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Original Articles |
The John Radcliffe Hospital, Headington, Oxford, UK
Correspondence: J M T Perkins MBChB FRCS MD, Consultant Vascular Surgeon, The John Radcliffe Hospital, Headington, Oxford OX3 9DU, UK. Email: Jeremy.perkins{at}orh.nhs.uk
Abstract
This article examines the practice of standard varicose vein surgery including sapheno-femoral and sapheno-popliteal ligation, perforator surgery and surgery for recurrent varicose veins. The technique of exposure of the sapheno-femoral junction and the sapheno-popliteal junction is outlined and advice given on avoidance of complications for both. The evidence regarding methods of closure over the ligated sapheno-femoral junction is examined as is the requirement for stripping and the use of different types of stripper. The requirement to strip the small saphenous vein and the extent of dissection necessary in the popliteal fossa is also examined. Complications of standard varicose vein surgery are outlined. The frequency of wound infection, nerve injury, vascular injury and venous thromboembolism are listed and strategies to avoid these complications are examined.
Key Words: varicose veins • great saphenous vein • small saphenous vein • complications • recurrence • venous intervention project
Standard open varicose vein surgery has been used to treat uncomplicated varicose veins for over 100 years. The specific techniques of the operation have been subject to regular, and often cyclical, change over the years. However, the essential aim of the operation, to ligate and disconnect the great (GSV) or small saphenous vein (SSV) at its junction with the deep venous system has remained constant.
Standard surgery remains the gold standard against which newer interventions need to be evaluated. These techniques have evolved over time and have been evaluated over long periods of time. Newer methods of ablating the GSV and SSV, using either laser, radio-frequency or foam sclerotherapy, are being used more widely, but conventional surgery remains the mainstay of varicose veins treatment in the National Health Service (NHS).1 The newer techniques must demonstrate comparable results in the long-term, not merely the benefits of short-term gain through earlier mobility.
Surgery or conservative management?
Patients with uncomplicated varicose veins complain of symptoms of pain, aching, heaviness, itching, cramps and restless legs.2 These symptoms may be accompanied by swelling of the leg. The cosmetic appearance of the varicose veins may also be an important factor for the patient. Surgery can only be justified if these symptoms are significantly improved or abolished.
Patients with varicose veins have been shown to have lower scores than UK population norms for domains relating to pain and physical function. Improvements in these aspects of quality of life have been demonstrated after standard varicose vein surgery3,4 at two years.
A randomized trial comparing surgery and conservative treatment for severe varicose veins showed that surgical treatment produced better results than conservative measures in terms of health-related quality of life, symptomatic relief, anatomical extent and patient satisfaction.5 The limitations of conservative management, relying largely on the use of compression stockings, are further confirmed by the large proportion of patients (52%) in this study who had crossed over to the surgical arm by three years.
Much of the debate regarding the effectiveness of surgery revolves around the issue of recurrence of varicose veins after surgical treatment. Recurrent varicose veins develop frequently after surgery and recurrence rates of 20–80% are reported at 5–20 years.6 In spite of the recurrent varicosities, many patients remain satisfied with their operation with 77% reporting their symptoms cured or better at 10 years.7 This same 10-year evaluation of patients after varicose vein surgery reported that 66% of patients remained ‘pleased’ overall at 10 years. The recurrence rate was 70% with 44% having a few recurrent veins only and 26% demonstrating varicose veins that were as bad or worse than before their original operation. The development of recurrent varicose veins does not therefore automatically equate with patient dissatisfaction with their varicose veins operation.
Evaluation of varicose veins before surgery
An initial history and clinical examination is essential. Further evaluation of the leg(s) is required to establish reflux within the GSV and SSV. The council of perfection is for every patient to have a complete duplex ultrasound assessment of the veins in the leg to fully evaluate the deep and superficial venous systems. For many centres this would place a significant burden on the provision of duplex services that would be deemed unacceptable or unsustainable.
