Presence of varices after operative treatment: a review
Part 1: This is the first of 2 chapters that will comprise the ‘PREsence of Varices After operatIve Treatment (PREVAIT)’. These 2 chapters will be published in the journal consecutively.
Abstract
Background: PREsence of Varices after operatIve Treatment (PREVAIT ) occurs in 13% to 65% of patients and remains a debilitating and costly problem. The first part of this review provides an overview of the current understanding of the etiology and pathogenesis of PREVAIT . Methods: A PubMed search was conducted in English and French for the years 2000-2013 by using keywords (Duplex scanning, endothermal ablation, neovaricoses, REVA S, sclerotherapy, varices recurrence, varicose vein, varicose vein surgery).
Results: Epidemiology and socioeconomic consequences were analyzed according to the initial operative treatment. Then a classification of possible mechanisms and causes for PREVAIT are classified in terms of tactical and technical errors, evolution of the disease, considering that the systematic use of ultrasound investigation has minimized the former.
Conclusion: The cause and underlying mechanisms for recurrences of varicose veins are poorly understood. Large prospective studies should be performed to clear up the picture.
Background
The presence of varicose veins after operative treatment is a common, complex, and costly problem for both the patients and the physicians who cope with venous diseases. An international consensus meeting was held in Paris in 1998 and guidelines were proposed for the definition and description of REcurrent Varices After Surgery (REVA S).1 In a related article from 2000, 94 references dealing with recurrence after operative treatment or including information on its presence or absence after operative treatment were listed. Since then, 140 additional publications in English and French have been identified.2-141
Classical surgery, which used to be the most frequent operative procedure for treating varicose veins in the last decade, has been progressively taken over by chemical and thermal ablation procedures, and to a slight extent, by mini-invasive surgeries including CHIVA (French acronym for ambulatory conservative hemodynamic management of varicose veins)142 and ASVAL (French acronym for tributary varices phlebectomy under local anesthesia).143,144 Therefore, the experts of the VEIN-TERM transatlantic interdisciplinary consensus meeting suggested replacing the classical surgery-related acronym REVA S with PREVAIT (PREsence of Varices After Interventional Treatment).145
During the same meeting, the following terms were defined:
1. Recurrent varices: Reappearance of varicose veins in an area previously treated successfully.
2. Residual varices: Varicose veins remaining after treatment.
3. PREVAIT : PREsence of Varices (residual or recurrent) After Interventional Treatment.
The concept of PREVAIT was developed for two reasons: (i) it is often difficult to correctly classify the results of initial procedures done by others and consequently to differentiate recurrent varices from residual varices; and (ii) the term REVA S was limited to patients previously treated by surgery as previously mentioned. The term PREVAIT encompasses both recurrent and residual varicose veins after any kind of operative treatment including open surgery and endovenous procedures, either thermal or chemical.
Table I. REVAS Classification sheet.
Modified after reference 98: Perrin et al. Eur J Vasc Endovasc
Surg. 2006;32:326-333.
It was also argued that the term ‘interventional treatment’ was not equivalent to the term ‘operative treatment,’ ecause even noninvasive therapies such as venoactive drugs or compression therapy may modify the natural history of varicose veins and be considered as ‘interventional.’
In 2000, a REVA S classification form was elaborated for future studies (Table I). The REVA S classification was hen subject to intraobserver and interobserver reproducibility,98 and then used in an international survey.95,97 A form similar to this should be adapted to PREVAIT for possible future studies.
AIM
The purpose of this review is to analyze all available data on PREVAIT in order to help physicians identify the best operative treatment, if any, likely to prevent PREVAIT . Such analysis might help build a revised classification, as mentioned above.
Material and methods
A PubMed search was conducted to retrieve published articles in English and French for the years 2000-2013 using the keywords varices recurrence, REVA S, endothermal ablation, sclerotherapy, varicose vein surgery, varicose vein, duplex scanning, neovaricose, and their counterparts in French. Abstracts were not selected, only publications dealing with PREVAIT were chosen, some of them focused on PREVAIT patients, others concerned patients presenting with varices and operatively treated whose follow-up specified the absence or presence of varices.
