Comment to: Selective high ligation of the saphenofemoral junction decreases the neovascularization and the recurrent varicose veins in the operated groin by Mariani F, Mancini S, Bucalossi M, Allegra C. Int Angiol 2014 Jul 16 [Epub ahead of print]

The classical radical high ligation (RHL) performed with the Babcock technique is defined as the traditional gold standard technique: superficial tributaries dissection, followed, when possible, back to the secondary branch points, division and ligation; GSV ligation flush to the junction. In the present study the authors analyze, as an alternative, the selective high ligation (SHL) of the Junction with 5/12 years follow-up. The rationale is that SFJ tributary veins coming from the abdominal wall have an important role in draining the venous flow to the deep veins or to the opposite vein network, particularly when the venous abdominal flow is modified for physiological condition (i.e. pregnancy) or external compression or obstruction (i.e. deep venous thrombosis) . In SHL the veins coming from the abdominal wall, as the superior epigastric vein (SEV) or the superior iliac circumflex vein (SICV), are spared, while the superior external pudendal vein (SEPV) and the others tributaries which have an acute angle with the saphenic axis or a T branch from the thigh, are carefully isolated and ligated with 2/0 or 3/0 non absorbable thread; the GSV is ligated and dissected flush the confluence of the spared tributary veins, usually about 1 cm from the SFJ, to maintain its drainage into the GSV stump. The study included a homogenous cohort of 360 patients (mean aged 51.9 years range 18 to 75 years - CEAP C2S Ep), that underwent unilateral varicose vein surgery from January 2001 to December 2008. The neovascularization and the recurrences in the groin were found in seven patients (1.9%) of the total cases: 3 patients were symptomatic, 4 asymptomatic. The recurrences were due to inadequate groin surgery: the anterior lateral thigh vein, the posterior medial thigh or a T branch of tributaries left, a GSV stump exceeding 1 cm. The GSV stumps and the spared tributaries were open to venous flow; no venous reflux in the groin at Valsalva in standing position was present; the compression ultrasonography of the GSV stump was negative in all the patients. During the past 10 years minimal invasive surgery or endovascular approaches with radiofrequency and endolaser ablation have developed. These techniques leave all or nearly all tributaries of the SFJ and the results in terms of recurrences from the saphenous stump seem to be better than the Babcock’s RHL. The selective high ligation is a reliable technique, decreasing the incidence of neovascularization and recurrent varicose veins in the operated groin.