Great uncertainty regarding treatment of varicose vein recurrence

O. Nelzén

doi:10.12687/phleb2172-1-2014

Phlebologie, Table of Contents

Phlebologie 2014; 43(01): 13-18
DOI: 10.12687/phleb2172-1-2014

Review

Schattauer GmbH

Great uncertainty regarding treatment of varicose vein recurrence

Die große Unsicherheit im Umgang mit wiederkehrender Varikose

O. Nelzén

¹Dept. Surgical Sciences, Uppsala University & Dept. of Vascular Surgery, Skaraborg Hospital Skövde, Sweden

› Author Affiliations

Abstract

Summary

Introduction: Although varicose vein recurrence is common and 10–30 % of all varicose vein surgery is done for recurrence of some sort, there are very few studies that can guide us to the best re-treatment option. With the introduction of minimal invasive endovenous treatments there is a variety of possible options besides traditional open surgical techniques.

Method: The Scandinavian Venous Forum held a symposium at the GSP meeting in Lü-beck 2012 and this review article is based on data from the presentations at that symposium. Further data has been added regarding new knowledge that was not available a year ago, from PubMed search and article references.

Results: The most common reasons for recurrence are discussed and also the discrepancy between neovascularization (NV) and recurrence due to technical failures. It is likely that NV is the most commonly duplex detected type of recurrence following open groin surgery, less common early after endovascular techniques. However, technical or tactical failures are the most common reasons for redo surgery because of symptomatic recurrence. NV seldom leads to symptomatic recurrences and thus a need for re- treatment. There is a risk that the stumps left following endovenous treatments will become a source for symptomatic recurrence after 5–10 years and indications of that have been reported in the few available 5 year RCT-reports following laser treatments. Treatment of recurrence due to stumps in the groin can be done safely within a reasonable operating time through a medial approach and the stump itself can generally not be treated with any of the endovenous alternative methods. Foam treatment can be used for most other recurrent veins but the durability is unknown. Endovascular thermal ablation can only be used for reopened or remaining saphenous veins and accessory saphenous veins while tributaries have to be treated by stab excisions or foam.

Conclusion: Long term reports of results of redo surgery are limited but suggest reasonably good results from open surgical intervention and are non-existent for the endovenous techniques. So far groin recurrence seems best treated surgically by an indirect approach, preferably medial. More studies are needed to find the best treatment regime for varicose vein recurrence in general and hybrid procedures might be the way forward by combinations of different techniques.

Zusammenfassung

Einleitung: Obwohl die Rezidivvarikose häufig ist und 10 bis 30 % aller chirurgischer Eingriffe darauf entfallen, gibt es sehr wenige Studien, die dabei zur besten Behandlungsoption raten könnten. Mit der Einführung der minimal-invasiven endovenösen Behandlung gibt es eine Vielzahl möglicher Optionen neben den klassischen offenen chirurgischen Eingriffen.

Methoden: Das Skandinavische Venenforum hielt auf der Tagung der Deutschen Gesellschaft für Phlebologie e.V. 2012 in Lübeck ein Symposium ab. Diese Überblicksarbeit basiert auf Daten der Präsentation, die dort gehalten wurde. Weitere Daten neueren Wissens wurden hinzugefügt, außerdem Informationen aus einer Literaturrecherche bei PubMed und anderen Artikeln.

