J Curr Surg

Journal of Current Surgery, ISSN 1927-1298 print, 1927-1301 online, Open Access

Article copyright, the authors; Journal compilation copyright, J Curr Surg and Elmer Press Inc

Journal website http://www.currentsurgery.org

Original Article

Volume 7, Number 3, September 2017, pages 27-34

Causes and Treatment of Varicose Recurrence in the Popliteal Region

Figure 1. (a) A woman of 67 years of age. Appearance of symptomatic VR in the PR 4 years after the previous surgical procedure for varicose veins at the PR. Cross scanning of DUS examination at the PR: incompetent gastrocnemius perforator (GP) connected with the long residual SSV stump. The internal gastrocnemius vein (GV) is visible. (b) Treatment: SPJ surgical interruption and intraoperative DUS-guided foam sclerotherapy of gastrocnemius perforator (GP) and residual SSV. DUS examination after 30 days: the SS stump is not compressible and partially hyper-echogenic from early fibrosis (SSV), the gastrocnemius perforator (GP) is hyper-echogenic from early complete fibrosis in the subfascial segment, the internal gastrocnemius vein (GV) is patent and compressible. (c) DUS examination after 30 days: the gastrocnemius perforator (GP) is occluded with no flow into the lumen, the SS stump is not compressible and hyper-echogenic from advanced fibrosis (SSV), the internal gastrocnemius vein (GV) is patent and compressible.

Figure 2. (a) A woman of 42 years of age, operated on for VVLL at the SPJ. Appearance of symptomatic VR in the PR, belonging to a residual SSV, after 2 years. The clinical and preliminary DUS examination demonstrated an aneurysm of the proximal long SSV incompetent stump (SS) connected with a small incompetent collateral vein (CV). (b) Preoperative skin mapping. A more extended DUS examination detected the following combined sources of reflux which are visible in the preoperative skin drawing: aneurysm of the residual SS, double high non-saphenous popliteal perforator, connection with the medial accessory of the GSV as main causes of VR at the PR; low gastrocnemius and peroneal perforators. The black arrow indicates the SS aneurysm. The black circles correspond to the four incompetent perforators.

**Table 1.** Distribution of VR at the Junctions in 1,831 Limbs of 1,760 Patients
Site of varicose recurrence	N	%
SFJ: sapheno-femoral junction; PR: popliteal region. Causistry of the years 2005 - 2016.
Limbs	1,831	100
Varicose recurrence SFJ - SPR	207	11.3
Varicose recurrence PR (isolated)	19 19/207	1.0 9.1

Table 1. Distribution of VR at the Junctions in 1,831 Limbs of 1,760 Patients

Site of varicose recurrence

SFJ: sapheno-femoral junction; PR: popliteal region. Causistry of the years 2005 - 2016.

Limbs

1,831

100

Varicose recurrence SFJ - SPR

207

11.3

Varicose recurrence PR (isolated)

19
19/207

1.0
9.1

**Table 2.** Characteristics of 19 Limbs of 17 Patients Affected With Varicose Recurrence (VR) at the PR
	Mean	Min.	Max.
C2-C6: CEAP clinical classification; CHIVA: cure hemodinamique insuffisance veineuse ambulatoire; EVLA : endovenous laser ablation.
Patients (17)
Years of age	38.8	27	73
Years from surgery and VR	4.8	1	12
	N	%
Patients	17	100
Males	7	41.1
Females	10	58.8
Symptomatic (C2-C6)	16	94.1
Limbs (bilateral 2)	19	100
Right	7	36.8
Left	12	63.1
C2	12	63.1
C3	2	10.5
C4	2	10.5
C5	2	10.5
C6	1	5.2
Previous treatments
Surg. interruption + stripping	8	42.1
Low ligation +/- stripping SSV	6	31.5
CHIVA	3	15.7
EVLA	2	10.5

Table 2. Characteristics of 19 Limbs of 17 Patients Affected With Varicose Recurrence (VR) at the PR

Mean

Min.

Max.

C2-C6: CEAP clinical classification; CHIVA: cure hemodinamique insuffisance veineuse ambulatoire; EVLA : endovenous laser ablation.

