Hrev_master Veins and Lymphatics 2017; volume 6:6822 [Veins and Lymphatics 2017; 6:6822] [page 65] The sapheno femoral junction involvement in the treatment of varicose veins disease Stefano Ricci Università Campus Bio Medico, Roma, Italy Abstract Sapheno femoral junction (SFJ) incom- petence has been considered the most important cause of chronic venous insuffi- ciency in a high percent of cases since the beginning of history varicose veins treat- ment. As a consequence SFJ dissection, lig- ation and section has been practiced all along the last century, generally associated to great saphenous vein stripping, with the porpoise of stopping the effect of hydrostat- ic pressure considered the origin of varicose veins. Recurrence prevalence at the site of SFJ, even in correctly performed dissection suggests that this attitude may not be the ideal one. Moreover, with the introduction of catheter-based systems of endovenous heating of the great saphenous vein with radiofrequency or endovenous laser abla- tion, it was shown that venous ablation could be achieved without high ligation of the SFJ. Also foam sclerotherapy demon- strated good results, even if less effective, always leaving the SFJ untouched. Following this trend several methods have been suggested that spare the SFJ, so that this site have lost its strategical importance. In this review history of the SFJ involve- ment in the varicose vein strategy is ana- lyzed with particular attention to the new generation methods, technology assisted, launched on the market. Introduction Sapheno femoral junction (SFJ) as ori- gin of the varicose veins disease has been the center of the attention from the begin- ning of the history of varicose veins treat- ment, however its responsibility has been weighted differently in the course of the last 100 years in parallel to technological inno- vations (US, endovascular methods), clini- cal evolution (conservative surgery, follow up experience), new materials (nitinol, cyanoacrylate) and physical preparations (Foam). At the beginning of 1900, very rapidly SFJ surgical ablation become a truism for any ideal treatment and on this basis the phlebologists proceeded without any doubts for a century; but how history teaches, cyclic changes of ideas are the rule and not the exception, so that now the SFJ, still important, is a supporting actor of the screenplay, needing a lesser if no attention at all. It would not be strange if in the fol- lowing cycle things would turn back again, however, this review is centered mandatori- ly on the first present revolution and its rea- sons and causes. Trendelemburg era In 1890 Friedrich Trendelemburg1 pub- lished a fundamental paper entitled: Ligation of the greater saphenous vein in varicose veins of the leg. The author describes the phenomenon of downward filling of the varicose bed through the incompetent saphenous trunk: A very simple experiment will prove the correctness of this view. One lays the patient flat again, raises the leg to perpen- dicular, lets all the blood flow out of the saphenous field and compresses the trunk of the saphenous with a finger at a spot where it is definitely recognizable. Now one lets the patient come down from the cot cau- tiously, without removing the compressing finger from the saphenous. We see that the whole saphenous vein now remains empty at first on standing. Not until the lapse of a quarter to a half minute does one see the varicosities in the leg gradually begin to fill with blood again. The fullness, however, is not nearly so tense as it previous was, as long as pressure on the trunk persists. Only when removes the compressing finger, does a larger amount of blood rush down from above into the saphenous and the old pic- ture of the tensely distended varicosities returns. This is the birth of what will be called the Trendelemburg test. As a consequence, quoting Trendelemburg: In thus the simple fact that the varicose branches of the saphenous are separated from the vena cava by no valve closure as the result of the simultaneous dilatation of the trunk causes a large part of difficulties and dangers to which the sufferers from varicosities of the legs are subject, then the next thought is to prevent the back flow of blood from the vena cava through the saphenous into the varices operatively, by a permanent closure of the saphenous at one place, and to the same time to relieve the veins at the lower leg and foot from the abdominal pressure which burdens them. Such a permanent closure can be produced easily and without danger by double liga- tion and section of the vein between the lig- atures, and as I have used the operation since the year 1880 in a large series of cases with the best results, I can recommend it for all cases of lower