Over the past 20 years, treatment methods for varicose veins have evolved substantially, with endovenous treatments such as endovenous thermal ablation (EVTA) and endovenous non-thermal ablation recently becoming the primary methods. However, the fundamental principle of conventional surgical treatment—the oldest approach, which can be performed without specialized equipment or disposable surgical materials—remains largely unchanged. This principle involves performing flush ligation at the saphenofemoral junction (SFJ) and severing all tributary veins draining to the saphenofemoral confluence. Surgical treatment necessitates surgical dissection to access the SFJ, which is located relatively deep for flush ligation. The incidence rate of minor complications such as hematoma, surgical site infection, lymph leakage, and nerve injury has been reported to be 17% [1]. Furthermore, the rate of neovascularization around the SFJ stump has been described as quite high, ranging from 20% to 53% [2-5]. In contrast, EVTA does not require surgical dissection in the inguinal area. A radiofrequency catheter or laser fiber is placed 2.5 to 3 cm from the terminal valve of the SFJ, from which point closure is initiated. This method preserves the blood flow of the superficial epigastric vein (SEV) in more than 50% of cases, but the incidence of neovascularization in the SFJ is very low, ranging from 0% to 2.0% [6-8]. Therefore, based on experience with EVTA, the notion has emerged that flush ligation at the SFJ and division of all branches of the saphenofemoral confluence is not necessarily required during surgical treatment. Since 2015, author has performed a modified surgical procedure that preserves the SEV drainage into the saphenofemoral confluence, instead of the conventional surgical procedure.

The aim of this study was to evaluate the follow-up outcomes of SFJ neovascularization and recurrence rates originating from the SFJ, in addition to postoperative complications and changes in quality of life, after modified surgical treatment.

This study was approved by the institutional review board of National Health Insurance Service Ilsan Hospital, (2023-03-005). The requirement for informed consent from individual patients was omitted because of the retrospective design of this study.

Between January 2015 and April 2022, patients were included if they exhibited lower extremity symptoms, had confirmed pathologic reflux in the great saphenous vein (GSV), and underwent surgical treatment.

Lower extremity symptoms and past medical history were recorded during outpatient visits. Then, clinical features were classified using the Clinical-Etiology-Anatomy-Pathophysiology classification system. To compare the preoperative and postoperative conditions, evaluations utilizing the Venous Clinical Severity Score (VCSS) and the Aberdeen Varicose Vein Questionnaire (AVVQ) were performed prior to surgery. Patients in the C0 and C1 clinical classes were selected for the procedure if they declined conservative treatment, such as wearing compression stockings or taking venoactive drugs, and instead opted for surgery. Additionally, patients with concomitant valve failure in the small saphenous veins were included in the study. Patients were excluded if they had previously received treatment for varicose veins, including sclerotherapy, as well as if they lacked post-procedure Doppler follow-up. Duplex ultrasonography (DUS) of the lower extremity veins was performed using a LOGIQ S7 device (GE Healthcare, Seongnam, South Korea) equipped with a 5–12 MHz linear probe. The criteria for pathologic reflux were defined as a reflux duration of more than 0.5 seconds for saphenous veins and more than 1.0 seconds for deep veins. The diameter and reflux of the GSV were examined at areas including the SFJ, mid-thigh, knee, and below the knee. The SFJ section was examined between the terminal and preterminal valves, and the below-knee section was examined 10 cm inferior to the knee crease.

Surgical treatment was indicated when the ultrasound examination revealed that over half of the above-knee GSV segment with valve failure was located 5 mm or less from the skin surface. Additionally, the patient had to express a desire for surgical treatment that would be covered by the National Health Insurance Service.