Patients (17)

Years of age

38.8

Years from surgery and VR

4.8

Patients

100

Males

41.1

Females

58.8

Symptomatic (C2-C6)

94.1

Limbs (bilateral 2)

100

Right

36.8

Left

63.1

10.5

5.2

Previous treatments

Surg. interruption + stripping

42.1

Low ligation +/- stripping SSV

31.5

CHIVA

15.7

EVLA

10.5

**Table 3.** Treatment Performed in 19 Limbs of 17 Patients (Two Bilateral) Affected With VR at the PR
Treatment	N	%
DUS: duplex ultrasound examination.
Surgical revision interruption + sclerotherapy	13	68.4
Surgical revision interruption + short SSV stripping	1	5.2
USD-guided sclerotherapy	4	21.0
Conservative treatment	1	5.2
Postoperative sclerotherapy	5	26.3
Elastic compression	19	100

Table 3. Treatment Performed in 19 Limbs of 17 Patients (Two Bilateral) Affected With VR at the PR

Treatment

DUS: duplex ultrasound examination.

Surgical revision interruption + sclerotherapy

68.4

Surgical revision interruption + short SSV stripping

5.2

USD-guided sclerotherapy

21.0

Conservative treatment

5.2

Postoperative sclerotherapy

26.3

Elastic compression

100

**Table 4.** Residual Varicose Veins and Anatomical Findings Detected by DUS Examination in 19 Limbs and by Direct Surgical Dissection in 14
Sites of VR	N	%
Comparison DUS/surgery analyzed by exact Fisher’s test (P = 1). SSV: short saphenous vein; GSV: great saphenous vein; VV: varicose vein. Sapheno-politeal junction: normal outflow of the SSV. Popliteal region: absence of the SSV outflow. In cursive writing 1 aneurysmatic of the 13 saphenous stumps. Percentages calculated on the total of 19 limbs.
Sapheno-popliteal junction	14	73.6
Saphenous stump +/- residual tributary (1 aneurysmatic = 5.2%)	13	68.4
SSV persistence in a previous duplicity	2	10.5
Popliteal perforator (non saphenous) (combined)	2	10.5
Medial gastrocnemius perforator	2	10.5
Medial communicating SSV-GSV	3	15.7
Medial accessory (Giacomini)	1	5.2
Gluteal perforator	1	5.2
Lateral perforator of the thigh	1	5.2
VV of the sciatic nerve	0	0
Neovascularization by neoangiogenesis (suspected)	0	0
Complex collateral circulation (cavernoma)	4	21.0
Sapheno-popliteal region	5	26.3
Saphenous Stump - outflow into superficial femoral	1	5.2
SSV outflowing into the medial accessory (Giacomini)	1	5.2
Popliteal perforator (non saphenous)	2	10.5
Medial gastrocnemius perforator	2	10.5
VV of the sciatic nerve	0	0
Neovascularization by neoangiogenesis	0	0
Complex collateral circulation (cavernoma)	0	0

Table 4. Residual Varicose Veins and Anatomical Findings Detected by DUS Examination in 19 Limbs and by Direct Surgical Dissection in 14

Sites of VR

Comparison DUS/surgery analyzed by exact Fisher’s test (P = 1). SSV: short saphenous vein; GSV: great saphenous vein; VV: varicose vein. Sapheno-politeal junction: normal outflow of the SSV. Popliteal region: absence of the SSV outflow. In cursive writing 1 aneurysmatic of the 13 saphenous stumps. Percentages calculated on the total of 19 limbs.

Sapheno-popliteal junction

73.6

Saphenous stump +/- residual tributary (1 aneurysmatic = 5.2%)

68.4

SSV persistence in a previous duplicity

10.5

Popliteal perforator (non saphenous) (combined)

10.5

Medial gastrocnemius perforator

10.5

Medial communicating SSV-GSV

15.7

Medial accessory (Giacomini)

5.2

Gluteal perforator

5.2

Lateral perforator of the thigh

5.2

VV of the sciatic nerve

Neovascularization by neoangiogenesis (suspected)

Complex collateral circulation (cavernoma)

21.0

Sapheno-popliteal region

26.3

Saphenous Stump - outflow into superficial femoral

5.2

SSV outflowing into the medial accessory (Giacomini)

5.2

Popliteal perforator (non saphenous)

10.5

Medial gastrocnemius perforator

10.5

VV of the sciatic nerve

Neovascularization by neoangiogenesis

Complex collateral circulation (cavernoma)