Definition
Vein ligation and stripping is a surgical procedure for the treatment of varicose veins sometimes referred to as phlebectomy. Ligation is the surgical ligation of the saphenous vein in the leg, while stripping is the removal of this vein through an incision in the groin area or behind the knee. If some of the valves of the saphenous vein are functioning properly, the weak part of the vein can be closed by ligation. If the entire vein is weak, it can be stripped by making an incision underneath the vein. The ligation and removal of the saphenous vein is done to reduce the pressure of the blood returning to some of the smaller geniculate veins within it.
Phlebectomy is one of the oldest methods of treating varicose veins. It was first described by the Roman medical historian Aurelius refuting Criso (45 AD). The first description of a phlebectomy hook was published in 1545 in a textbook of surgery. Modern (outpatient) phlebectomy was initiated in 1956 by a Swiss dermatologist named Robert Muller. As of 2003, surgical ligation and stripping of the saphenous vein has been used less frequently because of the introduction of some minimally invasive treatment methods.
Objectives
The purpose of venous ligation and stripping is to reduce the number and volume of varicose veins that cannot be treated or closed by other measures. Reasons for undergoing vascular surgery generally include
To improve the appearance of the leg. Many people agree that large varicose veins seriously affect the appearance of their legs.
To reduce the pain, twitching and fatigue that may be associated with varicose veins.
Addressing skin conditions that may be associated with varicose veins, including conditions such as chronic eczema, skin ulcers, external bleeding, and abnormal pigmentation.
Prevent diseases such as blood clots and pulmonary embolism.
The World Health Organization (WHO) estimates that approximately 25% of adults worldwide have some type of venous disease of the lower extremities. The prevalence of varicose veins is higher in developed countries. The American College of Phlebology (ACP), composed of dermatologists, plastic surgeons, obstetricians and gynecologists, surgeons and general surgeons with specialized training in the treatment of venous disease, claims that more than 80 million people in the United States suffer from varicose veins. In the past, the ratio of men to women was close to 1:4, but over the past 20 years, the ratio of men to women has been changing as the number of obese adult men has increased.
Middle-aged and older adults are more likely to develop varicose veins than children or young adults. Although varicose veins are familial, they do not appear to be associated with specific racial or ethnic groups.
Description
Causes of varicose veins
A brief description of the human venous system may help to understand why surgery is needed to treat varicose veins. In contrast to the arterial system, which carries already oxygenated blood from the heart to all parts of the body, the venous system carries blood from the circulatory system back to the heart and pumps it through the heart to the lungs for oxygenation. Veins are more likely to dilate or expand than arteries if the volume or pressure of blood increases, because they have only one layer of walls, while arteries have three layers.
There are three main types of veins: superficial veins, deep veins, and traffic veins. All varicose veins are superficial, and they lie between the skin and a layer of fibrous connective tissue called the deep fascia, which wraps around the muscles and internal organs and acts as a support. The deeper veins are located within the deep fascia. This distinction helps explain why the removal or occlusion of the superficial veins does not impair the deep circulation of the leg. The communicating vein is the vein that connects the superficial veins to the deep veins.
The vein contains a one-way open valve that, when normal, pushes blood back to the heart against the force of gravity. The superficial veins normally have blood pressure and ohadi, but if the blood pressure rises and remains at a high level, the valves fail to function and blood regurgitates and pools in the lower veins, which become enlarged, or dilated. The inability of the veins to function properly is called insufficiency. When the veins become dilated, they become more visible under the skin. Small veins, or capillaries, often take on a red spider or dendritic appearance under the skin and are medically known as capillary dilation, but are more commonly called spider-like or linear dilation. The larger veins form a flat, blue-green network of veins behind the knee called reticular varicose veins. True varicose veins are formed when the largest superficial veins in the lower extremities twist and tortuous due to increased venous pressure over time.
The most important veins in the lower leg are the two saphenous veins – the greater saphenous vein, which travels from the foot to the groin area, and the lesser saphenous vein, which travels through the ankle to the knee joint. Due to incompetence of the superior saphenous vein valves, more blood reflux in the saphenous vein leads to increased pressure on the smaller vein valves and this leads to the formation of varicose veins. The practice of ligation and stripping of the saphenous vein is based on this hypothesis.
