Historical Background

Ambulatory phlebectomy (AP) is a minor surgical procedure designed to remove varicose vein clusters located close to the skin surface. Originally performed in ancient Rome, the technique was published by Robert Muller in 1966.¹ In many office-based venous surgery practices in the United States, AP is performed with the use of local tumescent anesthesia. The six basic features of the technique are as follows:

Complete surgical removal of varicose veins may be achieved in a single session or in separate sessions. Endovenous ablation and AP are suitable for the office and, in the author’s practice, are routinely performed together. All procedures are guided with duplex ultrasound to get a “roadmap underneath the skin.” The advantage of this combination technique is that patients can expect all varicose veins to disappear after a 1-hour procedure.

Etiology and Natural History of Disease

Bulging varicose veins on the surface of the skin can originate from different sources. Identification of these sources is important because the source influences the treatment plan. Varicosities on the medial aspect of the thigh and calf are usually the result of great saphenous vein (GSV) incompetence. To minimize the chance for recurrence, the incompetent GSV must be eliminated from the circulation. This concept has been substantiated in several prospective randomized clinical trials involving patients who were treated with or without saphenectomy by conventional vein stripping.^2–5 The recurrence rates for limbs without saphenectomy were much higher than those for limbs with saphenectomy. Of course, now thermal ablation techniques with either radiofrequency or laser have proved to be the methods of choice for eliminating the GSV from the circulation.^6,7

Varicosities on the anterior thigh usually result from anterior accessory saphenous vein incompetence. These veins usually course over the knee and into the lower leg. Small saphenous vein (SSV) reflux produces varicosities on the posterior calf. When also present on the posterior thigh, the surgeon must consider a cranial extension of the SSV, which can be identified with duplex ultrasound imaging. Cranial extensions may enter the GSV (Giacomini vein) or enter the femoral vein directly.

In cases where no “feeding source” is found, phlebectomy of the varicosities may be all that is required. Labropoulos et al.⁸ have shown that varicose veins may result from a primary vein wall defect and that reflux may be confined to superficial tributaries throughout the lower limb. Without great and small saphenous trunk incompetence, perforator and deep vein incompetence, or proximal obstruction, their data suggest that reflux can develop in any vein without an apparent feeding source. This is often the case when bulging reticular veins are seen along the course of the lateral leg. This lateral subdermic complex and its vein of Albanese are often dilated and bulging in elderly patients. The underlying source of venous hypertension is usually perigeniculate perforating veins, not easily identifiable with duplex imaging. AP using an 18-gauge needle stab incision and a small crochet hook for exteriorization of the vein is an excellent procedure for this clinical problem.

Patient Selection

AP is indicated for the removal of varicosed venous tributaries, when visible and palpable on the surface of the skin. AP is simple to perform and well tolerated and can be used in conjunction with other treatment modalities. As stated earlier, it is critical to recognize that bulging veins are usually associated with an underlying source of venous hypertension, and treatment of the source is as important as the vein removal. Prior to AP, the treating physician must perform a thorough evaluation with duplex ultrasound imaging to determine whether a source is present for venous hypertension. The source of venous hypertension should be eliminated prior to, or in conjunction with, AP.

Prior to placing the patient in the supine position on the operating table, the veins of interest must be marked in the standing position with an indelible marker. Marking is performed in the standing position because hydrostatic pressure is elevated and the pressurized veins become visible and palpable. Bulging veins literally disappear when patients lie supine because the venous pressure drops to near 0 mm Hg.

Endovascular Instrumentation

AP is not truly endovascular in the purist sense; rather, it is a common and perfect adjunct to an endovascular procedure. The following are tools needed to perform AP:

Imaging

We prefer mapping these veins using visual inspection and palpation; other investigators might prefer transillumination mapping using specialized vein lights.⁹ Ultrasound-guided vein hooking is useful for deeper veins.

Hemostasis and Anticoagulation

Avulsion of venous segments treated by AP is relatively hemostatic when tumescent anesthesia is used. Hemostasis is augmented by applying gentle pressure over the incision site. The epinephrine in the anesthetic preparation enhances the hemostasis process through vasoconstriction. When extracting larger veins with the stab-avulsion technique, significant force may be required and some minor bleeding may be encountered. Placing the patient in the Trendelenburg position may also help control bleeding if there is more than usual.

Klein¹⁰ has shown through clinical studies that a dose of 35 mg/kg of dilute lidocaine solution is well tolerated and safe. Infiltrating solutions should contain epinephrine in appropriate concentrations to induce vasoconstriction and more gradual absorption of lidocaine into the bloodstream.

Infections are rare after liposuction and venous procedures with tumescent anesthesia and are usually confined to the incision site.¹¹ The reason for the low rate of infection is not clear, although there are reports of lidocaine concentration–dependent bacteriostatic and bactericidal activity. Pathogens commonly found on the skin may be sensitive to this activity.¹²

Compression bandage: Careful application of the postoperative dressing cannot be overstated because improper dressing placement can lead to bleeding and hematoma, blistering, nerve injury, and ischemia. The limb is wrapped circumferentially from foot to groin with a bulky compression dressing that is removed after 48 hours. The dressing should be applied with graduated pressure; the amount of pressure should decrease as one proceeds from foot to groin. It is critical to place extra padding over the lateral fibular head to avoid pressure-induced injury to the deep that is superficial peroneal nerves.

Deep peroneal nerve injury is quite serious because it is a motor nerve. A patient who develops a foot drop after venous surgery will have a decreased quality of life—a common source of litigation.

All patients are encouraged to ambulate immediately after the procedure to minimize thromboembolic complications.

Operative Steps

Tumescent anesthesia (Fig. 9-1): Tumescent anesthesia allows large areas of the body to be anesthetized with minimal effect on intravascular fluid status, avoidance of general anesthesia, and short postoperative recovery. Tumescent anesthesia provides a safe, easy-to-administer technique for use with AP. The technique of tumescent anesthesia involves infiltration of the subdermal compartment with generous volumes of a 0.1% solution of lidocaine with epinephrine. The anesthetic preparation is administered subdermally under pressure. The doctor pushes the fluid until a characteristic peau-d’orange effect is visualized on the skin. The tumescent fluid hydrodissects the subcutaneous fat from the venous tissue as it enters, thus facilitating vein extraction afterward.

Fig 9–1

Incisions (Figs. 9-2 and 9-3): The most popular instruments for creating incisions are No. 11 scalpel blades, 18-gauge needles, and 15-degree ophthalmologic Beaver blades. Incision length should correspond to vein size but is usually in the range of 1 to 3 mm. The author removes small varicose veins through an 18-gauge needle hole, while larger veins require slightly larger incisions made with a No. 11 scalpel blade.

Fig 9–2