Recurrence of varicose veins after surgical treatment is widely attributed to morphological and haemodynamic changes in pre-existing collateral veins. Transection of the great saphenous vein in the thigh under local analgesia was used to promote healing of varicose ulceration. When healing was complete, saphenofemoral ligation combined with stripping or multiple ligation was performed. At the same time the vascular changes at the site of transection were investigated in 10 patients by phlebography, surgical exploration and examination of the excised vessels by radiographic and histological methods. The results showed that the continuity of the vein was restored by growth of new vessels in the surrounding tissues and vein wall. Some vessels increased in size, developing smooth muscle and elastic tissue in their walls, while the majority underwent regression. It was concluded that the theory of recurrence through pre-existing veins requires revision.

Objective: To test the hypothesis that sapheno-femoral recurrence of varicose veins may be prevented by containment of neovascularization. Design: Prospective minimum 4-year follow-up by surgical exploration and morphological examination of recurrent vessels in all limbs with clinical or phlebographic evidence of sapheno-femoral recurrence. Setting: Varicose vein clinic of a teaching hospital. Interventions: Sapheno-femoral ligation and multiple ligation (group 1); sapheno-femoral ligation, interposition of cribriform fascia and multiple ligation (group 2); sapheno-femoral ligation, interposition of artificial implant and stripping (group 3). Main outcome measures: Incidence of sapheno-femoral recurrence. Results: The incidence of sapheno-femoral recurrence through neovascularization was lower ( p < 0.001) in groups 2 and 3 after containment of neovascularization at the sapheno-femoral junction by cribriform fascia or artificial implant than in group 1 after ligation alone (3% and 1% vs 25%, respectively). The incidence of recurrent or persistent varices distal to the groin was lower ( p < 0.001) after stripping (group 3, 57%) than after multiple ligation (group 1, 93%; group 2, 81%). Conclusions: Sapheno-femoral ligation, interposition of cribriform fascia or artificial implant at the sapheno-femoral junction, and stripping is a more effective treatment of varicose veins than sapheno-femoral ligation and multiple ligation.

A method of improving radiologic definition in phlebography of recurrent varicose veins in the groin is described. Before injection of contrast material, venous return from the distal part of the limb was temporarily suspended by inflating a tourniquet surrounding the lower part of the thigh to a level higher than the systolic pressure. Toward the end of the injection procedure the patient performed a valsalva maneuver. Phlebography showed that the recurrent varices were more frequently in continuity with the great saphenous vein than collateral to it. Their tortuous or irregular outline did not usually correspond in position or appearance to normal tributaries of the vein. Radiographs of excised great saphenous vein injected with barium sulfate suspension showed that the valves of tributaries proximal to the site of surgical interruption of the vein remained competent. The findings provide further evidence of neovascularization in recurrence of varices of the great saphenous vein at the site of transection.

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Objective: To investigate the surgical anatomy and morphology of recurrent sapheno-femoral incompetence after correctly performed sapheno-femoral ligation. To test the hypothesis that such recurrence develops through neovascularization. Design: Prospective study of single patient group. Setting: Varicose vein clinic of teaching hospital. Patients: One hundred and twenty-eight patients (141 limbs) were reviewed 4 or more years after accurately performed sapheno-femoral ligation with catgut, silk or tantalum wire. Intervention: Clinical assessment, phlebography, surgical exploration and examination of recurrent veins by radiographic and histological methods. Main outcome measures: Presence of reflux through newly formed veins at the site of previous ligation. Results: Of 141 limbs, clinical or phlebographic evidence of sapheno-femoral recurrence was confirmed in 35 of 37 on surgical exploration. The continuity of the saphenous vein with the previously ligated sapheno-femoral junction was restored through a newly formed vein or complex of veins. Conclusions: Neovascularization was the cause of recurrent sapheno-femoral incompetence after correctly performed sapheno-femoral ligation.