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Varicose vein surgery with preservation of the saphenous vein: A comparison between high ligation-avulsion versus saphenofemoral banding valvuloplasty-avulsion
Varicose vein surgery with preservation of the saphenous vein: A comparison between high ligation-avulsion versus saphenofemoral banding valvuloplasty- avulsion H a r r y Schanzer, M D , and Milan Skladany, M D N e w York, N . Y . Purpose: Surgical treatment of varicose veins with preservation of the greater saphenous
vein (GSV) was studied. Methods: Patients with reflux at the saphenofemoral junction and grossly normal GSV
were treated with two different surgical techniques: perivalvular banding val~loplasty (PVBV-A) of the saphenous valve, wherein the diameter of the uppermost saphenous valve was narrowed by Dacron-reinforced silicone band (12 patients, 15 extremities); and high ligation (HL-A) of the saphenous vein, wherein the GSV was ligated flush with the femoral vein (14 patients, 16 extremities). Both groups also had varicose tributaries of GSV a~xllsed through multiple stab incisions. Results: In the HL-A group two GSV (13%) remained completely patent, 10 GSV (62.5%) thrombosed partially, and the remaining four GSV (25%) had complete thrombosis. In the PVBV-A group 12 GSV (80%) remained completely patent and without reflux, one GSV (7%) remained patent but showing reflux. Two GSV (13%) thrombosed completely. There were no surgical complications or recurrences (mean follow-up was 9.4 months for PVBV-A and 9.5 months for HL-A), and the postoperative recovery time was similar for both groups. Conclusions: Both techniques are equally effective in the early elimination of varicosities. Preservation of the saphenous vein is significantly better after PVBV-A (p < 0.01). A prospective randomized trial with long-term follow-up is required. (J VAsc SURG 1994;20:684-7.
Recent advances in ultrasound technology (Doppler, duplex, and color-flow duplex scanning) have allowed the accurate determination of the anatomic and functional abnormalities present in the limbs of patients with primary varicose veins (PVV). Studies that use these noninvasive techniques have clearly established that PVV can result from deep to superficial system reflux at different levels (saphenofernoral, saphenopopliteal, or perforator veins or pelvic reflux). 1,2 Thus, with an appropriate evaluation, the pathogenesis of the varicose condition can From the Mount Sinai Schoolof Medicine, New York. Presented at the Sixth AnnualMeeting of the AmericanVenous Forum, Wailea,Maui, Hawaii, Feb. 23-25, 1994. Reprint requests: Harry Schanzer,MD, The Mount Sinai Hospital, Departmentof Surgery,Box 1259, One GustaveL. LevyPI., New York, NY 10029. Copyright © 1994 by The Society for Vascular Surgery and InternationalSocietyfor CardiovascularSurgery,North American Chapter. 0741-5214/94/$3.00 + 0 24/6/56845 684
be established, and a rational surgical intervention can be tailored to the specific pathologic abnormality. Quite unlike routine radical extirpations, selective venous surgery can be aimed at preserving the saphenous vein, a clearly desirable objective when considering the widespread use of this vessel in coronary and distal extremity bypass. In recent years, in fact, there has been a considerable increase in the level of awareness among physicians for the need to preserve the saphenous vein during the treatment of P W . 3 In the presence of saphenofemoral reflux, such an objective can be achieved by high ligation (HL) of the saphenous vein or by perivalvular banding valvuloplasty (PVBP) of the saphenofemoral valve. The correction of the saphenofemoral regurgitation, accompanied by local avxtlsion of varicose branches, can eliminate the varicosities while preserving the axial vein. This report presents our experience with these selective techniques in two consecutive groups of patients with P W .
