Recurrent varicose veins: causes and management

ABSTRACT

High recurrence rates after varicose vein VV surgery still represent a major problem facing vascular surgeons. The aim of this study was to identify the possible causes of recurrent varicose veins RVV and the available management options. This study was conducted on 27 limbs in 23 patients presenting with RVV at Surgery Department, Zagazig University Hospitals. Those were [17] men and [6] women. Their ages ranged from 21-52 years old [mean = 34.3 years]. Clinical assessment, colour Doppler ultrasound US and varicography alone or with ascending venography were done for every patient. We divided our patients into 2 main groups according to the radiological findings. Type I RVV was due to incompetent saphenofemoral venous complex and occurred in 19 limbs [70.37%]. This type was further subdivided into 3 subgroups, A with intact incompetent long saphenous vein LSV in 7 limbs [25.93%], B with incompetent tributaries in 11 limbs [40.74%], and C with neovascularization in one limb [3.70%]. Type I RVV was treated by groin re-exploration and re-ligation of the saphenofemoral junction SFJ with ligation-excision of all varicosities including the LSV. Type II RVV was not related to incompetent saphenofemoral venous complex and occurred in 13 limbs [48.15%]. This type was further subdivided into 4 subgroups, A with cross-groin connections in 2 limbs [7.41%], B due to incompetent thigh perforators in 3 limbs [11.11%], C due to incompetent leg perforators in 5 limbs [18.52%] and D due to incompetent saphenopopliteal junction SPJ and incompetent short saphenous vein SSV in 3 limbs [11.11%]. Subgroups IIA and IIB were treated by ligation-excision of the affected perforators or connections. Subgroup IIC was treated by subfascial ligation of incompetent leg perforators through a posterior longitudinal midline incision, while subgroup lID was treated by ligation of the SPJ with excision of the SSV. Any subgroup of type I or II could occur independently or in combination with any subgroup of either type. No recurrence could be detected in all patients at the end of the 2-year period of follow-up. In conclusion, RVV were mainly due to deficient preoperative investigations missing other important sites of venous reflux and due to improper surgical technique at the SFJ. So, proper preoperative assessment of patients with VV by colour Doppler ultrasound must be done to identify the exact sites of venous reflux to decrease the recurrence rate. Ascending venography may be needed in difficult cases. In addition, VV surgery should be done by experienced senior staff doing proper flush-ligation of the SFJ with ligation-excision of all tributaries to the secondary tributary points and excision of the thigh portion of the ESV. Our aim is to decrease the patient morbidity and medicolegal actions following VV surgery and to save the resources of the national health services