leg varicosities with simultaneous dilatation of the saphenous. This publication starts the modern treat- ment of varices: no more direct actions on varices (only), but attempt to eliminate the cause (saphenous reflux). Although the Discovery of saphenous vein incontinence has many previous fathers (Home, Rima, Brodie)2 Trendelemburg had the merit of a large scientific diffusion ligated to his repu- tation, but also times were ready to a better solution of varicose disease thanks to surgi- cal art evolution in the second half of the century ( antisepsis and anaesthesia over- all). Trendelemburg operation spread and had great success; results were reported as very satisfying3 but recurrences were already registered (22%, considered opti- mistic Rose4) as frequent for collateral veins canalization and Perthes, Trendelemburg’s pupil, already suggested to ligate GSV the higher possible for eliminating bypass pos- sibilities: When the ligation is made high up on the trunk there will be fewer side branches above the point of ligation and it will be less likely that one of them will reopen the area of varicose veins to the pathological blood pressure.3 He had a recurrence rate of 18%.4 Junction conquest The sapheno femoral junction, initially Correspondence: Stefano Ricci, Università Campus Bio Medico, via Alvaro del Portillo 200, Roma, Italy. E-mail: varicci@tiscali.it Key words: Sapheno femoral junction; high ligation; conservative surgery; history of vari- cose veins treatment. Conflict of interest: the author declares no conflict of interest. Received for publication: 28 May 2017. Revision received: 18 July 2017. Accepted for publication: 18 July 2017. This work is licensed under a Creative Commons Attribution 4.0 License (by-nc 4.0). ©Copyright S. Ricci, 2017 Licensee PAGEPress, Italy Veins and Lymphatics 2017; 6:6822 doi:10.4081/vl.2017.6822 No n c om me rci al us e o nly Review [page 66] [Veins and Lymphatics 2017; 6:6822] not considered, was involved - or at least nearly attained - already in Thelwell Thomas paper of 1896:5 to avoid new vari- cose vein formed along the branches which entered the saphena above the site selected by Trendelemburg…Since 1893 I resolved to tie and cut the internal saphena immedi- ately below the saphenous opening, and have operated upon fifteen cases in this manner with perfect results. Moore,6 in 1896, has the same sugges- tion: An incision one and a half to two inch- es long is then made parallel to the fold of the groin, and about two inches below Poupart’s ligament. In 1916 John Homans7 admirably describes the state of the art of varicose veins disease of its age, and in particular: The radical removal of the surface veins is perhaps most satisfactorily performed upon the following plan: A transverse inci- sion several inches long is made in the groin about one inch below Poupart’s liga- ment: Through this incision the great saphenous vein is divided at the saphenous opening. At the same time any other veins which parallel it or enter from above are found and divided in order to do away with any vessel capable of reestablishing a large, single, collateral trunk. The internal saphe- nous is then dissected out with the Mayo stripper or other appropriate means to the region just below the knee. Parallel to the groin dissection of the GSV, at the beginning of the century it appears evident that GSV interruption alone is not sufficient to control the disease, but also that the dilated GSV system should be eliminated for reducing recurrences. For this porpoise between 1905 and 1907, in the turning of only 3 years, 3 American sur- geons (Keller,8 Mayo,9 Babcock10) con- ceived the 3 basic stripping methods today still in use (respectively invagination, exter- nal, internal stripping), in the attempt of finding less aggressive methods than those in use at that time (Madelung: long inci- sions over the varices, Schede: circular inci- sions, Rindfleisch: spiral incisions).11 Interestingly, none of the 3 surgeons suggested junction ligation at their time. Babcock10 describes the inguinal time of his operation as: about 2, inches below Poupart’s ligament a transverse incision, one inch in length, is made through the skin and subcutaneous fat down to the muscular sheath. The index finger is then inserted to the bottom of the wound, slid backwards for a short distance close to the muscular sheath and then hooked inward and forward away from the muscle, when it at once catches the thik resistant cord of the saphe- nous vein., which is lifted into the wound and at once clamped above by a hemostat. Still it is not matter of high ligation, Homans’ rules came later. In Northern America Stripping becomes a new tool in surgeons’ hands obtaining pro- gressive (but not so fast) agreement, till