Open Surgical Techniques For Lower Extremity Vein Ablation

Introduction:

Most surgical vein ablation techniques have been upgraded to be less invasive, such as saphenous ligation and stripping (thermal and nonthermal ablation). Nonetheless, venous surgery continues to be the norm in many nations worldwide. Varicose veins are increasingly being treated using hybrid treatments that combine minimally invasive and traditional surgical methods. Open surgical approaches are frequently the most effective for treating large varicose veins, vein recanalization following minimally invasive procedures, and varicose vein complications. The patient's varicosities location, size, and extent, as well as the existence or absence of venous reflux, influence the approach used. The open surgical technique requires heightened ligation, division, and stripping of the great saphenous vein (GSV) or short saphenous vein (SSV), integrated with the excision of parts of varicose veins (an abnormal dilated and tortuous veins in the leg), if demanded. Open surgical procedure is considered a golden standard approach to treating lower limb ischemia (reduced oxygenated blood supply to the lower area of the body).

What Are the Indications for Open Surgical Techniques for Lower Extremity Vein Ablation?

• Residual vein after surgery.

• Isolated small dilated vein.

• Long or short saphenous vein varicosity.

• Vein insufficiency.

• Deep vein thrombosis.

• Rest pain that worsens at night.

• Intermittent claudication (refer to the distance a person can walk before the onset of pain).

• Non-healing ulcer.

• Gangrenous patches of the skin.

• Thromboangiitis obliterans (when the blood vessels become inflamed, swell, and eventually blocked with blood clots and thrombi, which lead to damaged or destroyed skin tissues and progress to infection).

What Are The Contraindications Of Open Surgical Techniques for Lower Extremity Vein Ablations?

• The danger of anesthesia is principally responsible for the risk associated with surgical treatment for varicose veins. Techniques utilizing local, tumescent, or regional anesthetics are preferable for individuals with major cardiopulmonary comorbidities.

• Truncal vein ablation is not recommended when the superficial system serves as the primary venous outflow, such as when deep veins are blocked or the deep venous system is congenitally absent. The risk of perioperative venous thrombosis should be considered when performing varicose vein surgery on individuals with a history of deep vein thrombosis.

• Because of their elevated likelihood of poor outcomes, diabetes, and moderate-to-severe peripheral artery disease are relative contraindications.

What Are the Open Surgical Techniques for Lower Extremity Vein Ablations?

Saphenous Vein Inversion and Removal: Saphenectomy (to remove the saphenous vein): Expatriation of the great saphenous vein (GSV) from circulation is done to remove varicose veins in the legs by stripping with ligation, avulsion, or ablation.

Indications:

Symptoms like aching, discomfort, leg fatigue, and leg heaviness are all reduced by leg elevation.

Superficial thrombophlebitis (inflammation of the vein that causes the blood clot within the vein that leads to slow blood flow) in varicose clusters.

Bleeding from venous ulcers.

Progressive transformations of chronic venous insufficiency include:

• Severe ankle hyperpigmentation.

• Subcutaneous lipodermatosclerosis (inflammation of the fat under the skin, which is accomplished by a change in color of the affected skin area).

• Frank ulceration.

High Saphenous Ligation: It can be performed as an outpatient (where the patient can be discharged on the same day after the procedure) surgery. Medical professionals prescribe a sedative (medication to induce sleep) with regional anesthesia (blocks pain in the region of the procedure) and, if needed, general anesthesia, which makes one unconscious. Once the anesthesia takes effect, the surgeon creates small incisions in the groin and lower leg, and then they try to locate varicose veins using ultrasound imaging and then hitches off the veins and removes them. High ligation and sections of the great saphenous vein(GSV) are served at the level of its junction with the common femoral vein. So to avoid a cul-de-sac, extreme care is required to avoid constricting the femoral vein, and all the tributaries of the great saphenous vein (GSV) should also be ligated and divided.

