Neovascularisation

Summary

There are different causes of neovascularisation: vascular endothelial growth factor, inflammatory process, hypertrophy of pre-existant vessels (lymph node veins), haematomas revascularisation, and high difference in pressure. The latter 3 depend directly on the way the operation is performed hence on the surgeon.

Concerning the primary varices patch saphenoplasty do not abolish neovascularisation. It is of first importance to perform a flush ligation only in case of incontinent terminal and pre-terminal valves. In that case an incision as small as possible must be carried out with minimal dissection and with tumescence to limit the bleeding and hematomas. When the terminal valve is competent it is better to choose endovascular technique.

Concerning re-do it is mandatory to avoid useless re-do, the best choice is foam sclerotherapy. I am convinced that neovascularisation are produced by the complications which are induced by a large dissection. The barrier technique are, probably, not as useful as we was told 10 years ago. The lack of aggressiveness during the operation is certainly far more important: “Doing less in the groin to do better for the recurrence and re-recurrence”

Zusammenfassung

Gefäßneubildung (Neovaskularisierung) kann auf mehrere Ursachen zurückzuführen sein: Gefäßwachstumsfaktor (VEGF), Entzündungen, Hypertrophie der Gefäße (Lymphknotenvenen), Revaskularisierung von Hämatomen und Druckdifferenzen. Die drei letztgenannten Faktoren sind unmittelbar von der Operationstechnik, d. h. vom Operateur, abhängig.

Bei primären Varizen kann die Neovaskularisierung nicht durch Patch-Plastik unterbunden werden. Es ist wichtig, dass nur dann eine Krossektomie vorgenommen wird, wenn die terminalen und präterminalen Klappen nicht mehr ordnungsgemäß schließen. In diesem Falle ist der Eingriff in Tumeszenz-Lokalanästhesie vorzunehmen, wobei die Inzision so klein wie möglich zu halten ist und die Dissektion minimal zu sein hat, damit Blutungen und Hämatome eingeschränkt werden. Wenn die terminale Klappe noch ordnungsgemäß schließt, ist eine endovaskuläre Operationstechnik vorzuziehen.

Bezüglich der Entstehung von Rezidiven sind unnötige chirurgische Zweiteingriffe unbedingt zu vermeiden. Die beste Option ist eine intraoperative Sklerotherapie. Wir sind davon überzeugt, dass Neovaskularisation als Folge von Komplikationen auftritt, die durch extensive Dissektionen hervorgerufen werden. Das Einbringen eines Venen-Patchs ist gewiss nicht in dem Maße erforderlich, wie dies noch vor 10 Jahren angenommen wurde. Weitaus wichtiger ist es sicher, während des Eingriffs Traumata zu verhindern: „Lieber weniger in der Leistenbeuge intervenieren, dafür mehr tun, um das Risiko von Rezidiven zu verhindern.”

Résumé

Plusieurs causes induisent la néovascularisation: facteur de croissance endothélial vasculaire, inflammation, hypertrophie de vaisseaux pré-existant (veine lymphoganglionnaire), revascularisation d’hématomes et différence de pression. Les trois dernières dépendent directement de la façon dont est réalisée l’opération, donc du chirurgien.

Concernant les varices primaires l’interposition d’un patch ne supprime pas la néovascularisation. Il est très important de ne faire une crossectomie que lorsqu’il y a une incontinence des valves terminales et préterminales. Dans ce cas l’incision doit être la plus petite possible et réalisée avec une dissection minimum, avec une tumescence afin de réduire le saignement et les hématomes. Quand la valve terminale est continente il est préférable d’utiliser une technique endovasculaire.

Concernant la récidive il est important d’éviter les reprises chirurgicales inutiles, le meilleur choix est la sclérothérapie peropératoire. Je suis convaincu que la néovascularisation est produite par les complications, elle-même induites par les dissections extensives. L’interposition d’un patch n’est certainement pas aussi nécessaire que nous l’avons prétendu 10 ans auparavant. Eviter tout traumatisme pendant l’intervention est certainement beaucoup plus important : « faire moins au niveau de l’aine pour faire mieux dans le risque de récidive et de re-récidive »