The surgical procedure began with the marking of the GSV path to be stripped and the distal part of the SEV origin, using ultrasound guidance immediately prior to surgery. This was followed by the creation of a 1-cm skin incision to separate the GSV at the distal part of the SEV origin. The exposed endothelium at the tip of the SFJ stump was then cauterized using electrocautery. After the division of all ascending tributary veins draining into the saphenofemoral confluence, a pin stripper was inserted into the distal end of the isolated saphenous vein. This was then advanced to the level of the knee crease, and a 5-mm wound was created to retrieve the pin stripper. Prior to the stripping procedure, an Illuminator device (Smith+Nephew, Memphis, TN, USA) was inserted through both the inguinal and knee wounds. This was used to infuse a tumescent solution (1 L of normal saline at 4°C mixed with 1 ampoule of 1:100,000 epinephrine) around the GSV section slated for stripping (Fig. 1). The stripping procedure was then conducted in the caudal direction using the invagination technique. Stripping was performed from the groin to the knee, irrespective of the presence or absence of GSV valve failure below the knee. Following stripping, the stripped area was compressed for 2 minutes; this was followed by 3 squeezes to evacuate the hematoma within the stripped area. Tributary varices were managed with phlebectomy, in conjunction with saphenous vein stripping.

Figure 1. (A) The Illuminator (Smith+Nephew, Memphis, TN, USA). (B, C) Infusion of cold saline tumescent solution around the great saphenous vein of the section to be stripped through the inguinal wound (B) and the knee wound (C).

Postoperatively, a 3-layer compression dressing was applied for 24 hours, after which a class II compression stocking was worn for 7 days. A nonsteroidal anti-inflammatory drug was prescribed as part of the postoperative discharge regimen, to be taken over a course of 5 days. No prophylactic antithrombotic therapy or antibiotics were administered.

Postoperative DUS follow-up examinations, along with VCSS and AVVQ surveys, were administered at 6 and 12 months. Beyond the 12-month mark, DUS examinations were conducted during outpatient visits, separated by a minimum interval of 6 months. Comparative analyses of preoperative and postoperative VCSS and AVVQ results were performed for patients who underwent treatment solely for GSV and had a minimum of 6 months of Doppler follow-up. Neovascularization was characterized as the formation of new, tortuous venous vessels exhibiting reflux at the previous SFJ.

Data were analyzed on a limb-by-limb basis. The paired t-test was employed for data analysis, utilizing IBM SPSS ver. 21.0 (IBM Corp., Armonk, NY, USA). A probability value of less than 0.05 was considered to indicate statistical significance.

From January 2015 to April 2022, a total of 206 patients (300 lower extremities), received surgical treatment for symptomatic lower-extremity GSV valve failure. After excluding patients with a history of varicose vein treatment before surgery and those without postoperative Doppler follow-up, 120 patients, representing 179 lower extremities, were included in the study. The mean follow-up period was 24 months (range, 6 to 90 months). Table 1 presents the preoperative clinical data of the study participants, while Table 2 displays the respective diameters and reflux durations of the SFJ and mid-thigh GSV segments based on preoperative DUS examination. Preoperative ultrasound revealed reflux in the SFJ in 134 instances (75%). In 164 instances (92%), phlebectomy of the tributary veins was conducted alongside GSV stripping, while in the remaining 15 cases, only GSV stripping was performed.

Table 1 . Clinical and duplex ultrasonography characteristics.

Characteristic	Value
Age (yr)	56.5±12.9
Sex (N=120)
Male	47 (39)
Female	73 (61)
Laterality (N=179)
Left	96 (54)
Right	83 (46)
Combined incompetent small saphenous vein	75 Limbs (42)
CEAP classification (N=179)
C0–C1	14 (8)
C2	157 (88)
C3–C6	8 (4)

Values are presented as mean±standard deviation or number (%)..

CEAP, Clinical-Etiology-Anatomy-Pathophysiology..

Table 2 . Results of preoperative duplex ultrasonography.

Variable	Mean±standard deviation
Diameter of the GSV (mm)
SFJ	6.8±2.3
Mid-thigh	5.7±1.9
Duration of reflux (sec)
SFJ	1.16±0.9
Mid-thigh	3.2±1.8

GSV, great saphenous vein; SFJ, saphenofemoral junction..

No complications were observed in association with GSV stripping, including postoperative hematoma, bleeding, lymph leakage, or surgical site infection. Most patients experienced surgical site ecchymosis to varying extents, but this resolved within 2 weeks following surgery in all instances. During the study period, neovascularization around the SFJ stump was noted in 2 cases (1.1%), with 1 found at the 6-month postoperative follow-up and another at the 12-month postoperative follow-up. One instance (0.6%) of varicose vein recurrence was observed, associated with an incompetent perforating vein at the mid-thigh level. This was identified 22 months postoperatively and did not originate from the SFJ stump.

