Hemodynamics-based treatment of varices: A therapeutic concept counteracting the intrinsic tendency of varicose veins to recur

Varicose vein disease is characterized by tenacious tendency to recur. Measures recommended to prevent recurrences (flush ligation at the saphenofemoral junction, removal of incompetent great saphenous vein in the thigh, and insertion of mechanical barriers in the fossa ovalis) did not succeed in preventing recurrence. Reflux recurrence is triggered by the hemodynamic phenomenon called hemodynamic paradox. Abolition of saphenous reflux removes the hemodynamic disturbance of any degree of severity but at the same time it releases the pathological process leading to recurrent reflux. This process is induced by drainage of venous blood from incompetent superficial thigh veins into deep lower leg veins during calf pump activity, which evokes the development of ambulatory pressure gradient between the femoral vein and incompetent segments of the saphenous system in the thigh. The pressure gradient sets off biophysical and biochemical events inducing recurrent reflux. The designed therapeutic strategy consists of reliable abolition of saphenous reflux and of hindering the pathological drainage of venous blood at the knee level in order to preclude development of the hemodynamic preconditions for reflux recurrence. In this way, the dividing line of the ambulatory pressure gradient would be kept below the knee, as is the case with healthy people.

Clinical Relevance of Neovascularisation on Duplex Ultrasound in the Long-Term Follow-up after Varicose Vein Operation

Objective:

To evaluate the clinical relevance of neovascularisation at the saphenous ligation site.

Design:

Long-term follow-up after previous varicose vein surgery in a single patient group.

Setting:

Vascular clinic of a university hospital.

Patients:

Eighty-two patients (106 limbs) with a mean follow-up period of 56 months after correct saphenous ligation were submitted to duplex scanning.

Intervention:

Clinical assessment and colour duplex scanning of all the operated limbs. Reintervention in 15 limbs with perioperative evaluation of recurrent veins.

Main outcome measures:

Limbs with and without recurrent varicose veins were classified according to the degree of neovascularisation: grade 0 = no new communicating veins, grade 1 = tiny new vein with diameter <4 mm, grade 2 = new communicating vein with diameter >4 mm and pathological reflux. On reintervention the presence of neovascular veins at the site of the previous ligation was checked.

Results:

In 68 limbs without recurrent varicose veins, grade 0 was observed in 50 limbs (74%), grade 1 in 12 limbs (18%) and grade 2 in six limbs (9%). In 38 limbs with recurrent varicose veins, grade 0 was diagnosed in eight limbs (21%), grade 1 in four limbs (11%) and grade 2 in 26 limbs (68%). In 15 limbs with recurrent varicose veins and grade 2 neovascularisation, reintervention confirmed the duplex findings.

Conclusions:

The presence of grade 2 neovascularisation was associated with the recurrence of varicose veins, suggesting a causal relationship.

Recurrence following Varicose Vein Surgery

Objective:

To determine the site-specific rates of recurrence following varicose vein surgery.

Design:

Postal questionnaire followed up by telephone enquiries. Full clinical review, including continuous wave and duplex Doppler investigations were carried out for all patients with responses suggesting recurrence.

Setting:

Surgicare Manchester, an independent provider of specialist varicose vein treatments. All procedures were guided by Doppler ultrasound and performed by surgeons working to the same protocol.

Subjects:

A consecutive series of 250 operations on 246 Patients. Of these, 208 (85%) could be contacted for follow-up. Mean time to re-examination was 27 months.

Results:

Twelve patients returned spontaneously and 51 were recalled for examination based on questionnaire responses. Recurrences were divided into ‘site’, ‘perforator’ or ‘new site’ recurrence. Primary surgery to the sapheno-femoral junction (SFJ) had the lowest ‘site’ recurrence rate of 2.3% compared with 9.5% for SFJ re-operation. Primary surgery and re-operation of the sapheno-popliteal junction (SPJ) had higher recurrence rates of 8.3% and 7.8% respectively. New incompetence was detected in 5% and 2% of previously competent SFJ and SPJ respectively. Minor perforator incompetence was found in a further 14%.

Conclusions:

Varicose veins were progressive in some individuals, with new sites of incompetence appearing over time. However, ‘cure’ remains possible for most Patients and major recurrence can be reduced by Doppler diagnosis and precise surgery.