the general consensus at the half of the centu- ry,11,12 finally popularized by Myers’11 expe- rience (1954) with the use of flexible strip- pers, also in Europe. Sclerotherapy (r)evolution Frightened by the cruelty of surgical procedures, physicians develop in parallel injection method starting from the archaic roots of the Pravaz syringe invention and of the first coagulating substances (ferric per- chlorure and iodotannin solution). Originally considered a too dangerous method (Congress of Surgery Lion 1894), injection treatment progressively evolved through the search of new less toxic sub- stances like phenic acid (Tavel 1904), potassium iodio-iodure (Schiassi 1906), sublimate 0.5% (Linser 1916), sodium car- bonate and finally salicylate (Sicard 1920).13Salicylate revolution, finally a non- toxic agent, fixed the beginning of scle- rotherapy renaissance at least in Europe. Sclerotherapy begun a very busy affair in Europe, enhanced by the creation of the first society of phlebology (Societé Francaise de Phlebologie) in 1947. A deep dualism between sclerotherapy and surgery took place that partly is present still nowadays. According to Marmasse14 starting with 30 years of advantage over sclertherapy - 1890-1920 - varices surgery fell to sleep during the following 30 years - 1920-1950. At present very effective and safe agents are in use (polidocanol, tetradecilsul- fate) and, finally, a new way of administra- tion (foam) that appears more efficient, however direct SFJ treatment is not really expected with this method as shown by, Butie,15 Biegelsen.16 Some attempts have been made in the past to treat directly the Junction.17-19 preferably by injections few centimeters below the groin to avoid Pudendal artery injection and Femoral vein thrombosis, but the wash out of the tributar- ies seems to avoid closure of the terminal part of the GSV, how demonstrated in Duplex era assessment.20,21 Surgery/sclerotherapy (liquid) combination Tavel (1904),22 from Berne, published the first an experience in injection treatment after subcutaneous GSV ligation, if sponta- neous post ligation saphenous thrombosis was lacking. However, Schiassi (1907)23 suggested what is considered a milestone in treatment of varices: simultaneous ligation (by local anesthesia) and injection (iodide solution) of varices. According to Foote,11 he was much in advance of his time, as the combination of the two methods became firmly established in 1925 and for quarter of century high resection of the GSV in com- bination with retrograde injection of scle- rosant has been employed all over the world.4,24-27 Interestingly, Nobili (1921), Schiassi pupil, had the merit of suggesting the injec- tion higher in the groin, allowing the scle- rosant to be eliminated through a second distal incision; Unger (1927) suggested to use a catheter for injecting the distal GSV through the groin dissection; Moszkowics (1927) employed dextrose injections; Mairano (1949) made thigh stripping and salycilate injection in the crural GSV.28 Rose4 tells us, in one historical talk, that: The operation I performed in 1941 was high ligation of SFJ, tributaries ligation and retrograde passage of a ureteric catheter down the cut end of the vein until it would go no further (Unger technique - Editor’s note.). About 6 to 8 ml of 5% to 10% of sodium morrhuate was injected down the catheter as it was slowly with- drawn. The entire procedure was carried out with the patient under local anesthesia and done in an outpatient basis. The result was an immediate massive reaction along the line of the saphenous vein from ankle to groin. A chemical thrombophlebitis was produced that required heavy bandaging and caused considerable disability. The patients were painfully incapacitated dur- ing the 2 to 4 weeks it took for the condition to solve. The ultimate fate of the thrombosed vein was recanalization, which took place sooner than expected…. Use of ureteric catheter was discontinued in 1945, and the practice of simultaneous sclerotherapy was ended in 1946. In the French survey (1962),29,30 over 147 participants, 24 still practiced the method, 20 of them reporting thromboembolic accidents or even death. More recently Lofgren,31 Jakobsen,32 Sladen,33 Neglen,34 Racek35 still practiced this method with good but not stable results, in any case inferior to stripping methods. Whatever method was used to treat the distal varices, high ligation become highly recommended for avoiding groin recanal- ization while sclerosing injection were preferably practiced in limited extension and successively. No n c om me rci al us e o nly Review [Veins and Lymphatics 2017; 6:6822] [page 67] Stripping prevalence After the II word war the american way took place.4,11,12,28,36,37 High ligation