You are in: eMedicine Specialties > Dermatology > SURGICAL Varicose Veins Treated With Ambulatory PhlebectomyArticle Last Updated: Aug 30, 2007AUTHOR AND EDITOR INFORMATIONSection 1 of 10
  Author: Robert Weiss, MD, Associate Professor, Department of Dermatology, Johns Hopkins University School of Medicine Robert Weiss is a member of the following medical societies: American Academy of Cosmetic Surgery, American Academy of Dermatology, American College of Phlebology, American Dermatological Association, American Society for Dermatologic Surgery, American Society for Laser Medicine and Surgery, and MedChi Coauthor(s): Albert-Adrien Ramelet, MD, Specialist in Dermatology and Angiology Editors: Désirée Ratner, MD, Director of Dermatologic Surgery, George Henry Fox Assistant Clinical Professor, Department of Dermatology, Columbia Presbyterian Medical Center, New York Presbyterian Hospital; David F Butler, MD, Professor of Dermatology, Texas A&M University College of Medicine; Director, Division of Dermatology, Scott and White Clinic; Director Dermatology Residency Training Program, Scott and White Clinic; John G Albertini, MD, Consulting Staff, Dermatologic Surgery, The Skin Surgery Center; Glen H Crawford, MD, Assistant Clinical Professor, Department of Dermatology, University of Pennsylvania School of Medicine; Chief, Division of Dermatology, The Pennsylvania Hospital; Dirk M Elston, MD, Director, Department of Dermatology, Geisinger Medical Center Author and Editor Disclosure Synonyms and related keywords: stab avulsion of varicose veins, phlebectomy hooks, venous insufficiency, reflux circuit, superficial varicose veins, varicose branches, venous valve failure, stasis dermatitis, superficial phlebitis, hook avulsion of varicose veins INTRODUCTIONSection 2 of 10
  Ambulatory phlebectomy permits removal of incompetent veins below the saphenofemoral and saphenopopliteal junctions, not including the proximal great or short saphenous veins. The junctions themselves cannot be treated with simple phlebectomy as junctional reflux must be addressed by endovenous ablation methods or rarely by surgical ligation and stripping. Veins that may be removed by ambulatory phlebectomy primarily include major tributaries; perforators; and reticular veins, including small reticular veins associated with telangiectasias. In contrast to traditional venous ligation, the small size of the skin incision or puncture usually results in little or no scarring. Performed with the patient under local anesthesia, ambulatory phlebectomy leads to greatly reduced surgical risks compared with traditional surgery for truncal (axial), reticular varicose veins and incompetent perforators. In contrast, for these larger veins, sclerotherapy involves risks including intra-arterial injection, iatrogenic phlebitis, deep vein thrombosis and pulmonary embolism, skin necrosis, and most of all, residual hyperpigmentation. History of the ProcedureCornelius Celsus first described phlebectomy in 45 CE. The earliest phlebectomy hooks were described in 1545, as illustrated in the Textbook of Surgery authored by W.H. Ryff. Dr Robert Muller, a Swiss dermatologist in private practice in Neuchâtel, Switzerland, rediscovered the technique in 1956. He developed his own technique and instruments and taught the technique to hundreds of physicians. Dr A.A. Ramelet, former president of the Swiss Society of Phlebology, was one of Dr Muller's students who further advanced the technique for smaller reticular veins with his own hooks. Today the technique is practiced by thousands of phlebologists around the world. PathophysiologyVenous insufficiency is caused by a refluxing circuit that results from failure of the primary valves at the saphenofemoral junction typically leads to superficial varicose veins. Varicose veins that branch off an incompetent saphenous vein are called branch veins or secondary varicosities. The typical signs and symptoms of venous insufficiency, including ankle edema, stasis dermatitis, and possibly ulceration, may occur when varicose veins are untreated. The most important aspect of pathophysiology is the origin point of reflux and its elimination. Only then can branch varicosities be treated. ClinicalDetailed general and phlebologic examination is mandatory before any phlebologic treatment is administered. Careful attention must be paid to the patient's medical history and to the general state of the patient, and any contraindications to local anesthesia or the surgical procedure itself must be identified. The integrity of the deep venous system and the proper function of the calf muscle pump should be ensured. Also, preoperative clinical and ultrasonographic examinations are essential to detect and map all types of the varicosities and their origins. Duplex ultrasonography mapping of the source of reverse flow or reflux is typically performed. Important sources of reflux (eg, saphenofemoral or saphenopopliteal junctions) should be corrected before any effort is made to address end-branch disease. INDICATIONSSection 3 of 10
