Journal of Vascular Surgery
Volume 44, Issue 5 , Pages 1051-1054, November 2006

Residual varicose veins below the knee after varicose vein surgery are not related to incompetent perforating veins

  • Pierre van Neer, MD

      Affiliations

    • Department of Dermatology, Laurentius Hospital, Roermond, The Netherlands
    • Corresponding Author InformationReprint requests: Pierre van Neer, MD, Department of Dermatology, Laurentius Ziekenhuis, Postbus 920, 6040 AX Roermond, The Netherlands.
    • ,
  • Alphons Kessels, MD

      Affiliations

    • Kemta and Horten-Zentrum Universitätsspital Zürich, The Netherlands
    • ,
  • Ed de Haan, MD

      Affiliations

    • Department of Surgery, Laurentius Hospital, Roermond, The Netherlands
    • ,
  • Rene Estourgie, MD, PhD

      Affiliations

    • Department of Surgery, Laurentius Hospital, Roermond, The Netherlands
    • ,
  • Joep Veraart, MD, PhD

      Affiliations

    • Department of Dermatology, University Hospital, Maastricht, The Netherlands
    • ,
  • Raf Lijnen, MD

      Affiliations

    • Department of Dermatology, Laurentius Hospital, Roermond, The Netherlands
    • ,
  • Martino Neumann, MD, PhD

      Affiliations

    • Department of Dermatology, Erasmus Medical Centre, Rotterdam, The Netherlands.

Received 1 March 2006; accepted 27 June 2006.

Article Outline

Objective

The objectives of this study were to investigate the occurrence of residual varicose veins (visible and ultrasonic) at the below-knee level after short-stripping the great saphenous vein (GSV) and to investigate the possible role of preoperative incompetent perforating veins (IPVs) on the persistence of these varicose veins.

Methods

In this prospective study in 59 consecutive patients (74 limbs) with untreated primary varicose veins, a preoperative clinical examination and preoperative color flow duplex imaging were performed. Re-evaluation (clinical examination and color flow duplex imaging) was performed 6 months after surgery. Dissection of the saphenofemoral junction and short-stripping of the GSV from the groin to just below the knee level was performed without additional stab avulsions on the lower leg. The association between postoperative reflux in the three GSV branches below the knee level and preoperative IPV and the association between postoperative visible varicose veins in the GSV below knee level and preoperative IPV were determined with odds ratios with the help of a univariate and multivariate logistic regression analysis.

Results

Preoperative varicosities in the GSV below the knee were visible in 62 limbs (70%) and were visible after surgery in 12 limbs (16%). The number of limbs with reflux in the 3 below-knee GSV branches was as follows: anterior branch, 34 (49%) before surgery and 31 (44%) after surgery; main stem, 59 (79%) before surgery and 62 (91%) after surgery; and posterior branch, 49 (67%) before surgery and 46 (63%) after surgery. No statistically significant association between postoperative reflux in the three GSV branches and preoperative IPV nor between postoperative visible varicose veins and preoperative IPV was found.

Conclusions

This study shows that reflux in the GSV below knee level after the short-stripping procedure persists in all below-knee GSV branches. Approximately 20% of patients with visible varicose veins in the GSV area below the knee level will have visible varicose veins in this area 6 months after the short-strip procedure. These clinical and ultrasonic residual varicose veins are not significantly related to the presence of preoperative IPV.

 

Recurrence of varicose veins after surgery is a common and costly problem in daily practice.1 At a consensus meeting on recurrent varicose veins (Paris 1998), recurrence of varicose veins after surgery was defined clinically as the presence of varicose veins in a lower limb previously operated on for varices.1 This definition includes true recurrences, residual veins, and varicose veins as a consequence of progress of the disease. Recurrence rates depend on the length of follow-up, the definition of recurrence, and the method of treatment. Recurrent reflux on duplex scan is found in 13% to 29% of patients 2 to 5 years after stripping of the great saphenous vein (GSV),2 whereas clinical recurrence is reported in 25% to 37% of these patients.2

Nowadays it is common practice to perform dissection of the saphenofemoral junction and stripping of the GSV to the knee level in patients with primary varicose veins of the GSV. However, it is currently unknown what the effect of this surgery is on the GSV varicosities below the knee level. Residual varicose veins in the below-knee area also could be caused by incompetent perforating veins (IPVs), especially of the paratibial type.3 This study was designed to investigate the incidence of residual varicose veins in the below-knee area after short-stripping the GSV and to investigate the possible role of IPV on these residual varicose veins.

