Eur J VascSurg 6, 512-517 (1992)
The Morphology of Recurrent Varicose Veins Simon G. Darke Department of Vascular Surgery, Royal Bournemouth Hospital, Bournemouth, U.K. Over an 18-month period, of 444 patients referredfor treatment for varicose veins, 95 (21%) had had previous surgery. By means of clinical hand-held Doppler and in selected venographic evaluation these were subdivided into three groups as follows. Type 1:29 of the 95 patients had recurrence through thigh perforators. Type 2:10 patients had developed incompetence through a second saphenous system, in nine of the 10 in the short saphenous having had previous long saphenous surgery. Type 3:46 patients had recurrent sapheno-femoral incompetence and 10 sapheno-popliteal incompetence. A persistent long saphenous trunk in the thigh was present in approximately two-thirds of cases of types I and 3. hz over half of the type 3 patients saphenofemoral recurrence was by reconstitution of the junction by neovascularisation. These morphological studies demonstrate why there may be an increased risk of recurrence if the long saphenous trunk is not excised at the time of primary surgery. Key Words: Varicose veins; Recurrent; Investigation classifi'cation;Morphology.
Introduction Varicose veins affect between 10 and 12% of the adult population. 1-3 Recurrence, defined as patients seeking further treatment after apparently adequate surgery, occurs in at least 20-30% of cases, increasing with time. This rate of occurrence is found both in patients at systematic postoperative follow-up and in those re-referred de novo for new appraisal. 4-11 The rate may even be as high as 70-80% particularly where the original surgery was confined to saphenofemoral ligation Without removal of the long saphenous trunk. 7' 11,12 These results are disappointing for surgeon and patient alike and have important implications for the resultant workload and the demand for what is an ever increasing resource allocation. 13 There would seem therefore to be merit in attempting to define the underlying morphology, in the hope that recurrence can be minimised, and to rationalise a strategy for redo surgery. In this respect it is particularly relevant to pay special attention to recurrence at the saphenofemoral junction because previous authors have found this to be a prominent feature.6' 10
Patients and Methods Over an 18-month period a consecutive series of new 0950-821X/92/050512+06 $08.00/0© 1992Grune & Stratton Ltd.
patients referred for treatment of varicose veins was reviewed. They were seen in a secondary referral practice and were thus thought to represent a relatively pure and unbiased sample of the population in an average community. A specific note was made as to whether any previous surgery had been undertaken and particularly whether this had included ligation of the saphenofemoral or the sapheno-popliteal junction. Recurrence after previous compression sclerotherapy was not considered relevant because this is so common. 4' 7 In addition to a standard clinical examination handheld Doppler was utilised to detect sapheno-femoral incompetence (SFI) and sapheno-popliteal incompetence (SPI). This technique has been described previously.14 In the specific context of recurrent SFI, particular significance was attached to the demonstration of a reflux signal over distal varicosities on patient coughing. This was regarded as a positive sign and of particular value where the anatomy had been distorted by previous surgery. This is discussed further below. All patients with recurrent SFI underwent comprehensive ascending and descending venographylS, 16 and varicography. In evaluating the results, specific note was made of sites of communication between superficial varicosities and the deep system; and any persistence of the main long saphenous trunk. Descending venography gave synchronous
Varicose Vein Morphology
513
information regarding the presence of primary deep incompetence. In keeping with established practice, this was graded from 0 to 4, grade 2 or greater was arbitrarily regarded as of clinical significance. 15 There were three patients with unsuspected evidence of previous deep vein thrombosis w h o were excluded from the study. By these means of clinical Doppler and venographic examination it was possible to classify patients as one of three morphological types. 17,18
Type 1 These patients demonstrated no evidence of recurrent or n e w incompetence of either SFI or SPI. Varicography in these patients reveals that the source is t h r o u g h incompetent thigh and calf perforating veins.
Type 2 This form of recurrence is attributable to evolution or persistence of varicosities derived from the incompetence in a second saphenous system, more frequently in the short saphenous f o l l o w i n g previous surgery in the long saphenous system. The opposite situation can occur.
Fig. 1. Venogram showing type 3A recurrence apparently due to a persistent side branch of the original saphenous trunk. Flush ligation was not secured in the original operation.
