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]

Stefano Ricci

Abstract

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.

Comment by Stefano Ricci

Papers about groin recurrence are always interesting: in fact GSV interruption at the groin is constantly debated due to recurrence high frequency (20-25% with more than 1/3 requiring reoperation);1 in fact, ultrasound facilities have demonstrated early recurrences even when new varices are still silent.
The Authors sponsor a selective high ligation showing a very favorable (1.9%) rate of recurrence at long term follow-up (5-12 years), apparently explained by the maintenance of the high tributaries drainage. This surgical variation seems simple and easy to perform.
However some questions arise:

  1. Every patient was studied before and after the operation (7-15-30 days + every year). This means a huge amount of exams per year (360) since at least 5 years, only for controls, plus 4 inital exams for every case (1440). How did you organize (time, costs, operators) this part of the study?
  2. Were the patients informed about the surgical variant and how and when was the Ethical Committee consensus obtained?
  3. No mention is done about the Duplex scanning protocol. In particular, no data are given about how the terminal valve, and particularly the femoral valves were studied; about GSV diameters (as an indication of the reflux volume); about the anatomical variations (anterior accessory saphenous vein joining as the highest vessel to the GSV, common trunks for tributaries, etc.);
  4. Neovascularization is identified with cavernoma, which is not the most modern definition. Neovascularization is better defined how tiny vessels arising from the operated vein wall. Cavernoma has possibly a relation with the vessels of the lamina lymphatica laying around the junction that has been not considered;
  5. It is not clear what a T branch is.
  6. The rational of this surgical variant is not completely clear: if a less aggressive manipulation is the matter, the groin surgical dissection is not very different from the traditional one; if the tributary drainage is concerned, pregnancies, DVT and hepatopathies (cited in the paper) don’t seem to be present in the patients observed. In other words, why SHL gives less recurrence?

References

  1. Fischer R, Chandler JG, De Maeseneer MG, et al. The unresolved problem of recurrent saphenofemoral reflux. J Am Coll Surg 2002;195:80-94. [Crossref] [Pubmed]

Author’s reply (Mariani F.)

  1. The organization is the same for all operated patients, we ask all operated patients to undergo checks at the times of 7-15-30 days + every year. Two operators (M. Bucalossi, S. Mancini) studied and check the patients, the surgical interventions were performed by F. Mariani (first surgeon), C. Allegra is the author of the design of the study, and he revised the casuistry, the statistical analysis and the paper.
  2. In the section Material and Methods of the paper is specified that patients signed informed consent; it isn’t mandatory to consult the Ethical Committee because the WMA Declaration of Helsinki - Ethical Principles for Medical Research Involving Human Subjects is respected, however the informed consent was approved by the Internal Ethical Committee of the Hospital.
  3. In the section Material and Methods is specified that: All patients had a venous reflux from terminal valve of SFJ and the femoral valves were continent; the diameters of the GSV were from 7 mm to 12 mm, the anatomical variations of the SFJ are not described because the casuistry is a standard casuistry of operated patients for GSV insufficiency, obviously not all the patients can be submitted to a selective ligation for some reasons, i.e.: i) if the SFJ greatest diameter is >12-13 mm it is usually very difficult to maintain the tributaries and in the same time to make a good ligation-dissection of the dilated (or in some cases even aneurismatic) SFJ; ii) the more complex anatomical variations of the SFJ that impede to distinguish clearly the superior and inferior tributaries, or when some common trunks of tributaries are detected. After the preoperative duplex examination the final decision to perform selective high ligation it is usually taken during the surgical intervention, when we can see clearly the anatomy of the SFJ. For this reason the SFJ is prepared surgically in a meticulous manner, as when we performed a radical high ligation of the SFJ.
  4. Your observation is right, the term of neovascularization is more adequate, but the term cavernoma is always widespread in literature and for this reason we have used it.
  5. The T branch is a branch of a tributary that may be a site of reflux as coming from the bottom of the SFJ, sometimes the pudendal or circumflex veins can have this anatomical variation.
  6. I answer you with the doubts expressed by JG Chandler et al. (JVS 2006) and JJ Bergan (The vein Book 2007): ...frustrated abdominal and pudendal superficial drainage consequent to SFJ-tributary ligation might be a principal trigger for recurrences and neovascularization at the operated SFJ..., it might be a surgical caused obstructive syndrome to drainage? The histological characteristics of neovascularization (B Geier et al., JVS 2006) seem to confirm this hypothesis. On the other hand it is clear that some recurrences are due to inadequate groin surgery, while it seems that Dissection techniques in the groin did not influence the clinical and sonographic result at 3 months and at 7 years after redo surgery for recurrent varicose veins (WG Mouton, MG De Maeseneer et al., Vasa 2011). BC Disselhof et al. (Eur J Vasc Endovasc Surg 2011) evaluate whether ligation of the saphenofemoral junction (SFL) improves the results of endovenous laser ablation (EVLA) of the great saphenous vein (GSV) in a 5-year randomized clinical trial (RCT). The results were: the rate of varicose vein recurrence was similar in both study groups, but it is very interesting to observe that there was less neovascularization in the EVLA without SFL group (0% vs 33%), but more incompetent tributaries (as an inadequate groin surgery!) and early recanalization at 5-year follow-up than in the EVLA with SFL group. The problem of the recurrences in the operated groin is very important and unresolved, also for the endovenous ablation techniques, but our surgical experience shows that probably it is a good choice to maintain some tributaries of SFJ, if these tributaries are chosen carefully and they cannot cause reflux in the postoperative period.

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