CEAP 2 30 C2 6 C4a 7 C4b 5 C5 6 C REVAS 2 Society for Vascular Surgery/American Venous Forum incompetent perforating vei

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1 recurrent varices after surgery: REVAS REVAS SEPS SEPS recurrent varices after surgery: REVAS 1 REVAS doi: /phlebol REVAS REVAS REVAS Perrin CEAP C2 11 C3 2 C4a 11 C4b 19 C5 10 C

2 CEAP 2 30 C2 6 C4a 7 C4b 5 C5 6 C REVAS 2 Society for Vascular Surgery/American Venous Forum incompetent perforating vein: IPV 66 Table 1 50 SFJ sapheno-femoral junction 7 greater saphenous vein: GSV Table 2 IPV subfascial endoscopic perforator surgery: SEPS Fig. 1 3, ultrasound guided foam sclerotherapy: UGFS IPV IPV 4 25 IPV IPV Table 1 Previous surgery before recurrent varices after surgery (REVAS) GSV (S) 36 GSV (RFA) 6 GSV (EVLA) 1 GSV (S) + IPV (SEPS) 10 GSV (S) + IPV (direct severing) 1 GSV (S) + SSV (S) 3 SSV (S) 3 SSV (high ligation) 1 Resection of tributary varices 4 Sclerotherapy of tributary varices 1 GSV: great saphenous vein, S: high ligation + stripping, RFA: radiofrequency ablation, EVLA: endovenous laser ablation, IPV: incompetent perforating vein, SEPS: subfascial endoscopic perforator surgery, SSV: small saphenous vein Table 2 Veins with reflux which cause recurrence, and treatment in a parenthesis IPV (SEPS) 26 IPV (direct severing) 31 IPV (sclerotherapy) 5 GSV in the lower limbs (S) 6 GSV in the lower limbs (sclerotherapy) 2 Distal SSV (S) 4 IPV: incompetent perforating vein, SEPS: subfascial endoscopic perforator surgery, GSV: great saphenous vein, S: stripping, SSV: small saphenous vein 260

3 Fig. 1 Subfascial endoscopic perforator surgery (SEPS) using screw-type ports. GSV GSV SSV 4 GSV IPV 4 SSV GSV 5 mm IPV GSV RFA Radiofrequency ablation100 cm IPV 2 IPV RFA SEPS Fig cm GSV GSV IPV GSV Fig GSV + 3 mm IPV IPV stab avulsion stab avulsion IPV IPV stab avulsion 6 5 IPV IPV IPV UGFS IPV Fig

skin ulcer scars (left photograph). On account of her, radiofrequency ablation (RFA) of the full-length GSV was planned by a one-day surgery. However, 2 months after RFA, phlebitis recurred.

4 Fig. 2 Case 1. A 56-year-old female with reflux of the great saphenous vein (GSV) of the full length (red line) and Cockett s perforator (black cross, IPV: incompetent perforating vein) with skin lesions containing skin ulcer scars (left photograph). On account of her, radiofrequency ablation (RFA) of the full-length GSV was planned by a one-day surgery. However, 2 months after RFA, phlebitis recurred. The Cockett s perforator (black cross) was still incompetent, and subfascial endoscopic perforator surgery (SEPS) was therefore performed (middle photograph). After SEPS, the skin lesion rapidly improved (right photograph). Fig. 3 Case 2. A 45-year-old male underwent high ligation and femoral greater saphenous vein (GSV) stripping 8 months prior. Leg skin lesion did not resolve after the first surgery. Residual reflux of the GSV on the calf connecting with an incompetent perforating vein (IPV) (Boyd s perforator) was observed (left photograph). Direct IPV severing and foam sclerotherapy were performed. Pigmentation and edema markedly improved after the procedure (right photograph). 262

5 Fig. 4 Case 3. An 80-year-old female underwent GSV stripping with tributary varicectomy by stab avulsion 15 month prior. Before the surgery, an incompetent perforating vein (IPV) (Cockett s perforator, red cross of the left photograph) was observed, but the IPV was failed to be treated at the surgery. One year after that, pain and edema was noted in the region of the suspected IPV, and ultrasonography was able to detect the IPV (right upper photograph). Ultrasound-guided foam sclerotherapy (UGFS) to the IPV was performed (right lower photograph). REVAS REVAS REVAS Perrin technical failure tactical failure neovascularizaion persistent new Perrin technical failure 19.1 tactical failure 9.6 neovascularizaion 20.1 persistent 11.6 new 31.7 REVAS van Rij Kostas Allegra Perrin 5 REVAS 199 IPV 54.7 IPV 42.7 sapheno-femoral junction 47.2 sapheno-popliteal junction 24.6 GSV 30.2 IPV 2 REVAS IPV IPV SEPS SEPS REVAS IPV 6, 9 11 SEPS IPV 263

