Congrès SFP décembre 2014

L’approche des récidives: plus créative, moins invasive A more creative and less invasive approach for patients with recurrent varicose veins


Erasmus Medical Centre
Rotterdam, Netherlands

In previous decades, treatment of patients with recurrent varicose veins used to be rather invasive.
Patients were often treated by means of extensive redo surgery in general anesthesia, including reexploration
of the groin or popliteal fossa. These reoperations were often diffi cult, time consuming
interventions, characterized by more postoperative morbidity and worse outcome, compared to a first
surgical intervention.
Nowadays, we should defi nitely move towards a less invasive approach in patients with recurrent
varicose veins. Based on patients’ complaints, clinical fi ndings and ‘duplex anatomy’ the modern
phlebologist may use his/her creativity to offer an adequate solution to each individual patient. Several
less invasive strategies have been investigated and reported in recent literature. A valuable alternative
for a classic redo procedure consists of performing extensive phlebectomies without reopening the
groin or popliteal fossa, which results in less complications and a much lower cost. This procedure can
easily be performed in local tumescent anesthesia. In case duplex ultrasound examination still reveals
an important refl uxing segment (of at least 5-10 cm in length) of the great saphenous vein (GSV), the
anterior accessory saphenous vein (AASV) or the small saphenous vein (SSV) endovenous thermal (or
non-thermal) ablation of the refl uxing trunk may be the treatment of choice. One randomised clinical trial,
comparing radiofrequency ablation with extensive redo surgery, and several cohort studies reported
excellent results after endovenous laser ablation in recurrent cases. However many patients presenting
with recurrent varicose veins, are not suitable for the options mentioned above, in view of the duplex
fi ndings, with lots of incompetent tortuous veins running in and out the saphenous compartment, or
recurrent refl ux in a partially recanalised GSV, AASV or SSV, presenting with wall thickening and so called
‘trabeculae’. In these cases ultrasound guided foam sclerotherapy is the treatment of choice.
Apart from one single option to treat a patient with recurrent varicose veins, a creative combination
of techniques, using the different tools available nowadays for the modern phlebologist, may result
in a considerable clinical improvement and excellent patient satisfaction. For instance, a combination
of endovenous thermal ablation with injection of sclerosant foam through the catheter, or combining
phlebectomies with foam injection in the most cranial tributary at the end of the procedure, are all
interesting alternative strategies.
Finally, a good communication with the patient, presenting with recurrent varicose veins, is of utmost
importance. This will often lead to a rather ‘step-by-step’ approach, in view of the chronic nature of the
In conclusion, extensive reoperations should defi nitely belong to history and minimally invasive
techniques, based on the phlebologist’s creativity, should largely be preferred.

Key words: recurrence, minimally invasive treatment