The Unresolved Problem of Recurrent Saphenofemoral Reflux

Abstract

Contemporary surgical treatment of lower-extremity varicosities and chronic venous insufficiency continues to be marred by the development of recurrent reflux, most commonly in the area of the ligated saphenofemoral junction (SFJ). Careful physical examination alone, while notably accurate in assessing lowerextremity arterial occlusive disease, has very poor sensitivity and specificity for detecting the presence, and particularly the source, of recurrent venous reflux. As a consequence, a rather surprising incidence of recurrent saphenofemoral reflux has been progressively unmasked over the past 30 years, beginning with hand-held Doppler assessments in the 1970s and culminating in widespread use of color-coded duplex imaging in the last decade of the 20th century. Systematic duplex scanning shows persistent or new connections allowing reflux of femoral vein blood into remnants of the superficial system within one or two years after SFJ ligation and greater saphenous vein (GSV) stripping, even in patients operated on in centers with a special focus on venous disease (Fig. 1). The prevalence of recurrent reflux appears to increase with additional years of followup, with 60% of the limbs of patients surviving 30 or more years after ligation and stripping showing demonstrable reflux at, or nearby, the site of the former junction. Approximately 40% of these limbs develop clinically distressing new varicosities (Fig. 2) and recurrent venous insufficiency symptoms sufficient to warrant further treatment. Despite repeated admonitions to ligate the GSV flush with the surface of the femoral vein and to transect all medial and lateral tributaries entering the saphenous vein in the area of the junction, the commonest findings at reexploration are a patent, intact SFJ and overlooked junctional tributaries. Duplex scanning also often shows new connecting veins that have presumably arisen in response to an angiogenic stimulus inherent to the surgical procedure. These are more commonly found in cases where redissection of the fossa ovalis confirms that the first procedure was anatomically correct and did interrupt all of the junctional tributaries. Typically, this neovascularity takes the form of multiple, small, convoluted, epifascial channels converging on the site of the former SFJ. In a perplexing number of instances they exist as a single conduit, juxtaposed to the site of an anatomically correct ligation, and conveying clinically Dr Chandler and Dr Bergan are paid consultants to VNUS Medical Technologies, Inc.