: Consent form explained and signed Pre-operative photo Laboratory tests performed Test reports provided by referring physician Varices were located visually. Reimbursement claims to third part payments should be accompanied by a proper operative report. it is highly recommended for it testifies to the surgeon’s commitment to the highest possible standards of care and safety and thus may reassure both patients and colleagues. and Goldman the best conditions for both surgeon’s work and patient’s safety. Accreditation may be required by insurance companies for reimbursement of office surgical procedures. an example of which follows. 9933 Lawler Avenue.246 Ricci. Accreditation programs and certification. Accreditation may well be an anticipated answer of the medical profession to such a trend. Georgiev. . 18 gage needle) . The problems related to planning and organizing a free-standing surgical office are discussed elsewhere (6–10). With the expansion of office surgery. Local infiltration anesthesia was performed with VOLUME INJECTED WAS RIGHT LEG LEFT LEG microincisions were made (number 11 blade. Surgical asepsis was obtained using Hibiclens/ Betadine/Technicare solution. even if it is not. It is the surgeon who should strive for a higher standard of care. high level of ambulatory care. Skokie.

. An external stripper was used to perform a stripping on the varicose trunk YES (Number) (cm) (cm) NO varicose veins or vein segments were extracted. Two curved nontoothed 12 cm Halsted hemostatic forceps. Two standard 14 cm 2 Â 3 teeth dissecting forceps. Ambulation was prescribed. A/an hook/Graefe iris forceps were used to grasp the vein. Free-standing platform with handrails for long-lasting examination (i. . Room Equipment . Operating table. FOLLOW-UP APPOINTMENT was scheduled for SPECIMEN WAS SUBMITTED EQUIPMENT AND MATERIALS Following is a list of the specific equipment and materials necessary for varicose vein surgery and sclerotherapy as described in this book. . Sporting activities were approved the day post-treatment.. length of vein extracted. Selective compression dressing of the varicose veins and compression bandages and/or stockings were applied for 7 days. Two 20/30 mm retractors (Goelet or Richardson – Easmann). . Mayo stand.e. . Need not be sophisticated surgical table. diameter of vein extracted. Three curved toothed 13 cm Halsted hemostatic forceps. All that is needed is to be comfortable and have head-down. . foot-up tilt capacity. Sterilization unit. . was prescribed as an analgesic/anti-inflammatory. One 14 cm Mayo dissecting scissors. duplex scan) and pre-operative marking. Surgical Instruments Standard surgical instruments for ligation and stripping (single set) . YES NO . Mosquito forceps were applied as a tractor to extract the vein.Varicose Vein Surgery Practice 247 A cleavage plane was created between the epidermis and the varicosity to free any adhesions.

One number 15 scalpel blade with holder. . Sterile saline solution. Acuderm. FL 33314. Syringes . . One fine-pointed curved Halsted mosquito forceps (10 –12 cm). 6 and 8 mm diameter. IA 51503. . Infiltration pump and tubing. . One Graefe iridectomy forceps. 500 or 1000 mL normal saline bag. Two curved 14 cm Kocher hemostatic forceps. . Ramlet. – Acuderm. .. Catgut or Vicryl #3-0 without and with needle. Needles . . 30 gage – Air-Tite. Specific Instruments for Phlebectomy (Single Set) . Inc. 18 – 19 gage hypodermic needle and/or blood lancet. NJ 07070. . . Oesch. . Virginia Beach. . Two 50 cm Corcos external strippers.4% sodium bicarbonate solution.. Ft. Georgiev. Rutherford. . One number 11 scalpel blade with holder or needle driver. One blunt-pointed 14 cm probe (optional). Straight iris scissors. . Becton –Dickinson & Company. . 6 and 8 cm diameter. Lauderdale. – Dermatologic Lab and Supply. Two Mayo external annular strippers.000. NJ 07070. One regular 14 cm needle holder. curved at 908. South Lynnhaven Road. . Plastipak eccentric syringe Becton–Dickinson & Company. Council Bluffs. Luer Lok or non-Luer Lok 20 mL syringe for anesthesia Becton – Dickinson & Company. . . 423. Inc. Sterile 1. Rutherford.248 Ricci. Lidocaine 1%/epinephrine with/without 1:100. . . Dorth. Six straight toothed hemostats. Materials for Anesthesia . VA 23452. – Precision Glide. One fine-pointed curved toothed mosquito forceps (12 –13 cm). and Goldman . NJ 07070. Millet). Various phlebectomy hooks (Muller. Vardey. . One blunt curve-pointed 14 cm probe. Rutherford. Suite 104. Vicryl #3-0 with or without needle.

including elastic adhesive bandages such as “Elastoplast. Support Bandage.e. North Hampton.Varicose Vein Surgery Practice 249 . . Lauderdale. Ft. class II – III: 30 –40 mm graduated support stockings. Adhesive monoextensive bandages (10 cm). Tubular elastic bandage (i.O. 8 and 10 cm. or 25 gage spinal needles.” We have found that the Comprilan. class I: 15– 18 mm stockings and pantyhose (many brands commercially available). Coban tape. Oldham OL1 3HS. NC 28209. MN 55144... . The ones that we recommend include Setopress (high compression bandage) (Setan Health Care Group. and Acrylastic are particularly useful for providing short-stretch compression.2 Â 40 mm2) for skin incision and vein dissection. Strong long-stretch elastic bandages (10 cm). Seaton Products. CT 06610. Inc. Tubigrip). Box 1088. 2.5 in. Connecticut 06856-5529) manufactures a variety of single. . two-way. Medi-Rip Bandage. Additional Localized Pressure . Protective skin underwrap. St. Tubigrip Tubular Montgomeryville. (1. Bridgeport. PA. 5825 Carnegie Blvd. Compression Bandages There are many companies that manufacture these bandages. This provides a reliable 30 –40 mm graduated compression. England). Jobst. the reader should be aware that there are many other companies who also provide very adequate bandages. . 20. Becton – Dickinson & Company. . . Materials for Bandaging . Conco Medical Company. 18 – 19 gage (Terumo) 1. Paul. and three-way stretch bandages. 80 Chart Road. Charlotte. . PLC. JUZO. Adhesive biextensive bandages (10 cm). Medical Surgical Division/3-M.. Cuyahoga Falls. . . FL 33314. However. The following are names and addresses of the most popular companies that distribute compression hosiery in the United States: 1. Tricoplast. Short-stretch elastic bandages. OH 44223. 22. Compression Stockings . P. Beiersdorf AG (Norwalk. Yale.

One inch paper tape (Micropore). Medication Material . NC 27377-3000. surgical skin disinfectant. Material for Local Anesthesia (MPG) . . hydrocortisone. 6481 Franz Warner Parkway. 2 Â 7 cm2. echo-Doppler (duplex) scanner with peripheral vascular (7. or better. Peachtree City. IV fluids and drugs: epinephrine. preferably with directional capability. Optional equipment may include defibrillator and cardiac/blood pressure monitor.5 linear probe). NC 27204-1067. GA 30269. 718 Industrial Park Avenue. Box 1067. Other Materials . 4. . . . Sterile 40 Â 70 cm2 drapes. 5 and 8/ 10 mHz). ephedrine/mephentermine. Georgiev. Optional ultrasound scanner with small parts probe (7. . or 25 gage spinal needles. Stethoscope and blood pressure cuff. Doppler ultrasound with 8 mHz probe (or two probes. diazepam. and labetalol/hydralazine. 5. . Ambu bag with airways. Skin disinfectant. Potassium permanganate 7.250 Ricci. . Cotton wool (for padding). 20. 10 Â 10 cm2 gauze. Asheboro. Examination Equipment . Medi USA. .O. and Goldman 3. Oxygen source. . atropine. .5 – 10 mHz) probe. 10 Â 10 cm2 gauze (sterile or to sterilize in the office). . Emergency Equipment . Sterile band-aids. 22. Transillumination device. Sterile disposable drapes. . Whitsett. Infiltration pump with appropriate sterile tubing. Marking Solution .5% water solution or Sharpie permanent marking pens for pre-operative marking. 1119 Highway 74 S. . P. Sigvaris. . Lidocaine 1% with epinephrine mixed 1:10 with sterile saline. Venosan North America.

1986. 3. 2001. 14:939. New York: McGraw-Hill. 4. Vein Diagnosis and Treatment. Chrisman BB. Bergan JJ. 14:247. Tobin HA. J Dermatol Surg Oncol 1988. 7. 14:1364 (Part I). 9. BIBLIOGRAPHY 1. de Takatz G. 1:509. Weiss MA. Myers TT. Sterile technique and the prevention of wound infection in office surgery. J Dermatol Surg Oncol 1988. 3rd ed. 94:1194. Scelrotherapy Treatment of Varicose and Telangiectatic Leg Veins. New York: Churchill Livingston. 1985. 8. Louis: CV Mosby Co. Miller RD. Anesthesia. Watson MA. 14:1300. Sedation. J Dermatol Surg Oncol 1988. eds. Sebben JE. Williams NB. Baskett PFJ et al. 2. St. Feied CF. Goldman MP. Malamed SF. MacDonald DE. 2001:211 – 221. Ambulatory ligation of the saphenous vein. Excellence in outpatient surgery. Weiss RA. Chrisman BB. 2. Planning and staffing an appropriate outpatient facility. Results and technique of stripping operation for varicose veins. 1989. 14:708. 5. J Dermatol Surg Oncol 1988. Chrisman BB. Assessment of fitness for surgical procedures and the variability of anesthetic judgement. 2nd ed. Office surgery: the surgical suite. 15:38 (Part II). . A Guide to Patient Management. 6. Br Med J 1980. J Am Med Assoc 1930. J Am Med Assoc 1957. 10.Varicose Vein Surgery Practice 251 REFERENCES 1. Louis: Mosby. St. Outpatient anesthesia. J Dermatol Surg Oncol 1988. 163:87. Wilson ME.

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Part V: Advanced Techniques .

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The increased thickness in these areas is due to the necessity for the vein to contain and transport blood under increased hydrostatic pressures. This factor is important when considering potential sources for a dermal filling substance. This adverse effect has not been noticed previously in more than 10 patients some of whom were treated over 255 . bovine and human collagen. being autologous. elastin. hyaluronic acid from avian or bacterial sources. Although other veins can be used (such as dorsal hand veins). bacterial. and muscle. One potential problem with using varicose veins as dermal implants is the hypothetical development of new vascular conduits by migration and/or extension of the intact endothelial cells. avian. or bovine sources. When the endothelium is removed or destroyed. elastin. will not be rejected and may become more resistant to autolysis than other nonautologous materials derived from human. Each of these compounds has advantages and disadvantages. and muscle. and plastic beads. they will contain less collagen. The vein wall. Vein wall thickness varies with the size and location of varicose veins. The extracted vein can be used either as a tubular structure or cut into pieces as tailor-made dermal implants. one is left with an excellent dermal filling substance. silicone. such as Gortex. Varicose veins are composed of endothelial cells surrounded by a layer of collagen. and various synthetic substances. Veins that are located on the leg and those located distally have a thicker wall.20 Autologous Vein Transplantation for Correction of Dermal Atrophic Changes Filling substances for dermal atrophic changes and tissue augmentation consist of various compounds: autologous fat. We have found that excised varicose veins on the legs and other unwanted veins (such as dorsal hand veins) are easy to procure and long lasting if not permanent.

we recommend placing the extracted varicose or hand vein(s) into a solution of 23. and Goldman Figure 20. as one would store autologous fat. Detailed descriptions for removing veins with this technique are presented elsewhere in this text as well as in numerous publications (2 –6) (Fig. 20. .1 Vein to be extracted is marked and tumescent anesthesia is infiltrated around the vein.256 Ricci. Georgiev. Unused portions of the veins are stored in a sub-zero freezer. TECHNIQUE Varicose or unwanted veins larger than 2 mm in diameter are removed through 1 –2 mm incisions under local anesthesia with ambulatory phlebectomy.4% hypertonic saline for 2 min to destroy any viable cells before implantation.1). Figure 20.2 The extracted vein is placed in 23. as described later.4% hypertonic saline. Nevertheless. 5 years (1).

Transplantation for Correction of Dermal Atrophic Changes 257 Figure 20.2). This results in total destruction of viable endothelial cells (Fig. The vein is grasped Figure 20.4% hypertonic saline solution for 2 min. the vein is then placed in the dermal defect or area requiring augmentation after the area is first anesthetized with 1% lidocaine with epinephrine. The veins are then rinsed three times with normal saline. . 20. One method to insert the vein segment is to create a tunnel with a blunt dissector/hemostat. (b) 6 months after transplantation.4 Clinical appearance of (a) nasolabial groove and marionette lines prior to autologous vein transplantation. After rinsing. The extracted vein(s) are placed in a 23.3 The vein is grasped with a long blunt forceps and then threaded into place.

as one would do for other filling substances such as Gortex into the subcutaneous compartment (Fig. Figure 20. 20.4 shows the clinical appearance before and after autologous vein placement into the nasolabial groove. We have not found it necessary to anchor the vein to any dermal structure. Figure 20.258 Ricci. 20. 20. The chopped-up vein is placed into a 1 mL syringe with normal saline and injected into place through an 18-gage needle (Fig. and Goldman Figure 20. Georgiev.6 Chopped-up vein in a 1 mL syringe.6). .7 shows a patient before and 16 months after injection of autologous vein fragments. An alternative technique is to chop-up the extracted vein with an instrument consisting of five dermatome blades placed in a parallel manner (Fig.3). Figure 20.5 Dermatome for cutting vein in action. The insertion holes are approximated with steri-strips or 6/0 prolene sutures that are removed in 5 –7 days. by the hemostat and then threaded into place.5).

4. Studies utilizing fresh-frozen autologous vein segments are underway to determine the relative efficacy for delayed use of vein segments.7 (a) Traumatic dermal defect before treatment. Goldman MP. Weiss MA. 2. Weiss RA. In: Ratz JL. 18– 22. We recommend that patients who may desire soft-tissue augmentation or correction be advised to save their extracted veins for later use. Ambulatory Phlebectomy: A Practical Guide for Treating Varicose Veins. Padilla RS. Inc. 31:393 – 413. Louis: Mosby-Year Book. Weiss RA. eds. St. Philadelphia: Lippincott-Raven Publishers. Blugerman G. Surgical treatment of primary varicosis. Ricci S. 4th Internationales Darmstadter Live-Symposium fur Operative Dermatology. Diagnosis and treatment of varicose veins: a review. 24:447– 450.. Dermatol Surg 1998. 3. Georgiev M. Goldman MP. Dermatol Surg 1998. Bergan JD. Maloney ME. Germany. 6. (b) 16 months after injection of 3 mL of chopped-up vein segments. REFERENCES 1. Goldman MP. Smith SR. 5. Fratila AAM. Transillumination mapping prior to ambulatory phlebectomy. Nov.Transplantation for Correction of Dermal Atrophic Changes 259 Figure 20. J Am Acad Dermatol 1994. Textbook of Dermatologic Surgery. Goldman MP. 1995. . 24:453 – 456. Geronemus RG. Tumescent anesthesia in ambulatory phlebectomy. 1998. Goldman MP. 1998:593 –620. Darmstadt. Note the persistent correction.

