Discussion

TriVex has evolved. The present technique yields extremely acceptable symptomatic and cosmetic results. As already mentioned in the results section, most patients and surgeons are happy. These studies were done with original technology and original technique. The majority of surgeons now use new technology and new technique. Results are better with the new method. As of this time, studies have not been done to quantitate this impression. What are some of the questions currently asked about TriVex?

• What is a learning curve? One can learn to resect veins after one or two cases. The key question is how many cases will it take to attain cosmetic results equal to an experienced TriVex surgeon? Approximately 10 to 20 cases are necessary to optimize your results.

• Can TriVex be used to resect the Great or Small Saphenous vein? No, these veins are too deep and cannot be visualized. More importantly, significant saphenous or sural nerve injury is possible.

• Can I use TriVex with other vein procedures? Yes, whatever procedures you would normally perform in conjunction with traditional varicose vein excision can be done with TriVex (e.g., laser or radiofrequency endovenous ablation, stripping, SEPS, etc.).

• What about difficult areas such as the knee, ankle, pudendal? These are all good candidates for TriVex after experience. The initial first stage tumescent hydrodissects the veins away from the underlying bony area.

• Is placement of incisions critical? Yes and no. With experience one can better "hide" incisions. For example, varicose veins over the anterior thigh or shin can be resected by incisions placed medially on the inner aspect of the thigh, thus hiding them. With traditional techniques, incisions must be placed directly over the veins, making them more visible.

• Are there any varicose veins for which TriVex cannot be used? TriVex works well for all varicose veins regardless of size or location. In fact, postsclerotic friable varicose veins are better removed with the suctioning and morcellating effect as compared to the hook or clamps of traditional procedures. The tumescence helps to partially exsanguinate large veins, size does not matter. Large veins are removed as easily as smaller veins.

• Does TriVex require general or regional anesthesia? No. This author and other experienced TriVex users perform most procedures using local tumescent and mild intravenous sedation. Since late 2004 we have performed almost all procedures with local anesthesia and sedation. When learning TriVex it is preferable to begin with laryngeal mask airway or short-acting regional since these patients should ambulate soon after procedure completion.

• What are the contraindications to TriVex? These are the same as those for any venous surgery: acute DVT, active thrombophlebitis, inability to ambulate, and so on. There are no specific contraindications relative to TriVex.

• What are some of the more common complications utilizing the newer technique and technology? Temporary subcutaneous sensory nerve parastheias occur, hematoma may still occur but is now in the range of 1%, and bruising lasting longer than one to two weeks occurs in approximately 5% of patients. Long-term subcutaneous scarring has almost been totally eliminated with slower, larger blades. The TriVex technique also has been used in countries aside from the United States and Europe.1314

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