No new neovascularization or recurrence was identified in the 59 patients (33%) who underwent DUS follow-up at 24 months or more after surgery.

Of the eligible lower extremities, 87 limbs exhibited below-knee GSV valve failure prior to surgery, and 43 limbs (49%) showed improvement in this condition during the 12-month postoperative DUS follow-up. However, 44 limbs continued to display residual below-knee GSV valve failure. Of these, 10 limbs (23%) presented with lower extremity discomfort, which included 1 instance of heaviness, 1 of heaviness and edema, 2 of heaviness and numbness, 1 of edema and pain, and 5 of pain. These symptoms were intermittent and not severe, and they improved with the use of compression stockings or venoactive drugs. Therefore, no additional procedures, such as ultrasound-guided foam sclerotherapy, were necessary. Among the 39 lower extremities with deep venous valve failure, 3 limbs (8%) displayed postoperative lower extremity symptoms, including 2 instances of persistent GSV valve failure below the knee following surgery.

A total of 104 patients underwent GSV surgery without small saphenous vein incompetence. Of these, 88 individuals, representing 85% of the eligible patients, were followed up with 6 months postoperatively. At the 12-month mark, follow-up was conducted with 56 participants, which constituted 54% of the eligible patients. The results of the preoperative and postoperative VCSS are depicted in Fig. 2, while the AVVQ findings are presented in Fig. 3. Both the VCSS and AVVQ results demonstrated statistically significant reductions relative to the preoperative test results.

Figure 2. Evaluation of the Venous Clinical Severity Score (VCSS) at 6 months (A) and 12 months (B) after operation. Values are presented as mean±standard deviation. Preop, preoperative.

Figure 3. Evaluation of the Aberdeen Varicose Vein Questionnaire (AVVQ) at 6 months (A) and 12 months (B) after operation. Values are presented as mean±standard deviation. Preop, preoperative.

Conventional surgical treatment for varicose veins involves flush ligation at the SFJ and division of all tributary veins draining into the SFJ. This approach is based on the principle that a long residual stump may enable reflux from the femoral vein to affect the branch veins around the stump, leading to varicose vein recurrence [9]. However, EVTA treatments, such as radiofrequency ablation (RFA) and endovenous laser ablation (EVLA), have become preferred approaches in recent years. These treatments typically begin with placement of a radiofrequency catheter or laser fiber approximately 2 to 2.5 cm distal to the SFJ. This allows for the preservation of the branch veins connected to the SFJ. Wallace et al. [10] reported a statistically significantly lower rate of SFJ-derived reflux in lower extremities treated with EVLA compared to surgical treatment in a 2-year follow-up study after EVLA for incompetent GSV. Theivacumar et al. [6] reported that after EVLA for GSV incompetence in 81 lower extremities, patency of 1 or more SFJ-connected branch veins was confirmed in 59% of extremities at 12-month follow-up, with a rate of recurrence at the SFJ of only 1.2% [6]. Pichot et al. [7] reported that at 2-year follow-up after RFA, patency of the SEV was confirmed in 52.4% of cases, with no observed neovascularization at the SFJ and no recurrence of varicose veins originating from the SFJ. Given the follow-up results of EVTA, no apparent need exists to strictly adhere to the surgical principle of flush ligation and division of all branch veins of the SFJ. In fact, this principle could potentially obstruct the normal drainage of the SEV or pudendal vein, which have no valve abnormalities. Moreover, the surgical wound healing process after surgical dissection to access the SFJ may stimulate the formation of new connecting veins between the deep and superficial venous systems, thereby increasing the likelihood of neovascularization [9,11]. Pittaluga et al. [12] reported that after performing GSV ablation with preservation of the SEV and perineal veins in 151 patients with a mean follow-up period of 24.4 months, neovascularization at the SFJ occurred in only 1 case (0.9%) and did not lead to varicose vein recurrence. The rate of varicose vein recurrence originating from reflux at the saphenofemoral confluence was also 0.9% [12]. In a study of 220 patients, Pagano et al. [13] reported a varicose vein recurrence rate of 2.7% at 2-year follow-up when GSV ablation was performed while preserving the superior tributary veins, such as the SEV of the SFJ, and ligating all inferior tributary veins. They also reported that the preserved superior tributary veins could prevent neovascularization in the stump by flushing the reflux flow from the femoral vein. When the superior tributary veins were blocked, varicose vein recurrence was observed in all cases [13]. In the present study, the GSV was divided while the SEV was identified and preserved. Neovascularization on DUS follow-up occurred in only 2 limbs (1.1%), both of which were identified at follow-up within 12 months after surgery. No neovascularization was identified in 59 limbs with DUS follow-up for more than 24 months after surgery. This compares favorably with reported neovascularization rates of 0% to 2% after EVTA [6-8] and is considerably lower than reported neovascularization rates of 20% to 53% after conventional surgical treatment [2,5].

