Historical Background
By the 1890s Trendelenburg not only had developed the compression test to evaluate saphenous vein reflux but also had performed great saphenous vein ligations using a transverse upper thigh incision, thus establishing the foundation for surgical treatment of varicose veins. In 1916 Homans described ligation of the saphenofemoral junction as it is commonly practiced today. A major advancement was contributed by Mayo, who postulated additional benefit by removing the saphenous vein. Although quite effective at eliminating great saphenous vein reflux, this extensive surgical approach resulted in long operative times and significant wound complications. The introduction of an intraluminal stripping technique by Babcock reduced the invasiveness of vein stripping, which has persisted with few refinements for most of the last century. Development of noninvasive venous testing in the 1980s improved the ability to target appropriate veins for intervention. Although sclerotherapy and endovenous ablation occupy preeminent roles in the contemporary management of superficial venous disease, open surgical approaches remain relevant when applied appropriately and executed expertly.
Indications
Chronic venous insufficiency may lead to debilitating pain, swelling, skin changes, and ulcerations. Conservative treatment including gradient compression remains important, but surgical correction of superficial venous reflux has proved superior to compression alone for a number of indications in a large prospective randomized trial ( Box 59-1 ).
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Symptomatic varicose veins or venous insufficiency
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Pain and tenderness associated with varicosities
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Heavy sensation in the extremity after prolonged standing
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Edema
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Complications related directly to varicose veins
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Lipodermatosclerosis
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Venous ulceration
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Superficial thrombophlebitis
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External hemorrhage
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Cosmetic appearance
Because of the less invasive nature of endovenous ablation, the use of open surgical approaches to varicose vein surgery has declined in recent years. However, there remain situations in which open venous surgery has advantages and is indicated. Specifically, endovenous ablation is contraindicated in the following situations:
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The target vein, such as the great saphenous vein, small saphenous vein, or accessory saphenous vein, adheres closely to the skin.
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It is not possible to create a 1-cm zone between the catheter and the skin, with tumescent anesthesia increasing the risk of thermal injury to the skin.
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The endovenous ablation catheter or sheath cannot be passed through a tortuous great saphenous vein or a great saphenous vein in which synechia have formed because of chronic thrombophlebitis. In this situation it is often possible to pass a more rigid vein stripper or the more flexible Codman stripper. If these instruments cannot be passed, then ligation and phlebectomy may be appropriate.
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Segments of the saphenous vein are extremely dilated or aneurysmal, with diameters greater than 2.5 cm. They may not ablate effectively and may be prone to thrombotic complications.
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Acute thrombosis in the target vein buffers the thermal effect and reduces the effectiveness of the endovenous ablation procedure. In addition, crossing the thrombus with an endovenous ablation catheter without proximal ligation risks embolization.
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In certain settings, the cost of endovenous ablation may represent an economic barrier to its use.
Preoperative Preparation
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History. The first step in preparing for venous surgery is to obtain a history, including symptoms, complications related to the varicose veins, history of deep vein thromboses, prior venous interventions, and recurrent thrombotic episodes or varicose veins. It is also important to assess for concomitant peripheral arterial disease and associated medical comorbidities.
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Physical examination. Examination of the axial venous system from groin to ankles should be performed with the patient standing, noting edema, telangiectasias, varicose veins, skin discoloration, and evidence of ulcerations. Palpation of the lower extremities should focus on the compliance of the subcutaneous tissue and the turgidity of the veins.
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Duplex ultrasound. A detailed ultrasound assessment of the axial venous system focused on identifying areas of reflux in the superficial, deep, and perforating veins and areas of obstruction or postthrombotic changes provides a road map of the functional venous anatomy of the leg. To plan the appropriate procedure, it is crucial to understand the anatomy of the great saphenous vein. The great saphenous vein runs from the medial malleolus cephalad to the anteromedial surface of the calf. Around the knee, the great saphenous vein continues in a more superficial plane. As it courses farther cephalad, it enters the superficial fascia and most commonly remains between the deep and the superficial fascia. The great saphenous vein may be “duplicated” such that two veins run the length of the thigh, both within the fascial envelope. Particularly relevant is the “S-type” anatomy, where the great saphenous vein is only a partially duplicated, the dominant vein remains above the fascia, and the intrafascial vein is atretic. Preoperative knowledge of which variation is present is important to ensure that all refluxing segments or accessory veins are treated.
