Venous insufficiency is caused by a refluxing circuit that results from failure of the primary valves at the saphenofemoral junction and typically leads to superficial varicose veins. Varicose veins that branch off an incompetent saphenous vein are called branch veins or secondary varicosities.[1] The incidence of varicose veins is estimated to be 25% of the white population. The incidence is higher with age and with female hormonal environment.
Histologic specimens of removed varicose vein typically demonstrate features of veins that have had a dynamic response to venous hypertension. Varicose veins are dilated and tortuous veins with significantly larger wall areas and higher amounts of collagen. They have a higher content of smooth muscle and elastin.
The typical signs and symptoms of venous insufficiency, including ankle edema, stasis dermatitis, and possibly ulceration, may occur when varicose veins are untreated. The most important aspect of pathophysiology is the origin point of reflux and its elimination. Only then can branch varicosities be treated.
Ambulatory phlebectomy permits removal of incompetent veins below the saphenofemoral and saphenopopliteal junctions, not including the proximal great saphenous vein (GSV) or small saphenous vein (SSV).[2] The junctions themselves cannot be treated with simple phlebectomy, because junctional reflux must be addressed with endovenous ablation methods, which allow saphenous reflux to be treated.
Cornelius Celsus first described phlebectomy in 45 CE. The earliest phlebectomy hooks were described in 1545 in the Textbook of Surgery authored by WH Ryff. Dr Robert Muller, a Swiss dermatologist in private practice in Neuchâtel, Switzerland, rediscovered the technique in 1956. He developed his own technique and instruments and taught the technique to hundreds of physicians.[3, 4, 5] Dr Albert-Adrien Ramelet, one of Dr Muller's students and a former president of the Swiss Society of Phlebology, further advanced the technique for smaller reticular veins with his own hooks.[6, 7, 8] Today, the technique is practiced by thousands of phlebologists around the world.
For patient education resources, see Varicose Veins.
Although any branch varicosity can be removed by means of hook extraction, inexperienced physicians should be careful to avoid the popliteal fold, the dorsum of the foot, and the prepatellar and pretibial areas. These regions are more susceptible to injury, and they contain veins that can be more difficult to extract.
Veins most readily treated with phlebectomy include branch varicosities of the GSV and SSV, pudendal veins in the groin, and reticular varices in the popliteal fold or lateral part of the thigh. Phlebectomy can also be used as an immediate treatment for small segments of superficial phlebitis because the intravascular coagulum is expressed and the involved vein segment can be extracted through the same incision.
Large, tortuous distal branch varicosities are typically treated by means of ambulatory phlebectomy, but some large branch varicosities may rarely be treated by means of endovenous ablation. Ambulatory phlebectomy is best for tortuous varicosities. Radiofrequency ablation (RFA) catheters or optical laser fibers cannot easily be passed along a tortuous vein.
Large, tortuous varicosities can also be treated by foam sclerotherapy in which a detergent sclerosant, such as 1-3% sodium tetradecyl sulfate, is agitated with air. The physician's assessment of the thickness of the vein wall can be the determining factor in the decision to use ambulatory phlebectomy or foam sclerotherapy, with the latter procedure being reserved for thinner-walled veins.
Clinical practice guidelines published by the European Society of Vascular Surgery in 2015 stated that phlebectomy can be considered either as an adjunctive treatment in association with stripping or endovenous ablation of the main refluxing truncal vein or as the sole treatment of varicose veins.[9]
The main contraindication for ambulatory phlebectomy is reflux at the saphenofemoral or saphenopopliteal junction. These junctions must be treated by other means, such as endovenous RFA or endovenous laser ablation (EVLA).
Veins that may be removed by means of ambulatory phlebectomy include major tributaries such as the anterolateral vein, pudendal vein, and branches of the saphenous vein around and below the knee (see the image below). Perforators and reticular veins may also be addressed, rarely including small reticular veins associated with telangiectasias.
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This vein on calf represents major varicose tributary of small saphenous vein that was removed by means of ambulatory phlebectomy.
