Original article

Standard varicose vein surgery

J M T Perkins
The John Radcliffe Hospital, Headington, Oxford, UK

Abstract
This article examines the practice of standard varicose vein surgery including sapheno-
femoral and sapheno-popliteal ligation, perforator surgery and surgery for recurrent
varicose veins. The technique of exposure of the sapheno-femoral junction and the
sapheno-popliteal junction is outlined and advice given on avoidance of complications for
both. The evidence regarding methods of closure over the ligated sapheno-femoral junction
is examined as is the requirement for stripping and the use of different types of stripper.
The requirement to strip the small saphenous vein and the extent of dissection necessary in
the popliteal fossa is also examined. Complications of standard varicose vein surgery are
outlined. The frequency of wound infection, nerve injury, vascular injury and venous
thromboembolism are listed and strategies to avoid these complications are examined.

Keywords: varicose veins; great saphenous vein; small saphenous vein; complications;
recurrence; venous intervention project

Introduction comparable results in the long-term, not merely

Standard open varicose vein surgery has been used
to treat uncomplicated varicose veins for over 100
years. The specific techniques of the operation
have been subject to regular, and often cyclical,
change over the years. However, the essential
aim of the operation, to ligate and disconnect the
great (GSV) or small saphenous vein (SSV) at its
junction with the deep venous system has remained
constant.
Standard surgery remains the gold standard
against which newer interventions need to be eval-
uated. These techniques have evolved over time
and have been evaluated over long periods of
time. Newer methods of ablating the GSV and
SSV, using either laser, radio-frequency or foam
sclerotherapy, are being used more widely, but con-
ventional surgery remains the mainstay of varicose
veins treatment in the National Health Service
(NHS).1 The newer techniques must demonstrate
Correspondence: J M T Perkins MBChB FRCS MD,
Consultant Vascular Surgeon, The John Radcliffe Hospital,
Headington, Oxford OX3 9DU, UK.
Email: Jeremy.perkins@orh.nhs.uk
Accepted 5 January 2009
the benefits of short-term gain through earlier
mobility.
Surgery or conservative
management?
Patients with uncomplicated varicose veins com-
plain of symptoms of pain, aching, heaviness,
itching, cramps and restless legs.2 These symptoms
may be accompanied by swelling of the leg. The
cosmetic appearance of the varicose veins may
also be an important factor for the patient.
Surgery can only be justified if these symptoms
are significantly improved or abolished.
Patients with varicose veins have been shown to
have lower scores than UK population norms for
domains relating to pain and physical function.
Improvements in these aspects of quality of life
have been demonstrated after standard varicose
vein surgery3,4 at two years.
A randomized trial comparing surgery and conser-
vative treatment for severe varicose veins showed
that surgical treatment produced better results than
conservative measures in terms of health-related
quality of life, symptomatic relief, anatomical extent
and patient satisfaction.5 The limitations of conserva-
tive management, relying largely on the use of

Phlebology 2009;24 Suppl 1:34–41. DOI: 10.1258/phleb.2009.09s004

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J M T Perkins. Standard varicose vein surgery
compression stockings, are further confirmed by the
large proportion of patients (52%) in this study who
had crossed over to the surgical arm by three years.
Much of the debate regarding the effectiveness of
surgery revolves around the issue of recurrence of
varicose veins after surgical treatment. Recurrent
varicose veins develop frequently after surgery
and recurrence rates of 20– 80% are reported at
5 – 20 years.6 In spite of the recurrent varicosities,
many patients remain satisfied with their operation
with 77% reporting their symptoms cured or better
at 10 years.7 This same 10-year evaluation of
patients after varicose vein surgery reported that
66% of patients remained ‘pleased’ overall at 10
years. The recurrence rate was 70% with 44%
having a few recurrent veins only and 26% demon-
strating varicose veins that were as bad or worse
than before their original operation. The develop-
ment of recurrent varicose veins does not therefore
automatically equate with patient dissatisfaction
with their varicose veins operation.
Evaluation of varicose veins
before surgery
An initial history and clinical examination is essential.
