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SURGICAL MANAGEMENT

OF VARICOSE VEIN
David H. Christian
The CEAP classification
C linical Classification

E tiological
Classification

A natomical segmental
localization

P athophysiological
CEAP Classifications advanced
2006
Clinical Classifications of Venous
Insufficiency (CEAP)
Class 0 - No visible or palpable signs of
venous disease
Class 1 - Telangiectasias or reticular
veins
Class 2 - Varicose veins
Class 3 - Edema
Class 4 - Skin changes
(4a) Skin changes including pigmentation or
venous eczema
(4b) Skin changes with lipodermatosclerosis
Class 5 - Healed venous ulceration
Class 6 - Active venous ulceration
SURGICAL MANAGEMENT
Surgical options should be considered in
patients with CVD refractory to medical
and less invasive therapy, including those
with persistent discomfort and disability or
nonhealing venous ulcers despite maximal
medical effort.
Invasive and surgical options may also be
considered in patients who are unable to
comply with compression therapy or have
recurrences of varicose veins
INDICATION FOR SURGERY
GREAT SAPHENOUS VEIN LIGATION
AND STRIPPING
For the best cosmetic results and the most reliable access to the
saphenofemoral junction, the great saphenous vein should be
approached through an oblique incision, typically 1 cm above
and parallel to the groin crease.
The incision is guided by preoperative duplex ultrasound
marking.
Otherwise, the incision should start over the palpable femoral
artery and extend medially to ensure visualization of the
saphenofemoral junction and its tributaries.
Dissection through the subcutaneous tissue proceeds in a
cephalad-caudal axis to limit injury to lymphatics.
Once the saphenofemoral junction has been clearly identified,
suture ligation of the great saphenous vein is performed close to
the femoral vein, taking care not to narrow the femoral vein or
leave a long great saphenous vein stump that might serve as
nidus for a thrombus and potential embolus.
GREAT SAPHENOUS VEIN LIGATION
AND STRIPPING
Ligation plus stripping of the great saphenous
vein results in significant improvement in
venous hemodynamics, may eliminate
concomitant deep venous reflux, provides
symptomatic relief, and assists in ulcer
healing
Removal of the saphenous vein with high
ligation of the saphenofemoral junction is
considered durable and has been the surgical
standard for superficial saphenous
insufficiency in CEAP clinical classes 2 to 6
STAB OR AMBULATORY
PHLEBECTOMY
After removing the source of axial reflux by ligation
and stripping of the great saphenous vein, small
saphenous vein, or both, the remaining superficial
varicosities, if left uninterrupted, will drain via
alternate pathways and may remain both
symptomatic and cosmetically displeasing
Use of 2-mm stab incisions to effectively isolate
and eliminate these tributary varices produces
excellent results
Preoperative markings are essential, because these
veins cannot be visualized when the patient is
supine
POSTOPERATIVE CARE
Bandaging the extremity
When the procedure is complete, the patient is
dressed in compressive bandages
This bandaging decreases postoperative ecchymosis
and hematoma formation, which in turn reduces pain
The primary dressing is usually removed on the
second postoperative day, after which a compression
garment is worn.
Ambulation
Upon discharge, ambulation is encouraged, but
patients are advised to avoid long walks, prolonged
standing, or vigorous exercise for 1 to 2 weeks.
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