The Varicose Veins File: Promising Treatment Options

The Varicose Veins FileSM
C E N T E R F O R C U R R E N T R E S E A R C H

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Stripping for Varicose Veins

Eur J Vasc Endovasc Surg 2001 Jun;21(6):545-9
Long saphenous vein stripping and quality of life--a randomised trial.
Durkin MT, Turton EP, Wijesinghe LD, Scott DJ, Berridge DC
Department of Vascular and Endovascular Surgery, St James's University Hospital, Leeds Teaching Hospitals Trust, Leeds, UK.

OBJECTIVES: To assess the quality of life of patients undergoing sapheno-femoral junction (SFJ) ligation and long saphenous vein stripping (LSV), using two different techniques. DESIGN: Prospective, randomised trial. MATERIALS AND METHODS: Eighty patients were recruited and randomised to either Perforate Invagination (PIN) stripping (43) or Conventional stripping (37). Patients completed the Short Form 36 (SF-36) and EuroQol (EQ) questionnaires preoperatively, and postoperatively at 6 weeks and 6 months. RESULTS: Bodily pain, role function and physical summary were significantly improved at 6 months in the PIN stripping group. In the Conventional group, bodily pain and physical function were similarly improved, but not role function. EQ global quality of life was significantly and progressively improved at 6 weeks and 6 months in the PIN group (global score p<0.003; self-rated score p <0.001). In the Conventional group there was no overall improvement in global score or self-rated health. CONCLUSIONS: Primary varicose vein surgery is associated with significant and progressive improvements in quality of life scores. Whilst overall quality of health does improve in the Conventional group, this appears to be to a lesser extent than in the PIN group.

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J Vasc Surg 2000 Nov;32(5):941-53
Defining the role of extended saphenofemoral junction ligation: a prospective comparative study.
Chandler JG, Pichot O, Sessa C, Schuller-Petrovic S, Osse FJ, Bergan JJ
Department of Surgery, University of Colorado Health Sciences Center and VNUS Medical Technologies, Boulder, CO, USA.

OBJECTIVE: This study explores the added effect of extended saphenofemoral junction (SFJ) ligation when the greater saphenous vein (GSV) has been eliminated from participating in thigh reflux by means of endovenous obliteration. GSV obliteration, unlike surgical stripping, can be done with or without SFJ ligation to isolate and study SFJ ligation's specific contribution to treatment results. METHODS: Sixty limbs treated with SFJ ligation and 120 limbs treated without high ligation were selected from an ongoing, multicenter, endovenous obliteration trial on the basis of their having primary varicose veins, GSV reflux, and early treatment dates. RESULTS: Five (8%) high-ligation limbs and seven (6%) limbs without high ligation with patent veins at 6 weeks or less were excluded as unsuccessful obliterations. Treatment significantly reduced symptoms and CEAP clinical class in both groups (P =.0001). Recurrent reflux developed in one (2%) of 49 high-ligation limbs and eight (8%) of 97 limbs without high ligation by 6 months (P =.273). New instances of reflux did not appear thereafter in 57 limbs followed to 12 months. Recurrent varicose veins occurred in three high-ligation limbs and four limbs without high ligation by 6 months and in one additional high-ligation limb and two additional limbs without high ligation by 12 months. Actuarial recurrence curves were not statistically different with or without SFJ ligation (P >.156), predicting greater than 90% freedom from recurrent reflux and varicosities at 1 year for both groups. CONCLUSION: These early results suggest that extended SFJ ligation may add little to effective GSV obliteration, but our findings are not sufficiently robust to warrant abandonment of SFJ ligation as currently practiced in the management of primary varicose veins associated with GSV vein reflux.

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J Vasc Surg 1999 Apr;29(4):589-92
Stripping the long saphenous vein reduces the rate of reoperation for recurrent varicose veins: five-year results of a randomized trial.
Dwerryhouse S, Davies B, Harradine K, Earnshaw JJ
Gloucestershire Vascular Group, Gloucestershire Royal Hospital, Goucester, United Kingdom.