JOURNAL OF VASCULAR SURGERY Volume 20, Number 5
Schanzer and Skladany 6 8 5
Table I. Clinical presentation Group
Age
Sex (F/M)
Pain (%)
Edema (%)
Cosmetic concerns(%)
A B
40 +- 11.6 43 +- 8.6
10/2 11/3
12 (80%) 16 (100%)
4 (27%) 6 (38%)
15 (100%) 15 (94%)
Table II. Patency of saphenous vein Group
Thrombosed100%
Open 25%
Open 50%
Open 75%
Open 100%
PVBV-A HL-A
13 25
0 0
0 37.5
0 25
87 12.5
MATERIAL A N D M E T H O D S
Study population. Two groups of patients were studied in a consecutive, nonrandomized fashion. Group A consisted of 12 patients (15 extremities) treated between February 1988 and January 1989 with use of the PVBV procedure plus avulsion of varicose tributaries (PVBV-A). Group B consisted of 14 patients (16 extremities) treated by HL of the long saphenous vein plus avulsion of the varicose tributaries (HL-A) between July 1991 and January 1993. Both groups were similar for sex distribution, age and in clinical presentation (Table I). Evaluation. All patients were evaluated before surgery and at 1 and 6 months after surgery with a detailed history, physical examination, and duplex testing. The latter was performed according to the technique described by van Bemmelen et al.4 The extremity was examined while the patient was in a standing position and bearing his/her weight on the other extremity. Reflux was induced by rapidly deflating a wide cuff placed distally on the leg. All extremities in both groups had reflux into the long saphenous vein demonstrated by duplex scanning. The examination also documented that the varicosities were arising from the tributaries of the long saphenous vein. The main axial vein was grossly normal, without dilation or tortuosity as determined by physical examination, palpation, and occasional duplex examination. Follow-up beyond 6 months was done only on the basis of clinical examination. Surgical procedures. Surgery was performed on an outpatient basis, with the patient receiving general or spinal anesthetic. In both groups, the saphenofemoral junction was approached through a transverse incision at the groin crease. The groin tributaries of the saphenous vein were ligated and transected, thus mobilizing a segment 3 to 4 cm long. In patients undergoing PVBV-A, the uppermost valve was banded with a 1.5 cm wide stri[~ of
Dacron-reinforced silicone (Venocuft]. Successful correction of the reflux was confirmed by the strip test. Details of this technique have been described elsewhere,s,6 HL of the saphenous vein was performed by placing a 2-0 silk tie at the saphenofemoral junction flush with the femoral vein. In both groups, the varicosities were avulsed through multiple stab incisions. One leg undergoing PVBP-A had additional ligation of one incompetent calf perforator. In both groups, patients with residual varicose veins were treated with sclerotherapy (sodium tetradecyl sulfate 1%) during follow-up visits. Statistical analysis. Comparison of results on preservation of the saphenous vein between both groups was performed by use of ridit analysis. 7 RESULTS
Surgery was well tolerated in both groups, and no complications were observed. All patients were fully ambulatory on the day of surgery and resumed full activities within a week. Immediate satisfaction with the procedure, with improved cosmetic results and alleviation of symptoms, was universal in patients of both groups. Follow-up for patients with PVBV-A was 9.5 _+ 4.5 months and for patients with HL-A 9.4 + 4.9 months. During this period, no recurrences were observed. With regard to patency of the saphenous vein (Table II), the group undergoing PVBV-A was found to have complete patency in 13 of the 15 extremities (8 7%), throughout the period of followup. Twelve of these banded valves maintained their competency as well, whereas one continued to reflux. Complete thrombosis of the saphenous vein was observed in two extremities. In both instances this occurred soon after surgery. In the group undergoing HL-A, only two of the 16 extremities (12.5%) were found to have the
JOURNAL OF VASCULAR SURGERY
686 Schanze~"and Skladany
saphenous vein patent in its entirety. Four extremities (25%) had at least one fourth of the vein thrombosed, and six extremities (37.5%) had thrombosis of half of the length of the vein. The remaining four extremities (25%) had saphenous veins thrombosed from the groin to the ankle. Presence of retrograde flow in the saphenous vein was observed in two of the extremities (12.5%). The difference in patency between the two groups was statistically significant (p < 0.01). DISCUSSION
Recent studies with use of ultrasound technology (Doppler, duplex) have shown a variety of different sites of reflux in PVV. Goren and Yellin, ~ in a study with Doppler technology, found that a population of 163 patients with 230 extremities affected by PVV could be divided into three different groups, according to the point of reflux. One group (71.3%) consisted of extremities that had incompetence at the saphenofemoral or the saphenopopliteal valve. A second group (22.17%) consisted of extremities with atypical incomplete saphenous varicosities and competent saphenofemoral valve. In 9.8% of these legs, no point of escape could be identified. In the remaining legs, reflux occurred through incompetent perforators at the midthigh, lower thigh, or calf level. In the third group (6.25%) the limbs had nonsaphenous varicosities. The varicose veins were located in the lateral aspect of the calf or thigh, and the reflux occurred through incompetent perforators that communicated the deep femoral system to this lateral superficial system of veins. In