Randomised Trial of Polytetrafluoroethylene Patch Insertion for Recurrent Great Saphenous Varicose Veins

OBJECTIVES

The aim of this study was to assess the possible value of a polytetrafluoroethylene (PTFE) patch in the treatment of recurrent varicose veins.

METHODS

Thirty-one patients (40 legs) with recurrent saphenofemoral junction incompetence were randomised to redo saphenofemoral ligation and great saphenous vein stripping with, or without the insertion of a PTFE patch over the ligated junction. Patients underwent assessment preoperatively, and at 6 weeks, 1 year and 2 years postoperatively with clinical examination, duplex imaging and completion of the Aberdeen Varicose Vein Symptom Severity Score (AVVSSS).

RESULTS

A total of 27 patients (32 legs) attended for assessment at 6 weeks, 25 patients (30 legs) at 1 year and 27 patients (32 legs) at 2 years. At 6 weeks, seven legs (22%) had an area of cutaneous numbness; all but one had resolved by 1 year. Four legs (13%) developed a groin infection, which required antibiotics, 2 had a groin haematoma and four had a seroma, all of which resolved spontaneously. The overall complication rate was 35% (11 legs), with no statistically significant difference between the groups. Four of 16 legs without a patch and five of 16 legs with a patch developed neovascularisation at the saphenofemoral junction on duplex imaging by two years postoperatively. Two cases of neovascularisation in the patch group and one in the no patch group directly resulted in clinical recurrence (p=1.0). There was an improvement in patients' AVVSSS two years postoperatively (p<0.03), that was similar in both groups.

CONCLUSIONS

In this study, insertion of a PTFE patch did not affect the rate of perioperative complications and it did not appear to contain neovascularisation.

Closure of the Cribriform Fascia: An Efficient Anatomical Barrier Against Postoperative Neovascularisation at the Saphenofemoral Junction? A Prospective Study

BACKGROUND

Neovascularisation at the sapheno-femoral junction (SFJ) ligation site in the groin may occur within one year after great saphenous vein (GSV) surgery. Several anatomical and prosthetic barrier techniques have been proposed to prevent this evolution.

OBJECTIVE

A prospective study examined whether closing the cribriform fascia could reduce the incidence of postoperative neovascularisation in the groin.

PATIENTS AND METHODS

Patients with primary varicose veins and incompetence at the level of the SFJ were included. After SFJ ligation in 235 limbs of 193 patients an anatomical barrier was constructed by closing the cribriform fascia. Postoperative duplex scanning was performed after 2 and 12 months. Results were compared with historical control groups in which either a silicone patch saphenoplasty or no barrier technique had been performed.

RESULTS

After one year, 10 limbs had developed recurrent thigh varicose veins and duplex scan showed neovascularisation at the SFJ ligation site in 15 of 223 re-examined limbs (6.7%). This was comparable to the group of 191 limbs with silicone patch saphenoplasty (5.2%) (P=0.526) and superior to the group of 189 limbs without barrier (14.8%) (P<0.01).

CONCLUSION

Interposition of an anatomical barrier by closing the cribriform fascia after SFJ ligation reduced ultrasound detected neovascularisation at the SFJ after one year. In primary varicose vein operations application of an anatomical barrier technique (without prosthetic patch) is an alternative option to prevent postoperative neovascularisation.

Early and late complications of silicone patch saphenoplasty at the saphenofemoral junction

BACKGROUND

To reduce the incidence of postoperative recurrence after great saphenous vein (GSV) surgery, various barrier techniques have been introduced, aiming at containment of postoperative neovascularization at the saphenofemoral junction in the groin. Interposition of a prosthetic barrier (patch saphenoplasty) may be useful for this purpose; however, the incidence of postoperative complications after patch saphenoplasty is unknown. A prospective study examined the incidence of complications after patch saphenoplasty in primary and repeat varicose vein surgery.

METHODS

Silicone patch saphenoplasty was performed in a consecutive series of 462 limbs (primary GSV surgery in 380, repeat surgery in 82) in 387 patients. Early and late complications in the groin potentially related to patch saphenoplasty were registered at clinical follow-up after 1 week and at clinical and duplex ultrasound examination after 2 months, 1 year, and later in case of new symptoms.

