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 Table of Contents  
ORIGINAL ARTICLE
Year : 2021  |  Volume : 34  |  Issue : 4  |  Page : 1428-1432

Recurrent varicose veins after surgery


1 Department of General and Vascular Surgery, Faculty of Medicine, Menoufia University, Menoufia, Egypt
2 Department of Vascular Surgery, Faculty of Medicine, Menoufia University, Menoufia, Egypt
3 Department of General Surgery, Mit-Ghamr, General Hospital, Dakahlia, Egypt

Date of Submission20-Jan-2021
Date of Decision20-Apr-2021
Date of Acceptance30-Apr-2021
Date of Web Publication24-Dec-2021

Correspondence Address:
Wagih M Farahat
MBBCh, Mit-Ghamr, Dakahlia
Egypt
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/mmj.mmj_17_21

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  Abstract 


Background
Varicose vein surgery is characterized by high recurrence rate of 60% after 5 years of follow-up observation, and this is a disappointing finding, both for the patients and the surgeon.
Objective
The aim was to study cases of recurrent varicose veins after surgery regarding incidence, causes, and management.
Participants and methods
This descriptive prospective cohort study was carried out on all patients who underwent surgery for primary varicose veins from June 2017 to June 2020 in our vascular outpatient's clinics. All patients were assessed by a preoperative clinical examination and color duplex imaging to establish the incidence, causes, and management of the recurrent cases.
Results
During the study period, 120 operative procedures were performed for primary varicose veins. Only 45 patients enrolled in our study showed recurrence. The incidence of recurrence was 37.5%. Regarding the cause of recurrence detected by duplex ultrasound, 33 patients (73.3%) had disease progression, four patients (8.9%) had inadequate surgery, five patients (11.1%) had incompetent perforator, one patient (2.2%) had inadequate surgery and incompetent perforator, and two patients (4.4%) had neovascularization. Regarding the management of recurrence, 28 patients (62.2%) were subjected to conservative treatment, seven patients (15.7%) were subjected to two sessions of injection sclerotherapy with 4 weeks between the sessions, and surgery was needed in 10 patients (22.2%).
Conclusion
Recurrent varicose veins after surgery are inevitable part of treating venous disease. The common causes of recurrence are disease progression, inadequate surgery, neovascularization, and incompetent perforators.

Keywords: disease progression, duplex ultrasound, neovascularization, recurrence, varicose veins


How to cite this article:
Said M, Saleh HA, Farahat WM. Recurrent varicose veins after surgery. Menoufia Med J 2021;34:1428-32

How to cite this URL:
Said M, Saleh HA, Farahat WM. Recurrent varicose veins after surgery. Menoufia Med J [serial online] 2021 [cited 2024 Mar 28];34:1428-32. Available from: http://www.mmj.eg.net/text.asp?2021/34/4/1428/333228




  Introduction Top


Varicose veins of lower extremities are a common clinical condition. The recurrence rate remains high despite surgical treatment often being successful [1]. Recurrence of varicose veins after surgery is a complex problem, which accounts for more than 20% of the patients requiring venous surgery [2]. Recurrent varicose veins after surgery (REVAS) were defined as varicose veins' existence in a lower limb previously operated on for varicosities, with or without adjuvant therapies, which includes true recurrences, residual veins, and new varices, as a result of disease progression [3]. Recurrent varicose veins were initially thought largely to be due to inadequate intervention; however, more recently, neovascularization and other factors have been implicated [4]. Causes of recurrence include inappropriate preparation by the radiologist. Furthermore, other factors can intervene like neovascularization or an unsuitable and incomplete surgical gesture [5]. The progression of the disease, therefore, can be explained by the unsuitable surgery and venous dynamics [6],[7]. Endovenous thermal and chemical ablation have replaced surgical ligation and stripping of varicose veins within the last decade, which were the accepted treatment for almost a century. Surgery is not without significant complications including paresthesia and has reflux recurrence rates of up to 54% at 5 years, even though it has been shown to provide significant health-related quality-of-life benefits and being cost-effective. Ultrasound-guided foam sclerotherapy, endovenous laser ablation, and radiofrequency ablation are all consistently proving to be at least as beneficial as surgery, without the same complications and with less postprocedure morbidity and more rapid recovery [8]. Surgical failure at the saphenofemoral junction remains an important cause of recurrent varicose veins. It is generally agreed that recurrence is minimized by flush ligation of the great saphenous vein. Great saphenous vein at its junction with the femoral vein, together with ligation of all tributaries of the saphenofemoral junction and also any tributaries of the femoral vein in the region [9]. Duplex ultrasound is extremely accurate in the assessment of reflux in femoral and popliteal veins [10]. All patients with varicose veins should undergo duplex scanning, so that optimal surgery could be planned and performed. Although it gives complete physiological data with respect to lower limb function, some authors claimed that there is no clear evident that such policy reduces the rate of recurrence of varicose veins after surgery [11],[12]. Etiology and pathogenesis of recurrent varicose veins remain unclear. A source of reflux can be identified with duplex scan in ∼90% of the patients with variable and usually multiple locations: groin region accounts for about 37%, at the thigh for 68%, popliteal fossa for 23%, lower leg for 85%, and other areas for 11% [3].