See Superficial Venous Insufficiency: Varicose Veins and Venous Ulcers, a Critical Images slideshow, to help identify the common risk factors and features of this condition and its management options.
Skin incisions as small as 1 mm or needle punctures with an 18-gauge or larger needle are used to extract veins with a phlebectomy hook. The procedure is well tolerated by patients under local anesthesia and typically produces good cosmetic results. Long-term results from the authors’ experience are excellent, as long as the most proximal source of reflux is eliminated via endovenous ablation.
In contrast to sclerotherapy of large varicose veins, ambulatory phlebectomy minimizes the risks of intra-arterial injection, skin necrosis, and residual hyperpigmentation. The source vein is extracted by the procedure.
Traditional venous ligation is no longer considered an acceptable method, because the vein is interrupted rather than removed, and this leads to relatively high recurrence rates. With ambulatory phlebectomy, the small size of the skin incision or puncture usually results in little or no scarring. This procedure, only performed with local anesthesia, leads to greatly reduced surgical risks as compared with traditional surgery for truncal (axial) reticular varicose veins and incompetent perforators.
Long-term results after phlebectomy are excellent when the procedure is performed for the appropriate indications.
The main indication is an incompetent primary or secondary branch of the great or small saphenous vein. Long-term success rates of 90% or greater are reported. Long-term success is typically associated with the elimination of high-grade junctional reflux before or immediately prior to phlebectomy. It is common practice to perform endovenous ablation of saphenous reflux and then perform ambulatory phlebectomy of varicose branches arising from the saphenous system.
A randomized trial involving 50 patients undergoing EVLA for great saphenous vein insufficiency, in which 25 underwent ambulatory phlebectomy concomitantly with EVLA and 25 underwent EVLA alone with subsequent phlebectomy as needed a minimum of 6 weeks later, found that the former approach yielded better results with regard to disease severity and quality of life.[10]
The AVULS (Ambulatory Varicosity avUlsion Later or Synchronized) trial, in which 101 patients undergoing endovenous truncal ablation received either simultaneous phlebectomy (n = 51) or delayed varicosity treatment (n = 50), found that the patients in the simultaneous group had improved clinical outcomes and less need for further procedures, as well as early improvements in quality of life.[11]
As with any therapy, new varicose veins may develop over time, and patients must be informed about the likely evolution and progression of venous insufficiency and the associated genetic predisposition.
A prospective study by Kishore et al compared ambulatory phlebectomy with foam sclerotherapy in patients with isolated perforator incompetence with regard to evaluating clinical (return to normal activity, primary symptom relief), functional (procedural time, change in disease severity, course of venous ulcer), and duplex parameters (recurrence in treated veins, complete occlusion of treated veins).[12] The authors found that whereas the procedural time was shorter with foam sclerotherapy, the other parameters of primary symptom relief were better with ambulatory phlebectomy. They concluded that ambulatory phlebectomy was superior for treating patients with isolated perforator incompetence.
Zolotukhin et al studied short-term outcomes of isolated phlebectomy with preservation of an incompetent GSV (ambulatory selective varices ablation under local anesthesia [ASVAL] procedure) in 67 patients (51 women, 16 men; 75 limbs; age range, 17-71 years; mean age, 46.8 years) with primary varicose veins and GSV incompetence.[13] They found that this procedure led to disappearance of reflux in most cases and significantly decreased vein diameter in all. They suggested that ASVAL could be considered in selected cases as a less aggressive and less expensive option but noted that no clear indications for the procedure had yet been established.
Detailed vein examination and ultrasonography (US) are obligatory before treatment is administered. Careful attention must be paid to the patient's medical history and general status, and any contraindications for local anesthesia or the surgical procedure itself must be identified.
Hematologic or other laboratory investigations are not typically normally required, unless indicated by previous disorders revealed by the patient history. If previous episodes of venous thrombosis have occurred, testing for a factor V Leiden mutation, a prothrombin 20210 mutation, or both is recommended; these patients are poor surgical candidates.