Ligation and division of the short saphenous vein (SSV) are accomplished at the level of the popliteal vein crease after the short saphenous vein (SSV) is recognized with an intraoperative duplex scanning. A short saphenous vein can be ligated below the skin at a 4-centimeter distance to the saphenopopliteal junction, simplifying the procedure.

Endovenous Thermal Ablation: The technique utilizes heat or laser energy to seal off varicose veins. Ultra-sonographically guided percutaneous catheter is inserted inside the vein at the demanded area where the thermal ablation harms the endothelium and degrades collagen. Endovenous laser ablation employed is of two types:

• Hemoglobin-specific laser (810, 940, and 980 nm wavelengths).

• Water-specific lasers (1319, 1320, and 1470 nm wavelengths).

Stripping: Entire stripping must be avoided to prevent trauma to nerves. Likewise, for the GSV, stripping is accomplished up to the knee and for the SSV up to mid-calf. In addition, perivenous tumescent anesthetic infiltration and postoperative compression bandages are used to decrease postoperative bleeding. Either can perform stripping: Intraluminal stripping with silk thread or cryo-stripping is a new liquid nitrogen method.

Conservative Hemodynamic Cures for Venous Insufficiency (CHIVA) Technique: It is the most sophisticated procedure and requires special skills. It is based on a theoretical hemodynamic concept and utilizes the ultrasound-guided strategy with minimally invasive surgical achievement under local anesthesia for varicose vein patients.

Phlebectomy is a surgical procedure in which a small incision removes the varicose vein in the affected skin area. There are mainly two types of phlebectomy:

• Ambulatory Phlebectomy: Done under anesthesia, where the varicose veins are removed with hooks or forceps (stab avulsion or microphlebectomy)

• Transilluminated Powered Phlebectomy: Hydrodissection of the varicose vein using fiber optic transillumination

What Are the Complications After Open Surgical Techniques for Lower Extremity Vein Ablation?

Potential problems following the procedure are:

• Discomfort, Bruising, or Swelling: It is usual to expect some discomfort, mild swelling, and bruising after treatment, which can be relieved using prescribed medications. Extreme pain or numbness of the leg should be notified to the doctor immediately. It may be due to extremely tight bandaging around the ankle, so it is better to consult the doctor.

• Bleeding: Oozing blood around the bandage can occur in the first 24 hours following the procedure. It is not dangerous and usually gets controlled on its own with rest.

• Infection: Seen in 1 % of cases and commonly involves the groin wound, which settles with oral antibiotics.

• Lymph Leak: A fluid leak from the wound area is rarely seen following redo surgery in the groin.

• Deep Vein Thrombosis (DVT): The physician notices it following the follow-ups and resolves it with prescribed oral anticoagulation. Clot formation in the veins of lower limbs that cause severe signs and symptoms.

• Nerve Injury: The saphenous nerve lies very close to the long saphenous vein in the lower leg. It can be injured during surgery in 5% of cases, which causes tingling, numbness, and shooting discomfort in the inside of the lower leg, which takes weeks or months to improve.

• Recurrent Veins: Appear in 20% of patients within five years following the procedure for varicose veins.

What Is The Outcome Of Open Surgical Techniques For Lower Extremity Vein Ablation?

Minimally invasive treatments have been contrasted with surgical therapy for chronic venous illness. Most patients are typically happy with surgical surgery for venous illness, and surgical intervention improves symptoms. However, in randomized trials, minimally invasive techniques for saphenous ablation for the management of reflux appear to be as effective as saphenous ligation and removal and offer important benefits like avoiding a groin incision, experiencing less postoperative pain, and recovering more quickly. A higher frequency of recurrence may be linked to less invasive techniques. But for the vast majority of patients, minimally invasive procedures may effectively control chronic venous illness.

Conclusion:

Open surgical techniques for vein insufficiency will remain the first choice of treatment by experts. The procedures may include many side effects and complications but provide the best outcome and efficiency to address lower limb issues. Thus, ligating with stripping, in addition to phlebectomy, is typically considered the "gold standard" for treating long saphenous veins.