Keywords

Varices - surgery - neovascularisation - prevention

Schlüsselwörter

Varizen - Chirurgie - Neovaskularisation - Vorbeugung

Mots clés

Varices - chirurgie - néovascularisation - prévention

• References

• 1 De Maesseneer MG. Neovascularisation: an adverse response to proper groin dissection. In : Bergan JJ. (ed) The Vein Book. San Diego CA USA: 2007: 239-246.
• 2 De Maesseneer MG. Strategies to minimize the effect of neovascularization at the saphenofemoral junction after great saphenous vein surgery: an overview. Phlebolymphology 2006; 13: 205-220.
• 3 Von Langenbeck B. Beiträge zur chirurgischen Pathologie der Venen. Arch Klin Chir 1861; 1: 47.
• 4 Glass GM. Neovascularization in recurrence of the varicose great saphenous vein following transection. Phlebology 1987; 2: 81-91.
• 5 Schmid-Schönbein GW. Molecular basis of venous insufficiency. In: Bergan JJ. (ed). The Vein Book. San Diego CA USA: 2007: 67-78.
• 6 Shoab SS, Scuit JH, Coleridge-Smith PD. Increased plasma vascular endothelial growth factor among patients with chronic venous disease. J Vasc Surg 1998; 28: 535-540.
• 7 Hollingsworth SJ, PowelI GL, Barker SGE, Cooper DG. Primary varicose veins: Altered transcription of VGFE and its receptors (KDR, flt-1, soluble flt-1) with sapheno-femoral junction Incompetence. Eur J Vasc Endovasc Surg 2004; 27: 259-268.
• 8 Rewerk S, Labretsas K, Winkler M, Nüllen H, Duczek C, Meyer AJ, Grobholtz R, Thomas N. Vascular endothelian grouth factor (VEGF) and VEGF-receptor (VEGF-R) in the pathogenesis of primary and recurrent varicose. Phlebolymphology 2007; 14: 154.
• 9 Takase S, Schmid-Schönbein G, Bergan JJ. Leukocyte activation in patients with venous insufficiency. J Vasc Surg 1999; 30: 148-156.
• 10 Raffetto JD. Chronic venous insufficiency: molecular abnormalities and ulcer formation. In: Bergan JJ. (ed). The Vein Book. San Diego CA USA: 2007: 79-87.
• 11 El Wajeh Y, Giannoukas AD, Gulliford CJ, Suvarna SK, Chan P. Saphenofemoral venous channels associated with recurrent varicose veins are not neovascular. Eur J Vasc Endovasc Surg 2004; 28: 590-594.
• 12 Takase S, Lerond L, Bergan JJ, Schmid-Schönbein GW. The inflammatory reaction during venous hypertension in the rat. Microcirculation 2000; 7: 41-52.
• 13 Owatverot TB, Oswald SJ, Chen Y, Wille IJ, Yin Fe. Effect of combined cyclic stretch and fluid shear stress on endothelial cellmorphological responses. J Biomech Eng 2005; 127: 374-382.
• 14 Resnick N, Yahav H, Shay-Salit A, Shushy M, Schubert S, Zilberman LC, Wofovitz E. Fluid shear stress and the vascular endothelium: For better and for worse. Prog Biophys Mol Biol 2003; 81: 177-199.
• 15 Abumiya T, Sasaguri T, Taba Y, Miwa Y, Miyagi M. Shear stress induces expression of vascular endothelial growth factor receptor (Flk-1/K.DR) through the CT-rich Sp 1 binding site. Arterioscler Thromb Vasc Biol 2002; 22: 907-913.
• 16 Coleridge Smith PD. Leg ulcers: Biochemical factors. Phlebology 2000; 15: 156-161.
• 17 Lefebvre-Vilardebo M. Vous avez dit „Néovascularisation inguinale post-chirurgicale”?. Phlébologie 2001; 54: 253-254.
• 18 Munasinghe A, Smith C, Kianifard B, Price BA, Holdstock JM, Whiteley MS. Strip-track revascularization after stripping of the great saphenous vein. Br J Surg 2007; 94: 840-843.
• 19 Mitchel G, Rosser S, Edwards PR, Dimitri S, de Cossart L. Vascularisation of the haematoma tract following long saphenous vein stripping: a new cause of recurrent varicose veins. Phlebology 2003; 18: 48.