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si.) 261 . & velut in orbes quosdam implicatur. pluresque inter se involvuntur. or transverse. aut adusta tabescit. melius aduritur. if [the vein] is curved. or simple and not much dilated. Celsus also advises on selection of the appropriate procedure according to the type of vein to be treated: Si recta. quae noxia est. It is mentioned as early as 1 ACE by Celsus in Medicinae libri octo. utilius eximere est.) Interestingly. Si curva est. Goldman and Robert A. Weiss HISTORY OF VEIN OBLITERATION The obliteration and destruction of varicose veins as an alternative to surgical avulsion has a long history. it is better to avulse. bent in more convolutions or there are more veins intertwined together. si modica est. tamen simplex.21 Treatment of the Great Saphenous Vein with Endoluminal Laser or Radiofrequency Closure Mitchel P. quamvis transversa. book VII/XXXI: Igitur vena omnis. aut manu eximitur. (Any noxious vein is either burned or avulsed. it is better burned. (If the vein is straight.

With this procedure. in 1852 (3). It thus became possible to obliterate veins by applying electric current to them (electrocoagulation) and by injecting irritating solutions into them (sclerotherapy). at the time of Celsus and for many centuries.262 Goldman and Weiss The instrument for burning veins. after the death of the patient (Plate 1). in the following terms: In a case of aneurism in the external iliac artery. surgeon in London. during which the pulsation in the tumour was diminished. . on withdrawing the needle the orifice was marked by a single drop of coloured serum (1). and the needle was heated through the medium of the steel by a spirit lamp. and only later extended by Italian surgeons to varicose veins (2). into the center of the tumour where the pulsation was most violent [. in 1952. The first one was the invention of a source of electric power—the first battery—by Alessandro Volta. The first endoluminal electrocoagulation of varicose veins was performed by Bertani in Milan in 1846.] the needle was passed through a small orifice in a bar of steel three inches long. to which is given the name of acupunctorium. “on request of few Professors had his varices designed [. 21. It was only in the first half of the 19th century that obliterating technique was to change and become endoluminal. The second one. The endoluminal obliteration of an arterial aneurism was described in 1826 by Sir Everard Home. nor arrested the increase of the size of the tumor. Six cases are described. In the monograph “On the radical cure of varices. Few years later. but not very severe. the skin of the thigh was guarded by cork.” Gaetano Conti describes the electrocoagulation of the great saphenous vein (GSV) in the Surgical Clinic of Palasciano in Naples. the “obliteration is achieved by electropuncture with Pulvermacher’s chains. by Pravaz in Lyon (France) in 1851. on the 16th September 1825. upon finding that this operation neither diminished the pulsation. in Chelsea Hospital. Two inventions led to new methods of vein obliteration.1). In a few minutes the patient felt heat and pain in the center of the tumour. with the battery of . . . for the cure of which I tied the femoral artery below the sac. haemorrhoids and varicocele according to the method of professor Palasciano.] and included as illustration” (see Fig. in Pavia (Italy) in 1796. one of which. the first sclerotherapy of varicose veins was performed by Petrequin in Lyon. . I was led to introduce a needle. and soon became so widespread that a commision of enquiry into the general effects of galvano-puncture was nominated and released its report in the January 1847 issue of Annali Universali di Medicina (2). one of which presents the endoluminal aspect of the treated aneurism 3 months later. so that the application was continued for fifteen minutes. the invention of the syringe for hypodermic and intravenous injections. Electrocoagulation of blood vessels was also performed first for the treatment of arterial aneurisms. Home’s paper has three fine plates. was the red-hot iron.

. This chapter will discuss two methods where a patient’s damaged and improperly functioning axial vein is treated without requiring its removal—endovenous closure through the thermal action of radiofrequency (RF) or a variety of lasers. once the GSV obliterated. development of technology brought new methods of vein obliteration. since the obliteration of the varicose vein is not a guarantee of success. . . In addition. sooner or later the clot dissolves and the circulation resumes. This surgical procedure is most often performed under general anesthesia with patients usually taking a week or so to get back to normal activities. the challenge is the same as pointed out by Palasciano in 1854: to permanently obliterate the vein and avoid its recanalization. Unfortunately. The major drawback of vein obliteration was described by Palasciano himself in the following terms: “[.] This is a most solid proof that varicose veins cannot be cured by methods which simply form a clot.” During the 20th century. Palasciano destroyed its varicose branches by means of the corrosive Vienna paste. This evolution has entered the field of phlebology. The first attempt at minimizing the extent of surgery for varicose vein disease was to ligate the area of reflux from the saphenofemoral junction (SFJ) into the GSV.] after ceasing the application of electricity [. touching each other in the point of intersection. . Therefore. treatment of the GSV with incompetence through the SFJ has been demonstrated to result in a high degree of recurrence when the SFJ is merely ligated and the distal varicose veins are treated with either sclerotherapy or ambulatory phlebectomy (AP) (4 – 8).Treatment of the GSV with Endoluminal Laser or RF Closure 263 Bunsen. INTRODUCTION Medical care in the 21st century is evolving into a minimally invasive specialty. This is secondary to re-anastomosis through hemodynamically significant perforator veins present extending from the knee to the groin. complete removal of the GSV from the SFJ to the knee is recommended after ligating the SFJ. . applied on the skin overlying the varicose veins. .. which are often not eliminated during the surgical procedure. . Although the means of obliteration may change. . Procedures once performed under general anesthesia where patients’ bodies were surgically opened to allow removal of organ systems are being replaced by techniques that allow the treatment of damaged organ systems to occur with the patient awake. as electricity etc. The most recent and advanced of these are the endoluminal laser treatment and Closure (VNUS) described in this chapter. both goals and concepts of treatment remain much the same as during the 19th century pioneering works.” To obtain permanent results.] the clot softens and is even completely absorbed [. to provide the maximal degree of improvement in abnormal venous hemodynamics.] with the current directed towards the blood and the internal wall of the varicose veins by two needles inserted into the vein at a cross. Wollaston or Volta [. .

Both these figures of the natural size. and connected together by threadlike filaments. 3) One of these leaves magnified 10 diameters. like so many drops of melted wax. (Fig. The opening into the arterial trunk from the coats having given way for the space of 1 in. 1) The aorta and external iliac passing on the outside of the aneurismal sac. compact.1 An internal view of the aneurismal sac..264 Goldman and Weiss Plate 21. which has a foliated structure. . exposing the upper and lower orifice of the artery. (Fig. and showing that the sac adhered to the artery even higher than the going off of the internal iliac. the leaves thin. its surface studded over with nodules of coagulable lymph. (Fig. 2) A small portion of the blood coagulated by the heated needle. The lamina of the coagulum first formed and resembling those met with in other aneurismal tumors.

(Fig.Treatment of the GSV with Endoluminal Laser or RF Closure 265 Plate 21. 2) The extremities of needles are placed over plates of plaster to guard the underlying skin (c. . treated by electrocoagulation of the great saphenous vein and caustication of the subcutaneous varicose branches in Ospedale degli Incurabili of Naples on July 23. which poles are attached to the needles to transmit galvanic current from a source (Volta’s battery) to the internal wall of the vein (b). c0 . a 62-year-old pharmacist. and c00 ).2 Artist’s design of the leg of Giuseppe Costa. 1852. 1) A needle indroduced in the vein. (Fig. chain of Pulvermacher. (a) second needle is passed through the vein in a way to touch the other at a right angle inside the vein (x).

and carbonization of the tissues are avoided (14). Delivered in continuous or sinusoidal wave mode. This is a relatively safe process because the temperature increase remains localized around the active electrode provided that close. subtle gradations of either controlled collagen contraction or total thermocoagulation of the vein wall can be achieved. This is part of the process whereby heat is dissipated by conduction into surrounding normothermic tissue (13). Simultaneous with development of RF closure. By limiting temperature to 858C. vaporization. The mechanism by which RF current heats tissue is resistive (or ohmic) heating of a narrow rim (. Venous occlusion with RF by the mechanism of venous blood coagulation has been previously reported. Within cardiology. Although the concept of endovenous elimination of reflux is not new. When the RF catheter is pulled through the vein while feedback controlled with a thermocouple. previous approaches have relied on electrocoagulation of blood causing the resulting thrombus to occlude the vein. the surgeon can heat the section of vein wall to a specified temperature. stable contact between the active electrode and the vessel wall is maintained. They are typically performed under local anesthesia (LA) with patients returning to normal activities within 1–2 days. The potential for recanalization of the thrombus is high. a technique in which a spider-shaped intravascular electrode produces venous occlusion by electrocoagulation with minimal perivascular damage (12).1 mm) of tissue that is in direct contact with the electrode. RF TECHNOLOGY Directing RF energy into tissue to cause its destruction is potentially safer and more controllable than other mechanisms for doing so. endoluminal lasers have also been demonstrated to effectively close axial veins through thermal damage to endothelium with subsequent thrombosis and resorption of the damaged vein.266 Goldman and Weiss RF energy can be delivered through a specially designed endovenous electrode to accomplish controlled heating of the vessel wall. this technique is rapidly being added to the armamentarium of ways to deal with axial venous reflux. application of RF directly to tissue. Another term in the medical literature is endovascular diathermic vessel occlusion. we have shown that heating the endothelial wall . but is different than the modern approach (10. With worldwide clinical experience on thousands of patients since 1999. not to blood. They also can serve as a substitute for duplex-guided sclerotherapy and other venous ablation techniques. causing vein shrinkage or occlusion by contraction of venous wall collagen. there is no stimulation of neuromuscular cells using a high frequency between 200 and 3000 kHz. Deeper tissue planes may be slowly heated by conduction from the small volume region of heating. By carefully regulating the degree of heating with microprocessor control. boiling. In addition. These endovenous occlusion techniques are less invasive alternatives to saphenofemoral ligation and/or stripping.11). has been effectively applied for ablation of abnormal conduction pathways for arrhythmias (9).

1). Sunnyvale. which has been demonstrated to contract collagen. 21. As coagulation of tissue occurs. Selective insulation of the electrodes results in a preferential delivery of the RF energy to the vein wall and minimal heating of the blood within the vessel. The RF generator can be programed to rapidly shutdown when impedance rises. there is a marked rise in impedance (resistance to RF). Alternatively if clot builds up on the electrodes. there is a marked decrease in impedance that limits heat generation (15). (Courtesy VNUS Medical Technologies. Thus. Sunnyvale.1 Schematic diagram of use of the Closure catheter. Electrode-mediated RF vessel wall ablation is a self-limiting process. USA). the electrodes fold up within the vein that allows maximal physical contraction (Fig. Animal experiments (described later) demonstrate endothelial denudation along with denaturation of media and intramural collagen with a subsequent fibrotic seal of vein lumen. Figure 21. CA. When the vein wall contracts. recent technological advances including introduction of specific application electrodes and accompanying microprocessor-controlled systems to precisely monitor the electrical and thermal effects have allowed the safe application of this technology. This device produces precise tissue destruction with a reduction in the occurrence of undesirable effects such as the formation of coagulum. thus assuring minimal heating of blood but efficient heating of the vein wall. CA.) . bipolar electrodes are placed in contact with the vein wall. One such system is the ClosureTM catheter (VNUS Medical Technologies. With the Closure catheter system. USA.Treatment of the GSV with Endoluminal Laser or RF Closure 267 to 858C results in heating the vein media to $658C. blood is heated instead of tissue.

1 mm. With sclerotherapy. The goat saphenous vein is a high-flow vessel so that sclerotherapy would not be predicted to be very effective as sclerosing solutions require time to interact with the vessel wall but are washed away quickly in these situations (16. ANIMAL STUDIES Initial animal studies comparing RF ablation with a potent sclerosing solution were performed on goat rear limb saphenous veins. and elapsed time so that precise control may be obtained. At 6 weeks.5– 1 cc of 3% sodium tetradecyl sulfate delivered under duplex guidance showed no evidence of occlusion. A larger 8F catheter allows treatment of saphenous veins up to 1. HISTOLOGY Histologic changes confirm the clinical findings in the animal study described. sclerotherapy of the posterior limb saphenous vein from five goats utilizing 0. This permits treatment of veins as small as 2 mm and as large as 8 mm. For safety.7 mm) catheter. Thirteen adult goats were treated by the endovenous RF occlusion device with a pre-treatment mean vein diameter of 5.3 mm.3–1. Percutaneous access obtained through a 5F introducer sheath permits introduction of the RF catheter positioned at the treatment site under fluoroscopic guidance.17). In contrast. Both catheters have thermocouples on the electrodes embedded in the vein wall.2 mm in diameter. This was despite compressing the limb for 72 h compared with no compression following RF occlusion.6 summarizes treatment results of RF vein occlusion of goat saphenous vein. Blood flow is impeded and as RF is applied the catheter is moved distally along the vein causing immediate contraction and cessation of flow. impedance. if a coagulum forms on the electrodes. Figure 21. Acute observations indicate that 92% of limbs treated resulted in significant reduction of vein diameter with a mean diameter reduction of 5. temperature. Collateral flow is visible with high-pressure venography. The unit delivers the minimum power necessary to maintain the desired electrode temperature. The electrodes maintain direct contact with the vein wall to maximize vein wall heating and minimize blood coagulation. persistent occlusion is maintained with no flow through the treatment site. the impedance rises rapidly and the programed RF generator automatically cuts off. The control unit displays power. limited endothelial denudation accompanied by some loss of . Those veins that did not immediately occlude demonstrated total occlusion within 1 week. Mean diameter change for sclerotherapy was from 5 mm pre-treatment to 4 mm posttreatment with almost no change at 5 weeks follow-up.268 Goldman and Weiss The catheter design includes collapsible catheter electrodes around which the vein may shrink and a central lumen to allow a guidewire and/or fluid delivery structured within the 5F (1. which measure temperature and provide feedback to the RF generator for temperature stabilization.

some thrombus formation.2 Histology of RF occlusion. A high acute success rate of 92% is followed by long-term vessel occlusion. Figure 21. Thrombus extension did not occur beyond the treatment site. (b) Acute histologic features of RF occlusion. 21. thickened vessel walls. From these histologic findings. . and thickened.Treatment of the GSV with Endoluminal Laser or RF Closure 269 birefringence in vessel wall and 1 mm of surrounding tissue can be seen. whereas the zone of thermal damage has been limited to 2 mm beyond the targeted vessel. A small residual lumen may be recognized but occluded by organized fibrous thrombi through the length of treated vein. Depth of vein wall damage is limited to 1–2 mm.2). For RF occlusion. Abundant new collagen and intercellular matrix formation appear within several weeks following RF occlusion. The result is a thickened vein wall with further constriction of lumen diameter. Electron microscopic findings confirm the light microscopic findings with marked endothelial damage and loss of the endothelium. Birefringence is almost fully restored with new collagen growth detected. demonstrating fibrous cord with no recanalization. (c) At 6 weeks after RF occlusion. neutrophils in vessel lumen. No differences between acute and follow-up specimens are noted. the conclusions reached are that acute contraction of myocytes and fibroblasts from thermal denaturation occurs. the acute changes show a 65% reduction in vessel lumen. denaturation of tissue with loss of collagen birefringence. Chronic histologic changes 6 weeks following RF occlusion show further reduction in lumen diameter to complete occlusion. bulbous collagen fibrils. Acute histologic features include denudation of endothelium. This is accompanied by acute constriction and folding of intercellular matrix and collagen bundles. (a) Before treatment. This indicates heat-induced contraction of collagen fibers and is indistinguishable from those changes seen with CO2 laser resurfacing-induced collagen contraction. (H&E) 100Â. The potential safety of this technique is supported by the fact that in animal studies there has been no evidence of thrombus extension. and neutrophil (PMN) inflammation (Fig.