Further evaluation of the leg(s) is required to establish
reflux within the GSV and SSV. The council of perfec-
tion is for every patient to have a complete duplex
ultrasound assessment of the veins in the leg to fully
evaluate the deep and superficial venous systems.
For many centres this would place a significant
burden on the provision of duplex services that
would be deemed unacceptable or unsustainable.
The use of hand-held Doppler (HHD) assessment
has developed as a useful screening tool in the
outpatient setting, particularly for the evaluation of
the saphenofemoral junction (SFJ) and reflux within
the GSV. Comparison of duplex and HHD has demon-
strated good concordance and sensitivity, and speci-
ficity rates of 95% and 100%, respectively, for HHD.8
In contrast, the results comparing HHD and duplex
in the assessment of saphenopopliteal junction
(SPJ) incompetence and SSV reflux are less
favourable9 and the accuracy of HHD scanning in
this area varies widely with a high false-positive rate
reported.8,10 This is caused by other incompetent
veins in the popliteal fossa such as gastrocnemius
veins, the popliteal vein itself, or superficial tributaries
of the GSV crossing the back of the knee. The
anatomy of the popliteal fossa and the position of
the SPJ varies more widely than the anatomy of the
SFJ in the groin, which is more constant. The SPJ
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Original article
may be located in its traditional site and within 9 cm
of the knee crease in only 45% of patients.11
This anatomical variation and the unreliability of
HHD makes duplex scanning indispensable in the
definitive diagnosis of SPJ incompetence. Marking
of the SPJ, either just prior to surgery with the
duplex scanner, or by indicating the position of
the SPJ in relation to the knee crease, is essential
in SPJ operations, particularly if small transverse
incisions are to be used.
HHD is inaccurate in assessing recurrent varicose
veins, where the SFJ and SPJ have been ligated in a
previous operation.12
Assessment of the patient with varicose veins is
suggested as follows:
(1) Full history and clinical examination including
peripheral pulses;
(2) HHD assessment of SFJ, GSV, SPJ, SSV;
(3) Duplex scan for: uncertain HHD assessment,
any reflux in popliteal fossa on HHD, recurrent
varicose veins, skin changes, ulceration, pre-
vious history of DVT or suspected DVT.
Surgical management of GSV
incompetence
Dissection of the SFJ
The operation is performed in a sterile operating
theatre under general, spinal or epidural anaesthe-
sia. Simple ligation of the SFJ can, except in the
most obese patients, be performed under local
anaesthesia, but stripping of the GSV will usually
require regional or general anaesthesia.
A transverse skin crease incision is made starting
just medial to the femoral pulse and continuing medi-
ally. Reference to the femoral pulse will prevent dis-
section onto the common femoral artery and ensure
exposure of the SFJ and GSV.
All tributaries of the SFJ are divided. Except in
very thin patients, the GSV will not be found in a
very superficial position immediately underneath
the skin incision. Any vein encountered in this
position is likely to be a superficial branch and
may be used as a guide to follow down to the SFJ.
Anecdotal opinion states that the branches should
be followed beyond their first branch and divided
here, but there is no evidence to support this.
It is imperative to demonstrate the junction of the
GSV with the common femoral vein to ensure that it
is the SFJ that is ligated and not simply the junction
of a superficial branch with the GSV. The deep vein
(the common femoral vein) should be at the same
Phlebology 2009;24 Suppl 1:34–41 35
Original article
depth as the common femoral artery and this can be
checked by reference to the femoral pulse.
Operative techniques to reduce recurrence
As outlined above, adequate surgery, with correct
exposure and demonstration of the relevant
anatomy, allows successful ligation of the SFJ,
which is the first prerequisite for prevention of
recurrence.13 This implies that all surgeons under-
taking venous surgery should be adequately
trained and supervised to ensure that technical
errors are minimized.
SFJ ligation
Different methods have been proposed for closing
the SFJ once this has been divided. The theories
behind them have raised the following questions:
(1) Does the use of a non-absorbable suture or
ligature to close the SFJ prevent neovasculari-
zation developing from the SFJ stump?
(2) Does flush ligation of the SFJ prevent recurrence
compared with simple ligation of the GSV?