and GSV stripping became the gold standard although with plenty of variations and “inventions” as: long or short stripping, below-upward or above downwards strip- ping, pleating or inversion by string or mesh, redon drainage, association to perfo- rator ligation or varicectomy or sclerothera- py, by general, spinal, local anesthesia, with a choice of plenty of strippers in commerce. In 1962 the French Enquete sur la crossectomie et le stripping29 based on a questionnaire to whom participated more than 147 phlebologists (69)/surgeons (77) experts of France (93) and Europe (53) reveals that high ligation/stripping is largely prevalent over sclerotherapy alone, but evi- dence appeared that neither surgery alone, or sclerotherapy alone (apart Carl Sigg opinion), could satisfy the request of the ideal treatment of varices, a wise combina- tion being the best solution: (E. Maes- Belgique): That phlebologist that operates on varices excluding sclerosant injections is like a piano player playing only on white keys leaving out the black ones.29 The Myth While things constantly change in vari- cose treatment history, one single concept becomes a myth: Spheno-femoral junction should be full dissected and all junction col- laterals should be ligated/divided possibly till their secondary division. This act would stop the pressure from above, primary cause of varicose disease. Every single junction collateral vein left could be the origin of recurrence. Dissection should be even extended to the Common Femoral Vein, to possibly exclude branches joining separate- ly to the deep system.30 According to Foote,11 The only way to ensure a satisfactory clearance is to divide everything entering the sapheno-femoral trunk, however small it may be. It is essen- tial to seek out the circumflex iliac branch for a little distance laterally to ensure that it has no descending branch… The rule is, therefore, any adjacent descending branch must be ligated however small it may be. According to Geier:38 Although never proven by a randomized study, long-lasting experience with varicose vein surgery has led to the postulate that resection of the SFJ should be done as close to the femoral vein as possible, without leaving a long residual stump. The rationale behind this technique is the assumption that such a long residual stump will be affected by refluxing blood from the femoral vein, which with time will cause further dilatation and incompetence of the stump and its branches, resulting in recurrent varicose veins. Recurrences No other disease, maybe except dental pathology, has so great tendency to recur- rence than varicose veins. As soon as a sci- entific method of treatment has been under- taken (Trendelemburg, Perthes), the first cases of recurrence were recorded (22, 18% respectively). Already in 1940 Stalker26 writes: With all types of treatment there have been a large percentage of recurrences in spite of the fact that immediate results have been encouraging. No type of therapy for the relief of varicose veins of the lower extremities is new. All have been tried, have been discarded, and have reappeared at one time or another. Due to the benign nature of varices, that are not life threatening and respond posi- tively to any treatment in the immediate, usually phlebologists consider their results very positively unless their patients are assessed after at least 5 years (but often even 2 years are critical). Furthermore recurrence are generally due to others’ man- agement. A more scientific approach (Hobbs39) and US facilities (Fisher40) showed a different and more realistic situa- tion in outcomes that is going to originate a new research movement, still going on today. Hobbs,39 in 1974 by clinical analysis comparing “enthusiastic sclerotherapy with enthusiastic surgery” observed, after one year 82% of unselected patients were cured (no symptoms or signs and no varicose veins ) by injection, but after six years the cure rate was only 7%. At the opposite after surgery, at one year 40% were cured versus 20% at six years. According to Fisher,40 in 2001, 125 limbs (77 patients) that under- went operation between 1960 and 1967, were evaluated clinically and with duplex sonography for possible superficial-to-deep vein reconnections and clinical recurrence of thigh varicosities at a mean follow-up of 34 years. Clinical examination suggested sapheno femoral recurrence in 59 limbs (47%)while duplex ultrasonography demonstrated sapheno femoral reflux in 75 limbs (60%). Interestingly, all the patients were considered receiving a correct termi- nal high ligation. More than 50% of recurrences are local- ized at the SFJ: a phenomenon that is linked to GSV trunk recanalization, a pelvic leak- ing point involvement and/or a neovascular- ization.41-44 