6 with a mean vein diameter of 7. the effectiveness of endovenous RF occlusion is quite high. Occlusion persisted at 6 weeks in 95% and 6 months in 92%. the degree of pain. thrombus has not been observed (18). some entire greater saphenous (21%) with the remaining including below-knee greater saphenous. Skin burn (prior to the tumescent anesthesia technique) in 2. the RF endovenous occlusion procedure rapidly reduces patient pain. this will persist to 12 months and beyond. Two separate studies evaluated patients treated with either a percutaneous approach or a vein cut-down allowing access of the Closure catheter to treat the proximal GSV with phlebectomy of the distal GS and tributaries.270 Goldman and Weiss CLINICAL EXPERIENCE Two years of clinical experience suggests that the Closure procedure is effective at occluding saphenous veins and abolishing reflux. Mean age was 47. if the saphenous vein is closed at 6 months. The high flow rate appears to diminish the possibility of extension of any thrombus (in the unlikely event that this would occur) from the GSV. clinical phlebitis at 6 weeks in 5. We believe that there is a high margin of safety by maintaining flow through this tributary. temporary quarter sized areas of paresthesia in 18% with most of these occurring immediately above the knee and resolving within 6 months to a year. In our patients. The genders of treated patients included 24% male and 76% female. but the adjunctive procedures did not affect the outcome. and accessory saphenous. tenderness. RF CLOSURE WITHOUT AP Enrollment criteria for the first group of patients were symptomatic saphenous reflux with a saphenous vein diameter of 2– 12 mm. When patients have had surgical stripping on the opposite leg. compared with most techniques but in particular traditional surgery of ligation and stripping of similar size saphenous veins.7%. .1). Adjunctive procedures performed at the time of treatment were phlebectomy on more distal branches in 61% and high ligation in 21%. Most of the veins treated were above-knee greater saphenous (73%). fatigue.8%.4 mm. and aching correlating with a reduction in CEAP clinical class for symptoms and clinical severity of disease (Table 21. Side effects of the Closure technique have included thrombus extension from the proximal GSV in 0. and bruising have been far greater on the leg treated by stripping. lesser saphenous.2 + 12. we typically see closure of all the major tributaries at the SFJ except for the superficial epigastric that continues to empty superiorly into the common femoral vein (CFV). Vein occlusion at 1 week has been documented by duplex ultrasound in 300 out of 308 legs on a success rate of 97%. all the patients followed from 6 to 12 months have remained occluded. with one case of pulmonary embolus. in other words.5%. In our personal experience. To date. Thus. For clinical symptoms.

In short.4 6 weeks 0.2.3 1. The first 47 sequential. nonrandomized patients who presented to the clinic of one of the authors (M.0 4.1% liodcaine tumescent anesthesia.5 0.Treatment of the GSV with Endoluminal Laser or RF Closure 271 Table 21.8 6 months 0. The amount of tumescent fluid averaged 800 mL with a lidocaine dose of 8 mg/kg.0 3.) having incompetent GSV from an incompetent SFJ and painful varicosities in 50 legs were treated with the VNUS Closure procedure after appropriate informed consent.2 Patient Characteristics 50 patients (54 legs) 38 female.G.4 0. The GSV was then accessed through a 2 –3 mm Table 21.6 RF CLOSURE WITH AP Closure with AP was equally as effective as closure of the GSV described earlier. 47) 100% varicose veins þ reticular and telangiectatic veins 100% reflux through SFJ with valsalva maneuver 81% moderate pain and/or leg fatigue 41% ankle and/or pedal edema 25% dermal sclerosis and pigmentation . Details of the operative procedure were previously reported (19).5 0.5 2.P. The varicose veins were marked with the patient standing and again with the patient lying down in the operative position with a VenoscopeTM as previously described (19 – 21).0 2. after appropriate marking.1 CEAP Class Description with Findings After Endovenous RF Occlusion Description Asymptomatic Telangiectasia Varicose veins Edema Skin changes Healed venous ulcer Venous ulcer Mean CEAP class CEAP clinical class 0 1 2 3 4 5 6 Closure study population Pre-Tx CEAP Class ¼ 2 Pre-Tx CEAP Class ¼ 3 Pre-Tx CEAP Class ¼ 4 Total Pre-Tx 2.3 0. 12 male Age 22 – 79 (avg. Patient characteristics are detailed in Table 21. the area surrounding the GSV and distal tributaries to be treated was infiltrated with 0.

and 24 months are detailed in Table 21. Complete surgical time including the phlebectomy portion of the procedure was $20 min (range 13 –35 min).3).76 cm/min over an average length of treated GSV of 19 cm (6 –42 cm). Other surgeons have had a different experience with the use of VNUS Closure in the treatment of incompetent GSV. The proximal portion of the GSV was then treated with VNUS Closure and the distal portion including all varicose tributaries were removed with a standard AP technique. Ninety-five percent of all patients could resume all pre-operative activities within 24 h. The reason for the different results is likely to be secondary to the anesthesia used as well as the technique described subsequently.3 Treatment Complications 0 0 0 0 0 0 0 28/54 (lasted . The average catheter pull-back rate was 2. Clinical and duplex evaluation performed by an independent laboratory and/or physician at 6. Twenty-eight of fifty treated legs had some degree of purpura lasting 1 – 2 weeks. Six patients (nine treated legs) could not be located for re-evaluation after 6 months because of change in location (often out of state). usually 20 cm inferior to the SFJ. Thirty-nine patients with 41 treated legs were available for evaluation at the longest follow-up period. Five patient legs developed mild-erythema over the GSV closure site that lasted 2 –3 days (Table 21. The average time to access the GSV in the medial thigh was 7 min (1 – 30 min). thrombophlebitis Hematoma Thrombus extension Infection Purpura Erythema Fibrous cord . Adverse sequelae were minimal with four patients complaining of heat distal to the SFJ during the procedure that resolved with additional tumescent anesthesia. No new varicose veins were noted to appear in three patients with recurrent reflux in the GSV. One patient who developed reflux had the development of new veins at 1 year post-treatment (22). 9.272 Goldman and Weiss incision in the medial mid-thigh. Twenty-one of twentytwo patients who presented with ankle edema had resolution of ankle edema.4. Table 21. 18. Eight legs had an indurated fibrous cord over sites of AP that lasted up to 6 months.2 weeks) 5/54 8/54 Edema Phlebitis Paresthesia Sup. The other two patients could resume all activities within 48 h. All patients said that they would recommend this procedure to a friend. Every patient had complete elimination of leg pain and fatigue. 12. Twenty-seven patients had the GSV accessed in $1 min.

It is presumed that patients were not ambulatory and treated under general anesthesia.6% rate when treatment was confined to the thigh. Eight patients (30. 8 patient legs unavailable for 6-month evaluation.8%) developed scaring from skin burns and three patients developed a deep vein thrombosis (DVT) with one embolism. 11 legs at 6 months. 8 legs at 18 months. 8 legs at 9 months. Here.8% closure rate. In addition. Three separate papers detail a similar cohort of patients treated in a multicenter study ranging from 16 to 31 clinics with 210– 324 patients with 6 –12 month follow-up (23 – 25). the surgeons treated the patient with a groin incision and passage of the catheter from the groin downward. One patient (3. The important information to come out of a review of various treatments of the GSV is that the use of tumescent anesthesia in awake patients who can ambulate immediately after the procedure is important in preventing skin burns and .8%) had total recurrence of the GSV. Forty-nine patients were followed at 2 years with duplex scans and showed a 89.Treatment of the GSV with Endoluminal Laser or RF Closure 273 Table 21.4 Post-Operative Duplex Evaluation 29/42 9/42 4/42 3/42 1/42 (69%) (21%) (9%) (7%) (2%) Veins closed Veins open without reflux Veins open with reflux Recurrent veins Recurrent symptoms Note: Time after VNUS Closure procedure of last evaluation: 8 legs at 24 months. Sybrandy and Wittens (26) from Rotterdam reported 1 year follow-up of 26 patients treated with VNUS Closure.8%) could not be treated due to a technical failure. The reason for the increase in adverse effects appears to be the use of general anesthesia without tumescent anesthesia by a majority of the surgeons. they treated all patients from the ankle proximally. They had a total of 88% of patients with a totally occluded GSV. They reported five patients with postoperative paresthesia of the saphenous nerve and one with a cutaneous burn for an overall complication rate of 23%. The vein occlusion rate at 1 year examination was 91. Another report describes two episodes of DVT in 29 patients treated with the RF Closure (27). which exposed the GSV within the calf to heat from the RF catheter. 7 legs at 12 months. Their mean operating time was 67 min (range 25– 120 min).9% from 14 centers. One patient (3. There was a 3% incidence of paresthesia as well as a 1. The authors do not report the type of anesthesia used or the length of vein treated. Two limbs (0.6% from 9 centers and 81. The probable reasons for the increase in adverse effects were their use of a spinal anesthesia instead of the recommended tumescent anesthesia.8%) had closure of the GSV but with persistent reflux of the SFJ. Fifty percent of patients had closure of both the GSV and the SFJ.

Because this permits some slow leakage of blood around the Closure catheter during the procedure. Before proceeding. As detailed. The sheath is then threaded along the guidewire. and describing alternative procedures such as ligation and stripping in detail. SIDE-EFFECTS In our experience using tumescent anesthesia in awake patients. Our technique requires one needle puncture only and is more likely to result in better cosmesis. This is usually just below where reflux is no longer seen in the GSV or where the vein becomes too small to cannulate with a 16 gage introducer set. These resolved within 6 months. a guidewire must be first inserted through the 16 gage needle initially inserted into the skin. we prefer to insert a sheath through which the Closure catheter is then advanced. with duplex guidance. The procedure begins with the vein to be treated marked on the skin using duplex ultrasound. two patients have developed focal numbness 4 cm in diameter on the lower medial leg. The patient is then prepped and draped after which 0. No skin injury or thrombus has been observed in any of our patients. piercing the skin. For the majority of patients in our series. Treatment when limited to the GSV segment above the knee is also important in preventing paresthesia to the saphenous nerve. the Closure catheter may at this point be placed directly through the needle into the vein. the patient signs the appropriate consent form (Fig. a heating pad is placed under the thigh and a small amount of 2% nitrol paste is rubbed onto the intended entry point to minimize vasoconstriction during the initial cannulation process. Presently. Reflux may originate at the junction itself as this region may be safely treated. patients with reflux in the greater or lesser saphenous vein are candidates if the vein size does not exceed 1. Since adopting the principles outlined earlier of tumescent anesthesia with moving the catheter rapidly from any points of sharp pain. the patient’s feet are wrapped in warm material or socks to minimize vasoconstriction. 21.3). a 16 gage needle is inserted through the skin and guided into the saphenous vein. In order to place the sheath.274 Goldman and Weiss DVT. After eliciting a detailed history as with all the other venous procedures.1 cc of 1% lidocaine without epinephrine is injected at the pre-marked site.2 mm. Others prefer gaining entry via a venous cut-down or pulling of the vein close to the surface with an AP hook. The guidewire is passed $5 cm into the GSV. TECHNIQUE OF CLOSURE WITHOUT PHLEBECTOMY (VIDEO CD) The patient undergoes the same diagnostic process as previously outlined. no paresthesias have been noted. When venous return is noted through the attached syringe. this is at a point just above or below the knee along the course of the GSV. An appropriate entry point is selected. its progress is followed by duplex until it is seen firmly placed within the .

Treatment of the GSV with Endoluminal Laser or RF Closure 275 Figure 21. .3 Consent form for Closure procedure.

further diminish the size of the GSV and reduce the possibility of heating blood rather than vein wall. Sometimes the patient must rotate the leg. Rather the catheter is twisted or external pressure is applied to the leg to change the shape of the GSV. If the patient experiences a sudden sharp pain. the guidewire is carefully withdrawn. the procedure may be repeated assuming the Closure catheter can be advanced past the treated distal segment. impedance will suddenly rise and the RF generator cuts off. If the catheter gets hung-up on a valve or slight bend of the GSV. tumescent anesthesia (consisting of 0. After establishing the intraluminal placement of the sheath. the catheter is pulled 1 mm past that point. When the catheter has been pulled back to the introducer sheath site. Duplex monitoring of the anesthesia injection at the SFJ is recommended as the shape of the SFJ is changed from the round “hook” to a straighter path. Once the Closure catheter is in place. no repeat treatment is performed.5% lidocaine neutralized to pH 7 with sodium bicarbonate) is injected between the skin and the cannulated GSV. quickly to minimize the possibility of nerve injury. the physician monitors the temperature and impedance. as vein perforation would be the most likely outcome of such an attempt. The Closure catheter. Once positioned. the final check of the position of the catheter is made with duplex.25 –0. Impedance of the vein wall should be between 200 and 350 ohms. The tips of the electrodes are placed so that they align with the base of the terminal valve cusps. When the leg wrapping has not been tight enough. no additional force is used or perforation will occur. Its progress up the GSV is monitored by duplex. and the catheter is temporarily held in place for 5– 10 s until 858C is reached again. an impedance and temperature check is performed to make sure the catheter is functioning properly. The first 4 cm are treated over 3 min but then the catheter is advanced at a rate of 2. one waits for 30 s and then slow withdrawal of the catheter begins. If a sharp drop in temperature occurs during pullback. we have observed a much higher likelihood of a small coagulum building up at the electrodes of the Closure catheter. Tumescent anesthesia volume is typically 60– 120 cc for the course of the vein along the thigh. If one cannot pass the catheter easily. If this does not occur. The leg is then wrapped with a short stretch bandage from the ankle up to the mid-thigh. This is to minimize blood return from the GSV. After target temperature is achieved. The RF is then applied. Impedance would most likely rise quickly and the RF generator shutdown automatically. Duplex ultrasound of the SFJ should reveal no flow except the superficial epigastric emptying into the CMV. with a diluted heparin solution slowly running through a central lumen. the catheter has been mistakenly advanced too far into the CFV. the target temperature of 858C should be reached. The tip is positioned with the electrodes deployed. and the thermocouple should transmit a baseline temperature of 33 –378C. . Within 15 s. is now inserted through the sheath. If flow is seen in the GSV.276 Goldman and Weiss lumen of the GSV. it most likely represents a large branch point or perforator. Once the leg is wrapped. The GSV should be more echogenic with thicker appearing walls.5 cm/min.

