Great saphenous varicose vein surgery without saphenofemoral junction disconnectionZamboni P, Gianesini S, Menegatti E, Tacconi G, Palazzo A, Liboni A. Br J Surg. 2010;97:820-825.
Reviewed by
Michel Perrin, Lyon, France
ABSTRACTA duplex protocol including reflux elimination test (RET) [Figure 1] and assessment of the terminal valve was used in 200 patients.
Click on the figure to enlarge i
[b]http://www.veinews.com/wp-content/uploads/2011/01/Per003img.jpgt One hundred patients who had a positive RET result and an incompetent terminal valve were compared with 100 patients matched for age, sex, and CEAP clinical class who had a positive RET result and a competent terminal valve. All patients were treated by incompetent tributary phlebectomy sparing the segments above the reentry perforators as described in previous articles (ambulatory conservative hemodynamic management of varicose veins, or cure CHIVA in French).1 At 3-year follow-up, 100% of patients with competent terminal valve were cured according to the Hobbs classification2 and 14% developed recurrence; 71% of patients with incompetent terminal valve were not cured according to the Hobbs classification and 82% developed recurrence (P<0.001).
COMMENTARY This article is interesting for 2 reasons
1) Preservation or nonpreservation of the saphenofemoral junction
Until recently non-flush ligation of the saphenofemoral junction (SFJ) was considered a technical mistake when treating by open surgery great saphenous vein incompetence. This dogma was based on the descending pathophysiology theory of varicose vein progression as stipulated by Trendelenburg in 1890. Because of ultrasound investigation this pathophysiological concept is now being questioned.
Firstly because many patients with varicose great saphenous vein have no reflux at the SFJ.3-16
Furthermore, when reflux is identified at the SFJ the terminal valve is competent in about 50% of cases, knowing that the subterminal valve is incompetent.17 We have long known that sclerotherapy is successful in many cases although great saphenous vein termination remained patent. More recently thermal ablation without high ligation has led to excellent outcomes at medium- and long-term follow-up.18 The fate of the SFJ was assessed after thermal ablation by ultrasound and no persistent reflux was identified.19,20 A randomized control study comparing at 2 years great saphenous vein laser ablation with and without ligation of the SFJ did not find a difference in terms of outcome between the 2 groups.21 This could explain why classic surgery, ie, high ligation plus stripping with preservation of the SFJ, has been adopted by some centers.
The first report of saphenous stripping with preservation of the SFJ was by Pittaluga who reported a retrospective series of 195 incompetent great saphenous veins (151 patients) treated by stripping with preservation of the SFJ, knowing that the terminal valve was incompetent in 157 cases (80.5%).22 At a mean of 24.4 months postoperatively (median 27.3 months, range 8 to 34.
, persistent SFJ reflux was observed in only two cases (1.8%) and SFJ neovascularization in one case (0.9%). The latter percentage is crucial as we know that after flush high ligation neovascularization is the main cause of recurrence and is estimated to occur in between 20 and 40% of cases, depending on the duration of follow-up.23-27
2) For assessment of CHIVA and outcome
While SFJ was preserved but the saphenous trunk stripped in the Pittaluga’s study, 22 the saphenous trunk was preserved in the CHIVA 2 procedure, as reviewed in the present study. According to Zamboni et al, a complementary maneuver is recommended in order to determine if the SFJ must be preserved or not. This is a new recommendation in the CHIVA 2 procedure.
Another point worth underlining is that in their introduction Zamboni et al state that with CHIVA-2 reported rates of recurrent reflux were 15% after 6 months 3 and 92% after 3 years.28 These recurrence rates are not in accordance with data from a randomized controlled trial by Parés et al in which clinical and ultrasound recurrence rates after CHIVA were 26.8% and 36.3%, respectively, at 5-year follow-up.29,30
Hypothesis
How can we explain these differences in outcome between classic surgery, thermal and chemical ablation (group 1) and surgery preserving the saphenous trunk (CHIVA) when the SFJ is preserved?
In the first group it seems that competence or incompetence of the terminal valve does not influence the results; in CHIVA group it does. The explanation could be that in the first group saphenous ablation significantly decreases the “reservoir” in which the reflux drains, whereas in CHIVA the draining reservoir persists.
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30. See also VEINEWS of December 14, 2010 for comprehensive bibliographic references
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