Several theories to explain the cause of recurrence have been considered: poor understanding of the venous anatomy and hemodynamics and/or inadequate preoperative assessment, inappropriate or incomplete surgical treatment, development of new sides of venous reflux as a consequence of disease progression, usually at the level of anterior accessory saphenous vein, and neovascularization [13].

The aim of this work was to study cases of REVAS regarding the incidence, causes, and management.


  Participants and methods Top


A descriptive prospective cohort study was carried out on 120 consecutive operative procedures for primary varicose veins in outpatient vascular clinic from June 2017 to June 2020. A total of 45 patients were complaining of recurrent varicose veins after being subjected to surgery. All patients of any age group and both sexes with REVAS at the same limb with or without incompetent perforators were included in our study. Pregnancy, history of deep venous thrombosis, or postphlebitic limb was excluded.

Ethical approval was taken from the concerned institutional committee for the commencement of the study. Informed written consent was taken from all patients.

Data were collected by us and our residents. Diagnosis of REVAS was done through patient's evaluation by complete history taking, examination (general and local which include inspection, palpation and specific tests), and duplex ultrasound. This technique involves the use of high-resolution B-mode ultrasound imaging and Doppler ultrasound to obtain images of veins and simultaneously measure flow in these vessels. It allows direct visualization of the veins and provides functional, as well as anatomical information. Modern duplex ultrasound machines represent blood flow as a color map, which is superimposed on gray-scale image of the vessel. All lower limb veins may be imaged with ease to test the patency and competency. This technique is to evaluate patency of the deep system and the varicosities excited with or without superficial thrombophlebitis.

In this study, the management of REVAS depended on clinical data and duplex ultrasound finding. The patients were managed by conservation (elastic stocking, venotropics), injection sclerotherapy therapy, and surgery (stripping of long saphenous vein, punchectomy, re-exploration, and stripping with ligation of the perforators).

Statistical analysis

Data entry was done by SPSS Inc. Released 2015. IBM SPSS statistics for windows, version 23.0 (IBM Corp., Armonk, New York, USA) Descriptive statistics were done, for example, number, percentage, mean, and SD.

Presentation of the statistical outcome in the form of tabulation and graphs was accomplished by windows-based Microsoft Excel the Microsoft Corporation, NewYork, USA.


  Results Top


A total of 120 operated cases for primary varicose veins were reviewed, and 45 were found to have recurrence, comprising 19 males and 26 females. Their ages ranged from 23 to 62 years, with mean age of 36 years. The incidence of recurrence in our study was 37.5% [Table 1].
Table 1: Incidence of varicose vein recurrence after surgery among the studied patients (n=45) from 120 patients of primary varicose veins previously operated on

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Regarding complaint of the patients, 40% of patients presented with cosmetic disfigurement, 13.3% with leg pain, 13.3% with leg heaviness, 13.3% with cosmetic and leg pain, 13.3% with cosmetic and leg heaviness, and 6.7% with leg pain and leg heaviness. Regarding the type of operation done before recurrence, they were Trendelenburg in four patients (8.9%), Trendelenburg and stripping in 33 patients (73.3%), Trendelenburg and punchectomy in two patients (4.4%) and Trendelenburg, stripping, and punchectomy in six patients (13, 3%). Regarding the site of recurrence detected by duplex ultrasound, 21 patients (46, 7%) showed recurrence in the leg; three patients (6.7%) in the thigh; two patients (4.4%) in the groin; one patient (2.2%) in the popliteal; seven patients (15.6%) in the leg and popliteal; one patients (2.2%) in the leg and thigh; one patient (2.2%) in the thigh and popliteal; five patients (11%) in the thigh and groin; two patients (4.4%) in the thigh, popliteal, and leg; and two patients (4.4%) in the thigh and gluteal. Regarding time of recurrence, it ranged from 1 to 3 years, with a median of 2 years [Table 2].
Table 2: Clinical data of patients with recurrent varicose vein after surgery (n=45)

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Regarding the causes of recurrence detected by duplex ultrasound, 33 patients (73.3%) had disease progression, four patients (8.8%) had inadequate surgery, five patients (11%) had incompetent perforators, one patient (2.2%) had inadequate surgery and incompetent perforator, and two patients (4.4%) had neovascularization [Table 3].
Table 3: Causes of varicose vein recurrence after surgery of the studied patients (n=45)

