Stripping the long saphenous vein: peroperative retrograde saphenography in patients with and without venous ulceration

Clinical Examination, Duplex Ultrasound and Plethysmography for Varicose Veins

Objective:

In pursuing a policy of selective greater saphenous vein (GSV) preservation in the treatment of varicose veins we hypothesized that limbs with isolated tributary disease (TD) would be ideal candidates for GSV preservation.

Design:

Prospective blinded series.

Setting:

University teaching hospital.

Patients:

Fifty-nine symptomatic legs in 45 consecutive patients presenting with varicose veins.

Interventions:

Patients were evaluated by physical examination, quantitative photoplethysmography (QPG) and colour flow duplex examination.

Main outcome measure:

Colour flow duplex as the standard of comparison.

Results:

Of the limbs studied, 29% had isolated TD. The sensitivity of physical examination for GSV incompetence was 43%, but specificity was 100%. QPG yielded a similar sensitivity of 24% and specificity of 100%.

Conclusions:

Twenty-nine per cent of limbs were optimal candidates for sparing of the GSV with excision of branch varicosities alone. Duplex examination was necessary only when the GSV was clinically normal, and QPG was not helpful.

A Modified Technique for Stripping of the Long Saphenous Vein

Objective:

To describe a modification of the standard stripping technique that facilitates varicose vein surgery, avoiding unsightly scars and damage to the venous nerve.

Interventions:

Long saphenous vein stripping using a modified standard stripping device.

Conclusions:

The modified stripper provides a satisfactory method of removing the long saphenous vein without resulting in large scars.

Application of Doppler/ultrasound examination for varicose veins in a provincial hospital

There are a number of different primary problems in patients presenting with varicose veins. Treatment needs to be appropriate to the different causes. Doppler/ultrasound examination of varicose veins can very accurately define almost all abnormalities that cause varicose veins, but this can be time consuming. Over 3 years' experience of the clinical application of colour Doppler/ultrasound investigation in the assessment of patients with varicose veins in a small general hospital is reported. The selection of patients and how improved understanding of the various presenting problems of patients examined may affect treatment are described. All surgeons with access to this technology are encouraged to include it in the investigation of their patients.

Femoral venous reflux abolished by greater saphenous vein stripping

Preoperative venous duplex scanning has revealed unexpected deep venous incompetence in patients with apparently only varicose veins. Acting on the hypothesis that the deep vein reflux was secondary to deep vein dilation caused by reflux volume, the following was done. Between July 1990 and April 1993, 29 limbs in 21 patients (16 females) were examined by color-flow duplex imaging to determine valve closure by the method of van Bemmelen. Instrumentation included high-resolution ATL-9 venous interrogation using a pneumatic cuff deflation stimulus of reflux in the standing, nonweight-bearing limb. All limbs showed greater saphenous vein reflux. Twenty-nine showed superficial femoral vein reflux and of these three showed popliteal vein reflux. Duplex testing was performed by a certified vascular technologist whose interpretation was blinded as to the results of clinical examination and grading of the severity of venous insufficiency. Surgery was performed on an outpatient basis under general anesthesia using groin-to-knee removal of the greater saphenous vein by the vein inversion technique of Van Der Strict. Stab avulsion of varicose tributary veins was accomplished during the same period of anesthesia. In 27 of 29 limbs with preoperative femoral reflux, that reflux was abolished by greater saphenous stripping. In patients with popliteal reflux both femoral and popliteal reflux was abolished. Improvement of deep venous hemodynamics by ablation of superficial reflux supports the reflux circuit theory of venous overload. Furthermore, preoperative evaluation of venous hemodynamics by duplex scanning appears to provide useful pre- and postoperative information regarding venous insufficiency in individual patients.

Stripping of the long saphenous vein in the treatment of primary varicose veins

Eighty-nine legs with long saphenous vein (LSV) reflux and saphenofemoral junction incompetence were treated by saphenofemoral ligation and multiple avulsions; patients were randomized to undergo additional stripping of the LSV from groin to upper calf (n = 43) or no additional treatment (n = 46). At a median of 21 months after surgery recurrence was evaluated by duplex ultrasonography, photoplethysmography, clinical examination and patient assessment. Fewer persisting incompetent LSVs in the calf were found (21 versus 38) and median (interquartile range) photoplethysmographic refilling times were longer (20 (13-27) versus 14 (11-21) s) when the LSV was stripped than after saphenofemoral ligation alone (both P < 0.1). More patients were completely satisfied (65 versus 37 percent and were recurrence-free (65 versus 17 per cent) when the LSV had been stripped compared with saphenofemoral ligation alone (P < 0.05 and P < 0.001 respectively). The addition of LSV stripping to saphenofemoral ligation and multiple avulsions results in a better overall outcome.

