Saphenous Surgery

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For varicose vein surgery to be successful, two tasks must be accomplished. The first is ablation of reflux from the deep to the superficial veins, including the saphenofemoral junction, the saphenopopliteal junction, and midthigh varices from the Hunterian perforating vein. Accomplishment of this task is guided by the careful preoperative duplex mapping of major superficial venous reflux.

The second task is removal or destruction of all vari-cosities present at the time of the surgical intervention. Accomplishment of this task is guided by meticulous marking of all varicose vein clusters.

A number of options are available for surgical treatment of varicose veins. Regardless of the specific approach taken, the general technical objectives are the same: 1) ablation of the hydrostatic forces of axial saphenous vein reflux (see Figure 25.3) and 2) removal of the hydrodynamic forces of perforator vein outflow.

Ankle-to-groin stripping of the saphenous vein has been a dominant treatment of varicose veins over the past 100 years.33,34,35 One argument against routine stripping of the leg (i.e., ankle-to-knee) portion of the saphenous vein is the risk of concomitant saphenous nerve injury.19 Another argument is that whereas the objective of saphenous vein removal is detachment of perforating veins emanating from the saphe-nous vein, which are seen in the thigh, the perforating veins in the leg are actually part of the posterior arch vein system rather than the saphenous vein system. This latter argument notwithstanding, preoperative ultrasonography frequently shows that the leg portion of the saphenous vein is in fact directly connected to perforating veins. Therefore, removal of the saphenous vein from ankle to knee should be a consideration in every surgical case.

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