Recurrent varicose veins after short saphenous vein surgery: a duplex ultrasound study

Ultrasound-guided foam sclero -therapy of the small saphenous vein

Ultrasound guided sclerotherapy (UGFS) of varicose veins is a worldwide spread method, in many countries recognized by guidelines. Important for the outcome is the patients history, clinical investigation and a detailed colour coded ultrasound mapping previous to UGFS.

In previous studies varicose small saphenous vein (SSV) treatment with UGFS were reported to have worse results compared to GSV. Other studies report good outcome after UGFS of SSV varicose veins up to 12 months follow up.

In my experience UGFS of insufficient SSV is safe and effective with high patient‘s satisfaction, good longterm results and improvement in quality of life. UGFS can be used in all age groups. UGFS has the additional benefit that repeated treatments are easy to perform if needed and that this method is very cost effective. Treatment sessions last 20 to 30 minutes so that patients do not need significant time off work.

The Incidence, Clinical Importance and Management of Incompetent Gastrocnemius Vein

PURPOSE

To report the incidence, clinical importance and management of the incompetent gastrocnemius vein.

METHODS

The incompetency was examined by duplex and pulse-Doppler ultrasound at the popliteal fossa in a standing position between July 2006 and August 2014.

RESULTS

Among 1805 legs surveyed, 14 legs showed primary incompetent gastrocnemius vein (0.78%). The incompetency was in medial gastrocnemius vein in 13 legs (93%). Clinical manifestation was varicose vein in the small saphenous territory in nine, varicose vein in great saphenous territory in one, congestive dermatitis in two, calf clamp in one and no symptom in one. The nine cases with varicose vein in the small saphenous territory received surgical management. These included three cases with residual varicose veins after saphenopopliteal disconnection and stripping small saphenous vein. The root of the gastrocnemius vein was divided leaving no complication. In cases without varicose vein in small saphenous territory, an elastic compression socks was useful in some degree.

CONCLUSIONS

Incompetency of gastrocnemius vein was not so rare. When a case is accompanied by small saphenous varicose veins, division of the root of gastrocnemius vein along with small saphenous vein stripping is recommended in order to reduce residual varicose vein.

Midterm Clinical Outcomes after Modified High Ligation and Segmental Stripping of Incompetent Small Saphenous Veins

Background

The aim of this study was to evaluate the midterm clinical outcomes after modified high ligation and segmental stripping of small saphenous vein (SSV) varicosities.

Methods

Between January 2010 and March 2013, 62 patients (69 legs) with isolated primary small saphenous varicose veins were enrolled in this study. The outcomes measured were reflux in the remaining distal SSV, the recurrence of varicose veins, the improvement of preoperative symptoms, and the rate of postoperative complications.

Results

No major complications occurred. No instances of the recurrence of varicose veins at previous stripping sites were noted. Three legs (4.3%) showed reflux in the remaining distal small saphenous veins. The preoperative symptoms were found to have improved in 96.4% of the cases.

Conclusion

In the absence of flush ligation of the saphenopopliteal junction, modified high ligation and segmental stripping of small saphenous vein varicosities with preoperative duplex marking is an effective treatment method for reducing postoperative complications and the recurrence of SSV incompetence.

Medium-term results of ultrasound-guided foam sclerotherapy for small saphenous varicose veins

Background

The results of surgery for small saphenous varicose vein (SSV) varicosities may be suboptimal in terms of recurrence and complications. The role of minimally invasive alternatives remains incompletely defined. The aim was to review the medium-term outcomes of ultrasound-guided foam sclerotherapy (UGFS) for SSV.

Methods

Eighty-six patients (92 legs) undergoing UGFS for SSV were assessed before, and 1, 6 and 12 months after treatment. Outcome measures were occlusion of, and abolition of reflux in, the SSV (technical success), absence of visible varicose veins (clinical success) and improvement in disease-specific health-related quality of life (HRQL) following treatment (Aberdeen Varicose Vein Symptom Severity Score (AVSS)).

Results

The technical and clinical success rates at 12 months were 91 and 93 per cent respectively; only three patients required a second treatment. After treatment of isolated SSV varicosities there was a significant improvement in AVSS, from a median of 19·0 (interquartile range 13·4–26·8) before treatment to 10·2 (4·0–18·3) and 9·7 (3·5–19·1) at 6 and 12 months respectively. The only complication was a popliteal vein thrombosis that required anticoagulation.

Conclusion

UGFS was an effective treatment for SSV, with abolition of reflux and visible varicose veins, and improvement in HRQL for at least 12 months.

Subfascial ligation at three different levels versus partial exeresis of the incompetent short saphenous vein: A randomized clinical trial

OBJECTIVE

The study's objective was to compare subfascial ligation at three different levels and partial exeresis of the short saphenous vein for persistence of a reflux route and patients' subjective improvement of symptoms.

DESIGN

A prospective randomized clinical trial was conducted.

