Gabriel Goren and Albert E. Yellin J Cardiovasc Surg 1990; 31:672-77

Regardless of the implicated etiological factors, all truncal varicose veins, have a proximal escape point (source of reflux), a pathway of incompetence
( conductor of the axial reflux ), and a reentry point always situated in the low pressure area, beneath a pumping mechanism. Together, they constitute the well known retrograde circuit.

It was Bjordal of Sweden, in his elegant studies in the early seventies, who demonstrated that occlusion of the proximal escape point only, will cause a reduction in the elevated ambulatory venous pressure (AVP) existing in varicose veins. Occlusion of the distal perforator(s) did not similarly alter the elevated pressure levels. It is therefore imperative to precisely localize and map the first two elements of the retrograde circuit in order to ensure a long lasting therapeutic effect.

Doppler flowmetry provides accurate anatomic and functional detail(s) of the complex venous reflux mechanism present in varicose veins. This study was conducted to correlate the various clinical presentations of uncomplicated (normal calf pump function) primary varicose veins (P.V.V.) with the topographic and anatomic sources of reflux or escape points. 163 patients with P.V.V. (144 females, 19 males; 96 unilateral, 67 bilateral) in 230 involved limbs were examined. The origin and extent of the venous reflux were traced and recorded with Doppler ultrasound, using a Parks Vascular Mini-Lab III, model 1059. Three distinct groups were recognized:

Group I. Typical (complete) saphenous, long and short, varicosities with junctional escapes were found in 164 (71.3%). SFJ incompetence demanding ligation was detected in 147 (63.91%), and SPJ incompetence demanding ligation was detected in 17 (7.39%) limbs.

Group II. Atypical ( incomplete) saphenous, long and short varicosities with non-junctional escapes were detected in 51(22.17%) limbs. In 5 limbs, no escape could be detected, and the varicosities were minimal ("in situ" varicose veins). 22 limbs had their escapes localized in the main perforators: a mid thigh perforator (MTP) was recognized in 17, upper calf (Boyd) in 2, and distal ankle (Cockett) in 3 limbs. The remainder of 24 limbs had their escapes localized in the auxiliary perforators. In 17 limbs, it belonged to the territorial distribution of the branches of the internal iliac vein, constituting the upper thigh medial group (abdomino-pelvic escapes ). In 7 limbs, it belonged to the territorial distribution of the circumflex iliac and external epigastric veins constituting the upper thigh lateral group.

Group III. Non saphenous varicosities were encountered in 15 (6.52%) limbs. They were all localized in the lateral aspect of the thigh and calf and represented varicosities of the lateral venous system described by Albanese and Hach.

Clear contraindication to ankle to groin stripping was encountered in 55 (23.91%) of the total 230 limbs. With the proximal escape points localized elsewhere, contraindication of the ligation of the S.F.J. was encountered in 83 (36.08%) of limbs.

The polymorphic presentation of uncomplicated P.V.V. and the limited ability of the physical examination to provide clinically useful anatomic and hemodynamic information, makes Doppler examination an important non-invasive tool that can accurately map the origin and extent of the venous reflux. The anatomic and hemodynamic information obtained will permit the surgeon to design, in all cases of PVV, an individualized, more selective therapeutic protocol that will avoid the indiscriminate and often unnecessary stripping of the entire saphenous system(s).

G.Goren VASA 1991; 20:365-68

The recently accumulated hemodynamic and topographic data on primary varicose disease, coupled with the concomitant quest for maximal cost efficiency, cosmesis and saphenous vein preservation, is slowly changing the surgical approach to the classical stripping operation. It is however unfortunate that even today, many surgeons still believe and blindly follow an outdated rationale for the surgical treatment of varicose veins.

The currently available hemodynamic information on primary uncomplicated varicose disease, such as the less than constant occurrence of an ostial, especially sapheno - femoral junction, (SFJ) incompetence, the possible presence of competent (partially or even in entirety ) saphenous trunk(s) and the lack of outward flow in the distal perforators makes the known and accepted axioms (upon which the classical surgical treatment - high ligation and ankle to groin stripping was based) wrong, outdated, and long overdue for a major overhaul. Furthermore, the severity of the tissue trauma inflicted by the large stripper head and the multiple extensive incisions responsible for long convalescence and loss of income, the possible permanent nerve injury, the possibility of removing normal and competent truncular veins, and the lack of cosmesis, make the "classical - ankle to groin" stripping operation antiquated and in many cases, overkill.

As the clinical examination may be incomplete and occasionally even misleading, a judicious Doppler examination of the venous systems is mandatory to provide accurate information on the site of the escape point and the localization as well as the extension of incompetence / reflux present in varicose veins. In severe and complex cases, duplex imaging and the recently introduced calibrated air-plethysmograph (APG) will certainly add valuable diagnostic clues. The information gathered should permit the formulation of an individualized treatment protocol for each existing case.

The judicious and meticulous high ligation of the detected most proximal escape point is a sine qua non for a long recurrence free interval. However, the practice of indiscriminate and blind ligation of SFJ in all cases of primary varicose veins as still commonly practiced, should by all means be avoided.

