Interventional Treatment Options for Small Saphenous Varicose Veins
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authors:
Caroline D. Rodd, MD, FRCS, Alison M. Young, MBBS, Jonothan J. Earnshaw, DM, FRCS
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Introduction
Varicose veins are common, and affect nearly a third of adults in Western societies. Although women present more frequently for treatment, Lee et al observed a significantly higher age-adjusted prevalence of varicose veins in men (40% vs. 32% in women).1 Patients present with a variety of symptoms that they attribute to their varicose veins, including pain, heaviness, burning, itching, superficial thrombophlebitis, skin changes, and cosmetic issues. Bradbury et al found that even in the presence of truncal varices, most lower limb symptoms probably have a nonvenous etiology.2 Venous ulceration is known to be related to venous incompetence,3,4 and Gohel et al have shown that while superficial venous surgery does not improve the healing rate of venous ulcers, it does reduce the risk of recurrence.5 Despite the lack of supporting evidence regarding symptomatology, many patients request intervention for their varicose veins, and upwards of 50,000 interventional procedures are undertaken each year in the United Kingdom (UK). The vast majority of procedures are for great saphenous varicose veins (GSV). The surgical treatment of small saphenous vein (SSV) incompetence is regarded by most vascular surgeons as more challenging and as a higher risk than GSV surgery. The aim of this article is to examine the different interventional options for small saphenous varicose veins.
Why Does SSV Management Pose a Challenge?
The anatomy of the saphenofemoral junction is relatively constant, whereas that of the saphenopopliteal junction (SPJ) is highly variable.6–9 The SSV terminates at the SPJ, which is usually located in the popliteal fossa at the level of the knee crease. However, invasive and non-invasive investigations have revealed great variation in the location of the SPJ in relation to the knee crease; 49% of SPJ are at least 2 cm from the knee crease, and up to 13% may be more than 10 cm above or below.9 There is also significant variation in the presence and location of the Giacomini vein.6 Locating the SPJ at operation can be far from straightforward. There is also concern regarding the risk of nerve damage during the SPJ dissection and SSV stripping.10 Both the common peroneal and tibial nerves may lie close to the SPJ and be encountered during the exposure. The sural nerve often lies in close proximity to the SSV in the lower third of the calf, although this may be variable.11 The role of pre-procedural duplex ultrasonography to identify the level of the SPJ has been widely debated (Figure 1). De Maeseneer et al found duplex to be reliable in demonstrating the location of the SPJ location to within 1 cm.12 Yet, the routine use of pre-operative duplex to mark the site of the SPJ has not always improved the operative outcome. In 2002, Rashid et al reported that in 59 patients who underwent pre-operative duplex marking, the SPJ remained intact and incompetent six weeks later in 14% of procedures.13 Kambal et al reported that diagnostic duplex imaging and subsequent marking with the hand-held Doppler accurately located the SPJ in 88% of patients and obviated the need for a second pre-operative duplex.14
While there has been considerable research into the treatment of both primary and recurrent GSV, few studies have looked specifically at SSV. There is limited evidence on which clinicians can base their clinical practice. Furthermore, in recent years, there has been an explosion in the development of interventional techniques for varicose veins, and the options now include: endovenous laser ablation (EVLA), radiofrequency ablation (RFA), and foam sclerotherapy, in addition to standard surgery.
Surgical Management
The traditional surgical approach to the treatment of saphenopopliteal junction incompetence is open flush ligation of the SSV at the SPJ. The access is usually obtained via a transverse incision in the popliteal fossa at the site of the SPJ, which is marked preoperatively. A survey of UK vascular surgeons in 2004 found great variation in open surgical techniques for SSV procedures, with respect to pre-operative assessment, marking and surgical technique.15 Of those surveyed, the majority (89%) requested diagnostic duplex imaging for SSV, but only 50% requested pre-operative duplex marking of the SPJ. At operation, approximately three quarters of surgeons followed the SSV into the popliteal fossa and divided it as close to the SPJ as possible, though only 10% formally exposed the junction with the popliteal vein (Figure 2). A total of 55% surgeons removed a segment of proximal SSV, whereas 15% formally stripped the SSV routinely (Figure 3).15
A study in 1996 examined the cause in 70 legs with recurrence following SSV surgery using duplex imaging. In 61% of cases, the SSV was found to be the main source of reflux in the popliteal fossa; an incompetent gastrocnemius vein accounted for 34%.16 O’Hare et al conducted a multicenter observational study of the outcome after primary SSV surgery at nine UK hospitals, and among 219 patients. The incidence of recurrent varicose veins was not reduced in patients who had undergone SSV stripping. After one year, stripping the SSV (compared to simple ligation) did, however, reduce the rate of recurrent SPJ incompetence significantly (13% vs. 32%, P < 0.01) without increasing the risk of nerve injury.17 The results of SSV surgery in this series were generally regarded as satisfactory. There were no major complications, and the most common minor morbidity was a wound infection. No patient had a postoperative deep vein thrombosis (DVT). Open surgery remains the standard against which new methods must be tested.
Endovenous Treatments
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