RESULTS

Complications occurred in 44 limbs (9.5%), 28 (7.4%) after primary GSV surgery and 16 (19.5%) after repeat surgery (P < .01). After repeat surgery, half of the complications were lymphatic problems. Nine limbs (2.0%) developed a complication after >2 months. Wound infection was registered in 13 limbs (2.8%), lymphocele or lymphedema in the groin or thigh in 15 limbs (3.2%), symptomatic or asymptomatic proximal venous thromboembolism in 14 limbs (3.0%), and swelling of the thigh due to important stenosis of the common femoral vein visible on duplex scan in 4 limbs (0.9%). Two of the latter remained symptomatic even after venoplasty and stenting of the pinpoint stenosis of the common femoral vein.

CONCLUSION

Patch saphenoplasty can cause early and late postoperative complications in the groin, which are usually minor. In exceptional cases, major complications may cause important morbidity and may be difficult to handle.

Service comparison between vascular and general surgery in the treatment of chronic venous insufficiency with special reference to preoperative Doppler techniques

AIMS

To compare the ability of vascular and general surgical services to abolish reflux in superficial venous system with a special reference to preoperative use of Doppler techniques.

MATERIALS AND METHODS

68 lower limbs operated on for venous insufficiency based on either preoperative Duplex evaluation and Doppler marking in a vascular surgical unit (Vascular Surgical Service, VSS: 33 limbs, clinical class C2-C6) or clinical findings in a general surgical unit (General Surgical Service, GSS: 35 limbs, clinical class C2-C4) were re-examined clinically and with duplex scanning for reflux some three years postoperatively.

RESULTS

Marked superficial or perforator vein reflux was observed in 27 of 68 (39.7 %) operated limbs, thirteen of which in VSS and fourteen in GSS. However, axial reflux at saphenofemoral or thigh level was observed significantly less in VSS compared to GSS (3 vs 13, p = 0,006).

CONCLUSION

Total ablation of any reflux appeared difficult irrespective of the preoperative assessment. Preoperative Duplex examination, however, aided in identifying and treating axial reflux at thigh level.

Patient characteristics and physician-determined variables affecting saphenofemoral reflux recurrence after ligation and stripping of the great saphenous vein

OBJECTIVE

To identify patient and physician-controlled treatment variables that might predict the persistence or redevelopment of saphenofemoral junction (SFJ) reflux.

METHODS

Thirteen European centers, with substantial lower extremity venous disease practices, examined their experience with SFJ ligation and GSV stripping for primary varicose veins in patients followed for > or =2 years, entering their data into a protocol-driven matrix that stipulated duplex Doppler imaging as an essential component of follow-up examinations and required a complete review of all peri-operative examinations, as well as all operative procedure and anesthesia notes. Matrix entries were centrally audited for consistency and credibility, and queried for correction or clarification before being accepted into the study database. Presence or absence of Doppler-detectable SFJ reflux was the dependent variable and principal outcome measure.

RESULTS

Among 1,638 limbs, 315 (19.2%) had SFJ reflux. After adjustment for follow-up length and inputting for missing values, multivariable analysis identified seven significant predictors. Ultrasonic groin mapping (odds ratio [OR], 0.28; 95% confidence interval [CI], 0.20 to 0.40) and <3-cm groin incisions at or immediately below the groin crease (OR, 0.50; 95% CI, 0.32 to 0.78) were both uniquely associated with diminished probability of follow-up SFJ reflux. Prior parity (OR, 2.69; 95% CI, 1.45 to 4.97), body mass index >29 kg/m(2) (OR, 1.65; 95% CI, 1.12 to 2.43), <3-cm suprainguinal incisions (OR, 3.71; 95% CI, 1.70 to 5.88), stripping to the ankle (OR, 2.43; 95% CI, 1.71 to 3.46), and interim pregnancy during follow-up (OR, 4.74; 95% CI, 2.47 to 9.12), were each independent predictors of a greater probability of having SFJ reflux.

CONCLUSIONS

The findings suggest that ultrasound groin mapping, reticence for short suprainguinal or longer groin incisions and extended stripping, and counseling women about the effect of future pregnancy are prudent clinical choices, especially for obese or previously parous patients.

Accuracy of Duplex Evaluation One Year after Varicose Vein Surgery to Predict Recurrence at the Sapheno–Femoral Junction after Five Years

OBJECTIVE

To investigate whether the results of duplex examination 1 year after sapheno-femoral junction (SFJ) ligation might be helpful in predicting long-term results after 5 years.