In the case of hemodynamically significant axial reflux (responsible for the elevated ambulatory venous pressure) the long saphenous vein trunk should be removed, either partially (knee to groin) or totally (ankle to groin) depending on each individual case. However, in cases in which there is no involvement of the main saphenous trunk(s), with the incompetence / reflux and varicosities limited to tributaries only (as the case of varicosities of the two accessory saphenous veins), performance of any form of saphenectomy (stripping) is totally contraindicated. The frequently and still practiced indiscriminate and blind ankle to groin stripping in all cases of primary varicose veins, should also be avoided.

Removal of the tributary varicosities through the stab evulsion technique, via incisions no longer than 1.5-3 mm, using specially designed hooks, will take care of the dilated, diseased and incompetent veins, and will also automatically disconnect any potentially outflowing perforators, further guaranteeing the long term results of the procedure.

Moreover, performing the required saphenectomy with a small headed stripper that will promote the less traumatic invaginated stripping (or even via the same stab evulsion technique used for removal of the varicose tributaries) will eliminate the need for convalescence and will drastically lower the incidence of saphenous and sural nerve injury as well. Then, due to incisions only 1.5-3mm long, which don't require stitching, the cosmetic effects obtained will be excellent too, silencing all those critics who, exploiting the lack of cosmesis of the classical stripping procedure, promote a much inferior alternative: injection sclerotherapy.

Performed in an outpatient setting and under local anesthesia , this approach will have medical as well as cost effective merits that include: no hospitalization, general anesthesia, or need for convalescence with loss of income. And last but not least, in many of these cases, the trunk of the long saphenous vein will be preserved, partially or in its entirety, as a possible future bypass conduit.

The minimal trauma stab evulsion phlebectomy performed in conjunction with ligation of the most proximal source of reflux (escape point), will effectively abolish the regurgitant flow and lower the existing increased ambulatory venous pressure. When performed under loco-regional anesthesia and in an ambulatory setting the method is expected to become, when properly indicated, the ideal surgical procedure for the treatment of primary varicose veins.

G. Goren and A.E. Yellin. Ann Vasc Surg 1995; 9: 401-14

Primary varicose veins, if left untreated, can lead to discomfort and pain, thrombophlebitis, bleeding and chronic venous insufficiency including venous ulceration.

With a 5 year failure rate incidence of 60-100% (assessed by clinical randomized as well as duplex follow-up studies) injection sclerotherapy can no longer be performed if critical review of results is practiced. Therefore, surgery remains the only reliable treatment option for primary varicose veins.

The classical Babcock operation calls for blind intraluminal stripping of the entire greater or lesser saphenous vein which will end up bunched and wrapped around the oversized acorn shaped stripper head. This thick and hard "plug" traumatizes the subcutaneous tissues including the saphenous or sural nerve, leaving behind a large raw tract in which blood accumulates. The ensuing discomfort and pain are responsible for the prolonged convalescence and loss of income. Multiple and usually generous incisions used to remove the varicose tributaries add to the already inflicted trauma and may also result in cosmetically unacceptable scarring. Performed under general anesthesia and in a hospital setting, this traditional approach is also costly, with charges ranging, in the United States, from $8000 - $12,000.

The purpose of this article is to present a more conservative surgical protocol as an alternative to classical stripping that is hemodynamically sound, minimally invasive and responsive to the need for maximal preservation of the saphenous trunk as a potential vascular by-pass conduit. To precisely tailor the operation to each patient's individual pathologic condition, the two main elements of the retrograde circuit, the escape point (proximal insufficiency point) and the extent of the axial reflux (Hach's distal insufficiency point) were assessed by continuous wave Doppler ultrasound examination. Duplex examination was used only when the Doppler findings were inconclusive.

This protocol, which is based on principles that evolved in Europe over the past 25-30 years, calls for ligation of saphenous junctions [Fig 1-2] only when incompetence and reflux are clearly demonstrated clinically and conformed by c.w. Doppler ultrasound. In the presence of axial reflux, it also calls for a limited (segmental) groin - to - knee (rather than ankle - to - groin) and less traumatic invaginated form of intraluminal stripping, of which we prefer the recently introduced PIN stripping [Fig. 3-4-5-6] rather than flexible ministrippers that require an additional distal incision [Fig 7] . Tributary varicosities are removed by stab avulsion which requires minimal skin openings only 1.5-3 mm in length, using specially designed phlebextractor hooks [Fig. 8-9-10]. This procedure is performed in an office rather than hospital setting and uses femoral nerve block anesthesia, supplemented if necessary with local infiltration [Fig 11]. This minimally invasive approach is also remarkably cost efficient. Depending on the extent of stripping (one leg) the charges for the procedure are approximately $2000-$2500 including the surgeon's fee, and all supplies.

In the past 51/2 years (May 1990- November 1995) more that 850 such procedures have been performed with utmost patient and physician satisfaction. It is our belief that such a protocol, reported by others as well, has placed varicose vein surgery in realm of minimally invasive and cost efficient procedures.

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