This “blind” retrieval of the GSV is usually accomplished in . The distal GSV and varicose veins are then removed through a series of 2 mm incisions with a standard AP technique.1 min. The patient then lies on the examining table in the operative position and all varicose veins are transilluminated and marked with another marking pen. 750 –1000 mL of 0. A #3 or #4 Muller hook is used to grasp the GSV and bring it through the incision. the patient is asked to stand and the locations of all varicose veins are highlighted with a marking pen. the leg is prepped with TechnicareTM solution and sterile drapes are placed allowing exposure of the varicose veins including the SFJ and medial thigh. The location of the GSV (that is usually not visible) is marked with either Doppler or duplex control. The proximal portion is then opened with two toothed hemostats. After the entire proximal GSV is treated. The patient is seen the next day and the compression bandage is removed. Correct tip placement is confirmed by measuring the length of the catheter and with duplex ultrasound. Anesthesia of the . The patient is then taken to the operating theater. All incisions are covered with antibacterial ointment and a band-aid. Patients will note some bruising from the tumescent anesthesia. The stocking is left on 24 h a day for 1 week. and a 30 – 40 mm/Hg graduated stocking is applied. the distal stump is ligated with a #3/0 Vicryl suture. both above the facial sheath as well as circumferentially around the GSV within its facial sheath. A 2–3 mm incision is then made with an 11 blade medial to the GSV in the mid-thigh typically 20 cm distal to the SFJ. Intravenous midazolam (2 – 3 mg) is sometimes given through a hep-lock to alleviate patient apprehension. The leg is checked for hematoma or other adverse sequelae. Tumescent anesthesia is given along the entire course of the varicose veins as well as around the GSV.000 epinephrine is used averaging between 5 and 10 mg/kg of lidocaine. The table is placed in 308 Trendelenburg position. the entire leg is wrapped in a short-stretch compression bandage over copious padding over the varicose veins removed through phlebectomy. Confirmation of the location of the GSV in the mid-thigh is obtained in the operative position with duplex or Doppler. A slow heparin drip is then started and the catheter withdrawn slowly as described earlier. No incisions are closed at all.1% lidocaine with 1 : 100.Treatment of the GSV with Endoluminal Laser or RF Closure 277 TECHNIQUE FOR CLOSURE WITH AP (VIDEO CD) After establishing incompetence of the SFJ with duplex and/or Doppler examinations. Hemostats are placed across the exposed GSV and it is ligated. Tumescent anesthesia is then given as previously described through a 21 gage spinal needle. At the conclusion of the surgery. FOLLOW-UP CARE Class 2 compression hosiery is worn for 3 days with the percutaneous closure technique and 7 days with the Closure and Phlebectomy techniques. The Closure catheter is then placed into the vein and its tip positioned to within 1–2 cm of the SFJ. Typically. The open 2 mm incisions allow for drainage of the anesthetic solution over 24 h minimizing bruising.

These authors used a 940 nm diode laser with multiple 15 J. Although the patient instructions after the Closure technique are very straightforward including 3 days of compression. 21. 21. At that time.5). the GSV will remain closed. The extent of thermal injury to tissue is strongly dependent on the amount and duration of heat the tissue is exposed to. . Clinical improvement in appearance of varicosities is typically seen within 6 weeks as well (Fig. It has been our experience that when closed at 6 weeks. an increase in body temperature to 588C will produce cell destruction if the exposure is . Tissues. 1 s pulses to treat the GSV. As a 940 nm laser beam can only penetrate 0. they are still provided with an instruction sheet (Fig. Symptom reduction is rapid with many patients experiencing relief at 3 days but some not until 6 weeks.278 Goldman and Weiss treated portion of the leg may persist for 8 –24 h. thermal damage with resorption of the GSV has also been seen in veins emptied of blood. For example. however. any open segments can be treated by duplex-guided sclerotherapy. Once comfortable with the procedure. we recommend that for the initial cases. 940.508C would be expected to be reversible. Thus. can withstand temperatures up to 708C if the duration of the exposure is maintained .4). and almost indistinguishable from surrounding tissue at 6 months in all cases. It is presumed that destruction of the GSV with laser is a function of thermal destruction. This produced the homogeneous thrombotic occlusion of the vessel. 980. Therefore.3 mm in blood (30). Histologic examination of one excised vein demonstrated thermal damage along the entire treated vein with evidence of perforations at the point of laser application described as “explosive-like” photodisruption of the vein wall. However. One in vitro study model has predicted that thermal gas production by laser heating of blood in a 6 mm tube results in 6 mm of thermal damage (29).6).10 s. The presumed target for lasers with 810. and 1064 nm wavelengths is intravascular red blood cell absorption of laser energy. Moritz and Henriques (28) investigated the time – temperature response for tissue exposed to up to 708C. the formation of steam bubbles is the probable mechanism of action. CLOSURE OF THE GSV WITH ENDOLUMINAL LASER ABLATION Endovenous laser treatment (EVLTTM ) allows delivery of laser energy directly into the blood vessel lumen in order to produce endothelial and vein wall damage with subsequent fibrosis (Fig. one should re-evaluate the treated veins at 3 days by duplex ultrasound. A median of 80 pulses (range 22 –116) were applied along the treated vein every 5 –7 mm. any tissue injury from brief exposure to temperatures .1 s. fibrosed. the physician may want to see the patient for a duplex ultrasound follow-up study at 6 weeks. 21. They found that skin can withstand temperature rises for very short exposure times and that the response appears to be logarithmic as the exposure times become shorter. To gain experience. This will allow correlation of results with the pull-back rate or any difficulty encountered during the procedure. direct thermal effects on the vein wall probably also occur.

Collagen has been noted to contract at about 508C. Latino woman with large varicosities for 20 years and mild changes of chronic venous insufficiency with major reflux originating at the SFJ. and edema resolved totally. collagen contraction.Treatment of the GSV with Endoluminal Laser or RF Closure 279 Another possibility for the mechanism of action of EVLT is similar to RF closure. thermal damage. before. fatigue. with recent onset of small varicosities traced to reflux at the SFJ occurring during her second pregnancy—immediately before treatment. The symptoms and signs of pain. Treatment resulted in rapid alleviation of symptoms of leg fatigue. or a combination of the two effects is responsible for destruction and resorption of the GSV is unknown. aged 28. Only two punctures were necessary for the accompanying AP of small side branches of the incompetent GSV. Figure 21. Two weeks after RF occlusion of the GSV along with AP of the veins below the knee.4 Two cases of before and after VNUS Closure. whereas necrosis occurs between 708C and 1008C (22). Six weeks after treatment showing complete clearance. . Young woman. Weather collagen contraction.

Our patients treated with EVLT with an 810 nm diode laser have shown an increase in post-treatment purpura and tenderness.1% incidence of transient paresthsia (31. with 96% or higher occlusion at 9 months with a . The lack of significant heating of perivenous tissues probably explains the low complication rate found and argues well for the continued lack of significant complications.280 Goldman and Weiss Figure 21. we believe that nonspecific .32). no other major or minor complications have been reported. Initial reports have shown this technique with an 810 nm diode laser to have excellent short-term efficacy in the treatment of the incompetent GSV.5 Post-operative patient instructions for Closure. Although most patients experience some degree of post-operative ecchymosis and discomfort. Most of our patients do not return to complete functional normality for 2 – 3 days as opposed to the 1 day “down-time” with RF closure of the GSV. As the anesthetic and access techniques for the two procedures are identical.

trying to vary the fluence and treating with a continuous laser pull-back vs. pulsed pull-back has not resulted in an elimination of vein perforation (34). A longer-wavelength such as 940 nm has been hypothesized to penetrate deeper into the vein wall with resulting increased efficacy. We await longer-term results from patients already treated with EVLT and additional refinement and evaluation of this promising new technique. perivascular thermal damage is the probable cause for this increased tenderness.33). Twenty vein segments were examined histologically.Treatment of the GSV with Endoluminal Laser or RF Closure 281 Figure 21.6 EVLT photo. In addition. 21. Veins . recent studies suggest that pulsed 810 nm diode laser treatment with its increased risk for perforation of the vein as opposed to continuous treatment which does not have intermittent vein perforations may be responsible for the increased symptoms with EVLT vs. RF treatment (Fig. In fact.7) (29. A report of 280 patients with 350 treated limbs with 18 month follow-up demonstrated complete closure in 96% (35).

the lateral saphenous goat vein was used. treated vessels were not perforated even with a fluence of 224 J/cm2. Skin overlying the treated vein was cooled with cold water. At this wavelength. and localized hematomas in 0.8% of patients. Perforations were not present. Occlusion was more likely when fluence exceeded 84 J/cm2. superficial phlebitis in 1.282 Goldman and Weiss Figure 21. this resulted in superficial burns in 4. Unfortunately. The author suggests that his use of tumescent anesthesia as well as the aforementioned laser parameters is responsible for the lack of significant perforations and enhanced efficacy. In one study (36).6%. Clinical results as well as post-operative adverse sequelae are identical to that seen with VNUS Closure treatment. In an attempt to bypass absorption of hemoglobin. TECHNIQUE FOR CLOSURE USING ENDOLUMINAL LASER (VIDEO CD) The patient is evaluated and marked in an identical manner as with RF closure of the GSV.5%. Studies in the porcine GSV demonstrate full thickness thermal damage at 5 W with the 1320 nm laser and 20 W with the 1064 nm laser (38). More importantly. Three studies have evaluated a 1064 nm Nd:YAG endolumenal laser (36 – 38). we have been involved in the development of a 1320 nm endolumenal laser.3 s pulses. tissue water is the target and the presence or absence of red blood cells within the vessels is unimportant.8%. In addition.2 and 1. paresthesia in 36. Anesthesia is given along the vein in an identical manner as with RF . Spinal anesthesia was used and the laser was used at 10– 15 W of energy with 10 s pulses with manual retraction of the laser fiber at a rate of 10 s/cm. A diffusing fiber was also used to obtain circumferential damage. were treated with 1 s duration pulses at 12 J. we utilize a mechanical catheter drawback system and a diffusing laser fiber to provide uniform heating of the vessel. microperforations did occur and were said to be self-sealing.7 Vein perf with EVLT. Clinical studies have demonstrated 100% efficacy without evidence of vessel perforation with use of the 1320 nm Nd:YAG intravascular laser in the first 30 patients with 6 month follow-up (at the time of this writing). the surgeons also ligated the SFJ which did not allow for a determination of the efficacy of SFJ ablation. When the fluence was increased to 15 J with 1. A clinical study using an endolumenal 1064 nm Nd:YAG laser in the treatment of incompetent GSV in 151 men and women with 252 treated limbs was also reported (37). Unfortunately.

8 Sheath destroyed by EVLT. using the laser in a continuous firing mode with slow withdrawal at a rate of 1 cm/s is advocated. and viewing the He : Ne aiming beam through the skin. On the coagulation by heat of the fluid blood in an aneurismal tumour. REFERENCES 1. The only difference between the two procedures is that with EVLT a 600 mm laser fiber is inserted into the vein within a protective sheath so that only the distal 2 –3 mm of laser fiber exits from the sheath. . SUMMARY A new technique for endovenous occlusion using RF ablation catheters or endoluminal laser offers a less invasive alternative to ligation and stripping as well as a safer alternative to duplex-guided sclerotherapy of saphenous trunks and junctions. The remaining portion of the procedure is identical to RF closure. A helium neon aiming beam that is continuously illuminated when the laser is on insures that the laser fiber is outside of the sheath. thermal destruction of the sheath occurs (Fig. To prevent perforation of the GSV. Philos Trans MDCCCXXVI:189 – 201. In the near future.Treatment of the GSV with Endoluminal Laser or RF Closure 283 Figure 21. A Steri-strip was placed on the fiber at the entrance of the protective sheath to mark its length. It was found that this technique minimizes pain and maintains efficacy of treatment. Correct placement of the laser fiber tip 2 cm distal to the SFJ is confirmed through catheter length measurement.8). duplex examination. Initial clinical experience in several hundred patients shows a high degree of success with minimal side-effects. many venous ablative procedures involving saphenous trunks may be replaced or supplemented by this technique. Home E. most of which can be prevented or minimized with minor modifications of the technique. closure. If the laser fiber retracts within the sheath. 21.

1999:217 – 224. Olgin JE. 8. 66:182 –184. Goldman MP. The fate of residual saphenous vein after partial removal or ligation. Scurr JH. 17. emorroidi e varicocele secondo il metodo del prof. Haines DE. Br J Surg 1991. Goldman MP. 28:38– 42. 5. Le HJ et al. Assessment of stripping the long saphenous vein in the treatment of primary varicose veins. Pacing Clin Electrophysiol 1993. Conti G. Radiology 1982. Stabilimento Tipografico di Gaetano Gioja: Napoli. 82(3):1034 –1038. 89(Spec No 1):57– 63. McMullin GM. Electrophysiological effects of long. 19. Morton JB. Gradman WS. Controlled radiofrequency-mediated endovenous shrinkage and occlusion. 12. Weiss RA. Varicose Veins and Telangiectasia: Diagnosis and Treatment. Dermatol Surg 1998. Coleridge Smith PD. 10. 24:453– 456. Castaneda-Zuniga WR. 26:452 – 456. 21. Dermatol Surg 2000. 14. 16(3 Pt 2):586–591. Maguire M. Phlebologie (Fr) 1987. Feied CF. J Dermatol Surg Oncol 1994.284 Goldman and Weiss 2. Weiss RA. 4. Smith S. Rysavy JA. Tumescent anesthesia in ambulatory phlebectomy. Cragg AH. 24:447 – 450. 96(8):2715 – 2721. eds. Weiss MA. RF-mediated endovenous occlusion. Weiss RA. Arch Mal Coeur Vaiss 1996. 2nd ed. Copie X. In: Weiss RA. Closure of the greater saphenous vein with endoluminal radiofrequency thermal heating of the vein wall in combination with ambulatory phlebectomy: preliminary 6-month follow-up. Louis: Quality Medical Publishing Inc. Jones DN. linear atrial lesions placed under intracardiac ultrasound guidance. New York: McGraw-Hill. 13. Van Cleef JF. Verow AF. The biophysics of radiofrequency catheter ablation in the heart: the importance of temperature monitoring. 79:889 – 893. Ursel P et al. The value of different forms of treatment for varicose veins. 20. eds. Circulation 1997. 2001:211– 221. Chin M. 18. Haines DE. Weiss RA. Sulla cura eradicativa delle varici. Macbeth W et al.. Br J Surg 1992. Goldman MP. Weiss MA. 1854. Chapman HT. Dermatol Surg 1998. 9. 144(2):303 –308. 1853:148 –152. Jakobsen BH. Weiss RA. Br J Surg 1979. Sarin S. Observations on electrode-tissue interface temperature and effect on electrical impedance during radiofrequency ablation of ventricular myocardium. Kalman JM. 6. Sebag C. Radiofrequency ablation: physical bases and principles. Palasciano. 78:1139– 1142. Amplatz K. Cincinnati: Electric Publishing Office. With an Inquiry into the Best Mode of Effecting the Permanent Cure of Varicose Veins. Rutherford RB. Ollitrault J. Goldman MP. 15. Transillumination Mapping Prior to Ambulatory Phlebectomy. Endovascular diathermic vessel occlusion. Galliani CA. J Vasc Surg 1990. 16. On Treatment of Ulcers on the Leg. In: Goldman MP. Objective assessment of high ligation without stripping the long saphenous vein. Coleridge Smith PD. Lavergne T. Controlled radiofrequency occlusion using a unique radiofrequency catheter under duplex guidance to eliminate saphenous varicose vein reflux: a 2-year follow-up. Stillson C. 11. . 20(7):482 – 485. 40(2):423– 426. 68:426 – 428. Scurr JH. Sawyer JD. Preliminary report. Bergan JJ. Munn SR. Venoscopic obliteration of variceal tributaries using monopolar electrocautery. La “nouvelle electrocoagulation” en phlebologie. Dermatol Surg 2002. Br J Surg 1981. Circulation 1990. To strip or not to strip the long saphenous vein? A varicose veins trial. Weiss MA. 12:426– 428. Vein Diagnosis and Treatment. St. Chouari S. 3. Without Confinement. 7.

