Comment to: Postoperative varicose recurrence at the junctions. A multicentric study of 1056 patients by the Italian Society of Phlebolymphology. Preliminary conclusions by Corcos L, Aloi T, Alonzo U, et al. Acta Phlebol 2014;15:69-78.

Stefano Ricci

Abstract

In spite of a history and evidence of efficacy, numerous attempts have been made to replace traditional surgery with new techniques in the hypothesis that the surgical trauma and high pressure on the venous wall are responsible for the development of neovascularisation by neoangiogenesis (NN) and, consequently, high postoperative recurrent rates.
To verify the anatomical causes of postoperative varices recurrence (VR) at the SFJ and SPJ fourteen centres belonging to the Italian Society of Phlebolymphology collected the requested data from 1056 patients (1081 limbs, 25 bilateral) who were either previously subjected to ligation-interruption of SFJ and/or SPJ (927 between 2001-2010) or treated in the last two years (154 between 2011-2012); 611 limbs (56.5%) were examined by DUS only, 470 limbs (43.4%) were subjected to DUS examination and surgical revision (270 with Li technique).
The residual saphenous stump (SS), all residual tributaries with their outflows into the stump or directly into the common femoral or popliteal veins and their anatomical variants were investigated; neovascularisation by neoangiogenesis was investigated, searching for thin and tortuous veins measuring <2 mm in diameter and connected with an SS, with the common femoral vein or with thinner subcutaneous veins. The majority of the SS were found to be combined with residual identified or unidentified tributaries. In many cases, the VR consisted of a complex varicose collateral circulation (CVC).
The residual SS (n=711, 65.7%) was the most common finding, followed (by decreased frequency) by the anterior accessory of the GSV (n=298, 27.5%), UT at the SFJ (n=290, 26.8%), superficial iliac circumflex vein (n=127, 11.7%), residual GSV (most likely from a previous duplicity), (n=95, 8.7%), superficial epigastric (n=60, 8.8%) A large number of cases with development of a CVC (n=386, 35.7%) were found in the supra-fascial subcutaneous. The anatomical residuals, which were single or multiple and variously combined, were found in a total of 939 operated junctions. Neovascularisation was suspected or demonstrated in a total of 142/1081 cases (13.1%).
The data obtained from the different centres appeared to be scarcely detailed to define the various tributary veins involved in the mechanism of recurrence; nevertheless, it is possible to assess the prevalence of SS connected with residual tributaries as major causes of recurrence in both the SFJ and SPJ. NN was recently described as the most dangerous enemy of surgeons and patients operated on for varicose veins. The word neovascularisation seems more appropriate to indicate the appearance of new vessels produced by the phenomenon of neoangiogenesis and does not appear to be appropriate, as it refers to pre-existing veins that remain under the impulse of the venous reflux and progressively dilate. Histological observations have led to describe neoangiogenesis as a physiologic process, which follows inflammation and mainly represents a constant product of large wounds, haematomas and thrombosis). The same reparative process, leading to the appearance of specific progenitor cells, takes place in every anatomical district and in every kind of tissue, not only in veins. It can be invoked as a cause of VR in a small percentage of cases, and it seems to play a minimal role at the groin and popliteal region of the operated limbs. In many cases in which no residual tributary could be detected, except for small, weak and tortuous veins, the VR was represented by an anatomical anarchic development of the collateral circulation, similar to cavernous haemangioma.
The presence of anatomical residuals at the SFJ and SPJ has been always indicated in the past as the main cause of VR; this research confirms that residual saphenous stump and tributaries caused by inadequate surgery appear to be the main cause of VR at the saphenous junction. Recent studies have clearly demonstrated that the only way to prevent VR is still traditional surgery. The only trap is represented by the presence of anatomical variants at the junctions but DUS investigation systematically performed before applying any therapeutic technique can prevent such difficulties.

Comment by Stefano Ricci

Although GSV interruption is the base of varicose veins treatment, junctions’ recurrences are still under debate, the end of the debate moving away. While the medium term results of physical or chemical Endovascular Vein Ablation (EVA) seem to support the theory of less manipulation/less recurrences at the groin, here is a counter-current study siding the good old high ligation (±stripping), where the recurrences are due simply to inadequate surgery. The authors have performed an extremely accurate analysis of the post surgical anatomy of groin recurrences, showing with great evidence that the persistence of the junction stump is the origin of the varicose recurrence. Neoangiogenesis, defined as thin and tortuous veins measuring <2 mm in diameter and connected with an SS, with the common femoral vein or with thinner subcutaneous veins is rare and most of the times suspected more than confirmed. However, Devil is in the details, so that some aspects need to be analysed:

