INTRODUCTION — In the United States, surgical methods of vein ablation (eg, saphenous ligation and stripping) have largely been updated to less invasive methods (eg, thermal and nonthermal ablation). However, globally in many countries, venous surgery remains the standard. Increasingly, varicose veins are treated with hybrid procedures that combine minimally invasive with conventional surgical techniques [1]. Large varicose veins, vein recanalization after minimally invasive techniques, and complications of varicose veins are often best managed with open surgical techniques. Available techniques are chosen based upon the location, size, and extent of the patient's varicosities, and the presence or absence of venous reflux.
Open surgical techniques for lower extremity vein ablation are reviewed. Alternative approaches to the treatment of chronic venous disease using thermal and nonthermal ablation methods are discussed separately.
●(See "Overview of lower extremity chronic venous disease".)
●(See "Techniques for radiofrequency ablation for the treatment of lower extremity chronic venous disease".)
INDICATIONS — Candidates for surgical ablation are patients with persistent symptoms/signs of venous disease after a trial of medical therapy and documented reflux (ie, retrograde flow >0.5 second duration) as a source of their symptoms. (See "Overview of lower extremity chronic venous disease" and "Medical management of lower extremity chronic venous disease" and "Approach to treating symptomatic superficial venous insufficiency".)
With the introduction of minimally invasive methods of vein ablation, surgical therapy, for the most part, is reserved for the management of visible veins not amenable to treatment by minimally invasive techniques, complications of varicose veins (ie, varicose vein hemorrhage, recurrent phlebitis), and refractory or recurrent venous ulceration. Surgical treatment may also be combined with less invasive treatment options in selected patients to reduce the number of treatments needed. (See "Injection sclerotherapy techniques for the treatment of telangiectasias, reticular veins, and small varicose veins" and "Techniques for radiofrequency ablation for the treatment of lower extremity chronic venous disease" and "Techniques for endovenous laser ablation for the treatment of lower extremity chronic venous disease".)
CONTRAINDICATIONS — The risk of the surgical treatment of varicose veins is related primarily to the risk of anesthesia. For patients with significant cardiopulmonary comorbidities, techniques that use local, tumescent, or regional anesthetic are preferred. (See "Evaluation of cardiac risk prior to noncardiac surgery".)
Ablation of truncal veins (eg, great saphenous or small saphenous veins) is contraindicated if the superficial system represents the dominant venous outflow as in cases of deep vein obstruction or congenital absence of the deep venous system. In patients with a history of deep vein thrombosis, varicose vein surgery should be undertaken with caution because of the risk of perioperative venous thrombosis.
Diabetes and moderate-to-severe peripheral artery disease are relative contraindications because these conditions are associated with an increased risk of poor wound healing. When clinically significant arterial and venous diseases are both identified, the arterial disease should usually be addressed first, particularly in those with nonhealing lower extremity ulcers.
ANATOMY
Venous anatomy — The major superficial veins of the lower extremity include the great saphenous and small saphenous veins (figure 1A-B). These and the saphenous accessory veins are collectively referred to as axial or truncal veins. The great saphenous vein joins the common femoral vein at the confluence of the superficial inguinal venous tributaries at the saphenofemoral junction. The small saphenous vein has more variable anatomy, especially with respect to the location of the saphenopopliteal junction. (See "Classification of lower extremity chronic venous disorders", section on 'Superficial venous system (As)'.)
The deep veins of the lower extremity are contained within the deep muscle compartments bounded by the muscle fascia (figure 2). (See "Classification of lower extremity chronic venous disorders", section on 'Deep venous system (Ad)'.)
Perforating veins traverse the muscular fascia and serve to connect the superficial veins with the deep veins.
Bicuspid valves in the venous system direct the flow of blood in both the superficial and deep veins from distal to proximal (ie, toward the heart). With the exception of the foot, flow in the perforating veins is directed from superficial to deep. (See "Pathophysiology of chronic venous disease", section on 'Venous anatomy'.)
Saphenous nerve — The saphenous nerve is the terminal branch of the femoral nerve and provides sensory innervation to the medial aspect of the lower leg. It passes through the adductor canal in proximity to the superficial femoral artery, after which it becomes closely related to the saphenous vein. The saphenous nerve is most vulnerable to injury in the calf, where it may have several touch points to the saphenous vein [2]. Injury to the saphenous nerve variably results in pain and numbness on the medial calf and foot.