OBJECTIVE: The purpose of this study was to investigate the possible long-term clinical advantages of stripping the long saphenous vein during routine primary varicose vein surgery. METHODS: The study was designed as a 5-year, clinical and duplex scan follow-up examination of a group of patients who were randomized to stripping of the long saphenous vein during varicose vein surgery versus saphenofemoral ligation alone. The study was conducted in the vascular unit of a district general hospital. One hundred patients (133 legs) with uncomplicated primary long saphenous varicose veins originally were randomized. After invitation 5 years later, 78 patients (110 legs) underwent clinical review and duplex scan imaging. RESULTS: Sixty-five patients remained pleased with the results of their surgery (35 of 39 stripped vs 30 of 39 ligated; P = .13). Reoperation, either done or awaited, for recurrent long saphenous veins was necessary for three of 52 of the legs that underwent stripping versus 12 of 58 ligated legs. The relative risk was 0.28, with a 95% confidence interval of 0.13 to 0.59 (P = .02). Neovascularization at the saphenofemoral junction was responsible for 10 of 12 recurrent veins that underwent reoperation and also was the cause of recurrent saphenofemoral incompetence in 12 of 52 stripped veins versus 30 of 58 ligated legs. The relative risk was 0.45, with a 95% confidence interval of 0.26 to 0.78 (P = .002). CONCLUSION: Stripping reduced the risk of reoperation by two thirds after 5 years and should be routine for primary long saphenous varicose veins.

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Ann R Coll Surg Engl 1999 May;81(3):171-4
A prospective randomised trial of PIN versus conventional stripping in varicose vein surgery.
Durkin MT, Turton EP, Scott DJ, Berridge DC
Department of Vascular and Endovascular Surgery, St James's Hospital, Leeds, UK.

A prospective, randomised trial was carried out to examine the efficacy of perforate invagination (PIN, Credenhill Ltd, Derbyshire, UK) stripping of the long saphenous vein (LSV) in comparison to conventional stripping (Astratech AB, Sweden) in the surgical management of primary varicose veins. Eighty patients with primary varicosities secondary to sapheno-femoral junction (SFJ) incompetence and LSV reflux were recruited. Patients were randomised to PIN or conventional stripping with all other operative techniques remaining constant. Follow-up was performed at 1 and 6 weeks postoperatively. There were no statistically significant differences between the two techniques in terms of time taken to strip the vein, percentage of vein stripped or the area of bruising at 1 week. The size of the exit site was significantly smaller with the PIN device (P < or = 0.01). Optimal use of the conventional stripper provides results comparable to the PIN device. Choice of stripping device remains the surgeon's, bearing in mind that the PIN stripper achieves slightly better cosmesis.

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Acta Chir Belg 1999 Feb;99(1):22-5
Invaginating versus classic stripping of the long saphenous vein. A randomized prospective study.
Lacroix H, Nevelsteen A, Suy R
Department of Vascular Surgery, University Hospital Leuven, Belgium.

Although sound evidence is lacking, many surgeons claim that stripping of the long saphenous vein (LSV) is best performed by invagination. The aim of this prospective, randomized study was to test the hypothesis that invaginating stripping of the LSV is associated with less pain, smaller haematomas and less frequent injury to the saphenous nerve. Thirty patients with bilateral varicose veins and incompetent LSV, but normal short saphenous veins and deep venous systems, were treated by high ligation and stripping of the LSV and multiple stab avulsions. At one side the stripping was performed by invagination (group I), while a classic stripping was done on the other side (group C), so that one leg served as the control of the other. The results were analysed on an intention to treat basis. The median surface of the thigh haematoma between post-operative day seven and ten was 115 cm2 in group I and 135 cm2 in group C (NS). The median pain score was 0.25 and 1.75 respectively (NS). The incidence of saphenous nerve injury was 13% in group I and 17% in group C (NS). At one month 23% of patients stated that the leg with the invaginating stripping had been the more painful, while 33% of patients claimed that the side of the classic stripping had been more painful. The results show that the benefit of invaginating stripping is not as obvious as is generally suggested.

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Ann Chir 1997;51(7):745-8
[Technique and results of cryo-stripping in the treatment of varicose veins of the lower limbs]. [Article in French]
Constantin JM, Etienne G, Hevia M
Unite de Chirurgie Vasculaire, Clinique Saint-Joseph, Angouleme.

Stripping of varicose veins, a reference method, causes postoperative pain and sometimes dysesthesia due to saphenous nerve damage. Ankle wound healing is sometimes painful and often unaesthetic. Invaginated stripping eliminates some of the drawbacks, but keeps the lower wound and must be left in the case of recurrent saphenous rupture. Those two techniques do not allow total saphenous resection in the case of infected ulcers. Cryosurgery can be used regardless of the state of the ankle skin. It allows a complete invaginated stripping without ankle wound. METHODS: Over a 9-year period, 6157 limbs (3255 patients) underwent cryosurgery for varicose veins. The indication in 88% of cases was based on functional or aesthetic reasons and in 7% of the cases, hypodermitis, in 3% ulcerations and in 2% superficial venous thrombosis. RESULTS: Postoperatively, a single case of sural phlebitis was observed. Frequency and intensity of pain and hematomas are decreased. Thanks to this technique, the lower incision can be avoided thus giving better aesthetic results. CONCLUSION: Cryosurgery for varicose veins can be used in any circumstances. It has a similar efficacy to the stripping technique. Aesthetic and functional results are better. It is an important improvement especially in case of ulceration.