Although any branch varicosity can be removed by means of hook extraction, inexperienced physicians should be careful to avoid the popliteal fold, the dorsum of the foot, and the prepatellar and pretibial areas. These regions are more susceptible to injury, and they contain veins that can be more difficult to extract. Veins most readily treated with phlebectomy include branch varicosities of the great and short saphenous veins, pudendal veins in the groin, and reticular varices in the popliteal fold or lateral part of the thigh. Phlebectomy can also be used as an immediate treatment for small segments of superficial phlebitis because the intravascular coagulum is expressed and the involved vein segment can be extracted through the same incision. Large, tortuous distal branch varicosities are typically treated by using ambulatory phlebectomy but some branch varicosities may be rarely treated by endovenous ablation techniques. Ambulatory phlebectomy is best for tortuous varicosities. Radiofrequency ablation catheters or optical laser fibers cannot easily be passed along a tortuous vein. Large, tortuous varicosities can also be treated by foam sclerotherapy in which a detergent sclerosant, such as 1 - 3% sodium tetradecyl sulfate, is agitated with air. Physician assessment of the thickness of the vein wall can be the determining factor in terms of use of ambulatory phlebectomy versus foam sclerotherapy, the latter being reserved for thinner-walled veins. CONTRAINDICATIONSSection 4 of 10
Contraindications to ambulatory phlebectomy are reflux at the saphenofemoral or saphenopopliteal junctions. These junctions must be treated by other means such as endovenous radiofrequency or laser ablation. WORKUPSection 5 of 10
Lab Studies
Imaging Studies
Histologic FindingsHistologic specimens of removed varicose vein typically demonstrate features of varicose veins that have had a dynamic response to venous hypertension. Varicose veins are dilated and tortuous veins with significantly larger wall areas and higher amounts of collagen. Varicose veins have a higher content of smooth muscle and elastin. TREATMENTSection 6 of 10
Surgical therapyAmbulatory phlebectomy requires a small number of surgical instruments. A No. 11 scalpel or an 18-gauge needle is used to make microincisions. Multiple mosquito forceps are used to grasp the veins as they are extracted. Ambulatory phlebectomy hooks include the classic Muller hook, which most resembles a crochet hook with a blunt tip and a straight shaft that is designed to be placed under the veins and pulled out from below. The Oesch hook, which is available in 3 sizes, is characterized by a massive squared-off grip, and is designed with a small barb at the tip to pierce the vein from the lateral aspect and elevate it. The Ramelet hook, which is available in 2 sizes, is a small, fine hook. The smaller of the 2 is designed to remove reticular or medium-sized truncal varicose veins. The larger one has a thicker stem that is useful in large truncal and perforating veins. The cylindrical grip permits gentle rolling of the hook between the fingers, which diminishes the amount of rotation of the wrists and minimizes wrist and hand stress during the procedure. The shaft is short and allows precise and close work as well as moderate traction. The hook angulation facilitates vein dissection, while the sharp tip grips the vein by the perivenous collagen bundles and tunica externa, allowing them to be lifted from above. (This approach limits damage to the surrounding tissues and lymphatics.) Preoperative detailsPremedication is rarely required, and it should be avoided as much as possible. Premedication may hinder immediate postoperative walking, which is the best means of preventing potential vascular complications. The varicose veins are carefully identified with an indelible marking pen or surgical marker with the patient standing. The patient is then placed supine for further marking. Cutaneous transillumination may be helpful in marking the veins for removal and, particularly, in detecting shifts in position of the veins when the patient moves from a standing position to a supine position. The most common anesthetic for phlebectomy is large-volume, low-concentration lidocaine known as tumescent anesthesia. Tumescent anesthesia is very different from local anesthetic injection at points along a vein or a field block. Using the tumescent technique, up to 800 mL of 0.1-0.2% lidocaine with epinephrine is injected in order to push the vein closer to the skin and cause vasoconstriction of skin capillaries to minimize postoperative bleeding. This can be infused below the vein, just under the dermis, using a peristaltic pump or a series of large syringes. To minimize the pain that accompanies the injection of a normally acidic anesthetic solution, commercial lidocaine-epinephrine solutions can be buffered to a near-neutral pH by adding 1 mL of an 8.4% sodium bicarbonate solution to every 10 mL of lidocaine solution used. When lidocaine is used without epinephrine, the recommended dose is as much as 4.5 mg/kg, not to exceed 300 mg. The addition of epinephrine slows the absorption of lidocaine and permits the use of as much as 7 mg/kg, not to exceed 500 mg, in a single session. Allergic and toxic reactions are rare, but intravenous perfusion solutions, resuscitation equipment, epinephrine, injectable steroids, and intravenous diazepam should be readily available. Intraoperative