The recurrent varicose veins after sur- gery study (REVAS)41 reported the out- comes from a large cohort of patients treat- ed with ligation and stripping at a number of international centers and demonstrated that 20% of these recurrences originated from sapheno femoral neovascularization, 19% from incorrect junctional ligation, and 55% from perforator reflux. Evidence based results and ultrasound assessment of outcome outlined that the phlebologists’ optimism had to be reviewed. While groin recurrence has been univer- sally related to insufficient quality of surgi- cal procedure (technical failure), evidence exists that junction recanalization occurs in proper groin dissection too.45 This phenom- enon of formation of new venous channels between the saphenous stump on the com- mon femoral vein (CFV) and the residual GSV or its tributaries is called neovascular- ization.46 The potential pathophysiological mechanisms of reference are many: angio- genic stimulation in the free endothelium of the ligated stump, trans-nodal lympho- venous connection, dilation of small adven- titial vessels in the vasa vasorum of the femoral vein, disturbed venous drainage of the ligated tributaries of the SFJ. A significantly higher risk of SFJ recur- rence was reported44 in cases of Iliac Femoral Valve incompetence (IFV) with an odd ratio of 4.8. In the 45 cases of recur- rence over 381 cases analyzed at 5 years follow up, 27% of recurrences were associ- ated to IFV incompetence, versus 7% in non-recurrence patients. Paradoxically, when the SFJ has been missed and a portion of the GSV has been left attached to the CFV, the postoperative hemodynamic situation (reflux) remains unchanged, with minimal or missing impe- tus for postoperative neovascularization. On the contrary, after correct ligation, the hemodynamic situation at the SFJ changes completely, activating possible pathophysi- ologic mechanisms.47 Complete resection of the GSV stump48 and inversion suturing of the common femoral vein did not seem to decrease neo- vascularization.49 Results on the use of barrier materials are conflicting and these techniques have also not yet been introduced into common clinical practice.50,51 Re-do surgery In symptomatic patients with varices recurrence and hemodynamic anomalies treatment is indicated. There is no consen- No n c om me rci al us e o nly Review [page 68] [Veins and Lymphatics 2017; 6:6822] sus on preferring sclerotherapy versus sur- gery as evidence is very poor.52 Surgery is considered the best option when a major reflux may be identified due to a large stump. A lateral approach first visualizing the Femoral artery has been the most employed technique,53 while a medial indi- rect approach may be used in alternative.54 However this type of surgery, easy in skilled hands, but rarely analyzed in the lit- erature is anecdotally considered technical- ly challenging, time consuming, at risk of complication, reported to fail in 30 to 80% of cases,44 inducing to refrain from aggres- sive surgery.55,56 As an alternative, scle- rotherapy alone57,58 or associated to sur- gery59 may give good results. The Duplex advent The development of duplex ultrasound has been like the invention of the micro- scope or telescope in biology or physics, allowing us to see better in real time the venous network, to monitor venous disease noninvasively in clinical and research uses. Ultrasound is now used preoperatively, intraoperatively, and postoperatively.60 Duplex evaluation of varicose veins was first reported in 1986,61-63 however rou- tine use of duplex scanning prior to varicose vein surgery has not become an established practice till the end of the century. In the mid-1990s, it was found that in the United States, 18% of noninvasive vascular labora- tories did not use duplex ultrasound for vein mapping and another 37% did so only occa- sionally.64 Some investigators advocated using color coded duplex sonography only for investigation of the popliteal fossa65,66 or recurrences. Phlebology practice of 2000 is strongly ligated to Duplex /Color assessment due to the large diffusion of modern, simple and relatively cheap equipment allowing the single phlebologist to display its own assessment. This induced a progressive enormous advancement in anatomic and functional knowledge of venous patholo- gy67-68 and, as a consequence, an evolution of treatment methods. Already in 1989 Sclerotherapy through Ultrasonic guidance of injection into the superficial venous sys- tem was first published.69 The initial aim of this technique was more to reduce the risks inherent in injection of hidden (non visible and palpable) veins than to improve results.70 In 1990s foam appeared and rapid- ly became popular and diffused for its effi- cacy