Comment to: Less invasive ultrasonography-guided high ligation of great saphenous vein in endovenous laser ablation, by Okazaki Y, Orihashi K. Ann Vasc Dis 2013;6:221-5.

Endovenous laser ablation (EVLA) has two pitfalls: endovenous heat-induced thrombosis (EHIT) and great saphenous vein (GSV) recanalization. Trying to avoid these pitfalls, the authors developed a novel method of ultrasonography-guided high ligation (UGHL) as an adjunct to EVLA. After positioning a 5-F introducer sheath over a guidewire by a venous catheter above or blow the knee, the GSV at 2 cm distal to the SFJ was located by US, and 2 small 2–3-mm skin incisions were made next to the GSV under local anesthesia. The bilateral aspects of the GSV were dissected using mosquito forceps under duplex scanning guidance. The dorsal aspect of the GSV was then dissected using a Deschamps aneurysm needle, appearing as a strong echo behind the GSV. The needle, advanced to the other incision hooked a 2-0 silk thread which was pulled through to the first incision, encircling the dorsal aspect of GSV. The Deschamps needle was then advanced on the anterior aspectof the GSV for dissection, and led to the other incision carrying the thread, encircling the GSV. After EVLA of the GSV was completed the thread was tied around the GSV. Skin incisions were closed with Steri-strips.The procedure was performed in 20 patients who were scheduled for EVLA for incompetent GS. The mean GSV Diameterat 2 cm distal to the saphenofemoral junction (SFJ) in the standing position, was 5.1–11.5 mm. The CEAP clinical class was C2–C5. EVLA and UGHL were performed without complications. The time needed for UGHL was 191–853 s). UGHL took longer than 360 s (6 min) in 4 patients in the first 10 cases and in 1 patient in the last 10 cases. In the case with a deeply located GSV, encircling of the GSV was fairly difficult, and surrounding tissue could be caught during ligation. Successful GSV ligation was immediately confirmed by US. The postoperative courses were uneventful in all cases.