Preoperative Preparation

Over the years, much space has been given to clinical examination of the patient with varicose veins. Many clinical tests have been described. Most carry the names of now-dead surgeons who were interested in venous pathophysiology. This august history notwithstanding, the Trendelenburg test, the Schwartz test, the Perthes test, and the Mahorner and Ochsner modifications of the Trendelenburg test essentially are useless in preoperative evaluation of patients today.28

The clinical evaluation can be improved by using handheld Doppler devices. However, preoperative evaluation is best performed by means of duplex scanning and a focused physical examination. Our protocol for duplex mapping of incompetent superficial veins has been pub-lished.29 Although many cite cost considerations as a reason for omitting duplex evaluation, we believe that duplex scanning for venous insufficiency is in fact both simple and cost effective. Duplex mapping defines individual patient anatomy with considerable precision and provides valuable information that supplements the physician's clinical impression.

Three principal goals must be kept in mind in planning treatment of varicose veins: 1) the varicosities must be permanently removed and the underlying cause of venous hypertension treated; 2) the repair must be done in as

FIGURE 25.2 In the past, a proper groin dissection consisted of laying out each of the named saphenofemoral junction tributaries and dissecting them back beyond their primary tributaries. Now, this is acknowledged by most to be the strongest stimulus to neovascularization.

cosmetic a fashion as possible; 3) complications must be minimized.

Current practice of treating the source of venous hypertension, the saphenous vein alone either by EVLT or VNUS technology, is inadequate. The patient's complaint, the varicose veins, must be addressed. This is as important as the physician's knowledge that the sources of venous hypertension must be addressed.

To speak of permanent removal of varicosities implies that all potential causes of recurrence have been considered and that surgery has been planned so as to address them.

There are four principal causes of recurrence of varicose veins, of which three can be dealt with at the time of the primary operation.

One cause of recurrent varicosities is failure to perform the primary operation in a correct fashion. Common errors include missing a duplicated saphenous vein and mistaking an anterolateral or accessory saphenous vein for the greater saphenous vein. Such errors can be eliminated by careful and thorough groin dissection. Accordingly, failure to do a proper groin dissection has long been held to be a second principal cause of recurrent varicose veins. It is now known,

FIGURE 25.3 Inversion stripping of the saphenous vein was an important step forward in minimizing soft tissue trauma while accomplishing the principal objective of ablating hydrostatic venous hypertension by removing saphenous reflux. Tearing of the vein during its removal flawed its performance.

however, that such dissection causes neovascularization in the groin, leading to recurrence of varicose veins.30 A third cause of recurrent varicosities is failure to remove the greater saphenous vein from the circulation. As mentioned earlier, reasons often cited for this failure is the desire to preserve the saphenous vein for subsequent use as an arterial bypass. It is clear, however, that the preserved saphenous vein continues to reflux and continues to elongate and dilate its tributaries. This produces more and larger varicosities. A fourth cause of recurrent varicosities is persistence of venous hypertension through nonsaphenous sources—chiefly, perforating veins with incompetent valves. Muscular contraction generates enormous pressures that are directed against valves in perforating veins. Venous hypertension induces a leukocyte endothelial reaction, which, in turn, incites an inflammatory response that ultimately destroys the venous valves and weakens the venous wall.31 The perforating veins most commonly associated with recurrent varicosities are the midthigh perforating vein, the distal thigh perforating vein, the proximal anteromedial calf perforating vein, and the lateral thigh perforating vein, which connects the profunda femoris vein to surface varicosities.

Finally, there is a fifth cause of recurrent varicosities, which is out of control of the operating surgeon—namely, the genetic tendency to form varicosities through development of localized or generalized vein wall weakness, localized blowouts of venous walls, or stretched, elongated, and floppy venous valves.32

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