Sural nerve — The sural nerve is a sensory nerve supplying the lateral leg and foot [3]. It courses with the small saphenous vein traveling posterior to the lateral malleolus toward the fifth toe. Injury to the sural nerve causes pain and numbness on the lateral aspect of the ankle and calf.
PREOPERATIVE PREPARATION
Medications — The management of anticoagulants (eg, warfarin, direct oral anticoagulants [DOACs]) and antiplatelet agents (eg, clopidogrel, aspirin) in the perioperative period must be individualized to balance the risk of bleeding with the risk of an unwanted thromboembolic event. Anticoagulants and antiplatelet agents should not be discontinued without consideration of the potential risks. As an example, clopidogrel or other antiplatelet agents should not be discontinued in patients with drug-eluting coronary stents without consultation with the prescribing cardiologist. For those in whom the risk of discontinuing antiplatelet agents is judged to be low, they are discontinued prior to open venous surgery (table 1). Warfarin may be temporarily discontinued or bridging anticoagulation initiated depending upon the original indication. Bridging anticoagulation is generally not necessary for DOACs. The management of antithrombotic agents in the perioperative period is reviewed in detail elsewhere. (See "Perioperative medication management", section on 'Medications affecting hemostasis' and "Perioperative management of patients receiving anticoagulants".)
Prophylactic antibiotics — Prophylactic antibiotics are typically given even though most vein excision procedures are clean cases (table 2) [4,5]. Surgical site infections occur at a higher rate in patients with open cutaneous wounds or venous stasis ulcers. (See 'Infection' below.)
In one randomized trial, antibiotic prophylaxis prior to great saphenous vein excision significantly improved postoperative ASEPSIS scores compared with controls (3 versus 6) and reduced other wound-related problems [6,7]. In this trial, specific patient factors, including obesity and current cigarette smoking, were associated with higher ASEPSIS scores. Factors such as diabetes and corticosteroid use were not able to be evaluated. A late retrospective cohort study lack of antibiotic prophylaxis increased the risk for surgical site infection (most located in the groin); diabetes was a significant contributing risk factor [8]. (See "Antimicrobial prophylaxis for prevention of surgical site infection in adults".)
For patients with venous ulceration, the choice of antibiotic is based upon the results of wound cultures, if available.
Thromboprophylaxis — Periprocedural thromboprophylaxis should be individualized based on known risk factors for deep vein thrombosis (DVT) and pulmonary embolism (PE). The available data suggest that the incidence of venous thromboembolism is relatively low in the perioperative period after vein surgery. For patients at high risk, such as patients with a known thrombophilia, strong family history, or prior episodes of DVT, appropriate prophylaxis should be provided. (See "Prevention of venous thromboembolic disease in adult nonorthopedic surgical patients".)
Pharmacological thromboprophylaxis is often not administered prior to surgical vein excision due to the perceived low risk of venous thromboembolism (VTE) and the fear of unwanted bleeding. Minimizing the duration of the surgical procedure (eg, less than 45 minutes), use of local anesthetic that allows muscular contractions during the operation, and early postoperative ambulation are believed to reduce the risk of deep vein thrombosis. There is a need for additional study regarding the real-world incidence of VTE after vein surgery. In a large review of 2196 patients undergoing high ligation and stripping of the saphenous vein under general or epidural anesthesia, the incidence of DVT in those who did not receive DVT prophylaxis was 5 percent, and the incidence of PE was 1.5 percent [9]. Among those randomly assigned to one of three pharmacologic prophylaxis regimens the incidence of thromboembolism was significantly reduced (<1 percent). Bleeding complications were low for each group but significantly higher in the group that received unfractionated compared with the groups that received low-molecular-weight heparin (0.75 versus 0.17 and 0.18 percent) or no prophylaxis (0.75 versus 0.18 percent).
Patient counseling — The decision to offer surgical vein excision/ligation depends upon the severity of symptoms, response to conservative medical therapy or prior intervention (eg, sclerotherapy, endovenous ablation), extent of lower extremity venous disease, and patient goals.
The most important risks of the procedure include recurrence, bleeding and the possible need for transfusion, infection, superficial phlebitis, deep venous thrombosis, lymphatic injury, and cutaneous nerve injury leading to numbness or paresthesias. A less than optimal cosmetic result may also occur due to hyperpigmentation and telangiectatic matting. (See 'Complications of surgery' below.)
