Surgical treatment of varicose veins

There are several lesser surgical procedures that are of value in the modern treatment of varicose veins.

Ambulatory phlebectomy

The first of these is a procedure known as ambulatory phlebectomy. Phlebectomy, of course, means vein removal—and the use of ambulatory refers to the fact that patients are able to walk immediately following the vein removal. The technique is used to remove large varicosities that protrude and cause the legs to appear lumpy. The procedure is done in the office under a type of local anesthesia known as tumescent anesthesia, which is also commonly used for liposuction.

The incisions used to remove the veins are miniscule—typically only about one-eighth of an inch long. They are small enough that they don’t need sutures to heal and leave a nearly imperceptible scar. The veins are removed with the aid of a sterile crochet hook. The veins are able to be pulled out through the small incisions because the veins collapse once they are grasped.

A question that is commonly asked is “If the veins are removed as described, won’t there be a lot of bleeding from the vein fragments that are left behind?” This doesn’t happen for four different reasons. First, usually the main vessel supplying blood the varicose veins, the great saphenous vein, has already been treated with thermal ablation, which closes the vessel and prevents any blood from flowing to the varicosities that are to be removed.

Second, there is normally little blood flow through varicose veins when a patient is lying down. Blood flow in varicosities is produced by patients being upright and walking. Obviously, patients undergoing ambulatory phlebectomies are either laying on their backs or their stomachs, and certainly aren’t walking.

Third, prior to doing the phlebectomies we inject these veins with a foamed sclerosant, usually sodium tetradecyl sulfate (STS). The sclerosant works by irritating the inner lining of the vein and causing clot to form that tightly adheres to the walls of the vein—and therefore stops blood flow in the vein.

Fourth, following the procedure the leg is placed in a tight compression wrap, which prevents venous bleeding once the patient is up and walking—even if they didn’t have a more proximal vein treated with thermal ablation, and didn’t have sclerotherapy that produced thrombosis in the vein fragments left following the phlebectomies.

High saphenous vein ligation

The second of these procedures is a high saphenous vein ligation—simply a noose put around the great saphenous vein in the groin near its junction with the femoral vein. This procedure is used to minimize a known complication of thermal ablation procedures. While laser and radiofrequency treatment of the great and small saphenous veins has been shown to be quite effective and safe, there is one particular situation in which thermal ablation is associated with thrombo-embolism (blood clots to the heart and lung). When the great saphenous vein is greatly dilated, the thrombus that develops as a consequence of the thermal ablation process is more likely to break off and pass through the heart and possibly become lodged in the lungs. Consequently, we perform this procedure on patients who have markedly dilated great saphenous veins near the junction with their respective deep veins. This is done immediately before doing the thermal ablation, and requires about a half-inch incision in the groin. It is done under local anesthesia, and adds about ten minutes to the thermal ablation procedure.