Comment to: Combined endovenous laser therapy and pinhole high ligation in the treatment of symptomatic great saphenous varicose veins, by Zhu H-P, Zhou Y-L, Zhang X, Yan J-L, Xu Z-Y, Wang H, Zhao Q-M, Jing Z-P. Ann Vasc Surg 2013. [Epub ahead of print].

Recanalization and DVT/PE are two major complications of ELTV, To prevent them minimally invasive pinhole high ligation (PHL) has been added to EVLT for the treatment of saphenous vein reflux in 200 patients (254 limbs) from February 2011 to May 2012. Sixty-eight of them had concurrent TriVex suction for clusters of varicose veins (VV). After conscious sedation and local anesthesia, venous access puncture was made using a Seldinger needle under US guidance. The tip of the sheath was placed approximately 1 cm distal to SFJ, and the location was marked on the skin. A 600-mm laser fiber was introduced through the sheath and advanced to the skin mark. Local anesthesia was achieved by injecting 1% lidocaine around the proximal GSV under US guidance with laser beam marking of the skin. Two 2-mm pinholes 1 cm distal to SFJ using an ophthalmic scalpel, approximately 5 mm from the laser fiber on each side were performed. A cutting needle with a 2-0 silk suture was passed through the pinholes underneath the GSV, but superficial to the femoral vein, which was confirmed by US. The needle and suture were then passed backward through the original two needle holes, but stayed in the subcutaneous space between the GSV and the skin.. A single knot was made first. Reinsertion of the laser fiber was gently attempted, and resistance indicated that ligation of the GSV was satisfactory. US was performed to confirm femoral vein patency, and then two more knots were tied down and buried in the subcutaneous space. If US showed that the femoral vein was captured, the needle and suture were removed and direct pressure was applied for 5 minutes to prevent bleeding. Then high ligation of GSV was performed again. EVLT was started immediately distal to the pinhole ligation, which was approximately 1 cm distal to the SFJ. An 810- nm diode laser system was used. In the 68 patients with venous clusters, transilluminated powered phlebectomy (TIPP) was performed using a TriVex system. After the procedures, compression pads were applied over the treated GSV and venous cluster areas. Elastic bandages were placed starting from the foot to the upper thigh. The technical success rate was 100%. Total occlusion of GSV was achieved in all treated limbs. There was no GSV recanalization during the 3 - 20 months of follow-up. No reintervention was needed for any patient. There were no cases of DVT. Use of PHL avoids the complications after open high ligation, and can be performed within 5-10 min in >90% of patients.