Chapter 38. Management of Lower Extremity Venous Insufficiency

• Swelling.
• Leg heaviness.
• Aching.
• Cramping.
• Skin discoloration.
• Venous ulcers.

• Acute deep venous thrombosis.
• Malformation of the deep venous system.
• Active infection.
• Symptomatic peripheral arterial disease.
• Cardiopulmonary comorbidities (relative).

Expected Benefits

• Removal of varicose veins of the lower extremity.

Potential Risks

• Phlebectomy.
  • Bleeding or hematoma formation at the operative site.
  • Superficial surgical site infection.
  • Paresthesias.
  • Recurrent varicose veins.
• Endovenous laser or radiofrequency ablation.
  • Recanalization.
  • Thromboembolism.
  • Burning pain.
  • Swelling.
  • Bruising.
  • Scarring.

Stab Phlebectomy

• No. 11 blade scalpel.
• Mosquito clamps.
• Vein hooks of several sizes.

Endovenous Laser Ablation

• No. 11 blade scalpel.
• Micropuncture kit.
• Endovenous laser generator, laser catheter.
• Ultrasonographic equipment.
• Tumescent anesthesia (infused by hand or Klein pump): lidocaine 1% with epinephrine, 50 mL; sodium bicarbonate 1 mEq/mL, 30 mL; saline 0.9%, 1000 mL.

Endovenous Radiofrequency Ablation

• No. 11 blade scalpel.
• Micropuncture kit.
• Radiofrequency generator, catheter.
• Ultrasonographic equipment.
• Tumescent anesthesia (as discussed earlier).

TriVex Transilluminated Power Phlebectomy

• No. 11 blade scalpel.
• Power phlebectomy unit and handpiece.
• Tumescent anesthesia.

• Nothing by mouth after midnight on the evening before the procedure.
• Ultrasound mapping.
• Veins should be marked in the preoperative area while the patient is standing upright to distend affected veins.
• Antimicrobial prophylaxis: cefazolin, 1 g intravenous, if phlebectomy is indicated (not needed for ablation only) or if skin changes indicative of chronic venous insufficiency are present.
• Deep vein thrombosis prophylaxis as appropriate for risk factors, using unfractionated or low-molecular-weight heparin.

• The patient is usually placed in the supine position initially, with exposure of the entire affected extremity.
• The leg should be prepared circumferentially from the inguinal ligament to the foot.
• If necessary, the patient may be repositioned prone.
  • This is especially helpful when access to posterior perforators or the small saphenous vein is necessary.

• The patient may receive either general or regional (spinal) anesthesia.
• Figure 38–1A: The anatomy of the superficial veins of the lower extremity, showing the location of the great saphenous vein (GSV) and small saphenous vein (SSV) as well as the tributaries to the GSV near the saphenofemoral junction.
  • Ablation of the GSV and SSV reduces venous hypertension transmitted to the varicose veins.
• Figure 38–1B: The saphenofemoral junction.
  • The tributaries that join the GSV near the saphenofemoral junction are shown in greater detail.
  • Formal stripping requires identification and division of these branches.
• Figure 38–2A: A 3-cm incision is made in the medial thigh, below the inguinal ligament, lateral to the femoral arterial pulse.
• Figure 38–2B: The tributaries to the saphenofemoral junction are identified, ligated, and divided.
  • The GSV is traced distally from the saphenofemoral junction, then doubly ligated and divided 1 cm distal to the junction.
• Figure 38–3A-D: Stab avulsion.
  • Small (< ...