Excision of Varicose Veins

M.S. Gohel and A.H. Davies

There has been an explosion of new technologies for the treatment of truncal vein reflux, and a bewildering range of endovenous thermal and chemical ablation modalities are now available, many having replaced traditional saphenous junction disconnection and stripping operations. Although not to the same extent as truncal venous treatment, the treatment of varicosities has also evolved, with new technology and paradigm shifts. This is of great importance because residual varicosities are a common cause of patients’ dissatisfaction after venous intervention. A 100% success rate for great saphenous occlusion is little comfort to the patient with residual symptomatic varicosities.

Importance of Treating Truncal Incompetence

It has been a widely accepted principle that in the treatment of superficial venous disease, the underlying truncal incompetence must be treated before the prominent varicosities are addressed. An assumption exists that treating the varicose veins alone would result in rapid recurrence because of unresolved venous hypertension in the truncal vein. This view has been challenged, and the concept of saphenous-preserving procedures such as CHIVA (Conservatrice et Hémodynamique de l’Insuffisance Veineuse en Ambulatoire) or external valvuloplasty at the saphenofemoral junction have been proposed by a number of authors. The CHIVA procedure involves strategic ligation (using local anesthesia) of specific junctions and points in the superficial venous system on the basis of detailed color duplex imaging to restore normal hemodynamic function. Enthusiasts from mainly European centers have reported excellent anatomic and clinical results. Conceptual challenges have limited the use of CHIVA and similar techniques in many countries, including the United States and United Kingdom.

In some patients, it may be difficult to convincingly associate the presence and location of varicose veins to the truncal reflux that is present. In these cases, it may be acceptable to treat the varicosities alone. However, in view of the enormous heterogeneity of venous anatomy and presentation, clinical decisions should be made on an individual basis.

Principles of Treating Varicosities

Do Varicosities Need to Be Treated? When?

The majority of patients treated for superficial venous reflux formerly underwent open surgical procedures performed under general anesthesia. Concomitant phlebectomy of prominent varicosities was considered an integral part of the open procedure. However, the widespread availability, acceptance, and office-based nature of endovenous modalities has introduced a new dilemma regarding the treatment of visible varicose veins. Experts are divided over whether varicosities should be treated at the same time as the truncal intervention, later, or not at all.

Treating the Truncal Reflux Alone

The truncal reflux may be treated alone, leaving the varicosities to regress in due course. This approach has the advantages of minimizing procedural duration and stress, as well as avoiding the risks of phlebectomy. In some patients, it may be clear that treatment of the truncal reflux will probably lead to a good resolution of prominent varicosities. However, the veins might not regress, and the lack of visible improvement after varicose vein intervention can cause significant dissatisfaction in some patients. Also, multiple treatment episodes can have cost implications for the health care provider and patient.

Treating the Reflux and Varicosities at the Same Time

The truncal reflux and varicosities may be treated at the same time. This reduces the risk of residual varicosities and results in completed treatment in one sitting for the majority of patients. However, because some patients do experience complete regression of varicose veins after truncal treatment alone, patients may be overtreated and exposed to the risks of an unnecessary procedure.

Selectively Treating Varicosities

Some clinicians offer concomitant treatment of varicosities in some patients, depending on the size, extent, and location of their varicose veins. This approach is limited by the lack of valid selection criteria for which patients should be offered additional treatment of varicosities.

Other Considerations

Another factor that can influence the decision regarding treatment of varicose veins is type of anesthetic. The requirement of a general anesthetic can be an important disincentive for both patient and doctor. However, a number of authors have reported the feasibility and effectiveness of ambulatory phlebectomy performed in an office-based setting using local and tumescent anesthesia alone. A randomized study by Carradice and colleagues comparing concomitant and delayed phlebectomy (with truncal endovenous laser ablation) reported a high requirement of subsequent interventions in patients in whom phlebectomy was delayed, which equated to a significant quality-of-life deficit.

The cost implications to the patient and health care provider of different treatment strategies should also be considered. A health economic modeling study suggested that in patients with symptomatic great saphenous vein (GSV) reflux, endovenous thermal ablation of the GSV with delayed treatment of varicosities (if required) might be the most cost-effective treatment strategy, although patient and local factors can also influence cost-effectiveness and should be considered.

How Can They Be Treated?

Although not as diverse as the options for treating truncal reflux, a range of surgical and minimally invasive treatments is available for prominent varicose veins.

Hook Phlebectomy

Hook phlebectomy has remained the mainstay of treatment for varicosities. The procedure involves careful marking of prominent superficial veins preoperatively with the patient in the standing position. During surgery, microincisions are placed over the veins and the vein is delivered through the skin using an Oesch hook. The varicose veins are then segmentally avulsed. Further technical details of the procedure are described later.

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