Type 3 In these patients the varicosities are found on handheld Doppler to be derived from recurrent incompetence in either the SFI, or less c o m m o n l y the SPI, as defined above. A combination of ascending and descending v e n o g r a p h y and varicography in these patients allows for a more precise definition of the source of the recurrence in those with SFI. In type 3A, recurrence is due to incomplete or inadequate previous ligation and is illustrated in Figure 1. It will be seen that there is reflux d o w n w h a t appears to be an untied tributary of the sapheno-femoral junction linking with varicosities more distal in the limb. Type 3B recurrence is s h o w n in Figure 2. There is reflux d o w n an incompetent femoral vein and out t h r o u g h a midthigh perforating vein. Strictly speaking this is a variation on type 1 recurrence but is indistinguishable clinically and on hand-held Doppler because valve failure in the deep system allows for a positive cough
Fig. 2. Venogram showing type 3B recurrence with reflux down incompetent superficialfemoraland out through mid-thigh perforating veins. Eur J Vasc Surg Vol 6, September 1992
514
S.G. Darke
i m p u l s e to be elicited w i t h i n s o n n a t i o n o v e r the distal varicosity. D e s c e n d i n g v e n o g r a p h y is of particular value in d e m o n s t r a t i n g this m o r p h o l o g y . Occasionally this m a y be m o r e c o m p l e x e m a n a t i n g f r o m a distal tributary of an i n c o m p e t e n t d e e p f e m o r a l vein as s e e n in Figure 3. T y p e 3C recurrence is d u e to reconstitution of the SFI or SPI as d e m o n s t r a t e d in Figures 4 a n d 5 respectively. The bizarre t o r t u o u s multi-channelled trunks are a characteristic feature of this m o r p h o l o g y . The p a t h o g e n e s i s of this p h e n o m e n o n is discussed further below.
Fig. 4. Venogram showing type 3C recurrence due to reconstitution of the sapheno-femoral junction due to neovascularisation, thus establishing reconnection with a residual long saphenous trunk.
Fig. 3. Venogram showing complex recurrence with reflux down an incompetent deep femoral vein joining with a thigh perforator.
Results
A total of 444 patients w e r e seen o v e r the 18-month period of w h o m 349 (79%) h a d h a d no p r e v i o u s surgery. Ninety-five patients (21%) h a d h a d surgery, c o n f i r m e d b y the p r e s e n c e of scars in the a p p r o p r i a t e areas directed t o w a r d s the s a p h e n o - f e m o r a l or s a p h e n o - p o p l i t e a l junction. All patients felt the recurrences w e r e of sufficient i m p o r t to be desirous of further surgery. Table 1 s h o w s the t y p e of recurrence within these patients. F r o m this it will be seen that in 29 cases the recurrence w a s t h r o u g h a thigh perforator. This w a s c o n f i r m e d on varicography. There w e r e no patients Eur J Vasc Surg Vol 6, September 1992
Fig. 5. Venogram showing type 3C recurrence in the sapheno popliteal junction. This can be demonstrated by descending venogram because there is co-existent incompetence of the femoropopliteal veins.
Varicose Vein Morphology
Table 1.
Type of recurrence
n
Total
95
Type1
Thigh perforator
29
Type 2
Emergence of SPI
9
Emergence of SFI
1
Type 3
Recurrent SFI
46
Recurrent SPI
10
with recurrence through calf or ankle perforators exclusively although this was a contributory factor in a proportion of these patients. Twenty-three of these patients had a persistent long saphenous trunk demonstrable. Of those with type 2 recurrence, emergence through the sapheno-popliteal junction was the cause in nine out of 10 patients (having had previous sapheno-femoral ligation). Type 3 recurrence, particularly through SFI was the most common source. These patients were further appraised by comprehensive ascending venography in all but five patients (one bilateral) who were too infirm for this to be justifiable. In seven patients there was bilateral recurrence thus making a total of 47 out of the potential of 53 limbs completely evaluated. Of the group as a whole there was a slight female preponderance (1.5 to 1) and the mean period since previous surgery was 20.4 years (range 3-40 years). In six limbs there was a venous stasis ulcer and in seven limbs the recurrence had already been operated on twice before (re-recurrent). Three patients of these seven had had the groin ligated three times before. The mean age of these patients was 55 years (range 37-76 years). Table 2 summarises the morphology of reflux from groin level. Table 2.
Total no. of limbs evaluated
47
3A
United tributary
4
3B
Incompetent SFV and thigh perforator
9
3C
Reconstitutedjunction
3B & 3C
Combined
28 4
These was associated with primary deep incompetence of Grade II or greater in 30 limbs (64%) on descending venography.15 Sixteen were Grade III or greater. There was an identifiable residual long
515
saphenous trunk in 26 (55%). The proportion of those with a retained trunk was similar in all types. In addition to those described above there were two limbs in which the recurrence was found to be from incompetent pelvic veins. There was no difference between the right and the left leg.
