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 Table of Contents  
Year : 2021  |  Volume : 27  |  Issue : 2  |  Page : 146-147

Recurrent varicose veins - Radiological and operative profile from a tertiary care centre

Department of General Surgery, Government Medical College, Trivandrum, Kerala, India

Date of Submission06-Sep-2021
Date of Decision20-Sep-2021
Date of Acceptance26-Sep-2021
Date of Web Publication15-Nov-2021

Correspondence Address:
Dr. Anil Sundaram
Department of General Surgery, Government Medical College, Trivandrum - 695 011, Kerala
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ksj.ksj_43_21

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Background: Recurrent varicose vein (RVV) still remains a complex, debilitating, common clinical condition despite the advances in imaging technology and operative techniques. The prevalence of developing recurrence ranges from 5% to 65% over a time period of 5–15 years. Aim: The aim of the study is to identify the radiological patterns and operative profile leading to RVV. Materials and Methods: Twenty-eight patients were included in our study who presented with RVV from 1 January 2019 to 1 January 2021. Results: Recurrence was identified in 19 patients post-Trendelenburg (TBG) procedure and perforator ligation, 5 patients post-TBG and stripping above knee, 3 patients post-TBG and sclerotherapy for perforators and 1 case post-endovenous LASER therapy. RVV developed in a time span from 1 to 15 years. Conclusion: TBG along with just perforator ligation has high chance of recurrence, and thorough knowledge regarding the tributaries and anomalous connections at saphenofemoral junction is of utmost importance in primary surgical management of varicose veins.

Keywords: Doppler scan, endovenous LASER therapy, recurrent varicose vein, saphenofemoral junction, Trendelenburg procedure and multiple perforator ligation

How to cite this article:
Sundaram A, Sreekumar R C. Recurrent varicose veins - Radiological and operative profile from a tertiary care centre. Kerala Surg J 2021;27:146-7

How to cite this URL:
Sundaram A, Sreekumar R C. Recurrent varicose veins - Radiological and operative profile from a tertiary care centre. Kerala Surg J [serial online] 2021 [cited 2023 Mar 25];27:146-7. Available from: http://www.keralasurgj.com/text.asp?2021/27/2/146/330408

  Introduction Top

Varicose vein surgery is characterised by a high recurrence rate of 20%–60% after 5 years and even higher after longer periods of follow-up observation and recurrence may be due to several causes: inaccurate initial diagnosis, progression of disease, inadequate initial surgery, altered venous dynamics and neovascularisation.[1] A major cause of recurrence after open surgery is “neovascularisation” in the groin, which is the re-growth of multiple small incompetent veins, re-connecting the ends of the remaining veins after treatment, resulting in the re-establishment of pathological venous reflux.[2] If this process continues down the tract of the truncal vein that has been stripped, it is called “strip-tract revascularisation.”[3],[4] Careful assessment of technical details will decrease the regrettably high rate of recurrence after saphenofemoral disconnection and render safer exploration. Early post-surgical recurrence results from an incomplete operation; late recurrence after correct surgery is due to deterioration of the remaining superficial venous system or in case of inappropriate surgery.[5] Ultrasound still remains the best diagnostic modality to identify the exact anatomy of recurrent varicose veins (RVVs) pre-operatively.[6] In our series, the most common cause of recurrence was neovascularisation followed by improper identification of saphenofemoral junction (SFJ), and Trendelenburg (TBG) surgery along with multiple perforator ligation was identified with more recurrence compared to TBG plus stripping surgery.

  Materials and Methods Top

Written informed consent was obtained from the participating patients. Twenty-eight patients were included in our study who presented with RVV from 1 January 2019 to 1 January 2021. Full detailed history, examination and duplex ultrasound were made over the superficial and deep venous system of the patients of this study. Sample was taken as all patients with RVVs after previous varicose veins surgery in an outpatient clinic.

Statistical analysis

Data entry and analysis were accomplished using windows operating system and the based statistics program (SPSS 10.0) (IBM SPSS Statistics, Software version 10.0, USA, 2020) adopting in the outcome the following statistical tests:

  1. Continuous variables are expressed as means
  2. Discrete variables are expressed as frequencies and percentages.

  Results Top

Female-to-male ratio was 18:10.

Out of 28 patients, 19 had undergone TBG + multiple perforator ligation, 5 underwent TBG + stripping above knee, 3 underwent TBG + sclerotherapy (for perforators) and one patient underwent endovascular LASER therapy.

