Congrès SFP décembre 2014

Quelle chirurgie pour les grosses saphènes ?

Which surgery for the large saphenous veins ?

A. CAVEZZI (1), F. CAMPANA (3), G. MOSTI (2), S.U. URSO (1)

(1) Eurocenter Venalinfa, San Benedetto del Tronto (AP), Italy
(2) Clinica Barbantini, Lucca, Italy
(3) Vascular Medicine, Hospital Bufalini, Cesena, Italy

Varicose vein surgery (VVS) has undergone a major reappraisal in the last two decades, due to the
diffusion of mini-invasive techniques in local anesthesia and with duplex ultrasound (DUS) guidance.
Furthermore the introduction and validation of the endovenous therapies (EVT) has led to a more
conservative approach.
Saphenous vein surgery moved from old-fashion

long stripping in general or spinal anesthesia, to more
tailored and mini-invasive therapies. More in detail a few treatments have been proposed and validated
in the last decades: a) crossectomy + segmental inverted saphenous stripping (CSS) tailored to the
length of saphenous refl ux, b) saphenous stripping without crossectomy, c) single phlebectomy without
any saphenous stripping in selective cases, d) combination of surgery with foam sclerotherapy, e) CHIVA.
When great saphenous vein (GSV) present large diameters (e.g. above 8 mm at the proximal thigh)
and aneurysmal dilations, incompetence of the terminal valve is invariably combined to incompetence/
absence of the iliac-femoral valve. This specifi c morpho-hemodynamic condition may orientate towards
CCS, in order to avoid a large residual GSV stump in case of EVT. No literature data support any
conclusion on different prognosis of EVT or stripping when treating larger diameter saphenous veins, but
in most publications on EVT the average size of the treated GSVs was 5-6 mm.
Our 24 year experience with CSS + hook phlebectomy in local anesthesia and with duplex guidance has
always included large diameter saphenous veins as well, with a high degree of effi cacy and safety. Recent
literature data show similar outcomes for stripping and EVT in terms of quality of life and recurrence, with
a slightly higher morbidity for CSS.
In presence of large, aneurysmal saphenofemoral/saphenopopliteal junction and large saphenous
trunks, CSS may present some complexity, though a higher degree of radicality is expected over more
conservative approaches in these few cases (CSS is performed in less than 5% of cases in our current
practice).
VVS is routinely performed in local anesthesia (e.g. with buffered mepivacaine 0.125% in a tumescent
administration); pre-operative DUS exploration allows a tailored local anesthesia administration and a
targeted surgical approach, thus increasing precision of inguinal/popliteal incision and of any surgical
manoeuvre.
If crossectomy is avoided, the combination of segmental saphenous stripping with foam sclerotherapy
of the proximal saphenous tract has been proposed. A few additional techniques, such as the usage of
long catheter, tumescence infi ltration and saphenous irrigation, provides improved outcomes of foam
sclerotherapy (94% success rate at 18 months in our experience).
Single phlebectomy (e.g. ASVAL or fi rst step of CHIVA 2) provides worse outcomes in case of large
saphenous veins, whereas CHIVA results seems to be independent from saphenous caliber.
Mini-invasive, duplex-targeted VVS may represent a valid alternative to ETA for the treatment of large
saphenous veins, both with or without foam adjuvant treatment.

Key words: varicose vein, surgery