The superficial venous systems of the leg consist of the long and short Saphenous veins.
The venous circulation.
Veins are tube shaped blood vessels that carry blood back to the heart, the pump that keeps blood in constant circulation. In veins localized above the level of the heart ( upper chest, neck and head) there are no problems as the gravity will help bring blood back to the heart.
However, in veins localized below the level of the heart, and especially in the distant leg veins, there is a problem as blood in these veins has to return to the heart against the existing gravitational forces.
Fortunately, as long as there is pressure in the venous system (provided by the heart constant pumping activity and the calf muscles contraction during walking) and as long as the existing little double winged gates that we physicians call VALVES (that exist in every veins) open and close normally, blood cannot be pulled back by gravitation and will slowly but surely reach the heart. Please compare the activity of these vein valves to the activity of locks on a dam: blood can go only in one direction, namely uphill, back to the heart and never downhill back to the ankle. To see an animation of the circulation of blood in varicose veins, the reader is referred to the excellent website of Dr. Tibbs of Oxford, England.
Varicose veins are distended, tortuous / twisted bulging "ropey" superficial veins of the leg that instead of conducting blood upward, back to the heart, conduct blood downward, in a reversed fashion, back to the...foot. This reversed flow pattern is called reflux. As blood accumulates and forms stagnant pools, the veins become visible. All this is possible as the little gates or valves existing in the veins, which ensure a normal unidirectional uphill flow, cannot close properly due to the vein wall distension. This enables gravitation to take over in the upright position, causing the reversed flow pattern. Basically, the existing valves along the vein simply put, leak. As restitution of the normal uphill flow is not possible, a lasting treatment requires control i.e. correction of the reversed flow and removal of the distended varicosities.
1. CONSERVATIVE (elastic support) TREATMENT. By reducing vein distension, elastic support controls the symptoms of varicose veins such as discomfort, pain and occasional ankle swelling. Elastic stockings also help squeeze the superficial veins and force blood to enter the deep veins and through them go upward, back to the heart. Elastic compression is very useful when definitive treatment cannot be undertaken because of disease, pregnancy or obesity.
2. INJECTION SCLEROTHERAPY for varicose veins should be an appealing therapeutic modality, as it shifts treatment away from the costly hospital care. Unfortunately, however, sclerotherapy in all of its forms, including the much publicized and "fashionable" ultrasound guided injections, cannot control or correct the existing reversed flow patterns and thus should no longer be performed as its results will be only short lived.
WHY DOES INJECTION SCLEROTHERAPY FAIL FOR VARICOSE VEINS? Numerous reports, ours included, have critically evaluated the long term results of this therapeutic modality and have concluded that sclerotherapy carries an unacceptably high (60-100%) 2-5 year failure (recurrence) rate. The reason for that is that sclerotherapy causes a blood clot in the injected vein. This clot will dissipate ("melt") with time and the injected vein will reopen again. This is not difficult to understand if you remember that varicose veins mimic waterfalls that have a top of the hill source of downpour and a bottom of the hill water accumulation or pool(s). So do varicose veins, except that the downpour is blood rather than water. The proximal source of downpour in the case of varicose veins is usually located either at the level of the groin or behind the knee. The varicose branches are the equivalent of the water pools. Siphoning the water from the pools at the bottom of the hill without sound control of the flow (downpour) at the top of the hill will result in rapid refilled pools. Due to the melting clot, sclerotherapy can only temporarily control the proximal source of downpour, therefore, it is easy to understand why just a few months after treatment the reversed flow is reestablished again and the leg varicosities will simply "blossom" in no time.
The handbook of Venous Disorders-Guidelines of American Venous Forum published in January of 1996 by Chapman and Hall Medical clearly states on page 343 that "injection sclerotherapy is contraindicated in varicose veins with communication with a source of reflux (reversed flow)" and on page 399 "experience teaches that sclerotherapy of varicose veins in presence of saphenous reflux (reversed flow) will fail."
