Postoperative varicose recurrence at the junctions. A multicentric study of 1056 patients by the Italian Society of Phlebolymphology. Conclusive considerations

AIM: Since new endovascular procedures and foam sclerotherapy have been developed for the treatment of varicose veins of the lower limbs the recent literature seems to demonstrate that surgery of the saphenofemoral and saphenopopliteal junctions (SFJ, SPJ) is the main responsible for varicose recurrence (VR) owing to neovascularization by neoangiogenesis (NN). Aim of the study was to verify the anatomical causes of postoperative VR at the SFJ and SPJ. METHODS: Fourteen centers belonging to the Italian Society of Phlebolymphology collected the data of 1056 patients (=1081 limbs-25 bilateral) affected with VR. Clinical feature ranged from C2 to C6. Limbs were studied by Duplex ultrasound (DUS) investigation and by surgical revision from 2001 up to now: N. 927 (85.7%) retrospectively, 154 (14.2%), prospectively. Distribution of the limbs was as follows: mean age of patients was 56.6 years; the study enrolled 291 males (27.5%) and 765 females (72.4%); right limbs were 532 (49.2%), left limbs were 549 (50.7%); symptoms from venous insufficiency were found in 1043 subjects (96.4%). Previous surgery data: SFJ+stripping 873 (80.7%), SFJ alone 156 (14.3%), SPJ 52 (4.8%). Only 611 (56.5%), were studied by Duplex ultrasound (DUS), 470 by DUS+introperative observation (43.4%). The surgical revision was performed by direct dissection in 200 limbs and by Li technique in 270. The following elements were investigated: saphenous stump (SS), identified and unidentified tributaries (IT, UT) of the SFJ, tributaries of the SPJ, common tributaries outlet, tributaries outlet into the deep veins, suspected NN. RESULTS: Residual veins detected: saphenous stump+identified tributary (IT) 711 (65.7%), anterior accessory 298 (27.5%), superficial iliac circumflex 127 (11.7%), superficial epigastric 96 (8.8%), residual greater saphenous 95 (8.7%), medial accessory 88 (8.1%), superficial external pudendal 44 (4%), deep external pudendal 4 (0.3%), common outlet into the common femoral 14 (1.3%), independent outlet into the common femoral 7 (0.6%), unidentified tributaries (UT) at the SFJ 290 (26.8%), UT at the SPJ 52 (4.8%), complex varicose collateral circulation (CVC) total 386 (35.7%), CVC+IT 147 (13.5%), CVC+UT 149 (13.7%), CVC without IT/UT (unrecognized-suspected NN) 90 (8.3%). Unrecognized IT/UT at the SFJ (suspected NN) 45 (4.1%); unrecognized IT/UT at the SPJ (suspected NN) 2 (0.1%), surgically assessed NN 5 (0.4%). CONCLUSION: The causes of VR must be investigated by detailed DUS examination. Direct observation by surgical dissection leads to a verify better than by the Li technique. CVC is a consequence of VR and renders more difficult the detection of IT/UT both by DUS and surgical revision. NN plays a minimal role in VR at the groin and at the popliteal region but is not yet sufficiently demonstrated. Residual saphenous stump and IT/UT caused by inadequate surgery appeared to be the main causes of VR at the saphenous junctions.