Comment to: Great saphenous vein surgery without high ligation of the saphenofemoral junction by Casoni P, Lefebvre-Vilardebo M, Villa F, Corona P. J Vasc Surg 2013;58:173-8.

Abstract

Traditional surgical treatment of varicose disease requires an invasive procedure like high ligation of sapheno femoral junction (SFJ), resulting in high recurrence rates, especially in the long term.
The aim of this prospective randomized study was to evaluate whether great saphenous vein (GSV) surgery without high ligation of the SFJ is beneficial in terms of varicose vein recurrence. The study enrolled 120 patients with GSV reflux due to SFJ incompetence, from December 2000 to May 2004, randomly allocated preoperatively to two groups undergoing GSV surgery with (group A) or without (group B) high ligation of the SFJ (60 patients and 62 limbs in each group). Surgery was performed under tumescent local anesthesia, continuous femoral block and Kleine tumescence by a single operator. Group A underwent standard GSV surgery, including high ligation of the SFJ, foramen ovale plasty and infolding suture to hide the free endothelium of the saphenous stump. Group B underwent GSV surgery without high ligation of the SFJ.
After the GSV was hooked through a small incision at lower leg level, a stripper device was inserted. Invagination stripping was performed without echographic guidance. The GSV was hooked at the thigh level, 2 to 3 cm below the groin (SFJ), and GSV ligature was performed in distal to epigastric and perineal veins to preserve physiologic drainage. Clinical evaluation and Duplex ultrasound scanning (DUS) were performed at 6 months and yearly thereafter. The follow-up of the last operated-on patient ended in May 2012, so that all patients had a minimal follow-up of 8 years. The primary end point was varicose vein recurrence, defined as an operated-on limb with new minimal thigh varices at clinical evaluation (CEAP C2) or venous reflux at the thigh or groin level, as assessed by DUS, or both. A total of 123 limbs were followed up 8 years after surgery.
The combined clinical and DUS-determined recurrence rate was 24.4% (30 of 123), consisting of 32.2% (20 of 62) in group A vs 16.4% (10 of 61) in group B. Long-term actuarial freedom from varicose vein recurrence was significantly higher in group B [85% than in group A (67%)]. The 1-year recurrence rate of 3.3% was lower than that achieved with endovenous laser ablation (EVLA) (11.6%), radio frequency ablation (RFA) (7.3%), ultrasound-guided foam sclerotherapy (UGFS) (13.8%), and conventional surgery (14.8%). At 5 years postoperatively, surgery without high ligation of the SFJ resulted in a recurrence rate of 9.8%, which is significantly lower than the 25 to 47.1% reported for conventional surgery. This minimally invasive surgical approach was associated with a lower rate of treatment failure at short-term and long-term follow-up compared with conventional surgery. This could be due to the preservation of the SFJ during GSV reflux treatment enabling the sparing of some normal, competent tributaries (epigastric and perineal vein) draining the residual stump.
Finally, this surgical technique is less invasive and is associated with a reduced risk of inflammatory reactions at the site of groin dissection, resulting in a lower grade of neovascularization. Other advantages of GSV surgery without high ligation include lower costs of the procedure and earlier return to work.