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Great saphenous varicose vein surgery without saphenofemoral junction disconnection
Zamboni P, Gianesini S, Menegatti E, Tacconi G, Palazzo A, Liboni A. Br J Surg. 2010;97:820-825.
Reviewed by
Michel Perrin, Lyon, France
ABSTRACT


A duplex protocol including reflux elimination test (RET) [Figure 1] and assessment of the terminal valve was used in 200 patients.
Click on the figure to enlarge i
[b]http://www.veinews.com/wp-content/uploads/2011/01/Per003img.jpgt


One hundred patients who had a positive RET result and an incompetent terminal valve were compared with 100 patients matched for age, sex, and CEAP clinical class who had a positive RET result and a competent terminal valve. All patients were treated by incompetent tributary phlebectomy sparing the segments above the reentry perforators as described in previous articles (ambulatory conservative hemodynamic management of varicose veins, or cure CHIVA in French).1 At 3-year follow-up, 100% of patients with competent terminal valve were cured according to the Hobbs classification2 and 14% developed recurrence; 71% of patients with incompetent terminal valve were not cured according to the Hobbs classification and 82% developed recurrence (P<0.001).
COMMENTARY
This article is interesting for 2 reasons
1) Preservation or nonpreservation of the saphenofemoral junction
Until recently non-flush ligation of the saphenofemoral junction (SFJ) was considered a technical mistake when treating by open surgery great saphenous vein incompetence. This dogma was based on the descending pathophysiology theory of varicose vein progression as stipulated by Trendelenburg in 1890. Because of ultrasound investigation this pathophysiological concept is now being questioned.
Firstly because many patients with varicose great saphenous vein have no reflux at the SFJ.3-16
Furthermore, when reflux is identified at the SFJ the terminal valve is competent in about 50% of cases, knowing that the subterminal valve is incompetent.17 We have long known that sclerotherapy is successful in many cases although great saphenous vein termination remained patent. More recently thermal ablation without high ligation has led to excellent outcomes at medium- and long-term follow-up.18 The fate of the SFJ was assessed after thermal ablation by ultrasound and no persistent reflux was identified.19,20 A randomized control study comparing at 2 years great saphenous vein laser ablation with and without ligation of the SFJ did not find a difference in terms of outcome between the 2 groups.21 This could explain why classic surgery, ie, high ligation plus stripping with preservation of the SFJ, has been adopted by some centers.
The first report of saphenous stripping with preservation of the SFJ was by Pittaluga who reported a retrospective series of 195 incompetent great saphenous veins (151 patients) treated by stripping with preservation of the SFJ, knowing that the terminal valve was incompetent in 157 cases (80.5%).22 At a mean of 24.4 months postoperatively (median 27.3 months, range 8 to 34.8), persistent SFJ reflux was observed in only two cases (1.8%) and SFJ neovascularization in one case (0.9%). The latter percentage is crucial as we know that after flush high ligation neovascularization is the main cause of recurrence and is estimated to occur in between 20 and 40% of cases, depending on the duration of follow-up.23-27
2) For assessment of CHIVA and outcome
While SFJ was preserved but the saphenous trunk stripped in the Pittaluga’s study, 22 the saphenous trunk was preserved in the CHIVA 2 procedure, as reviewed in the present study. According to Zamboni et al, a complementary maneuver is recommended in order to determine if the SFJ must be preserved or not. This is a new recommendation in the CHIVA 2 procedure.
Another point worth underlining is that in their introduction Zamboni et al state that with CHIVA-2 reported rates of recurrent reflux were 15% after 6 months 3 and 92% after 3 years.28 These recurrence rates are not in accordance with data from a randomized controlled trial by Parés et al in which clinical and ultrasound recurrence rates after CHIVA were 26.8% and 36.3%, respectively, at 5-year follow-up.29,30
Hypothesis
How can we explain these differences in outcome between classic surgery, thermal and chemical ablation (group 1) and surgery preserving the saphenous trunk (CHIVA) when the SFJ is preserved?
In the first group it seems that competence or incompetence of the terminal valve does not influence the results; in CHIVA group it does. The explanation could be that in the first group saphenous ablation significantly decreases the “reservoir” in which the reflux drains, whereas in CHIVA the draining reservoir persists.
References:
1. Franceschi C. Théorie et Pratique de la Cure Conservatrice et Hémodynamique de l’Insuffisance Veineuse en Ambulatoire. Precy-sous-Thil, France: Editions de l’ Armancon; 1988.