Chang C-J. Dermatol Surg 2002. Espinosa-Klein C et al. Dorschel K et al. 28. 27:117 – 122. Regarding “endovenous treatment of the greater saphenous vein with a 940-nm diode laser: thrombolytic occlusion after endolumenal thermal damage by laser generated steam bubbles. 31:257– 262. Sessa C et al. Isaacs MN. Defining the role of extended saphenofemoral junction ligation: a prospective comparative study. Cos Dermatol 2003. Closure of the greater saphenous vein with endoluminal radiofrequency thermal heating of the vein wall in combination with ambulatory phlebectomy: 50 patients with more than 6 months follow-up. Nguyen ET. 12:1167– 1171. 50:523 – 529. Manfrini S. 31. Comparison of endovenous radiofrequency versus 810 nm diode laser occlusion of large veins in an animal model. J Biomed Opt 1999. Moritz AR. Friebel M. 36:1311. 30. Am J Pathol 1947. Is there an increased risk for DVT with the VNUS closure procedure? J Vasc Surg 2002. Weiss RA. Henriques EC Jr. Amiry S. J Phlebol 2001. Goldman MP. Vascular Surgery 2000. (suppl 14):121. 36:242.” J Vasc Surg 2003. 24. Studies of thermal injury II: the relative importance of time and surface temperature in the causation of cutaneous bums. 32:330 – 342. 35. 29. Chua J-J. Twelve and twenty-four month follow-up after endovascular obliteration of saphenous vein reflux—a report from the multi-center registry. Bone C. 23. Pichot O. 38. laser treatment to promote venous occlusion. 28:56 –61. 35:729– 736. Kargl A. 36. Min RJ. Endovenous 1064-nm and 1320-nm Nd:YAG laser treatment of the porcine greater saphenous vein. Navarro L. Lehr HA. Goldman MP. 34. Endovenous laser photocoagulation (EVLP) for varicose veins. Goldman MP. Kabnick LS. 23:695– 720. 16:25 – 28. J Vasc Surg 2002. Rosenblatt M. Forrestal MD. 28:29– 31. . Gasbarro V. Detwiler SP. Dermatol Surg 2002. 33:115– 118. Merchant RF. 36:1207 –1212. Initial experience in endovenous treatment of saphenous vein reflux. 26. J Vasc Interv Radiol 2001. Min RJ. Endovenous laser treatment of the incompetent greater saphenous vein. Danielsson G et al. 37. Chandler JG. Optical properties of circulating human blood in the wavelength range 400– 2500 nm. Proebstle TM. Endovenous management of saphenous vein reflux. 27. Dermatol Surg 2001. Endovenous treatment of the greater saphenous vein with a 940-nm diode laser: thrombotic occlusion after endoluminal thermal damage by laser-generated steam bubbles. Endovenous. 25. Bush RG. Roggan A. 33. Endovenous laser: a new minimally invasive method of treatment for varicose veins—preliminary observations using an 810-nm diode laser. Parente EJ. Wittens CHA.Treatment of the GSV with Endoluminal Laser or RF Closure 285 22. J Vasc Surg 2002. Laser Surg Med 2002. Sybrandy JEM. 1:17– 24. Endovenous laser treatment of the greater saphenous vein at 810 nm. J Vasc Surg 2000. Komenaka IK. 34:201– 214. 32. Lasers Surg Med 2003. Lasers Surg Med 2002. Zimmet SE.

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technique. according to a recent research (1). The difficulty for the phlebologist is the patient’s certain lack of confidence in the procedure or worst. No source Abdominopelvic Saphenofemoral junction (SFJ) Thigh perforators Saphenopopliteal junction (SPJ) Popliteal perforators Gastrocnemious perforators Leg perforators Causes may be surgical. . or nonsurgical. and residual varices. . . They can evolve during the patient’s entire life and appear several years after successful treatment. the patient appears to be either deceived or desperate. . . 48% at 10 years. and appearance in different sites. angiogenesis. and 77% at 34 years. from 4% to 52%.22 Ambulatory Phlebectomy of Recurrent Varicose Veins Recurrent varicose veins are an important part of phlebological work [18% rate at 3 years. the surgeon. In fact. according to Perrin’s classification (3): . . otherwise the operation must have been done “unsuccessfully” by a colleague. No matter what the cause if for the development of new veins. some embarrassment will be present. Their appearance arises from a retrograde flow fed by a source detectable at different levels. These 287 . tactique. If the primary operation was done by the same phlebologist. recurrent varicose vein treatment gives rise to a wonderful opportunity to demonstrate proper ambulatory phlebectomy as the ideal treatment. evolution. strategy. the saphenous tributary veins in these cases are generally removed and the recurrent varicose veins arise entirely from more superficial veins. according to different authors (2)]. . Nevertheless.

and Goldman veins are much more evident. both in number (32) and in follow-up (oldest cases date of 1999). an endovenous catheter (Fig. 22. while the detection of a re-anastamosis formed by multiple tiny veins or capillaries does not require operative repair (10%) (1). it is possible to do the same procedure in distal direction (Fig. If the recurrence is secondary to re-anastamosis of the SF or SP junctions.1). 22. as it is better to isolate a dilated and straight vein tract. its interruption and possible ligation during the phlebectomy is generally sufficient in removing all the connected varicose veins. (5)]. a simplified management of recurrence at the SFJ is possible. although at some distance from the groin. The sclerosing foam. Surgical revision of the SFJ is a demanding operation. If a saphenous vein stem is still present at the thigh (if the saphenectomy was not performed during the initial operation).5). Following the experience of one of the authors (SR). has superficial varicosities. but the general principles appear to be useful. even when grossly dilated. 22. This early experience shows that it is not convenient to extract the varicose vein until the limit of its passage below the fascia. It is possible then to insert into an exposed varicose vein (Fig. If it is due to a perforator vein. but also easier to remove. (2)]. Georgiev. The typical case of recurrence secondary to junction re-canalization after saphenectomy.4). gently pushing the agent toward the junction (Fig.6). the true problem comes from the inadequate treatment from the source of the reflux. Surgery is required in the presence of a saphenous stump.2(a – c)]. performed in scar tissue full of venous tracts and is not manageable in an ambulatory setting. 22. In case of a . or in the presence of a large vein connected to the junction (85%) (1). if the catheter is inserted very close to the skin. are easily removed by phlebectomy until the penetration point below the superficial fascia. a sign of insufficient junction dissection. re-recurrences are not rare [28% in Ref.3). where only ultrasound may visualize them. The varicose veins. This experience is based on a limited experience. Although good results have been reported [73% in Ref. it may not pass through and the injection may be impossible. The exposed vein may then be pulled out till breaking (the foam stops the bleeding) or tied. This operation usually requires the lateral dissection of the femoral vein up to SFJ dissection and section/ligation. to facilitate the catheter’s introduction. (2) and 40% in Ref. 22. usually [67% according to Stonebridge (4)] surgical revision is necessary. 22. Some authors still prefer to perform this surgery under local anesthesia (2) in a more structured environment. and inject 2– 3 cc of polidocanol foam at 1%. more suitable for surgery on large deep vessels. These are caused by unknown pathologic and/or genetic factors and are called neo-vasculogenesis. they travel below the fascia only in close proximity (5 – 10 cm) to the groin crease [Fig. (Different is the case of groin recurrence with saphenous conservation. which converge in the groin region to meet the neo-junction (Fig. more than a sclerosing solution has a long lasting “filling” effect into the entire vascular bed.) Of course.288 Ricci. Alternatively. The varicose veins run above the superficial fascia.

Right leg pre-operative mapping: varices “disappear” at 10 cm from the groin ending in a sub-fascial saphenous stamp. Left leg nonmarked: varices end in a sub-fascial cavernoma at 3 cm from the groin. The sclerosis of these veins is generally very effective as their walls are dysplastic in nature and.AP of Recurrent Varicose Veins 289 Figure 22. leak in the vein wall. At some distance from the groin.1 Recurrences typically appear with superficial bulging varices. The suture can be employed successively for tying the vessel after the procedure. because the absence of blood flow as a consequence of the removal of drainage by the distal varicose veins. a suture is placed on the vein’s wall around the catheter. in particular. Post-operative ultrasound examination demonstrating noncompressibility of the varicose veins . they become deeper passing below the hypodermic fascia.

290 Ricci. Figure 22.2 Usual pattern in recurrences. (a) At the groin. Georgiev.3 The phlebectomy of the superficial varices (dotted line) stops at the point where they get below the fascia (black line). a residual saphenous stump or a cavernoma or a neo-vessel is found below the saphenous fascia. (c) The most of the varicose network is evidenced over the fascia. clinically invisible. and Goldman Figure 22. (b) GSV residual tracts are detected below the saphenous fascia. .

The foam is gently pushed upward to fill the system.5 Foam sclerosing agent (polidocanol 1%. 1/4 foam – air ratio) is introduced without forcing into the catheter.AP of Recurrent Varicose Veins 291 Figure 22. A veno-cath is introduced in the last extracted varice to access to the deeper Figure 22. .4 groin veins.

foam sclerotherapy through the catheter procedure may be used also in distal direction.7 present.292 Ricci. Figure 22. No open lumen is . Georgiev. stripped. or only partially.6 If the saphenous vein was not. and Goldman Figure 22. US imaging at 7 days follow-up of the groin cavernoma.

Classification des recidives variqueuses apres chirurgie: un document de ´ ´ travail preliminaire. the effects of treatment is easily followed by ultrasound and simply corrected by further injections. the treatment of micro-vein cases being more effective than the big stump cases. Stonebridge PA. Fischer R. Creton D. Preliminary results of PTFE patch saphenoplasty to prevent neovascularisation leading to recurrent varicose veins. 1:49– 60. Bradbury AW. REFERENCES 1. Harradine K. Phlebologie 1998. by a traditional surgery. 82:60– 62. Phlebology 1998. Linde N. Sometimes. 22. These vein segments may require a subsequent ultrasound guided sclerotherapy treatment. 51:423– 430. The described procedure may be practiced as a complement to phlebectomy simplifying an otherwise complicated operation. ´ ` 3. Chalmers N.7). Br J Surg 1995. Cure and reappearance of symptoms of varicose veins after stripping operation—a 34 year follow-up. Recurrent varicose veins: a varicography analysis leading to a new practical classification. Duff C. J Phlebology 2001. if necessary. 4.AP of Recurrent Varicose Veins 293 confirms the effect of this procedure (Fig. 2. a portion of the vein may still appear permeable (compressible). It is possible that the effects of treatment are conditioned by the anatomical picture. Perrin M. . Surgery for recurrent sapheno-femoral incompetence using expanded polytetrafluroethylene patch interposition in front of the femoral vein: long term outcome in 119 extremities. Beggs I. 5. Heather BP. In each case. Earnshow JJ. Davies K. Phlebology 2002. Ruckley CW. 13:10– 13. An unsatisfactory result will have a very slow and measurable evolution that can always be corrected. 16:93 – 97. but has an absence of blood flow.

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Part VI: Appendices .

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and increases during the day. then heal only to reopen. Therefore. These two elements build the “muscular-venous leg pump. Vein dilation. For this reason. This explains why your leg starts swelling in the morning. It is the rhythmic movements of the foot—flexion and extension—that drive blood up. leg swelling and induration. In such cases. Therefore. Ultimately.Appendix 1 Instructions for Patients Affected by Chronic Venous Insufficiency Leg veins transport blood from the foot upward to the heart. inflammation. skin redness. and consequently blood tends to stagnate. Healthy veins have valves which prevent blood from flowing downward. but no standard operation has been developed. and brown or white discoloration develop and with time skin ulceration may occur. it is your responsibility to take care of your legs. You have a chronic venous disorder.” If the “pump” does not function properly. continued care is indispensable to maintain your leg in optimal condition. movement of blood up the leg becomes difficult. Some do not heal at all without prolonged bed rest. Some leg veins may be obstructed whereas others are dilated. but there are also other veins which cannot be treated. It is tried sometimes. Reconstructive vein surgery is experimental. no treatment exists which can completely and permanently heal your leg. accumulation of fluid may occur beginning at the ankle and extending up the thigh. some valves are destroyed. itching. and consequently blood flows down rather than up. Some of the diseased veins may be eliminated (surgically or by sclerotherapy). Such ulcers may stay open for many months or even years. good venous circulation depends on two factors: (1) healthy veins with normal valves and (2) muscular exercise. This care consists of: (1) regular use of elastic support stockings and (2) an appropriate lifestyle which includes the suggestions discussed later. 297 .

Make it a habit to take long walks. Being overweight makes it much more difficult to keep your legs in good condition. Wear comfortable shoes and avoid high heels. when possible. it is indispensable to wear the prescribed elastic support bandage or below-knee medically approved graduated compression stocking daily. 3. To maintain your leg in good condition. reading. Avoid lifting and carrying weights of . i. Check your leg every evening for swelling. but does so only during leg movement. 6. train. 7.298 Appendix 1 If your leg is in very poor condition. You may have additional benefit if. you need not keep your legs fully extended. . make it a habit to sleep with your legs slightly elevated ($6 in. During long trips (car.. use an appropriate skin moisturizing cream regularly. If you smoke. Do not use medicated products without consulting a physician. Avoid activities which risk leg trauma. 10. The elastic support stocking alone does not pump blood upwards. If leg compression and lifestyle are adequate. Many topical preparations may damage the sensitive skin of your leg. If you have dry skin.). The best thing to do is to stop smoking. but also your legs. Therefore. you lay down. Once healing is achieved. and every evening make sure that the calf is soft and the leg is not swollen. you must not allow swelling to occur. it is usually possible to maintain your leg in an acceptable condition by adhering to a few simple rules. lose weight and maintain your optimal body weight. Some activities. get up for a walk. your leg should not be swollen in the evening. because in some legs swelling may start a few minutes after assuming an upright position. know that smoking damages not only your heart and lungs. Avoid prolonged standing or sitting without moving the legs. regular pace walking.20 pounds. If you do not have gastritis (heartburn). before starting your daily activities. 11. 4. may well be done lying down with the legs raised.e. 5. raise your leg and move the foot repeatedly up and down for a few minutes. as full-knee extension obstructs venous circulation. move your feet up and down often and. and airplane). Place suitable support under the foot of the bed so that you may comfortably change position. 9. Walking with an elastic support stocking is an important exercise for the venous circulation. 1. Keep your feet and toenails clean. after putting on the stocking. Leg movement during usual daily activities is of limited value when compared with long. Make it a habit to keep your legs higher than the rest of the body a few times a day. keep your knees flexed. 8. healing may require a few months (or even more than a year) of professional bandaging and considerable changes in your life. Put on the stocking (or bandage) early in the morning. 2. If necessary.

if not promptly and adequately treated. . Replace the old support stocking when it wears out and loses its efficacy. Should symptoms like swelling. contact us immediately. Keep a spare stocking (or bandage) on hand to avoid going without the needed elastic support. or you traumatize the leg. With proper care. may lead to serious consequences.Appendix 1 299 12. 13. Even a trivial or small wound. redness or pain occur. itching. good quality elastic support hose will last up to 6 months.