a similar study, using Doppler and occasional varicography, Lutter et al.2 were able to divide the population of 482 patients with PVV into two groups. The first one (65.2%) had grossly abnormal saphenofemoral reflux with dilated saphenous trunk and extensive varicosities. The second group (34.8%) had normal nonrefluxing saphenous vein, and the varicosities were located in the tributaries. In both of these reports the authors concluded that, to plan an adequate treatment, it was imperative to perform a careful evaluation of the varicose limb. They also stressed that sparing of the saphenous vein should be done in limbs with PVV and a competent saphenofemoral valve. Attempts at preservation of the saphenous vein in limbs with saphenofemoral incompetence, normal axial vein, and branch varicosities have been reported. In all of these reports, the junctional reflux was corrected by either HL or valvuloplasty and the varicosities were stab avulsed or obliterated with
November1994
sclerotherapy. Lofgren et al. s in 1958 was the first to describe a retrospective experience in which he compared HL-sclerotherapy and stripping. Results at 5 years were superior in the stripping group, with an excellent outcome in 70% and a poor outcome in only 1% of cases. In contrast, in the HL-sclerotherapy group t h e incidence of excellent and poor outcomes was 30% and 55%, respectively. His population, however, included patients with superficial, deep, and perforator disease and advanced chronic venous stasis. Since then, several clinical studies have been reported, some supporting the effectiveness of HL associated with sclerotherapy or avulsion, whereas others describe poor results. Munn et al.9 performed a randomized study that compared HL-A versus ankle-to-groin stripping. He conduded that stripping had a significant advantage, when the assessment was done objectively by the examiner, but that "the incidence of paresthesia and pain biased patient's opinion against stripping." Good and comparable results between these two techniques were reported by Hammarsten et al.10 At 52 months, he found a recurrence rate of 11% for HL-A and 12% for stripping. With regard to preservation of the saphenous vein, the same author found that in the patients undergoing HL-A, 78% had preservation of the saphenous vein. Freidell et al) ~ reported a 78% rate of total preservation of the saphenous vein after HL-sclerotherapy, partial preservation of 15% and extensive thrombosis in 7% of cases. In the group that underwent HL-A, the rate was 61% for total preservation, 15% for partial preservation, and 7% for extensive thrombosis. Rutherford et al., ~2 in a small group of 10 limbs undergoing HL, found total preservation of 70% and partial preservation of 30%. External valvuloplasty of the saphenofemoral valve, performed with an encircling tie or external banding was attempted by Royle and Somscn. la In an exF.:fience of 35 limbs, they found 82.8% of saphenous vein preservation and competence, 11.4% of occluded veins, and 5.7% of veins with persistent re~ux.
The clinical results of this series, both in the patients undergoing HL-A and PVBV-A were excellent. There were no operative complications, postoperative pain was minimal, and reassumption of full activity occurred very soon after surgery. The cosmetic results were very good, and no recurrences were observed in a short follow-up period of 10 months. With regard to the preservation of the saphenous vein, there was a significant superiority for the PVBV-A group. In these patients, 80% of the saphenous veins were patent and competent, and 7%
JOURNAL OF VASCULAR SURGERY Volume 20, Number 5
were patent with persistent reflux. In the patients undergoing HL-A, the patency of the axial vein was inferior. Full patency was present in 12.5%, partial patency in 62.5%, and occlusion in 25%. These results on patency are worse than those reported by others. 9.n The reason for this difference is unclear. The reflux rate of 12.5% observed in our HL-A group has also been reported in other series. Sarin et al.14 found a 45% of reflux rate in the saphenous vein after HL. This abnormality has been explained by persistent incompetent tributaries that connect the hypogastric or external iliac system to the saphenous system or by the so-called "neo-vascularization.''~s Its prognostic implication is unknown. In conclusion, patients with PVV can be classified into different groups according to the point of reflux. To perform an adequate therapy, the procedure has to be tailored to the patient-specific disease. This implies a careful preoperative clinical and ultrasonographic assessment of the limb. In patients with saphenofemoral reflux, normal saphenous vein, and branch varicosities, preservation of the saphenous vein and elimination of the varicose veins can be achieved by treating the reflux, either by high ligation or valvuloplasty, and local stab avulsion of the abnormal dilated veins. Based on our experience, both of these techniques give excellent short-term clinical resuks. With regard to preservation of the saphenous vein, however, valvuloplasty produces a significantly better outcome. Because the series are small and the follow-up is short, this report should be considered preliminary. For a more definite answer to the question posed by this work, a randomized prospective clinical trial is clearly needed. REFERENCES 1. Goren G, Yellin AE. Primary varicose veins: topographic and hemodynamic correlations. J Cardiovasc Surg 1990;31: 672-7. 2. Lutter KS, Villavicencio JL, Cabellon S Jr, Rich NM. Long-
Schanzer and Skladany 6 8 7
3.
