CONTROVERSIES & UPDATES IN VENOUS SURGERY
ESSION II: WHAT HAS CHANGED IN THE PAST 10 YEARS? S Does long term follow-up confirm that high ligation is an obsolet procedure? Olivier Pichot CHU de Grenoble, Grenoble, France Sapheno-femoral junction (SFJ) residual stump and neovascularization are considered to be the main causes of recurrence after surgery; that is why surgeons have emphasized the necessity to perform an extended high ligation (flush sapheno-femoral ligation and ligature-section of the related SFJ tributaries), even if no surgical technique artifice has been demonstrated to be effective to really avoid SFJ neovascularization. Thermal and chemical ablations of the saphenous veins have introduced a new treatment concept based on the trunk ablation alone with preservation of the SFJ. Mid-term follow-up already demonstrated that this approach decrease significantly the incidence of neovascularization, but persistence of a saphenous stump could be considered as a remaining risk factor for recurrence. 1 Endo-venous procedures are used since more than ten years for the treatment of varicose veins of the lower limbs, and five years follow-up studies are now available. Five years is accepted to be a long-term follow-up, since this interval is long enough for the development of clinical recurrence.2 Even if high ligation and stripping has been considered as the gold standard, van Rij at long-term follow-up has observed clinical recurrence in 51% of the cases, and anatomical recurrence on duplex, in 23% of the cases at the SFJ and 52% of the cases at the sapheno-popliteal junction (SPJ), neovascularization accounting for 85% of recurrences at the SFJ and 62% of recurrences at the SPJ. 3 At 14 years follow-up after GSV primary surgery, Nelzen has observed with duplex groin recurrence in 38 % of the case, including residual stump and neovascularization. 4 At 5 years follow-up after radiofrequency (ClosurePlus®), clinical recurrence was observed in 27.4%, with an obliteration rate of 87.2%. During follow-up cases of failure was related to three different mechanisms: primary non occlusion (12.4%) , total or partial recanalisation (69.7%), or SFJ reflux draining in a lower thigh tributary (17.8%). 5 ClosureFast® improved the outcomes of radiofrequency with an occlusion rate of 91.9% and a reflux-free rate of 94.9% at 5 years follow-up. Clinical recurrence was observed as scattered varicose veins in 40.7% at 5 years but only 5.9% of the treated limbs had multiple varicose veins originating from the GSV. In a randomized prospective study, Rasmussen did not find any difference at 5 years follow-up between endovenous laser (EVL) and surgery with clinical recurrence observed in respectively 46.6 and 54.6%. On duplex reflux was observed in the groin respectively in 8 and 4% of the cases with more frequent reflux in the anterior accessory saphenous vein (AASV) after EVL and more frequent reflux in thigh perforators after surgery. 6 Because ultrasound guided foam sclerotherapy (UGFS) allows sequential sessions to perform reflux and varicose vein ablation, a precise comparison with surgery and thermal ablation is difficult to perform. Nevertheless, in Chien-Hsun Chen study, with a mean follow-up interval of 37.8 months (18-68), occlusion was achieved in 60.1% of the legs after one session of foam sclerotherapy, in 29.5% additional legs after a second session, and in 8.3% additional legs after a third session. 1.47 session was necessary to achieve GSV occlusion in the 19 patients with a follow-up period of longer than 5 years.7 All the available data on long-term follow-up do not demonstrate an inferiority of endovenous ablation, whatever the technique used, compared to surgery. We can conclude that high ligation is not useful in the treatment of saphenous reflux. References
1. Lurie F, Creton D, Eklof B, Kabnick L, et al. Prospective Randomised Study of Endovenous Radiofrequency Obliteration (Closure) Versus Ligation and Vein Stripping (EVOLVeS): Two-year Follow-up. Eur J Vasc Endovasc Surg 2005 : 29, 67–73 2. De Maeseneer M, Pichot O, Cavezzi A et al. Duplex ultrasound investigation of the lower limbs after treatment for varicose veins e UIP consensus document. Eur J Vasc Endovasc Surg 2011;42: 89-102. 3. van Rij AM, Jiang P, Solomon C, et al. Recurrence after varicose vein surgery: a prospective long-term clinical study with duplex ultrasound scanning and air plethysmograpy. J Vasc Surg 2003;38: 935-43. 4. O. Nelzén O, Fransson I. Varicose Vein Recurrence and Patient Satisfaction 14 Years Following Combined Superficial and Perforator Vein Surgery: A Prospective Case Study. Eur J Vasc Endovasc Surg 2013 ; 46: 372-7. 5. Merchant R and Pichot O. Long-term outcomes of endovenous radiofrequency obliteration of saphenous reflux as a treatment for superficial venous insufficiency. J Vasc Surg 2005; 42:502-9. 6. Rasmussen L, Lawaetz M, Bjoern L, Blemings A, Eklof B. Randomized clinical trial comparing endovenous laser ablation and stripping of the great saphenous vein with clinical and duplex outcome after 5 years. J Vasc Surg 2013; 58:421-6. 7. Chien-Hsun Chen, Cheng-Sheng Chiu, Chih-Hsun Yang. Ultrasound-Guided Foam Sclerotherapy for Treating Incompetent Great Saphenous Veins - Results of 5 Years of Analysis and Morphologic Evolvement Study
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