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Abstract Purpose: This study was designed to evaluate a recently introduced form of stripping of primary varicose veins by the technique of perforate-invaginate (PIN) stripping. Methods: One hundred twelve consecutive limbs presenting with 91 long and 21 short saphenous varicosities displaying saphenofemoral or saphenopopliteal junctional escapes with varying length of greater or lesser saphenous (axial) reflux underwent operation in 1 year. All surgeries were performed in an office setting with the patient receiving locoregional anesthetic with use of the invaginated PIN stripping in conjunction with tributary hook-stab avulsion. Results: In the 112 procedures performed, there were no tract hematomas or dysesthesias caused by nerve damage. Postoperative morbidity was nonexistent, permitting all patients to resume normal daily occupational and sporting activities immediately. Conclusions: PIN stripping is an excellent method of invagination stripping. There is a minimal likelihood of vein tearing. Compared with conventional ankle-to-groin (or popliteal fossa) stripping, PIN stripping is minimally invasive, does not cause damage to structures around the vein, does not require convalescence, eliminates the need for a lengthy distal second incision, can be performed in an office setting with the patient receiving locoregional anesthetic, and is most costefficient. (J VASC SURG 1994;20:970-7.) During the classical Babcock/Myers intraluminal stripping, the entire saphenous vein trunk from the ankle to the groin (or popliteal fossa) ends up bunched and wrapped around an oversized acorn-shaped stripper head. This thick hard "plug" causes trauma to the perivenous tissues and leaves behind a substantial raw tunnel in which clotted blood may accumulate. The ensuing discomfort and pain are responsible for the often prolonged convalescence. In the lower calf, this "plug" can also cause injury to adjacent lymphatic vessels, as well as irreversible damage to the saphenous or sural nerves existing in the perivenous tissue. 1 Moreover, conventional stripping also requires a second, generous, distal skin opening to tie the vein to the intraluminal stripper head. This incision, followed by the dissection to expose the vein and the intraluminal stripper, is time consuming and leaves a cosmetically undesirable scar. The purpose of this article is to present our 1-year experience with the recently introduced perforate-invaginate (PIN) stripping (Personal communication. Presented at The Annual Meeting of the Swiss Phlebological Society, January 1993, Lenzerheide, Switzerland). 2 The procedure involves the use of a specially designed simple instrument. This invagination method is minimally invasive and

eliminates the need for a lengthy second distal incision. Back to Article Outline

PATIENTS AND METHODS In a 1-year period (February 1993 to February 1994) PIN stripping was performed in 112 consecutive limbs with primary varicose veins. All presented with saphenofemoral or saphenopopliteal (junctional) escapes associated with trunk (axial) incompetence and reflux of varying extent. Ninety-one limbs had varicose involvement of the long and 21 of the short saphenous veins.

Technique The operation was designed to be performed with the patient receiving local anesthetic in an office setting. It causes minimal trauma or nerve damage and is associated with minimal convalescence. It results in maximal cosmesis. By avoiding charges for a hospital operating room, recovery room, and general anesthetic, this procedure is most cost-effective. Just before surgery, with the patient standing and with use of continuous-wave Doppler ultrasonography, the most proximal escape point (source of reflux), which was previously identified at the initial office visit, is reconfirmed, and the saphenous trunk is mapped by the operating surgeon and marked, together with the all varicose tributaries, with an indelible marker. Premedication is not used. Short saphenous varicosities are operated on with the patient receiving local anesthetic with use of lidocaine hydrochloride (Xylocaine) 1% diluted in bacteriostatic 0.9% normal saline solution to 0.5%. Long saphenous varicosities are operated on with the patient receiving a combination of locoregional anesthetic: local infiltration for the ligation of the junction (Xylocaine 0.5%) and femoral nerve block (20 ml Xylocaine 1%) for the stripping. Detailed examination3 and locoregional anesthesia 4, 5 protocols have been previously published. Introduced by Oesch 2 in 1993, PIN stripping was first advised for short saphenous varicosities. The stripper is manufactured from a 30 cm long, semirigid, stainless steel rod (T + R TĂźscher AG, Bern, Switzerland). It has a minuscule head in continuity with a flattened neck to enable the surgeon to grasp the instrument with a clamp. The distal end terminates in a pointed tip, similarly to the "tail of a rattle snake." A small groove, engraved just below the flattened neck of the instrument orients the operator to the position of the pointed tip, which is meant to perforate the cannulated vein (Fig. 1).


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Fig. 1.

