Varicose veins surgery

The following are “Know” from the syllabus

• Varicose vein surgery
• Operations for recurrent varicose veins
• High saphenous ligations

Saphenous ligation with stripping

• 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
  • Perforators
    • Ligate incompetent perforators
• 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

Endovenous options

• Options
  • Thermal
  • Non-thermal
    • Most common is sclerosing agents
• Contraindications
  • Acute DVT
  • Thrombophlebitis
  • Pregnancy
  • Relative
    • In patients with deep venous insufficiency
    • PVD

Thermal Ablation

• Advantage:
  • Avoids GA
  • Office based procedure
  • Early mobility and return to work
  • Low risk of nerve injury
  • Lower risk of recurrence (Success at 5 yrs = 95%)
• Disadvantages:
  • Tumescent аոеsthesia
  • Some pts unsuitable
• Two methods of ablation therapy
  • Endovenous Laser Ablation (EVLA) Therapy – Delivers > 1000 temps to vein and damages intima
  • RFA – Delivers temps > 100 degrees to damage intima
• Complications:
  • Bleeding/bruising – less than open surgery
  • VTE – very low <1% - can get a tongue of thrombus from superficial vein into deep vein – usually no occlusion but can occur
  • Skin burns – inadequate tumescent anaesthesia
  • Nerve injury – Actual injury to sensory nerves is rare however can get area of abnormal sensation over where therapy performed

Non-thermal ablation

• Options
  • Mechanical ablation
    • Mechanical occlusion chemically assisted (MOCA) ablation
      • Uses both mechanical damage to vein endothelium with a rotating wire and simultaneous chemical injury with installation of a liquid sclerosant
  • Cyanoacrylate embolisation
    • Using catheter access, a glue is delivered into the saphenous vein that induces a foreign body reaction leading to iոflаmmаtiοn and fibrotic occlusion of the vessel.
  • Sclerotherapy - USS guided
    • Polidocanol endovenous microfoam (PEM)
      • PEM uses a proprietary gas mixture of O2:CO2 (65:35) with 1% рοliԁοсaոοl solution within a pressurized sterile canister to create uniform microfoam bubbles that can be delivered into the saphenous vein under սltrаѕоund guidance.
    • Detergent (Sodium Tetradecyl Sulphate)
    • Osmotic – Hypertonic saline
    • Chemical irritant – Chromated Glycerine
• Technique for sclerotherapy:
  • Cannulation of vein to be treated
  • Sclerosant is injected under USS guidance
  • Elevate leg to empty vein and inject foam – monitor movement in leg with USS
  • Compress veins with bandage or stockings
• Complications:
  • Thrombophlebitis – common
  • Occasionally need to aspirate retained thrombus
  • Local ulceration
  • Discolouration (Haemosiderin)
  • VTE low ~ 1% - reduce by encouraging ankle flexion to promote deep vein flow
  • Neurological symptoms
    • Transient in 1%
    • CVA is extremely rareWith sclerotherapy transient visual disturbance
  • Hypersensitivity and anaphylaxis
• Post op care:
  • Pressure dressings for 72 hours – 2 weeks of compression stockings at skin institute
  • 2-3 weeks later – regular clinic review
  • May need up to 4 treatments