The use of hand-held Doppler (HHD) assessment has developed as a useful screening tool in the outpatient setting, particularly for the evaluation of the saphenofemoral junction (SFJ) and reflux within the GSV. Comparison of duplex and HHD has demonstrated good concordance and sensitivity, and specificity rates of 95% and 100%, respectively, for HHD.8
In contrast, the results comparing HHD and duplex in the assessment of saphenopopliteal junction (SPJ) incompetence and SSV reflux are less favourable9 and the accuracy of HHD scanning in this area varies widely with a high false-positive rate reported.8,10 This is caused by other incompetent veins in the popliteal fossa such as gastrocnemius veins, the popliteal vein itself, or superficial tributaries of the GSV crossing the back of the knee. The anatomy of the popliteal fossa and the position of the SPJ varies more widely than the anatomy of the SFJ in the groin, which is more constant. The SPJ may be located in its traditional site and within 9 cm of the knee crease in only 45% of patients.11
This anatomical variation and the unreliability of HHD makes duplex scanning indispensable in the definitive diagnosis of SPJ incompetence. Marking of the SPJ, either just prior to surgery with the duplex scanner, or by indicating the position of the SPJ in relation to the knee crease, is essential in SPJ operations, particularly if small transverse incisions are to be used.
HHD is inaccurate in assessing recurrent varicose veins, where the SFJ and SPJ have been ligated in a previous operation.12
Assessment of the patient with varicose veins is suggested as follows:
Surgical management of GSV incompetence
The operation is performed in a sterile operating theatre under general, spinal or epidural anaesthesia. Simple ligation of the SFJ can, except in the most obese patients, be performed under local anaesthesia, but stripping of the GSV will usually require regional or general anaesthesia.
A transverse skin crease incision is made starting just medial to the femoral pulse and continuing medially. Reference to the femoral pulse will prevent dissection onto the common femoral artery and ensure exposure of the SFJ and GSV.
All tributaries of the SFJ are divided. Except in very thin patients, the GSV will not be found in a very superficial position immediately underneath the skin incision. Any vein encountered in this position is likely to be a superficial branch and may be used as a guide to follow down to the SFJ.
Anecdotal opinion states that the branches should be followed beyond their first branch and divided here, but there is no evidence to support this.
It is imperative to demonstrate the junction of the GSV with the common femoral vein to ensure that it is the SFJ that is ligated and not simply the junction of a superficial branch with the GSV. The deep vein (the common femoral vein) should be at the same depth as the common femoral artery and this can be checked by reference to the femoral pulse.
Operative techniques to reduce recurrence
As outlined above, adequate surgery, with correct exposure and demonstration of the relevant anatomy, allows successful ligation of the SFJ, which is the first prerequisite for prevention of recurrence.13 This implies that all surgeons undertaking venous surgery should be adequately trained and supervised to ensure that technical errors are minimized.
Different methods have been proposed for closing the SFJ once this has been divided. The theories behind them have raised the following questions:
The use of synthetic patches, or techniques to close the cribriform fascia over the ligated SFJ, have been proposed as methods to reduce recurrence arising from the groin.
Both silicone and polytetrafluoroethylene (PTFE) patches have been placed over the ligated SFJ in an attempt to prevent recurrence from neovascularization by placing a physical barrier between the junction and other veins in the area.
A randomized study of PTFE patch use in redo groin surgery showed no reduction in further neovascularization compared with a standard closure.17 The use of a silicone patch was similarly examined in a non-randomized study and shown to reduce neovascularization and recurrent thigh varicosities when compared with a standard two-layer closure.18 Complications occurred in 19.5% of limbs after redo surgery, of which half were lymphatic in nature.19 This non-randomized study showed a benefit for the use of silicone patch saphenoplasty, but the groups were later used as historical controls in a further study examining the benefit of closure of the cribriform fascia after SFJ ligation for primary varicose veins.20 Closure of the cribriform fascia was then proposed as an alternative option to prevent postoperative neovascularization as this was reduced at one year. The work of Glass21 is also widely cited as evidence, which states that closing the cribriform fascia reduces recurrence. In non-randomized groups, he demonstrated a reduction at four years from 25% to 4% for recurrence at the SFJ. GSV was not stripped in these operations which were done before duplex imaging was available for monitoring.