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PIN stripper. Minuscule head is followed by flattened "neck." Small groove indicates position of the pointed tip meant to perforate vein.

Short saphenous vein After ligation of the saphenopopliteal junction, the PIN stripper is passed, with its pointed tip in a retrograde (from above downward) fashion through the already transected distal end of the short saphenous vein (Fig. 2).

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Fig. 2.

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Retrograde passage of PIN stripper.

A vessel loop passed twice around the cannulated vein will prevent oozing of blood that may otherwise obscure the surgical field. Halfway down the calf, the pointed tip is easily palpated through the skin. The index finger of the nondominant hand is positioned below the pointed tip and pressed into the calf. The instrument is pushed against this finger, which, acting as a stopper, forces the pointed tip of the PIN stripper to perforate the vein wall and lodge itself just beneath the skin (Fig. 3). • • •

Fig. 3.

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Perforation of vein wall with distal bent tip of PIN stripper.

A clamp is used to grasp the flattened neck of the stripper, which facilitates perforating the vein wall (Fig. 4).

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Fig. 4.

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Perforation of vein and skin is facilitated by clamp grasping flattened neck of PIN stripper.

A 2 to 3 mm stab incision is made with an 11 blade, and the distal (pointed) end of the instrument is easily exteriorized without the need to dissect and directly

visualize the vein. Unlike conventional intraluminal stripping, the proximal end of the vein is, however, not tied directly to the stripper head. After a strong suture such as Vycril or nylon 1.0 is secured around the small head of the instrument, the two arms of the suture are tied in a "floating knot." The stripper head with this floating knot is pulled, via the protruding distal end, inside the vein trunk until it becomes invisible (Fig. 5).

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Fig. 5.

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Specific technique of attaching vein to PIN stripper: tie around stripper head and floating knot are pulled inside of vein trunk.

The two ends of the suture, protruding from the transected proximal end of the vein, are, with the help of a bare needle, transfixed through the opposing vein walls and tied into a tight knot (Fig. 6).

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Fig. 6.

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Specific technique of attaching vein to PIN stripper: after transfixtion through opposing vein walls suture, anchoring minuscule stripper head, is tied into firm knot.

One should make sure that one of the sutures, acting as a guiding thread, is left more than twice the length of vein segment to be stripped. Traction on the protruding distal end of the stripper will start to invaginate the vein, a step that is facilitated by anchoring the vein with two pickups or forceps (Fig. 7).

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Fig. 7. Beginning of invagination is facilitated by two holding forceps.

Further traction on stripper's distal end will fully exteriorize the invaginated vein (Fig. 8).

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Fig. 8.

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Completion of invagination

The moment the vein, turned inside out, becomes visible, the traction on the stripper is exchanged for direct traction on the invaginated vein trunk itself, by use of either two small grasping forceps or manual traction and a 2 × 2 inch gauze pad. The long intraluminal guiding thread gives additional strength to the vein trunk and should prevent possible tearing of the vein. No ligature is applied to the distal end of the vein after it has been transected and no bleeding has been observed. Long saphenous vein Although there is a 47.5 cm long PIN stripper specially designed for the long saphenous vein, our experience has shown that cannulation of the long saphenous vein from the groin to below the knee is frequently impossible because of the relative rigidity of the PIN stripper. Bending the stripper, however, may facilitate its passage. If the efforts fail, the small 30 cm version of the PIN stripper, meant for the short saphenous vein, should be used in a two-step maneuver. The stripper end is first exteriorized just below midthigh and the invaginated stripping is carried out to this level. Thereafter, if the detected Doppler incompetence and axial reflux extends beyond this level, the stripper is reintroduced through the distal end of the exposed and transected vein and exteriorized further distally in the upper calf, followed by stripping of the main trunk to this final level. In case of straight through incompetence to the ankle, an identical third step maneuver will be needed. On rare occasions, when the introduction of the stripper through the transected distal end of the vein just below the junction (retrograde cannulation) is impossible for technical reasons, preparation and exposure of the main trunk or a tributary vein below the knee, with orthograde cannulation, becomes necessary. One should, however, be careful and avoid the inadvertent introduction of the PIN stripper into the deep venous system via an existing perforator. To prevent tearing of the vein trunk duringinvagination, the anchoring venous tributaries, which are detected by the skin puckering duringtraction on the vein trunk, are avulsed with specially designed phlebextractor hooks. 4, 5 If, in spite of all the precautions, the vein tears, the long guiding thread protruding from both skin openings is pulled taut by the assistant, making the vein palpable and an

easier target for the phlebextractor hook engagement. This maneuver, coupled with good preoperative mapping and marking of the vein, should facilitate the removal of the desired length of saphenous vein trunk. The stab avulsion – hook phlebextraction technique for varicose tributaries and saphenous trunks, as well as high ligation protocols, have been published in detail elsewhere. 4, 5

