Ultrasound assisted great saphenous vein ligation and division: an office procedure

Abstract

The aim of this proof of concept study is to describe an ultrasound (US) assisted simplified surgical procedure for pre-terminal great saphenous vein (GSV) high ligation/division avoiding groin dissection and tributary interruption, in an office setting, in association to varices phlebectomy and saphenous vein foam occlusion treatment. Inclusion criteria: primary GSV reflux due to terminal valve, vein diameter >6 mm. By ultrasonography in standing position, the point GSV passing over the adductor longus muscle (about 3 cm from the junction) is identified. This E (easy) point, relatively superficial, free from tributaries and other structures, allows an easy grasping and extraction of the GSV vein through a 3 mm stab incision provided an ultrasonography assistance. The vein is divided/ligated about 2 cm distal from the ostium, the distal stump is cannulated and foam is injected on the distal segment from the E-point incision in a retrograde fashion, varices are avulsed by phlebectomy. Twenty procedures in 18 patients (venous clinical severity score: mean 3.15 -GSV diameter: mean 7.34) were performed, all the cases without inconveniences, with a duration not exceeding 10 min in addition to the phlebectomy procedure time. No complications as hemorrhage, infection, nerve lesion, lymphatic leak or thrombosis have been registered. At one month the residual saphenous stump length was in average 2.16 cm with complete closure of GSV in all. Three patients have been controlled at 6 months showing GSV complete closure. The procedure described is a simple office US assisted method for GSV ligationdivision, leaving the 2 last cm of the saphenofemoral junction. It could be associated to most of the procedures in use with limited additional time and resources required.

Foam sclerotherapy of the great saphenous vein in association with pre-terminal saphenous junction ligation/division as an office-based procedure: 12-Month results

“…From October 2013 to June 2015, 36 cases underwent PTI þ FS. As reported in a previous paper, 27 early follow-up at 30 days showed GSV occlusion in all cases.…”

“…At operation, as previously reported, 27 all the veins to be avulsed were marked on the skin, and the patient was prepared for the procedure. After varicosities phlebectomy, under the same local anaesthesia and using sterile US assistance, the GSV was gently extracted, using a small right-angle forceps, from a 3 mm transversal incision made at the marked E-point (the point passing over the adductor longus muscle about 3 cm from the junction) ( Figure 2), 29 and sectioned between two forceps.…”

“…A US control was made at one week, 4-5 weeks and 12 months to assess post-operative results and confirm the absence of thrombosis. 27…”

“…GSV interruption by SFJ flush ligation in association with GSV sclerotherapy has been previously suggested. [23][24][25][26] We chose to associate GSV foam occlusion with a pre-terminal ultrasound (US)-assisted GSV division/ligation, as described in a previous paper, 27 as this technique does not require junction dissection and is simpler than traditional high ligation. Thus, it can be easily performed in an office setting during a standard phlebectomy.…”

The sapheno femoral junction involvement in the treatment of varicose veins disease

“…Recently Ricci 103 described GSV pre terminal ligation/transection by a simplified surgical approach made easy by US assistance: GSV is hooked 3 cm from the junction through a micro incision under direct visualization of the vein. The distal saphenous stem then can be treated in the preferred way or left for conservation.…”