Invited Commentary

Abstract

Dr. Stücker and his colleagues have classified the causes of recurrent saphenofemoral reflux on the basis of histologic analysis of a tissue sample larger than 2 × 1 cm removed from the groin of 91 symptomatic limbs that had previously undergone intended ligation of the saphenofemoral junction (SFJ) and stripping of at least the thigh portion of the greater saphenous vein (GSV). The apparent cause in 62 groins (68%) was original misidentification of the true SFJ, with persistence of some portion of the GSV and its tributaries. Consider this in the context that the original operations were all done elsewhere and sometimes well before color-coded duplex scanning was in common use. Hard criteria underlie this classification: valves (presumably incompetent) were present in 18 veins, 55 had intramural nerves, all had a three-layered wall structure, and many had signs of aneurysm degeneration or recanalization. Neovascularity, defined according to the criteria of Nyamekye et al,1Nyamekye I. Shephard N.A. Davies B. Heather B.P. Earnshaw J.J. Clinicopathological evidence that neovascularisation is a cause of recurrent varicose veins.Eur J Vasc Endovasc Surg. 1998; 15: 412-415Abstract Full Text PDF PubMed Scopus (153) Google Scholar was the second largest category, comprising 24 groins (26%). Those authors examined 28 groins that had undergone repeat operation, 19 of which had only saphenofemoral disconnection alone, and found superficial to deep and cross-groin, serpentine connecting veins, either in conjunction with saphenous remnants or as the sole refluxing connections (n = 19), in all but one groin. This groin had an “untouched” SFJ. The current series is not only larger, but also more homogeneous, inasmuch as all limbs previously had undergone intended SFJ ligation and stripping. Both studies, however, share the weakness of relying on mostly negative criteria to define a newly formed vein, to wit, no intramural nerves, incomplete wall structure, and lack of lumen regularity. Stücker et al added a positive criterion that scar must always surround a newly formed vein, which they used as one feature to differentiate neovascularity from hypertrophied venules. Why should new vein formation be so confined? The strikingly different proportioning in these two studies applying essentially the same criteria to groins that underwent repeat operation to treat recurrent symptomatic reflux, a mean of 11 to 12 years after the initial operation, principally reflects the differing populations. Newly formed veins readily bridged the gap between the SFJ and the disconnected but otherwise intentionally intact GSV in the Gloucester study, alleviating frustrated venous drainage.1Nyamekye I. Shephard N.A. Davies B. Heather B.P. Earnshaw J.J. Clinicopathological evidence that neovascularisation is a cause of recurrent varicose veins.Eur J Vasc Endovasc Surg. 1998; 15: 412-415Abstract Full Text PDF PubMed Scopus (153) Google Scholar, 2Glass G.M. Neovascularization in recurrence of the varicose great saphenous vein following transection.Phlebology. 1987; 2: 81-91Google Scholar In the current study, when the true SFJ was missed and a portion of the GSV remained attached to the common femoral vein, the immediate hemodynamic situation was unchanged, with flux and reflux still going freely to and from the saphenous remnant and attached tributaries, as was the case in Nyamekye et al's “untouched” SFJ. In both instances the impetus for neovascularity beyond basic wound healing was minimal or missing.3Fischer R, Chandler JG, De Maeseneer MG, Frings N, Lefebvre-Vilarbedo M, Earnshaw JJ, et al. The unresolved problem of recurrent saphenofemoral reflux. J Am Coll Surg 2002;195:80-94Google Scholar, 4Chandler J.G. Pichot O. Sessa C. Schuller-Petrovic S. Osse F.J. Bergan J.J. Defining the role of extended saphenofemoral junction ligation a prospective comparative study.J Vasc Surg. 2000; 32: 941-953Abstract Full Text Full Text PDF PubMed Scopus (138) Google Scholar The authors properly stress the importance of determining the cause of recurrent reflux, because it directs what should be done to lessen recurrence. My thought is that the causes are not so discrete or discontinuous as this article might imply. Nyamekye et al's1Nyamekye I. Shephard N.A. Davies B. Heather B.P. Earnshaw J.J. Clinicopathological evidence that neovascularisation is a cause of recurrent varicose veins.Eur J Vasc Endovasc Surg. 1998; 15: 412-415Abstract Full Text PDF PubMed Scopus (153) Google Scholar concept of a “principal cause” and Stücker et al's mix of “structured and unstructured veins” are probably more representative of what would be seen if the entire groin could be examined.