Surgical
principles
Horizontal incision
Skin - Aponevrosis
Lowest traumatism
Binocular loupes  3.5
Without electric scalpel
ANAESTHESIA
1. General
2.Spinal (homolateral)
3.Sciatic bloc
P <.001
Ambulatory
VLOKA JD et al. J Clin Anesth 1997;9:618-22
Vasoplegia
+ Neurologique risk
Local
ANAESTHESIA
Neurological risks
Un-crossing under the
sciatic nerve
Extraction of the vein
Inverse
intra-dermic
suture
Biosyn®
Residual stump
Great saphenous
Short saphenous
Cotton wool dressing
Biflex bandage n°16
Double elastic stocking Classe II
Surgery for
recurrent saphenofemoral
incompetence using ePTFE patch
« long-term outcome »
Follow up  5 ans
100 patients -119 legs
Creton D presented at EVF 2001 Roma
Creton D Phlebology 2002 ;16 : 93-7
4%
New neovascularization in the groin
Failure
A
23%
Varices :
Perforators
Popliteal fossa
Thigh
Calf
B2
B0
28%
No varices
B1
Diffuse varices :
no reflux
45%
Refluxing inguinal vein
without connection
to the femoral vein
Near the femoral vein
Frequency of re-neovascularization
after re-do for recurrence
Re-surgery for recurrence without patch
DE MAESSNER
DE MAESSNER
n=14
n=11
1 an
4.6 ans
21 %
63 %
Re-surgery for recurrence with patch
EARNSHAW
CRETON
No dissection
No resection
in the groin
n =15
n =119
1 an
5-6 ans
????
40 %
4.2 %
Conclusion GSV:
Minimal dissection
1 Stop the leak
3 Echosclerosis
2 Suppress the tank
!
Complete ablation of varicose veins
Ablation of insufficient trunk
Randomized studies with and without patch
must be done to separate the role of :
1) No dissection/resection in the groin
2) Patch
3) Complete ablation of varicose veins
In this good results
Surgical treatment of the
recurrence in popliteal fossa
« Short term results »
24 Legs
Premedication
Local anaesthesia Lilocaïn 1%
Midazolan - Hypnovel ®
Alfentanyl - Rapifen ®
0
35 ml
2 ml
0.5 ml
CRETON D. Phlébologie 2000;53:419-24
Hospitalisation
•Day surgery……….19
5
4
3
2
1
0
5
15
30
60
80
100
230
Km
Distance of their home to the center
•24 hours…………...5
Sick leave
4
44%
3
2
1
1 3 8 12 13 15 16 20 21
0
Days
Complication and morbidity (24)
§ failure in ablation 1
(double Perf Popl Fossa)
§ neurologic injury 1
(posterior cutaneous nerve)
Patient’s acute pain during the dissection !
= accidental section of the
posterior cutaneous nerve
Suture of the
posterior
cutaneous
nerve
Tinel
(new growth)
J + 6 months
good result
Complications and bad results (15)
« General Anaesthesia »
Œdemas
7
Injury of fibular sciatic nerve 1
Hypertrophic vertical scars 4
LUCERTINI G et al. Minerva Cardioangiol 1998;46:91-5
Conclusion SSV:
Anatomical situation of
the incompetent SPJ
is favourable to surgery
Provided that !!!
Preoperative
duplex US
Local
Anesthesia
Atraumatic
Impossible to avoid
x% of recurrences
Specific problem of the
deep vein pressures
between calf and thigh
Popliteal
Fossa
23% Vein
Systolic reflux !!!!!
Conclusions
Local Anesth (Re-do SSV) 100%
Loco-regional Anesth (Re-do GSV) 100%
Ambulatory 90%
Complications  0
Conclusion : which treatment ?
Surgery
can
do
Atraumatic
everything !
Local anaesthesia
Echo-guided
failures
GSV 4%
SSV ?%
Perf popliteal
fossa ?%
Which
treatment ?
•Perforator Popliteal fossa
•Inguinal
neovascularization
•Lymphoganglionic
veins
Echo-guided
sclerotherapy
Conclusions
Recurrence risks SPJ
?
less controled than SFJ
Recurrence SPJ
Major role of the
Deep Vein Pressures
Recurrence SFJ
Major role of the
Residual Varicose Veins
?
?