MATERIALS AND METHODS

Eighty-four limbs with incompetent short saphenous veins were randomized for subfascial ligation at three different levels (n = 44) or partial exeresis (n = 40). Duplex ultrasound was performed preoperatively and postoperatively. The short saphenous vein was mapped before surgery. The patients' symptoms were documented before and after surgery. The Student t test and chi(2) test were used to calculate differences between the two treatment groups. Logistic regression analyses were performed to determine predictive values for the primary outcome measures: persisting reflux route and patients' subjective improvement after surgery.

RESULTS

Patients' characteristics and previous and additional surgical intervention were not significantly different between the two treatment groups (chi(2) test). Postoperative duplex sonography showed reflux in 64 limbs (76%). Improvement of symptoms was demonstrated in 57 cases (68%). There was no significant difference in the persistence of reflux or patients' improvement of symptoms between the two treatment groups.

CONCLUSIONS

Our study showed poor technical results after subfascial ligation at three different levels or partial exeresis of the short saphenous vein. No significant differences in the persistence of a reflux route and patients' subjective improvement of symptoms between both treatments were demonstrated. Routine postoperative monitoring with duplex ultrasound would facilitate the surgical techniques, and anatomic knowledge of all variations of the saphenopopliteal junction is needed.

Recurrent varicose veins following surgical treatment: our experience with five years follow-up

OBJECTIVE

To report the 5 year outcome of varicose veins surgery and to establish the factors determining recurrence.

STUDY DESIGN

Prospective observational study.

MATERIALS AND METHODS

This study reports the outcome in 1326 patients treated in a day surgery centre of an institutional referral centre. Patients were investigated clinically and by colour flow duplex scanning before operation. Treatments used included flush ligation of the sapheno-femoral junction (SFJ) and the sapheno-popliteal junction (SPJ). Incompetence of the great saphenous vein (GSV) and small saphenous vein (SSV) were managed by stripping of these veins. Perforating vein ligation and hook phlebectomy were also used. Patients were evaluated 3 weeks and 5 years following treatment by clinical examination and duplex ultrasonography.

RESULTS

412 patients were excluded from the study because they failed to attend for follow-up or did not wear elastic stockings post-operatively. No residual saphenous truncal reflux was found at the initial assessment 3 weeks following surgery. After 5 years, recurrence of varicose veins occurred in 332 patients out of 1326 (25 %). Recurrences arose at the sapheno-femoral junction in 109 out of 862 patients (13%), at the sapheno-popliteal junction in 39 out of 132 patients (30%), in both saphenous regions 38 out of 107 patients (36%) and in 146 out of 225 subjects (65 %) with secondary varicose veins.

CONCLUSION

Varicose veins recurred despite technically correct surgery confirmed on post-operative duplex ultrasonography. The likelihood of recurrence increased in the presence of SSV reflux, perforating vein incompetence and post-thrombotic deep vein incompetence.

Minimally invasive technique for ligation and stripping of the small saphenous vein guided by intra-operative duplex ultrasound

BACKGROUND

Small saphenous vein (SSV) disconnection and removal are challenging and considered by some authors to have too high a morbidity and failure rate to justify their routine use. Our audited results are at variance with these views.

METHODS

We describe a reliable, ultrasound guided, minimally invasive technique for ligation and stripping of the SSV with an incision usually <1 cm. From our total series, 50 random patients attended for ultrasound review. The sapheno-popliteal junction (SPJ), strip track and signs of recurrence were assessed and recorded.

RESULTS

Since 1999, 627 patients (679 limbs) have undergone surgery for ultrasound proven SSV reflux. Fifty-two limbs (50 patients) were ultrasound assessed post-operatively. Fifty-one had flush ligation of the SPJ with one showing a 'stump' <1 cm. All showed successful SSV removal. Three limbs had minor strip track revascularisation but none had obvious clinical recurrence. Of the whole series, 11/627 (1.8%) developed proven deep vein thrombosis (DVT). There were six superficial wound infections and one strip track abscess. Sural nerve neurapraxia occurred in 13/627 (2.1%); one showing no sign of recovery at four weeks post-operatively.

CONCLUSIONS

Ultrasound guided SSV is a safe, minimally invasive technique with high success and low recurrence and complication rates

The synergism of penile venous surgery and oral sildenafil in treating patients with erectile dysfunction