Ergebnisse: Die häufigsten Ursachen für die Rezidivvarikose werden diskutiert und auch die Diskrepanz zwischen Neovaskularisation (NV) und Rezidivierung infolge technischer Fehler. Es ist wahrscheinlich, dass NV die häufigste durch Duplexsonographie entdeckte Form des Rückfalls ist nach offener Leistenoperation, weniger häufig ist es kurz nach endovenösen Eingriffen. Aber technische oder taktische Fehler sind die häufigsten Gründe für nochmalige Operation wegen eines symptomatischen Rezidivs. NV führt selten zu symptomatischem Wiederauftreten und Bedarf für erneute Behandlung. Es besteht ein Risiko dafür, dass die Stümpfe, die man bei endovenöser Behandlung belässt, Ursache für ein symptomatisches Rezidiv nach 5 bis 10 Jahren werden. Hinweise darauf gibt es in den wenigen 5-Jahres-RCTStudien bezüglich Laserbehandlung. Behandlungen wiederkehrender Varikosen aufgrund von Stümpfen in der Leiste können sicher innerhalb einer überschaubaren Operationszeit vorgenommen werden durch einen medialen Ansatz. Der Stumpf selber kann normalerweise nicht behandelt werden mit einer der alternativen endovenösen Verfahren. Schaumbehandlung kann bei den meisten anderen Rezidivvarikosen eingesetzt werden, aber die Nachhaltigkeit ist hier unbekannt. Die endovaskuläre Thermoablation kann nur für wiedereröffnete oder verbleibende Saphena-Venen und accessorische Saphena-Venen genutzt werden, während Nebengefäße mit Exzision oder Schaum behandelt werden müssen.

Schlussfolgerung: Berichte zu Langzeiter-gebnissen von erneuten Behandlungen sind selten, aber sie deuten auf recht gute Resultate aus der offenen chirurgischen Intervention hin. Keine Daten hierzu gibt es bislangfür endovenöse Techniken. Bislang ist eine Rezidivvarikose in der Leiste am besten operativ zu behandeln durch einen indirekten Ansatz, vorzugsweise medial. Mehr Studien sind notwendig, um die beste Behandlungsoption für Rezidivvarikose zu finden. Hybrid-Techniken könnten ein zukünftiger Weg seindurch Kombination verschiedener Ansätze.