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Materials and methods 

This was a prospective study in 59 patients (74 limbs) with untreated primary varicose veins who underwent short-stripping of the GSV. Consecutive patients who presented to the dermatology/phlebology or surgery outpatient clinics with untreated varicose veins (no conservative treatment and no intervention of any kind previously) were asked to enroll in the study. Patients with varicose veins and reflux of the saphenofemoral junction and the GSV were included, whereas patients with reflux in the deep venous system of the lower leg (vena poplitea) and patients with a history of deep venous thrombosis were excluded. The study was approved by the hospital medical ethics committee.

All patients were assessed by a preoperative clinical examination and preoperative color flow duplex imaging (CFDI; GE Medical 2294512 with a linear M12L probe; GE, Waukesha, Wis) performed by an experienced vascular technician. Re-evaluation (clinical examination and CFDI) was performed 6 months after surgery by the same investigator and the same vascular technician. Because we wanted to study residual varicose veins, we considered a follow-up period of 6 months appropriate; less than 6 weeks gives no reliable data because of postoperative influences (such as thrombophlebitis), and more than 1 year is not appropriate because of the potential effect of neovascularization.4

On physical examination, clinical severity was graded according to the standard CEAP score.5 Clearly visible veins, defined as veins that are larger than spider veins and reticular veins,5 were noted. Photographic pictures were also taken. The CFDI investigation was performed as follows: the entire venous system from groin to ankle, including the deep, superficial, and perforating veins, was carefully examined. The investigation was performed in the standing position. Reflux was measured every 10 cm on all sites. The GSV below the knee was divided and investigated in three branches: the anterior branch (anterior tributary vein), main stem (GSV itself), and posterior branch (posterior arch vein). Reflux was defined as retrograde flow on the Valsalva maneuver and/or release after distal compression. In the superficial and perforating veins, a retrograde flow of longer than 0.5 seconds was considered as reflux, and in the deep venous system, the criterion was a retrograde flow of more than 1 second. The most proximal IPV in the area 10 cm distal to the knee was marked before surgery. Diameters of the three GSV below-knee branches were measured before and after surgery, and the difference in diameter before and after surgery of all detectable branches was tested with the paired t test.

Surgery was performed by two experienced surgeons belonging to one institution. The surgical procedure conformed to the current surgical standard for treatment of varicose veins of the GSV: dissection of the saphenofemoral junction and stripping of the GSV from the groin to just below the knee level. Additional stab avulsion on the lower leg was not performed to study the effect of short-stripping of the GSV on these veins. In patients with a significant perforating vein in the proximal calf, GSV stripping was performed from the groin to 2 cm above that vein. This allowed us to investigate the possible influence of preoperative IPV in the lower leg on postoperative residual visible or echographic varicose veins of the GSV in the below-the-knee area. All patients received prescription compression stockings for 6 weeks.

Outcomes of the study were (1) reflux in the remnant GSV branches below the knee and the influence of preoperative IPV on this reflux and (2) visible varicose veins in the GSV below-knee level and the role of preoperative IPV in these visible veins. The association between postoperative reflux in the three GSV branches below knee level and preoperative IPV and between postoperative visible varicose veins and preoperative IPV was determined by use of univariate and multivariate logistic regression models and reported as odds ratios. This analysis was adjusted for age, CEAP, follow-up period, and preoperative reflux, again by using a multivariate logistic regression model.

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Results 

A total of 74 limbs (36 right and 38 left) from 59 patients (51 women and 8 men) were included in the study. Both limbs were treated in 12 women and in 3 men, whereas in all others only one leg was treated. The distribution of preoperative CEAP scores was as follows: C2, n = 55 (74.3%); C3, n = 12 (16.2%); C4, n = 6 (8%); and C5, n = 1 (1.4%). The mean period in which the patients returned for the postoperative CFDI examination was 21 weeks (range, 6-45 weeks), and the mean period in which the clinical re-evaluation was performed was 25 weeks (range, 5-50 weeks).

