Comment to: Defence’s argument for stripping without high ligation (Plaidoyer pour le stripping sans crossectomie) by Creton D. Phlébologie 2013;66:49-53.

Stefano Ricci

Abstract

Stripping without high ligation (HL), although commonly practiced by many centers, is still disputed. It is now assumed that HL is not necessary when GSV incontinence is not due to Junction incompetence but depends from perineal, Giacomini, perforating or lymphatic-ganglion veins. Following the traditional knowledge, leaving a long stump at the junction, like after a stripping without HL or an endovascular procedure should be followed by a high incidence of recurrence. Surprisingly, 6 months and 2 years follow up stripping + HL versus laser randomized studies do not show any difference in recurrences. Moreover, 2 and 3 years follow up randomized studies comparing stripping + HL versus radiofrequency report similar results. Finally, the Closure Fast study, concerning 295 GSVs shows very good results at 3 and 5 years. At the opposite it is now proved that HL induces neovascularization, as in the EVOLVeS study or a recent 5 years follow up study1 ( 33% in HL versus 0% in no HL).
Stripping without HL was studied in 195 cases with recurrence in 1.8% at two years,2 and in a randomized trial comparing stripping with (60 cases) and without (60 cases) HL:3 at 8 years f.u. clinical recurrence was 29% versus 9.8% , while ultrasound showed 32.2% versus 11.4% recurrences.
In the Author’s experience of 8595 cases from 1997 to 2008, the stripping without HL replaced totally the traditional technique since 2005.

Comment by Stefano Ricci

This paper touches one of the most respected dogmas of Phlebology (and Vascular Surgery): the junction must be fully dissected and all the tributaries must be interrupted. As underlined by the Author, ultrasound facilities and favorable results of endovascular procedures (including sclerotherapy) show that an open residual junction not necessarily correspond to a surgical failure. This probably may explain why so many patients badly operated (with long residual stumps) live and run happily all around. The reason why other long stumps develop recurrences is not clear, as many other aspects of varicose disease.
As in the comment published for Casoni’s paper (Bybliolab 2014), it is a pity that the authors did not cite, in particular, Dortu’s pioneering work, published on the French journal Phlébologie,4 concerning 596 patient operated by what he called supra-fascial crossectomy. Minumum follow up was three years. Over 125 cases (149 limbs), blindly chosen inside the patients list of the period 1982-1988, he could find 146 very good results, 2 recurrences on posterior accessory and 1 on anterior accessory (15 years after).
From the technical point of view, it would be interesting to know where the skin incision is made (if low may be more visible), how large is it, how long the residual stump should be.
And what about the anterior accessory saphenous vein (the most common source of recurrence)?
Should it be spared?
Moreover, are there cases (other than the ballooning dilatations you cited) where HL is better indicated, like f.e. when a refluxing tributary is present?

References

1. Disselhoff BC, der Kinderen DJ, Kelder JC, Moll FL. Five years results of a randomized clinical trail of endovenous laser ablation of the great saphenous vein with and without ligation of the saphenofemoral junction. Eur J Vasc Endovasc Surg 2011;41:685-90.[Abstract][PubMed]
2. Pittaluga P, Chastanet S, Guex JJ. Great saphenous vein stripping with preservation of the sapheno-femoral confluence: hemodynamic and clinical results. J Vasc Surg 2008;47:1300-4.[Abstract][PubMed]
3. Casoni P, Lefebvre-Vilardebo M, Villa F, Corona P. Great saphenous vein surgery without crossectomy. J Vasc Surg 2013;58:173-8.[Abstract][PubMed]
4. Dortu J. La crossectomie sus-fasciale au corse de la Phlebectomie Ambulatoire du complexe saphenien interne à la cuisse. Phlébologie 1993;46:123-37.[PubMed]

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