Keywords

Varicosis - recurrence - endovenous treatment - vein surgery

Schlüsselwörter

Varikose - Rezidivvarikose - endovenöse Behandlung - Venenchirurgie

Full Text

References

References
1 Fischer R, Linde N, Duff C, Jeanneret C, Chandler JG, Seeber P. Late recurrent saphenofemoral junction reflux after ligation and stripping of the greater saphenous vein. J Vasc Surg 2001; 34: 236-240.
2 Winterborn RJ, Foy C, Earnshaw JJ. Causes of varicose vein recurrence: Late results of a randomized trial of stripping the long saphenous vein. J Vasc Surg 2004; 40: 634-639.
3 Nelzén O, Fransson I. Varicose vein recurrence and patient satisfaction 10–14 years following combined superficial and perforator vein surgery: a prospective case study. Eur J Vasc Endovasc Surg 2013; 46: 372-377.
4 MacKenzie RK, Lee AJ, Paisley A, Burns P, Allan PL, Ruckley CV, Bradbury AW. Patient, operative, and surgeon factors that influence the effect of superficial venous surgery on disease-specific quality of life. J Vasc Surg 2002; 36: 896-902.
5 Beresford T, Smith JJ, Brown Greenhalgh L, Davies AH. A comparison of health-related quality of life of patients with primary and recurrent varicose veins. Phlebology 2003; 18: 35-37.
6 Nesbitt C, Eifell RK, Coyne P, Badri H, Bhattacharya V, Stansby G. Endovenous ablation (radiofrquency and laser) and foam sclerotherapy versus conventional surgery for great saphenous vein varices. Cochrane Database Syst Rev 2011; Oct 5 (10) CD005624
7 van Rij AM, Jiang P, Solomon C, Christie RA, Hill GB. Recurrence after varicose vein surgery: a prospective long-term clinical study with duplex ultrasound scanning and air plethysmograpy. J Vasc Surg 2003; 38: 935-943.
8 van Rij AM, Jones GT, Hill GB, Jiang P. Neovascularization and recurrent varicose veins: more histologic and ultrasound evidence. J Vasc Surg 2004; 40: 296-302.
9 Blomgren L, Johansson G, Emanuelsson L, Dahlberg-Åkerman A, Thermaenius P, Bergqvist D. Late follow-up of a randomized trial of routine duplex imaging before varicose vein surgery. Br J Surg 2011; 98: 1112-1116.
10 Papapostolou G, Altenkämper H, Bernheim C, Broermann M, Dresler C, Frings N. et al. The LaVaCro study: long-term results after saphenofemoral ligation and stripping of the great saphenous vein. First year results. (German) Phlebologie 2013; 42 (05) 253-260.
11 Egan B, Donnely M, Bresnihan M, Tierney S, Feeley M. Neovascularisation: an ”innocent bystander” in recurrent varicose veins. J Vasc Surg 2006; 44: 1279-1284.
12 Geier B, Stücker M, Hummel T, Burger P, Frings N, Hartmann M, Stenger D, Schwahn-Schreiber C, Schonath M, Mumme A. Residual stumps associated with inguinal varicose vein recurrences: a multicenter study. Eur J Vasc Endovasc Surg 2008; 36: 207-210.
13 Mumme A, Burger P, Hummel T, Frings N, Hartmann M, Schonath M. et al. Der lang belassene Saphenatumpf: Implikationen für die endovenöse Therapie der Varikosis. Phlebologie 2007; 36: 256-259.
14 Mumme A, Hummel T, Burger P, Frings N, Hartmann M, Broermann M. et al. High ligation of the saphenofemoral junction is necessary. Results of the German Groin Recurrence Study. Phlebologie 2009; 38: 99-102.
15 Spreafico G, Piccioli A, Bernardi E, Giraldi E, Pavei P, Borgoni R, Baccaglini U. Six-year follow-up of endovenous laser ablation for great saphenous vein incompetence. J Vasc Surg: Venous and Lym Dis 2013; 1: 20-25.
16 De Maeseneer M. Surgery for recurrent varicose veins: towards a less-invasive approach. Perspect Vasc Endovasc Ther 2011; 23: 244-249.
17 Frings N, Nelle A, Tran P, Fischer R, Krug W. Reduction of neoreflux after correctly performed ligation of the saphenofemoral junction: a randomized trial. Eur J Vasc Endovasc Surg 2004; 28 (03) 246-252.
18 Rass K, Frings N, Glowacki P, Hamsch C, Grãber S, Vogt T, Tilgen W. Comparable effectiveness of endovenous laser ablation and high ligation with stripping of the great saphenous vein. Arch Dermatol 2012; 148 (01) 49-58.
19 De Maesener MG, Vandenbroeck CP, Van Schil PE. Silicone patch saphenoplasty to prevent redo recurrence after surgery to treat recurrent saphenofemoral incompetence: long term follow-up study. J Vasc Surg 2004; 40: 98-105.
20 Disselhoff BCVM, der Kinderen DJ, Kelder JC, Moll FL. Five-year results of a randomised clinical trial of endovenous laser ablation of the great saphenous vein with and without ligation of the saphenofemoral junction. Eur J Vasc Endovasc Surg 2011; 41: 685-690.