6 GSV GSV 12 IPV SSV REVAS Perrin 5 Kostas 7 GSV tactical failure Allegra 8 GSV SSV van Neer 12 GSV GSV 2 91 GSV 2/3 2 IPV SSV 13 REVAS REVAS REVAS REVAS IPV SEPS GSV 1 Perrin MR, Guex JJ, Ruckley CV, et al: Recurrent varices after surgery (REVAS), a consensus document. REVAS group. Cardiovasc Surg 2000; 8: ; 25: Kusagawa H, Katayama Y, Haruta N, et al: Subfascial endoscopic perforator surgery using screw-type ports is a very useful component of a comprehensive treatment program for chronic venous insufficiency. Ann Vasc Dis 2012; 5: EndoTIP cannula ; 22: Perrin MR, Labropoulos N, Leon LR: Presentation of the patient with recurrent varices after surgery (REVAS). J Vasc Surg 2006; 43: ; discussion van Rij AM, Jiang P, Solomon C, et al: Recurrence after varicose vein surgery: a prospective long-term clinical study with duplex ultrasound scanning and air plethysmography. J Vasc Surg 2003; 38: Kostas T, Ioannou CV, Touloupakis E, et al: Recurrent varicose veins after surgery: a new appraisal of a common and complex problem in vascular surgery. Eur J Vasc Endovasc Surg 2004; 27: Allegra C, Antignani PL, Carlizza A: Recurrent varicose veins following surgical treatment: our experience with five years follow-up. Eur J Vasc Endovasc Surg 2007; 33: van Rij AM, Hill G, Gray C, et al: A prospective study of the fate of venous leg perforators after varicose vein surgery. J Vasc Surg 2005; 42: Rutherford EE, Kianifard B, Cook SJ, et al: Incompetent perforating veins are associated with recurrent varicose veins. Eur J Vasc Endovasc Surg 2001; 21: Labropoulos N, Touloupakis E, Giannoukas AD, et al: Recurrent varicose veins: investigation of the pattern and extent of reflux with color flow duplex scanning. Surgery 1996; 119: van Neer P, Kessels FG, Estourgie RJ, et al: Persistent reflux below the knee after stripping of the great saphenous vein. J Vasc Surg 2009; 50: ABC ; 14:

7 Abstract Surgical Management of Recurrent Varices Secondary to Reflux from Incompetent Perforating Veins or Saphenous Vein Trunks in the Calves Hitoshi Kusagawa, 1 Yasuhisa Ozu, 2 Kentaro Inoue, 2 Takuya Komada, 2 and Yoshihiko Katayama 2 1 Matsusaka Ohta Clinic 2 Department of Thoracic and Cardiovascular Surgery, Matsusaka Chuo General Hospital Key words: recurrent varices after surgery (REVAS), redo, reflux vein, incompetent perforating vein (IPV), subfascial endoscopic perforator surgery (SEPS) Background: Recurrent varices after surgery (REVAS) remain a common problem. Some REVAS can be avoided using accurate manual skills and specific surgical treatment strategies at the time of the first surgery. Treatment strategies for REVAS are also important, and analysis of cases of REVAS may prove useful in determining systematic strategies to prevent recurrence after the first surgery. Patients and Methods: One hundred and eight limbs (7.1%) among a total of 1519 limbs which had varicose vein surgery, required surgery for REVAS between January 2008 and July Of those limbs, 66 limbs among 59 patients had REVAS due to reflux from incompetent perforating veins or saphenous vein trunks in the calves. The period between previous surgery and REVAS was 10 years in 15 limbs, 5 years and <10 years in nine limbs, 2 years and <5 years in 12 limbs, and <2 years in 30 limbs. According to CEAP (clinical, etiologic, anatomic, pathology) classification, the 66 limbs were categorized into C2 (n=11), C3 (n=2), C4a (n=11), C4b (n=19), C5 (n=10), and C6 (n=13). Deflection to severe cases was remarkably seen. Twenty-four limbs (36%) also had reflux origin from subfascial veins or saphenous vein trunks in the thighs. Analysis of REVAS was conducted using venous ultrasonography. Results: The original surgery consisted of high ligation and stripping of the greater saphenous vein (GSV) in 50 limbs, endovenous ablation of GSV in seven limbs, and resection of tributary veins in 12 limbs. For limbs in which reflux caused REVAS, incompetent perforating veins (IPVs) were observed in 62 limbs. These veins were ablated via subfascial endoscopic perforator surgery (SEPS) utilizing screw-type ports in 26 limbs, direct severing in 31 limbs, and ultrasound-guided foam sclerotherapy (UGFS) in five limbs. IPV localization was as follows: 51 Cockett s perforators, 18 paratibial perforators, one Boyd s perforator, and one posterior perforator. In other veins with reflux, eight distal GSVs in calves were found after high ligation and partial stripping of the GSV. Of those, distal GSVs were drained from small saphenous veins in four cases and from IPVs in three cases. Conclusion: The IPV is an important etiology of REVAS, and such IPVs should be treated in the first surgery if present. SEPS represents a very useful choice for surgical management of REVAS. Some cases require full stripping of the GSVs during the first surgery. It is important in order to avoid a recurrence to handle all the reflux diagnosed at the time of the first operation, but when it is left, it should be followed up properly, and it was thought to be treated appropriately. Jpn J Phlebol 2016; 27 (3):

脈管学55巻7号　pp.105-110

脈管学55巻7号　pp.105-110 Online publication August 10, 2015 105 原著 55 要旨 : 18 29 31 27 87.1 EHIT class 1 class 2, 3 1 J Jpn Coll Angiol 2015; 55: 105 110 Key words: saphenous vein surgery, saphenous vein stump, endovenous heat-induced