The role of new reflux of accessory veins in clinical recurrence of varicose veins after endovascular laser ablation (EVLA)

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1 Cyprus Society of Vascular and Endovascular Surgery The role of new reflux of accessory veins in clinical recurrence of varicose veins after endovascular laser ablation (EVLA) Toursidis Achilleas, MD, MSc, Secretary General of Cyprus Society of Vascular and Endovascular Surgery (CSVES) Vascular Surgery Center, Limassol, Cyprus Trigonakis Konstantinos, MD, PhD, FEBVS Department of Vascular and Endovascular Surgery, Euromedica General Clinic of Thessaloniki, Greece

2 Recurrent varicose veins are known to be a common problem after surgery. The incidence of those patients with recurrent veins after surgery is reported to be between 20-80% [1-4] 1] L. Jones, B. D. Braithwaite, D. Selwyn, S. Cooke, and J. J. Earnshaw, Neovascularisation is the principal cause of varicose vein recurrence: results of a randomised trial of stripping the long saphenous vein, European Journal of Vascular and Endovascular Surgery, vol. 12, no. 4, pp , [2] R. J.Winterborn, C. Foy, and J. J. Earnshaw, Causes of varicose vein recurrence: late results of a randomized controlled trial of stripping the long saphenous vein, Journal of Vascular Surgery, vol. 40, no. 4, pp , [3] S. Dwerryhouse, B. Davies, K. Harradine, and J. J. Earnshaw, Stripping the long saphenous vein reduces the rate of reoperation for recurrent varicose veins: five-year results of a randomized trial, Journal of Vascular Surgery, vol. 29, no. 4, pp , [4] L. Blomgren, G. Johansson, A. Dahlberg- Akerman et al., Recurrent varicose veins: incidence, risk factors and groin anatomy, European Journal of Vascular and Endovascular Surgery, vol. 27, no. 3, pp , 2004.

3 MAIN FACTORS FOR RECCURENCE OF VVS AFTER TREATMENT Ligation & Stripping NEOVASCULARIZATION PERFORATORS of THIGH and CALF Endovenous laser ablation (EVLA) New reflux from side branches of safeno-femoral junction, mainly anterior accessory great safenous vein (AAGSV) [5] M. R. Perrin, N. Labropoulos, and L. R. Leon Jr., Presentation of the patient with recurrent varices after surgery (REVAS), Journal of Vascular Surgery, vol. 43, no. 2, pp , [6] R. G. Bush, P. Bush, J. Flanagan, R. Fritz, T. Gueldner, J. Koziarski, K. McMullen, and G. Zumbro, Factors Associated with Recurrence of Varicose Veins after Thermal Ablation: Results of The Recurrent Veins after Thermal Ablation Study Hindawi Publishing Corporation, Volume 2014, Article ID , 7 pages

4 While during the classic saphenectomy procedure all the side branches of saphenofemoral junction are being ligated, when the thermal ablation is performed the side branches (mainly AAGSV or PAGSV) that end up at the first 2 cm from the saphenofemoral junction or to the epigastric vein are most of the times not being treated when a reflux is absent. These veins could be the cause of a new reflux and recurrence of varicose veins.

5 MATERIALS and METHODS Retrospective study compared two groups of patients The first group A contained a large number of patients (totally 168 legs) treated with EVLA from 2004 to 2010 to whom the accessory veins were not treated, when not refluxing and were followed up for 5 years. The accessory veins were punctured with micro set 4 French when the diameter was from 1 to 3 mm. The second group B of patients (totally 380 legs) treated from 2011 to 2016 when the accessory veins were treated non-regarding their reflux and followed up until The patients were followed up in 12, 24, 26, 48, 60 months after the procedure with Duplex Ultrasound

6 MATERIALS and METHODS 980 nm laser and bare optical fibers 600 micron YEARS nm laser and radial fibers of 400 and 600 micron, bare fibers of 400 microns YEARS

7 RESULTS During 12 years 548 legs were treated for the great saphenous vein insufficiency., The first group A legs Legs that had to be retreated with EVLA were 10 out of 50 when the length of the insufficient vein was more than 2 cm and with no significant tortuosity, the rest legs were retreated by foam sclerotherapy. The second group B legs Only 4 legs (1%) appeared with new reflux from accessory veins during 4 years of follow up but with no clinical signs of recurrence and didn t need retreatment yet. It is important that in those patients those accessory veins were not initially treated due to a very small size (less than 1 mm) Sclerotherapy Re EVLA New REFLUX Sclerotherapy Re EVLA New REFLUX

8 CONCLUSION There is a strong evidence that the accessory veins within the first 2 cm from the saphenofemoral junction or confuenting to epigastric vein should be treated during the prior procedure even if not refluxing as is beeing done during classic ligation and stripping procedure. [7] Mendoza, Erika, Lattimer, Christopher R., Morrison, Nick (Eds.) Duplex Ultrasound of Superficial Leg Veins (pp )

9 THANK YOU! Cyprus Society of Vascular and Endovascular Surgery

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