and US visibility.71-73 Furthermore, also postoperative analy- sis changed its perspective as clinical aspects could be verified by Duplex reveal- ing a much higher recurrence rate.74 In particular, it became clear that GSV reflux is not always associated to SFJ incompetence;75 in fact terminal valve may be competent in a very high number of cases (33% Abu-Own;76 40% Pieri;77 55% Cappelli;78 56% Somjen79). In this instance junction dissection and high ligation is use- less80 and even harmful, the source of reflux coming from a perforator or tributaries. Terminal and pre-terminal valves func- tion,77 prevalence of AASV incompetence,81 possible influence of common femoral valve on SV hemodynamics,44-78 peri junc- tional veno-lymphatic network,82 GSV hypoplasia83 are all aspects revealed by US observation, influencing treatment strategy and tactic, and often rising recurrences. A new perspective given by US studies was started already in 1988 (maybe too much early over an unprepared audience) by Franceschi84 who conceived a method (CHIVA) that allowed conservation of the GSV stem and venous network - even incompetent - for possible bypass use, with simple limited surgical actions (ligatures), but after a deep analysis of the single patient’s venous hemodynamic. Again SFJ is the chief character but in a new conservative perspective, to be adapt- ed to single patients hemodynamic. Chiva Crossotomy In ideal CHIVA treatment cases, the junction is high ligated without interruption of the junction tributaries which are drained through the incompetent saphenous stem in counter current through the distal perfora- tor(s) centered on the same saphenous stem; the incompetent tributaries are de-connect- ed from the saphenous stem but are not removed. The final result is a normalization of the venous hypertension without removal of any venous tract. The junction phase is called Crossotomy (section of the crosse, the French name for Junction), in opposition to what is conventionally called Crossectomy (removal of the crosse). Unfortunately, sci- entific evidence of crossotomy results is lacking and single CHIVA authors mostly report anecdotic experience. Junction dissection without tributaries interruption may be a challenging operation due to the great anatomical variations of tributary arrangement when they merge proximal to the Femoral vein . Once the junction dissected, interruption may be obtained by placing a clip flush to the femoral vein plus a second clip in proximity placed in opposite direction. Traditional lig- ation by non-resorbable threads seems at risk of ice effect recanalization. Section of ligated saphenous stump is the best option for a de-connection but may be difficult if a limited space remain between the femoral wall and the tributaries. In some instances the more proximal tributary(s) can be sacri- ficed.85 Del Frate86 compared surgical divi- sion crossotomy to two different triple superimposed flush ligations (N. 2 non- absorbable braided coated suture versus N. 0 polypropylenene ligation) without divi- sion. The incidence rates of neovasculariza- tion was 4.9%, 6.1% and 37.5% respective- ly. According to Zamboni,87 recurrence rate at 3-10 years is 2.9% for crossotomy versus 5.5% for crossectomy (stripping). Valvuloplasty Another way of sparing incompetent GSV opposite to ablation is the reconstitu- tion of competence of the junction when valvular incompetence is due to diameter dilatation while the valves are still efficient. The basic idea has inspired different meth- ods of obtaining the goal: banding of the junction area with fascia lata,88 with pros- thetic material (Dacron or Politetrafluoretilene - PTFE),89 fenestrated for tributary sparing,85 with the VENOCUFF stapler (Dacron/silicon band- ing with automatic caliber fixation),90 with the EVS (Gore External Valve Support), a Dacron device Nitinol reinforced,91 with OSES™ (Oval Shaped External Support): acting traction onto the inter-commissural diameter of an incompetent valve (Assut Europe SpA, Italy)92 Perivenous injection of viscose fluids like jaluronic acid has also been attempted for the same porpoise.93 Generally good results are reported even at long term considering symptoms and function, however usually studied pop- ulation is limited in numbers and specifical- ly selected. Belcaro94 reported his 15 years clinical experience of external valvuloplas- ty with EVS in 101 patients. This author completed a four-year follow-up of a total of 47 patients without infections, thrombo- sis, foreign body reactions or other prosthe- sis-related complications, with 4% of SFJ reflux recurrence. Jin-Hyun Joh95 re-exam- ined thirty-one limbs from 27 patients at mean of 92.6 months registering persistent reflux in 19 (61%). The true advantage