Some people are at a higher risk of developing varicose veins. These risk factors include
Gender. Women are more likely to develop varicose veins than men at any age. Women’s sex hormones can cause veins to dilate, which can lead to a greater susceptibility to developing varicose veins. The discomfort associated with varicose veins is more pronounced in many women during their menstrual period.
Genetic factors. Some people have abnormally weak vein walls or valves and can develop varicose veins even if the pressure in the superficial veins is not increased. This condition often runs in families.
Pregnancy. During pregnancy, the total circulating blood volume increases and so does the blood pressure in the venous system. In addition, hormonal changes during pregnancy can lead to softening of the vein walls and vein valves.
Use of birth control pills.
Obesity. Being overweight can increase the pressure in the veins.
Occupational factors. Occupations that involve long hours of standing or sitting without being able to walk are more likely to develop varicose veins.
Phlebectomy
As of early 2003, phlebectomy was the most common surgical procedure for the treatment of medium-sized varicose veins. It is also known as vein stripping or punctate stripping. After the leg is anesthetized, the surgeon makes a number of small longitudinal 1-3 mm incisions next to the involved vein, which do not require stitches or bandages. Starting with the more severely involved area, the surgeon inserts a phlebectomy hook through each small incision. These vein segments are hooked out of the incision and then removed through the incision with the help of a mosquito vascular clamp. This technique requires special care when removing varicose veins in the ankle, foot, or back of the knee.
Once all the veins have been removed, the leg is cleaned with hydrogen peroxide, covered with a cotton dressing, and wrapped with an adhesive bandage. The bandage is removed 3 to 7 days after surgery, but the elastic stocking must continue to be worn for 2 to 4 weeks to minimize subcutaneous bruising and swelling. The patient is encouraged to walk for approximately 10-15 minutes before leaving. This moderate amount of activity helps reduce the risk of deep vein thrombosis.
Fluoroscopic subphlebectomy
Fluoroscopic phlebectomy is a new technique that avoids some of the disadvantages of simple vein stripping, such as longer operative times, postoperative scar formation, and a relatively high risk of postoperative incisional infection. Transilluminated phlebectomy requires an illuminator and a mechanical resector. After the patient is lightly anesthetized, the surgeon makes only two small incisions: one to place the illumination device and one to place the resector. After the lighting device is placed through the first incision, the surgeon uses a technique called swelling anesthesia to increase the tissue gap around the vein, making it easier to remove. Swelling anesthesia was originally used for fat aspiration. It involves injecting a large amount of dilute anesthetic into the tissue surrounding the vein until the surrounding tissue becomes firm and swollen.
When the swelling anesthesia has been completed, the surgeon makes a second incision to insert the resector and aspirates the small vein segments through a built-in blade. Once all the varicose veins have been treated, the surgeon closes the incision with sutures or a band-aid. Gauze is used to cover the postoperative incision followed by a sterile dressing and pressure dressing.
Diagnosis/preparation
Diagnosis
Vein ligation and stripping and flow phlebectomy are elective procedures that are not performed on an emergency basis. Diagnosis begins with the patient’s appearance of the leg, complaints of pain as well as spasm, and the physician’s observations. It is important to highlight that the number and degree of varicose veins does not correlate with the degree of pain; some patients have very pronounced discomfort with very mild varicose veins, while others have prompt swelling and tortuous varicose veins without any symptoms. If the patient complains of pain, burning, or other physical symptoms, the physician needs to rule out other possible causes, such as nerve root irritation, osteoarthritis, diabetic neuropathy, or problems with the arterial blood supply. Elevation of the lower extremities to relieve pain is the most important diagnostic sign of varicose veins.
After obtaining the patient’s past and family history of venous disease, the doctor marks the site of the varicose vein starting from the waist down and palpates for signs of other venous disease. Palpation helps the physician to identify normal and abnormal veins, and in addition, palpation can reveal varicose veins that are not visible on the skin surface. Ideally, the doctor will have the patient stand on a small table to perform the examination. During the examination, the physician may have the patient slowly rotate and look for signs of scarring or other trauma, localized skin discoloration and bulging, or other signs of chronic venous insufficiency. During palpation of the lower extremity, the physician will mark areas of abnormal skin temperature, pain, cysts, or edema (swelling of soft tissue due to fluid retention). Next, the doctor will palpate the larger veins under the skin. By gently tapping or hammering these areas of the skin, the doctor can feel the fluctuating sensation of the veins and determine if further testing for venous insufficiency is needed.