It is routine practice for many surgeons to strip the GSV after SFJ ligation. Stripping the GSV exposes the patient to a greater risk of nerve injury and increased morbidity from pain, bruising and haematoma formation in the thigh. These disadvantages are felt to be outweighed by the benefit of a reduction in the development of recurrent varicose veins.
The evidence in favour of stripping is suggestive but not overwhelming. Stripping of the GSV is postulated to reduce recurrence by preventing neovascularization in the groin joining up with the residual trunk of the GSV in the upper thigh and producing significant GSV reflux in the lower limb. Neovascularization has been shown to be the cause of recurrence in up to two-thirds of patients,22 but this same trial showed no difference in rates of recurrence between legs that had undergone stripping and those that had undergone simple SFJ ligation.22,23 Despite this finding of equal rates of recurrent varicosities, those patients in the stripping group had fewer redo operations for recurrent varicose veins, a finding that is not explained. Other studies, albeit with small numbers and shaky methodology, have shown a reduction in recurrence and better venous haemodynamics to be lower in the leg after stripping.24,25
The GSV should be stripped to knee level. Stripping the GSV to the ankle does not improve symptomatic relief, but significantly increases the risk of saphenous nerve injury.26
Surgical management of SSV incompetence
The patient may be positioned prone or in the lateral position with the operated leg uppermost.
The anatomy behind the knee, and position of the SPJ, is more variable than the anatomy in the groin. Many surgeons have therefore advocated the use of duplex scanning to mark the position of the SPJ prior to surgery for small saphenous incompetence.27 Alternatively, the position of the SPJ can be measured from the knee crease at the time of the original duplex scan and this measurement used to site the skin incision appropriately.
A transverse incision is made at the level of the SPJ. The fascia is divided and the SSV exposed. After identifying the SSV, two surgical strategies are available:
Perioperative techniques to reduce recurrence
Surgery of the popliteal fossa and SSV is more challenging than that of the SFJ and GSV. The evidence relating to different operative techniques, stripping of the SSV and duplex marking is at best poor and at worst non-existent.
The incidence of visible recurrent varicosities may be as high as 20% at one year after surgery.29 Incompetence of the SSV has been found to be the main source of venous reflux in the popliteal fossa in recurrent veins after small saphenous surgery.30
In 2004 over 50% of surgeons used duplex marking of the SPJ preoperatively,28 and this had increased slightly to 64% in a further survey of the long-suffering members of the Vascular Society in 2007.31 Despite this, the results for small saphenous surgery remains poor with approximately 25% of patients having a failure to deal with an incompetent SPJ and SSV.32,33 In Rashid's series, only 39% had an ideal result with successful disconnection of an incompetent SPJ.
Exposure of SPJ and flush ligation or simple SSV ligation?
No evidence exists to favour one technique over the other. Formal exposure and identification of the popliteal vein was performed by only 10% of surgeons surveyed in 2004,28 but in 2007 practice had moved in favour of this technique with 67% performing flush ligation of the SPJ.31 Proponents of flush ligation would argue that it is analogous to the technique of SFJ ligation in the groin and avoids leaving a stump of SSV as a potential source of recurrence. This pattern was demonstrated in 16% of patients with recurrence.30
Those in favour of simple SSV ligation as close to the junction as possible feel that this is a safer technique particularly with regard to nerve injury, which may be associated with excessive dissection and traction in the popliteal fossa (see below Complications – Nerve injury).
The SSV can be stripped to mid-calf or the top section of the vein can be resected. No randomized trials exist comparing these two techniques. Stripping to various levels was performed by approximately 30% of surgeons surveyed in 2007.31
As with the GSV, those who strip the SSV argue that it removes the residual SSV and prevents this being reconnected by recurrent varicose or neovascularization in the popliteal fossa. Opponents feel that it carries a higher risk of nerve injury, particularly sural nerve damage.