is the conservation of GSV integrity opposite to ablation, and particularly the maintenance of centripetal flow in the same GSV. The present loss of compulsory need of absolute suppression of No n c om me rci al us e o nly Review [Veins and Lymphatics 2017; 6:6822] [page 69] Junction reflux can explain the loss of inter- est in these techniques. Surgery with Junction respect In 1993 Dortu96 suggested the possible over the fascia junction interruption: this Author currently practiced Muller Phlebectomy on varicosities and, in selected cases, pushed the vein avulsion to the saphenous stem arriving till the groin: through a micro incision of 2-3 mm, 2 to 3 cm below the skin projection of the junction he hooked the saphenous stem out, ligated the tributaries and finally double ligated the Saphenous stump, that remained 6-10 mm long. Over 276 limbs controlled after at least 3 years (mean 5.6 years) 271 had good outcome, two cases having recurrence on posterior accessory and 2 on anterior acces- sory and one as typical neogenesys. Rapidly other authors followed this revolutionary trend.97,98 This atypical and heretical surgical application, corresponding to a stripping with an uncomplete high ligation (and to EVA techniques result) has been succes- sively re-evaluated by several authors for its very satisfying outcomes: Pittaluga99 with only 2.7% recurrence at 27.3 months; Casoni100 with 8% recurrence at two years; this same author, in a randomized trial (stripping alone versus stripping - high lig- ation) found at 8 years 9.8% versus 29% of clinical recurrences and 11.4 versus 32.2 of US reflux recurrence respectively.101 Mariani in 2015102 reported an experi- ence of selective high ligation (sparing veins coming from the abdominal wall, as the superior epigastric vein or the superior iliac circumflex vein), on 360 limbs with follow up from 5 to 12 years, recording only 1.9% (7 cases) of groin recurrences. Recently Ricci103 described GSV pre terminal ligation/transection by a simplified surgical approach made easy by US assis- tance: GSV is hooked 3 cm from the junc- tion through a micro incision under direct visualization of the vein. The distal saphe- nous stem then can be treated in the pre- ferred way or left for conservation. Tributary avulsion without GSV reflux treatment The evidence of varicose veins develop- ment not associated to SFJ and GSV incom- petence (Labropulos, Coleridge) suggested a possible ascending mechanism of progres- sion of varicose disease, for which the ter- minal/junctional valve represents the last stage of a venous reflux that advances from lower levels, challenging the traditionally accepted retrograde theory descending directly from Trendelemburg’s observa- tions. Venous wall weakening is the initiating factor of primary reflux that, therefore, might not develop in a retrograde manner beginning from the terminal valve but, more likely, following a reverse, upward directed, pattern.104 According to this hypothesis, Pittaluga in 2005 suggested the ablation selective of varices in anesthesia in local (ASVAL). Following the Author’s words:105 Progression of the disease starts in the supra fascial tributaries, which are the most superficial, the most exposed veins outside the saphenous compartment and whose walls are the thinnest. Venous dilatation begins on the supra fascial tributaries dis- tally, where the hydrostatic pressure is high- er, creating a dilated and refluxing venous network called varicose reservoir (VR) within the supra fascial space.106 When this refluxing network becomes large enough, it can create a filling effect in the saphenous vein, leading to decompensation of the saphenous vein wall, reaching progressive- ly the SFJ or SPJ. The goal of the ASVAL method is to decrease or eliminate the saphenous vein reflux by minimizing VR using ambulatory phlebectomy described by Robert Muller107 or sclerotherapy. Pre- operative ultrasound assessment has enhanced the precision for phlebectomy. Although isolated treatment of varices leaving an incompetent GSV was not new,107-109 ASVAL had the merit of giving a scientific dignity to an empiric method. Endovascular generation Endovenous laser treatment of saphe- nous veins developed during the 1990s, only from 2000 were published the first rel- evant papers about endovenous treatments of the Great Saphenous vein. At the beginning of the new century, minimally invasive endovenous laser abla- tion (EVLA)105 and radiofrequency (RF) ablation106 have emerged as effective outpa- tient treatment approaches both delivering electromagnetic energy to destroy by heat- ing the vein wall.107 Initially, reports of successful ablation of the GSV using either radiofrequency or laser energy without ligation or stripping were treated