PATIENTS AND METHODS

Follow-up data concerning patients operated on for primary or recurrent varicose veins of the great saphenous vein were studied 1 year and 5 years after surgery, focusing on the thigh and groin region. Clinical examination was undertaken to detect recurrent thigh varicose veins. The site of SFJ ligation was carefully screened for any signs of neovascularisation by duplex ultrasound. Sensitivity, specificity, positive and negative predictive value of the 1-year duplex scan were calculated, based upon the outcome of a further duplex scan 5 years following surgery.

RESULTS

A total of 100 limbs were studied: 50 limbs operated on for primary varicose veins and 50 limbs for recurrent varicose veins. The 1-year duplex ultrasound of the SFJ ligation site had a sensitivity of 80%, a specificity of 91%, a positive predictive value of 70% and a negative predictive value of 95% in assessing the 5 year recurrence rate.

CONCLUSION

A postoperative duplex scan of the SFJ 1 year after varicose vein surgery to the great saphenous vein predicts which patients are most likely to have a good outcome 5 years after surgery. The 1-year duplex scan is a reliable diagnostic tool for future studies evaluating the effect of new methods of treating sapheno-femoral incompetence.

Validity of the macroscopic identification of neovascularization at the saphenofemoral junction by the operating surgeon

PURPOSE

The intraoperative classification of recurrent veins at the saphenofemoral junction as neovascularization is based on certain macroscopic criteria. The validity of this neovascularization identification by the surgeon was evaluated by histologic and immunohistochemical examinations of the resected veins as the gold standard.

METHODS

One hundred-four patients (mean age 57 +/- 10.9 years) with 130 affected extremities underwent redo surgery of the saphenofemoral junction for recurrent varicose veins at a mean of 12.0 +/- 7.9 years after the initial stripping of the greater saphenous vein. The surgeon used intraoperative findings to classify the recurrent veins as neovascularization (group A), no neovascularization (group B), or unclear findings (group C). The resected veins then underwent histologic and immunohistochemical examinations and were again classified into the same three groups (a, neovascularization; b, no neovascularization; c, unclear) according to the histologic results.

RESULTS

The operating surgeon correctly recognized 16 (41%) of 39 histologically proven neovascularizations, whereas 22 (56%) were not identified. In contrast, 66 (84%) of 79 cases with no neovascularization were correctly identified during the operation. A definite classification by macroscopic criteria was not possible in 4 cases (3%) and the histologic examinations revealed unclear findings in 12 cases (9%). The macroscopic neovascularization identification had a sensitivity of 42.1% and a specificity of 85.7%. The positive predictive value reached 59.3% and the negative predictive value, 75%.

CONCLUSION

The validity of intraoperative neovascularization identification is poor, but the surgeon is able to recognize non-neovascularization recurrences with relatively high accuracy. The etiologic classification of recurrent veins at the saphenofemoral junction should not be solely based on macroscopic criteria.

Reduction of Neoreflux After Correctly Performed Ligation of the Saphenofemoral Junction. A Randomized Trial

BACKGROUND

Neoreflux at the sapheno-femoral junction (SFJ) is an important cause of recurrent great saphenous varicose veins. This study compares four surgical methods of ligating the SFJ with the aim to reduce the rate of neoreflux.

METHOD

In a prospective study, 379 patients (500 SFJ ligations) were randomised to one of four surgical procedures at the SFJ (125 groins each). In group A (control group) the SFJ was ligated in standard fashion with Vicryl (absorbable ligature); in group B, after Vicryl ligation continuous Prolene (non-absorbable) was sutured over the stump endothelium to prevent any contact with surrounding tissue; in group C. SFJ ligation was done with Ethibond (non-absorbable); in group D Ethibond ligation was followed by Prolene oversewing. The final study group included 114 patients (152 groins) who were all known to be free from recurrent groin reflux 3 months postoperatively and had colour duplex venous imaging 2 years after operation.

RESULTS

Duplex imaging identified neoreflux at the SFJ in 10 out of 114 groins after 2 years (7%). There were differences in the rates between the four groups: Group A 3/31 (10%), Group B 0/32, Group C 5/44 (11%) and Group D 2/45 (4%). Neoreflux was significantly reduced in the two groups with endothelial closure (B and D): 2/70 (3%) versus 8/75 (11%, p<0.025).