Discussion
What implications are there from these data as to how recurrence might be minimised? The easiest and most obvious of these is the necessity for systematic and routine evaluation of the sapheno-popliteal junction at the time of the preliminary examination. It is of course perfectly legitimate to assume that further varicosities might subsequently develop after previous effective long saphenous surgery. These are not strictly recurrences. None the less it seems likely that in a proportion at least, the wrong system may have been removed at the original operation. Alternatively there may have been synchronous involvement at that stage that was not appreciated. This underscores the value of the hand-held Doppler in the identifying SPI. By these means the proportion of patients with incompetence at this level is found to be 2025%6,14,19 compared with only 10-15% when clinical evaluation alone is employed even by very experienced observers.4's'20 Comprehensive Doppler evaluation at the first examination can minimise this cause for recurrence. The second major issue is the role a retained long saphenous trunk might play in the evolution of recurrence. Two prospective randomised trials show a statistically significant increase in recurrence rates in those patients treated by sapheno-femoral ligation alone compared with synchronous stripping. Jakobsen 7 divided 516 patients into groups. The first of these received radical excision of the varicosities and the appropriate saphenous trunk with flush ligation. The second group of patients underwent saphenous ligation alone and subsequent compression sclerotherapy. At 3 years the recurrence rates in the two groups were 10% compared with 35%. In the second trial by Munn 21 a prospective randomisation of patients with bilateral symmetrical long saphenous incompetence was undertaken. The two sides were allocated either to groin ligation and excisions alone compared with radical surgery including stripping. At a follow-up of 2.5-3.5 years there was a significant difference between the two sides, a recurrence occurring in 34 out of 55 non-stripped limbs compared with Eur J Vasc Surg Vol 6, September1992
516
S.G. Darke
21 out of 55 stripped limbs. In contrast is a more recent study by Hammarsten 22 which showed no difference between stripped and non-stripped limbs at 3 years. However, this was a small trial and there is uncertainty about the extent of sapheno-femoral incompetence in the patients admitted to the trial. Other protagonists of simple ligation and saphenous trunk retention are not randomised and follow-up is relatively short. 23 It seems likely from the evidence to date and because recurrence increases with time, that any disparity between the two modalities of treatment will become more apparent as the years go by. 4-t2 The weight of the data suggests beyond reasonable doubt that, in the presence of SFI, leaving the long saphenous trunk increases significantly the risks of recurrence. Why should this be so? We know that in the majority the long saphenous trunk remains patent. Indeed protagonists of this policy highlight this point on the basis that it represents a viable potential conduit for future bypass surgery. 22 Furthermore in the majority, the valves in the trunk are incompetent and connected to the deep system by incompetent perforators, and thus reflux is not controlled. 24"25 This surely constitutes an anatomical recipe for recurrence of type 1 (incompetent thigh perforator) and type 3B (incompetent femoral and perforator). Finally we come to the reconstituted saphenofemoral junction. This was seen too in the saphenopopliteal junction although it is less easy to be certain of the precise morphology at this site because of the difficulties of imaging by venography unless there is deep incompetence (see venogram). Furthermore there is considerable anatomical variation, 26 and a number of muscular and other branches may become incompetent. 27 The concept of reconstitution of the saphenous vein by neovascularisation is well established. It was described on venography as a common cause of recurrence by Starnes et aI. in 1984, 28 and described on the basis of histological studies by Sheppard in 1978. 6 Recent serial studies in man have shown that after initial saphenous ligation there is an organising thrombus in which a leash of small vessels emerges. Over months these coalesce to a single or a few major trunks and develop muscle and elastin in the walls so resembling mature veins. It may become clinically significant within 6 months of surgery. 17,29,30 It has to be conceded that precise distinction between this form of recurrence (3C) and a branch missed at the time of original surgery (3A) is dependent on a somewhat subjective evaluation of the descending venogram. None the less these data confirm the view of others that it is the most common cause of Cur J Vasc Surg Vol 6, September 1992
recurrence. 2s-31 A retained saphenous trunk adjacent to this process would seem inevitably to exacerbate clinically significant recurrences. Finally, the relatively high proportion of patients with recurrence found to have primary deep incompetence is interesting. It is difficult to assign significance to this because we do not know whether this differs from patients who do not develop recurrence. It is probably a function of the widespread inherent valvular dysfunction. Whether this factor per se plays a role in the pathogenesis of superficial recurrences is difficult to say. Deep incompetence was not seen in all patients.