The next stage of diagnostic testing is to assess the function of the patient’s saphenous vein valves. While the patient is lying flat with the affected limb elevated, the physician ties a compression band around the patient’s upper thigh and then asks the patient to stand on the floor. If the valves are functioning properly, the superficial veins below will not fill rapidly as long as the compression band is not released. This test is called the Trendelenburg’s test. Of course, Doppler ultrasound has largely replaced this test. Ultrasound allows for the localization of varicose veins and can also provide information about the venous valves. Most insurance companies now require Doppler ultrasound prior to authorized surgical treatment. The physician’s examination determines whether ligation and stripping or endovenous ablation of the saphenous vein is required prior to treatment of minor varicose veins.
Some diseases and conditions are contraindications to vascular surgery, including the following:
Cellulitis and other infectious skin diseases.
Severe and cardiogenic or nephrogenic edema. These conditions should not be performed until they are under control.
Uncontrolled diabetes mellitus.
Diseases affecting the immune system, including HIV infection.
Severe cardiopulmonary disease.
Preparation
Discontinuation of aspirin or aspirin-related medications is required 1 week prior to vascular surgery. Fasting from food and water starting at 12 midnight on the day of surgery. Any moisturizers, creams, tanning lotions, or sunscreens are prohibited on the lower extremities where the procedure is to be performed.
Patients are scheduled to arrive at the Surgical Center 1 ½ hours prior to surgery. All clothing must be removed and changed into hospital gowns. The patient is asked to walk back and forth in the room or hallway for approximately 20 minutes to allow the veins to protrude. The surgeon uses waterproof ink to mark the travel of the veins in the lower extremities, and ultrasound can confirm the location and condition of the veins. The patient is then brought into the operating room for the procedure.
Although patients are encouraged to walk around for a few minutes after surgery, they still need to be transported home by family or friends.
Postoperative management
Saphenous vein ligation and stripping usually requires one night of observation in the hospital, followed by two to eight weeks of recovery at home. Post-operative management of varicose veins includes wearing medical elastic stockings with a compression range of 20-30 mmHg or 30-40 mmHg for 2-6 weeks. Wearing elastic stockings will reduce post-operative swelling, skin discoloration and pain. Fashionable shaping stockings should not be used, as they do not provide sufficient compression.
After returning home from surgery, it is necessary to continue to keep the elastic supplement of the intraoperative dressing and to take some mildly effective analgesics to treat postoperative pain and discomfort.
Patients are advised to observe for redness, swelling, heat, pain, and other signs of infection.
Encourage the patient to walk, bike, or participate in other low-impact exercises (e.g., yoga, tai chi) to prevent deep vein thrombosis. Lower extremities should be elevated above the level of the heart for at least 15 minutes twice a day while lying down. You should also use a footrest so that you can elevate your legs in a seated position.
Risks
Venous ligation and stripping has the same risks as other surgical procedures performed under general anesthesia, such as bleeding, incisional infection, and adverse reactions to anesthesia. Patients who have a combination of leg ulcers or fungal infections of the feet are at increased risk of varicose vein incision infection.
Risks specifically associated with vascular surgery, include
Deep vein thrombosis.
Subcutaneous petechiae. Subcutaneous ecchymosis is the most common complication after phlebectomy and usually resolves spontaneously after a few days or weeks.
Scar formation. Phlebectomy is more likely to result in scarring than sclerotherapy.
Saphenous nerve injury. This complication causes numbness, tingling, or burning sensation around the ankle and usually resolves spontaneously within 6 to 12 months, even without further treatment.
Seroma. A seroma is an accumulation of uninfected serum or lymphatic fluid in the tissues. It usually resolves spontaneously, or can be surgically drained if necessary.
Injury to the arteries in the thigh and groin area. This complication is very rare but when it occurs the consequences are very serious. An example is the need for amputation.
