Part Two: Against the Motion. Venous Perforator Surgery is Unproven and Does not Reduce Recurrences

Blood Flow Analysis of the Great Saphenous Vein in the Su-Pine Position in Clinical Manifestations of Varicose Veins of Different Severities: Application of Phase-Contrast Magnetic Resonance Imaging Data

The progression of clinical manifestations of lower-limb varicose veins remains unclear. This study investigated changes in lower-limb venous blood flow using phase-contrast magnetic resonance angiography. Data were collected on veins from 141 legs. We compared legs with and without varicose veins and related symptoms and examined varying levels of varicose vein symptom severity. Legs without varicose veins exhibited a lower absolute stroke volume (ASV, p < 0.01) and mean flux (MF, p = 0.03) for the great saphenous vein (GSV) compared with legs with symptomatic varicose veins. Legs with asymptomatic varicose veins exhibited lower MF for the GSV (p = 0.02) compared with legs with symptomatic varicose veins. Among legs with varicose veins, asymptomatic legs exhibited lower ASV (p = 0.03) and MF (p = 0.046) for the GSV compared with legs that exhibited skin changes or ulcers; however, no significant differences were observed between legs presenting with discomfort or edema and legs with skin changes or ulcers, and between legs presenting with discomfort or edema and asymptomatic legs. In conclusion, in the supine position, increased blood flow rate and blood flow volume in the GSV were associated with symptomatic varicose veins and increased symptom severity.

[Surgery of varicose vein insufficiency]

The basis of surgery of great saphenous vein insufficiency is the concept of "privat circulation" coined by Trendelenburg in 1891. It was only logical that the dissection of the insuffcient vein or it's partial or complete resection could bring about healing. Over the years varicose vein stripping was modified to finally result in the highly effectiv concept of crossectomy and stripping. For decades this was the Goldstandard in surgery of varicose vein insufficiency. All the other minimally invasive therapeutic techniques which have been developed in the last decades had to compete with crossectomy and stripping. Thanks to progress in technical development the classic stripping procedure has been replaced by highly effectiv, minimally invasiv procedures, at least in the western industrialisied countries. For a minority of patients with specific anatomical pathologies as well as countries with limited health resources vein stripping remains a surgical standard procedure.

A review of a new Dutch guideline for management of recurrent varicose veins

In 2013, the new Dutch guideline for "Venous Pathology" was published. The guideline was a revision and update from the guideline "Diagnostics and Treatment of Varicose Veins" from 2009 and the guideline "Venous Ulcer" from 2005. A guideline for "Deep Venous Pathology" and one for "Compression Therapy" was added to the overall guideline "Venous Pathology." The chapter about treatment of recurrent varicose veins after initial intervention was recently updated in 2015 and is reviewed here. The Dutch term "recidief varices" or the French "récidive de varices" should be used analogous to the English term "recurrent varicose veins." The DCOP Guideline Development Group Neovarices concluded that "recidief" in Dutch actually suggests recurrence after apparent successful treatment and ignores the natural progression of venous disease in its own right. So the group opted to use the term "neovarices." In the Dutch guideline, neovarices is meant to be an all embracing term for recurrent varicose veins caused by technical or tactical failure, evolvement from residual refluxing veins or natural progression of varicose vein disease at different locations of the treated leg after intervention. This report reviews the most important issues in the treatment of varicose vein recurrence, and discusses conclusions and recommendations of the Dutch Neovarices Guideline Committee.