(3) Can closure methods that cover all exposed
venous endothelium at the SFJ prevent recur-
rence by neovascularization?
There is conflicting evidence that the use of non-
absorbable sutures, flush ligation or endothelial
inversion contribute to a reduced recurrence rate.
Winerborn et al. randomized patients to flush
saphenofemoral ligation by oversewing with poly-
propylene sutures, or to standard saphenofemoral
transfixion with an absorbable suture. No difference
was shown in rates of clinical recurrence or neovascu-
larization at two years.14 A further non-randomized
study comparing standard SFJ ligation with resection
of the great saphenous stump and oversewing also
demonstrated no reduction of clinical recurrence
or neovascularization.15 Frings and co-workers’16
randomized study, however, did show a reduction
at two years in groin neoreflux in the two groups
where endothelial closure was undertaken.
Closing the groin dissection
The use of synthetic patches, or techniques to close
the cribriform fascia over the ligated SFJ, have been
proposed as methods to reduce recurrence arising
from the groin.
36 Phlebology 2009;24 Suppl 1:34–41
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J M T Perkins. Standard varicose vein surgery
Both silicone and polytetrafluoroethylene (PTFE)
patches have been placed over the ligated SFJ in an
attempt to prevent recurrence from neovasculariza-
tion by placing a physical barrier between the junc-
tion and other veins in the area.
A randomized study of PTFE patch use in redo
groin surgery showed no reduction in further
neovascularization compared with a standard
closure.17 The use of a silicone patch was similarly
examined in a non-randomized study and shown
to reduce neovascularization and recurrent thigh
varicosities when compared with a standard two-
layer closure.18 Complications occurred in 19.5% of
limbs after redo surgery, of which half were lym-
phatic in nature.19 This non-randomized study
showed a benefit for the use of silicone patch saphe-
noplasty, but the groups were later used as historical
controls in a further study examining the benefit of
closure of the cribriform fascia after SFJ ligation for
primary varicose veins.20 Closure of the cribriform
fascia was then proposed as an alternative option
to prevent postoperative neovascularization as this
was reduced at one year. The work of Glass21 is
also widely cited as evidence, which states that
closing the cribriform fascia reduces recurrence.
In non-randomized groups, he demonstrated a
reduction at four years from 25% to 4% for recur-
rence at the SFJ. GSV was not stripped in these oper-
ations which were done before duplex imaging was
available for monitoring.
Stripping the GSV
It is routine practice for many surgeons to strip the
GSV after SFJ ligation. Stripping the GSV exposes
the patient to a greater risk of nerve injury and
increased morbidity from pain, bruising and haema-
toma formation in the thigh. These disadvantages
are felt to be outweighed by the benefit of a reduction
in the development of recurrent varicose veins.
The evidence in favour of stripping is suggestive but
not overwhelming. Stripping of the GSV is postulated
to reduce recurrence by preventing neovasculariza-
tion in the groin joining up with the residual trunk
of the GSV in the upper thigh and producing signifi-
cant GSV reflux in the lower limb. Neovascularization
has been shown to be the cause of recurrence in up to
two-thirds of patients,22 but this same trial showed no
difference in rates of recurrence between legs that had
undergone stripping and those that had undergone
simple SFJ ligation.22,23 Despite this finding of equal
rates of recurrent varicosities, those patients in the
stripping group had fewer redo operations for recur-
rent varicose veins, a finding that is not explained.
J M T Perkins. Standard varicose vein surgery
Other studies, albeit with small numbers and shaky
methodology, have shown a reduction in recurrence
and better venous haemodynamics to be lower in
the leg after stripping.24,25
The GSV should be stripped to knee level.
Stripping the GSV to the ankle does not improve
symptomatic relief, but significantly increases the
risk of saphenous nerve injury.26
Surgical management of SSV
incompetence
Dissection of the SPJ
The patient may be positioned prone or in the
lateral position with the operated leg uppermost.
The anatomy behind the knee, and position of
the SPJ, is more variable than the anatomy in the
groin. Many surgeons have therefore advocated
the use of duplex scanning to mark the position
of the SPJ prior to surgery for small saphenous
incompetence.27 Alternatively, the position of the
SPJ can be measured from the knee crease at the
time of the original duplex scan and this measure-
ment used to site the skin incision appropriately.