2. Hobbs JT. Surgery and sclerotherapy in the treatment of varicose veins: a random trial. Arch Surg. 1974;109:793-796.
3. Zamboni P, Cisno C, Marchetti F, et al. Reflux elimination without any ablation or disconnection of the saphenous vein. A hemodynamic model for venous surgery. Eur J Vasc Endovasc Surg. 2001;21:361-369.
4. Zamboni P, Cisno C, Marchetti F, et al. Minimally invasive surgical management of primary venous ulcers vs. compression treatment: a randomized clinical trial. Eur J Vasc Endovasc Surg. 2003;25:313-318.
5. Abu-Own A, Scurr JH, Coleridge Smith PD. Saphenous vein reflux without incompetence at the saphenofemoral junction. Br J Surg. 1994;81:1452-1454.
6. Barros MV, Labropoulos N , Ribeiro AL, Okawa RY, Machado FS. Clinical significance of ostial great saphenous vein reflux. Eur J Vasc Endovasc Surg. 2006;31:320-324.
7. Bernardini E, De Rango P, Piccioli R, et al. Development of Primary Superficial Venous insufficiency: The Ascending Theory. Observational and Hemodynamic Data From a 9-Year Experience. Ann Vasc Surg. 2010;24:709-720.
8. 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.
9. Fassiadis N, Holdstock JM, Whiteley MS. The saphenofemoral valve: gate keeper turned into rear guard. Phlebology. 2002;17:29-31.
10. Hanrahan LM, Kechejian GJ, Cordts PR, et al. Patterns of venous insufficiency in patients with varicose veins. Arch Surg. 1991;126:687-691.
11. Hollingsworth SJ, Tang CB, Barker SGE. Primary varicose veins in the presence of an intact sapheno-femoral junction. Phlebology. 2001;16:68-72.
12. Labropoulos N, Giannoukas AD, Delis K, et al. Where does venous reflux start? J Vasc Surg. 1997;26:736-742.
13. Labropoulos N, Kokkosis AA, Spentzouris G, et al. The distribution and significance of varicosities in the saphenous trunks. J Vasc Surg. 2010;51:96-103.
14. Labropoulos N, Leon L, Kwon S, et al. Study of the venous reflux progression. J Vasc Surg. 2005;41:291-295.
15. Pichot O, Sessa C, Bosson JL. Duplex imaging analysis of the long saphenous vein reflux: basis for strategy of endovenous obliteration treatment. Intern Angiology. 2002;21:333-336.
16. Pittaluga P, Chastanet S, Rea B, Barbe R. Classification of saphenous refluxes: implications for treatment. Phlebology. 2008;23:2-9.
17. Cappelli M, Molino Lova R, Ermini S, Zamboni P. Hemodynamics of the sapheno-femoral junction patterns of reflux and their clinical implications. International Angiology. 2004;23:25-28.
18. Merchant RF, Pichot O; Closure Study Group. Long-term outcomes of endovenous radiofrequency obliteration of saphenous reflux as a treatment for superficial venous insufficiency. J Vasc Surg. 2005;42:502-509.
19. Pichot O, Perrin M. Aspects échographiques de la jonction saphéno-fémorale après oblitération de la grande veine saphène par radiofréquence (Closureâ). Phlébologie. 2002;55:329-334.
20. Pichot O, Kabnick LS, Creton D, et al. Duplex ultrasound scan findings two years after great saphenous vein radiofrequency endovenous obliteration. J Vasc Surg. 2004;39:189-195.
21. Disselhoff BC, der Kinderen DJ, Kelder JC, Moll FL. Randomized clinical trial comparing endovenous laser ablation of the great saphenous vein with and without ligation of the sapheno-femoral junction: 2-year results. Eur J Vasc Endovasc Surg. 2008;36:713-718.
22. Pittaluga P, Chastanet S, Guex JJ. Great saphenous vein stripping with preservation of sapheno-femoral confluence: Hemodynamic and clinical results. J Vasc Surg. 2008;47:1300-1304.
23. De Maeseneer M.G. The role of postoperative neovascularisation in recurrence of varicose veins: from historical background to today’s evidence. Acta Chir Belg. 2004;104:283-289.
24. Jones L, Braithwaite BD, Selwyn D,et al. Neovascularisation is the principal cause of varicose vein recurrence: results of a randomised trial of stripping the long saphenous vein. Eur J Vasc Endovasc Surg. 1996;12:442-445.
25. Kostas T, Ioannou CV, Touloupakis, et al. Recurrent varicose veins after surgery: A new appraisal of a common and complex problem in vascular surgery. Eur J Vasc Endovasc Surg. 2004;27,275-282.
26. Van Rij AM, Jones GT, Hill GB, Jiang P. Neovascularization and recurrent varicose veins: More histologic and ultrasound evidence. J Vasc Surg. 2004;40:296-302.
27. Van Rij AM, Jiang P, Solomon C,et al. 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.
28. Escribano JM, Juan J, Bofill R,et al. Durability of reflux-elimination by a minimal invasive CHIVA procedure on patients with varicose veins. A 3-year prospective case study. Eur J Vasc Endovasc Surg. 2003;25:159-163.
29. Parés JO, Juan J, Tellez R, et al. Varicose vein surgery. Stripping versus the CHIVA method: a randomized controlled trial. Ann Surg. 2010;251:624-631.
30. See also VEINEWS of December 14, 2010 for comprehensive bibliographic references

_________________
Viktor Knyazhev


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