Chapter 154 - Varicose vein surgical treatment

Question 1

Varicose vein definition

Answer 1

Subcutaneous veins in LE dilated > 3 mm diameter in upright position

Question 2

Treatment types of varicose veins

Answer 2

1) high ligation
2) ligate and strip
3) endovenous ablation
4) sclerotherapy
5) ambulatory phlebectomy

Question 3

Compression stocking grade for CEAP 2-4 and CEAP 6

Answer 3

2-4: 20-30 mmhg

6: 30-40 mmHg

Question 4

Varicose vein guidelines from SVS and AVF recommendations 8 points

Answer 4

1) 20-30 mmHg for symptomatic varicose veins
2) compression first line for healing ulcers
3) endovenous procedure > open surgery when possible
4) stripping to knee of GSV only
5) SSV incompetence high ligation 3-5cm distal to SPJ
6) CHIVA and ASVAL to be done in select patients only
7) ambulatory phlebectomy to be done concurrent with stripping
8) people who are candidates for ablation should get them instead of compression alone

Question 5

Course of GSV

Answer 5

1) anterior to medial malleolus
2) obliquely and posteriorly across anteromedial calf
3) posterior arch vein joins at the knee
4) anterior accessory vein merges around knee joint
5) GSV lies in superficial fascia

Question 6

Rate of a duplicate GSV in calf

Answer 6

33%

Question 7

U/S finding of variations in GSV

Answer 7

60% GSV normal with single medial-dominant system

1) Complete double system 10%
2) closed loop system 10%
3) lateral-dominant system 8%

Question 8

Kupinski three anatomic variants of GSV

Answer 8

I type: GSV within fascial envelope long entire length
H type: subcutaneous collateral running parallel and superficial
S type: caudal portion atretic and extrafascial tributary dominant

Question 9

SSV variabilities

Answer 9

1) termination at above knee popliteal 33%

2) low termination site < 10%

Question 10

SSV notable branches

Answer 10

1) posterolateral tributary vein (runs along SSV)
2) anterolateral superficial thigh vein
3) intersaphenous vein
4) posteromedial superficial thigh vein

Question 11

Nerves in popliteal fossa

Answer 11

1) tibial nerve
2) common peroneal nerve
3) lateral cutaneous sural nerve (off common peroneal)
4) medial ramus of tibial nerve

Question 12

Gastronemius veins track

Answer 12

1) arise from medial and lateral head of gastronemius muscle
2) join with SSV or popliteal vein directly
3) sometimes SSV joins gastrocnemius vein instead

Question 13

Incidence of incompetence of gastrocnemius veins

Answer 13

20%

Question 14

Intersaphenous vein course

Answer 14

prev. Giacomini

1) posterior medial aspect of thigh off SSV
2) joins GSV 64%
3) join deep system 45%

Question 15

Relationship of the sural nerve to SSV

Answer 15

sensory

superficial to SSV or intertwined

Question 16

Motor nerves near SPJ

Answer 16

1) tibial (medial popliteal nerve)

2) low lying sciatic nerve

Question 17

Location of incision for high ligation gsv

Answer 17

1) 1cm above and parallel to groin crease
2) oblique
3) start where palpable femoral is and extend medially

Question 18

6 main tributaries of the SFJ

Answer 18

1) inferior epigastric vein
2) superficial circumflex iliac vein
3) lateral accessory saphenous vein
4) deep external pudendal vein
5) superficial external pudendal vein
6) medial accessory saphenous vein

Question 19

Artery that runs between GSV and FV

Answer 19

External pudendal artery

Question 20

Rate of GSV incompetence in patients with CVI and symp VV

Answer 20

2/3

Question 21

Direction of stripping to minimize saphenous nerve injury

Answer 21

Downward direction

Question 22

Pro and con of inversion technique

Answer 22

1) smaller distal incision needed
2) tunnel diameter smaller
3) reduced local trauma
4) vein can tear resulting in incomplete removal