4.
5. 6.
7.
8. 9.
10.
11.
12.
13. 14.
15.
term results of selective venous surgery: does the greater saphenous vein have to be stripped in varicose vein operations ? Presented at Eighteenth Annual Symposium on Current Critical Problems and New Horizons in Vascular Surgery; November 22-24, 1991; New York, N.Y. Large J. Surgical treatment of saphenous varices, with preservation of the main great saphenous trunk. J VAse SURG 1985;2:886-91. van Bemmelen PS, Bedford G, Beach K, Strandness DE. Quantitative segmental evaluation of venous valvular reflux with duplex ultrasound scanning. J VAsc SURG 1989; 10:42530. Jessup G, Lane RJ. Repair of incompetent venous valves: a new technique. J Vasc SURG 1988;8:569-75. Schanzer H, Skladany M, Peirce EC II. The role of external banding valvuloplasty in the surgical management of chronic deep venous disease. Phlebology 1994;9:8-12. Fleiss, JL. The comparison of proportions from several independent samples. In: Fleiss, JL. Statistical methods for rates and proportions. 2nd ed. New York: John Wiley and Sons, 1981:138-58. Lofgren KA, Ribisi AP, Myers TT. An evaluation of stripping versus ligation for varicose veins. Arch Surg 1958;76:310-6. Munn SR, Morton JB, MacBeth WAAG, McLeish AR. To strip or not to strip the long saphenous vein? a varicose veins trial. Br J Surg 1981;68:426-8. Hammersten J, Pedersen P, Cederlund CG, Campanello M. Long saphenous vein saving surgery for varicose veins: a long-term follow-up. Eur J Vase Surg 1990;4:361-4. Friedell ML, Samson RH, Cohen MJ, et al. High ligation of the greater saphenous vein for treatment of lower extremity vaticosities: the fate of the vein and therapeutic results. Ann Vasc Surg I992;6:5-8. Rutherford RB, Sawyer JD, Jones DN. The fate of residual saphenous vein after partial removal or ligarion. J VAsc SUING 1990; 12:422-8. Royle JP, Somsen GM. Preservation of the long saphenous vein. J Cardiovascular Surg 1991;32:7. Sarin S, Scurr JH, Smith PDC. Assessment of stripping the long saphenous vein in the treatment of primary varicose veins. Br J Surg 1992;79:889-93. Glass GM. Neovascularization in recurrence of varices of the great saphenous vein in the groin: surgical anatomy and morphology. Phlebology 1987;2:81-92.
Submitted March 2, 1994; accepted April 17, 1994.
vein (GSV) was studied. Methods: Patients with reflux at the saphenofemoral junction and grossly normal GSV
were treated with two different surgical techniques: perivalvular banding val~loplasty (PVBV-A) of the saphenous valve, wherein the diameter of the uppermost saphenous valve was narrowed by Dacron-reinforced silicone band (12 patients, 15 extremities); and high ligation (HL-A) of the saphenous vein, wherein the GSV was ligated flush with the femoral vein (14 patients, 16 extremities). Both groups also had varicose tributaries of GSV a~xllsed through multiple stab incisions. Results: In the HL-A group two GSV (13%) remained completely patent, 10 GSV (62.5%) thrombosed partially, and the remaining four GSV (25%) had complete thrombosis. In the PVBV-A group 12 GSV (80%) remained completely patent and without reflux, one GSV (7%) remained patent but showing reflux. Two GSV (13%) thrombosed completely. There were no surgical complications or recurrences (mean follow-up was 9.4 months for PVBV-A and 9.5 months for HL-A), and the postoperative recovery time was similar for both groups. Conclusions: Both techniques are equally effective in the early elimination of varicosities. Preservation of the saphenous vein is significantly better after PVBV-A (p < 0.01). A prospective randomized trial with long-term follow-up is required. (J VAsc SURG 1994;20:684-7.