References 1 COON WW, WILLIS PW (III), KELLERJB. Venous thrombo-embolism and other venous disease in the Tecumseh Community Health Study. Circulation 1973; 48: 839-846. 2 WIDMERLK, KAUEMANNL, HARTMANNG, et al. Organisation der Basler Studie uber Arterier, Venen, und Herz Knankheiker. Schweiz Med Uschr 1967; 97: 4-99. 3 WIDMERLK, MALLT, MARTINH. Epidemiology and sociomedical importance of peripheral venous disease. In: HOBBSJT, ed. The Treatment of Venous Disorders. Lancaster: MTP Press, 1977; 3-12. 4 HOBBS JT. Surgery and sclerotherapy in the treatment of varicose veins. Arch Surg 1974; 109: 793-796. 5 DOREN FSA, WHITE M. A clinical trial to discover if primary treatment of varicose veins should be by F Egan's method or by an operation. Br J Surg 1975; 62: 72-6. 6 SHEPPARD M. A procedure for the prevention of recurrent sapheno-femoral incompetence. Aust N Z J Surg 1978; 48: 322326. 7 JAKOBSEN BH. The value of different forms of treatment for varicose veins. Br J Surg 1979; 66: 182-184. 8 LOFGRENEP. Treatment of long saphenous varicosities and their recurrence. A long term follow up. In: BERGANJJ, YAO JST, eds. Surgery of the Veins. London: Grune & Stratton, 1985; 285-300. 9 ROYLEJP. Recurrent varicose veins. World Surg 1986; 10: 944953. 10 BERRIDGEDC, MAKINGS. Day case surgery: a viable alternative for surgical treatment of varicose veins. Phlebology 1987; 2: 103108. 11 EINARSSONE. Compression sclerotherapy. In: EKLOFB, GIORES JE, THYLESlUSO, BERGQVISTD, eds. Controversies in the Management of Venous Disorders. London: Butterworth, 1989; 97-111. 12 LOFGREN KA. Management of varicose veins: Mayo Clinic experience. In: BERGANJJ, YAOJST, eds. Venous Problems. Chicago: Year Book Medical Publishers, 1978; 71-84. 13 CAMPBELLWB. Varicose veins. Br Med J 1990; 300: 763-764. 14 MITCHELL DC, DARKE SG. The assessment of primary varicose veins by Doppler ultrasound--the role of sapheno popliteal incompetence and the short saphenous system in calf varicosities. Eur J Vasc Surg 1987; 1: 113-115. 15 DARKESG, ANDRESSMR. The value of venography in the management of chronic venous disorders of the lower limb. In: GREENHALGH R/X/I, ed. Diagnostic Techniques and Assessment Procedures in Vascular Surgery. London: Grune & Stratton, 1985; 421-446. 16 CORBETTCR, MCIRVINEAJ, ASTONNO, JAMIESONCW, LEA THOMAS ML. The use of varicography to identify the sources of incompetence in recurrent varicose veins. Ann Roy Coll Surg 1984; 66: 412-415.
Varicose Vein Morphology
17 DARKE SG. Recurrent varicose veins. In: BERGANJJ, YAO JST, eds. Venous Disorders. Philadelphia: W. B. Saunders, 1991; 217232. 18 DARKE SG. Should the long saphenous vein be stripped? In: BARROSD'SA AAB, BELLPRF, DARKE SG, HARRIS PL, eds. Vascular Surgery. Current Questions. Oxford: Butterworth Heinemann, 1991; 207-218. 19 HOARE MC, ROYLE JP. Doppler ultrasound detection of sapheno-femoral and sapheno popliteal incompetence and operative venography to ensure precise sapheno popliteal ligation. Aust N Z J Surg 1984; 54: 49-52. 20 RIVLIN S. Primary varicose veins. Surg Rev 1981; 2: 331-334. 21 MUNN SR, MORTONJB, MACBETH WAAG, McLEISH AR. TO strip or not to strip the long saphenous vein? A varicose veins trial. Br J Surg 1981; 68: 426-428. 22 HAMMERSTENJ, PEDERSENP, CLAES-GORAN C, CAMPANELLOM. Long saphenous vein saving surgery for varicose veins. A long term follow up. Eur J Vasc Surg 1990; 4: 361-364. 23 LARGEJ. Surgical treatment of saphenous varices, with preservation of the main great saphenous trunk. J Vasc Surg 1985; 2: 886-891. 24 SUTTON R, DARKE SG. Stripping the long saphenous vein: per-
25 26 27 28 29 30 31
517
operative retrograde saphenography in patients with and without ulceration. Br J Surg 1986; 73: 305-307. McMuLLIN GM, COLERIDGE SMITH PD, SCURR JH. Objective assessment of high ligation without stripping the long saphenous vein. Br J Surg 1991; 78: 1139-1142. WILLIAMSAF. The formation of the popliteal vein. Surg Gynaecol Obstet 1953; 97: 769-772. DODD H. The varicose tributaries of the popliteal vein. BrJ Surg 1965; 52: 350-354. STARNESHF, VALLANCER, HAMILTON DNH. Recurrent varicose veins: a radiological approach to investigation. Clin Radiol 1984; 35: 95-99. GLASSGM. Neovascularisation in recurrent varices of the great saphenous vein in the groin, phlebography. Angiology 1988; 39: 577-582. GLASS GM. Neovascularisation in recurrence of the varicose great saphenous vein following transection. Phlebology 1987; 2: 81-91. GLASS GM. Neovascularisation in restoration of continuity of the not femoral vein following surgical interruption. Phlebology 1987; 2: 1-6.