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Ugeskr Laeger 1996 Jan 22;158(4):405-8
[Partial or total stripping of the great saphenous vein. 5-year recurrence frequency and 3-year frequency of neural complications after partial and total stripping of the great saphenous vein]. [Article in Danish]
Holme K, Matzen M, Bomberg AJ, Outzen SL, Holme JB

One hundred and sixty-three patients with primary long saphenous vein varices were randomized to either classical (total) stripping of the long saphenous vein (n = 84) or partial stripping, i.e. only of the femoral part of the vein (n = 79). Permanent nerve lesions were evaluated clinically three years and recurrence of varicosities evaluated five years postoperatively. It was found that 24 patients (29%) who had total stripping performed had permanent lesions of the saphenous nerve, whereas only four of the patients (5%) who had partial stripping of the vein had lasting nerve lesions (p < 0.01). Ten percent of patients in both groups had recurrence of varicosities. The present - one and only - long-term, randomized study of different stripping procedures shows that stripping the long saphenous vein below the knee increases the permanent nervedamage six-fold without reducing long-term recurrency. Total stripping of the long saphenous vein should be abandoned as a routine in varicose vein surgery.

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Presse Med 1995 Jun 17;24(22):1017-20
[Cryo-stripping: an advance in the treatment of varicose veins. 3811 operated limbs]. [Article in French]
Etienne G, Constantin JM, Hevia M
Unite de Chirurgie vasculaire, Clinique Saint-Joseph, Angouleme.

OBJECTIVES: Stripping varicose veins can cause invalidating durable dysaesthesia in 25% of the cases due to saphenous vein damage. Postoperative varicosis is also frequently encountered. Cicatrization may be inaesthetic at the ankle and the operation may even be impossible due to infected ulcerations. Alternative methods are therefore needed. Cryosurgery using a freezing probe can be used to remove the entire saphenous vein via the inguinal incision alone. METHODS: Over a 6 year period, 2,009 patients (3,811 members) underwent cryosurgery for varicose veins. The indication in 88% of the cases was based on functional or aesthetic reasons and in 7% hypodermitis, in 3% ulcerations resistant to medical treatment and in 2% superficial venous thrombosis. RESULTS: Postoperatively, a single case of sural phlebitis was observed (0.02%). Dysaesthesia occurred in the saphenous nerve territory in 2% of the cases and resolved in a few months. Functional signs present preoperatively had disappeared within one month of surgery in 98%. The aesthetic result was excellent since there is no scar tissue on the limb excepting the inguinal incision and since postoperative varicosis was rare (0.1%). All varicose ulcerations had healed in less than 3 months of surgery and no case of deep vein failure was observed. CONCLUSION: Cryosurgery for varicose veins is as effective as the stripping procedure and avoids certain complications. The aesthetic result and functional results are better. Cryosurgery is an important progress in the treatment of varicose veins of the lower limbs, especially in case of ulcerations.

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Am J Surg 1994 Oct;168(4):311-5
Randomized trial of stripping versus high ligation combined with sclerotherapy in the treatment of the incompetent greater saphenous vein.
Rutgers PH, Kitslaar PJ
Department of Surgery, University Hospital, Maastricht, State University Limburg, The Netherlands.

This prospective randomized study compared the treatment of greater saphenous vein insufficiency by stripping and local avulsions of varicose veins with high ligation of the saphenofemoral junction (crossectomy) combined with sclerocompression therapy. Of 156 consecutive patients, 89 legs were randomly allocated to stripping and 92 to high ligation. At follow-up of 3 months and 1, 2, and 3 years after treatment, clinical and Doppler ultrasound results, and complaints and cosmetic results, as judged by the patient and the surgeon, were scored. At 3 years, 69 limbs in the stripping group (78%) and 73 limbs in the ligation group (79%) were available to follow-up. The cosmetic results, both judged by the patient and the surgeon, were significantly better (P < 0.05) in the stripped limbs than in the limbs with high ligation and sclerotherapy. Clinical and Doppler ultrasound evidence of reverse flow in the saphenous vein was significantly less (P < 0.001) after the stripping operation. The results of treatment of isolated saphenous vein insufficiency by stripping operation, therefore, were superior to those obtained by high ligation combined with sclerotherapy.

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