21 Disselhoff BCVM, der Kinderen DJ, Kelder JC, Moll FL. Five-year results of a randomized clinical trial comparing endovenous laser ablation with cryostripping for great saphenous varicose veins. Br J Surg 2011; 98: 1107-1111.
22 Rasmussen L, Lawaetz M, Bjoern L, Blemings A, Eklof B. Randomized clinical trial comparing endovenous laser ablation and stripping of the great saphenous vein with clinical and duplex outcome after 5 years. J Vasc Surg 2013; 58: 421-426.
23 Rass K, Frings N, Glowacki P, Hamsch C, Gräber S, Tilgen W Vogt T. Endovenöse Lasertherapie versus Crossectomi und Stripping der V.saphena magna: 5-Jahres-Ergebnisse der RELACS-Studie. Phlebologie 2012; 41 (05) A7-A8.
24 Fischer R, Chandler JG, Stenger D, Puhan MA, DeMaeseneer MG, Schimmelpfennig L. Patient characteristics and physician-determined variables affecting saphenofemoral reflux recurrence after ligation and stripping of the great saphenous vein. J Vasc Surg 2006; 43: 81-87.
25 Theivacumar NS, Gough MJ. Endovenous laser ablation (EVLA) to treat recurrent varicose veins. Eur J Vasc Endovasc Surg 2011; 41: 691-696.
26 Darvall KA, Bate GR, Adam DJ, Silverman SH, Bradbury AW. Duplex ultrasound outcomes following ultrasound-guided foam sclerotherapy of symptomatic recurrent great saphenous varicose veins. Eur J Vasc Endovasc Surg. 2011; 42: 107-114.
27 Hayden A, Holdsworth J. Complications following re-exploration of the groin for recurrent varicose veins. Ann R Coll Surg Engl 2001; 83: 272-273.
28 Greaney MG, Makin GS. Operation for recurrent saphenofemoral incompetence using a medial approach to the saphenofemoral junction. Br J Surg 1985; 72: 910-911.
29 Nelzén O. A medial approach for open redo groin surgery for varicose vein recurrence: safe and effective. Phlebologie 2013; 42: 247-252.
30 van Groenendael L, van der Vliet A, Flinkenflögel L, Roovers EA, van Sterkenburg SMM. Treatment of recurrent varicose veins of the great saphenous vein by conventional surgery and endovenous laser ablation. J Vasc Surg 2009; 50: 1106-1113.
31 van Groenendael L, Flinkenflögel L, van der Vliet A, Roovers EA, van Sterkenburg SMM, Reijnen MMPJ. Conventional surgery and endovenous laser ablation of recurrent varicose veins of the small saphenous vein: a retrospective clinical comparison and assessment of patient satisfaction. Phlebology 2010; 25: 151-157.
32 van Rij AM, Hill G, Gray C, Christie R, MacFarlane J, Thomson I. A prospective study of the fate of venous leg perforators after varicose vein surgery. J Vasc Surg 2005; 42: 1156-1162.
33 Kianifard B, Holdstock J, Allen C, Smith C, Price B, Whiteley MS. Randomized clinical trial of the effect of adding subfascial endoscopic perforator surgery to standard great saphenous vein stripping. Br J Surg 2007; 94: 1075-1080.
34 Nelzén O. Fransson I for the Swedish SEPS Study Group. Early results from a randomized trial of saphenous surgery with or without subfascial endoscopic perforator surgery in patients with a venous ulcer. Br J Surg 2011; 98: 495-500.
35 Masuda EM, Kessler DM, Lurie F, Puggioni A Kistner RL, Eklöf B. The effect of ultrasound-guided sclerotherapy of incompetent perforator veins on venous clinical severity and disability scores. J Vasc Surg 2006; 43: 551-557.
36 Hissink RJ, Bruins RMG, Erkens R, Castellanos Nuijts ML, van den Berg M. Innovative treatments in chronic venous insufficiency: endovenous laser ablation of perforating veins: a prospective short-term analysis of 58 cases. Eur J Vasc Endovasc Surg 2010; 40: 403-406.
37 Marsh P, Price BA, Holdstock JM, Whiteley MS. One-year outcomes of radiofrequency ablation of incompetent perforator veins using the radiofrequency stylet device. Phlebology 2010; 25: 79-84.
38 Proebstle TM, Alm J, Göckeritz O, Wenzel C, Noppeney T, Lebard C, Pichot O, Sessa C, Creton D. for the European Closure Fast Clinical Study Group. Three-year European follow-up of endovenous radiofrequency-powered segmental thermal ablation of the great saphenous vein with or without treatment of calf varicosities. J Vasc Surg 2011; 54: 146-152.
39 De Maeseneer M, Pichot O, Cavezzi A, Earnshaw J, van Rij A, Lurie F, Smith PC. Duplex ultrasound investigation of the lower limbs after treatment for varicose veins – UIP consensus document. Eur J Vasc Endovasc Surg 2011; 42: 89-102.