Clinical Relevance

Varicose veins are an extremely common problem, affecting over 8 million Americans. Primary management is to treat the underlying reflux, which is most often down the great saphenous vein (GSV), but even after successful GSV ablation, many patients will still have visible varicose veins. Ambulatory phlebectomy (AP) is a simple procedure that can be used to remove these residual varicose veins. AP involves hooking the varicosities through multiple small stab incisions and then pulling the veins out, avulsing them from their attachments. AP was first developed around the time of the Roman Empire by Aulus Cornelius Celsus (56 bc to 30 ad). Although an ancient technique, AP is an integral part of managing varicose veins and should be a part of any modern vein practice.

Indications

The most common indication for AP is to treat varicose veins that persist despite adequate GSV ablation. Residual varicosities can cause symptoms such as pain or itching, and although GSV ablation may significantly diminish symptoms, it does not always completely eradicate them. Even if ablation relieves all symptoms, some patients will seek further treatment for cosmetic improvement of residual bulging and unsightly varicosities. The timing of AP is slightly controversial and will be discussed later.

There are some reasons to do AP as primary therapy for varicose veins rather than an adjunct to GSV ablation. Local therapy may be preferable when the deep system is compromised and GSV ablation is inadvisable, or if the varicose veins are fed by a focal source of reflux like a perforating vein. In the latter case, doing GSV ablation without addressing the perforator reflux would lead to clinical failure. This is a more common scenario in patients with more severe venous disease, since it has been shown that there is increasing frequency of refluxing perforators as the clinical severity of venous disease increases.1,2 AP may also be used as palliative treatment to treat local symptoms in a patient who refuses or is medically unable to undergo definitive treatment of the underlying source of reflux.

Contraindications

There are very few absolute contraindications to AP. Cellulitis in the planned operative field is a firm contraindication. Operating in an infected field may worsen the infection, and poor healing of the AP incisions is likely. The multidisciplinary guidelines on use of AP also list severe peripheral edema, lymphedema, serious illness, inability to follow postoperative instructions, and allergies to local anesthetics as other absolute contraindications.³ Allergies to local anesthetics may be a contraindication, but switching to a different family of local anesthetics (an ester vs. an amide) can allow safe anesthetic use. Coagulopathy, anticoagulation use, or any other bleeding diatheses are relative contraindications. These abnormalities may increase the risk of bleeding or hematoma. Although these are normally minor complications, greater attention has to be paid to this when doing AP for cosmetic reasons. Even relatively small hematomas or bruising may lead to decreased patient satisfaction if their goal is to improve the cosmetic appearance of the legs. Prior history of deep venous thrombosis is also a relative contraindication, since removal of additional veins may further compromise venous return from the leg. Past episodes of superficial phlebitis or prior attempts at sclerotherapy may not be actual contraindications, but can greatly increase the difficulty of AP if veins are adherent to surrounding tissue. These veins should be approached more cautiously.

Anatomy

AP can be used to treat a wide variety of veins almost anywhere in the leg. Large truncal varicose veins all the way down to small reticular veins can be removed by phlebectomy. Part of what makes AP suitable for most varicose veins is that these veins are located in the superficial subcutaneous tissue, making them easy to reach with a vein hook. Although incompetent perforating veins that dive deeper can also be treated with AP, it is still the superficial component that is initially hooked.

Although most varicose veins can be treated by AP, complications are more likely for veins on the feet and in the popliteal fossa. Varicose veins on the feet are often small and fragile. This makes it difficult to tease them out, and the extra manipulation of the vein hook plus the higher density of cutaneous nerves in the foot can more frequently lead to paresthesias than in other areas. The popliteal fossa is another risky area. Post-AP hematomas are more common here because it can be difficult to apply a dressing that adequately achieves good postprocedure compression.

Equipment

Table 105-1 offers a list of necessary equipment for performing the AP procedure.

Technique

The initial step is to map the varicose veins to be treated. This is done before the procedure, with the patient standing to distend the veins. The skin over the varices to be removed should be marked on with a marker. If this is not done, the varices may not be visible when the patient is supine (Fig. 105-1).

Local anesthesia alone is generally sufficient. Not only is sedation rarely needed, but it may inhibit early postprocedure ambulation, which is desirable. Tumescent anesthesia is usually recommended, using large volumes of dilute lidocaine. The large volume of anesthetic engorges the perivenous tissue and helps dissect the vein free from the surrounding tissue. The volume of anesthetic also provides some pressure on the veins, which will help decrease postprocedural bleeding.

The tumescent anesthetic solution is formulated by diluting either 25 or 50 mL of 1% lidocaine in 500 mL of saline. This yields 0.05% or 0.1% lidocaine, respectively. To reduce the discomfort of the lidocaine injection, the solution should be buffered by adding 5 mL of 8.4% sodium bicarbonate. It is recommended that the total volume of anesthetic used be limited to 5 mg of lidocaine per kilogram of body weight.³ Lidocaine with epinephrine can be used to reduce bleeding, but bleeding is rarely severe enough to require it, and skin necrosis has been attributed to epinephrine use in one case report.⁴

For best cosmetic results, incisions should be very small, approximately 1 to 2 mm in length. These small incisions do not require sutures, which facilitates healing without significant scarring. A #11 scalpel blade can be used to make the stab incisions, but care must be taken to avoid advancing the blade in too far, which would lead to a larger incision by virtue of the blade’s triangular shape. Placing a clamp on the blade can help limit the depth of penetration (Fig. 105-2). Small stab incisions can also be made with an 18-gauge needle. A Beaver blade (Fig. 105-3) is ideal for phlebectomy; it is a microblade that by virtue of its small size will limit the size of the incision.

It is important to make incisions in the appropriate direction; most (with two exceptions) should be made parallel to the long axis of the leg. Exceptions are around the knee and ankle. Here the incisions should be horizontal to follow the skin lines. Attention to the direction of the incisions will facilitate healing and reduce scar visibility. Incisions should not be made directly over the ink markings used to map out the varicose veins. This can introduce ink under the skin and result in tattooing.

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