detailsThis outpatient procedure requires good lighting and an operating table that allows the patient to be in a Trendelenburg position. Direct intraoperative support is seldom necessary, but a nurse or assistant should be present in the office. Emergency equipment and supplies should be nearby. Only a small number of surgical instruments are required to perform phlebectomy on an ambulatory basis. Cutaneous incisions are made with the No. 11 scalpel or 18-gauge needle. The incisions should be vertically oriented along the thigh and lower leg and should follow the skin lines at the knee or the ankle. The distance between the incisions varies from 2-15 cm, according to the experience of the surgeon, size of the vein, presence of perforators, previous episodes of phlebitis, and results of previous sclerotherapy. The varicose vein is gently dissected by undermining it with the stem of the phlebectomy hook. Undermining is largely performed along the course of the vein, but it is also slightly extended in a perpendicular direction. When freed of its fibroadipose attachments, the liberated vein can then be grasped by using the harpoon of the hook, and it is easily removed with the mosquito forceps held in the other hand. The surgeon also uses his or her nondominant hand to grip a sterile gauze strip and ensures hemostasis by applying local compression to the already removed venous network. The whole varicose vein is progressively extracted from one incision to the next. Incompetent perforators are carefully dissected and eliminated with gentle traction or torsion. Venous ligation is not necessary because hemostasis is achieved with local compression during and after surgery. Areas in which postoperative compression is most difficult (eg, popliteal folds, thighs, groin, areas with deep and large perforators) are surgically removed first to permit the maximum time for hemostasis while the patient remains supine. No skin closure is needed if the physician uses minimal incisions (1-3 mm) and good postoperative compression. With experience, removing extensive venous networks on both legs in a single 60- to 120-minute session is usually possible. Complementary fine-needle sclerotherapy of telangiectasias can be performed immediately before or after the eradication of their nourishing venules. Large telangiectasias may also be destroyed by means of gentle subcutaneous curettage with the harpoon of the hook, whereas debris of venectasias can be removed through tiny incisions. At the end of the operation, the leg is carefully cleansed with hydrogen peroxide or surgical soap. If oozing persists at any site, it is easily controlled with additional local compression. Punctures are not sutured or closed with adhesive strips. This aids drainage of tumescent fluid and improves the cosmetic result. Postoperative detailsPostoperative bandaging is an essential step in the procedure, and the physician or a well-trained assistant should carefully apply the bandages. The incisions or punctures are left open to allow tumescent anesthesia fluid to drain quickly. Large pads, either gauze or sanitary napkins, are placed along the site of vein removal and covered with an inelastic bandage. If the physician is experienced with bandaging, a second dressing with a highly elastic (long-stretch) bandage is applied to the leg. This compression dressing prevents postoperative hemorrhage and reduces the likelihood of pain, bruising, seroma formation, and other complications. The long-stretch bandage is applied from the foot up, beginning at the toe joints and including the heel; it is proximally extended to cover all incisions. To avoid a tourniquet effect, an elastic dressing must never be applied over the proximal part of the leg without beginning at the feet. If the physician is not experienced with elastic bandaging, compression stockings may provide an alternative means of compression. A single pair of 40- to 50-mm Hg compression hose may be used, or 2 layers of 20- to 30-mm Hg stockings may be applied for additive effects. If 2 layers of stockings are used, the topmost pair may be removed at night and replaced in the morning. Daily ambulation should be increased as much as possible in the immediate postoperative period. Under no circumstances should a patient be confined to bedrest after venous surgery. Patients may return to work immediately after the operation, but they should not drive an automobile until the next day, because distal motor function may be subtly impaired because of prolonged anesthesia, particularly after local anesthesia in the popliteal region. Dressings are removed after 24 or 48 hours. Typically, the incisions are minimal, and wound dressings are not necessary. However, ongoing compression therapy with elastic bandages or compression stockings is mandatory for 7-21 more days, depending on the size of the removed veins and the degree of the reflux treated. Stockings may be removed for showering after the fourth postoperative day; otherwise, stockings should be worn continuously. Complementary sclerotherapy of residual varicosities should be delayed several weeks until postoperative healing is well advanced. Many telangiectasias may progressively and spontaneously regress and disappear after varicose veins are removed by means of ambulatory phlebectomy. Patients should avoid early sun exposure because hyperpigmentation may result at the puncture or incision sites. Follow-upAt 6 weeks after surgery, the success of the procedure and the need for additional sclerotherapy or laser procedures for residual small veins are assessed. For excellent patient education resources, visit eMedicine's Circulatory Problems Center. Also, see eMedicine's patient education article Varicose Veins. COMPLICATIONSSection 7 of 10