Results
Since the REVA S publication,1 140 articles on recurrent varices have been published.2-141 29 randomized trials were added to the references from the REVA S articles list, taking the total papers regarding randomized trials to 34.6,7,13,16,17,42,52,61,62,66,69,80,83,90,92,103,107-111,117,118,120,122,124,136,137,140,146-152 Epidemiologic data and socioeconomic consequences will be analyzed according to the initial procedures, which will be followed by a discussion of the possible mechanisms for PREVAIT occurrence.
Magnitude of REVAS occurrence
With open surgery
The most documented outcomes are provided by classical surgery, but most studies are retrospective. In a 34-year follow-up study, varicose veins were present in 77% of the lower limbs examined and were mostly symptomatic: 58% were painful, 83% had a tired feeling, and 93% showed a reappearance of edema.50
Two prospective studies concerning classical surgery are available with a follow-up of 5 years.72,133 In both studies, patients were preoperatively investigated with duplex scanning (DS) and treated by high ligation, saphenous trunk stripping, and stab avulsion. In the Kostas et al series, 28 out of 100 patients had PREVAIT after 5 years: recurrent varices mainly resulting from neovascularization in eight limbs (8/28, 29%), new varicose veins as a consequence of disease progression in seven limbs (7/28, 25%), residual veins due to tactical errors (eg, failure to strip the great saphenous vein) in three limbs (3/28, 11%), and complex patterns in ten limbs (10/28, 36%).72 In the Van Rij et al series, 127 limbs (CEAP class C2–C6) were evaluated postoperatively by clinical examination, DS, and air plethysmography (APG). At the clinical evaluation, recurrence of varicose veins was progressive from 3 months (13.7%) to 5 years (51.7%). In line with clinical changes, a progressive deterioration in venous function was measured by APG and a recurrence of reflux was assessed by DS.133
These 2 studies showed that recurrence of varicose veins after surgery is common, even in highly skilled centers, and even if the clinical condition of most affected limbs after surgery improved compared with ‘before surgery.’ Progression of the disease and neovascularization are responsible for more than half of the recurrences. Rigorous evaluation of patients and assiduous surgical techniques might reduce the recurrence resulting from technical and tactical failures.
Table II. Rasmussen 3-year clinical and DS outcome and reoperation percentages.
Modified after reference 111: Rassmusen et al. J Vasc Surg: Venous and Lym Dis. 2013;1:349-356.
Table III. Pre and postoperative VCSS and AVVSS according to operative treatment.
Modified after reference 111: Rassmusen et al. J Vasc Surg: Venous and Lym Dis. 2013;1:349-356.
In a four arm randomized controlled trial (RCT) by Rassmussen et al, endovenous laser ablation (EVLA ), radiofrequency ablation (RFA), ultrasound-guided foam sclerotherapy (UGFS), and surgical stripping for great saphenous varicose veins (GSV ) were compared with a 3-year follow-up, the rate of PREVAIT was reported in each arm (Table II).111 There was no significant difference between the 4 procedures (P=0.29) in terms of clinical recurrence, but the presence of persisting reflux in the GSV was significantly higher in UGFS compared with the other 3 methods (P<0.0001) as well as the reoperation rate (P<0.0001).
Regardless of the procedure used, the severity of varicose disease as assessed with the Venous Clinical Severity Score (VCSS) was significantly reduced, and the quality of life using the Aberdeen Varicose Veins Severity Score (AVV SS) was significantly improved after all operative treatments no matter which procedure was used (P<0.0001; Table III)
With radiofrequency ablation
From a multicenter prospective study, recurrence rates after RFA with ClosurePlus® were reported. At the 5-year follow-up, PREVAIT was estimated at 27.4%.84 A 3-year follow-up RCT comparing ClosureFast®-RFA of the GSV with or without treatment of calf varicosities did not document the PREVAIT rate, but only the obliteration rate on DS investigation, venous clinical severity score (VCSS), and the presence of symptoms.102 In the four arm study by Rassmussen et al,111 there was no statistical difference regarding PREVAIT rates between RFA and the other operative procedures (P=0.29; Table II).
