Journal of Vascular Surgery
Volume 47, Issue 6 , Pages 1300-1304, June 2008

Great saphenous vein stripping with preservation of sapheno-femoral confluence: Hemodynamic and clinical results

Presented at the Nineteenth Annual Meeting of the American Venous Forum, San Diego, Calif, Feb 14-17, 2007.

  • Paul Pittaluga, MD

      Affiliations

    • Riviera Veine Institut, Nice, France
    • Corresponding Author InformationReprint requests: Paul Pittaluga, MD, Riviera Veine Institut, 6, rue Gounod, 06000 Nice, France.
    • ,
  • Sylvain Chastanet, MD

      Affiliations

    • Riviera Veine Institut, Nice, France
    • ,
  • Jean-Jérôme Guex, MD

      Affiliations

    • Cabinet de Médecine Vasculaire, Nice, France.

Received 10 October 2007; accepted 21 January 2008. published online 28 April 2008.

Article Outline

Background

Radiofrequency and laser vein treatment, which entail preservation of the saphenous confluence, have called into question the dogma of ligation of all tributaries at the sapheno-femoral confluence (SFC), so called “crossectomy”. Nevertheless, crossectomy is still done when saphenous vein stripping is chosen for varicose vein treatment. The purpose of this study was to evaluate results after stripping procedures in which the SFC was preserved.

Methods

This was a retrospective cohort study for which limbs treated for varicose veins by surgical stripping of the great saphenous vein and preservation of the SFC were studied. All limbs had a preoperative duplex examination and showed SFC and truncal incompetence of the great saphenous vein. Periodic postoperative standing duplex ultrasound and clinical examinations were carried out, and results were recorded and analyzed retrospectively.

Results

A total of 195 lower limbs were operated on in 151 patients (128 women and 25 men) aged from 22 to 88 years (mean age 56.8). The preoperative diameter of the SFC ranged from 4.7 to 17 mm (mean 9.5 mm). The preoperative CEAP class distribution was C1 1.5%, C2 82.1%, C3 6.7%, and C4-C6 9.7%. Preoperative symptoms were present in 61.8% of cases. Postoperative thrombosis of the SFC was observed in one case with an extension to the deep femoral vein and pulmonary embolization at 1 month. Recovery was complete. At a mean of 24.4 months postoperatively (median 27.3 months, range 8 to 34.8), persistent SFC reflux was observed in only two cases (1.8%) and a SFC neovascularization in one case (0.9%). Recurrence of varicose veins appeared in seven cases (6.3%) but in conjunction with SFC reflux in only one case. Post treatment 83.9% of limbs were converted to CEAP clinical class 0 to 1 and significant symptom improvement was observed in 91.3% of cases with an aesthetic benefit in 95.5%.

Conclusion

Preservation of the SFC during saphenous stripping gave good results with regard to hemodynamics and neovascularization on the SFC, varicose vein recurrence, improvement of symptoms, and aesthetic appearance for legs with a median follow-up of 27.3 months.

 

It has been established that in cases of great saphenous vein (GSV) reflux, the ostial valve is often continent. In the literature The frequency of sub-ostial or more distal trunk reflux was evaluated at around 50%.1, 2, 3, 4, 5, 6 Endovenous treatments for GSV reflux have called into question the principle of ligation of all tributaries at the sapheno-femoral confluence, so called “crossectomy”, leaving the sapheno-femoral confluence (SFC) in place upstream of the preostial valve.7, 8 Results of endovenous techniques show that SFC reflux frequency in the medium term does not exceed 15%, with anterograde drainage of the SFC collaterals towards the femoral vein in 85% to 100% of cases.9, 10, 11

However, when surgical ablation of the GSV is performed by means of stripping, crossectomy is still the norm. Given the results of endovenous treatments since October 2003, we have no longer performed crossectomies during surgical stripping of the GSV, including cases of ostial reflux. The aim of this study is to evaluate the hemodynamic and clinical results of this new approach.