The integrity of the deep venous system and the proper function of the calf muscle pump should be ensured. In addition, preoperative clinical and US examinations are essential to detect and map all types of varicosities and their origins. Duplex US mapping of the source of reverse flow or reflux is typically performed, especially with the high availability of highly portable and high-resolution US devices. Important sources of reflux (eg, saphenofemoral or saphenopopliteal junctions) should be corrected before any effort is made to address end-branch disease with ambulatory phlebectomy.
Ambulatory phlebectomy requires a small number of surgical instruments. A No. 11 scalpel or an 18-gauge needle is used to make microincisions. Multiple mosquito forceps are used to grasp the veins as they are extracted.
Ambulatory phlebectomy hooks (see the image below) include the classic Muller hook, which most resembles a crochet hook with a blunt tip and a straight shaft that is designed to be placed under the veins and pulled out from below. The Oesch hook, which is available in three sizes, is characterized by a massive squared-off grip and is designed with a small barb at the tip to pierce the vein from the lateral aspect and elevate it.
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Various hooks are used in ambulatory phlebectomy (eg, Ramelet, Muller, Oesch, and Varady hooks).
The Ramelet hook, which is available in two sizes, is a small, fine hook. The smaller of the two is designed to remove reticular or medium-sized truncal varicose veins. The larger one has a thicker stem that is useful in large truncal and perforating veins. The cylindrical grip permits gentle rolling of the hook between the fingers, which diminishes the amount of rotation of the wrists and minimizes wrist and hand stress during the procedure.
The shaft of the Ramelet hook is short and allows precise and close work, as well as moderate traction. The hook angulation facilitates vein dissection, while the sharp tip grips the vein by the perivenous collagen bundles and tunica externa, allowing them to be lifted from above. (This approach limits damage to the surrounding tissues and lymphatics.)
Premedication is rarely required. Generally, it should be avoided as much as possible because it may hinder immediate postoperative walking, which is the best means of preventing potential vascular complications.
The varicose veins are carefully identified with an indelible marking pen or surgical marker with the patient standing. The patient is then placed supine for further marking. Cutaneous transillumination may be helpful in marking the veins for removal and, particularly, in detecting shifts in position of the veins when the patient moves from a standing position to a supine position.
The most common anesthetic approach for phlebectomy is large-volume administration of low-concentration lidocaine in a technique known as tumescent anesthesia. Tumescent anesthesia is very different from local anesthetic injection at points along a vein or a field block. In the tumescent technique, as much as 600 mL of 0.1% lidocaine with 1:1,000,000 epinephrine is injected in order to push the vein closer to the skin and cause vasoconstriction of skin capillaries to minimize postoperative bleeding (see the image below).[14, 15]
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Tumescent anesthesia placed subcutaneously pushes vein closer to skin for easier removal.
Subcutaneous infusion of 0.1% lidocaine with 1:1,000,000 epinephrine in a concentration of 35 mg/kg is considered safe. The maximum plasma levels reached 11-15 hours postoperatively are well below the toxic level (ie, 5 mg/mL). Compared with conventional local anesthesia, tumescent anesthesia produces a delay in achieving the peak serum lidocaine level and does not produce as high a level. This allows coverage for removal of long vein segments. The solution is pumped into the subcutaneous area of the leg to elevate the veins closer to the skin surface.
The use of tumescent anesthesia offers the following major advantages:
Decreased pain with injection
Low toxicity
Predissection of the vein from surrounding tissue
Perioperative capillary compression effect for improved hemostasis and less postoperative bruising
Pushing the vein to be removed closer to the skin
Postoperative rinsing and cleansing effect as the solution slowly drains from the punctures
Long-lasting anesthetic properties that reduce patient discomfort well into the postoperative day
The anesthetic can be infused below the vein, just under the dermis, by using a peristaltic pump or a series of large syringes. The authors primarily use the peristaltic pump because it reduces the time needed to infuse the anesthetic by 75%.