Clearly visible varicosities in the GSV area below the knee were seen in 62 (70%) of the limbs before surgery and in 12 (16%) of the limbs at the 6-month follow-up. All patients without visible preoperative GSV varicosities on the lower leg remained unchanged after surgery. The number of limbs with reflux in the three below-knee GSV branches by CFDI was as follows: anterior branch, 34 (49%) before surgery and 31 (44%) after surgery; main stem, 59 (79%) before surgery and 62 (91%) after surgery; and posterior branch, 49 (67%) before surgery and 46 (63%) after surgery.

Table I shows the results of the regression analysis of the relationship between reflux by CFDI in the three different GSV branches and preoperative IPV and the visible varicose veins and preoperative IPV. Logistic regression, both univariate and multivariate, showed no association between IPV and reflux in any of the GSV below-knee branches nor between IPV and visible varicose veins. Table II shows the difference in diameters of the three GSV below-knee branches before and after surgery. There was a significant decrease in diameter in all branches.

Table I. Odds ratios between preoperative incompetent perforating veins and clinical outcome 6 months after short-stripping the great saphenous vein (GSV)
VariableUnivariate OR (95% CI)Multivariate OR (95% CI)
Reflux GSV anterior1.054(0.777-1.430)1.217(0.539-1.252)
Reflux GSV main stem0.936(0.592-1.482)1.056(0.567-1.579)
Reflux GSV posterior1.013(0.751-1.367)0.840(0.584-1.208)
Visible varicosis0.480(0.135-1.704)0.521(0.134-2.030)

OR, Odds ratio; CI, confidence interval.

Table II. Difference in diameters of GSV below-knee branches before and 6 months after short-stripping the GSV
VariableDifference (mm)P value⁎
GSV anterior0.4(2.6-2.2).009
GSV main stem1.3(4.6-3.3)<.001
GSV posterior0.6(3.4-2.8).001

GSV, Great saphenous vein.

⁎Paired t test.

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Discussion 

Reflux in the residual GSV below knee level after the short-strip procedure persists in all GSV branches. Previous studies report persistent reflux in the below-knee-level GSV in 44% to 69%,6, 7, 8 with follow-up of 2 months to 2 years. However, the proportion of patients in our study with visible varicose veins in the GSV area below knee level decreased from 70% to 16% (Fig 1, Fig 2). Additionally, these residual varicose veins were not significantly related to preoperative IPVs.

A follow-up period of 6 months is not very long in studies on venous problems. In this study, however, we were specifically studying residual varicose veins, one of the possible contributors to recurrence.1 Because neovascularization may become evident as little as 1 year after surgery,4 we think that a follow-up period of 6 months is adequate to study these residual varicose veins and to limit the possibility of neovascularization as a cause of recurrent varicosities. The follow-up period varied from 5 to 50 weeks, which could affect the observed occurrence of varicose veins. However, adjusting for follow-up duration did not influence the results. Finally, we decided not to perform stab avulsion of visible varicose veins below the knee, which could influence our results, but this allowed us to observe the influence of short-stripping of the GSV on the remnant GSV below knee level and to investigate the possible relationship between preoperative IPV and residual GSV varicosities below the knee.

One could speculate that residual visible varicose veins after short-stripping of the GSV are caused by IPVs functioning as proximal points of reflux. It has been described, for instance, that the Boyd perforating vein in the anteromedial calf may be responsible for varicosities of the anterior and posterior tributary veins of the GSV.3 Additionally, in many articles on the relationship between IPV and varicose veins, the presence of IPVs seems to be associated most commonly with correctable superficial reflux alone or a combination of superficial and deep reflux.9 Furthermore, correction of the superficial reflux is associated with reversal of the IPV to competent in most cases.9 A study by Rutherford et al10 also showed a higher prevalence and a greater number of IPVs in patients with recurrent varicose veins than in patients with primary varicose veins. However, as was stated by the authors, a causative link is not yet established.