Assessment of stripping the long saphenous vein in the treatment of primary varicose veins

Stripping of the long saphenous vein (LSV) may prevent recurrence of varices, although this has not been demonstrated using objective criteria. The aim of this study was to determine whether the addition of LSV stripping, from groin to upper calf, to saphenofemoral junction (SFJ) ligation prevents residual reflux, and whether LSV stripping to the upper calf results in greater neurological complications. Sixty-nine patients with primary varicose veins, LSV reflux and SFJ incompetence, confirmed by duplex ultrasonography and photoplethysmography, were studied. A total of 105 limbs were treated by SFJ ligation and avulsion of varices; patients were randomized to undergo stripping of the LSV to the upper calf (n = 49) or no additional treatment (n = 56). Three months after surgery all patients were examined clinically, by duplex ultrasonography and by photoplethysmographic tests of venous function, to establish the extent of persisting varices. Fewer persisting incompetent LSVs in the calf were found when the LSV was stripped (n = 9) than after SFJ ligation alone (n = 25) (P < 0.01). Photoplethysmographic refilling times were improved to a similar extent in both groups after surgery but were lower in those who had residual LSV reflux (P < 0.05). Six limbs developed paraesthesia in the distribution of the saphenous nerve: two in the group that were stripped and four in those that were not. These data suggest that LSV reflux is more completely abolished by combining LSV stripping with SFJ ligation; stripping the LSV to the upper calf does not result in a higher incidence of injury to the saphenous nerve.

The morphology of recurrent varicose veins

Over an 18-month period, of 444 patients referred for treatment for varicose veins, 95 (21%) had had previous surgery. By means of clinical hand-held Doppler and in selected venographic evaluation these were subdivided into three groups as follows. Type 1:29 of the 95 patients had recurrence through thigh perforators. Type 2:10 patients had developed incompetence through a second saphenous system, in nine of the 10 in the short saphenous having had previous long saphenous surgery. Type 3:46 patients had recurrent sapheno-femoral incompetence and 10 sapheno-popliteal incompetence. A persistent long saphenous trunk in the thigh was present in approximately two-thirds of cases of types 1 and 3. In over half of the type 3 patients saphenofemoral recurrence was by reconstitution of the junction by neovascularisation. These morphological studies demonstrate why there may be an increased risk of recurrence if the long saphenous trunk is not excised at the time of primary surgery.

Venous ulceration and saphenous ligation

Over an 8-year period prospective series of 213 consecutive patients with venous ulceration of 232 limbs has been studied. By means of clinical, hand-held Doppler ultrasound and comprehensive ascending and descending venography examination, it was possible to identify underlying morphological abnormalities and on the basis of these to divide patients into four principal types. Type I:4%--ankle perforator incompetence alone; Type II:39%--ankle perforator and saphenous incompetence; Type III: 35%--primary deep incompetence (usually associated with perforator and saphenous incompetence); Type IV:22%--patients with postphlebitic damage. This study reports the outcome of Type II patients that have been treated by saphenous ligation alone (no perforator ligation). Healing was maintained over a mean period of 3.5 years in all but five patients. In these, other factors were shown in retrospect to be contributory to failed healing. It is concluded, therefore, that approximately 40% of venous ulcers can be ascribed to a combination of incompetence of saphenous and ankle perforating veins and that medium-term healing can be achieved in at least 90% of these by saphenous ligation alone.

Long saphenous vein saving surgery for varicose veins. A long-term follow-up

The autologous saphenous vein is widely recognised as the graft material of choice in infra-inguinal arterial reconstructions. This study was undertaken to evaluate the long-term results of long saphenous vein saving surgery compared with standard stripping. Forty-two patients with varicose veins were randomly allocated to treatment, either with standard stripping of the long saphenous vein or high ligation. In both groups, local varicosities were avulsed and insufficient perforators ligated, on the basis of physical examination and phlebography. Follow-up was performed 52 +/- 5 months postoperatively. The recurrence rate was 12 and 11% in the stripping and the high ligation group respectively. At follow-up, the venous return time was increased significantly in both groups (P greater than 0.001). Vein mapping by means of high-resolution, real-time ultrasound at follow-up showed that 78% of the preserved saphenous veins were suitable for use as arterial conduits. These results suggest that removal of the long saphenous vein per se is of no therapeutic value if insufficient perforators have been ligated. It is possible to perform elective vein surgery for varicose veins with good results and preserve the long saphenous vein, which in turn can be used for future arterial reconstruction in most cases.

Number and anatomical distribution of incompetent thigh perforating veins

Although incompetent thigh perforating veins are considered to be a common cause of recurrence of varicose veins after high saphenous ligation, the number and distribution of such incompetent veins have not been reported. The aim of the study was to determine the number and anatomical distribution of incompetent thigh perforating veins. Sixty-five limbs in 48 patients with varicose veins who were found to have incompetent thigh perforating veins on ascending deep to superficial venography were studied. In 80 per cent of patients one incompetent thigh perforating vein was found and in 20 per cent more than one was found. Concomitant incompetent calf perforating veins were found in 92 per cent of the limbs studied. The incompetent thigh perforating veins were found to occur anywhere in the thigh, from the upper edge of the patella to a few centimetres below the saphenofemoral junction. The majority (71 per cent) were found in the middle third of the thigh. All incompetent thigh perforating veins were communicating with the long saphenous vein, including those in five patients with incomplete stripping. The surgeon should be aware of incompetent thigh perforating veins which may be multiple and occur at any site on the medial aspect of the thigh.