Dressing and postoperative care Although bleeding into the saphenous vein tract is rare, closure, in layers, of the ligation wound is left to the end of the procedure. Steristrips (3M Health Care, St. Paul, Minn.) are used to close the stab wounds covered by a Tegaderm sheeting (3M Health Care). The leg is then placed in a groin level, 30 to 40 mm Hg ankle pressure gradient, elastic stocking with waist attachment. This is used for day time only. Patients leave the office on their own, 15 to 20 minutes after surgery. Postsurgical discomfort is minimal and 1 to 2 tablets of ibuprofen (Advil) 200 mg will be sufficient for pain control in the immediate postoperative period. Thirty percent of patients did not require any postoperative analgesia. All patients are immediately permitted to resume normal daily activities, including work and sporting activities, with the exception of swimming and weight lifting. No leave of absence from work is necessary. Showering is permitted with proper impermeable leg coverage. Stitches, dressing, and stocking are removed after 1 week. Back to Article Outline

RESULTS All 112 varicose limbs underwent operation in an office setting and with the patient receiving locoregional anesthetic. Bilateral cases were never operated on in the same setting because of possible dose limitations of the local anesthetic. The six limbs that presented with concomitant short and long varicose veins underwent operation simultaneously with no added morbidity. Of the 91 long saphenous varicosities, 85 (93%) limbs with competent infrapopliteal segments of the saphenous trunk had only a groin-to-belowknee stripping, whereas six (7%) limbs presenting with straight through incompetence had a complete ankle-to-groin stripping. In no patient was the PIN stripping procedure abandoned in favor of traditional stripping with conventional oversized acorn head strippers. Similarly, of the 21 short saphenous varicosities, only in two (10%) limbs was complete (to the ankle) stripping necessary; in the remaining 19 (90%), stripping of only the proximal third or half was necessary. Although superficial skin ecchymosis is frequent, tract hematomas were not observed. No nerve damage was noted in this series. Performed in conjunction with tributary stab avulsion via

hook phlebextraction, 4, 5 postoperative morbidity was nonexistent, permitting all patients immediate resumption of normal daily and sporting activities. Back to Article Outline

DISCUSSION Eighty-nine years ago Keller 6 was the first to describe the invaginated form of varicose vein stripping. However, because of frequent tearing of the vein, results were not always successful. The method was replaced with the intraluminal ankle-to-groin stripping, via a large-sized acorn-shaped stripper head, which was introduced by Babcock 7 just 2 years later. Together with the communication of Mayo, 8 these three publications from the turn of the century marked the introduction of the classic ankle-to-groin (or popliteal fossa) stripping for surgical management of primary varicose veins. The rationale for the total stripping was, and to many still is, based on the erroneous assumption that all primary varicose veins have a junctional valve, that is saphenofemoral or saphenopopliteal incompetence, that the existing incompetence and reflux is evenly distributed over the entire length of one or both saphenous trunks, and that all cases have incompetent distal ankle perforators as well. It was therefore logical to suggest and perform, in all patients diagnosed with primary varicose veins, blind stripping of the entire saphenous trunk(s), in conjunction with ligation and excision of the varicose tributaries and division an ligation of distal perforators. Advances in our understanding of the anatomy 9, 10, 11, 12, 13 and hemodynamics 14, 15, 16, 17 of varicose veins brought us to the understanding that, in most of the cases of long saphenous varicosities, a limited groin-to-knee stripping is all that is necessary. 12, 18, 19, 20, 21 Similarly, experience shows that the incompetent and refluxing part of the short saphenous vein is also limited to the proximal third or half, 2, 22 making total stripping to the ankle unnecessary in most cases. In our opinion, the above-mentioned new anatomic and hemodynamic data, coupled with the quest for maximal preservation of the main saphenous trunk as possible vascular graft material, makes the classic and routine ankle to groin stripping unnecessary "overkill." Although also practicing blind ankle-to-groin stripping, van der Stricht, 23 60 years after Keller, used an intraluminal nylon filament to improve the invagination technique. This drastically reduced, for the first time, operative trauma and saphenous nerve injury. 1 More recently, Fullerton and Calvert 24 reported the performance of invaginated stripping with use of the Myers flexible stripper without any of the available acorn-shaped heads. Similarly, postoperative trauma and nerve damage were minimal. Both methods need, however, a lengthy

