Causes and Treatment of Varicose Recurrence in the Popliteal Region

Abstract

Background: In a previous study of 1,081 limbs affected with varicose recurrence (VR) at the saphenofemoral junction (SFJ) and at the sapheno-popliteal junction (SPJ), the anatomical causes were investigated. VR appeared to be due to inadequate diagnosis and surgery; neoangiogenesis appeared to play a minimal role. The so-called cavernoma was secondary to reflux and consisted with a complex collateral circulation (CC). Only 52 of 1,081 (4.8%) studied limbs developed a VR at the SPJ, but the anatomical findings were poorly described. The aims of this study were: 1) to distinguish between VR at the SPJ and the ones caused by different sources of reflux, 2) the reliability of the preoperative DUS examination, and 3) the efficacy and safety of the treatment.

Methods: DUS examinations, surgery and sclerotherapy were performed by one single group of physicians. Nineteen of 207 (9.1%) limbs affected with VR at the popliteal region were studied and treated. Most of the previous interventions performed in different vascular units (only one in our center) were high or low interruption +/- stripping of the small saphenous vein (17/19, 89.4%). VRs > 3 mm were treated by surgical high ligation and intraoperative sclerotherapy in 13/19 (68.4%) and short invagination stripping in 1/19 (5.2%); 4/19 (21.0%) with VR < 3 mm were treated by sclerotherapy only. One patient (5.2%) asked for conservative treatment. In all the cases, intraoperative and postoperative elastic compressions were applied. DUS and surgical findings were compared. Controls were performed by clinical and DUS examination (mean follow-up 3.8 years, min. 1, max. 8).

Results: Of 19 limbs observed, residual SPJ with a long saphenous stump (SS) was in 14 (73.6%) and SPJ was absent in 5 (26.3%): 1/19 (5.2%) was a long SS with high outlet into the superficial femoral, one was (5.2%) a long SS with high outlet into the medial accessory, and two (10.5%) were non-saphenous popliteal perforator. More frequent residuals were in various combinations: SS 14 (73.6%), non-saphenous popliteal perforators 10 (52.6%), intersaphenous communicating veins 3 (15.7%), CC 4 (21.0%), multiple sources of reflux 10 (52.6%), and no suspected neoangiogenesis. DUS/surgical findings were overlapping in 13/14 re-operated limbs (92.8%): no post-treatment residual sources of reflux, short saphenous vein (SSV) permanently occluded by sclerotherapy in 17/18 (94.4%); minor complications in 4/18 (27.7%). Mean follow-up was 3.8 years (min. 1, max. 8).

Conclusions: The main causes of VR at the popliteal region are the postoperative anatomical residuals, mainly a long SS and perforators due to incomplete diagnosis and treatment and/or disease progression. Neovascularization was absent. CC appears to be a consequence of residual reflux. DUS is a reliable method for detecting the anatomical causes and indications for the treatment. Surgical revision combined with intraoperative sclerotherapy and elastic compression appeared to be a simple, effective and inexpensive procedure for the larger VR (> 3 mm) at the PR. Sclerotherapy gave satisfactory results in the treatment of the smallest VR (< 3 mm).




J Curr Surg. 2017;7(3):27-34
doi: https://doi.org/10.14740/jcs325w