Most minor complications are benign and resolve spontaneously. Typically, varicose veins recur when the source of venous reflux is missed. Sometimes, the cause may not be apparent until the phlebectomy is performed, particularly when many varicose veins are present. The chief complications are edema, excessive hemorrhage, hematoma formation, scarring, trauma-induced telangiectatic matting, and blisters due to wound dressings. Other complications, such as occasional nerve injury with sensory disturbances, are relatively unavoidable because a fibrotic nerve may be attached to the removed venous segment. Severe infections have been reported. Rarely, skin necrosis may occur and it is believed to be related to a high pH caused by adding too much bicarbonate to the anesthetic solution. Superficial hematomas are common. Hematoma formation depends on individual variations in coagulation and on the effectiveness of the postoperative compression. Hematomas are most common in the popliteal fold, the most difficult area in which to achieve good postoperative compression. Some patients complain of persistent subcutaneous nodules, which correspond to deep hematomas in the tunnel of the removed vein. When subcutaneous nodules occur, they are reabsorbed over several months. Significant delayed postoperative oozing may occur. After postoperative dressings are applied, the patients (particularly those with a long journey home) should be asked to walk around for 30 minutes, and the dressing should be reevaluated. Superficial phlebitis may occur in incompletely removed varicose veins or neighboring veins. Deep venous thrombosis is not yet reported after ambulatory phlebectomy, probably because compression bandages and ambulation are effective forms of prophylaxis. Lymphatic pseudocysts may be complications of phlebectomy of the ankle or pretibial or popliteal areas. When a subcutaneous nodule develops rapidly, the lymph collection may be punctured and drained. The best treatment is increased compression along with periodic gentle circular massage. In resistant cases, lymphatic drainage may be required. Neotelangiectasia (ie, telangiectatic matting) is the most annoying potential complication of phlebectomy. This complication is observed after classic stripping, as well as after sclerotherapy, and the etiology is unclear. In some cases, it seems to be related to a sudden local increase in venous pressure or to an area of persistent reflux that remains to be corrected. In others, it may be an abnormal angiogenic response to tissue injury. Some authors have noted an association with exogenous estrogens, but this association has not been confirmed. Usually, matting spontaneously fades away after several months. In some cases, matting may be treated with sclerotherapy of the tiniest vessels; however, in other cases, every attempt to sclerose the vessels results in a new blush of recurrent matting. Laser or high-energy intense pulsed-light therapy could also be considered. Small cutaneous sensory nerve injury is common when veins are removed under general or regional anesthesia. However, sensory nerve injury is much less common when local anesthesia is used, because intraoperative manipulation of a sensory nerve is painful. If the surgeon stops immediately when the patient reports pain, sensory branches are typically left intact. Small-nerve injury is possible in patients previously treated with sclerotherapy because inflammatory fibrous reaction and surrounding tissue adhesions bind the vein to the adjacent sensory nerves. Hyperanesthesia, hypoanesthesia, or total anesthesia secondary to nerve injury usually resolves within weeks or months. Neuroma is an extremely uncommon complication of peripheral nerve injury. OUTCOME AND PROGNOSISSection 8 of 10
Long-term results after phlebectomy are excellent when the procedure is performed for the appropriate indications. The main indication is an incompetent primary branch of the greater or lesser saphenous vein. Long-term success rates of 90% or greater are reported. Long-term success is typically associated with the elimination of high-grade junctional reflux before or immediately prior to phlebectomy. It is common practice to perform an endovenous ablation of saphenous reflux and then perform ambulatory phlebectomy of varicose branches arising from the saphenous system. As with any therapy, new varicose veins may develop over time, and patients must be informed about the likely evolution and progression of venous insufficiency and the associated genetic predisposition. MULTIMEDIASection 9 of 10
REFERENCESSection 10 of 10
Varicose Veins Treated With Ambulatory Phlebectomy excerpt Article Last Updated: Aug 30, 2007 | |||||||||||||||||||||||||||||||||||