Question 23

Tumescent anesthesia

Answer 23

1) 1% lidocaine + epi 40 ml
2) sodium bicarb 10 ml
3) normal saline 450 ml

Question 24

Clinical situations suggestive of SSV incompetence

Answer 24

1) persistent varicosity after GSV treatment
2) posterior calf varicosities
3) isolated lateral malleolar ulcer
4) ulcer recurrence after perforating surgery

Question 25

Incision for SSV

Answer 25

transverse skin incision just distal to SPJ based on U/S

Question 26

Other considerations of SSV exposure

Answer 26

1) Ligate gastrocnemius veins if reflux 2) care taken not to injure tibial or sural nerve 3) segment of SSV cut but not stripped (sural nerve injury)

Question 27

Relative contraindications to using epinephrine in tumescence

Answer 27

1) DM 2) glaucoma 3) CAD 4) dysrhythmias 5) HTN 6) hyperthyroidism 7) PAD

Question 28

Mueller technique of stab avulsion

Answer 28

1) 11 blade or 18 gauge needle | 2) longitudinal incision except in groin, knee and ankle where Langer lines exist

Question 29

TriVex

Answer 29

Transilluminated power phlebectomy 1) smaller incision 2) shorter procedure time 3) worse QOL 4) higher complications

Question 30

Saphenous sparing operations rationale

Answer 30

1) Ascending cause of varicose veins 2) remove only reflux segments focusing on varicosities of peripheral venous network 3) CHIVA and ASVAL

Question 31

CHIVA by Franchesci

Answer 31

Conservatrice et Hemodynamique de l'insuffisance veineuse en ambulatoire 1) U/S map all incompetence tributaries 2) incompetent tributaries ligated and varicosities removed 3) recurrence of VV 10 years lower 18% than HLS 35%

Question 32

Franchesci types of communication between superficial and deep venous system

Answer 32

TYPE 1: reentry by venovenous shunt at saphenous trunk TYPE 2: no reflux from deep but reflux from superficial venous network TYPE 3: reentry on extrasaphenous superficial perforator TYPE 4: reflux from pelvic circulation

Question 33

ASVAL

Answer 33

Ambulatory selective varices ablation 1) remove venous varicose reservoir through multiple stab incisions No clear evidence to demonstrate or compare with HLS

Question 34

ESCHAR trial key points

Answer 34

1) CEAP 5-6 randomized to medical vs surgical 2) surgery has less recurrence 3) no difference in rate of healing 4) intent to treat; 20% crossed from surgery to med

Question 35

Michaels et al RCT

Answer 35

1) 246 patients with varicose vein - compression vs HLS | 2) quality of life improved in surgery

Question 36

RCT's comparing EVA with HLS

Answer 36

1) early post op advantage of EVA in QOL | 2) equalizes at 1 month

Question 37

REVAS study key pionts

Answer 37

Recurrence of varicose veins after surgery | 1) no difference in recurrence between EVA and L&S

Question 38

Failure of SSV treatment are due to

Answer 38

1) inadequate ligation of proximal SSV >60% 2) incompetent popliteal area perforating vein 3) incompetent gastrocnemius veins

Question 39

EVA in SSV benefits

Answer 39

1) higher success 2) reduced pain 3) faster return to work 4) sensory disturbance lower Still has concern of thermo injury

Question 40

Key criteria for pushing elective venous therapy

Answer 40

1) symptomatic varicose vein 2) duplex evidence of reflux > 1 sec 3) GSV > 4 mm 4) trial of compression stocking 6 week to 3 months without relief 5) venous ulceration 6) bleeding 7) thrombophlebitis

Question 41

Indication for L&S over EVA

Answer 41

1) vein of interest close to skin <1cm 2) Large aneurysmal or dilated GSV > 2.5 cm (vein 2mm - 15mm is target EVA territory) 3) chronic thrombophlebitis 4) excessive tortuosity 5) acute superficial thrombosis