To minimize the pain that accompanies the injection of a normally acidic anesthetic solution, commercial lidocaine-epinephrine solutions can be buffered to a near-neutral pH by adding 1 mL of an 8.4% sodium bicarbonate solution to every 10 mL of lidocaine solution used. In a prospective study that included 101 patients undergoing ambulatory Muller phlebectomy for varicose veins, Krasznai et al found that the use of 1.4% sodium bicarbonate to alkalinize the tumescent anesthesia solution yielded significantly greater patient comfort during anesthetic injection.[16]
When lidocaine is used without epinephrine, the recommended dose is as high as 4.5 mg/kg (not to exceed 300 mg). The addition of epinephrine slows the absorption of lidocaine and permits the use of a dose as high as 7 mg/kg (not to exceed 500 mg) in a single session.
Allergic and toxic reactions are rare, but intravenous (IV) perfusion solutions, resuscitation equipment, epinephrine, injectable steroids, and IV diazepam should be readily available.
At 6 weeks after surgery, the success of the procedure and the need for additional sclerotherapy or laser procedures for residual small veins are assessed.
Ambulatory phlebectomy for varicose veins requires good lighting and an operating table that allows the patient to be in a Trendelenburg position. Direct intraoperative support is seldom necessary, but a nurse or assistant should be present in the office. Emergency equipment and supplies should be nearby. Only a small number of surgical instruments are required to perform phlebectomy on an ambulatory basis.
Cutaneous incisions are made with the No. 11 scalpel or 18-gauge needle. The incisions should be vertically oriented along the thigh and lower leg and should follow the skin lines at the knee or the ankle. The distance between the incisions ranges from 2 to 15 cm, depending on the experience of the surgeon, the size of the vein, the presence of perforators, any previous episodes of phlebitis, and the results of previous sclerotherapy.
The varicose vein is gently dissected by undermining it with the stem of the phlebectomy hook. Undermining is largely performed along the course of the vein, but it is also slightly extended in a perpendicular direction. When freed of its fibroadipose attachments, the liberated vein can then be grasped by using the harpoon of the hook, and it is easily removed with the mosquito forceps held in the other hand. The surgeon also uses the nondominant hand to grip a sterile gauze strip and ensures hemostasis by applying local compression to the already removed venous network. (See the image below.)
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Extraction of veins by means of ambulatory phlebectomy.
The whole varicose vein is progressively extracted from one incision to the next. Incompetent perforators are carefully dissected and eliminated with gentle traction or torsion. Venous ligation is not necessary, because hemostasis is achieved with local compression during and after surgery. Areas in which postoperative compression is most difficult (eg, popliteal folds, thighs, groin, areas with deep and large perforators) are surgically removed first to permit the maximum time for hemostasis while the patient remains supine.
No skin closure is needed if the physician uses minimal incisions (1-3 mm) and good postoperative compression. With experience, removing extensive venous networks on both legs in a single 60- to 120-minute session is usually possible.
Complementary fine-needle sclerotherapy of telangiectasias can be performed immediately before or after the eradication of their nourishing venules. Large telangiectasias may also be destroyed by means of gentle subcutaneous curettage with the harpoon of the hook, whereas debris of venectasias can be removed through tiny incisions.
At the end of the operation, the leg is carefully cleansed with hydrogen peroxide or surgical soap. If oozing persists at any site, it is easily controlled with additional local compression. Elevating the leg for 5-10 minutes may also be helpful. Punctures are not sutured or closed with adhesive strips. Leaving puncture sites open helps with more rapid drainage of tumescent fluid and improves the cosmetic result.
Postoperative bandaging is an essential step in the procedure, and the physician or a well-trained assistant should carefully apply the bandages. The incisions or punctures are left open to allow tumescent anesthesia fluid to drain quickly. Large pads, either gauze or sanitary napkins, are placed along the site of vein removal and covered with an inelastic bandage.