Accepted 12 April 1992
Eur J Vasc Surg Vol 6, September 1992
The Morphology of Recurrent Varicose Veins Simon G. Darke Department of Vascular Surgery, Royal Bournemouth Hospital, Bournemouth, U.K. Over an 18-month period, of 444 patients referredfor treatment for varicose veins, 95 (21%) had had previous surgery. By means of clinical hand-held Doppler and in selected venographic evaluation these were subdivided into three groups as follows. Type 1:29 of the 95 patients had recurrence through thigh perforators. Type 2:10 patients had developed incompetence through a second saphenous system, in nine of the 10 in the short saphenous having had previous long saphenous surgery. Type 3:46 patients had recurrent sapheno-femoral incompetence and 10 sapheno-popliteal incompetence. A persistent long saphenous trunk in the thigh was present in approximately two-thirds of cases of types I and 3. hz over half of the type 3 patients saphenofemoral recurrence was by reconstitution of the junction by neovascularisation. These morphological studies demonstrate why there may be an increased risk of recurrence if the long saphenous trunk is not excised at the time of primary surgery. Key Words: Varicose veins; Recurrent; Investigation classifi'cation;Morphology.
Introduction Varicose veins affect between 10 and 12% of the adult population. 1-3 Recurrence, defined as patients seeking further treatment after apparently adequate surgery, occurs in at least 20-30% of cases, increasing with time. This rate of occurrence is found both in patients at systematic postoperative follow-up and in those re-referred de novo for new appraisal. 4-11 The rate may even be as high as 70-80% particularly where the original surgery was confined to saphenofemoral ligation Without removal of the long saphenous trunk. 7' 11,12 These results are disappointing for surgeon and patient alike and have important implications for the resultant workload and the demand for what is an ever increasing resource allocation. 13 There would seem therefore to be merit in attempting to define the underlying morphology, in the hope that recurrence can be minimised, and to rationalise a strategy for redo surgery. In this respect it is particularly relevant to pay special attention to recurrence at the saphenofemoral junction because previous authors have found this to be a prominent feature.6' 10
Patients and Methods Over an 18-month period a consecutive series of new 0950-821X/92/050512+06 $08.00/0© 1992Grune & Stratton Ltd.
patients referred for treatment of varicose veins was reviewed. They were seen in a secondary referral practice and were thus thought to represent a relatively pure and unbiased sample of the population in an average community. A specific note was made as to whether any previous surgery had been undertaken and particularly whether this had included ligation of the saphenofemoral or the sapheno-popliteal junction. Recurrence after previous compression sclerotherapy was not considered relevant because this is so common. 4' 7 In addition to a standard clinical examination handheld Doppler was utilised to detect sapheno-femoral incompetence (SFI) and sapheno-popliteal incompetence (SPI). This technique has been described previously.14 In the specific context of recurrent SFI, particular significance was attached to the demonstration of a reflux signal over distal varicosities on patient coughing. This was regarded as a positive sign and of particular value where the anatomy had been distorted by previous surgery. This is discussed further below. All patients with recurrent SFI underwent comprehensive ascending and descending venographylS, 16 and varicography. In evaluating the results, specific note was made of sites of communication between superficial varicosities and the deep system; and any persistence of the main long saphenous trunk. Descending venography gave synchronous
Varicose Vein Morphology
513
information regarding the presence of primary deep incompetence. In keeping with established practice, this was graded from 0 to 4, grade 2 or greater was arbitrarily regarded as of clinical significance. 15 There were three patients with unsuspected evidence of previous deep vein thrombosis w h o were excluded from the study. By these means of clinical Doppler and venographic examination it was possible to classify patients as one of three morphological types. 17,18
Type 1 These patients demonstrated no evidence of recurrent or n e w incompetence of either SFI or SPI. Varicography in these patients reveals that the source is t h r o u g h incompetent thigh and calf perforating veins.
Type 2 This form of recurrence is attributable to evolution or persistence of varicosities derived from the incompetence in a second saphenous system, more frequently in the short saphenous f o l l o w i n g previous surgery in the long saphenous system. The opposite situation can occur.
Fig. 1. Venogram showing type 3A recurrence apparently due to a persistent side branch of the original saphenous trunk. Flush ligation was not secured in the original operation.