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swelling of the leg. transitory pigmentation. Administration of Anesthetics. stripping. and secondary telangiectasias (spider veins). Endovenous Closure with Laser or Radiofrequency. and I understand that among the known risks are bruising. nerve pain. These 301 . scarring. C) RISKS The nature of the procedure to be performed has been explained to me.Appendix 2 Consent for Ambulatory Phlebectomy. sclerotherapy (injection of sclerosing agents into diseased veins). including conservative treatments (elastic stockings). and vein ligation. and the Rendering of Other Medical Services PATIENT NAME: DATE: TIME: A) AUTHORIZATION FOR VEIN SURGERY I hereby authorize and/or associates to extract or interrupt diseased veins for the purpose of attempting to improve the symptomatology and/or appearance of my legs. accumulation of localized lymphatic fluid. dermatitis. B) ALTERNATIVES I understand that alternative treatments for varicose veins exist.

302 Appendix 2 adverse events are almost always temporary in nature but may persist for 2 –6 months. and results of both the surgical procedure and necessary anesthetic which were made known. such as loss of blood. and after the treatment. to be administered by or under his/her direction. I fully understand the inherent potential risks. during. and. These photographs shall remain the property of and may be published in scientific journals and/or shown for scientific reasons. H) INFORMED CONSENT I certify that I have read the above consent for surgery permit. E) PROPOSED TREATMENT RESULTS I know that the practice of medicine and surgery is not an exact science. infection. reputable practitioners cannot guarantee results. therefore. as to the results that may be obtained. which may lead to temporary numbness. and nerve trauma. post-operative bleeding. I believe that I have adequate knowledge on which to base an informed consent to the proposed treatment. complications. inflammation in the venous systems with formation of a thrombus (clot). No guarantee or assurance has been given by anyone. should he/she encounter an unhealthy or unforeseen condition during the course of the procedure. G) PHOTOGRAPHS I consent to be photographed before. D) ANESTHESIA I consent to the administration of anesthesia. F) COOPERATION I agree to keep and staff informed of any changes in my permanent address and I agree to cooperate with them in my after care. there are other risks that may accompany any surgical procedures. I am aware that risks are involved with the administration of local anesthesia. It has been fully explained to me and I fully understand the above consent for surgery permit. such as allergic or toxic reactions to the anesthetic and cardiac arrest. I have had sufficient opportunity to discuss my condition and proposed treatment with and all of my questions have been answered to my satisfaction. I am aware that in addition to the minor risks specifically described earlier. I hereby authorize to perform any other treatment which may be deemed necessary. and I accept full responsibility for these or any other complications that may arise or .

Appendix 2 303 result during the surgical procedure(s). Signature of Doctor Date . PLEASE INITIAL EACH PARAGRAPH AND SIGN BELOW. which is to be performed at my request according to this consent and surgical permit. and results that may occur as a result of said procedure. Patient (or Legal Guardian) Patient Name (please print) Witness Date Relationship to Patient I certify that I have informed the patient of the available alternative(s) with respect to the proposed surgical procedure. complications. and of the inherent potential surgical risks.

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DISCOLORATION Bruising is common and occurs with any procedure. Use scissors to cut off the heavy gauze bandages. Should any of the surgical wounds remain open and drain fluid. The stocking is then worn during the day and left off at night and with bathing for an additional 2 to 3 weeks. BANDAGES The pressure bandages are designed to decrease swelling and increase the rate of healing. In the early days after surgery. On the second day after your surgery. your legs may tire. drive a car. Lumps 305 . Vigorous activity such as jogging. They should be left in place for 24 hours. you will be able to walk. bicycling. unroll the elastic bandages and roll them up once again. sit. In general. sit down and elevate your legs above the level of your heart if possible. The stocking should be worn 24 hours a day for a one week. cover them with a Band-Aid and a non-prescriptive antibiotic ointment such as Polysoporin or Bacitracin. or aerobics should be avoided for 7 to 10 days following surgery. When they are removed. If they do. It will follow the pathway of the removed veins and become more apparent 2 to 3 days after surgery. and pursue normal physical activity. the bulky dressings will be removed and you will be fitted in a graduated support stocking. as recommended by your physician. (usually in our office).Appendix 3 Varicose Vein Surgery Suggestions Following Surgery ACTIVITY Your physical activity after surgery will determined by how your legs feel.

1 to 2 tablets every 4 to 6 hours. These will go away in a few weeks. Be sure that the surgical wounds are thoroughly dried after bathing to decrease the chances of developing a wound infection. you may shower. please call our office. BATHING & SHOWERING After the bulky surgical dressings are removed. Patient Survey Give: Patient Signature . please call our office. If you should have questions or concerns prior to that appointment. OFFICE RETURN VISIT Please schedule a follow-up appointment for 2 to 3 weeks after surgery. This discomfort can usually be relieved with Tylenol or Extra Strength Tylenol. Should you need stronger pain medication.306 Appendix 3 may also be present where veins were removed. PAIN MEDICATION Modern varicose vein surgery is remarkably pain free although it remains an uncomfortable procedure.

hemostats (distal tooth) #2. Patient is then placed on surgery table and entire area (leg) is prepped with Hibiclens or another antiseptic solution. Vardey. An absorbent chuck is placed beneath the patient’s leg and sterile drapes are placed to expose the vein which will be excised. straight iris scissors. #11 blade. and payment received. Infiltration is accomplished with #25 and/or #20 gage spinal needle with a Klein infusion pump at settings ranging from three to nine Number of people required to perform procedure: 2 Minimum qualification of employee performing procedure: medical assistant PROCEDURE 1. diluted with normal saline. All informed consents are explained to the patient. 307 . Ramlet. venous probes. 4 Â 4 gauze (large pack).75 mg/L). needle holder. short stretch elastic bandages. epinephrine 0. (lidocaine 0. hemostats (large and medium size) #6. kling bandage.Appendix 4 Nursing Instructions Title of procedure: ambulatory phlebectomy Time required to complete procedure: 30– 60 min Supplies needed to perform procedure: phlebectomy hooks (Muller.1%. 2. The solution is mixed in a 500 or 1000 mL bag of normal saline. The liter bag is warmed prior to infiltration to achieve a temperature of 37– 408C. and other). The patient is then photographed after the physician marks the veins to be treated. 3. tissue forceps. 30 –40 mm graduated compression stocking Anesthesia: 1:10 dilution of 1% lidocaine with epinephrine.

the next day after the compression bandage is removed. 8. 9. 16. . Physician will then infiltrate diluted anesthetic solution along the course of the entire vein which will be excised. to get at the proximal aspect of the vein. This procedure is repeated until entire vein is removed. Post-operative care is explained. proximal and distal. #11 blade will be used to make a 2 – 3 mm linear incision. 17. phlebectomy probe may be inserted into entire course of vein. Physician will extract portion of distal and proximal vein through incision with tug. Physician will then insert phlebectomy hook to grasp vein and pull it out of the wound. 15. 14.308 Appendix 4 4. A 30– 40 mm/Hg graduated compression stocking is given to the patient. Physician will then utilize blunt probe to undermine incision site. Short stretch elastic bandage is wrapped on to treated leg starting at the foot and continuing 4 –6 cm above last phlebectomy incision. Entire treated leg and incision sites are cleansed with hydrogen peroxide. 10. Alternatively. 13. Sample of vein tissue is to be sent for pathology. Absorbent 4 Â 4 gauze pads placed along course of vein and affixed with roll of kling gauze. 7. 5. 12. 6. Assistant/physician will then clamp vein. which will be applied to the treated leg. with hemostat and sever connection between hemostats with iris scissors. 11. Incision sites are not closed to allow anesthetic fluid to leak out.

Appendix 5 Ambulatory Phlebectomy Operative Report Patient Name: Date of Surgery: Physician: Assistant: Anesthesia: 1% xylocaine with Epinephrine 1:100. infection. Total of ml Pre-operative anesthesia: Versed mg IVP Diagnosis: Surgical Procedure: Operative Time: Alternative therapies were discussed with patient prior to obtaining written and verbal consent for surgery after explanation of the risks of bleeding. PROCEDURE: Vaices were identified both visually. The patient was 309 . Cutaneous Marking was performed. scarring and consequences of no treatment. diluted 1:10 with normal saline. with transillumination and with Doppier Ultrasound.000.

310

Appendix 5

placed in a slight Trendelenburg position. Surgical asepsis was obtained using Hibiclens solution. Microincisions were made using a #11 blade. A #2, #3 and #4 blunt hook was used to Grasp the vein. Varicose vein(s) was/were extracted measuring cm in length and mm in diameter. Absorbant pads were placed over the microincisions. Elastic compression bandages and/or stockings were applied including a selective compressive dressing of the varicose vein for 7 days. Estimated blood loss was . The patient tolerated the procedure well. Postoperative care was reviewed. Follow-up appointment was scheduled for 24 hours and in one week.

Comments:

Physician Signature

Date

Appendix 6
Operative Report for Endoluminal Radiofrequency Closure

MARYLAND LASER, SKIN AND VEIN INSTITUTE, LLC
NAME DIAGNOSIS: Incompetent saphenous vein from incompetent saphenofemoral junction. great DATE PROCEDURE: Endovenous closure of greater saphenous vein from saphenofemoral junction. PROCEDURE TIME: hrs. PRE-OP MEDS: Valium 10 mg, lnderal 20 mg po

PHYSICIAN: ASSISTANTS:

ANESTHESIA: 0.2% Lidocaine with Epinephrine, cc total along the course of the greater saphenous vein in a tumescent technique.

OPERATIVE REPORT: The patient was informed of the risks and benefits of the above-mentioned procedure, as well as alternative forms of treatment including no treatment. Sterile preparation and adequate anesthesia was obtained as described above.
311

312

Appendix 6

A 16 gauge needle puncture was performed at the level of the . A guide wire was placed through the 16 gauge needle. The needle was withdrawn and a tapered 6 French sealed catheter was threaded along the guidewire. Then the VNUS endoluminal Closure catheter was inserted through the 6 French catheter under Duplex guidance. The tip of the catheter was placed under Duplex visualization at the sapheno-femoral junction. The catheter was inserted for a distance of cm. At this time the tumescent anesthesia was placed overlying the vein under Duplex guidance. The VNUS radio-frequency machine was activated. The electrodes were expanded and an Impedence check showed impedence of 130 Ohms. The catheter was pulled back over_minutes for a pull-back rate of 2.0 cm per minute. During the pullback period, the temperature was maintained at 908C ranging between 788 & 928 averaging approximately 908C. Average energy utilized was approximately 2.5 watts. At the end of the pullback the Duplex ultrasound showed total occlusion and closure of the greater saphenous vein from the saphenofemoral junction distally to the . The patient tolerated the procedure well and without complications. At the conclusion of surgery a bulky gauze pad dressing was placed under a graduated compression stockings. The patient was ambulatory immediately following the procedure ensuring that proper hemostasis had been obtained. ESTIMATED BLOOD LOSS: 5 cc DISPOSITION: The patient will return in 6 weeks for follow-up Duplex ultrasound.

PHYSICIAN

DATE

Appendix 7
Operative Report for Endoluminal Laser Closure

Patient Name: Procedure Time: Date of Surgery: minutes

PREOPERATIVE DIAGNOSIS: Painful (729.5) varicose veins (454.9) with saphenofemoral incompetence and multiple clusters of varicose veins tributary to the saphenous system, r left r right r both r lower extremity

POSTOPERATIVE DIAGNOSIS: Painful (729.5) varicose veins (454.9) with saphenofemoral incompetence and multiple clusters of varicose veins tributary to the saphenous system, r left r right r both r lower extremity

OPERATION PERFORMED: 1 2 Endovenous closure of the r left r right greater saphenous vein(s) from the saphenofemoral junction distally (37720). Selective catheter placement, venous system; first order branch (36011).
313

314

Appendix 7

3 4 5

Transcatheter occlusion or embolization, percutaneous, any method, non-central nervous system, non-head, non-neck (37204). Transcatheter therapy, embolization, any method, radiological, supervision and interpretation. Removal of multiple clusters of varicose veins (37785), r left r Right r both lower extremity.

6

Intraoperative ultrasound monitoring (76986). Other

PREOP MEDICATIONS: Versed SURGEON: ASSISTANT: ANESTHESIA: r Tumescent r Other ESTIMATED BLOOD LOSS: Nil. COMPLICATIONS: None PATIENT CONSENT:

r General

r Laryngeal Mask

The patient was informed of the risks, benefits, and possible complications of the procedure as planned. Alternative forms of treatment were discussed, including no treatment at all. The patient verbalized understanding of the risks, benefits and possible complications and agreed to proceed. Informed consent was obtained, and the patient was taken to the operating suite. DESCRIPTION OF PROCEDURE: With the patient supine on the operating table milligrams of Versed was given intravenously. After adequate skin preparation and draping, tumescent anesthesia was instilled. This consisted of 0.1% lidocaine with epinephrine and a total of milliliters was given. This was instilled in and around the course of the greater saphenous vein to be treated and in the region of the multiple clusters of varicose veins. The ultrasound scanner was brought to the operating table. Visualization was obtained with the 7.5 to 9.0 megahertz probes at a frame rate of 12 frames per

Appendix 7

315

second. The receptor angle was 26 degrees, and adequate visualization of the saphenous vein, the femoral vein, and the saphenofemoral junction was obtained. Access to the saphenous vein was gained through a 3 millimeter incision in the mid-thigh over the greater saphenous vein which was grasped with #3 or #4 Mueller hook and an intraluminal cannula was placed. Monitoring of the catheter placements was accomplished. The endolominal catheter was then inserted and the laser activated. This insertion and eventual location was monitored with the ultrasound as well as externally by visualization of the Helium:Neon aiming beam. The catheter was placed precisely just distal to the saphenofemoral junction, and the sheath removed. The laser was then activated at 1320 nanometers, 5.0 watts at 30 hertz and 167 millijoules, continuous mode. Pullback rate was approximately 1.0 millimeter per second for a total of seconds required to treat centimeters of the proximal portion of the greater saphenous vein, and seconds to treat centimeters to treat the distal portion of the greater saphenous vein. A 3-0 vicryl absorbable suture was placed around the free ends of the vein to ensure complete ligation. Varicose clusters were treated by the stab avulsion technique using a series of 2 millimeter incisions and removal of the veins with #2 and #3 Mueller hooks and appropriate clamps. A total of approximately centimeters of varicose veins were removed in this fashion through cutaneous incisions. The patient tolerated the entire procedure will. The instrument, needle and sponge counts were reported to be correct. A bulky gauze dressing was placed under graduated short-stretch bandaging. The patient was ambulatory immediately and was discharged in stable condition to the postoperative area. FOLLOW-UP INSTRUCTIONS: The patient will return in 1 day and 7 days for follow-up, bandaging changes and placement of a graduated compression stocking.

