Efforts To Mitigate Neovascularizationrelated Recurrent Reflux

Barrier Techniques to Contain Neovascularization

Containment involves constructing an anatomical barrier or inserting a prosthetic barrier between the ligated SFJ stump and the surrounding superficial veins in the groin. Various barrier techniques recently have been studied in primary as well as in recurrent varicose veins, with different rates of success.20,21 In particular, in repeat surgery at the SFJ, patch saphenoplasty at the level of the religated saphe-nous stump significantly improved the clinical and duplex scan results, after a follow-up period of five years.22

Endoablation of the GSV Stump

Isolating the stump endothelium from the wound milieu, by oversewing the "mouth" of the ligated SFJ with a running polypropylene suture resulted in reduction of recurrent reflux on color duplex venous imaging two years after oper-ation.23 Other investigators have chosen to destroy the stump endothelium, with chemical or heat cauterization, or in some instances to reduce the amount exposed by placing a second ligature near the free end of the GSV stump, all without conclusive results.

Abandoning SFJ Ligation?

Finally, what about comprehensive SFJ ligation, the "sacred cow"? Although we have always been taught that an accurate groin dissection with detachment of all tributaries is the ideal method to prevent recurrence from the groin, in fact, the reverse could become true during the forthcoming years. The usefulness of stripping the GSV (above knee) rests on firm experimental clinical evidence, but the importance of ligating all tributaries of the GSV in the groin is assumed rather than proved. Chandler et al.18 attempted to define the role of extended SFJ ligation in a study on endo-venous radiofrequency obliteration. Because endovenous obliteration can be done with or without a groin incision or SFJ ligation, they compared no ligation with extended SFJ ligation. The nonligation group, by its nature, coincidentally embraced the no stump, no stump-related neovascularization axiom. They found no notable between-group differences in 57 limbs at one year. Both groups had less than 10% recurrence of either reflux or varicosities. These results questioned the widely held but unproved axiom that SFJ ligation with ligation of all tributaries is an essential component of the treatment of GSV insufficiency. Maybe complete removal of the thigh portion of the GSV could be sufficient to achieve equal therapeutic benefits. The quite revolutionary idea of abandoning SFJ ligation in the management of primary varicose veins associated with GSV reflux will not be widely accepted without a prospective, five-year, randomized study.

Alternative Treatment Methods without SFJ Ligation

Endovenous treatment methods do not seem to be associated with neovascularization in the groin and could therefore become the future method of choice for treatment of primary varicose veins. The results of GSV radiofrequency obliteration after two and three years are promising, and duplex ultrasound findings confirm the absence of neovascular veins in the groin.19 Endovenous laser treatment is another technique developed to treat saphenous vein incompetence. If duplex scan showed occlusion of the vein one year after the procedure, it remained occluded at further controls up to three years after treatment.24 Ultrasound-guided foam sclero-therapy was introduced as a third alternative treatment method. The increased efficacy of foam, compared to liquid sclerotherapy, enabled treatment of varicose veins with larger diameter and even main superficial trunks. Encouraging results have even been obtained even in patients with recurrent varicose veins.

The results of these alternative treatment methods are promising, but yet inconclusive. Follow-up periods of at least five years are needed to better evaluate whether the recurrence rate after primary or recurrent varicose vein treatment could be reduced with these procedures.

Importance of Follow-up after Treatment

Whatever technique has been used, serial duplex examinations remain the cornerstone of follow-up. Early evaluation, two to three months after the procedure, is useful for initial quality control of the completeness of the (surgical) intervention. Further controls may help to understand and define the process and causes of recurrence. It has been shown that color duplex scan of the SFJ one year after GSV surgery has a high sensitivity and specificity. It accurately predicts which patients are more likely to have a good outcome five years after surgery.25

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