Comment to: Postoperative varicose recurrence at the junctions. A multicentric study of 1056 patients by the Italian Society of Phlebolymphology. Preliminary conclusions by Corcos L, Aloi T, Alonzo U, et al. Acta Phlebol 2014;15:69-78

Abstract

In spite of a history and evidence of efficacy, numerous attempts have been made to replace traditional surgery with new techniques in the hypothesis that the surgical trauma and high pressure on the venous wall are responsible for the development of neovascularisation by neoangiogenesis (NN) and, consequently, high postoperative recurrent rates. To verify the anatomical causes of postoperative varices recurrence (VR) at the SFJ and SPJ fourteen centres belonging to the Italian Society of Phlebolymphology collected the requested data from 1056 patients (1081 limbs, 25 bilateral) who were either previously subjected to ligation-interruption of SFJ and/or SPJ (927 between 2001-2010) or treated in the last two years (154 between 2011-2012); 611 limbs (56.5%) were examined by DUS only, 470 limbs (43.4%) were subjected to DUS examination and surgical revision (270 with Li technique). The residual saphenous stump (SS), all residual tributaries with their outflows into the stump or directly into the common femoral or popliteal veins and their anatomical variants were investigated; neovascularisation by neoangiogenesis was investigated, searching for thin and tortuous veins measuring <2 mm in diameter and connected with an SS, with the common femoral vein or with thinner subcutaneous veins. The majority of the SS were found to be combined with residual identified or unidentified tributaries. In many cases, the VR consisted of a complex varicose collateral circulation (CVC). The residual SS (n=711, 65.7%) was the most common finding, followed (by decreased frequency) by the anterior accessory of the GSV (n=298, 27.5%), UT at the SFJ (n=290, 26.8%), superficial iliac circumflex vein (n=127, 11.7%), residual GSV (most likely from a previous duplicity), (n=95, 8.7%), superficial epigastric (n=60, 8.8%) A large number of cases with development of a CVC (n=386, 35.7%) were found in the supra-fascial subcutaneous. The anatomical residuals, which were single or multiple and variously combined, were found in a total of 939 operated junctions. Neovascularisation was suspected or demonstrated in a total of 142/1081 cases (13.1%). The data obtained from the different centres appeared to be scarcely detailed to define the various tributary veins involved in the mechanism of recurrence; nevertheless, it is possible to assess the prevalence of SS connected with residual tributaries as major causes of recurrence in both the SFJ and SPJ. NN was recently described as the most dangerous enemy of surgeons and patients operated on for varicose veins. The word neovascularisation seems more appropriate to indicate the appearance of new vessels produced by the phenomenon of neoangiogenesis and does not appear to be appropriate, as it refers to pre-existing veins that remain under the impulse of the venous reflux and progressively dilate. Histological observations have led to describe neoangiogenesis as a physiologic process, which follows inflammation and mainly represents a constant product of large wounds, haematomas and thrombosis). The same reparative process, leading to the appearance of specific progenitor cells, takes place in every anatomical district and in every kind of tissue, not only in veins. It can be invoked as a cause of VR in a small percentage of cases, and it seems to play a minimal role at the groin and popliteal region of the operated limbs. In many cases in which no residual tributary could be detected, except for small, weak and tortuous veins, the VR was represented by an anatomical anarchic development of the collateral circulation, similar to cavernous haemangioma. The presence of anatomical residuals at the SFJ and SPJ has been always indicated in the past as the main cause of VR; this research confirms that residual saphenous stump and tributaries caused by inadequate surgery appear to be the main cause of VR at the saphenous junction. Recent studies have clearly demonstrated that the only way to prevent VR is still traditional surgery. The only trap is represented by the presence of anatomical variants at the junctions but DUS investigation systematically performed before applying any therapeutic technique can prevent such difficulties.