We firmly believe, therefore, that it is immoral and unethical to promote and perform a medical procedure with such a high failure rate. If a practitioner still suggests this treatment modality, you are in the wrong hands! We can provide anyone interested with the existing literature on the subject to prove our point.
3. SURGERY is and remains, therefore, the best and the only reliable therapeutic option for varicose veins.
The high ligation, stripping and excision / ligation of varicose veins (shortly known as stripping surgery) is a procedure that was introduced at the turn of the century by three American surgeons (Keller, Mayo and Babcock) It is a very good procedure as it controls the source of downpour and also takes care of the existing varicosities (or "pools" if you prefer). It is still widely used. Unfortunately, however, it is a very traumatic procedure requiring general anesthesia, hospital setting and up to two-three weeks convalescence at home. It is also a very costly procedure too, due to the need for general anesthesia, hospital setting, convalescence and possible loss of income. Basically, the procedure consists of ligating (tying off) the proximal source of the reversed flow (the previously mentioned downpour) which in most of the cases (70-80%) is localized at the groin. This is followed by a "roto-rooter" type procedure called stripping, by which a long wire is threaded into the vein from the groin to the ankle. At this level the vein is secured to a thumb size acorn shaped head attached to the long wire. Traction on the wire at the groin will basically "yank" the whole vein out from the ankle to the groin. The oversized stripper head is responsible for the trauma inflicted to the soft tissues around the vein (with occasional permanent nerve injury) and the long convalescence as well. The remainder of the varicose veins are excised and ligated through usually generous incisions which require several stitches each. The occasional ugly scarring leaves the cosmetic effects of the procedure much to be desired.
Ambulatory phlebectomy is almost completely a European procedure. Progress in evaluation of the venous system by invasive and non-invasive means produced a better understanding of hemodynamical patterns existing in varicose veins which fueled the dramatic change in the surgical protocol. British surgeons (Rivlin, Negus) first came to the conclusion that stripping from the ankle to groin is not necessary in most cases of varicose veins and that a limited groin to knee stripping is quite sufficient. In some cases it is not even needed at all. At the same time, while still performing the conventional long ankle to groin stripping, a Belgian surgeon (Van der Stricht) reintroduced the more simple, elegant and far less traumatic inverted stripping that was suggested by Keller at the turn of the century. This method was recently further perfected by a Swiss surgeon, a good friend of mine (Oesch). Under this protocol, an atraumatic small headed stripper is turning the vein inside out and is basically peeled out from soft tissues of the leg. No trauma is afflicted to the surrounding soft tissues. Moreover, the introduction of specially designed small hooks, by yet another Swiss physician (Muller) permitted further reduction of operative trauma, as the varicose veins could be now removed through minimal skin openings of 2-3mm that do not require stitches at all. As no scars are visible after 3-4 months,the cosmetic outcome also became much, much improved. We started operating, using this protocol since 1990 and in the past 10 years we have performed over 1800 procedures of the kind with outmost patient and physician satisfaction. We have presented the method in medical meetings and also wrote 7 publications on the subject, some of them with the cooperation of Dr. Yellin from Department of Surgery, University of California Medical School.
We went even further as to perform the procedure in an office setting and under strictly loco-regional anesthesia. That means that 15 minutes after the procedure ( which may last between 1 1/2-2 1/2 hours per leg) the patients is ready to leave the office and drive home and resume his/her normal daily activities, sporting activities included. You will wear, only during the day, a surgical stocking on your leg for one week's time, and you will certainly be able to shower every day. We have not given to a single of our operated patients a certificate of leave of absence as convalescence with this protocol is totally eliminated. In conclusion, ambulatory phlebectomy is a minimally invasive procedure (that is the trend of modern surgery anyhow)and by avoiding general anesthesia, hospital setting and convalescence it is also a very cost efficient procedure as well.
The correct title of the procedure is the MINIMALLY INVASIVE SURGERY FOR VARICOSE VEINS ( AMBULATORY PHLEBECTOMY) OR THE WALK –IN / WALK-OUT SURGERY.
The Main Conclusions after 1800 surgeries performed are :
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