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Evaluation. Detailed evaluation of the popliteal fossa is also important given the highly variable location of the saphenopopliteal junction and local venous anatomy. Accurately assessing the relationship between the small saphenous vein and the gastrocnemius veins, intersaphenous vein, and other tributaries increases the success of small saphenous vein ligation and stripping. Approximately one third of small saphenous vein terminate in the popliteal vein above the knee, whereas a low termination occurs in approximately 10% of patients. Likewise, determining whether the gastrocnemius vein is incompetent is important, because it must be ligated with the small saphenous vein to prevent persistent reflux and recurrence. Duplex ultrasound has become the standard of care in evaluating venous insufficiency. However, the presence of venous outflow obstruction is better assessed by computed tomography, intravascular ultrasound, or venography.
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Preoperative marking. Before surgery, the patient should be marked in the standing position with an indelible marker. Such markings are crucial in cases of ambulatory phlebectomy, because visualization of the varicose veins may be impossible when the patient is supine. Areas of vein clusters should be marked for removal by phlebectomy, and only segments of either the great saphenous vein or the small saphenous vein with venous reflux should be marked for vein stripping. Duplex-guided marking of the saphenofemoral or saphenopopliteal junctions also allows precise placement of incisions.
Pitfalls and Danger Points
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Varicose vein recurrence. The most common reason for recurrent varicose veins is a missed refluxing great saphenous vein segment. Overdissection of the groin region can also result in neovascularization at the saphenofemoral junction. Finally, inadequate preoperative evaluation may fail to identify segments contributing to venous reflux, such as the small saphenous vein with posterior calf varices.
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Nerve injury with ligation and stripping. Injury to the saphenous nerve, which accompanies the great saphenous vein behind the medial border of the tibia, may lead to a sensory deficit to the medial aspect of the lower leg and foot. Injury to the sural nerve, which lies close to the small saphenous vein, may lead to a sensory deficit to the lateral lower leg and foot. Several motor nerves are also at risk for injury, including the tibial nerve, the common peroneal nerve, and occasionally a low-lying sciatic nerve, all of which course through or arise within the popliteal fossa and may be near the saphenopopliteal junction.
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Arterial or venous injury. Ligation of the common femoral vein may occur if it is mistaken for the saphenous vein. Ligation and stripping of the posterior tibial artery has been reported when it is mistaken for the saphenous vein at the ankle.
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Great saphenous vein stump. Ligation and division of the great saphenous vein that leaves a substantial blind stump may lead to thrombus formation with risk of pulmonary embolus.
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Hematoma, extensive ecchymosis, and pain
Operative Strategy
General Considerations
The technical goal of most venous surgery is elimination of axial reflux because of incompetent valves in the great saphenous vein and small saphenous vein, varicose vein clusters, and incompetent perforators. The best way to ensure that these goals are achieved is to perform a complete preoperative ultrasound assessment before the procedure. In addition, several intraoperative strategies can be used to avoid the major pitfalls of varicose vein surgery.
Preventing Recurrence
Preoperative markings with duplex ultrasound of the saphenofemoral or saphenopopliteal junction are helpful for proper placement of incisions. This reduces both incision size and unnecessary subcutaneous dissection, potentially reducing neovascularization and recurrent varicose vein formation. Ligation of incompetent accessory saphenous veins also reduces recurrence. Ligation of the great saphenous vein alone without vein stripping is associated with a higher recurrence rate. However, stripping of competent portions of the great saphenous vein can result in removal of important venous collateral pathways that may exacerbate the presence and development of varicose veins ( Fig. 59-1 ). Inadequate attention to the small saphenous vein and posterior calf varicosities is another cause of recurrence. In a recent survey nearly 90% of surgeons carried out preoperative duplex imaging, but only 50% marked the saphenopopliteal junction and even fewer explored this region, thus limiting treatment of gastrocnemius veins or other incompetent veins that could serve as a source of persistent reflux. Awareness of small saphenous vein anatomy, careful preoperative marking, and gentle retraction and dissection can increase the success and reduce the morbidity of small saphenous vein ligation.