A transverse incision is made at the level of the
SPJ. The fascia is divided and the SSV exposed.
After identifying the SSV, two surgical strategies
are available:
(1) Formally dissect the SPJ and perform a flush
ligation of the SPJ;
(2) Putting gentle traction on the SSV, follow the
vein as far down into the popliteal fossa as is
possible without the need for forcible retrac-
tion in the popliteal fossa. The SSV can then
be ligated proximally.
After proximal division of either the SPJ or the
SSV, the surgeon then has the option to strip the
SSV to mid-calf, or simply to resect the upper
part of the SSV. It is claimed that 10 cm of SSV can
be resected. The latter technique was the method
used by 55% of respondents in a survey of the
Vascular Society of Great Britain and Ireland, with
only 14% routinely stripping the SSV.28
Perioperative techniques to reduce recurrence
Surgery of the popliteal fossa and SSV is more chal-
lenging than that of the SFJ and GSV. The evidence
relating to different operative techniques, stripping
of the SSV and duplex marking is at best poor and at
worst non-existent.
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Original article
The incidence of visible recurrent varicosities may
be as high as 20% at one year after surgery.29 Incompe-
tence of the SSV has been found to be the main source
of venous reflux in the popliteal fossa in recurrent
veins after small saphenous surgery.30
Preoperative duplex marking
In 2004 over 50% of surgeons used duplex marking
of the SPJ preoperatively,28 and this had increased
slightly to 64% in a further survey of the long-
suffering members of the Vascular Society in
2007.31 Despite this, the results for small saphenous
surgery remains poor with approximately 25% of
patients having a failure to deal with an incompe-
tent SPJ and SSV.32,33 In Rashid’s series, only 39%
had an ideal result with successful disconnection
of an incompetent SPJ.
Exposure of SPJ and flush ligation
or simple SSV ligation?
No evidence exists to favour one technique over the
other. Formal exposure and identification of the
popliteal vein was performed by only 10% of sur-
geons surveyed in 2004,28 but in 2007 practice had
moved in favour of this technique with 67% per-
forming flush ligation of the SPJ.31 Proponents of
flush ligation would argue that it is analogous to
the technique of SFJ ligation in the groin and
avoids leaving a stump of SSV as a potential
source of recurrence. This pattern was demon-
strated in 16% of patients with recurrence.30
Those in favour of simple SSV ligation as close to
the junction as possible feel that this is a safer tech-
nique particularly with regard to nerve injury,
which may be associated with excessive dissection
and traction in the popliteal fossa (see below Com-
plications – Nerve injury).
Stripping the SSV
The SSV can be stripped to mid-calf or the top
section of the vein can be resected. No randomized
trials exist comparing these two techniques. Strip-
ping to various levels was performed by approxi-
mately 30% of surgeons surveyed in 2007.31
As with the GSV, those who strip the SSV argue
that it removes the residual SSV and prevents this
being reconnected by recurrent varicose or neovas-
cularization in the popliteal fossa. Opponents feel
that it carries a higher risk of nerve injury, particu-
larly sural nerve damage.
Phlebology 2009;24 Suppl 1:34–41 37
Original article
Prospective, non-randomized evaluation of the
results of SSV surgery at one year showed a non-
significant reduction in visible recurrent varicose
veins in patients whose SSV was stripped, without
any increase in rates of numbness. Duplex-detected
SPJ incompetence was significantly lower in those
who had undergone stripping.29 This provides
some slight, but non-proven evidence in favour of
stripping the SSV.
Surgical management of perforator
vein incompetence
The whole subject of incompetent perforators is
by debate and uncertainty not only about the best
technique for ligating perforators, but also a more
fundamental uncertainty as to whether they should
be treated at all, especially in patients with uncompli-
cated varicose veins (CEAP 2–4). Isolated perforator
disease is rare and incompetence of perforator veins
is usually found in conjunction with reflux at other
venous sites, both superficial and deep. It cannot,
therefore, be considered as a separate entity in its
own right, but as part of a spectrum of severity of
venous reflux throughout the leg.