Alternatives, either alone or in combination, to surgical ablation include compression therapy, endovenous ablation, or sclerotherapy. In the United States, there are no FDA-approved medications for the treatment of superficial venous insufficiency. (See "Overview of lower extremity chronic venous disease" and "Medical management of lower extremity chronic venous disease", section on 'Pharmacologic therapy'.)
Recurrent varicosities that occur are usually smaller in caliber. Supplemental vein excision or sclerotherapy may be required to achieve the desired result. (See "Injection sclerotherapy techniques for the treatment of telangiectasias, reticular veins, and small varicose veins" and "Laser and light therapy of lower extremity telangiectasias, reticular veins, and small varicose veins".)
Compression stockings — Regardless of the surgical method employed in vein ablation, compression in the form of elastic wraps (eg, ACE) or graduated compression stockings are recommended by many surgeons to limit bruising and swelling in the postoperative period [10]. However, randomized trials have not consistently found a benefit to wearing compression stockings with respect to postoperative pain, complications, return to work, or patient satisfaction [11-15]. A systematic review identified four trials evaluating the use of compression stockings following varicose vein surgery [16]. No significant differences were found between short duration (3 to 10 days) versus longer duration (3 to 6 weeks) compression with respect to postoperative pain (three trials), leg volume (one trial), incidence of complications (two trials), and absenteeism from work (three trials).
When elected, patients are prescribed 20 to 30 mmHg compression stockings (eg, thigh-high or pantyhose), which they should obtain prior to the day of the scheduled procedure (table 3). A variety of nonprescription elastic compression stockings, shorts, and pants (eg, "cycling" shorts, "running" stockings, "dance" hose) have been marketed for a wide range of athletes and may offer an alternative form of postoperative compression for some patients; however, these are not graduated and will not aid in reducing venous hypertension. (See 'Postoperative instructions' below and "Compression therapy for the treatment of chronic venous insufficiency", section on 'Compression hosiery'.)
Vein mapping/marking — With the patient standing, the veins that are to be removed are marked with indelible ink prior to the procedure. Patients should actively participate in this process to ensure that all the veins of concern have been addressed. Near-infrared (IR) imaging using a wavelength of 880 to 930 nm may improve the accuracy of vein identification [17]. Failure to accurately mark the location of varicose veins can lead to the inability to locate the collapsed varicosities with the patient in the supine position.
Anesthesia — Surgical vein removal is typically performed in the outpatient setting using local/tumescent, regional, or general anesthesia, depending upon the magnitude of the procedure, surgeon experience, and patient preference. Light sedation can be achieved with propofol, and for most procedures (eg, saphenous vein removal), a dilute anesthetic mixture of lidocaine, bicarbonate [18], and epinephrine can be injected subcutaneously along the course of the marked veins to achieve a peau d'orange appearance to reduce perioperative pain and improve hemostasis; this is referred to as tumescent anesthesia. For small areas of varicosities, oral sedatives combined with local anesthesia provide sufficient pain control during the procedure.
TECHNIQUES — Surgical techniques involve ligation and/or removal of veins; the specific method chosen is based upon the location, size, and extent of the patient's varicosities, and the presence or absence of venous reflux.
General principles — We prefer to perform surgical vein removal on one leg at a time because extensive, bilateral surgery is often not well tolerated.
For saphenous vein stripping, the groin hair is trimmed to facilitate exposure of the saphenofemoral junction as well as adhesion of the postoperative dressing. The lower extremity is prepared circumferentially from the anterior superior iliac spine to the level of the ankle. Alcohol-containing skin preparation should be avoided because it can remove skin markings. (See "Antimicrobial prophylaxis for prevention of surgical site infection in adults".)
Venous ulcerations, if present, are prepared last with a separate prep kit. The wounds are cleansed, dried, and covered with an occlusive dressing to limit transmission of microbes to the remainder of the operative field. Portions of the extremity that are affected with ulceration should be draped out of the sterile field.
Blood loss during surgical removal of large varicosities can occasionally be significant, and the need for transfusion, although seldom, has been reported. Bleeding can be significantly reduced by elevation of the lower extremity during the procedure.