CONCLUSION

Recurrent reflux in the groin was reduced by over sewing the ligated SFJ in patients having varicose vein surgery. This adds weight to the theory of neovascularisation as a cause of recurrent veins and offers a means to reduce clinical recurrence rates.

Silicone patch saphenoplasty to prevent repeat recurrence after surgery to treat recurrent saphenofemoral incompetence: long-term follow-up study

OBJECTIVE

Barrier techniques have been proposed to improve the results of repeat surgery to treat recurrent saphenofemoral junction incompetence. We hypothesized that interposition of a silicone implant would contain postoperative neovascularization and thus reduce the incidence of clinical recurrence at 5-year follow-up.

METHODS

We compared the results of repeat interventions with use of silicone sheeting with a control group without artificial implants. The study was performed in hospitalized patients in a level 3 referral center (University Hospital). All patients underwent new flush ligation in the groin, with stab avulsion of recurrent varicosities. Two closure techniques were compared: in group A (33 limbs) the groin incision was closed in two layers; in group B (35 limbs) a piece of silicone sheeting was sutured on the saphenous stump. Clinical examination and duplex scanning were performed after 1 and 5 years postoperatively. Limbs operated on were checked in particular for the presence of recurrent thigh varicose veins. Color-coded duplex scanning was performed to assess for the presence of clinically relevant neovascularization, defined as the presence of a new vein with diameter at least 4 mm and with pathologic reflux in direct connection with incompetent varicose veins at thigh level.

RESULTS

Clinical examination after 1 year showed recurrent thigh varicosities in 24% of limbs in group A and 12% of limbs in group B (P =.369). After 5 years recurrent thigh varicosities were observed in 58% of limbs in group A and in 26% of limbs in group B (P =.009). Duplex scans after 1 year revealed neovascularization in 27% of limbs in group A and 6% of limbs in group B (P =.018). After 5 years neovascularization was present in 45% of limbs in group A and 9% of limbs in group B (P =.0007).

CONCLUSIONS

The use of a silicone patch at repeat operation to treat recurrent varicose veins caused by new incompetence at the level of the saphenofemoral junction is associated with a lower incidence of recurrent thigh varicosities and neovascularization compared with a control group in which no additional barrier technique was used.

Can interposition of a silicone implant after sapheno-femoral ligation prevent recurrent varicose veins?

OBJECTIVES

To investigate whether a silicone implant at the sapheno-femoral ligation site could prevent recurrent varicosities.

MATERIALS AND METHODS

Two non-randomised groups of patients were studied prospectively. In group A 173 patients and 212 limbs had sapheno-femoral ligation, while 172 patients and 210 limbs additionally had a piece (2x3cm) of silicone sheet sutured to the saphenous stump to cover the anterior half of the common femoral vein. The implant was fixed in apposition to the deep vein by carefully closing the cribriform fascia. Colour duplex scanning was performed after 2 and 12 months.

RESULTS

In the no implant group neovascularisation was observed in 35 (17%) after 12 months, but only in 13 (6%) limbs treated with a silicone implant (p<0.05).

CONCLUSIONS

Interposition of a partition of silicone implant seems to lower the incidence of neovascularisation one year after saphenofemoral ligation. This technique may constitute an efficient method to prevent recurrence at the correctly ligated saphenous stump.

Surgery for Recurrent Sapheno-Femoral Incompetence Using Expanded Polytetrafluoroethylene Patch Interposition in Front of the Femoral Vein: Long-Term Outcome in 119 Extremities

Objective:

To assess the long-term results of re-do surgery for recurrent varicose veins using polytetrafluoroethylene patch interposition to correct a recurrent varico-femoral junction (RVFJ).

Methods:

In 170 extremities (137 patients) with RVFJ greater than 3 mm in diameter, re-do surgery was done with patch interposition and without extensive resection of neovascularisation. Follow-up data based on physical and ultrasound examinations were obtained for 119 of these extremities (100 patients).

Setting:

Private-practice vascular surgery centre.

Results:

At follow-up (mean 4.9 years), 5 extremities (4.2%) had another RVFJ. In the 114 extremities with no RVFJ, 27.7% had no varicose veins or incompetent superficial veins, 45.3% had several small varicose veins without reflux, and 22.6% had diffused varicose veins and a new site of incompetence between the deep and superficial venous system.