International clinical practice guidelines favor EVTA over high ligation and stripping (HLS) for the treatment of symptomatic GSVs. This preference is due to EVTA’s superior long-term outcomes, cost-effectiveness, reduced postoperative pain and complications, and facilitation of a more rapid return to normal activities [14,15]. However, in terms of long-term outcomes, several studies have reported no significant difference in the anatomical treatment success rate between HLS and EVTA [16-18]. Regarding postoperative pain, both EVTA and HLS commonly result in pain during the short-term postoperative period, with pain scores ranging from 0 to 3. No statistically significant difference has been present between the groups, suggesting that this distinction holds little clinical value [19,20]. In terms of cost-effectiveness, Marsden et al. [21] reported in 2015 that the treatment cost per patient of incompetent GSV was British pound (GBP) 869 (US dollar [USD] 1,328) for EVTA and GBP 1,222 (USD 1,867) for HLS. This makes surgical treatment the most expensive option. However, in Korea, the treatment cost for EVTA is not capped and is at least USD 1,571, based on the current exchange rate. This includes the cost of the required materials. In contrast, surgical treatment is the cheapest option at USD 373 and is covered by health insurance. Therefore, the medical environment in Korea differs substantially from that in Europe when considering cost-effectiveness. In terms of postoperative complications, the present study employed a direct approach through a small incision of about 1 cm, after using ultrasound to pre-mark the area to be divided. This was done to minimize surgical injury. Before GSV stripping was performed, a cold saline tumescent solution mixed with epinephrine was infused around the GSV to induce vasoconstriction of the tissues around the stripping area. A 24-hour eccentric compression was applied to the area in which the stripping was performed to prevent hematoma in that region. Saphenous nerve injury was avoided by limiting the stripping area from the inguinal region to the knee, even in the presence of below-knee preoperative GSV valve failure. Of the 87 limbs with such preoperative valve failure that were stripped to the knee alone, only 10 limbs (11%) displayed postoperative below-knee GSV valve failure with lower extremity symptoms after DUS follow-up. None of these required additional procedures, such as ultrasound-guided foam sclerotherapy, because the patients’ symptoms improved with conservative treatment, such as wearing compression stockings or taking venoactive drugs. As reported in a previous study by the authors, in patients with valve failure in both the above- and below-knee GSVs, 49% of patients with below-the-knee GSV valve failure improved when only the above-the-knee GSV was treated. Only 19% of patients with persistent below-knee GSV valve failure had lower extremity symptoms [22]. This study revealed similar results.

The limitations of the present study include its retrospective nature and the relatively small number of patients who underwent long-term follow-up. Specifically, 54% of the patients were followed up for 12 months, and 33% underwent follow-up for 24 months or longer. However, when compared to a study that reported 2-year follow-up for 25% of patients [13], we do not consider our patient numbers to be relatively small. Nevertheless, we believe that a future randomized controlled study involving a larger patient population is necessary to validate the findings of this study.

In conclusion, we believe that this modified surgical procedure for treating incompetent GSV, which involves preserving the SEV and stripping a short section to the knee, is an effective treatment method. This is evidenced by the favorable outcomes in terms of postoperative complication rate, neovascularization rate around the SFJ stump, varicose vein recurrence rate, and improvement of symptoms in the lower extremities.

Author contributions

All the work was done by Ki Pyo Hong.

Conflict of interest

Ki Pyo Hong is an editorial board member of the journal but was not involved in the peer reviewer selection, evaluation, or decision process of this article. No other potential conflict of interest relevant to this article was reported.

Funding

This work was supported by a research grant from National Health Insurance Service Ilsan Hospital (NHIMC-2023-CR-035).