- Pre-op marking indicated as reduces recurrence rate (definitely need it if want to deal to SSV as its course & termination highly variable)
- Procedure
- Mark all sx varicosities to be avulsed
- Groin crease incision over the SFJ
- Dissection down to SFJ and isolate the SV + tie of tributaries as required
- Ligation of SFJ
- Should involve flush saphenofemoral ligation/disconnection (also expose femoral vein 2cm proximal & distal to ensure there are no accessory vessels which may lead to recurrence) and long saphenous vein stripping (with ‘phlebectomies’ of venous side branches)
- Create a venotomy in the SV and pass the flexible stripper
- Pass the stripper to the level of the knee
- Make a small incision at this level
- Dissect and ligate and divide the SV at this level
- The SV is then attached to the stripper by either suturing it to it or attaching the removable tip
- It is then removed in a proximal to distal direction
- Strip GSV to below knee, avulsion of perforators
- Don’t strip GSV below knee - Perforators probably drain to Posterior Arch Vein & increased risk of Saphenous Nerve damage
- Strip down, also apply inversion stripping – reduces risk of lymphatic or nerve damage
- Perform avulsions on prior marked varicose veins
- Close deep then skin
- Considerations
- Appropriate in pts with reflux isolated to superficial veins
- May be beneficial for pts with mixed superficial and segmental deep reflux
- Segmental reflux in the deep veins is reversed in ≈ 50% of cases by ablative superficial venous surgery, as is reflux in calf perforating veins
- Surgery to correct venous reflux in the deep veins is complex and of unproven value
- Surgery for perforators should be reserved for the few (2-3%) with isolated calf perforator incompetence & ulceration
- Pregnancy: Delay Rx for > 6 months after delivery, as may resolve
- Post-op:
- Leg elevation
- Bandages or stockings 7/7 day and night
- Then supportive stockings during the day for 2-6/52 post op
- Aim for return to work within 10/7
- Complications
- Bleeding
- Bruising
- Healing fibrosis → Firmness under the scars
- Wound infections ≈ 1%
- VTE – 1-5% - Generally recommend LMWH during surgery
- Neuropraxia: numbness, Saphenous Nerve – Mild changes in sensation up to 40% but true saphenous injury (5-10% after LSV strip)
- Sural Nerve injury if SSV stripped
- Recurrence – 20-80% at 5-20 yrs but pts usually still happy with results