Recent advances in ultrasound technology (Doppler, duplex, and color-flow duplex scanning) have allowed the accurate determination of the anatomic and functional abnormalities present in the limbs of patients with primary varicose veins (PVV). Studies that use these noninvasive techniques have clearly established that PVV can result from deep to superficial system reflux at different levels (saphenofernoral, saphenopopliteal, or perforator veins or pelvic reflux). 1,2 Thus, with an appropriate evaluation, the pathogenesis of the varicose condition can From the Mount Sinai Schoolof Medicine, New York. Presented at the Sixth AnnualMeeting of the AmericanVenous Forum, Wailea,Maui, Hawaii, Feb. 23-25, 1994. Reprint requests: Harry Schanzer,MD, The Mount Sinai Hospital, Departmentof Surgery,Box 1259, One GustaveL. LevyPI., New York, NY 10029. Copyright © 1994 by The Society for Vascular Surgery and InternationalSocietyfor CardiovascularSurgery,North American Chapter. 0741-5214/94/$3.00 + 0 24/6/56845 684
be established, and a rational surgical intervention can be tailored to the specific pathologic abnormality. Quite unlike routine radical extirpations, selective venous surgery can be aimed at preserving the saphenous vein, a clearly desirable objective when considering the widespread use of this vessel in coronary and distal extremity bypass. In recent years, in fact, there has been a considerable increase in the level of awareness among physicians for the need to preserve the saphenous vein during the treatment of P W . 3 In the presence of saphenofemoral reflux, such an objective can be achieved by high ligation (HL) of the saphenous vein or by perivalvular banding valvuloplasty (PVBP) of the saphenofemoral valve. The correction of the saphenofemoral regurgitation, accompanied by local avxtlsion of varicose branches, can eliminate the varicosities while preserving the axial vein. This report presents our experience with these selective techniques in two consecutive groups of patients with P W .
JOURNAL OF VASCULAR SURGERY Volume 20, Number 5
Schanzer and Skladany 6 8 5
Table I. Clinical presentation Group
Age
Sex (F/M)
Pain (%)
Edema (%)
Cosmetic concerns(%)
A B
40 +- 11.6 43 +- 8.6
10/2 11/3
12 (80%) 16 (100%)
4 (27%) 6 (38%)
15 (100%) 15 (94%)
Table II. Patency of saphenous vein Group
Thrombosed100%
Open 25%
Open 50%
Open 75%
Open 100%
PVBV-A HL-A
13 25
0 0
0 37.5
0 25
87 12.5
MATERIAL A N D M E T H O D S
Study population. Two groups of patients were studied in a consecutive, nonrandomized fashion. Group A consisted of 12 patients (15 extremities) treated between February 1988 and January 1989 with use of the PVBV procedure plus avulsion of varicose tributaries (PVBV-A). Group B consisted of 14 patients (16 extremities) treated by HL of the long saphenous vein plus avulsion of the varicose tributaries (HL-A) between July 1991 and January 1993. Both groups were similar for sex distribution, age and in clinical presentation (Table I). Evaluation. All patients were evaluated before surgery and at 1 and 6 months after surgery with a detailed history, physical examination, and duplex testing. The latter was performed according to the technique described by van Bemmelen et al.4 The extremity was examined while the patient was in a standing position and bearing his/her weight on the other extremity. Reflux was induced by rapidly deflating a wide cuff placed distally on the leg. All extremities in both groups had reflux into the long saphenous vein demonstrated by duplex scanning. The examination also documented that the varicosities were arising from the tributaries of the long saphenous vein. The main axial vein was grossly normal, without dilation or tortuosity as determined by physical examination, palpation, and occasional duplex examination. Follow-up beyond 6 months was done only on the basis of clinical examination. Surgical procedures. Surgery was performed on an outpatient basis, with the patient receiving general or spinal anesthetic. In both groups, the saphenofemoral junction was approached through a transverse incision at the groin crease. The groin tributaries of the saphenous vein were ligated and transected, thus mobilizing a segment 3 to 4 cm long. In patients undergoing PVBV-A, the uppermost valve was banded with a 1.5 cm wide stri[~ of