Back to Article Outline

Methods 

Data studied 

This was a retrospective cohort study for which we reviewed all the files for patients who had had a GSV stripping since October 2003. The preoperative clinical and hemodynamic data were gathered, as was information collected during the patient follow-up period.

At each appointment, we classified signs according to CEAP class and looked for symptoms suggesting chronic venous insufficiency (CVI), such as pain, heaviness, weightiness, restless leg syndrome, nocturnal cramps, pruritus, edema, and phlebalgia.

On the eighth postoperative day, we assessed analgesic use and measured the surface area of ecchymoses (bruising) and hematomas (solid swelling of clotted blood within the tissues). This evaluation was done by a transfer paper on which were drawn the apparent ecchymosis and the palpable hematomas, and then reported it on a cross-section paper for measurement.

An echo-Doppler examination was systematically performed before surgery and during the follow-up period (after 1 month and 6 months, and then once a year). We identified GSV reflux by a venous flushing maneuver with manual compression and release of the calf muscles, and SFC reflux by the Valsalva maneuver, both in standing position. We considered reflux to be pathological if it lasted for longer than 0.5 seconds.

Exclusion criteria 

We excluded files without a detailed echo-Doppler examination or operation report. We also excluded cases where a crossectomy had been associated with GSV stripping.

Statistical analysis 

The qualitative bivariate comparisons were tested using the χ2 test, and the mean comparisons were tested using the Student t test (paired t test). A significance level of 0.05 was chosen for each comparison.

Back to Article Outline

Results 

Population studied 

Between October 2003 and June 2006, we operated on 975 lower limbs (LL) to treat varices with GSV reflux, including 220 GSV strippings. Among this 220 GSV strippings, 10 crossectomies have been carried out because of a large diameter of the SFC (>20 mm) or the presence of a thrombus in the SFC, and 15 strippings with preservation of the SFC were excluded because of a lack of data. Thus, 195 strippings with preservation of the SFC were studied. These operations involved 151 patients (126 women and 51 men) with a mean age of 59.8 (median 57, range 22 to 88 years).

The preoperative spread of these 195 LL over class C of the CEAP classification was as follows: 3 LL were classed as C0 or C1 (1.5%); 160 LL were classed as C2 (82.1%); 13 LL were classed as C3 (6.7%); and 19 LL were classed as C4 to C6 (9.7%). A total of 157 patients (80.5%) presented symptoms that suggested CVI, whilst 38 patients (19.5%) were asymptomatic.

Preoperative echo-Doppler examinations showed GSV reflux in all cases (Table I), with an incontinent ostial valve in 157 cases (80.5%), whereas 38 cases (19.5%) presented subostial reflux. The mean preoperative diameter of the SFC was 9.5 mm (median 9, range 5 to 17 mm).

Table I. Preoperative competence of the ostial valve at the sapheno-femoral junction (SFJ) assessed by duplex scan
Competent ostial valve3819.5%
Incompetent ostial valve15780.5%
Total195100%
Mean diameter of SFJ (mm)9.5(5-17)

Operations performed 

We performed a ligature of the GSV using a short inguinal approach, upstream of the last descending collateral of the arch (Fig 1), which in the vast majority of cases, was identified as the anterior collateral of the GSV in the thigh (193 times out of 195). We performed stripping according to the extension of the saphenous reflux: long stripping up until the internal malleolus in 87 cases (44.6%) and a short stripping below the knee (superior third of the leg) in the remaining cases. The mean number of phlebectomies was 39.7 (median 38, range 0 to 87) according to the Muller's technique12 for a mean operation time of 79.2 minutes (median 85, range 30 to 125 minutes). All of the operations were unilateral and carried out under tumescent local anesthesia. The mean hospitalization period was 4 hours, and 194 times out 195, surgery was carried out in ambulatory procedure. A preventative dose of low molecular weight heparin (LMWH) was given in 15 cases (7.7%).

Immediate follow-up (Table II) 

We followed up all patients on the eighth postoperative day. We noted ecchymosis on the operated LL in 101 cases (51.8%) with a mean surface area of 9.15 cm2 (median 9.9 cm2, range 2 to 21 cm2), and hematomas in 23 cases (7.6%) with a mean surface area of 13.5 cm2. (median 10 cm2, range 2 to 55 cm2) In 119 cases (32.2%), patients did not take any analgesics during this period. We prescribed time off work in 71 cases for a mean duration of 4.5 days.