, MD Surgeon’s name Surgeon’s signature Date

The varicose veins are removed by special small instruments through small holes ($1– 2 mm of diameter). we can assure you that several short procedures achieve a more accurate and complete treatment. either causing symptoms or simply bringing cosmetic problems. a slightly bigger incision is needed at the groin (3 cm) that will be invisible after a few months. but sub-divided into two or even three sessions. compared with a single long and (sometime) stressful session. Sometimes. the operated leg is tightly bandaged. with less anesthesia amount as well as being less boring and worrisome for the patient. but after many years of experience. After half-an-hour patient is ready for going home. 317 .Appendix 8 Explanation Card for the Patient TREATMENT OF VARICOSE VEINS BY AMBULATORY PHLEBECTOMY The most effective treatment for eliminating both large and small varicose veins. In this case. the only limitation being a bandage and/or compression stocking on the leg. and the patient gets up and walks in the waiting room. However. The operation is called Ambulatory phlebectomy (AP). and going home). the operation is not done in a single session. The saphenous vein too may be removed by this method (local anesthesia. After this procedure. the patient goes home and continues normal everyday life. immediate walking. the patient has to come more than once. In those cases. is their surgical removal in the office. At the end of the procedure. a leg has an extended network of varicose veins. Not only will the patient not need to lay down and rest. in this case. The wounds are so small that often after 2 months they are hardly visible and at 6 months no signs of surgery can be found. made on the skin by needles or special pointed blades. for verifying that all is going right. using local anesthesia (the same used by your dentist). along the course of the varicose vein. but also walking and being active through the whole day is encouraged.

for removing veins that have reappeared. taking estrogen supplements. AP operation is very simple as it is carried out on the surface. Walking and other activities are usually the best medicine for this discomfort. inconveniences are nevertheless possible (blister formation. This will confirm that the treatment can be performed safely in our surgical center. and in some patients an electrocardiogram. bruising or hematomas along the course of the removed varicose vein. In fact. and does not concern “dangerous” structures. Even if rarely occurring. The capillary dilatations or telangiectasia that remain after the procedure or that appear in the treated areas may be tended by sclerosing injections. everyday life can be continued. Removing all the varicose veins does not mean that the problem is solved for your entire life. it is possible that after sometime (years). varicose veins may reappear. as the bruising disappears. laboratory examinations. These are related to familial (genetic) and individual tendency. The compression bandage ensures minimal blood loss. which will be carried out after few weeks. body weight. A little pain may be felt at the end of the effect of the anesthesia. These varicose veins will be related to veins that are different from those removed in the past. job and physical activity. pregnancies. and the like. COMMENTARY This card is given to all the patients who need to undergo an AP with a map of the varicose veins where the specific treatment is outlined (see the drawing).318 Appendix 8 If more sessions are foreseen. directly under the skin. visible scars. they are trivial events that soon disappear without any problems. have not happened in our 20– 30 years of experience. Between the sessions. At times. Before the office discharge. This moderate compression period helps to obtain the complete resolution of all the traces of the operation. Serious complications. they will be done 2– 3 days apart. analgesics like Tylenol may be taken if necessary. A telephone call is always available even for simple advice. possible in any kind of surgery. and loss of sensibility in small areas). It is for these reasons that once a year it is suggested to check the venous circulation in our center. One to seven days after the last session. wound infection. are requested to check the general state of the patient’s health. so that compression is not excessively prolonged (1– 2 weeks). an accurate post-operative check-up will confirm that everything is all right. and other less defined factors such as the wearing of tight clothing and/or high healed shoes. all bandages are removed and changed with moderate graduated compression stockings that are worn for 1 –2 months until complete healing occurs. Most of the times. In our experience. however. it has a calming effect and may remind the patients of some concepts . Before the procedure. a revision must be performed.

by other relatives and friends and providing positive marketing of your practice. However.Appendix 8 319 of the procedure’s simplicity that they may have misunderstood during the “horrifying” visit. patients prefer not to read it but to entrust its lecture to their husbands or wives. by cardiologists. Sometimes. it is always favorable to the AP operator that all the explanations have been offered in a written form. . Moreover. the explanation card may be read by family physician.

.

the better you will feel. the prescribed analgesic medications (Tylenol) will solve the problem.Appendix 9 Post-Operative Explanation Card for the Patient POST-OPERATIVE INSTRUCTIONS Local anesthesia lasts from 2 to 8 h after the procedure. a nice walk will be useful for “breaking up” little pains or discomforts. Tumescent anesthesia usually lasts 6– 8 h with higher concentrations of local anesthesia lasting up to 2 h. sit. It is advised not to sit down for a long period (!2 h). Sometimes the foot or the ankle may swell. getting up from sitting or lying position. The elastic band or the stocking that has been placed over the adhesive bandage is there to avoid this event. This event is of short duration and is overcome by lying down again for a short time then sitting up slowly. giving discomfort. If blood traces appear . However. During the day. the best thing to do is to lie down and raise the leg: in this way every blood loss will stop automatically. however. blood pressure may be low as reflected by dizziness. drive. the faster the better. Getting in the car to return home is OK as long as the ride is not longer than 1 h. In 321 . Generally. if there is some pain. etc. usually a slow infiltration of blood stained anesthesia solution through the bandage is the cause. For longer car rides to return home. always taking in mind that the more you move.) on the first operative day. Normal daily activities may be resumed (stand. If blood stains appear on the bandage (which is rare) after the discharge from the office. In rare cases. it is appropriate to stop every 30 – 45 min and walk for 10 min. it is advisable to call the available phone numbers marked on this card.6 h after the operation. In this case nothing needs to be done. after a few hours. After the procedure it is required to walk actively. the operative site does not ache. The inconvenience will solve simply waiting until the blood dries up.

we began to write down all the points to be remembered. When they have troubles. A few patients did not understand or remember some of the concepts. these things were told to the patient at the moment of office discharge. pain. it is wise to insist for that instructions are considered by both the patient and the accompanying relatives. They simply do not read it when they have no troubles. starting at the ankle. As it is elastic. and when something happened (foot swelling. COMMENTARY At the beginning of our experience with AP. it must be adequately stretched. etc. bleeding. they do not remember to read the papers. The adhesive bandage placed after the operation must not be touched. It is curious that in our long experience even with written instruction some patients do not follow our recommendations. For this reason. To avoid this event. When wearing the elastic band. . Read all these instructions again. and continuing until just below the knee. it will be enough to tighten the elastic bandage on foot and ankle and walk actively. this must be removed at night and repositioned the next morning. Phone numbers to call in case of trouble or simply for asking an advise.322 Appendix 9 case of swelling.) they would say that nothing had been told to them. going on with four turns on the foot (covering the heel).

Appendix 10 Duplex Evaluation Forms 323 .

324 Appendix 10 .

see also local infiltration anesthesia (LIA) allergic reactions. 245 – 246 Activity after varicose vein surgery. 97 nursing instructions. 179 Aetius of Amida. 227 Adhesive compression below-knee bandage. 231 – 238 rare complications. 242. 226–228 consent for. 217 tumescent side effects. 218 local for office varicose vein surgery. 162 toxic reactions. 5 – 79 anesthetic complications. 215– 228. 97 – 104. 250 local complications. 215 – 218 consent for. 243 Anesthesia. 307 –308 operative report. 225 – 226 technique for closure. xxxv– xxxvi psychological aspects. 301– 303 defined.Index Absorbent gauze. 217 Ambulatory phlebectomy (AP) advantages of. 309– 310 325 patient explanation card. 277 American Society of Anesthesiologists (ASA) physical status classification. 146 Accreditation requirements office varicose vein surgery. 217 complications. see anterior crural vein (ACV) Adhesive bandage. 216 compression bandage complications. xxxiv Allergy to adhesive bandage. 102 SSV phlebectomy. 274 Aneurismal sac internal view of. 301 – 303 late reactions. 264 . 305 ACV. 227 to anesthesia. 244 for office varicose vein surgery. 146– 147 allergy to. 317 – 319 pioneers. 3 – 4 LIA. 248 preoperative. 3 – 4 history. xxxii–xxxiii Albucasis. 218 office varicose vein surgery. xxix– xxxvi indications for. 215 – 218 complications of. 235– 238 anatomical basis of.

151 AP. 14– 15. 146– 147 adhesive compression below-knee. 139 isolation of. 18 Celsus. 255 –259 technique. 226 –228 Index pressure after varicose vein surgery. 94 patterns. 33 Anterior leg superficial vein topography. 270 Closure technique consent form. 53 Anterior crural vein (ACV). 180 – 182 Bandaging materials for office varicose vein surgery. 38 topography. xxix Arterial aneurysm endoluminal obliteration. 305 removable. 262 B-mode ultrasound imaging. 37 Anterior thigh topography. 134 Bruises. 226 – 228 Blood lancet for incision. 179 compression. 191 Bandage adhesive. 139 Calf transverse scan. 32 Anterior accessory saphenous vein (ASV). see anterior accessory saphenous vein (ASV) Asymptomatic varicose veins office varicose vein surgery. 32 lateral knee. 274 Closure with ambulatory phlebectomy technique for. see ambulatory phlebectomy (AP) Aristotle. 277 – 278 postoperative patient instructions for. 20 –21 Babcock technique. xxxiii Blisters with compression bandage. 14– 17. 75 –76 Autologous vein transplantation dermal atrophic changes. 148 complications. 277 . see common femoral vein (CFV) Chronic venous insufficiency patient instructions. Aulus Cornelius. xxxi – xxxii. 306 Battery invention of. 34 topography. see American Society of Anesthesiologists (ASA) ASV. 37 Anterior knee superficial vein topography. 282 – 283 followup care. 275 with endoluminal laser. 110 Blood vessels electrocoagulation of. 262 Berengarius from Carpi. 33 Anxiety patient discharge. 52 incompetent color flow imaging. 147 – 149 removable elastic compressive application techniques. 280 without phlebectomy. 297 – 299 Closure catheter.326 Anterior topography thigh. 256– 259 Autonomous collateral varicosities. 262 ASA. 109. 54–55 varicose patterns. 249 Bathing after varicose vein surgery. 147 with bleeding. 267 clinical experience. 261 – 262 CFV. 48 anatomy. 69 – 70 Boyd perforator.

18 superficial.Index Codeine tylenol with. see deep venous insufficiency (DVI) DVT. 9. 41 of SSV. 148 complications. see collateral varicose veins (CVV) de Chauliac. see postoperative compression Compression bandage. 262 327 . Gaetano. 207– 208 Consent form closure technique. 147 with bleeding. 167 Electrocoagulation GSV. 69 popliteal area. 30 reflux origin. 250 Endoluminal laser closure technique. 226– 228 excessive compression. 63 Competent Giacomini vein transferring reflux from saphenopopliteal junction to GSV. 40 Double great saphenous vein varicose patterns. 47 CV. see deep vein thrombosis (DVT) Edema with phlebectomy. 21 Color-Duplex ultrasound examination. 137 – 138. 22 Collateral veins (CV) dorsal foot. 205– 207 Custom made stripping. 151 Collateral varicose veins (CVV). 275 Contact dermatitis with compression bandage. 64 – 67. 69– 71 Combined collateral and saphenous varicosities. 156 for office varicose vein surgery. 223 Elderly patient discharge. 64 – 67 method. 258 Diazepam toxic reactions. 277– 278 Compression stockings. 41 Dorsal venous arch. 8 organization of. 12 DVI. see collateral veins (CV) CVV. 233 Dodd popliteal area vein. 203– 305. 61 – 62 pitfalls. 262 Emergency equipment for office varicose vein surgery. 61 – 63 groin examination. 151 Electric shock. 228 Conti. 262 Corcos stripper GSV. 35 Doppler orthostatic reflux test. 63 interpretation. 305 – 306 Doctor-patient relationship. 218 Discoloration after varicose vein surgery. 20 groin. 57. 29 posterior thigh reflux. 249 Compression hosiery. 26 Common femoral vein (CFV) Doppler orthostatic reflux test. 64 Dorsal foot collateral veins. 76 with phlebectomy. xxxiv Deep vein thrombosis (DVT). 224 Deep venous insufficiency (DVI). 22– 24 Combined varicose veins. 63 – 64 GSV. 226 for office varicose vein surgery. 313 – 315 Endoluminal obliteration arterial aneurysm. 249 – 250 Compressive adhesive bandage GSV. 282 – 283 GSV. 261 – 284 Endoluminal laser closure operative report for. 42 Dermatome. 55 Compression. Guy.

xxxiii EVLT. 190 division technique. 283 Endovenous RF ablation consent form. 63 double varicose patterns. 168 vein avulsion. 301– 303 Endovenous laser treatment (EVLT). 6. 94 preservation of. 35. 231 – 233 Feeding vein. 114 – 116. 121 – 124 vein hooking with. 117. 278. 190 – 191 incompetent color flow imaging.328 Endoluminal probe for ambulatory SSV phlebectomy. 261 – 284. 35 Foam sclerotherapy for recurrent varicose veins. 3. xxxiii Erophilous of Calcedonia. 41 h type. 55 varicose. 163 Endoluminal RF closure operative report for. 218 Equipment and materials office varicose vein surgery. 311– 312 Endoluminal strippers vs. 30 Glutamate receptors. 250 Eye sign. 40– 42 Foot care patient instructions. 136 –138 superficial vein topography. 168 –169 SSV phlebectomy. 48 Doppler orthostatic reflux test. Claudius. 282 destroying sheath. 18. 262 endoluminal laser ablation. 298 Fragile veins with phlebectomy. 121 distal progression. 41 topography. 125 Great saphenous vein (GSV). 168 proximal progression. see endovenous laser treatment (EVLT) Examination equipment for office varicose vein surgery. 278 – 282 foot transverse scan. 24. 121 – 124 vein stripping. 36 bayonet type varicosity. 137. 174 transferring reflux from saphenopopliteal junction to GSV. 292 Foot GSV transverse scan. 247 –248 Erisitratus from Chio. 198 – 206 Doppler orthostatic reflux test. 128 vein hooking. 135 Freestanding surgical office. 12 electrocoagulation of. 146 Giacomini vein. 41 phlebectomy complications. 189 – 190 . 5 Graefe forceps. 24 anatomical arrangement. 65 long segment of. 281. 53 anatomic types of. xxxii Gauze absorbent. 11 – 13. 29 dilatation. extraluminal strippers. 271 Epinephrine toxic reactions. 275 Endovenous RF occlusion CEAP class description after. 49 anterior group. 237 Endovenous closure with laser or radiofrequency consent for. 145 ambulatory SSV phlebectomy. 245– 250 Index Galeno. 35. 163 dissection with. 48 advanced varicose disease. 45 Femoropopliteal vein superficial vein topography. xxix Galenus. 13 Fear. 53 incompetence alternative treatments for.