Most studies evaluating the role of perforator lig-
ation have looked at patients with ulceration and
the effects on ulcer healing. Even in this area there
are no convincing randomized trials that defini-
tively support the role of perforator ligation in
ulcer healing.
The role of perforator surgery in primary varicose
veins is less clear still. Haemodynamically there
appears to be no additional benefit from adding
perforator ligation to standard SFJ ligation and
stripping.34 A small randomized study did show an
increase in the number of incompetent perforator
veins at one year in patients who did not have endo-
scopic perforator ligation (SEPS) in addition to stan-
dard SFJ ligation and stripping.35 However, at one
year this had no effect on recurrence or quality of life.
Surgical technique
The traditional operations proposed by Linton and
Cockett have fallen out of favour because of exces-
sive wound problems associated with long incisions
in unhealthy skin. Wound infection rates in some
series exceed 50%.36 Unsurprisingly, comparisons
of SEPS with these open operations show a benefit
for SEPS in reducing wound complications and
length of hospital stay.36
SEPS can effectively treat perforators, but compli-
cations of saphenous neuralgia (6 – 10%), sural
38 Phlebology 2009;24 Suppl 1:34–41
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J M T Perkins. Standard varicose vein surgery
neuralgia (2%), wound haematoma and infection
(6%), and DVT (1%) are reported.37,38
Alternatively, incompetent perforators can be
divided by marking the site with duplex and ligat-
ing the perforating vein through a small incision.
There are no randomized comparisons of this tech-
nique with other perforator vein procedures.
Techniques for the avulsion of
varicosities (phlebectomy)
Standard surgical management of surface varicos-
ities is to avulse these through small stab incisions
using phlebectomy hooks.
This technique has been compared with transillu-
minated powered phlebectomy (TIPP). TIPP does
not reduce operative time, but does reduce the
number of stab incisions made.39,40 One random-
ized study showed TIPP to cause more bruising
and pain in the early postoperative period and con-
sequently an adverse impact on early generic
quality of life.40
Complications of standard varicose
vein surgery
Complications (major and minor) are reported in
approximately 18– 20% of patients having standard
varicose vein surgery.41,42 Major complication rates
are reported in around 0.8% of patients.41
Wound complications
These include infection, haematoma and abscess
formation. Reported rates vary from 3 – 10%.5,41
Only one randomized study has looked at anti-
biotic prophylaxis in varicose vein surgery. Patients
who received antibiotics had fewer GP attendances
and fewer post-operative courses of antibiotics than
those who did not.43 Suspected wound infection
was not confirmed by wound culture.
Thigh haematomas
Some degree of thigh haematoma formation is
inevitable with stripping of the GSV and, as such,
many surgeons would not consider this as a compli-
cation.
Thigh haematoma formation is reduced by the
installation of local anaesthetic with adrenaline
into the stripper track.44
J M T Perkins. Standard varicose vein surgery
The use of different strippers and tourniquet use
in reducing haematoma formation is discussed
below after the section on ‘Nerve injury’.
Nerve injury
Some degree of sensory abnormality has been
reported in up to 40% of patients undergoing SFJ
ligation and stripping of the GSV to the knee.45
The incidence of true saphenous nerve injury
appears to be significantly less and is reported in
7% of patients who have stripping to the knee, com-
pared with 39% who had total GSVs stripping to the
ankle.26
The femoral nerve is almost never injured in
saphenofemoral ligation as it does not lie in close
vicinity to the vein.
Common peroneal nerve (CPN) and sural nerve
injury are complications of SSV surgery. The rate
of CPN injury is reported to be as high as 2 – 4%
in some series.46,47 This significant nerve injury
results in foot drop. It is often said to occur from force-
ful use of the phlebectomy hook close to the neck of
the fibula, but an assessment of medicolegal claims
after varicose vein surgery showed that 17/18 CPN
injuries occurred during dissection in the popliteal
fossa.48
Sural nerve injury may occur as a complication of
up to 20% of SSV operations.
Only careful dissection can avoid CPN and sural
nerve injuries in operations of SSV incompetence.
Can the use of different types of stripper or
the use of a tourniquet reduce postoperative
complications?