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Regarding the management of recurrence, 28 patients (62.2%) were managed by conservative treatment, three patients (6.6%) by stripping of long saphenous vein, seven patients (15.4%) by injection sclerotherapy, three patients (6.6%) by punchectomy, two patients (4.4%) by re-exploration surgery, and two patients (4.4%) by stripping of long saphenous vein and ligation of perforators [Table 4].
Table 4: Management of studied patients (n=45)

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  Discussion Top


REVAS are a common, complex, and costly problem. The incidence lies between 20 and 80%, depending on the definition of REVAS and the time of recurrence. This extremely wide range of prevalence underscores the need for a better definition of this condition. An international consensus meeting held on REVAS in Paris (July 1998) agreed to adopt a clinical definition of it, that is, the existence of varicose veins in a lower limb previously operated on for varicosities, with or without adjuvant therapies, which includes true recurrence, residual veins, and new varices, as a result of disease progression [3]. Primary avalvular varicose anomaly is a phenomenon in patients with primary varicose vein that resembles new vascular tissues in postoperative recurrence, which is diagnosed by duplex ultrasound. Primary avalvular varicose anomaly is distinct from tributaries, competent or incompetent, as it appears as serpiginous mass of thin-walled veins showing reflux, winding around truncal veins or through lymph nodes [14].

Surgical ligation and stripping of varicose veins have been the accepted treatment for almost a century, but within the past decade, this has been challenged by endovenous thermal and chemical ablation methods. Surgery is not without significant complications, including paresthesia, and has reflux recurrence rates of up to 54% at 5 years [8].

In our study, 45 patients with REVAS were clinically evaluated to detect the time of recurrence, the type of surgery was done, the presenting complaint, site, cause of recurrence, and the proper management.

The complaints of the patients that brought them for medical consultation differed according to the system affected. Patients complained of cosmetic disfigurement and the bad appearance of dilated veins, patients complained of pain that was dull and aching, patients complained of cramp-like pain that sometimes hindered them from work, and patients complained of heaviness, which was uncomfortable although not painful. The combined symptoms of two or more of those mentioned previously brought other patients to medical consultation, as well as recurrence in patients complaining of spider naive, and patient who showed local dilatation of veins (blow out) below the knee in the vicinity of long saphenous vein but was compressible and painless. Most patients showed varicosities of superficial veins that were dilated, elongated, and sometimes tortious and were in different areas of the lower limb, mostly in the thigh and occasionally below the knee with few cases near the genitalia in females.

All patients showed recurrence in the period ranging from 1 year to 3 years, with a median 2 years.

There are three major causes of recurrence following varicose vein surgery. In the first group, the causes are owing to inadequate or incomplete initial treatment. These arise either owing to a tactical error resulting in failure to identify all incompetent veins or due to failure to carry out technically adequate primary treatment (despite a correct preoperative diagnosis). The second group of causes arises from the progression of venous disease resulting in development of varices in previously normal veins. The third cause of recurrence is neovascularization where varices arise in the track of previously stripped or ligated veins [15].

Despite technically correct surgery confirmed on postoperative with duplex evaluation, recurrence of varicose veins occurred owing to the presence of short saphenous vein reflux and perforating vein incompetence [15].

In our study, regarding the management, 28 were subjected to conservative treatment with good results, and there was satisfaction among patients regarding their complaints of pain and cosmetic effect of recurrent varicosities. Successful results after two sessions of injection sclerotherapy with 4 weeks between the sessions were seen in some patient.

Our data came in agreement with the study by Allegra et al. [15], where surgery was needed in patients for stripping of the long saphenous vein owing to incompetence of its valves with resulted varicosities, punchectomy owing to localized superficial varicosities not related to the vicinity of either the long or short saphenous vein was needed in other patients, and re-exploration of the previous scar was needed in two patients.


  Conclusion Top


REVAS are inevitable part of treating venous diseases. The common causes of recurrence are disease progression, inadequate surgery, neovascularization, and incompetent perforators. Treatment of these patients requires rigorous clinical and duplex ultrasound evaluation. Assiduous surgical techniques might reduce recurrence by avoiding technical and tactical errors. Duplex scanning is currently the gold standard in preoperative assessment and suggested for all varicose vein surgery. Advantages of duplex scanning are that it is noninvasive, repeatable, reproducible, reliable and objective during follow-up. There is no way of guaranteeing that varicose veins do not recur following surgery. The risk may be reduced through accurate surgery performed in special unit and based on the result of preoperative duplex ultrasound scan, where appropriate simple measure may help to prevent new veins, such as regular exercise, maintain normal weight, and wearing support stockings if one's job involves a lot of standing.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

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Ostler AE, Holdstock JM, Harrison CC, Fernandez-Hart TJ, Whiteley MS. Primary avalvular varicose anomalies are a naturally occurring phenomenon that might be misdiagnosed as neovascular tissue in recurrent varicose veins. J Vasc Surg 2014; 2:390–396.  Back to cited text no. 14
    
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    Tables

  [Table 1], [Table 2], [Table 3], [Table 4]



 

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