Prospective, non-randomized evaluation of the results of SSV surgery at one year showed a non-significant reduction in visible recurrent varicose veins in patients whose SSV was stripped, without any increase in rates of numbness. Duplex-detected SPJ incompetence was significantly lower in those who had undergone stripping.29 This provides some slight, but non-proven evidence in favour of stripping the SSV.
Surgical management of perforator vein incompetence
The whole subject of incompetent perforators is by debate and uncertainty not only about the best technique for ligating perforators, but also a more fundamental uncertainty as to whether they should be treated at all, especially in patients with uncomplicated varicose veins (CEAP 2–4). Isolated perforator disease is rare and incompetence of perforator veins is usually found in conjunction with reflux at other venous sites, both superficial and deep. It cannot, therefore, be considered as a separate entity in its own right, but as part of a spectrum of severity of venous reflux throughout the leg.
Most studies evaluating the role of perforator ligation have looked at patients with ulceration and the effects on ulcer healing. Even in this area there are no convincing randomized trials that definitively support the role of perforator ligation in ulcer healing.
The role of perforator surgery in primary varicose veins is less clear still. Haemodynamically there appears to be no additional benefit from adding perforator ligation to standard SFJ ligation and stripping.34 A small randomized study did show an increase in the number of incompetent perforator veins at one year in patients who did not have endoscopic perforator ligation (SEPS) in addition to standard SFJ ligation and stripping.35 However, at one year this had no effect on recurrence or quality of life.
The traditional operations proposed by Linton and Cockett have fallen out of favour because of excessive wound problems associated with long incisions in unhealthy skin. Wound infection rates in some series exceed 50%.36 Unsurprisingly, comparisons of SEPS with these open operations show a benefit for SEPS in reducing wound complications and length of hospital stay.36
SEPS can effectively treat perforators, but complications of saphenous neuralgia (6–10%), sural neuralgia (2%), wound haematoma and infection (6%), and DVT (1%) are reported.37,38
Alternatively, incompetent perforators can be divided by marking the site with duplex and ligating the perforating vein through a small incision. There are no randomized comparisons of this technique with other perforator vein procedures.
Techniques for the avulsion of varicosities (phlebectomy)
Standard surgical management of surface varicosities is to avulse these through small stab incisions using phlebectomy hooks.
This technique has been compared with transilluminated powered phlebectomy (TIPP). TIPP does not reduce operative time, but does reduce the number of stab incisions made.39,40 One randomized study showed TIPP to cause more bruising and pain in the early postoperative period and consequently an adverse impact on early generic quality of life.40
Complications of standard varicose vein surgery
Complications (major and minor) are reported in approximately 18–20% of patients having standard varicose vein surgery.41,42 Major complication rates are reported in around 0.8% of patients.41
These include infection, haematoma and abscess formation. Reported rates vary from 3–10%.5,41
Only one randomized study has looked at antibiotic prophylaxis in varicose vein surgery. Patients who received antibiotics had fewer GP attendances and fewer post-operative courses of antibiotics than those who did not.43 Suspected wound infection was not confirmed by wound culture.
Some degree of thigh haematoma formation is inevitable with stripping of the GSV and, as such, many surgeons would not consider this as a complication.
Thigh haematoma formation is reduced by the installation of local anaesthetic with adrenaline into the stripper track.44
The use of different strippers and tourniquet use in reducing haematoma formation is discussed below after the section on ‘Nerve injury’.
Some degree of sensory abnormality has been reported in up to 40% of patients undergoing SFJ ligation and stripping of the GSV to the knee.45 The incidence of true saphenous nerve injury appears to be significantly less and is reported in 7% of patients who have stripping to the knee, compared with 39% who had total GSVs stripping to the ankle.26
The femoral nerve is almost never injured in saphenofemoral ligation as it does not lie in close vicinity to the vein.