Swelling of the lower extremities. This is due to intraoperative damage to the lymphatic system. It usually lasts for about 2 to 3 weeks and can be treated by wearing elastic stockings.
Smaller recurrence of varicose veins.
Normal outcome
Usually, vein ligation and stripping or flow phlebectomy can reduce the size and number of varicose veins in the lower extremities, and about 95% of patients have a significant reduction in postoperative pain.
Morbidity and mortality
The mortality rate for vein ligation and stripping has been reported to be 1 in 30,000. The incidence of postoperative deep vein thrombosis is approximately 0.6%.
Options
Conservative treatment
One or more of the following options may be helpful in reducing the patient’s discomfort due to varicose veins.
Exercise. Walking or other forms of exercise can stimulate the calf muscles, which can reduce pain and twitching since these are the muscles that maintain venous return in the legs. One particular exercise that is often recommended is repetitive ankle flexion. Flexing the ankle joint 5 to 10 times every few minutes and walking for about 1 to 2 minutes every half hour, performed daily, helps prevent venous congestion caused by prolonged sitting and standing positions.
Avoid wearing high heels. High heels are not conducive to full flexion of the ankle joint during walking. This restriction on the range of motion of the ankle joint is not conducive to contraction of the leg muscles, making it difficult for venous blood to return to the heart.
Elevate the lower extremities 1-2 times a day for 15-30 minutes each time. This change in posture can reduce edema in the ankle foot and ankle joint.
Wearing elastic stockings. Compression reduces inflammation and improves venous return thus benefiting the veins of the lower extremities. Most manufacturers now produce some fairly clear elastic stockings that look aesthetically pleasing in addition to their therapeutic effects.
Medications. There are medications that have been used to treat the discomfort associated with varicose veins, including NSAIDs (non-steroidal anti-inflammatory drugs) and medications such as vitamins C and E. One medication that is sometimes used to treat circulation disorders in the legs and feet is capsaicin, which improves blood flow to the smaller capillaries. The trade name for this medication is called Trendar.
If appearance is the primary concern of the patient, varicose veins can be concealed by using specially formulated cosmetics that are suitable for different skin tones. Waterproof formulas for swimming and other athletic activities are also available.
Endovenous Ablation
Endovenous ablation refers to two new minimally invasive methods of treating saphenous vein insufficiency. The procedure involves a surgeon inserting a catheter into the lumen of the saphenous vein to occlude it, which was approved by the U.S. Food and Drug Administration (FDA) in 1999. The catheter is connected to a radiofrequency generator and emits heat through electrodes into the vein, where the tissue in the wall of the vein contracts and coalesces, causing the vein to occlude. Radiofrequency ablation of the saphenous vein has been shown to be safe and at least as effective as vein stripping; in addition, patients can live and work normally the day after the ablation procedure. The main risk is sensory disturbance in a small area of skin above the knee, and this numbness usually disappears after about six months.
Endovenous laser therapy, also known as EVLT, uses a laser rather than an electrode radiofrequency catheter to heat the tissue in the vein wall to occlude the vein used to treat saphenous vein insufficiency. Although EVLT is also a safe and effective radiofrequency ablation treatment, patients may experience discomfort and bruising, and most patients require two to three days to recover at home after treatment.
Sclerotherapy
Sclerotherapy is a treatment in which a liquid or foamy, irritating chemical is injected into spider-like dilated veins or smaller reticular varicose veins to occlude them. These chemicals cause inflammation of the vein and result in the formation of fibrous tissue that occludes the lumen or the center of the lumen. Sclerotherapy is often combined with other techniques to treat larger varicose veins.
Other treatments
According to Dr. Ding Perettiere, former director of the Stanford University School of Medicine, who is in charge of the complementary and alternative treatment program, hepatica extracts have similar effects to compression stockings as a conservative method of treating varicose veins. In Europe, hepatica preparations have been used for many years to treat circulation disorders in the legs; recently, numerous studies have been conducted in this area in the United Kingdom and Germany. The regular dose of hepatica preparations is 75 mg twice a day, taken with meals. The most common side effect of the oral preparation is occasional indigestion in some patients.