36 I type. 93 Groin cavernoma US imaging. 110 Incompetent anterior accessory saphenous vein trunks color flow imaging. 195– 196 postoperative bandage. 36 and SVV patterns. 199 H anatomic type varicose patterns of. 53 superior group. 53 reflux. 63 – 64 preoperative marking. 50 Hand phlebectomy complications. Everard. 78 Hippocrates. 50 S type. see great saphenous vein (GSV) Halsted forceps clamping GSV. 59 thigh. 109. 29 Doppler orthostatic reflux test. xxx HIV. 29 ultrasound identification of. 262 Hooks. see human immunodeficiency virus (HIV) Home. 54 segmental involvement. 241– 242 ligation and stripping. 56 via intersaphenous anastomoses. 219 Hemorrhage with phlebectomy. 200– 201 full-length thigh bandage. 79 Hypertrophic scars with phlebectomy. 207– 208 preoperative marking. 200 – 201. 139 above postoperative bandage. 54 phlebectomy complications. 187– 209. 30 Groin CVV. 200. 53 ligation and division performed by. 221 Hepatitis B. 139 posterior group. 16 varicose patterns. 17 GSV. 36 radiofrequency closure. xxix Hippocratic texts. xl. xxxviii Hematoma. 279 segmental involvement. 191 – 192 pudendal artery crossing anteriorly. 219 – 220. 94 Incompetent Giacomini vein transferring reflux from GSV to SSV. 36 marked. 225 Hypodermic needle for incision. William. 188– 189 skin preparation. 55 tapping. 53. 144 Harvey. 8 RF occlusion. 194– 195 patient position. 208– 209 division. 14.Index inferior group. 192– 193 programming operation. 218 – 219. 292 Groin-to-knee stripping. 194 technique. 78 Hepatitis C. 113 – 114 Hosiery compression. 146 with phlebectomy. 194 complications. 205– 207 anesthesia for. 277 – 278 Human immunodeficiency virus (HIV). 7 lower leg. 194 patient preparation for. 187– 190 instruments. 55 329 . 209 indications for. 202– 206 location of. 202 saphenofemoral junction incompetence. 261– 284 reflux origin. 13–14. 193 patterns.

171 Lateral leg superficial vein topography. 98 – 102 . 79 office varicose vein surgery. 217 Limbs postoperative examination. 55 Leg pump function evaluation. 30– 32 Leg anterior superficial vein topography. 98 – 102 preparation and dosage. 100 tumescent technique. 37 Lateral subdermal plexus (reticular vein). 37 lower deep veins. 71 – 73 Leonardo vein. 37 artist’s design of. 98 – 104 solution preparation. 38 topography. 138 topography. 99 technique. 47 Invaginating technique. 250 Local infiltration anesthesia (LIA) ambulatory phlebectomy. 140 – 141 Local anesthesia for office varicose vein surgery. 37– 40 superficial vein topography. 79 Instruments for ambulatory SSV phlebectomy. 102 –103 traditional technique. 94 Incompetent posterior leg perforators. 36 LIA. 215 – 216 dosage. 98 – 99 tumescent solution preparation. 38 topography. 30 Lateral thigh topography. Jeffrey. 42 – 43 GSV. 189– 190 Infectious disease office varicose vein surgery. 30 Lateral subdermal venous system. 36– 37 posterior superficial vein topography. 44 medial topography. see local infiltration anesthesia (LIA) Lidocaine. 98 – 104 preparation. 32– 35 Knee joint X-ray of. 38 topography. 34 topography. 34 topography. 217 for office varicose vein surgery. 97 allergic reactions. 153 Lipodermatosclerosis. 39 Incompetent saphenopopliteal junction preservation of. 101 – 102. 265 edema. 32– 33 phlebectomy complications. 191 Klein. 250 toxicity.330 Incompetent great saphenous vein preservation of. 163 Interfacial veins. 78– 79 Informed consent. 98 –104. 189– 190 trunks color flow imaging. 14 Leg intersaphenous anastomosis transferring reflux from GSV to SSV. 76. 34 transverse scan. 55 transferring reflux from SSV to GSV. 248. 12 medial superficial vein topography. 12 Index lateral superficial vein topography. 36 telangiectatic flare. 98 – 99 preparation and dosage. 99 Knee anterior superficial vein topography. 97 complications. 33 GSV. 39 topography. 77 GSV.

116. 243 – 244 procedure modification. 151 elderly. 298 walking. 298 postoperative for closure technique. 107 – 108 331 . 244 emergency measures. 203. 76 – 79 operator’s experience. 280 sleeping. 75 – 76 Operating room office varicose vein surgery. 43 –44 Oesch hooks sizes of. xxx. 242 –243 selection for. 245 Pain medication after varicose vein surgery. 248 – 249 Nerve damage with phlebectomy. 298 Patient position during surgery. xxxv Muller hook. 250 Mayo’s technique. 36– 37 Medial thigh topography.Index Lower leg deep veins. Ambroise. 75 – 79 varicose vein and leg conditions. 205– 207 Medial knee superficial vein topography. 116 Office varicose vein surgery advantages of. 42–43 GSV. 257 Needle puncture. 194 toxic reactions. 114. 245 – 250 general health. 115 with venous leg telangiectasia. 32– 33 Medial leg topography. 306 Palpation. 298 smoking. 78 procedure type. 151 – 152 anxiety. 119–120. 217 Middle Ages. 34 topography. 235 – 238 anesthesia. 142 – 143 Muller’s technique incision. 244 patient consent. 223 Marionette lines autologous vein transplantation. 137 sizes of. 244 safety in. 223 Nerves. 242 – 243 postoperative management. 250 Mepivacaine. 107– 108 for GSV ligation. 29– 30 Medication material for office varicose vein surgery. 257 Marking solution for office varicose vein surgery. 244 preoperative management. 217 Methylparabens allergic reactions. 114 Needles for office varicose vein surgery. 245 freestanding surgical office. 44 Lymphatics. 36 telangiectatic flare. xxxiii– xxxiv Modern Times. 222 Lymphorrhea with phlebectomy. 113– 114. 79 patient selection for. 151 Patient instructions foot care. 82– 84 Nasolabial groove autologous vein transplantation. 58 – 59 ´ Pare. 191 Mayo stripper GSV. xxxiv– xxxv Patient discharge. 43– 44 Lymphocele with phlebectomy. 109 Multi-session phlebectomy.

30 Postoperative adhesive bandage (POB). xxxv Phlebectomy. 19 Popliteal fossa deep anatomy. 177 removable bandage. 184 compression stockings. small saphenous vein (SSV). 26. 184 insufficient compression. 153 – 154 further compression. Jean-Louis. see postoperative adhesive bandage (POB) Polidocanol. 130 flow in. 129– 130 small saphenous vein. 183 – 184 excessive compression. 42 postoperative duplex scan. 177 – 178 protective pads. 153. 30 varicose veins. 30 Posteromedial thigh vein (PMV). 157 – 158 Postoperative groin bandage. 146 – 149 Postoperative compression. 154 Postoperative medication. 64 Posterior arch vein (PAV). 177 – 185 adhesive bandage. 179 bandaging errors. 143 Popliteal area Doppler orthostatic reflux test. 178 protective skin underwrapping. 277– 278 Perforating veins (PV). 109–144. 277– 278 incision. 32 Posterior thigh collateral varicose veins reflux. 65 –68 duplex scan. xxxii–xxxiii PAV. 59 Petit. 145 Postoperative patient instructions for closure technique. 185 degree of compression. 178 – 183 application technique. 155 – 156 part of. 242 followup care. 64 topography. 110 within lipodermatosclerotic area. 177 Postoperative bandaging. 109. 82– 84 performed by. 241 progression of. 135– 144 Phlebectomy hook. 182 – 183 difficult areas. phlebectomy alternative applications of. xxx PMV. 179 – 182 bandage extension. 159– 173 technical difficulties. see also ambulatory phlebectomy. 115 Pigmented scars with phlebectomy. 155 between phlebectomy sessions. 141 multi-session. 153 compression after removal of. 170 preoperative marking. 208 Postoperative management. see posteromedial thigh vein (PMV) POB. 184 local compression pads. 24– 27. see posterior arch vein (PAV) Percussion test. 151 Plutarch. 225 Piroxicam. 156 – 158 special care. 183 Postoperative followup. 280 .332 Patient postoperative explanation card. 161 groin. 37 – 40 Posterior thigh topography. 58– 59. 143 Perthes test. 36 Posterior leg superficial vein topography. 34– 35 Popliteal artery. 321– 322 Paul from Aegina. 60 Percutaneous closure followup care. 39 topography. 109–111 instruments. 184 testing bandage. 153 – 156 after last operation. 93 Index Popliteal vein Doppler orthostatic reflux test. 34 Doppler orthostatic reflux test. 28 Periorbital veins.

306 Skin necrosis with anesthesia. 218 Sleeping patient instructions. 271 postoperative duplex evaluation. 10 transfer. 91– 95. 26 Reflux extension of. 137 – 138 SFJ. see saphenofemoral junction (SFJ) Shin phlebectomy complications. 287 – 293 foam sclerosing agent. 64 levels of. 305 Primary varicose veins circles. 47 – 56 Scalpel blade for incision. 306 Rima. 268– 270. 272 Radiofrequency closure with AP. xxxvii varicose vein disease. 291 with superficial bulging varices. 65 ligation of. 291 Red-hot iron. 109. 269 patient characteristics. 242 – 243 S anatomic type varicose patterns of. xxxvii Safety office varicose vein surgery. 199 division of. Tommaso. 298 333 . 180 – 182 Renaissance. 30 Retromalleolar fossa SSV collaterals. 268 histology.Index Preoperative anesthesia. 53 Proximal reflux points. 7 Removable bandage. 270 Recurrent varicose veins AP. 292 Segmental great saphenous vein involvement. 290 veno-cath. 8. xxxiv Reticular vein. 268 foam for recurrent varicose veins. 9 collateral intraoperative finding. 41 Return office visit after varicose vein surgery. 54 Selective occlusion (Trendelenburg) test. 61 Sensory nerves. 161 Doppler orthostatic reflux test. 262 Reentry perforator. 92 Pressure bandage after varicose vein surgery. 147– 149 Removable elastic compressive bandage application techniques. 224– 225 PV. 198 – 202 surgical anatomy of. see perforating veins (PV) Radiofrequency ablation animal studies. 237. 50 Saphenofemoral junction (SFJ). 138 Showering after varicose vein surgery. 273 technology. 53 reflux. 289 usual pattern. 6. 63. 48 circuits. 13 Saphenous veins incontinence discovery. 9. 197 – 198 Saphenopopliteal junction (SPJ). 110. 173 Saphenous compartment appearing as Egyptian eye. 111 Schwarz test. 10 Pulmonary embolism with phlebectomy. 266– 268 treatment complications. 271– 272 without AP. 102 Preoperative marking. 6. 58 – 59 Sclerotherapy. 198 – 202 Doppler orthostatic reflux test.

3. 245 – 250 Surgical staging. 169 –170 incisions. 81 – 87 Symptomatic varicose veins office varicose vein surgery. 140 Tibia-gastrocnemius sign. 29– 30 phlebectomy complications. 30– 32 medial topography. 139 –140 diagnosis. 163. 21 Superficial thrombophlebitis. 162– 176. 76. 225 Thigh anterior lateral knee topography. 14 Toothed clamps. 34. 159–173 advantages of. 140 Superficial veins topography. 247 – 248 Surgical office freestanding. 35. 217 Sodium salicylate. 141 Thrombophlebitis superficial. 143 SPJ. 298 Sodium metabisulfite allergic reactions. 7. 15 upper topographic description. 56 phlebectomy. 138 – 139 posterior topography. 30 varicose veins. 58. 162 atypical popliteal terminations. 32 transverse scan. 160 proximal termination of. 76. 8 organization of. 164 –167 preoperative marking of. 169 staging. 162. 65 location of. 171 beginning.334 Small saphenous vein (SSV). 143 Sodium tetradecyl sulfate. 48 anatomy of. 168 higher popliteal incision. see saphenopopliteal junction (SPJ) SSV. 248 Tapping test. 31. 59. 38 tapping. 17– 20 Doppler orthostatic reflux test. see small saphenous vein (SSV) Stockings compression. 171 –173 preoperative marking. 59 thigh extension of. 162– 163 patient position. 7 pattern. 298 Superficial collateral veins. 76 Syringes with chopped up vein. 163–164 complications. 33 Superficial venous system organization. 258 for office varicose vein surgery. 19 reflux posterior leg. 162 saphenopopliteal division and ligation. 58. 60 Telangiectatic matting with phlebectomy. 159– 161 Graefe forceps. 5. 14. 162 technique. 249 –250 patient instructions. 5 – 27 Surgical instruments office varicose vein surgery. 163 Index . 17– 20. 29 lateral topography. 163 postoperative compression. 33 GSV. 48 Smoking patient instructions. 27 – 29 Thin skin. 64. 173–174 anesthesia. 116 for ambulatory SSV phlebectomy. 156 for office varicose vein surgery. 28.

13 distribution of. 72 collateral. 57– 73. 130 – 133 PV division. Alessandro. 137 deep veins. 121 – 124 obliteration history of. 223 – 224 Venous leg telangiectasia. 136 Varicose Giacomini vein. 72 Vasoconstriction. 136. 72 previous treatment. 128 phlebectomy progression. 27 – 42 types of. 125 – 126 traction. 274 Tylenol with codeine. 305 – 306 surgery practice setting up. 215 – 216 Traumatic dermal defect. 104 Vasospasm. 49 diagnostic errors. 57–58. 72 examination of. 59 Varicose clusters with phlebectomy. 133 – 135 extraction. 130 – 135 stripping Graefe forceps. 140 saphenous trunk. 256 hooking with Graefe forceps. 130 – 135. see also recurrent varicose veins ambulatory venous pressure. 72 duplex scan. 121 – 125. 86– 87 clinical examination. 69– 70 color-Duplex. 20 with collateral origin of reflux. 241 – 250 symptomatic office varicose vein surgery. 5 Valvular incompetence. 43 with phlebectomy. 127 division. 261 – 262 retrieval. 9. 113 – 135 instruments. 103 Vein avulsion. 26 complex patterns of. 72 avulsion. 58– 59 plethysmography. 9 Doppler examination. 25 combined. 76 symptoms. 298 Wound infection with phlebectomy. 113 –144 technique. 59. 135. 137 multi-sessions. 61 Tumescent anesthesia side effects. 27– 29 Valves. 72 number of.Index Transitory malaise with local infiltration anesthesia. 57 – 58 topographic description. hooking and exteriorization. 151 Ultrasound imaging B-mode. 220 – 222. 125 thrombosis with phlebectomy. 133 side branch division. 69– 71 Upper thigh topographic description. 116 – 129 vein division. 131 – 133 end division. 30 Varicose short saphenous vein reflux origin. 44 – 45 treatment. xxxiii Volta. 142 – 143 surgical anatomy of. 121 – 135 dissection. 140 recurring after traditional surgery. 58 recurring after sclerotherapy. 40 Varicose veins. 221 335 . 30 Varicose great saphenous vein reflux. Friedrich. 72 medical history. 9 venogram. xxxvii Trendelenburg test. 9 physical examination. 57– 58. 259 Trendelenburg. 262 Walking patient instructions. 121 Graefe forceps. 142 – 143 Vesalius. 49 surgery suggestion following.

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