With endovenous laser ablation
At the 2-year follow-up, a RCT by Rass et al found no significant difference (P=0.15) when comparing EVLA with classical surgery (EVLA 16.2% vs 23.1%).107 An Italian group reported a PREVAIT rate of 6% at month 36.2 In a RCT comparing EVLA with GSV stripping with a 5-year follow-up, PREVAIT was reported in 36% and 37% of patients, respectively, with no statistical difference between groups (P=0.9). In this study, reoperative treatment was performed in 38.6% and 37.7%, respectively, mainly by UGFS.110 Again in the four arm study by Rassmussen et al,111 there was no statistical difference regarding PREVAIT rates between EVLA and the other operative procedures (P=0.29; Table II).
Ultrasound-guided foam sclerotherapy
Hamel-Desnos et al reported a 36% and 37% recanalization rate at the 2-year follow-up with UGFS, one injection with 1% and 3% polidocanol foam, espectively.62 In a RCT of UGFS vs surgery for the incompetent GSV with a follow-up of 2 years, PREVAIT was identified in 9% vs 11.3%, respectively. P=0.407, which is not significant. Conversely, reflux was significantly higher in UGFS (P=0.003).118
In the British long-term RCT by Kalodiki et al of UGFS combined with sapheno-femoral ligation vs standard surgery for GSV, clinical severity of venous disease assessed by VCSS and venous segmental disease score (VSDS) were equally reduced in both groups, and the quality of life equally improved as well (using AVV Q and 36-Item Short-Form).69 Unfortunately, PREVAIT was not reported in this study.
With procedures saving the saphenous trunk
CHIVA
PREVAIT was assessed when using the CHIVA method vs classical surgery in 2 RCT’s with a follow-up of 5 and 10 years.16,90 In both studies, the Hobbs classification was used to assess PREVAIT.148,149
If we add failure (presence of VV >0.5 cm) and slightly improved patients in terms of cosmetic appearance (presence of VV <0.5 cm), the outcomes were as follows: (i) At 5 years postsurgery, the PREVAIT rate in the group operated by stripping was 70.7% vs 55.6% in the CHIVA group (P>0.001).90 In the 10-year follow-up RCT by Carandina, the recurrence rate of varicose veins was significantly higher in the stripping group compared with the CHIVA group (CHIVA , 18%; stripping, 35%; P<0.04 Fisher’s exact test). The associated risk of recurrence at 10 years was doubled in the stripping group (odds ration [OR], 2.2; 95% confidence interval [CI] 1-5; P=0.04).16 In both RCTs, the recurrence rate was lower with CHIVA ,90,16 yet there is a great discrepancy between the studies, PREVAIT was unexpectedly higher in the 5-year follow-up RCT,90 compared with the 10-year follow-up.16
ASVAL
No published data is available regarding the mid-term results.
Socioeconomic consequences
No socioeconomic data on PREVAIT has been published. When a redo surgery is performed, the cost is higher than the first surgery because of the number of peri- and postoperative complications. In one observational study, 40% of patients had complications after classical surgery for PREVAIT.64
Possible mechanisms leading to PREVAIT
They must be classified in 2 groups: tactical errors and technical problems.
Tactical errors
Tactical errors are common to all operative treatments. It includes wrong or incomplete diagnosis of the extent and/or location of varices, source of reflux, onidentification of deep venous anomalies including pelvic reflux (Figures 1, Figure 2), primary vein compression or reflux, and posthrombotic syndrome. Fortunately, the systematic use of DS before any operative treatment has minimized this cause of error. In most of the articles published before systematic use of preoperative DS, tactical error was the most frequent mechanism leading to PREVAIT .
Figure1. PREVAIT clinical aspect.
A. Pelvic vein leak. B. Selective pelvic venography from the same
patient as A. (Courtesy of Drs Monedero and Zubicoa).
Figure 2. Selective pelvic venography.
After a Valsalva maneuver. Reflux through the obturator vein
feeding the nonsaphenous vein network.
(Courtesy of Drs Monedero and Zubicoa).
There is a consensus on the fact that saphenous ablation provides a better outcome when saphenous trunk incompetence is present and when classical surgery, thermal or chemical, is performed. Yet, the proponents of the CHIVA and ASVAL procedures contest this point by arguing that trunk conservation would provide good results. In the CHIVA procedure, the argument is that the preservation of the saphenous trunks together with sparing of their functions (cutaneous and subcutaneous drainage) is allowed thanks to appropriate shunt disconnections that breaks the higher-than-normal hydrostatic pressure and subsequently improves hemodynamics.16,90,142 In the ASVAL method, the ablation of the reservoir incompetent tributaries leads to a reduction in the reflux in the saphenous trunk.143,144
Technical problems related to the first operative treatment (surgery, thermal, or chemical ablation)
Such problems can overlap in the same patient, and some are specific and related to the procedure used, while others are identified no matter what procedure was used.