If the physician is experienced with bandaging, a second dressing with a highly elastic (long-stretch) bandage is applied to the leg. This compression dressing prevents postoperative hemorrhage and reduces the likelihood of pain, bruising, seroma formation, and other complications. The long-stretch bandage is applied from the foot up, beginning at the toe joints and including the heel; it is proximally extended to cover all incisions. To avoid a tourniquet effect, an elastic dressing must never be applied over the proximal part of the leg without beginning at the feet.
If the physician is not experienced with elastic bandaging, compression stockings may provide an alternative means of compression. A single pair of 30- to 40-mm Hg compression hose may be used, or two layers of 20- to 30-mm Hg stockings may be applied for additive effects. Use of 30- to 40-mm Hg hose is recommended. If two layers of stockings are used, the topmost pair may be removed at night and replaced in the morning.
Daily ambulation should be increased as much as possible in the immediate postoperative period. Under no circumstances should a patient be confined to bed rest after venous surgery. Patients may return to work immediately after the operation, but they should not drive an automobile until the next day, because distal motor function may be subtly impaired as a consequence of prolonged anesthesia, particularly after local anesthesia in the popliteal region.
Dressings are removed after 24 or 48 hours. Typically, the incisions are minimal, and wound dressings are not necessary. However, ongoing compression therapy with elastic bandages or compression stockings is recommended for 7-21 more days, depending on the size of the removed veins and the degree of the reflux treated. Stockings may be removed for showering after postoperative day 4; otherwise, stockings should be worn continuously.
Complementary sclerotherapy of residual varicosities should be delayed several weeks until postoperative healing is well advanced. Many telangiectasias may progressively and spontaneously regress and disappear after varicose veins are removed by means of ambulatory phlebectomy. Patients should avoid early sun exposure because hyperpigmentation may result at the puncture or incision sites.
Most minor complications are benign and resolve spontaneously. Typically, varicose veins recur when the source of venous reflux is not treated by means of endovenous ablation techniques (see the image below). Sometimes, the cause may not be apparent until the phlebectomy is performed, particularly when many varicose veins are present.
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Before and 2 months after ambulatory phlebectomy. Reflux at saphenofemoral junction was treated with radiofrequency endoluminal ablation during same p....
The chief complications are as follows:
Edema
Bleeding
Hematoma formation
Scarring
Trauma-induced telangiectatic matting
Blisters due to wound dressings
Other complications, such as occasional nerve injury with sensory disturbances, are relatively unavoidable because a fibrotic nerve may be attached to the removed venous segment. Severe infections have been reported.[17] Very rarely, skin necrosis may occur; this is believed to be related to a high pH caused by adding too much bicarbonate to the anesthetic solution.[18]
Transitory hyperpigmentation usually fades in a few months without any treatment. Blisters secondary to skin shearing due to the use of adhesive tape may induce postbullous depigmentation or transitory hyperpigmentation. Contact dermatitis secondary to the use of antiseptic solutions or adhesives is uncommon, and it usually heals quickly with topical steroid application. Keloids and hypertrophic scars are extremely rare because of the minimal size of the incisions.
Superficial hematomas are common. Hematoma formation depends on individual variations in coagulation and on the effectiveness of the postoperative compression. Hematomas are most common in the popliteal fold, the most difficult area in which to achieve good postoperative compression.
Some patients complain of persistent subcutaneous nodules, which correspond to deep hematomas in the tunnel of the removed vein. When subcutaneous nodules occur, they are reabsorbed over 3-6 months. Significant delayed postoperative oozing may occur. After postoperative dressings are applied, the patients (particularly those with a long journey home) should be asked to walk around for 10 minutes, and the dressing should be reevaluated.
Superficial phlebitis may occur in incompletely removed varicose veins or neighboring veins. Deep venous thrombosis is not yet reported after ambulatory phlebectomy, probably because compression bandages and ambulation are effective forms of prophylaxis.