Alternatively, it has been proposed that tourniquets (eg, Esmarch, Lofquist cuff, Rhys-Davis Cuff) may be used during varicose vein surgery to reduce blood loss [19-21]. In our experience, tourniquets have not been necessary or beneficial. A systematic review identified three randomized trials each supporting significantly decreased blood loss with the use of a tourniquet [22]. Because of the small number of patients in each trial and expected rarity of complications, no conclusions were drawn with respect to any potential complications (eg, nerve injury) from the use of the tourniquet. In addition, if the tourniquet is used improperly, it can increase the bleeding by inducing venous hypertension or lead to flow stagnation leading to deep vein thrombosis. A retrospective review of 1461 patients who underwent varicose vein surgery where a tourniquet was routinely used identified deep vein thrombosis (DVT) in 7.7 percent (1.3 percent proximal) [23].
Once the procedure is completed, a sterile compression dressing is applied. Many different types of dressings can be used, ranging from graduated compression hose to complex three-layer bandage. The patient may ambulate immediately. The dressing is left in place for at least 24 hours depending on the proceduralist. (See 'Compression stockings' above.)
Saphenous vein inversion and removal — A small transverse incision (1 to 2 cm depending on body habitus) is made over the saphenofemoral junction, which is usually located 2 to 3 cm peripheral and lateral to the pubic tubercle. Ultrasound may be used preoperatively to mark the precise location. The junction of the great saphenous vein with the common femoral vein (ie, saphenofemoral junction) is identified and isolated. Anteromedial and posterolateral tributaries are ligated and divided; however, tributaries draining the abdominal wall are preserved. In one trial, preservation of the abdominal wall tributaries was associated with lower rates of clinical and ultrasound-detected varicose vein recurrence [24].
The great saphenous vein is divided and the proximal end ligated near its junction with the common femoral vein. [24]. The vein stripper is passed retrograde through the open end of the divided vein distally toward the foot. Due to the incompetence of the vein valves, the stripper should pass easily. A small skin incision is made over the tip of the stripper, which is palpated through the skin, usually near the knee joint. After incising the skin, a forceps is used to grasp the stripper and pull it through the incision.
In the groin, the stripper is securely tied to the vein. The author prefers not to use the mushroom tips supplied with the typical stripper, because excessive tissue trauma and bleeding can result. The vein inverts on itself, and the vein is removed by pulling the stripper toward the foot. Tributary veins that are tethering the vein are disrupted. Once hemostasis is achieved by direct pressure along the vein bed, the groin incision is closed in layers with interrupted, absorbable suture.
A similar procedure can be used to strip the small saphenous vein. Care must be taken to avoid injury to the adjacent structures during dissection in the popliteal fossa or the sural nerve when stripping.
High saphenous ligation — Ligation of the saphenous vein at the saphenofemoral junction alone, without vein removal, is not usually performed alone due to the high rate of recurrent varicose veins and persistent symptoms [24-26]. High ligation may also be accompanied by the development of superficial thrombophlebitis in the saphenous vein distal to the site of ligation. (See 'Outcomes' below.)
High ligation of the saphenous vein, however, is occasionally appropriate for selected patients with proximal superficial phlebitis that encroaches on the saphenofemoral junction, and who have a contraindication to anticoagulation [27]. (See "Techniques for radiofrequency ablation for the treatment of lower extremity chronic venous disease" and "Superficial vein thrombosis and phlebitis of the lower extremity veins" and "Overview of lower extremity chronic venous disease".)
Ambulatory phlebectomy — Excision and avulsion of superficial varicosities (ie, phlebectomy) through multiple tiny incisions is referred to as "ambulatory phlebectomy" or "microphlebectomy."
Ambulatory phlebectomy is useful for removing a wide range of varicose and reticular veins. Ambulatory phlebectomy can be combined with saphenous inversion for complete treatment at a single session.
An 18 gauge needle or 11 blade scalpel are utilized to make a puncture immediately adjacent the marked vein. Sequential venous segments are engaged with a variety of small, specially designed crochet-like hooks and are grasped, ligated, and avulsed [28]. Bleeding is controlled with direct pressure and limb elevation.
Transilluminated powered phlebectomy — Another technique for vein removal, usually performed under general or regional anesthesia and adopted by only a few surgeons, relies on the use of a powered, mechanical aspirator called transilluminated powered phlebectomy (TIPP). The device is similar to devices used by orthopedic surgeons to shave off cartilage. The device consists of a long, narrow tube that has a rotating blade at its tip to macerate and aspirate the target vein. An illuminator (light source) is placed into the subcutaneous tissue through a counter incision to improve visualization of the target veins through the skin [29].