Common peroneal nerve (CPN) and sural nerve injury are complications of SSV surgery. The rate of CPN injury is reported to be as high as 2–4% in some series.46,47 This significant nerve injury results in foot drop. It is often said to occur from forceful use of the phlebectomy hook close to the neck of the fibula, but an assessment of medicolegal claims after varicose vein surgery showed that 17/18 CPN injuries occurred during dissection in the popliteal fossa.48
Sural nerve injury may occur as a complication of up to 20% of SSV operations.
Only careful dissection can avoid CPN and sural nerve injuries in operations of SSV incompetence.
Can the use of different types of stripper or the use of a tourniquet reduce postoperative complications?
The simple and succinct answer to this question is no. It has been proposed that inversion stripping may reduce the problems of bruising, haematoma formation and nerve injury compared with conventional stripping. The evidence does not support this claim, and the only demonstrable advantage of inversion stripping is that it produces a smaller exit wound for the stripper at the knee.49,50 Cryostripping confers no benefit over conventional stripping.
The use of tourniquets during varicose vein surgery has not been shown to reduce postoperative pain or bruising or to improve cosmesis.51 The only robust improvement demonstrated was a reduction in blood loss. Although this reduction was statistically different, in practice the difference would not be clinically significant.
Vascular injury and complications
Vascular complications are rare,52 with injury to the common femoral vein occurring more frequently than arterial injury. Laceration or division of the common femoral vein is the most common injury. Partial stripping of the femoral vein is uncommon and occurs when the stripper passes via a perforator into the deep system.
Arterial injury results from stripping of the superficial femoral artery for a variable distance down the leg. Recognition of this problem is often delayed (30% detected intraoperatively)52 and consequently the outcome is poor, with an amputation being required in one-third of cases.
The key to avoidance of vascular injuries is adequate exposure and identification of the relevant structures in the groin dissection. In thin patients excessive traction on the SFJ can lead to common femoral vein (CFV) injury, and if bleeding occurs blind grasping with artery forceps should be avoided. Spasm of the arteries may make them appear like veins in young patients. Division of structure should not be performed until identification is entirely clear.
The incidence of venous thromboembolic complications in varicose vein surgery is low. Deep vein thrombosis occurs in around 1:200 patients and pulmonary embolism in 1:600.41 This low risk of venous thromboembolism (VTE) would seem to preclude the use of routine anticoagulant prophylaxis, and surveys of vascular surgeons seem to corroborate this view, with only 27% routinely using heparin prophylaxis and 62% using it selectively.53
The development of VTE remains a constant source of litigation and claims where VTE occurred in patients who received no prophylaxis despite identifiable risk factors, were usually successful.54 Failure to perform a risk assessment and provide prophylaxis is considered negligent.
NICE guidelines for prevention of VTE in surgical patients were published in 2007 with a list of identifiable risk factors and listed in the recommendation below.
In vascular surgery (including venous surgery) patients with one or more risk factors should receive mechanical prophylaxis and low molecular weight heparin. This applies to inpatient treatment only.
It is clear that adequate training in standard venous surgery is essential to:
The new surgical curriculum places the technical skills required to perform primary SFJ/SPJ ligation with or without stripping and multiple avulsions at the ST2 level. The more advanced skills required for redoing the SFJ and SPJ ligation are placed at the end of training.
No specific number of procedures are stipulated. A conservative estimate would suggest that a minimum of 30 SFJ and SPJ ligations each should be performed, with at least 15 each of the redo operations.
Standard varicose vein surgery remains the gold standard against which other techniques should be measured. Effectiveness of newer techniques should be demonstrated over a minimum of a 10-year period.
Adequate training is essential to prevent unnecessary recurrence and avoidable complications.
Recurrence rates remain high, although exact definitions of recurrence remain unclear. The causes of recurrence are varied and can be seen as occurring against a background of an evolving venous system in the limb that is altered at one point in time by superficial venous surgery.
The author hereby declares no conflict of interests.
Accepted January 5, 2009
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