with great skepticism. In fact all the endovascular approach methods are applied for closing the GSV stem, leaving untouched the last 2-3 cm of GSV, i.e. the SFJ. This technical aspect assures the junc- tion tributaries drainage and avoids the nearer Common Femoral Vein involvement (EHIT: endovenous heat-induced thrombus) 108 similarly to what occurs to sclerotherapy, where the washout of the same tributaries maintain the junction patent. However, the absence of neovascular- ization appeared so striking that many skep- tics have begun to believe that former emphasis on a clean groin dissection may have been in error.30 In fact, the majority of cases of recur- rence occurred due to recanalization of a segment of a previously treated vein with recurrent reflux or new reflux in an accesso- ry or alternate truncal pathway as shown by some 5 years outcome randomized stud- ies.109-113 Gradman, in a survey of members of the American Venous Forum and American College of Phlebology, concluded that regardless of the method of saphenous vein ablation (RF, laser, or foam sclerotherapy), concomitant ligation of the sapheno femoral junction offered no advantage in outcome no matter the size of the proximal great saphenous vein.114 In the same time sclerotherapy begun its renaissance through foam formula of the two detergent agents (polydocanol, tetradecilsulfate). Foam ultrasound guided sclerotherapy rapidly showing a better effi- cacy compared to liquid sclerotherapy became a valid alternative to EVA as endovenous chemical ablation. Although offering a lower occlusion rate as primary treatment, but with a good secondary suc- cess, it has the advantage of a low cost and a simple administration so that it can be eas- ily repeated.115 Based on the new concept that SFJ dis- section is not necessary while GSV stem still needs to be eliminated, several methods are constantly and progressively conceived to satisfy the following requests, the order of importance of the factors being variable: i) outpatient setting; ii) ease to perform; iii) efficacy; iv) industrial business. In 2007 Milleret116 started to study an endovascular heat ablation employing steam. At the tip of the catheter, steam is emitted at 120°C achieving results similar to the other heating methods. In 2011 A new mechano chemical device (ClariVeinw, Madison, CT, USA), was developed to minimize the negative aspects of both endothermal ablation and ultrasound-guided sclerotherapy (UGS), while incorporating the benefits of each.117 The method has the advantage of not need- ing tumescent anesthesia that thermal abla- tions do. In 2013 Almeida118 begun to study fea- No n c om me rci al us e o nly Review [page 70] [Veins and Lymphatics 2017; 6:6822] sibility of GSV occlusion by a special glue, having the advantage of not requiring peri venous tumescence and post treatment com- pression. Post ablation thrombus extension (PASTE) through the SFJ, seen infrequently following thermal or foam saphenous abla- tion, was seen in 8/38 (21%) patients in the first human study; this problem appears to have been resolved by moving the 1st injec- tion to 5 cms below the SFJ.119,120 In 2013 Frullini121 published prelimi- nary results of a technique combining a par- ticular attenuated laser action, that shrinks the vein wall, to foam sclerotherapy. In 2013 thermal segmentary ablation has been suggested by Gianesini122 and con- temporarily by Passariello123 with the pur- pose of using endovascular techniques for high GSV occlusion (below the junction, for a length of few centimeters only) spar- ing the more distal part of the saphenous stem. Recently Mendoza124 employed this technique on 104 patients with results com- parable to surgical crossectomy. Followed: i) a vessel occluder that can be placed percutaneously, in initial study phase;125 ii) a mechanical closure using a spiral shaped device;126 iii) a Coil closure combined to foam injection US assisted127 or by image intensifier (and conscious seda- tion).128 To be continued… References 1. Trendelemburg F. Ueber die Unterbindung der Vena saphena magna bei unterschenkelvaricen). Beitrage zur klinischen Chirurgie 1890;7:195. 2. Ricci S. Who discovered saphenous vein incontinence? Acta Phlebol 2003;395-100. 3. Perthes. Ueber die Operation der Unterschenkelvvaricen nach Trendelemburg. Deutsche medinische Wochenschrift 1895;16:235. 4. Rose SS. Historical development of varicose veins surgery. In: Bergan JJ, Goldman M, ed. Varicose veins and telangectasias. St. Louis, Mo: QMP; 1993. 5. Thelwell T. Operative treatment of varicose veins of the lower extremity by ligature and division of the internal saphena vein at the dsaphenous open- ing. Liverpool Med Chir J 1896;16:278. 6. 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