A possible synergistic effect between penile venous surgery and oral sildenafil was inadvertently found in treating patients with erectile dysfunction in our clinic. We therefore sought to elucidate the possible synergic effect between venous surgery and sildenafil through studying patients who were non-responders preoperatively. From July 1998 to July 2003, 128 patients were diagnosed with veno-occlusive dysfunction. Subsequently, 65 of them underwent penile venous surgery and were assigned to the surgical treatment group. The remaining 63 men were assigned to the control group, and were subject to a simple re-exposure of oral sildenafil. All patients were evaluated with the international index of erectile function (IIEF-5) scoring. Sildenafil (12.5-100 mg) was prescribed postoperatively to all surgical patients as venous surgery alone was unsatisfactory and similarly, 100 mg preparation was prescribed for patients in the control group. The IIEF-5 scoring in the control group changed from a preoperative mean IIEF-5 score of 9.4 +/- 3.9 to 10.7 +/- 3.5 postoperatively. In surgical patients, however, the mean preoperative IIEF-5 score of 9.2 +/- 5.0, which increased to 15.1 +/- 5.0 (p < 0.001) postoperatively, further increased to 20.1 +/- 5.4 (p < 0.0001) after the addition of sildenafil. Although there was no significant difference between the two groups characteristics, there was a statistically significant difference between treatment results (p < 0.001). Overall, 61 men (93.8%) reported a positive response to sildenafil after venous stripping surgery. In contrast, only eight patients (12.7%) felt a beneficial response in the control group (p < 0.001). Forty-one of 65 patients had scores of > or =22, and 19 of these had a score of 25. No response was found in three (4.6%), and a decrease of 7 was seen in one (1.5%). In summary, patients in whom sildenafil was not effective preoperatively can become excellent responders after careful penile venous surgery. It appears that together, oral sildenafil and penile venous surgery may provide an encouraging solution to impotent patients with veno-occlusive dysfunction who are non-responders to sildenafil.

The Management of Short Saphenous Varicose Veins: A Survey of the Members of the Vascular Surgical Society of Great Britain and Ireland

OBJECTIVE

The outcome of short saphenous vein surgery is often unsatisfactory and the high litigation rate reflects this. The aim of this study was to explore the current management of short saphenous varicose veins in Great Britain and Ireland.

METHODS

This was a postal questionnaire survey of the surgical members of the Vascular Surgical Society of Great Britain and Ireland. Of 532 questionnaires 379 were returned (71.2%).

RESULTS

There was diversity of opinion about the management of short saphenous veins. Eighty nine per cent of surgeons requested duplex imaging for all patients and over 50% arranged additional duplex marking of the saphenopopliteal junction preoperatively. Only 10.4% formally exposed and identified the popliteal vein during saphenopopliteal ligation, the majority (75.7%) dissected down the short saphenous vein to visualise the junction. The short saphenous vein was stripped routinely by 14.5% of surgeons, the majority preferring to excise a proximal segment of up to 10 cm (55.1%). Compared with long saphenous vein surgery, surgeons were generally more likely to warn patients of nerve damage but equally likely to warn of deep vein thrombosis. A small number of surgeons failed to warn patients of these complications.

CONCLUSION

The variation in management of short saphenous veins may be explained by the lack of definitive clinical trials in this area.

Subfascial ligation of the incompetent short saphenous vein: technical success measured by duplex sonography

The aim of this prospective study was to assess the technical success of subfascial ligation of the short saphenous vein (SSV) in patients with SSV varices by postoperative duplex sonography. From January 1997 to October 2000, 28 patients (9 men and 19 women; mean age 56 years, range 32-72) underwent sapheno-popliteal ligation for incompetence of the sapheno-popliteal junction (SPJ). Four patients had operations on both limbs. Follow-up took place 3 months after the operation by using duplex sonography. In only 5 cases, the SSV was occluded completely. In 14 cases, there was no communication with the deep venous system, but a venous reflux via collaterals and epifascial veins still existed. In 13 cases, the SPJ still existed with tortuous development of the SPJ and sometimes with partial thrombosis. Postoperative duplex sonography showed that subfascial ligation of the SSV alone is not effective for the treatment of sapheno-popliteal reflux. Further prospective studies are necessary to find the best treatment for sapheno-popliteal reflux. Because of the immense progress in this treatment and the increased responsibility of nurses caring for these patients, the nurse must be thoroughly aware of the multifaceted problems of SSV varices.

Persistent popliteal fossa reflux following saphenopopliteal disconnection

BACKGROUND

This was a retrospective assessment of the technical adequacy of saphenopopliteal disconnection (SPD).

METHODS

Patients scheduled for SPD underwent preoperative colour-coded duplex imaging to localize the saphenopopliteal junction (SPJ). Operations were conducted with the patients under general anaesthesia in the prone position with planned full popliteal fossa exposure. Patients were reimaged 6 weeks after operation.

RESULTS

Some 69 patients had surgery over 4 years; complete data were available for 59 (27 men and 32 women, median age 55 (range 27-78) years). There were eight staged bilateral procedures. Postoperative duplex scans identified 23 (39 per cent) with ideal results (incompetent SPJ successfully disconnected), 12 (20 per cent) with satisfactory results (incompetent SPJ disconnected successfully but persisting venous reflux in superficial veins), eight duplex failures (14 per cent) (previously identified incompetent SPJ persisted but was competent after operation) and 13 surgical failures (22 per cent) (incompetent SPJ completely missed during surgery). There were three major postoperative complications (5 per cent) (two deep vein thromboses and one popliteal vein injury) and one patient suffered a sural nerve palsy.

CONCLUSION

Despite preoperative duplex localization of the SPJ, SPD proved an unreliable technique in this series.