Following the administration of tumescent anesthesia, which is a mixture of saline, lidocaine, and epinephrine, the device is inserted adjacent to the path of the target vein. The blade is activated, and the vein is aspirated into the device and destroyed.
The advantage of powered phlebectomy is the need for fewer incisions [2]; however, systematic reviews have found that TIPP is associated with more postoperative pain and hematoma formation compared with ambulatory phlebectomy [30,31]. Another disadvantage of TIPP is the additional cost of the specialized equipment and supplies. Many patients with varicose veins also require management of saphenous reflux, which is often performed with an endovenous procedure. The combined equipment cost (ie, endovenous plus TIPP) may be prohibitive, especially since cosmetic outcomes with TIPP do not appear superior to the conventional ligation/excision techniques described above [31].
Conservative venous ligation (CHIVA) — Conservative venous ligation (CHIVA; Conservatrice et Hémodynamique de l'Insuffisance Veineuse en Ambulatoire) is an alternative vein sparing method that aims to disrupt the column of hydrostatic pressure by disconnecting points of venous reflux while preserving venous drainage [32-37]. The saphenofemoral or saphenopopliteal junction is ligated and divided but not excised (ie, stripped), thus minimizing any nerve damage. Additional sites for ligation are identified with duplex ultrasound and clinical examination. A systematic review identified four randomized trials comparing CHIVA with vein stripping (n = 721). In two trials that evaluated varicose vein recurrence (follow-up of 3 to 10 years), the pooled estimate for the risk of recurrence was significantly lower for the CHIVA method compared with vein stripping (relative risk [RR] 0.63, 95% CI 0.51-0.78) [36].
Perforator ligation — Refluxing perforator veins may be identified as a source for varicose vein clusters and are typically ligated during the course of phlebectomy. For the treatment of severe chronic venous insufficiency and ulceration, it may also be appropriate to disrupt perforating veins contributing to ulcer formation. (See "Pathophysiology of chronic venous disease".)
Surgical perforator ligation — Surgical perforator vein ligation is rarely performed given the availability of minimally invasive options. Minimally invasive techniques are discussed elsewhere. (See "Techniques for radiofrequency ablation for the treatment of lower extremity chronic venous disease", section on 'Anatomic considerations' and "Techniques for endovenous laser ablation for the treatment of lower extremity chronic venous disease", section on 'Perforator veins' and "Nonthermal, nontumescent ablation techniques for the treatment of lower extremity superficial venous insufficiency", section on 'Perforator ablation'.)
Open surgical perforator ligation (Linton procedure) was abandoned due to the magnitude of the operation and location of incisions in vulnerable areas of skin. The surgical site was prone to secondary ulceration when perforator ligation was not successful at reducing venous pressures within the skin.
A less invasive surgical technique popularized in the 1980s used a videoscope placed through a small incision remote from the area of skin ulceration to identify and ligate perforating veins under direct vision [38-40]. This technique, subfascial endoscopic perforator surgery (SEPS), was used to treat patients with refractory symptoms or ulceration, or recurrent ulceration associated with perforator reflux. The long-term outcomes of a randomized, multicenter trial (mean follow-up 97 months) found a significantly lower rate of ulcer recurrence for surgical management of perforators compared with conservative therapy (49 versus 94 percent) [38]. These results support the treatment of incompetent perforator veins; however, given the development of minimally invasive methods of vein ablation, the open surgical approach to perforator ablation has largely been abandoned.
POSTOPERATIVE INSTRUCTIONS — Mild-to-moderate postoperative pain is common. Depending upon the extent of the vein excision, patients can be managed with extra strength acetaminophen or acetaminophen with codeine. Nonsteroidal anti-inflammatory agents may be added in patients who develop a significant phlebitic reaction. (See "Management of acute perioperative pain in adults" and 'Superficial thrombophlebitis' below.)
Patients are encouraged to ambulate following surgery. The patient should make an effort to walk for 5 to 10 minutes each hour during waking hours. The patient should avoid prolonged standing and sitting with the feet on the floor. When not walking, the patient is encouraged to elevate the leg above the level of the heart.
Bruising along the tract of excised veins is common and can take three weeks to three months following surgery to resolve. Postoperative compression may help to limit bruising [10]. (See 'Compression stockings' above.).