Dacron-reinforced silicone (Venocuft]. Successful correction of the reflux was confirmed by the strip test. Details of this technique have been described elsewhere,s,6 HL of the saphenous vein was performed by placing a 2-0 silk tie at the saphenofemoral junction flush with the femoral vein. In both groups, the varicosities were avulsed through multiple stab incisions. One leg undergoing PVBP-A had additional ligation of one incompetent calf perforator. In both groups, patients with residual varicose veins were treated with sclerotherapy (sodium tetradecyl sulfate 1%) during follow-up visits. Statistical analysis. Comparison of results on preservation of the saphenous vein between both groups was performed by use of ridit analysis. 7 RESULTS
Surgery was well tolerated in both groups, and no complications were observed. All patients were fully ambulatory on the day of surgery and resumed full activities within a week. Immediate satisfaction with the procedure, with improved cosmetic results and alleviation of symptoms, was universal in patients of both groups. Follow-up for patients with PVBV-A was 9.5 _+ 4.5 months and for patients with HL-A 9.4 + 4.9 months. During this period, no recurrences were observed. With regard to patency of the saphenous vein (Table II), the group undergoing PVBV-A was found to have complete patency in 13 of the 15 extremities (8 7%), throughout the period of followup. Twelve of these banded valves maintained their competency as well, whereas one continued to reflux. Complete thrombosis of the saphenous vein was observed in two extremities. In both instances this occurred soon after surgery. In the group undergoing HL-A, only two of the 16 extremities (12.5%) were found to have the
JOURNAL OF VASCULAR SURGERY
686 Schanze~"and Skladany
saphenous vein patent in its entirety. Four extremities (25%) had at least one fourth of the vein thrombosed, and six extremities (37.5%) had thrombosis of half of the length of the vein. The remaining four extremities (25%) had saphenous veins thrombosed from the groin to the ankle. Presence of retrograde flow in the saphenous vein was observed in two of the extremities (12.5%). The difference in patency between the two groups was statistically significant (p < 0.01). DISCUSSION
Recent studies with use of ultrasound technology (Doppler, duplex) have shown a variety of different sites of reflux in PVV. Goren and Yellin, ~ in a study with Doppler technology, found that a population of 163 patients with 230 extremities affected by PVV could be divided into three different groups, according to the point of reflux. One group (71.3%) consisted of extremities that had incompetence at the saphenofemoral or the saphenopopliteal valve. A second group (22.17%) consisted of extremities with atypical incomplete saphenous varicosities and competent saphenofemoral valve. In 9.8% of these legs, no point of escape could be identified. In the remaining legs, reflux occurred through incompetent perforators at the midthigh, lower thigh, or calf level. In the third group (6.25%) the limbs had nonsaphenous varicosities. The varicose veins were located in the lateral aspect of the calf or thigh, and the reflux occurred through incompetent perforators that communicated the deep femoral system to this lateral superficial system of veins. In a similar study, using Doppler and occasional varicography, Lutter et al.2 were able to divide the population of 482 patients with PVV into two groups. The first one (65.2%) had grossly abnormal saphenofemoral reflux with dilated saphenous trunk and extensive varicosities. The second group (34.8%) had normal nonrefluxing saphenous vein, and the varicosities were located in the tributaries. In both of these reports the authors concluded that, to plan an adequate treatment, it was imperative to perform a careful evaluation of the varicose limb. They also stressed that sparing of the saphenous vein should be done in limbs with PVV and a competent saphenofemoral valve. Attempts at preservation of the saphenous vein in limbs with saphenofemoral incompetence, normal axial vein, and branch varicosities have been reported. In all of these reports, the junctional reflux was corrected by either HL or valvuloplasty and the varicosities were stab avulsed or obliterated with
November1994