Table II. Immediate postoperative follow-up after stripping of the great saphenous vein without crossectomy
Ecchymosis at D810151.8%
Mean surface (cm2)9.15
Hematoma at D82311.8%
Mean surface (cm2)13.5
Analgesic taking7638.9%
Mean taking (no of tablets)3.2
Time off work prescription (number of patients)7158.7%
Mean time (no of days)4.5

We did not find any significant difference in terms of surface of ecchymosis and hematomas, and analgesics taking between the group of patient underwent short stripping and the group who underwent long stripping.

We observed postoperative complications in two cases:

•Thrombosis of the SFC which had been left in place, with extension to the femoral vein and a pulmonary embolism diagnosed on D30 in a 37-year-old woman with a SFC that was 16 mm in diameter. It was a moderate pulmonary embolism requiring a 6-day stay in hospital with heparin treatment, followed immediately by treatment with oral anticoagulation for 6 months. Thrombophilia caused by a mutation of the factor V Leiden gene was subsequently diagnosed. The patient did not present any clinical or echo-Doppler sequelae.

•A cutaneous infection of a micro-incision on the middle third of the leg.

We did not observe any other complications, particularly inguinal complications.

Follow-up after 1 year 

We followed up 112 out of 195 LL (57.4%) after the first postoperative year, with a mean follow-up of 24.4 months (median 27.3, range 12 to 37 months). We evaluated all of the LL using an echo-Doppler examination, and found SFC reflux in two cases (1.8%) during the follow-up after one year (Fig 2). This reflux was linked to inguinal neovascularization in one case, and with reflux in the GSV anterior collateral in the thigh in the other case. We observed one other case of inguinal neovascularization which was not connected to SFC reflux or to reflux in the underlying veins. The mean diameter of the SFC was 5.4 mm (median 5.3, range 2.6 to 9.4 mm), which is significantly lower than the mean preoperative diameter for the 112 LL followed up (9.7 mm, P < .05).

From a clinical point of view, the CEAP classification for the 112 LL followed up for more than a year was as follows: C0-C1 in 94 cases (83.9%); C2 in 7 cases (6.3%); C3 in 2 cases (1.8%); and C4 to C6 in 9 cases (8%) (Fig 3). Furthermore, there was a very clear improvement or a disappearance of symptoms in 63 out of 69 preoperative symptomatic patients followed (91.3%) and an esthetic improvement in 106 cases (94.6%).

We observed clinical varicose vein recurrence according to the REVAS definition13 in seven cases (6.3%) during the follow-up after 1 year (Fig 4): one case related to SFC reflux through the anterior collateral of the GSV in the thigh (diagnosed at 6 months postop); the six others were distal recurrences that were not related to the SFC, neither to the presence of an incompetent perforator vein. We treated two of the recurrences with another phlebectomy without repeated inguinal surgery (at 26 and 32 months), and three with foam echosclerotherapy (at 25, 30, and 31 months). The two remaining cases were not treated.