  1. A long SS connected to one or more tributaries does not mean necessarily that the tributary/ies was/were left untouched at the operation; re-connection could be due to neoangiogenesis (a physiologic process that follows inflammation). This could explain why many subjects have no recurrence even with long stumps left, if their repair process was favourable; and could explain also the CVC cases, where anarchic communications have developed. In these instances NN could be much more important and widespread.
  2. In fact, the high number of recurrences analysed is not referred to the number of operated cases so that the recurrences incidence is not known. In particular, only the big VR have been taken in account (most symptomatic), while the minor recurrences (possibly detectable only by US), the one more interesting as far as NN is concerned, are not considered.
  3. Valsalva manoeuvre for confirming the junction origin of the reflux is not mentioned in methods, so that recurrences due to pelvic reflux have not been separated.
  4. No data are available concerning terminal valve competence at first operation, nor GSV diameters (correlated to the valve competence according to Cappelli): these variables could condition different behaviours in tissues.
  5. No mention is made about the groin recanalization through the lamina lymphatica vein network, one of the most important pathways of the re-connection between the operated area and the residual veins. Again, this event may be mediated by NN. The so-called cavernoma could involve this area.
  6. There are evidences concerning the selective high ligation of the sapheno-femoral junction (sparing the tributaries coming from the abdomen); their sparing corresponds to the effect of the EVA techniques.
  7. A comment about CHIVA crossotomy would be interesting. This technique, as well known, do not ligate the tributaries but allows their drainage through the spared GSV, emptying through a perforator, with limited reported recurrences. Could the non-draining ligated tributaries of the traditional surgery have a role in recurrences?

Authors’ reply

The summary is excellent as it highlights the most significant reasons and findings of the work. Every criticism becomes productive as makes possible to improve the knowledge and often represents the major impulse for further research. So please see my answers.

  1. Answer 1) The probabilities of a large (>2 mm) residual tributary vein re-connection at the junction by NN is obviously lesser than the persistence of a residual large tributary vein which becomes dilated and incompetent. Answer 2) This is the reason why some researchers, mentioned in the references, based their conclusions on histology which some time makes possible to detect the new vessels only. As it may happen by USD examination, histologic slides may have been performed in areas not comprising the tributaries. Please see the enclosed PPT slide 1 where both the NN process and the residual tributary were detected in the same sample of a recurrent patient. Answer 3) The residual SS becomes a cause for recurrence only in the cases affected with a highly progressive disease for the same reasons why an apparently normal subject becomes varicose. Answer 4) In these cases NN can be more significant and represent an additional cause for the severity recurrence (in the paper NN is not cancelled as a possible cause for recurrence).
  2. This is an acceptable and interesting hypothesis, which could require further specific studies.
  3. Please note that in page 71 of the published paper you can find the following information: A) ...patients with pelvic reflux were excluded... . B) the DUS examinations were performed by the ...recommended criteria... . They obviously comprise the Valsalva manoeuvre. However this clarification could be useful for readers.
  4. I agree. These parameters are highly predictive, however our patients came from different and sometimes unknown centres where some defects in the basic preoperative diagnostic process, more than in the surgical procedure, may have occurred. Perhaps you should say …according with Labropoulos who first demonstrated the relation between venous dilatation (calibre) and incompetence.
  5. I agree. In one case only the lymphatic origin of recurrence from NN was detected by surgical dissection, which, at the present time, seems to be the more predictive method. Please see the enclosed PPT slide 2. Perhaps it should have been mentioned in the text. In the more recent experience the DUS investigation and the surgical dissection made possible to detect 2 similar cases at the groin.
  6. My personal opinion is that such evidences come from a too short follow-up. Please see PPT slide 3. This graphic has been shown in some congress presentations but unfortunately there was not enough space in the Journal for including it and extending the discussion. You can note that the peaks of recurrence belong to the first 7 years postoperative period. However a high number of the cases developed the recurrence from 8 up to 34 years after surgery. This can indicate 2 hypotheses: 1) residual veins can easily recur in the short term; 2) the role of NN should be mainly related with a longer term recurrence, however the responsibility of anatomical residuals must be assumed in the long term too.
  7. Why not? This is what we see whenever examining and treating patients with recurrence after simple crossotomy. Please see my previous answer: The residual SS becomes a cause for recurrence only in the cases affected with a highly progressive disease for the same reasons why an apparently normal subject becomes varicose.

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