Type 3 In these patients the varicosities are found on handheld Doppler to be derived from recurrent incompetence in either the SFI, or less c o m m o n l y the SPI, as defined above. A combination of ascending and descending v e n o g r a p h y and varicography in these patients allows for a more precise definition of the source of the recurrence in those with SFI. In type 3A, recurrence is due to incomplete or inadequate previous ligation and is illustrated in Figure 1. It will be seen that there is reflux d o w n w h a t appears to be an untied tributary of the sapheno-femoral junction linking with varicosities more distal in the limb. Type 3B recurrence is s h o w n in Figure 2. There is reflux d o w n an incompetent femoral vein and out t h r o u g h a midthigh perforating vein. Strictly speaking this is a variation on type 1 recurrence but is indistinguishable clinically and on hand-held Doppler because valve failure in the deep system allows for a positive cough
Fig. 2. Venogram showing type 3B recurrence with reflux down incompetent superficialfemoraland out through mid-thigh perforating veins. Eur J Vasc Surg Vol 6, September 1992
514
S.G. Darke
i m p u l s e to be elicited w i t h i n s o n n a t i o n o v e r the distal varicosity. D e s c e n d i n g v e n o g r a p h y is of particular value in d e m o n s t r a t i n g this m o r p h o l o g y . Occasionally this m a y be m o r e c o m p l e x e m a n a t i n g f r o m a distal tributary of an i n c o m p e t e n t d e e p f e m o r a l vein as s e e n in Figure 3. T y p e 3C recurrence is d u e to reconstitution of the SFI or SPI as d e m o n s t r a t e d in Figures 4 a n d 5 respectively. The bizarre t o r t u o u s multi-channelled trunks are a characteristic feature of this m o r p h o l o g y . The p a t h o g e n e s i s of this p h e n o m e n o n is discussed further below.
Fig. 4. Venogram showing type 3C recurrence due to reconstitution of the sapheno-femoral junction due to neovascularisation, thus establishing reconnection with a residual long saphenous trunk.
Fig. 3. Venogram showing complex recurrence with reflux down an incompetent deep femoral vein joining with a thigh perforator.
Results
A total of 444 patients w e r e seen o v e r the 18-month period of w h o m 349 (79%) h a d h a d no p r e v i o u s surgery. Ninety-five patients (21%) h a d h a d surgery, c o n f i r m e d b y the p r e s e n c e of scars in the a p p r o p r i a t e areas directed t o w a r d s the s a p h e n o - f e m o r a l or s a p h e n o - p o p l i t e a l junction. All patients felt the recurrences w e r e of sufficient i m p o r t to be desirous of further surgery. Table 1 s h o w s the t y p e of recurrence within these patients. F r o m this it will be seen that in 29 cases the recurrence w a s t h r o u g h a thigh perforator. This w a s c o n f i r m e d on varicography. There w e r e no patients Eur J Vasc Surg Vol 6, September 1992
Fig. 5. Venogram showing type 3C recurrence in the sapheno popliteal junction. This can be demonstrated by descending venogram because there is co-existent incompetence of the femoropopliteal veins.
Varicose Vein Morphology
Table 1.
Type of recurrence
n
Total
95
Type1
Thigh perforator
29
Type 2
Emergence of SPI
9
Emergence of SFI
1
Type 3
Recurrent SFI
46
Recurrent SPI
10
with recurrence through calf or ankle perforators exclusively although this was a contributory factor in a proportion of these patients. Twenty-three of these patients had a persistent long saphenous trunk demonstrable. Of those with type 2 recurrence, emergence through the sapheno-popliteal junction was the cause in nine out of 10 patients (having had previous sapheno-femoral ligation). Type 3 recurrence, particularly through SFI was the most common source. These patients were further appraised by comprehensive ascending venography in all but five patients (one bilateral) who were too infirm for this to be justifiable. In seven patients there was bilateral recurrence thus making a total of 47 out of the potential of 53 limbs completely evaluated. Of the group as a whole there was a slight female preponderance (1.5 to 1) and the mean period since previous surgery was 20.4 years (range 3-40 years). In six limbs there was a venous stasis ulcer and in seven limbs the recurrence had already been operated on twice before (re-recurrent). Three patients of these seven had had the groin ligated three times before. The mean age of these patients was 55 years (range 37-76 years). Table 2 summarises the morphology of reflux from groin level. Table 2.
Total no. of limbs evaluated
47
3A
United tributary
4
3B
Incompetent SFV and thigh perforator
9
3C
Reconstitutedjunction
3B & 3C
Combined
28 4
These was associated with primary deep incompetence of Grade II or greater in 30 limbs (64%) on descending venography.15 Sixteen were Grade III or greater. There was an identifiable residual long
515
saphenous trunk in 26 (55%). The proportion of those with a retained trunk was similar in all types. In addition to those described above there were two limbs in which the recurrence was found to be from incompetent pelvic veins. There was no difference between the right and the left leg.