Back to Article Outline

Discussion 

The population we operated on in this study presented advanced varices, since they required GSV stripping. Only 20% of the varices we operated on during this period had needed a GSV stripping. Furthermore, most of the patients presented symptoms, and we observed SFC reflux in 80.5% of the cases, whereas the rate is usually 50% in the literature if there is saphenous reflux.1, 2, 3, 4, 5, 6 In fact, the surgery we performed was relatively extensive: long stripping in nearly half the cases, with an average of 40 associated phlebectomies and a mean operation duration of 80 minutes. Yet, in our study, we observed no reflux in the preserved SFC in 98.2% of cases with a mean follow-up period of 24.4 months. These results are at least comparable or even superior to the data published after 2 years of follow-up after endovenous treatment using radiofrequency, where reflux absence in the SFC varied between 80% and 90%.8, 9, 10, 11 With the same follow-up period of 2 years, publications regarding endovenous laser treatment show that there is no SFC reflux in 93% to 97% of cases.14, 15 In view of these results, we can ask ourselves whether carrying out a surgical stripping in association with extensive phlebectomies improves hemodynamics of the preserved SFC, given the fact that the GSV cannot become permeable again and perhaps especially given the ablation of the varicose reservoir by the absence of an outflow for the reflux. In our series, one of the two persistent SFC reflux cases was linked to insufficiency of the GSV anterior collateral, which appeared early and was probably linked to insufficient excision of the crural varices. The hemodynamic benefits of ablation of the varicose reservoir are mentioned in the literature.16 However, certain publications 17, 18 show that varices treatment does not affect the result once endovenous treatment of the GSV has been performed, but these series only have a short follow-up period and include a large number of secondary procedures aimed at treating the varicose reservoir.

Despite an inguinal approach, the rate of inguinal neovascularization after 2 years was very low in our series (1.8% at 2 years). This figure is not higher than the figures recorded after endovenous treatment where the neovascularization rate varies from 0% to 2.8%,8, 9, 10, 11 and it is much lower than traditional surgical series including enlarged crossectomy with rates of 20% to 53%.19, 20, 21, 22 It seems that preserving the superficial abdominal and perineal venous drainage by not dissecting the SFC and by not dividing the collaterals, enables neovascularization to be avoided. Using a limited inguinal approach without dissecting the SFC does not, therefore, seem to cause more neovascularization since it does not prevent the SFC collaterals from draining into the femoral vein.

The clinical recurrence rate that we observed (6.3%) can be compared with series of strippings associated with traditional enlarged crossectomies where the figures varied from 10% to 25% after 2 years.19, 22 Our recurrence rate is also better than that observed after endovenous treatment with an identical follow-up period where there is a 12% to 15% clinical recurrence rate.9, 10, 11 It is difficult to compare the different series, because the extent of the preoperative varices and the extent of the varicose reservoir resection are never mentioned. However, these elements are probably determining factors in recurrence after a first line therapy treatment. Moreover, in our study, clinical recurrence was independent of SFC reflux in six cases out of seven, just as the ablation of the saphenous vein did not present recurrence in the series of endovenous treatments.9, 10, 11 These observations support the theory that varicose disease develops from the superficial distal venous network, which is increasing mentioned in the literature,3, 4, 5, 6, 23 contrary to the traditional description whereby varicose disease develops downwards from the saphenous confluences and veins.24, 25

The follow-up to our surgical series was uneventful, both in terms of ecchymoses (none in 48.2% of cases) and hematomas (none in 88.2% of cases), and in terms of postoperative pain (no analgesics taken in 68.1% of cases) and time off work (4.5 days on average). These data are similar to those published after endovenous treatment.26, 27 We have already reported the benefits of tumescent local anesthesia and immediate walking after varicose vein surgery.28 Obviously, prospective randomized studies would be required to compare postoperative quality of life after surgical saphenous ablation under tumescent local anesthesia and after endovenous procedures.

However, we did observe a serious postoperative complication with SFC thrombosis, complicated by an extension to the femoral vein and by a pulmonary embolism. SFC thrombosis with extension of the thrombus to the femoral vein has been reported in the literature after endovenous treatment.9, 29, 30 This potentially serious complication risk should probably be taken into account when preserving the SFC by means of targeted prevention, for example using LMWH treatment or a traditional enlarged crossectomy in cases of thrombophilia, history of thrombosis, or very dilated SFC (>20 mm). An early postoperative echo-Doppler examination (eg, after 24 to 48 hours) could also be recommended in order to detect thrombo-embolic complications.31

It seems that preserving the SFC during GSV reflux treatment is really worthwhile due to the preservation of inguinal venous drainage. Furthermore, surgical treatment can remain competitive compared with endovenous techniques if the surgery is mini-invasive and carried out under tumescent local anesthesia with immediate walking. This is particularly true if the GSV treatment also includes excision of widespread varices, as the benefits of endovenous treatment (which is, by definition, limited to the saphenous veins) are debatable.