sclerotherapy. Lofgren et al. s in 1958 was the first to describe a retrospective experience in which he compared HL-sclerotherapy and stripping. Results at 5 years were superior in the stripping group, with an excellent outcome in 70% and a poor outcome in only 1% of cases. In contrast, in the HL-sclerotherapy group t h e incidence of excellent and poor outcomes was 30% and 55%, respectively. His population, however, included patients with superficial, deep, and perforator disease and advanced chronic venous stasis. Since then, several clinical studies have been reported, some supporting the effectiveness of HL associated with sclerotherapy or avulsion, whereas others describe poor results. Munn et al.9 performed a randomized study that compared HL-A versus ankle-to-groin stripping. He conduded that stripping had a significant advantage, when the assessment was done objectively by the examiner, but that "the incidence of paresthesia and pain biased patient's opinion against stripping." Good and comparable results between these two techniques were reported by Hammarsten et al.10 At 52 months, he found a recurrence rate of 11% for HL-A and 12% for stripping. With regard to preservation of the saphenous vein, the same author found that in the patients undergoing HL-A, 78% had preservation of the saphenous vein. Freidell et al) ~ reported a 78% rate of total preservation of the saphenous vein after HL-sclerotherapy, partial preservation of 15% and extensive thrombosis in 7% of cases. In the group that underwent HL-A, the rate was 61% for total preservation, 15% for partial preservation, and 7% for extensive thrombosis. Rutherford et al., ~2 in a small group of 10 limbs undergoing HL, found total preservation of 70% and partial preservation of 30%. External valvuloplasty of the saphenofemoral valve, performed with an encircling tie or external banding was attempted by Royle and Somscn. la In an exF.:fience of 35 limbs, they found 82.8% of saphenous vein preservation and competence, 11.4% of occluded veins, and 5.7% of veins with persistent re~ux.
The clinical results of this series, both in the patients undergoing HL-A and PVBV-A were excellent. There were no operative complications, postoperative pain was minimal, and reassumption of full activity occurred very soon after surgery. The cosmetic results were very good, and no recurrences were observed in a short follow-up period of 10 months. With regard to the preservation of the saphenous vein, there was a significant superiority for the PVBV-A group. In these patients, 80% of the saphenous veins were patent and competent, and 7%
JOURNAL OF VASCULAR SURGERY Volume 20, Number 5
were patent with persistent reflux. In the patients undergoing HL-A, the patency of the axial vein was inferior. Full patency was present in 12.5%, partial patency in 62.5%, and occlusion in 25%. These results on patency are worse than those reported by others. 9.n The reason for this difference is unclear. The reflux rate of 12.5% observed in our HL-A group has also been reported in other series. Sarin et al.14 found a 45% of reflux rate in the saphenous vein after HL. This abnormality has been explained by persistent incompetent tributaries that connect the hypogastric or external iliac system to the saphenous system or by the so-called "neo-vascularization.''~s Its prognostic implication is unknown. In conclusion, patients with PVV can be classified into different groups according to the point of reflux. To perform an adequate therapy, the procedure has to be tailored to the patient-specific disease. This implies a careful preoperative clinical and ultrasonographic assessment of the limb. In patients with saphenofemoral reflux, normal saphenous vein, and branch varicosities, preservation of the saphenous vein and elimination of the varicose veins can be achieved by treating the reflux, either by high ligation or valvuloplasty, and local stab avulsion of the abnormal dilated veins. Based on our experience, both of these techniques give excellent short-term clinical resuks. With regard to preservation of the saphenous vein, however, valvuloplasty produces a significantly better outcome. Because the series are small and the follow-up is short, this report should be considered preliminary. For a more definite answer to the question posed by this work, a randomized prospective clinical trial is clearly needed. REFERENCES 1. Goren G, Yellin AE. Primary varicose veins: topographic and hemodynamic correlations. J Cardiovasc Surg 1990;31: 672-7. 2. Lutter KS, Villavicencio JL, Cabellon S Jr, Rich NM. Long-
Schanzer and Skladany 6 8 7
3.
4.
5. 6.
7.
8. 9.
10.
11.
12.
13. 14.
15.
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Submitted March 2, 1994; accepted April 17, 1994.