Conclusions:

Re-do surgery using patch interposition lowers the long-term risk of another RVFJ. Wide resection of neovascularisation in the groin seems unnecessary.

Surgery for Recurrent Sapheno-Femoral Incompetence Using Expanded Polytetrafluoroethylene Patch Interposition in Front of the Femoral Vein: Long-Term Outcome in 119 Extremities

Objective:

To assess the long-term results of re-do surgery for recurrent varicose veins using polytetrafluoroethylene patch interposition to correct a recurrent varico-femoral junction (RVFJ).

Methods:

In 170 extremities (137 patients) with RVFJ greater than 3 mm in diameter, re-do surgery was done with patch interposition and without extensive resection of neovascularisation. Follow-up data based on physical and ultrasound examinations were obtained for 119 of these extremities (100 patients).

Setting:

Private-practice vascular surgery centre.

Results:

At follow-up (mean 4.9 years), 5 extremities (4.2%) had another RVFJ. In the 114 extremities with no RVFJ, 27.7% had no varicose veins or incompetent superficial veins, 45.3% had several small varicose veins without reflux, and 22.6% had diffused varicose veins and a new site of incompetence between the deep and superficial venous system.

Conclusions:

Re-do surgery using patch interposition lowers the long-term risk of another RVFJ. Wide resection of neovascularisation in the groin seems unnecessary.

Causes of re-recurrence after polytetrafluoroethylene patch saphenoplasty for recurrent varicose veins

BACKGROUND

The aim of this study was to determine whether a polytetrafluoroethylene (PTFE) patch sutured over the religated saphenofemoral junction could reduce the rate of recurrence after operation for recurrent varicose veins.

METHODS

Fifty patients who had surgery for recurrent long saphenous incompetence (81 legs had a small PTFE patch sutured over the religated saphenofemoral junction. There were no major complications following surgery. Three patients had a wound infection or delayed healing. All patients were invited for clinical examination and duplex imaging at a median of 19 (range 6-39) months after operation.

RESULTS

Some 38 of 43 patients (70 legs) remained satisfied with the results of surgery; 16 (23 per cent) of 70 legs had visible veins on inspection and eight of these (11 per cent) involved symptomatic recurrence. Duplex imaging showed that recurrence was due to saphenofemoral junction incompetence in ten legs; two appeared to have a major groin connection but the other eight appeared to have neovascularization. Other causes were thigh perforator reflux (three legs) and cross-groin collaterals (three). Eleven of the 16 legs with recurrence had varicography but in two the procedure was a technical failure. Two legs had evidence of a significant connection (more than 3 mm) and two a minor connection (less than 3 mm) to the femoral vein at the level of the PTFE patch, but in the remainder recurrence was due to upper thigh perforating veins. There was good concordance between duplex imaging and varicography.

CONCLUSION

PTFE patch saphenoplasty appears to be safe. Although these are early results, the technique seems potentially as effective as other barrier methods that have been investigated; in ten legs (12 per cent) recurrence was attributed to failure at the level of the PTFE patch.

Reoperation for recurrent saphenofemoral incompetence: a prospective randomised trial using a reflected flap of pectineus fascia

OBJECTIVE AND DESIGN

in 1978 Sheppard described using a flap of pectineus fascia in an attempt to reduce the further development of neovascularised veins at the saphenofemoral junction. The perceived benefits of this manoeuvre have not been tested by a prospective randomised trial.

MATERIALS AND METHODS

consecutive patients with symptomatic recurrent varicose veins referred to a single consultant were examined for evidence of further reflux from the saphenofemoral junction. This was subsequently confirmed in forty limbs (thirty-seven patients) by descending venography. All had features of a neovascularised segment. These patients were treated by complete exposure and ligation of the recurrences arising from the common femoral vein, with or without the placement of a flap of pectineus fascia (prospectively randomised). The patients were assessed a minimum of eighteen months later by both clinical examination and duplex ultrasound scanning.

RESULTS

six patients were lost to follow-up. This left seventeen limbs remaining in each half of the study. The characteristics in each group were broadly matched.

CONCLUSIONS

this study failed to demonstrate any apparent benefit from the application of a flap of pectineus fascia. Most patients showed evidence of re-recurrence arising from the common femoral vein.