Opposite to conservative treatments, invasive treatments are those that require a more or less aggressive approach, but are intended to eliminate varicose veins or venous insufficiency (from Superficial Venous System only).
Here it’s necessary to point out something: although we know many factors that influence the worsening of venous insufficiency (obesity, sedentary lifestyle, pregnancies…), the actual reason that is causing it (the one responsible for the failure of the venous valve system) remains unknown (we believe it has a genetic origin, although it is still not clearly identified). This means that any of the following treatments will only remove the diseased veins, but not the cause that made them become ill.
Thus, if a patient has this cause (unknown yet) particularly intense, it is possible that after a while the varicose veins recur (form again). We estimate that the probability of recurrence after a surgical treatment can be up to 20% (considering any type of recurrence, from minimal to complete ones, and also taking into account the probability along the whole life of the patient). This probability of recurrence is more or less the same for all modalities of treatment that we have available nowadays, with some concrete exceptions that I will point out whenever appropriate.
The chance for recurrence for varicose veins that have been operated is generally unpredictable: we are not able to know to whom this is going to happen, or how long after the treatment. There are only a couple of circumstances that we may know in advance:
- A young female patient, if she undergoes varicose vein surgery and after that she becomes pregnant, the risk of recurrence is very high.
- A patient with postphlebitic syndrome (and therefore with secondary varicose veins), should he undergo any invasive treatment (usually contraindicated, because of the reasons explained in the e-book) they will surely recur.
Finally it should be noted that not all treatments that will be explained below are available for all types of varicose veins or for all patients. It is necessary to perform a comprehensive vein study, including a Venous Duplex Ultrasound, before advising which treatment options are recommended for any particular patient, as they must be customized for every case.
Classic surgery: stripping
The classic surgery for varicose veins means basically to remove the diseased vein: as it is hindering the return venous flow from the limb, after its removal, its job will be carried out by the other veins (the important ones, which are still healthy) and that way the problem is solved.
The most frequent case is the insufficiency of the Greater Saphenous Vein (the most important of all the Superficial Vein system, a vein that runs along the internal side of the lower limb, from the ankle to the groin). The technique to remove this vein is named “saphenectomy” or “stripping“. This technique was invented around 1905 (more than 110 years ago! ) and has not been substantially changed since 1954 (more than 60 years ago! ).
To describe it in a simple way, it requires an incision in the groin – to find where it drains into the Common Femoral Vein (the Saphenofemoral Junction, which is the most frequent place where the valve failure which causes these varicose veins starts), to close and divide it -, and a small incision to access the same Great Saphenous Vein at the ankle or knee level (sometimes some other tiny intermediate incisions might be necessary). Through the vein a small device is introduced, which will help us to remove it completely. Generally this surgical procedure is performed under general or spinal anesthesia, and often requires an overnight hospital admission.
If the saphenous vein has several branches (collateral veins) that are also varicose, they may be removed using Müller’s phlebectomy technique (I’ll discuss about it in the next post).
If the vein to be treated is the Small Saphenous Vein, which drains at the back side of the knee, the incision to disconnect it will be made at this point. But this vein is frequently accompanied by a small nerve that may cause significant discomfort at later stages if injured (neuritis), so the entire vein is not usually removed – only a small segment, or it’s just divided without removing it completely.
Below you will find a Youtube video (BupaHealth® authorship), where the stripping technique is explained using an animation:
Below I will cite other interesting videos, although this time they are from real surgical cases (they can be disgusting for some sensible persons). All these videos belong to their respective authors, and I also warn that some of them may include commercial advertisements:
- https://www.youtube.com/watch?v=01giasq-Dys
- https://www.youtube.com/watch?v=FDB4enWlY9Y
- https://www.youtube.com/watch?v=F67xLpD048k
- https://www.youtube.com/watch?v=Pp6I-k98-D4
The results of these techniques are reasonably good and they have been performed since decades, so we know quite well what can we expect in the long term. The main risks of these procedures are the same as any other surgery: wound infection or bruising (both more common in obese patients, diabetes or impaired function of the immune system). In fact, hematomas are quite common (after all, we are removing veins), so a number of measures are usually prescribed to minimize them: during the immediate postoperative period (several weeks), the patient should wear compression stockings and do some bed rest according to certain guidelines that will be provided by the responsible vascular surgeon.
There is also a common side effect worth mentioning it: below the knee, a small nerve joins the Great Saphenous Vein on its pathway; this small nerve very frequently ends up injured – if complete stripping is performed. Unlike its Small Saphenous sister, this nerve rarely causes major problems: most frequently, only some decreased sensation (paresthesia or numbness) in the area around the inner ankle and the first (big) toe, which may last for several weeks, but it’s usually not painful and recovers spontaneously. Only rarely can cause the neuritis described above (not impossible, but it is quite unfrequent).
After performing a Great Saphenous Vein stripping procedure, complete normal life can be achieved after 3-5 weeks, depending on the patient and the severity of his varicose veins.
Saphenectomy or stripping, with all its advantages and drawbacks, has been until recent years the “gold standard” against which we used to compare the results of all other surgical techniques. Nowadays, in most of the cases, we can use more modern techniques that offer the same or even better results but with a postoperative period that can be far more comfortable. I’ll be explaining every one of these techniques along the following weeks.
Should you be interested in getting to know this disease better, and its causes, consequences, how to treat them, and, even better, what can we do to prevent them, you can find it all well explained in the ebook VARICOSE VEINS: Truth & myths.