Lymphatic pseudocysts may be complications of phlebectomy of the ankle or pretibial or popliteal areas. When a subcutaneous nodule develops rapidly, the lymph collection may be punctured and drained. The best treatment is increased compression along with periodic gentle circular massage. In resistant cases, lymphatic drainage may be required.[19]
Neotelangiectasia (ie, telangiectatic matting) is the most annoying potential complication of phlebectomy. This complication is observed after classic stripping, as well as after sclerotherapy, and the etiology is unclear. In some cases, it seems to be related to a sudden local increase in venous pressure or to an area of persistent reflux that remains to be corrected. In others, it may be an angiogenic response to tissue injury that is part of the normal healing process. Some authors have noted an association with exogenous estrogens, but this association has not been confirmed.
Usually, telangiectatic matting spontaneously fades away after several months. In some cases, matting may be treated with sclerotherapy of the tiniest vessels; however, in other cases, every attempt to sclerose the vessels results in a new blush of recurrent matting. Pulsed dye laser or intense pulsed-light therapy could also be considered.
Injury to small cutaneous sensory nerves is common when veins are removed under general or regional anesthesia. However, sensory nerve injury is much less common when local anesthesia is used, because intraoperative manipulation of a sensory nerve is painful. If the surgeon stops immediately when the patient reports pain, sensory branches are typically left intact.
Small-nerve injury is possible in patients previously treated with sclerotherapy because inflammatory fibrous reaction and surrounding tissue adhesions bind the vein to the adjacent sensory nerves. Hyperanesthesia, hypoanesthesia, or total anesthesia secondary to nerve injury usually resolves within weeks or months. Neuroma is an extremely rare complication of peripheral nerve injury.
Albert-Adrien Ramelet, MD, Specialist in Dermatology and Angiology, Switzerland
Disclosure: Nothing to disclose.
Coauthor(s)
Robert Weiss, MD, Associate Professor, Department of Dermatology, Johns Hopkins University School of Medicine
Disclosure: Received honoraria from Angiodynamics for speaking and teaching; Received intellectual property rights from CoolTouch Corp for consulting; Received grant/research funds from Cynosure for independent contractor; Received grant/research funds from Palomar for independent contractor.
Specialty Editors
David F Butler, MD, Former Section Chief of Dermatology, Central Texas Veterans Healthcare System; Professor of Dermatology, Texas A&M University College of Medicine; Founding Chair, Department of Dermatology, Scott and White Clinic
Disclosure: Nothing to disclose.
John G Albertini, MD, Private Practice, The Skin Surgery Center; Clinical Associate Professor (Volunteer), Department of Plastic and Reconstructive Surgery, Wake Forest University School of Medicine; Past President, American College of Mohs Surgery
Disclosure: Serve(d) as a director, officer, partner, employee, advisor, consultant or trustee for: QualDerm Partners; Novascan<br/>Have a 5% or greater equity interest in: QualDerm Partners - North Carolina.
Chief Editor
Dirk M Elston, MD, Professor and Chairman, Department of Dermatology and Dermatologic Surgery, Medical University of South Carolina College of Medicine
Disclosure: Nothing to disclose.
Additional Contributors
Desiree Ratner, MD, Clinical Professor of Dermatology, NYU Langone Health
This vein on calf represents major varicose tributary of small saphenous vein that was removed by means of ambulatory phlebectomy.
Various hooks are used in ambulatory phlebectomy (eg, Ramelet, Muller, Oesch, and Varady hooks).
Tumescent anesthesia placed subcutaneously pushes vein closer to skin for easier removal.
Extraction of veins by means of ambulatory phlebectomy.
Before and 2 months after ambulatory phlebectomy. Reflux at saphenofemoral junction was treated with radiofrequency endoluminal ablation during same procedure.
Tumescent anesthesia placed subcutaneously pushes vein closer to skin for easier removal.
Various hooks are used in ambulatory phlebectomy (eg, Ramelet, Muller, Oesch, and Varady hooks).
Before and 2 months after ambulatory phlebectomy. Reflux at saphenofemoral junction was treated with radiofrequency endoluminal ablation during same procedure.
This vein on calf represents major varicose tributary of small saphenous vein that was removed by means of ambulatory phlebectomy.
Extraction of veins by means of ambulatory phlebectomy.
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