SummaryNeovascularisation can compromise the success of high ligation and resection of the greater saphenous vein. Studies using duplexultrasound to classify recurrent groin veins have described rates of neovascularisation as high as 60% and raised the question whether high ligation is actually able to prevent groin recurrences. In the present study, recurrent groin veins were excised and examined histologically in order to prove whether neovascularisation is the main cause for sapheno-femoral recurrences. Patients, methods: 419 patients accounting for 458 legs with clinically symptomatic groin recurrences were included in a country-wide multicenter study. The recurrent groin veins were excised in a standardized fashion and subsequently divided into the different types of recurrence based on histopathological criteria. Results: 427 specimen (93%) were available for histopathological examination. In 69 cases (16.2%) a neovascularisation was found to be the cause of recurrence. 311 specimen (72.8%) contained a long residual stump of the greater saphenous vein, out of which 32 (7.5%) showed additional neovascularisation at the site of the ligation. In 29 cases (6.8%) a venous side branch was found to be the recurrent groin vein. 11 specimen (2.6%) did not contain any evidence of venous material and in another 7 cases (1.6%) it was not possible to clearly identify the cause of recurrence during the histo pathological workup. Conclusion: The high rates of neovascularisation described in several duplex ultrasound studies could not be confirmed in our investigation. Recurrences seem to be mainly caused by a technically incorrect initial operation which leaves a long residual stump of the saphenous vein in place. Following a technically correct high ligation, clinically relevant recurrences appear to be rare. This finding underlines the necessity of a high ligation of the saphenous vein according to current guidelines.

No abstract

No abstract

The surgical procedure for recurrences at the saphenofemoral junction represents a great challenge for the surgeon due to the complex anatomic variability, the broad range of causes and the mostly extreme scar tissue. The incidences of postsurgical minor and major complications after recrossectomy in the groin area are determined and the clinical outcomes are analysed in this article. After specific and precise presurgical clinical and sonographical diagnoses having been undertaken a cutaneous incision is performed in the groin with the aid of tumescent local anaesthesia combined with total intravenous anaesthesia. From the proximal site any scar tissue exsisting is meticulously removed, the femoral vein is set free and the still remaining stump of the long saphenous vein or of the neovasculate as well as all left over varicose side branches of the saphenofemoral junction are removed. Within this special surgical procedure the stump of the long saphenous vein or the neovasculate are completely removed and, thereafter, a continuous longitudinal suture of the femoral vein is performed. Uncomplicated minor bleeding complications (haematoma in large extension or disseminated) appear quite frequently, lymphatic minor complications (conservatively treatable lymph oedema, lymphatic fistulae or lymphatic cysts) occur from time to time; major complications such as bleeding complications with the necessity of surgical reintervention occur only in sporadic cases and can be avoided by exact presurgical diagnosis, by meticulous special surgical technique matching the operation site as well as by regular and frequent postsurgical follow-ups. Absolute preconditions to achieve the very best results in the long run are the exact procedures of diagnosis and surgical technique. Performed by experienced phlebosurgeons or vascular surgeons, the recrossectomy of the saphenofemoral junction represents a low-risk surgery for the patient and is a singular and possibly time-consuming challenge for the surgeon.

ZusammenfassungHintergrund: Multizentrische Langzeitstudien mit hohen Fallzahlen nach Crossektomie und Stripping der Vena saphena magna (VSM) liegen nicht vor. Den in mehreren Studien und Registern erhobenen Daten zu den Rezidivraten der endovenösen Therapieverfahren stehen außerordentlich heterogene Daten der operativen Therapie gegenüber.Methode: In einer von der Arbeitsgemeinschaft für Venenoperationen (VOP-AG) der Deutschen Gesellschaft für Phlebologie (DGP) initiierten prospektiven Multizenterstudie wurden in 12 Zentren 841 Patienten (1 070 Extremitäten) mit einer Stammvarikose der VSM aufgenommen und entsprechend einem streng standardisierten Protokoll operiert. Primärer Endpunkt ist das hämodynamisch relevante saphenofemorale Rezidiv, definiert als eine Vene in der Crossenregion (Durchmesser >5 mm, Reflux >0,5 sec) mit einer Verbindung zur V. femoralis communis Sekundäre Endpunkte sind die Rate duplexsonografisch nachweisbarer pathologischer Crossenrefluxe (Durchmesser <5 mm, Reflux >0,5 sec.), perioperative Komplikationen und neu aufgetretene Varizen nach dem REVAS Klassifikation. Die klinischen und duplexsonografischen Kontrollen erfolgten 7 bis 14 Tage, 3 bis 4 Monate und ein Jahr postoperativ. Hiernach sind jährliche Kontrollen vorgesehen.Ergebnis: Die Rate klinischer Rezidive lag 3–4 Monate postoperativ bei 1,1 % und ein Jahr postoperativ bei 6,4 %. Die Rate duplexsonografischer Rezidive im Crossenbereich betrug nach 3–4 Monaten 0,53 % und nach einem Jahr 2,24 %. Davon waren lediglich zwei (0,29 %) ein Jahr postoperativ hämodynamisch relevant (Durchmesser >5 mm).Schlussfolgerung: Die unter standardisierten Bedingungen vorgenommene Crossektomie und Stripping-Operation weist im Verlauf bis zu einem Jahr eine geringe Rezidivrate auf.