The operative dressings including the elastic bandages/stockings are maintained for at for one to seven days. Once the operative dressing is removed, elastic stockings should be worn during the day but removed at night. A systematic review identified four randomized trials evaluating short duration (3 to 10 days) versus long duration (3 to 6 weeks) compression stockings following great saphenous vein stripping/phlebectomy [16]. There were no benefits to long duration compression therapy with respect to postoperative pain, leg volume, complications (hematoma, infection, seroma), or time off work. (See "Compression therapy for the treatment of chronic venous insufficiency", section on 'Compression hosiery'.)
The patient may reinforce any small areas of bleeding that occur through the dressing but should call their surgeon if excessive bleeding occurs. The patient may shower as soon as the initial dressing is removed. Normal activities can be resumed when tolerated, usually within three to four days. Time off work varies between one and three weeks depending upon the patient's job requirements and the magnitude of the operation.
When to call the surgeon — The patient should call their surgeon to be seen immediately if they notice:
●Recurrent bleeding through the bandages after reinforcement or excessive or sudden bleeding that saturates the bandage.
●Tingling, coolness, or discoloration of the toes of the treated extremity. The elastic bandages/stockings may be too tight and need to be removed.
●Swelling or excessive pain not relieved with the prescribed pain medications, because this may be a symptom of deep vein thrombosis.
COMPLICATIONS OF SURGERY — The most common complications of vein ablation surgery are bruising and hematoma formation. Other complications include wound infection, hyperpigmentation, telangiectatic matting, phlebitis (superficial or deep), and cutaneous nerve injury.
Hematoma — Small hematomas along the course of the excised vein are common, but large hematomas should prompt examination by the treating surgeon. Hematomas feel like lumps under the skin and may cause initial concern for the patient; however, reassurance that the irregularity of the subcutaneous tissues will diminish over time is usually all that is necessary.
Infection — Wound infection rates following surgical vein excision are often greater than would be expected for clean surgery. The incidence of surgical site infection is generally low (<5 percent), but higher incidences have been reported and may be related to the need for groin dissection, a propensity for hematoma formation along the course of excised veins, and the presence of venous ulceration [41-43]. Redo surgery is associated with double the rate of infection [43].
Saphenous or sural nerve injury — Saphenous nerve injury occurs in up to 10 percent of patients following saphenous vein removal and depends upon the method and extent of stripping [2,44,45]. In one small study, the direction of saphenous stripping did not affect the incidence of saphenous nerve injury [46]. Care should be taken during the procedure to avoid injury to these nerves, which leads to an unpleasant sensory abnormality along the medial (saphenous nerve) or lateral (sural nerve) leg. (See 'Anatomy' above.)
Superficial thrombophlebitis — Superficial thrombophlebitis is common in venous tributaries along the course of the excised vein and is usually self-limited. The treatment is medical. (See "Superficial vein thrombosis and phlebitis of the lower extremity veins".)
Deep vein thrombosis — Deep vein thrombosis following saphenous removal is a complication of the dissection of venous structures in the groin. It may also result from compression by significant groin hematoma. Deep vein thrombosis should be suspected in any patient who has excessive lower extremity swelling or pain following open surgical vein excision. Pulmonary embolism has been reported, although it is rare [47]. Deep vein thrombus is diagnosed and managed according to standard protocols. (See "Clinical presentation and diagnosis of the nonpregnant adult with suspected deep vein thrombosis of the lower extremity".)
Lymphocele and lymph leak — Occasionally patients may experience persistent lymph drainage from groin dissection or phlebectomy incisions. In most cases, lymph drainage stops spontaneously, but rarely it may become necessary to surgically ligate persistent lymph leaks.
OUTCOMES — Surgical therapy for chronic venous disease is the standard to which the minimally invasive therapies have been compared [48-51]. Surgical intervention for venous disease improves symptoms, and the majority of patients are generally satisfied with surgical intervention [52-56].
The cost effectiveness of surgery for patients with severe varicose veins and reflux compared with conservative management was evaluated in a randomized trial of 250 patients [57]. Surgery improved outcomes (quality of life, symptomatic relief, and anatomic extent) and was cost effective at two years, with a projected cost benefit out to 10 years.
However, in randomized trials, minimally invasive techniques for saphenous ablation appear to be as effective as saphenous ligation and removal for the management of reflux and offer significant advantages such as a lack of a groin incision, less postoperative pain, and quicker recovery times [58-71]. Less invasive methods may be associated with a higher incidence of recurrence [72,73].