A recent prospective study by van Rij et al11 with a follow-up period of 3 years, in which varicose vein surgery was combined with ligation of all IPVs, showed that incompetent perforator recurrence after surgery is far more common than previously recognized. Possible explanations for this IPV recurrence are, according to van Rij et al, neovascularization of treated perforators and development of newly detected perforators in association with persistent venous disease. Development of new IPVs after surgery has already been described by Sybrandy et al,12 who found a high number of newly developed perforating veins 4 years after performing subfascial endoscopic perforating vein surgery. This finding was significantly influenced by the presence of deep venous incompetence.

Because IPVs are not an explanation for persistent reflux, how, then, can we explain these persistent refluxing GSV branches below the knee after surgery? One of the most supported recent theories on the pathogenesis of varicose veins is structural weakness of the vein wall.13 This weakness results in dilatation of the vein, causes dysfunction of the valves, and eventually leads to reflux. This phenomenon can occur anywhere in the venous system of the leg14 and also in the below-knee GSV branches. Therefore, if residual reflux persists beyond 6 months, it could be the result of preoperative primary incompetence of these segments rather than a consequence of extension of reflux from the upper leg GSV segment.

Another possibility for the persistent reflux after surgery is the so-called neoreflux: the altered hemodynamic situation after surgery causing redistribution of venous flow, which could overload some veins that have been competent but have an inherent weakness or uncover others that had partial incompetence that was masked by the main source of reflux.15 This neoreflux may appear in a substantial number of patients, despite complete abolition of sites of reflux identified before surgery.15

Even though reflux in the below-knee GSV branches persists after surgery, the diameters of the GSV branches decrease significantly. This is probably the explanation for the fact that the visible varicose veins disappear in most of the limbs, despite the fact that reflux persists in most of these limbs. Patients with varicose veins visit their doctors for several reasons, such as the risk for complications such as venous ulcer, venous complaints, and cosmetic complaints. Studies show that these complaints improve dramatically after surgery.6 According to our results, one can expect that four of five patients will have no visible varicose veins left in the GSV below the knee level after just dissection of the saphenofemoral junction and short-stripping of the GSV to just below the knee. This indicates that additional therapy such as stab avulsion of varicose veins on the lower leg during surgery is unnecessary in most patients. Sclerotherapy for residual varicose veins after surgery could be used subsequently, if necessary.2 Additionally, in recent years, radiofrequency ablation and endovenous laser therapy are becoming more popular in the treatment of varicose veins.2 Because these therapies are treating the same part of the GSV as the short-strip procedure, we believe that our findings are probably true for these GSV ablative therapies as well.

In conclusion, modern varicose vein surgery for primary varicose veins of the GSV by means of dissection of the saphenofemoral junction and short-stripping the GSV will have a beneficial effect on visible varicose veins in the below-knee-level GSV in the great majority of patients but has hardly any beneficial effect on residual saphenous vein reflux. IPVs do not seem to be related to the persistence of visible residual varicose veins below the knee nor to the persistence of below-knee GSV reflux. Thus, in our opinion, to prevent residual varicose veins, it is not necessary to focus on IPVs during short-stripping the GSV.

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Author contributions 


Conception and design: PvN, JV, MN

Analysis and interpretation: PvN, AK, HN

Data collection: PvN, EdH, RE, RL

Writing the article: PvN, AK

Critical revision of the article: PvN, AK, RE, JV, HN

Final approval of the article: PvN, AK, EdH, RE, JV, RL, HN

Statistical analysis: PvN, AK

Obtained funding: PvN

Overall responsibility: PvN

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References 

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  15. Turton EPL, Scott DJA, Richards SP, Weston MJ, Berridge DC, Kent PJ, et al. Duplex derived evidence of reflux after varicose vein surgery: neoreflux or neovascularisation?. Eur J Vasc Endovasc Surg. 1999;17:230–233

 Funded by a grant of the Trial Judgment Committee of the Laurentius Hospital Roermond and by a grant of the corporation Bauerfeind Benelux BV.

 Competition of interest: none.

PII: S0741-5214(06)01363-2

doi:10.1016/j.jvs.2006.06.047

Journal of Vascular Surgery
Volume 44, Issue 5 , Pages 1051-1054, November 2006

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