Four cases had a history of deep venous thrombosis (DVT) post the primary procedure. Two cases post-TBG + multiple perforator ligation, 1 patient was post-sclerotherapy and 1 patient was post-above knee stripping.

  Discussion and Conclusion Top

Recurrence in varicose veins affected females more than males and the age group affected was between 46 and 60 years. Previous studies reported that the highest frequency of recurrence was in the age between 40 and 49 years and the least age of recurrence was 20–29 years.[7]

Neovascularisation and incomplete surgery were the main factors affecting recurrence in our series. An important recent study reported that recurrence after primary varicose vein surgery is associated with inadequate primary surgery or progression of disease, and neovascularisation alone is not a cause of recurrent varicose veins.[8]

TBG plus multiple perforator ligation can predispose to an early recurrence if the SFJ and tributaries are not identified promptly and addressed. Post-primary procedure, DVT is also a high risk factor for developing recurrence. Adequate surgery for perforators in the first time itself is very important to address the recurrence. These finding were almost similar most of the studies from the literature.[4],[5],[6] Duplex scanning can provide the necessary anatomical and functional information about the nature of recurrence and has become the investigation of choice in patients with recurrent varicose veins; further, inadequate preoperative assessment in the presence of DVT is one of the most common causes of recurrence; in addition to this, incompetent surgery of the wrong site of incision containing excess fat leads to incomplete ligation of all tributaries of the superficial system.[9]

In literature, many investigators stressed on the non-specialised surgeon as a factor of recurrence. Nearly, all of these studies reported the same incidence of recurrence in case of non-specialised surgeons (59.2%–70%).[10] In our study, of 28 patients, 78% (22) were operated by general surgeons, while 6 patients (21%) were operated with vascular surgeons.

To conclude, we would stress on correct identification of SFJ and incompetent tributaries pre-operatively by a good sonologist or even by the operating surgeon himself/herself. A thorough knowledge of normal anatomy and its variations at SFJ is a must to prevent the recurrence after primary surgery.

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Conflicts of interest

There are no conflicts of interest.

  References Top

Allaf N, Welch M. Recurrent varicose veins: Inadequate surgery remains a problem. Phlebology 2005;20:138-40.  Back to cited text no. 1
Jones L, Braithwaite BD, Selwyn D, Cooke S, Earnshaw JJ. Neovascularisation is the principal cause of varicose vein recurrence: Results of a randomised trial of stripping the long saphenous vein. Eur J Vasc Endovasc Surg 1996;12:442-5.  Back to cited text no. 2
Munasinghe A, Smith C, Kianifard B, Price BA, Holdstock JM, Whiteley MS. Strip-track revascularization after stripping of the great saphenous vein. Br J Surg 2007;94:840-3.  Back to cited text no. 3
Ostler AE, Holdstock JM, Harrison CC, Price BA, Whiteley MS. Strip-tract revascularization as a source of recurrent venous reflux following high saphenous tie and stripping: Results at 5-8 years after surgery. Phlebology 2015;30:569-72.  Back to cited text no. 4
Geier B, Olbrich S, Barbera L, Stücker M, Mumme A. Validity of the macroscopic identification of neovascularization at the saphenofemoral junction by the operating surgeon. J Vasc Surg 2005;41:64-8.  Back to cited text no. 5
Tatarchuk AN. Capacities of ultrasound study in a follow up of patients with lower extremity varicose veins after phlebectomy. Vestn Rentgenol Radiol 2011;1:22-5.  Back to cited text no. 6
van Rij AM, Jones GT, Hill GB, Jiang P. Neovascularization and recurrent varicose veins: More histologic and ultrasound evidence. J Vasc Surg 2004;40:296-302.  Back to cited text no. 7
Allegra C, Antignani PL, Carlizza A. Recurrent varicose veins following surgical treatment: Our experience with five years follow-up. Eur J Vasc Endovasc Surg 2007;33:751-6.  Back to cited text no. 8
Perrin M, Allaert FA. Intra-and inter-observer reproducibility of the Recurrent Varicose Veins after Surgery (REVAS) classification. Eur J Vasc Endovasc Surg 2006;32:326-32.  Back to cited text no. 9
Winterborn RJ, Foy C, Earnshaw JJ. Causes of varicose vein recurrence: Late results of a randomized controlled trial of stripping the long saphenous vein. J Vasc Surg 2004;40:634-9.  Back to cited text no. 10


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