Management of recurrent varices at the popliteal fossa after surgical treatment

Abstract

To analyze prevalence, incidence mechanisms, physiopathology, investigations, treatment techniques and results of recurrent varices at the popliteal fossa after surgery. Published literature was analyzed as personal experience. Recurrent varices after surgery at the popliteal fossa are much less frequent than at the sapheno-femoral junction because the short saphenous vein is less often the site of incompetence and treated by surgery. Precise prevalence and incidence is unknown. An analysis of recurrences at the popliteal fossa revealed three causes: (1) Incomplete division of the sapheno-popliteal junction (SPJ) at the terminal valve, which was incompetent at the initial surgery. The persisting reflux fills tributaries still connected to the saphenous stump; (2) Neovascularization reconnects the popliteal vein to the superficial network with new vessels, which are valveless; (3) Because the initial diagnoses is wrong and the incompetence involves the other veins of the popliteal fossa or arises from pelvic veins, which had not been recognized. Duplex scanning (DS) should identify the various sites of reflux and give precise anatomical and haemodynamic data. Treatment methods after recurrence at the popliteal fossa are repeat surgery, sclerotherapy or pelvic vein embolization when identified as the cause. Results provided by these different methods were analysed. At present, no randomized control has given grade 1A, 1B or 2A, 2B recommendations. We recommend that ultrasound-guided foam sclerotherapy should be the treatment of choice unless DS shows an incompetent stump at the SPJ with a gross reflux filling the venous network.