Chapter 154 - Varicose vein surgical treatment Flashcards
Varicose vein definition
Subcutaneous veins in LE dilated > 3 mm diameter in upright position
Treatment types of varicose veins
1) high ligation
2) ligate and strip
3) endovenous ablation
4) sclerotherapy
5) ambulatory phlebectomy
Compression stocking grade for CEAP 2-4 and CEAP 6
2-4: 20-30 mmhg
6: 30-40 mmHg
Varicose vein guidelines from SVS and AVF recommendations 8 points
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
Course of GSV
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
Rate of a duplicate GSV in calf
33%
U/S finding of variations in GSV
60% GSV normal with single medial-dominant system
1) Complete double system 10%
2) closed loop system 10%
3) lateral-dominant system 8%
Kupinski three anatomic variants of GSV
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
SSV variabilities
1) termination at above knee popliteal 33%
2) low termination site < 10%
SSV notable branches
1) posterolateral tributary vein (runs along SSV)
2) anterolateral superficial thigh vein
3) intersaphenous vein
4) posteromedial superficial thigh vein
Nerves in popliteal fossa
1) tibial nerve
2) common peroneal nerve
3) lateral cutaneous sural nerve (off common peroneal)
4) medial ramus of tibial nerve
Gastronemius veins track
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
Incidence of incompetence of gastrocnemius veins
20%
Intersaphenous vein course
prev. Giacomini
1) posterior medial aspect of thigh off SSV
2) joins GSV 64%
3) join deep system 45%
Relationship of the sural nerve to SSV
sensory
superficial to SSV or intertwined
Motor nerves near SPJ
1) tibial (medial popliteal nerve)
2) low lying sciatic nerve
Location of incision for high ligation gsv
1) 1cm above and parallel to groin crease
2) oblique
3) start where palpable femoral is and extend medially
6 main tributaries of the SFJ
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
Artery that runs between GSV and FV
External pudendal artery
Rate of GSV incompetence in patients with CVI and symp VV
2/3
Direction of stripping to minimize saphenous nerve injury
Downward direction
Pro and con of inversion technique
1) smaller distal incision needed
2) tunnel diameter smaller
3) reduced local trauma
4) vein can tear resulting in incomplete removal
Tumescent anesthesia
1) 1% lidocaine + epi 40 ml
2) sodium bicarb 10 ml
3) normal saline 450 ml
Clinical situations suggestive of SSV incompetence
1) persistent varicosity after GSV treatment
2) posterior calf varicosities
3) isolated lateral malleolar ulcer
4) ulcer recurrence after perforating surgery
Incision for SSV
transverse skin incision just distal to SPJ based on U/S
Other considerations of SSV exposure
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)
Relative contraindications to using epinephrine in tumescence
1) DM
2) glaucoma
3) CAD
4) dysrhythmias
5) HTN
6) hyperthyroidism
7) PAD
Mueller technique of stab avulsion
1) 11 blade or 18 gauge needle
2) longitudinal incision except in groin, knee and ankle where Langer lines exist
TriVex
Transilluminated power phlebectomy
1) smaller incision
2) shorter procedure time
3) worse QOL
4) higher complications
Saphenous sparing operations rationale
1) Ascending cause of varicose veins
2) remove only reflux segments focusing on varicosities of peripheral venous network
3) CHIVA and ASVAL
CHIVA by Franchesci
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%
Franchesci types of communication between superficial and deep venous system
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
ASVAL
Ambulatory selective varices ablation
1) remove venous varicose reservoir through multiple stab incisions
No clear evidence to demonstrate or compare with HLS
ESCHAR trial key points
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
Michaels et al RCT
1) 246 patients with varicose vein - compression vs HLS
2) quality of life improved in surgery
RCT’s comparing EVA with HLS
1) early post op advantage of EVA in QOL
2) equalizes at 1 month
REVAS study key pionts
Recurrence of varicose veins after surgery
1) no difference in recurrence between EVA and L&S
Failure of SSV treatment are due to
1) inadequate ligation of proximal SSV >60%
2) incompetent popliteal area perforating vein
3) incompetent gastrocnemius veins
EVA in SSV benefits
1) higher success
2) reduced pain
3) faster return to work
4) sensory disturbance lower
Still has concern of thermo injury
Key criteria for pushing elective venous therapy
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
Indication for L&S over EVA
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