Back to Article Outline

Conclusion 

As for endovenous treatments, conserving the SFC seems to be beneficial during surgical ablation of the saphenous vein, because the physiological venous drainage of the inguinal region is preserved, including a low level of neovascularization on the groin and varicose recurrence for legs with a median follow-up of 27.3 months. Furthermore, surgical ablation can remain competitive compared with endovenous treatments in terms of the simplicity of the surgical outcome, if it is performed under tumescent local anesthesia with immediate walking, particularly in cases of extensive varices. Further studies are needed in order to assess the postoperative risk of SFC thrombosis and the long-term hemodynamic results of both this surgical approach and of endovenous techniques.

Back to Article Outline

Author contributions 


Conception and design: PP, SC, JJG

Analysis and interpretation: PP

Data collection: SC

Writing the article: PP

Critical revision of the article: SC, JJG

Final approval of the article: PP

Statistical analysis: PP

Obtained funding: Not applicable

Overall responsibility: PP

Back to Article Outline

References 

  1. Abu-Own A, Scurr JH, Coleridge Smith PD. Saphenous vein reflux without incompetence at the sapheno-femoral junction. Br J Surg. 1994;81:1452–1454
  2. Labropoulos N, Delis K, Nicolaides AN, Leon M, Ramaswami G. The role of the distribution and anatomic extent of reflux in the development of signs and symptoms in chronic venous insufficiency. J Vasc Surg. 1996;23:504–510
  3. Labropoulos N, Giannoukas AD, Delis K, Mansour MA, Kang SS, Nicolaides AN, et al. Where does venous reflux start?. J Vasc Surg. 1997;26:736–742
  4. Labropoulos N, Leon L, Kwon S, Tassiopoulos A, Gonzalez-Fajardo JA, Kang SS, et al. Study of the venous reflux progression. J Vasc Surg. 2005;41:291–295
  5. Engelhorn CA, Engelhorn AL, Cassou MF, Salles-Cunha SX. Patterns of saphenous reflux in women with primary varicose veins. J Vasc Surg. 2005;41:645–651
  6. Pittaluga P, Chastanet S, Réa B, Barbe R, Guex JJ, Locret T. Corrélation entre l'âge, les signes et symptômes de l'insuffisance veineuse superficielle et les résultats de l'exploration écho-Doppler. Phlébologie. 2006;59:149–156
  7. Guex JJ, Min RJ, Pittaluga P. Traitement de l'insuffisance veineuse de la grande saphène par laser endoveineux: technique et indication. Phlébologie. 2002;55:239–243
  8. Pichot O, Kabnick LS, Creton D, Merchant RF, Schuller-Petroviae S, Chandler JG. Duplex ultrasound scan findings two years after great saphenous vein radiofrequency endovenous obliteration. J Vasc Surg. 2004;39:189–195
  9. Merchant RF, Pichot O. Long-term outcomes of endovenous radiofrequency obliteration of saphenous reflux as a treatment for superficial venous insufficiency. J Vasc Surg. 2005;42:502–509
  10. Nicolini P Closure Group. Treatment of primary varicose veins by endovenous obliteration with the VNUS closure system: results of a prospective multicenter study. Eur J Vasc Endovasc Surg. 2005;29:433–439
  11. Creton D et le Groupe Closure. Oblitération tronculaire saphène par le procédé radiofréquence closure: résultats à 5 ans de l'etude prospective multicentrique. Phlébologie. 2006;59:67–72
  12. Muller R. Traitement des varices par phlébectomie ambulatoire. Phlébologie. 1966;19:277–279
  13. Perrin M, Guex JJ, Ruckley CV, De Palma RG, Royle JP, Eklof B, et al. REVAS group Recurrent varices after surgery (REVAS): a consensus document. Cardiovasc Surg. 2000;8:233–245
