Surgery For Ssv Reflux

Surgery generally is directed toward dividing the saphe-nopopliteal junction, presupposing that reflux through the junction is the cause of varicose veins in the SSV territory. Anatomical variations for patterns of reflux determine technique and results of surgery.

Indications

Surgery appears to be the most frequently recommended treatment for SSV reflux in most countries,16 but many phle-bologists now prefer endovenous techniques. Repeat surgery for recurrent SSV reflux to remove the saphenous stump or other connections is technically demanding and prone to complications from damage to the popliteal vein or adjacent nerves, and it is our practice to always recommend endove-nous treatment.

Technique

The operation usually is performed under general anesthesia although spinal anesthesia or popliteal nerve and posterior nerve of thigh blocks can be used. Most surgeons operate with the patient prone and this requires intubation for general anesthesia. A transverse popliteal fossa incision is favored by most although an incision for a high SPJ can be disfiguring.

A survey of members of the Vascular Surgical Society of Great Britain and Ireland17 found that most surgeons performed flush ligation although few extensively exposed the popliteal vein unless surgery was for recurrent SSV reflux. There was a degree of caution about the extent of surgery for only 15% routinely stripped the SSV, and approximately one-quarter simply ligated the vein and over one-half avulsed or excised as much as possible within the operation field. Practice patterns in other countries do not appear to have been documented.

Each surgeon has a favored technique:

• Flush ligation and division require precise identification of the point where the SSV joins the deep vein. It is important not to leave a stump particularly if it includes a tributary.

• Excision of the terminal SSV within the operation field is preferred by many to eliminate tributaries near the junction that could contribute to recurrence. Care must be taken to identify and ligate important veins such as the gastrocnemius veins if they join the SSV. Gastrocnemial vein ligation may be the indication for surgery.

• Retrograde stripping to mid calf or further may be performed, now favoring invagination stripping. There is no evidence as to whether stripping reduces recurrence rates or increases risk of nerve damage, or whether invagination reduces the incidence of sural nerve injury.

• Antegrade stripping from the ankle may be performed and the presence of the stripper in the SSV at the junction makes it easier to identify the veins. Care must be taken to avoid damage to the sural nerve during the distal dissection.

There is little support for routinely ligating perforators at the same time as SSV surgery. Outward flow in perforators is more frequently associated with superficial reflux alone rather than with deep reflux making it unlikely that they are a "source" for superficial tributaries.

Results

The small number of prospective studies published that used ultrasound for surveillance after SSV surgery show disturbingly high recurrence rates. Van Rij and colleagues reported that recurrence rates at three weeks and three years were 23% and 52%, respectively, after SSV surgery compared to 1% and 25%, respectively, after GSV surgery.19 Smith and colleagues studied 37 limbs treated by SSV liga-tion with excision within the popliteal fossa and showed that the recurrence rate at 12 months was 38%, due to inadequate surgery in 27% and neovascularization in 11%.18 Another British report found an "ideal" outcome in only 39% of 67 limbs at six weeks, with persistent SSV reflux from tributaries in 20% and an intact patent SPJ in 36%.20 A Dutch study found that only five of 32 limbs treated by SSV ligation were completely controlled at three months, with persisting reflux into adjacent tributaries in 14 and a patent junction in 13 limbs.21 There is a need for larger prospective objective studies using ultrasound surveillance for outcome after liga-tion alone or ligation and stripping.

Sites for recurrence have been defined by retrospective ultrasound studies for recurrent varicose veins after SSV surgery. Tong and Royle showed an intact SSV to be the most common finding, with varices from the popliteal vein to residual SSV in the remainder.22 Labropoulos and colleagues showed that the most common pattern after previous SSV ligation was reflux into the SSV (75%), whereas the most common pattern after previous SSV stripping was reflux into SSV tributaries (64%).7

Complications

Many surgeons use deep vein thrombosis prophylaxis selectively prior to varicose vein surgery, but few use it routinely.16 However, the risk of deep vein thrombosis after SSV surgery has not been defined.

Nerve injury after venous surgery is the most common reason for medicolegal claims in vascular surgical practice.23 A survey from the Vascular Surgical Society of Great Britain and Ireland found that nerve injury is perceived to be more likely after SSV surgery since two-thirds of surgeons were more likely to warn of this complication for SSV surgery compared to GSV surgery.17 However, the incidence of sural or popliteal nerve injuries after SSV surgery has not been determined and may be low.24 Damage to the sural nerve during SSV surgery probably results from straying away from the vein during dissection.

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