Stefano Ricci
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Abstract This study reports the rate of strip-tract revascularization and reflux (STR&R = refluxing veins within the saphenous fascia, running in the line of where the GSV had run before being stripped) 5-8 years after high ligation and stripping (HSL&S). It was previously shown by the same group that 1 year after operation 23% of patients had revascularization of the strip-tract with reflux. DUS guided saphenofemoral ligation (using non-absorbable Prolene sutures) with closure of the cribriform fascia and inversion stripping was performed in 64 patients (70 legs) between 2003 and 2005. In 2008, 5-8 years after surgery, 35 patients attended the invited DUS appointment (39/70 legs of patients) (response rate 55%). Five limbs of patients showed full STR&R (12.8%), 23 limbs had partial strip-tract revascularization; 7 legs showed no evidence of revascularization of the strip-tract or of neovascularization of the SFJ. It has long been held that HSL&S is the gold standard treatment for varicose veins however a high rate of STR with reflux is associated with this procedure; 82% of patients showed either full or partial revascularization at between 5 and 8 years. It is interesting to see that some patients have shown an aggressive revascularization whilst other show little or no such reaction to the open surgery. This might be related to the volume of haematoma caused at the time of stripping. There is a progression of STR&R over and above that found at 1 year (23 %), suggesting a progressive deterioration (82%); interestingly, it has been observed that following endovenous laser ablation, only 1% of legs of patients showed neovascularization compared with 18% of legs of patients that showed neovascularisation following open surgery. |
Comment by Stefano Ricci
GSV stripping according to Babcock (1907), one of the most applied operations of the last 100 years of surgery history is still under debate. Strip-tract revascularization and reflux, a frequent finding in our follow-up evaluations, is very well studied and analysed in this interesting paper that leaves, however some questions unsolved:
I) No data are given about the origin of the reflux in the strip-tract; when reflux starts high (as when complete), does it comes from a junction recurrence, lymphatic space, pelvic reflux or perforators? When reflux is partial, does it come from a perforator, anterior accessory vein or tributaries?
II) How many patients had duplex recurrence and how many of these clinical recurrence, needing re-operation? In fact, not all the refluxing strip-tracts need to be treated.
III) Where did the strip-tract refluxes empty: perforators, varices?
IV) What was the original diameter of the GSVs and did it correlate with recurrence?
V) What was the saphenous terminal valve and common femoral valve situation? (even if not studied at the beginning these valves could be partly studied at follow-up).
VI) Is it possible that a partial sub-clinical recanalization of the GSV could be considered as a positive result, allowing the basic drainage of the thigh superficial veins and consequently avoiding subcutaneous varices reappearing (like in some sclerotherapy results)?
VII) What treatment is suggested?
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