Surgery
The most frequent technical error quoted in classical surgery was non flush ligation at the saphenofemoral junction (SFJ; Figure 3) or at the saphenopopliteal junction (SPJ; Figure 4). This point is now controversial as some series with conservation of the SFJ claim to achieve excellent results including patients with incompetent terminal valve.152 Several authors continue to state that non flush ligation of the saphenous termination is responsible for frequent recurrence,41,52 particularly over the long-term.55-57 In the CHIVA technique, PREVAIT would be mainly related to wrong preoperative marking and inappropriate technique.90
Figure 3. PREVAIT clinical aspect.
A. Massive groin recurrence related to non flush high ligation
in a patient with an incompetent GSV terminal valve. B. Same
patient with a B mode ultrasound. The terminal valve is identified
at the saphenofemoral junction. (Courtesy of Dr Gillet). C. Same
patient with a color duplex ultrasound. Massive reflux induced
by a Valsalva maneuver. (Courtesy of Dr Gillet).
Figure 4. PREVAIT clinical aspect.
A. Popliteal fossa massive recurrence related to non-flush
high ligation in a patient with an incompetent SSV terminal
valve. B. Postoperative duplex scanning identified reflux in the
SSVS, which feeds the varicose network after the compressiondecompression
maneuver. (Courtesy of Dr Gillet).
Thermal ablation
Inadequate technique consisting mainly of delivering insufficient energy, irradiance, or fluence in laser or radiofrequency procedures should be responsible for short or long-term recanalization of the treated vein.
Chemical ablation
Inadequate technique as well as inappropriate sclerosing agent dose should be responsible for short or long-term recanalization of the treated vein.
Technical problems not related to initial treatment
The neovascularization phenomenon was discovered 25 years ago, but remains not fully elucidated.152 It occurs mainly at the SFJ (Figure 5) and less frequently at the SPJ (Figures 6), and is considered, in many articles, as the main cause of PREVAIT after correct classical surgery.28,29,134,153,154 El Wajeh et al contests the term neovascularization and favors adaptive dilatation of preexisting venous channels (vascular remodeling), probably in response to abnormal hemodynamic forces.43 According to Lemasle et al, this phenomenon is related to preexisting anatomical anomalies.79 Egan et al minimizes its frequency as well as its importance in groin recurrence. 41 However, neovascularization has been reported not only in procedures including SFJ or SPJ ligation, but also after thermal ablation,76 albeit at a lower frequency.71,124
Figure 5. PREVAIT clinical aspect.
A. A varicose network at the thigh just below a previous groin
incision related to neovascularization. B. Same patient with a
duplex scan. Small refluxive veins identified above the CFV after
a Valsalva maneuver. (Courtesy of Dr Gillet).
Figure 6. PREVAIT clinical aspect.
A. A varicose network at the popliteal related to neovascularization.
B. Same patient with a duplex scan. Varicose network
above a refluxive popliteal vein (Courtesy of Dr Gillet).
Evolution of the disease
It should never be forgotten that superficial venous disease is a chronic condition that tends to progress over time.104 In other words, previously unaffected superficial veins or perforators may become incompetent. Varices may develop in the same territory initially treated including saphenous tributaries that were not incompetent at the time of the operative treatment or in another superficial vein territory.
Risks factors for chronic venous disease progression and, in particular, varices have been investigated in many prospective studies.155 However, underpinnings and constitution risk factors for disease progression are still poorly understood. It is generally accepted that there is a strong family predisposition, not only for presenting varicose veins, but also for developing recurrence related to disease evolution. The precise nature of the genetic basis for this family predisposition is far from clear. To shed more light on this issue, it will not be sufficient to study single genes, potentially implicated in varices. Instead, genome wide association studies will be needed using very large sample sizes to further unravel the genetic basis of varices and chronic venous insufficiency.156
Corresponding author
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