Surgical Management of Varicose Veins

SURGICAL MANAGEMENT OF
VARICOSE VEINS
by Dr. Madhumita Gupta
INDICATIONS
Cosmetic
Symptomatic
complications
AIMS OF SURGERY
abolish valvular incompetence & reflux

Cosmesis
Symptomatic cure
Prevention of complications
Less morbidity
Early return to work
Prevention of recurrence
Low cost
PRE-REQUISITES
Informed consent
Pre-operative marking
OPERATIVE PROCEDURES
ConventionalSFJ/SPJ flush ligation
stripping
avulsion of individual
varicosities
Minimally invasiveEVLA
RFA
foam sclerotherapy
external valvular stent
endoscopic phlebectomy-TriVex
Management of CVIPerforator surgery (ligation,SEPS)

Deep vein reconstruction
Surgery for recurrence
COMPLICATIONS
Damage to major veins, arteries, nerves
Wound complications-haematoma, infection
Thrombo-embolism
Recurrence
LIGATION & STRIPPING
In case of junctional incompetence on Duplex

Strip LSV if >1 cm in diameter
Partial stripping upto knee or just below (according
to Holme et al 1990).
Benefits
less chance of saphenous nerve injury
minimise impairment of accessory drainage of
foot
preserve vein for future use as bypass graft
Complications-
saphenous nerve injury

haematoma
recurrence
Post-operative compression-with
bandages,changed to anti-embolism
stocking after 24 hrs
PHLEBECTOMIES
Through multiple stab incisions
Marked pre-operatively
Avulsion of individual varicosities
if >6 mm
No remedy of reflux
ENDOSCOPIC VARICEAL LASER

ABLATION
Pre-requisites of endovenous therapy:

vein of any size
no tortuosity
no pacemaker
US guidance
Salient features:
-810 nm diode in 600 micron laser
fibre-specificity for blood
-temp at tip-729 degree C
-60-70J/cm optimum
ADVANTAGES
-OPD procedure
-less costly
-less complications
-less recurrence :7% at 2 yrs
DISADVANTAGES:
-needs complimentary procedure

-needs expertise
-time-consuming
Mechanism:
sufficient heating to cause collagen
contraction and denudation of endothelium
stimulates wall thickening, luminal contraction
and fibrosis
Technique:
tumescent LA only into perivenous space under
US guidance
GSV punctured, introducer sheath inserted,
fibre pass
provides wall apposition around fibre tip
EVLA duplex
criteria for success
1 week: enlarged non-compressible GSV,

minimal decrease in diameter, echogenic
thickened vein wall, no flow
3 and 6 months: occluded GSV with > 50 %
reduction in diameter
1-2 Yrs :complete disappearance or minimal
residual fibrous cord
COMPLICATIONS
delayed tightness at 4 to 7 days, lasting 3

to 10 days
5 % superficial phlebitis of varicose
tributaries
minimal heating complications
RADIO-FREQUENCY ABLATION
radiofrequency generated heating probe placed
through percutaneous puncture or mini incision
in calf
treatment flush with common femoral vein not
recommended because of possible thermal injury to
vein potentially leading to local
thrombosis or stenosis
-Study: Rautio et al
Non-tortuous GSV
<12 mm
General /regional
anaesthesia
Temp 85 degree C
Endothelial & collagen

damage, venoconstriction
EXTERNAL VALVULAR STENTS
LA/sedation
Adjustable GORE-TEX/dacron cuff at SFJ
after limited dissection and ligation of
collaterals
reduction in calibre of vein
reflux absent in all EVS
Less thrombosis, cusps mobile
Studies- Incandela et al, Lane et al
TriVex- ENDOSCOPIC
PHLEBECTOMY
Endoscopic vein resection and ablation of superficial

varicosities
tumescent anaesthesia (400 mg lignocaine, 2 mLof
1:1000 adrenaline in 1 L saline)
combined irrigation-illumination wand
powered vein resector (inner rotary blade and
stationary sheath) with lateral window vein sucked
in and morsellated
Advantages of TriVex
direct visualisation of vein to be avulsed
removal of veins through fewer incisions

conventional: 29 incisions (mean) (6 to 70)
trivex: 5 (2 to 8)
SCLEROTHERAPY
Indications: residual, recurrent varicosities

<6mm
Sclerosants- Sodium Tetradecyl Sulphate,
Polidocanol
Chemical thrombophlebitis, occlusion,
fibrosis
Advantage of foam-cover greater surface
area, displace blood from GSV, more cellular
damage
Complications:
tissue necrosis & ulceration
skin staining
haematoma
superficial thrombophlebitis
intra-arterial injection
DVT
anaphylaxis
RECURRENT VARICOSITIES
Approx 20% cases

Morphological types:
-recurrent saphenous junction
incompetence due to neovascularisation,
missed tributary
-multiple perforators
-through new saphenous system
Re-intervention requires careful judgement

&pre-operative duplex imaging
Methods:
-groin re-exploration with re-ligation of
junction
-stripping of residual or accessory vein
-multiple phlebectomies
-following EVLA- foam sclerotherapy
-following RFA- phlebectomies
SURGICAL TREATMENT OF CVI & CVU
Regular debridement with STSG or flap

Perforator incompetence:
OPEN:
original Lintons operation
Cocketts procedure, etc.
ENDOSCOPIC:
SEPS
Contra-indications:
- infected ulcers
- deep venous
occlusion
DEEP VEIN RECONSTRUCTION
Vein diameter reduction

Vein valve repair- open or closed
Vein valve transplantation
Vein transposition
Veno-venous bypass
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Surgical Management of Varicose Veins

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Surgical Management of Varicose Veins

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SURGICAL MANAGEMENT OF

by Dr. Madhumita Gupta

abolish valvular incompetence & reflux

Management of CVIPerforator surgery (ligation,SEPS)

Damage to major veins, arteries, nerves

Wound complications-haematoma, infection

LIGATION & STRIPPING

In case of junctional incompetence on Duplex

saphenous nerve injury

Through multiple stab incisions

Avulsion of individual varicosities

ENDOSCOPIC VARICEAL LASER

Pre-requisites of endovenous therapy:

-needs complimentary procedure

1 week: enlarged non-compressible GSV,

delayed tightness at 4 to 7 days, lasting 3

Endothelial & collagen

EXTERNAL VALVULAR STENTS

reduction in calibre of vein

reflux absent in all EVS

Less thrombosis, cusps mobile

Studies- Incandela et al, Lane et al

Endoscopic vein resection and ablation of superficial

direct visualisation of vein to be avulsed

removal of veins through fewer incisions

Indications: residual, recurrent varicosities

Approx 20% cases

Re-intervention requires careful judgement

SURGICAL TREATMENT OF CVI & CVU

Regular debridement with STSG or flap

DEEP VEIN RECONSTRUCTION

Vein diameter reduction

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