Discussion
What implications are there from these data as to how recurrence might be minimised? The easiest and most obvious of these is the necessity for systematic and routine evaluation of the sapheno-popliteal junction at the time of the preliminary examination. It is of course perfectly legitimate to assume that further varicosities might subsequently develop after previous effective long saphenous surgery. These are not strictly recurrences. None the less it seems likely that in a proportion at least, the wrong system may have been removed at the original operation. Alternatively there may have been synchronous involvement at that stage that was not appreciated. This underscores the value of the hand-held Doppler in the identifying SPI. By these means the proportion of patients with incompetence at this level is found to be 2025%6,14,19 compared with only 10-15% when clinical evaluation alone is employed even by very experienced observers.4's'20 Comprehensive Doppler evaluation at the first examination can minimise this cause for recurrence. The second major issue is the role a retained long saphenous trunk might play in the evolution of recurrence. Two prospective randomised trials show a statistically significant increase in recurrence rates in those patients treated by sapheno-femoral ligation alone compared with synchronous stripping. Jakobsen 7 divided 516 patients into groups. The first of these received radical excision of the varicosities and the appropriate saphenous trunk with flush ligation. The second group of patients underwent saphenous ligation alone and subsequent compression sclerotherapy. At 3 years the recurrence rates in the two groups were 10% compared with 35%. In the second trial by Munn 21 a prospective randomisation of patients with bilateral symmetrical long saphenous incompetence was undertaken. The two sides were allocated either to groin ligation and excisions alone compared with radical surgery including stripping. At a follow-up of 2.5-3.5 years there was a significant difference between the two sides, a recurrence occurring in 34 out of 55 non-stripped limbs compared with Eur J Vasc Surg Vol 6, September1992
516
S.G. Darke
21 out of 55 stripped limbs. In contrast is a more recent study by Hammarsten 22 which showed no difference between stripped and non-stripped limbs at 3 years. However, this was a small trial and there is uncertainty about the extent of sapheno-femoral incompetence in the patients admitted to the trial. Other protagonists of simple ligation and saphenous trunk retention are not randomised and follow-up is relatively short. 23 It seems likely from the evidence to date and because recurrence increases with time, that any disparity between the two modalities of treatment will become more apparent as the years go by. 4-t2 The weight of the data suggests beyond reasonable doubt that, in the presence of SFI, leaving the long saphenous trunk increases significantly the risks of recurrence. Why should this be so? We know that in the majority the long saphenous trunk remains patent. Indeed protagonists of this policy highlight this point on the basis that it represents a viable potential conduit for future bypass surgery. 22 Furthermore in the majority, the valves in the trunk are incompetent and connected to the deep system by incompetent perforators, and thus reflux is not controlled. 24"25 This surely constitutes an anatomical recipe for recurrence of type 1 (incompetent thigh perforator) and type 3B (incompetent femoral and perforator). Finally we come to the reconstituted saphenofemoral junction. This was seen too in the saphenopopliteal junction although it is less easy to be certain of the precise morphology at this site because of the difficulties of imaging by venography unless there is deep incompetence (see venogram). Furthermore there is considerable anatomical variation, 26 and a number of muscular and other branches may become incompetent. 27 The concept of reconstitution of the saphenous vein by neovascularisation is well established. It was described on venography as a common cause of recurrence by Starnes et aI. in 1984, 28 and described on the basis of histological studies by Sheppard in 1978. 6 Recent serial studies in man have shown that after initial saphenous ligation there is an organising thrombus in which a leash of small vessels emerges. Over months these coalesce to a single or a few major trunks and develop muscle and elastin in the walls so resembling mature veins. It may become clinically significant within 6 months of surgery. 17,29,30 It has to be conceded that precise distinction between this form of recurrence (3C) and a branch missed at the time of original surgery (3A) is dependent on a somewhat subjective evaluation of the descending venogram. None the less these data confirm the view of others that it is the most common cause of Cur J Vasc Surg Vol 6, September 1992
recurrence. 2s-31 A retained saphenous trunk adjacent to this process would seem inevitably to exacerbate clinically significant recurrences. Finally, the relatively high proportion of patients with recurrence found to have primary deep incompetence is interesting. It is difficult to assign significance to this because we do not know whether this differs from patients who do not develop recurrence. It is probably a function of the widespread inherent valvular dysfunction. Whether this factor per se plays a role in the pathogenesis of superficial recurrences is difficult to say. Deep incompetence was not seen in all patients.
