2016 Volume 27 Issue 3 Pages 259-265
Background: Recurrent varices after surgery (REVAS) remain a common problem. Some REVAS can be avoided using accurate manual skills and specific surgical treatment strategies at the time of the first surgery. Treatment strategies for REVAS are also important, and analysis of cases of REVAS may prove useful in determining systematic strategies to prevent recurrence after the first surgery. Patients and Methods: One hundred and eight limbs (7.1%) among a total of 1519 limbs which had varicose vein surgery, required surgery for REVAS between January 2008 and July 2015. Of those limbs, 66 limbs among 59 patients had REVAS due to reflux from incompetent perforating veins or saphenous vein trunks in the calves. The period between previous surgery and REVAS was ≥10 years in 15 limbs, ≥5 years and <10 years in nine limbs, ≥2 years and <5 years in 12 limbs, and <2 years in 30 limbs. According to CEAP (clinical, etiologic, anatomic, pathology) classification, the 66 limbs were categorized into C2 (n=11), C3 (n=2), C4a (n=11), C4b (n=19), C5 (n=10), and C6 (n=13). Deflection to severe cases was remarkably seen. Twenty-four limbs (36%) also had reflux origin from subfascial veins or saphenous vein trunks in the thighs. Analysis of REVAS was conducted using venous ultrasonography. Results: The original surgery consisted of high ligation and stripping of the greater saphenous vein (GSV) in 50 limbs, endovenous ablation of GSV in seven limbs, and resection of tributary veins in 12 limbs. For limbs in which reflux caused REVAS, incompetent perforating veins (IPVs) were observed in 62 limbs. These veins were ablated via subfascial endoscopic perforator surgery (SEPS) utilizing screw-type ports in 26 limbs, direct severing in 31 limbs, and ultrasound-guided foam sclerotherapy (UGFS) in five limbs. IPV localization was as follows: 51 Cockett’s perforators, 18 paratibial perforators, one Boyd’s perforator, and one posterior perforator. In other veins with reflux, eight distal GSVs in calves were found after high ligation and partial stripping of the GSV. Of those, distal GSVs were drained from small saphenous veins in four cases and from IPVs in three cases. Conclusion: The IPV is an important etiology of REVAS, and such IPVs should be treated in the first surgery if present. SEPS represents a very useful choice for surgical management of REVAS. Some cases require full stripping of the GSVs during the first surgery. It is important in order to avoid a recurrence to handle all the reflux diagnosed at the time of the first operation, but when it is left, it should be followed up properly, and it was thought to be treated appropriately.
