Great uncertainty regarding treatment of varicose vein recurrence

Abstract

SummaryIntroduction: 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.

Reconsidering the endovenous revolution

“…Current literature, however, suggests about equal risk of varicose vein recurrence for endovenous methods compared with open surgery. Overall, the mid‐term recurrence rates of around 22 per cent after 2–3 years are similar, but the nature of the recurrence differs markedly between open surgery and endovenous approaches. Neovascularization is the dominant finding following surgery, whereas proximal saphenous stumps and incompetent anterior accessory saphenous veins (AASVs) are the main factors following endovenous treatments.…”

“…In the era of open surgery, groin recurrence was the most common reason for repeat varicose vein surgery. Most patients had unligated tributaries close to the saphenofemoral junction (SFJ), reflecting inadequate primary surgery leaving saphenous stumps.…”

“…Most patients had unligated tributaries close to the saphenofemoral junction (SFJ), reflecting inadequate primary surgery leaving saphenous stumps. Neovascularization, the most commonly observed duplex‐detected recurrence following open surgery, rarely leads to symptomatic recurrence and a need for repeat treatment, unless it originates from a remnant saphenous stump (an intact SFJ). Because of this, the concept of ‘flush ligation’ of the great saphenous vein (GSV) at the femoral vein has always been considered essential, as failure to do so substantially increases the risk of late symptomatic recurrence and the need for repeat intervention.…”

“…Because of this, the concept of ‘flush ligation’ of the great saphenous vein (GSV) at the femoral vein has always been considered essential, as failure to do so substantially increases the risk of late symptomatic recurrence and the need for repeat intervention. This seems to have been neglected by proponents of endovenous treatments, where an emerging pattern of recurrence has become evident. The major problem is that most endovenous treatments result in residual stumps of varying length.…”

“…Tributaries connecting to the most proximal part of the GSV or the SFJ (within 1–2 cm from the common femoral vein) are common. The AASV appears to play a major role. An incompetent SFJ where the incompetence is propagated down the AASV seems to be the most common scenario, often with clinical recurrence and symptoms.…”