Marianne De Maeseneer

At the beginning of the twenty-first century, surgical treatment of varicose veins continues to be marred by the development of recurrent varicosities. This has always been a very disappointing phenomenon for patients and surgeons alike. Most commonly, recurrent reflux develops in the area of the saphenofemoral junction (SFJ), causing recurrent varicose veins from the thigh downward to the entire leg (see Figure 26.1).1 Even in clinical centers with a special focus on minimizing recurrence surgeons do not seem to be able to avoid such disfiguring and often disabling recurrent varicose veins.

Some causes of recurrence are obvious: insufficient understanding of venous anatomy and hemodynamics, inadequate preoperative assessment, and incorrect or insufficient surgery (most frequently too superficial ligation of the SFJ). However, recurrence at the SFJ cannot always be explained by technical inadequacy of the original surgical intervention. Its development has also been attributed to neovascularization in the granulation tissue around the ligated stump.2 Neovascularization is defined as new blood vessel formation (= angiogenesis) occurring in abnormal tissue or in an abnormal position. In some instances the growth of new blood vessels from the surrounding tissue may be induced by diffusible chemical factors (angiogenic factors). In the particular context of varicose recurrence after Great Saphenous vein (GSV) surgery, the term neovascularization describes a phenomenon of formation of new venous channels between the saphenous stump on the common femoral vein (CFV) and the residual GSV or its tributaries (see Figure 26.2). Neovascularization is a distinctly uncommon finding when the true SFJ has not been divided. However, when the SFJ has been ligated properly, it is actually a marker of an anatomically correct operation, as well as the best explanation for SFJ reconnections after such an operation.

Many surgeons only start to recognize the phenomenon after having to reoperate on patients with recurrent varicose veins some years after a previous varicose vein operation "correctly" performed by themselves. The observations during reexploration of the groin at the level of the saphenofemoral junction then frequently show neovascu-larization as the explanation for the recurrence. Despite the fact that this frustrating phenomenon frequently is encountered by each vascular surgeon, its nature and pathophysiol-ogy (hence its prevention) are poorly understood and the subjects of intensive ongoing research.

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