Epidemiology And Socioeconomic Consequences

Prevalence and Incidence of REVAS

They are not easy to determine as most studies are retrospective, analyzing patients that were not evaluated preoperatively by duplex scanning (DS), and usually the detailed operative report is not available. In a 34-year follow-up,12 varicose veins were present in 77% of the lower limb examined and were mostly symptomatic. Fifty-eight percent were painful, 83% had a tired feeling and edema had reappeared in 93%.

Two recently published prospective studies are available with a follow-up of five years.16,20

In both, the patients had preoperative DS and were treated by high ligation, saphenous trunk stripping, and stab avulsion.

In the Kostas series from Crete,16 true recurrent varices were present in eight limbs (8/28, 29%), primarily caused by neovascularization, new varicose veins as a consequence of disease progression were seen in seven limbs (7/28, 25%), residual veins were found in three limbs (3/28, 11%) mainly due to tactical errors (e.g., failure to strip the GSV), and complex patterns were identified in 10 limbs (10/28, 36%).

In the limbs with recurrence, 42 sources of venous reflux were identified: 19 new sites of venous reflux were due to disease progression, 15% of the operated limbs; 13 were caused by neovascularization, 11.5% of the operated limbs; six resulted from tactical failures, 5.3% of the operated limbs; and four were due to technical failures, 3.5% of the operated limbs. This study showed that recurrence of varicose veins after surgery is common. However, the clinical condition of most affected limbs remains improved. Progression of the disease and neovascularization are responsible for more than half of the recurrences. Rigorous evaluation of patients and assiduous surgical technique might reduce recurrence due to technical and tactical failures.

In the van Rij series20 from New Zealand, 127 limbs (C2-C6) were evaluated postoperatively by clinical exam, DS, and air plethysmography (APG). Clinical varices recurrence was progressive from three months onward (13.7%) to five years (51.7%). Corresponding to clinical changes there was a progressive deterioration in venous function measured by APG and recurrence of reflux evaluated by DS.

The longest prospective study22 gives a REVAS rate of 62% at 11 years and there was no statistical difference between the HL-only and the HL+GSV trunk stripping+ phlebectomies, but the patients were assessed preoperatively by handheld Doppler.

A prospective study concerning recurrence after radiofre-quency procedure has been reported.

At four-year follow-up recurrence is estimated at 21%.25

Socioeconomic Consequences

There are no available published socioeconomic data on REVAS. The incidence is variable according to the different National Health Service reimbursement rates. When redo surgery is performed its cost is higher than first time surgery because of the number of peri- and postoperative complications.

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