second distal skin opening to expose the saphenous vein trunk and the intraluminal stripper. 24 This technique of PIN stripping reported by Oesch 2 in 1993 is in our opinion not just simple, elegant, and effective, but also a superior invagination technique that is also in tune with the current, more conservative, limited stripping approach. It promotesdownward stripping, where the proximal strongest vein segment is attached to the stripper head and invaginated first. Therefore tearing, especially of the long saphenous trunk, as is common with the above-enumerated invaginated techniques, was drastically reduced. In our practice, because of its many advantages, PIN stripping has replaced the previously performed and reported invaginated orthograde stripping with use of a small headed Varady flexible mini-stripper 5, 25 in lieu of the previously described Myers type stripper (Aesculapa A.G., Tuttlingen, Germany). 24 Another advantage of this procedure compared with the previously described invagination technique 5 is the small distal incision size (stab wound) required. This avoids the need to blindly dissect the juxtagenicular saphenous vein trunk, also resulting in a cosmetically acceptable scar. Comparable with cryostripping, recently reported by Cheatle et al. 26 the two are the only invagination methods that eliminate the need to expose the saphenous vein and visualize the distal end of the stripper. Injection sclerotherapy for primary truncal varicose veins has been proven in three randomized studies 27, 28, 29 to have a 60% to 74% 5-year recurrence rate. With duplex imaging, the excessive failure rate of injection sclerotherapy is already evident at 2 years. 30, 31 Not even concomitant surgical control of proximal points of reflux prevent a high recurrence rate. 28,32, 33 Surgery therefore remains the method of choice for the treatment of primary varicose veins. Although performance of the conventional stripping with a big acorn-shaped stripper head assures the complete removal of the saphenous vein trunk(s) and confers excellent long-term results, 34 it potentially causes injury to the commitant saphenous or sural nerve(s) and causes definite soft tissues trauma, which in turn is responsible for the postoperative morbidity, prolonged convalescence, and possible loss of income. 1, 19, 34 Moreover, removal of the varicose tributaries with relatively large instruments via generous incisions adds to the trauma and results in undesirable scarring. In stripping by invagination the inverted vein trunk runs through its own track without harming the perivenous structures. The tunnel left behind is minimal and does not exceed the space previously occupied by the incompetent saphenous vein trunk. Moreover, the limited stripping, by retaining the distal saphenous trunks that are in proximity to delicate anatomic structures, further avoids possible nerve damage. Performing a limited "groin–to–below-knee" stripping, as

suggested by Rivlin, 18Negus, 19 using the conventional Babcock/Myers stripper, reported a drop in neurologic symptoms associated with classical "ankle-to-groin" stripping, from the reported 33% 34 to only 4.2%. 19 Creton, 35 using van der Stricht's nylon filament invagination technique, reported a 2% incidence of neurologic complication in the conventional "ankle-to-groin" stripping, whereas Staelens and van der Stricht, 1 in the same type surgery and technique, reported a further drop in neurologic complications to only 0.3% (four cases in 1300 operations). Saphenous tract hematomas were reported by the same authors, in the same series, in only six patients or 0.5%. Varicose vein surgery is now routinely performed in a surgical center or outpatient surgical theater. Hospital stay and associated costs have dropped; however, where the charges for the admitting room, operating room, anesthetic, recovery room, laboratory tests, supplies, and medications are added, the typical bill, excluding the surgeon's fee, is approximately $8000 to $10,000. The procedure we describe, depending on the extent of the stripping (one leg) is approximately $2000 to $2500, including surgeon's fee, local anesthetic, and all supplies. Therefore the atraumatic invaginated and limited PIN stripping performed in conjunction with the previously reported stab avulsion (hook phlebextraction) of varicose tributaries 4, 5 is, in our opinion, a sound surgical practice that does not require any hemodynamic compromise. 36 A judicious preoperative assessment 3 is, however, imperative to personally tailor the procedure(s) to each patient's specific anatomic and functional needs. With locoregional anesthetic and performance in an ambulatory (office) setting, this cost-efficient method, by now reported by others as well, 37, 38 has placed varicose vein surgery in the realms of minimally invasive procedures. Back to Article Outline

Acknowledgements We thank Dr. Andreas Oesch of Bern, Switzerland, for his numerous timely suggestions regarding the technical details of surgery for varicose veins during all these years. Back to Article Outline

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Invaginated axial saphenectomy by a semirigid stripper: Perforate-invaginate stripping