The simple and succinct answer to this question is no.
It has been proposed that inversion stripping may
reduce the problems of bruising, haematoma for-
mation and nerve injury compared with conventional
stripping. The evidence does not support this claim,
and the only demonstrable advantage of inversion
stripping is that it produces a smaller exit wound for
the stripper at the knee.49,50 Cryostripping confers
no benefit over conventional stripping.
The use of tourniquets during varicose vein
surgery has not been shown to reduce postoperative
pain or bruising or to improve cosmesis.51 The only
robust improvement demonstrated was a reduction
in blood loss. Although this reduction was statisti-
cally different, in practice the difference would not
be clinically significant.
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Original article
Vascular injury and complications
Vascular complications are rare,52 with injury to the
common femoral vein occurring more frequently
than arterial injury. Laceration or division of the
common femoral vein is the most common injury.
Partial stripping of the femoral vein is uncommon
and occurs when the stripper passes via a perfora-
tor into the deep system.
Arterial injury results from stripping of the
superficial femoral artery for a variable distance
down the leg. Recognition of this problem is often
delayed (30% detected intraoperatively)52 and con-
sequently the outcome is poor, with an amputation
being required in one-third of cases.
The key to avoidance of vascular injuries is ade-
quate exposure and identification of the relevant
structures in the groin dissection. In thin patients
excessive traction on the SFJ can lead to common
femoral vein (CFV) injury, and if bleeding occurs
blind grasping with artery forceps should be
avoided. Spasm of the arteries may make them
appear like veins in young patients. Division of
structure should not be performed until identifi-
cation is entirely clear.
Venous thromboembolism
The incidence of venous thromboembolic compli-
cations in varicose vein surgery is low. Deep vein
thrombosis occurs in around 1:200 patients and
pulmonary embolism in 1:600.41 This low risk of
venous thromboembolism (VTE) would seem to pre-
clude the use of routine anticoagulant prophylaxis,
and surveys of vascular surgeons seem to
corroborate this view, with only 27% routinely using
heparin prophylaxis and 62% using it selectively.53
The development of VTE remains a constant
source of litigation and claims where VTE occurred
in patients who received no prophylaxis despite
identifiable risk factors, were usually successful.54
Failure to perform a risk assessment and provide
prophylaxis is considered negligent.
NICE guidelines for prevention of VTE in
surgical patients were published in 2007 with a
list of identifiable risk factors and listed in the
recommendation below.
In vascular surgery (including venous surgery)
patients with one or more risk factors should receive
mechanical prophylaxis and low molecular weight
heparin. This applies to inpatient treatment only.
Training
It is clear that adequate training in standard venous
surgery is essential to:
Phlebology 2009;24 Suppl 1:34–41 39
Original article
(1) Prevent unnecessary recurrence by a failure to
properly expose, identify and ligate the SFJ
and SPJ in the surgical treatment of great and
small saphenous incompetence;
(2) Prevent avoidable vascular and neurological
complications in dissection in the groin and
popliteal fossa.
This requires a full knowledge of the standard
anatomy and its variations, and a sufficient
exposure to venous operations to achieve famili-
arity with the procedure and its potential compli-
cations and pitfalls.
The new surgical curriculum places the technical
skills required to perform primary SFJ/SPJ ligation
with or without stripping and multiple avulsions at
the ST2 level. The more advanced skills required for
redoing the SFJ and SPJ ligation are placed at the
end of training.
No specific number of procedures are stipulated.
A conservative estimate would suggest that a
minimum of 30 SFJ and SPJ ligations each should
be performed, with at least 15 each of the redo
operations.
Summary
Standard varicose vein surgery remains the gold
standard against which other techniques should
be measured. Effectiveness of newer techniques
should be demonstrated over a minimum of a
10-year period.
Adequate training is essential to prevent
unnecessary recurrence and avoidable compli-
cations.
Recurrence rates remain high, although exact
definitions of recurrence remain unclear. The
causes of recurrence are varied and can be seen as
occurring against a background of an evolving
venous system in the limb that is altered at one
point in time by superficial venous surgery.
Conflict of interest
The author hereby declares no conflict of interests.
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