  14. Min RJ, Khilnani N, Zimmet SE. Endovenous laser treatment of saphenous vein reflux: long-term results. J Vasc Interv Radiol. 2003;14:991–996
  15. Proebstle TM, Moehler T, Herdemann S. Reduced recanalization rates of the great saphenous vein after endovenous laser treatment with increased energy dosing: definition of a threshold for the endovenous fluence equivalent. J Vasc Surg. 2006;44:834–839
  16. Pittaluga P, Réa B, Barbe R, Guex JJ. A.S.V.A.L. method: principles and preliminary results. In:  Becquemin JP,  Alimi YS,  Watelet J editor. Updates and controversies in vascular surgery. Torino: Minerva Medica; 2005;p. 182–189
  17. Monahan DL. Can phlebectomy be deferred in the treatment of varicose veins?. J Vasc Surg. 2005;42:1145–1149
  18. Welch HJ. Endovenous ablation of the great saphenous vein may avert phlebectomy for branch varicose veins. J Vasc Surg. 2006;44:601–605
  19. Jones L, Braithwaite BD, Selwyn D, Cooke S, Earnshaw JJ. Neovascularisation is the principal cause of varicose vein recurrence: result of a randomized trial of stripping the long saphenous vein. Eur J Vasc Endovasc Surg. 1996;12:442–445
  20. van Rij AM, Jiang P, Solomon C, Christie RA, Hill GB. Recurrence after varicose vein surgery: a prospective long-term clinical study with duplex ultrasound scanning and air plethysmography. J Vasc Surg. 2003;38:935–943
  21. Perrin MR, Labropoulos N, Leon LR. Presentation of the patient with recurrent varices after surgery (REVAS). J Vasc Surg. 2006;43:327–334
  22. Rutgers PH, Kitslaar PJ. Randomized trial of stripping versus high ligation combined with sclerotherapy in the treatment of the incompetent greater saphenous vein. Am J Surg. 1994;168:311–315
  23. Cooper DG, Hillman-Cooper CS, Barker SG, Hollingsworth SJ. Primary varicose veins: the sapheno-femoral junction, distribution of varicosities and patterns of incompetence. Eur J Vasc Endovasc Surg. 2003;25:53–59
  24. Trendelenburg F. Ueber die Unterbindung der Vena Saphena magna bei Unterschenkel Varicen. Beitr Klin Chir. 1890;7:195–210
  25. Ludbrook J, Beale G. Femoral venous valves in relation to varicose veins. Lancet. 1962;13:79–811
  26. de Medeiros CA, Luccas GC. Comparison of endovenous treatment with an 810 nm laser versus conventional stripping of the great saphenous vein in patients with primary varicose veins. Dermatol Surg. 2005;31:1685–1694
  27. Lurie F, Creton D, Eklof B, Kabnick LS, Kistner RL, Pichot O, et al. Prospective randomized study of endovenous radiofrequency obliteration (closure) versus ligation and vein stripping (EVOLVeS): two-year follow-up. Eur J Vasc Endovasc Surg. 2005;29:67–73
  28. Pittaluga P, Marionneau N, Creton D, Lefebvre-Vilardebo M, Rea B, Sala F, et al. Traitement chirurgical des varices des membres inférieurs: approche moderne. Phlébologie. 2004;57:301–307
  29. Chandler JG, Pichot O, Sessa C, Schuller-Petrovic S, Kabnick LS, Bergan JJ. Treatment of primary insufficiency by endovenous saphenous vein obliteration. Vasc Surg. 2000;38:201–214
  30. Manfrini S, Gasbarro V, Danielsson G, Norgren L, Chandler JG, Lennox AF, et al. Endovenous management of saphenous vein reflux (Endovenous Reflux Management Study Group). J Vasc Surg. 2000;32:330–342
  31. Puggioni A, Kalra M, Carmo M, Mozes G, Gloviczki P. Endovenous laser therapy and radiofrequency ablation of the great saphenous vein: analysis of early efficacy and complications. J Vasc Surg. 2005;42:488–493

 Competition of interest: none.

PII: S0741-5214(08)00179-1

doi:10.1016/j.jvs.2008.01.042

Journal of Vascular Surgery
Volume 47, Issue 6 , Pages 1300-1304, June 2008

Article Tools

* Image Usage & Resolution