References 1 COON WW, WILLIS PW (III), KELLERJB. Venous thrombo-embolism and other venous disease in the Tecumseh Community Health Study. Circulation 1973; 48: 839-846. 2 WIDMERLK, KAUEMANNL, HARTMANNG, et al. Organisation der Basler Studie uber Arterier, Venen, und Herz Knankheiker. Schweiz Med Uschr 1967; 97: 4-99. 3 WIDMERLK, MALLT, MARTINH. Epidemiology and sociomedical importance of peripheral venous disease. In: HOBBSJT, ed. The Treatment of Venous Disorders. Lancaster: MTP Press, 1977; 3-12. 4 HOBBS JT. Surgery and sclerotherapy in the treatment of varicose veins. Arch Surg 1974; 109: 793-796. 5 DOREN FSA, WHITE M. A clinical trial to discover if primary treatment of varicose veins should be by F Egan's method or by an operation. Br J Surg 1975; 62: 72-6. 6 SHEPPARD M. A procedure for the prevention of recurrent sapheno-femoral incompetence. Aust N Z J Surg 1978; 48: 322326. 7 JAKOBSEN BH. The value of different forms of treatment for varicose veins. Br J Surg 1979; 66: 182-184. 8 LOFGRENEP. Treatment of long saphenous varicosities and their recurrence. A long term follow up. In: BERGANJJ, YAO JST, eds. Surgery of the Veins. London: Grune & Stratton, 1985; 285-300. 9 ROYLEJP. Recurrent varicose veins. World Surg 1986; 10: 944953. 10 BERRIDGEDC, MAKINGS. Day case surgery: a viable alternative for surgical treatment of varicose veins. Phlebology 1987; 2: 103108. 11 EINARSSONE. Compression sclerotherapy. In: EKLOFB, GIORES JE, THYLESlUSO, BERGQVISTD, eds. Controversies in the Management of Venous Disorders. London: Butterworth, 1989; 97-111. 12 LOFGREN KA. Management of varicose veins: Mayo Clinic experience. In: BERGANJJ, YAOJST, eds. Venous Problems. Chicago: Year Book Medical Publishers, 1978; 71-84. 13 CAMPBELLWB. Varicose veins. Br Med J 1990; 300: 763-764. 14 MITCHELL DC, DARKE SG. The assessment of primary varicose veins by Doppler ultrasound--the role of sapheno popliteal incompetence and the short saphenous system in calf varicosities. Eur J Vasc Surg 1987; 1: 113-115. 15 DARKESG, ANDRESSMR. The value of venography in the management of chronic venous disorders of the lower limb. In: GREENHALGH R/X/I, ed. Diagnostic Techniques and Assessment Procedures in Vascular Surgery. London: Grune & Stratton, 1985; 421-446. 16 CORBETTCR, MCIRVINEAJ, ASTONNO, JAMIESONCW, LEA THOMAS ML. The use of varicography to identify the sources of incompetence in recurrent varicose veins. Ann Roy Coll Surg 1984; 66: 412-415.
Varicose Vein Morphology
17 DARKE SG. Recurrent varicose veins. In: BERGANJJ, YAO JST, eds. Venous Disorders. Philadelphia: W. B. Saunders, 1991; 217232. 18 DARKE SG. Should the long saphenous vein be stripped? In: BARROSD'SA AAB, BELLPRF, DARKE SG, HARRIS PL, eds. Vascular Surgery. Current Questions. Oxford: Butterworth Heinemann, 1991; 207-218. 19 HOARE MC, ROYLE JP. Doppler ultrasound detection of sapheno-femoral and sapheno popliteal incompetence and operative venography to ensure precise sapheno popliteal ligation. Aust N Z J Surg 1984; 54: 49-52. 20 RIVLIN S. Primary varicose veins. Surg Rev 1981; 2: 331-334. 21 MUNN SR, MORTONJB, MACBETH WAAG, McLEISH AR. TO strip or not to strip the long saphenous vein? A varicose veins trial. Br J Surg 1981; 68: 426-428. 22 HAMMERSTENJ, PEDERSENP, CLAES-GORAN C, CAMPANELLOM. Long saphenous vein saving surgery for varicose veins. A long term follow up. Eur J Vasc Surg 1990; 4: 361-364. 23 LARGEJ. Surgical treatment of saphenous varices, with preservation of the main great saphenous trunk. J Vasc Surg 1985; 2: 886-891. 24 SUTTON R, DARKE SG. Stripping the long saphenous vein: per-
25 26 27 28 29 30 31
517
operative retrograde saphenography in patients with and without ulceration. Br J Surg 1986; 73: 305-307. McMuLLIN GM, COLERIDGE SMITH PD, SCURR JH. Objective assessment of high ligation without stripping the long saphenous vein. Br J Surg 1991; 78: 1139-1142. WILLIAMSAF. The formation of the popliteal vein. Surg Gynaecol Obstet 1953; 97: 769-772. DODD H. The varicose tributaries of the popliteal vein. BrJ Surg 1965; 52: 350-354. STARNESHF, VALLANCER, HAMILTON DNH. Recurrent varicose veins: a radiological approach to investigation. Clin Radiol 1984; 35: 95-99. GLASSGM. Neovascularisation in recurrent varices of the great saphenous vein in the groin, phlebography. Angiology 1988; 39: 577-582. GLASS GM. Neovascularisation in recurrence of the varicose great saphenous vein following transection. Phlebology 1987; 2: 81-91. GLASS GM. Neovascularisation in restoration of continuity of the not femoral vein following surgical interruption. Phlebology 1987; 2: 1-6.
Accepted 12 April 1992
Eur J Vasc Surg Vol 6, September 1992