Nevertheless, for the majority of patients, chronic venous disease can be effectively managed using minimally invasive techniques [74,75]. (See "Injection sclerotherapy techniques for the treatment of telangiectasias, reticular veins, and small varicose veins" and "Laser and light therapy of lower extremity telangiectasias, reticular veins, and small varicose veins" and "Techniques for radiofrequency ablation for the treatment of lower extremity chronic venous disease" and "Comparison of methods for endovenous ablation for chronic venous disease".)
Varicose vein recurrence — Because the treated veins are removed, the risk of recanalization with open surgery is zero; however, enlargement of other veins in the extremity can occur over time. Surgical techniques are associated with varicose vein recurrence rates between 20 and 28 percent [57,76-79]. The cause of recurrences may include surgical technique, progression of the underlying disease, or neovascularization. For those who have undergone limited stripping to the level of the knee, persistent reflux can lead to varicose veins emanating from the remnant [73,74,80].
In randomized trials, vein ligation plus removal has lower recurrence rates compared with vein ligation alone [26,81]. Of the open surgical techniques, vein removal is the preferred technique for patients with saphenofemoral reflux and varicose veins in the great saphenous distribution. (See 'High saphenous ligation' above and 'Saphenous vein inversion and removal' above.)
Compared with endovenous techniques, which do not remove the vein, varicose vein recurrence in the groin region is significantly improved for open surgery (7 versus 31 percent at five years, in one study [82]); however, this does not necessarily translate to any difference in venous symptoms, Comprehensive Classification System for Chronic Venous Disorders (ie, CEAP (table 4)) staging, or other quality-of-life measures.
Ulcer healing and recurrence — Superficial vein excision reduces reflux in the deep veins [83-85], and although it does not speed the rate of ulcer healing, vein excision significantly reduces ulcer recurrence compared with compression therapy alone [86-90]. The ESCHAR trial randomly assigned 500 patients with open or recently healed ulcers, and evidence for reflux, to compression therapy alone (multilayer) or compression therapy plus surgery (saphenous ligation or removal and nonsaphenous vein excision) [87]. For patients with ulceration, healing rates at 24 weeks with compression therapy plus surgery were similar to those with compression therapy alone, but recurrence rates at 12 months were significantly lower in the surgical compared with nonsurgical groups (28 versus 12 percent). Four-year follow-up data from the ESCHAR trial confirmed the long-term benefit of surgery plus compression over compression alone for the reduction of venous ulcer recurrence [90]. (See "Medical management of lower extremity chronic venous disease".)
SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Chronic venous disorders".)
INFORMATION FOR PATIENTS — UpToDate offers two types of patient education materials, "The Basics" and "Beyond the Basics." The Basics patient education pieces are written in plain language, at the 5th to 6th grade reading level, and they answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials. Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are written at the 10th to 12th grade reading level and are best for patients who want in-depth information and are comfortable with some medical jargon.
Here are the patient education articles that are relevant to this topic. We encourage you to print or e-mail these topics to your patients. (You can also locate patient education articles on a variety of subjects by searching on "patient info" and the keyword(s) of interest.)
●Basics topic (see "Patient education: Vein ablation (The Basics)")
SUMMARY AND RECOMMENDATIONS
●Surgical methods of vein ablation, particularly saphenous ablation, have been supplanted by minimally invasive methods but remain a standard to which the minimally invasive techniques are compared. (See 'Introduction' above.)
●Surgical therapy is most commonly used for the management of large varicose veins and complications of varicose veins (eg, varicose vein hemorrhage, recurrent phlebitis). (See 'Indications' above.)
●Surgical techniques involve ligation and/or removal of veins through multiple incisions. Specific techniques include saphenous vein inversion and removal, high ligation of the saphenous vein, ambulatory phlebectomy, transilluminated phlebectomy, conservative venous ligation (ie, CHIVA), and perforator ligation. (See 'Techniques' above.)
●Compression therapy (eg, ACE wraps, compression stockings) is used to limit bruising, hematoma formation, and swelling in the postoperative period. Compression stockings are maintained until bruising has resolved. (See 'Postoperative instructions' above.)
●Complications following varicose vein surgery include bruising and hematoma formation, infection, nerve injury, phlebitis (superficial or deep), and lymphatic leak. (See 'Complications of surgery' above.)
●Venous ulcer healing rates are not significantly improved following surgical intervention; however, ulcer recurrence is reduced compared with compression therapy alone. (See 'Outcomes' above.)
