Varicose vein is a very common disease. It is one of the most common diseases found in any surgical out patient. The incidence of varicose vein increases with age and is more common in women. Varicose veins may be due to sapheno femoral incompetence, sapheno popliteal incompetence, perforator incompetence or deep vein pathology either postphlebitic leg or primary valve incompetence. Generally, patients with deep vein pathology are not taken up for varicose vein ablation since the chances of recurrence is very high. Traditionally Sapheno femoral incompetence has been treated with open surgery which is ligation of the sapheno femoral junction and stripping of the saphenous vein. This has stood the test of time. Now a days minimal invasive procedures are being done and are being promoted actively by many.

● Thermal ablation:
Radio frequency ablation
Laser ablation
Steam ablation

● Chemical methods:
Glue implantation
Sclerotherapy

● Mechanical and chemical ablation

Hence many players without adequate training are embarking on varicose vein surgery. Unfortunately, since their clinical exposure is inadequate the treatment becomes sub-optimal resulting in complication and recurrence of varicose veins. There are many situations when endovenous procedure may fail such as when the great saphenous vein diameter is more than 2 cm, highly tortuous GSV (Fig. 1)and torturous accessory saphenous vein (Fig. 2).In these situations, hybrid approach of open SF ligation and thermal ablation gives better long-term results. It has been well documented that RFA and EVLT are as effective as surgery in the treatment of great saphenous varicose veins and at 12 months there was no difference between endovenous ablation and stripping surgery.

Moreover, it is well known that a single procedure however complete is unlikely to correct the problem and a combination of procedures is needed to eradicate all the varicosities. Thus, a patient with large varicosities in the leg will need phlebectomy (Fig. 3) along with sclerotherapy to remove all the varicosities in addition to RFA or Laser treatment of the main saphenous vein (Fig.4a, 4b). Such an expertise is available with only a well-trained vascular surgeon who can decide on the procedure according to the patient. He can perform both Endo and open surgery and ensure complete relief for the patient. Moreover, varicose veins however well treated tend to recur after some years and they all need regular follow up. Hence it is best to refer the varicose vein patients to a vascular surgeon so that the patient gets the most appropriate treatment.

Fig 1. Large very tortuous great saphenous vein

Fig2. Large tortuous Accessory saphenous vein

Fig 3. Stab phlebectomy.

Large varicosities can be removed through small stab incisions

Fig 4a.  Pre-op image

Fig 4b. Post op image at 10 days after RFA, Phlebectomy and Sclerotherapy

Primary Author:

Dr. N. Sekar
MS, MNAMS, MCh (Vascular), FICS, DSc (Hon. Causa), FRCS (Glasgow)
Past President – Vascular Society of India
Senior Consultant Vascular & Endovascular Surgeon
Dept of Vascular and Endovascular Surgery
Kauvery Hospital Chennai