• 20 Earnshaw JJ, Davies B, Harradine K, Heather BP. Preliminary results of PTFE patch saphenoplasty to prevent neovascularisation leading to recurrent varicose veins. Phlebology 1998; 13: 10-13.
• 21 Glass GM. Neovascularization in recurrence of varices of the great saphenous vein in the groin: Surgical anatomy and morphology. Vasc Surg 1989; 23: 435-442.
• 22 Glass GM. Neovascularization in recurrent sapheno-femoral incompetence of varicose veins: Surgical anatomy and morphology. Phlebology 1995; 10: 136-142.
• 23 Van Rij AM, Jones GT, Hill GB, Jiang P. Neovascularization and recurrent varicose veins: More histologic and ultrasound evidence. J Vasc Surg 2004; 40: 296-302.
• 24 Nyamekye I, Shephard NA, Davies B, Heather BP, Earnshaw JJ. Clinicopathological evidence that neovascularisation is a cause of recurrent varicose veins. Eur JVasc Endovasc Surg 1998; 15: 412-415.
• 25 Stücker M, Netz K, Breuckmann F, Altmeyer P, Mumme A. Histomorphologic classification of recurrent saphenofemoral reflux. J Vasc Surg 2004; 39: 816-821.
• 26 Frings N, Nelle A, Tran P, Fischer R, Krug W. Reduction of neoreflux after correctly performed ligation of the saphenofemoral junction. A randomized trial. Eur J Vasc Endovasc Surg 2004; 28: 246-252.
• 27 Haas E, Burkhardt T, Maile N. Rezidivhäufigkeit durch Neoangiogenese nach modifizierter Krossektomie. Phlebologie 2005; 34: 101-104.
• 28 Jones L, Braithwaite BD, Harradine K, Earnshaw JJ. Neovascularization is the principal cause of varicose vein recurrence: results of a randomized trial of stripping the long saphenous vein. Eur J Vasc Endovasc Surg 1996; 12: 442-445.
• 29 Egan B, Donnelly M, Bresnihan M, Tierney S, Feeley M. Neovascularization: an „innocent bystander” in recurrent varicose veins. J Vasc Surg 2006; 44: 1279-1284.
• 30 Glass GM. Prevention of recurrent saphenofemoral incompetence after surgery for varicose veins. Br J Surg 1989; 76: 1210.
• 31 Glass GM. Prevention of the sapheno-femoral and sapheno-popliteal recurrence of varicose veins by forming a partition to contain neovascularization. Phlebology 1998; 13: 3-9.
• 32 Sheppard M. A procedure for the prevention of recurrent saphenofemoral incompetence. Aust N Z J Surg 1978; 48: 322-326.
• 33 Gibbs PJ, Foy DM, Darke SG. Reoperation for recurrent saphenofemoral incompetence: a prospective randomized trial using a reflected flap of pectineus fascia. Eur J Vasc Endovasc Surg 1999; 18: 494-498.
• 34 De Maeseneer MG, Giuliani DR, Van Schil PE, De Hert SG. Can interposition of a silicone implant after sapheno-femoral ligation prevent recurrent varicose veins?. Eur J Vasc Endovasc Surg 2002; 24: 445-449.
• 35 Earnshaw JJ, Davies B, Harradine K, Heather BP. Preliminary results of PTFE patch saphenoplasty to prevent neovascularization leading to recurrent varicose veins. Phlebology 1998; 13: 10-13.
• 36 De Maeseneer MG, Philipsen TE, Vandenbroeck CP, Lauwers PR, Hendriks JM, De Hert SG, Van Schil PE. Closure of the cribriform fascia: an efficient anatomical barrier against postoperative neovascularisation at the saphenofemoral junction? A prospective study. Eur J Vasc Endovasc Surg 2007; 34: 361-366.
• 37 Pichot O, Sessa C, Bosson JL. Duplex imaging analysis of the long saphenous vein reflux: basis for strategy of endovenous obliteration treatment. Int Angiol 2002; 21: 333-336.
• 38 Cappelli M, Molino Lova R, Ermini S, Zamboni P. Hemodynamics of the sapheno-femoral junction. Patterns of reflux and their clinical implications. Int Angiol 2004; 23: 25-28.
• 39 Kianifard B, Holdstock JM, Whiteley MS. Radiofrequency ablation (VNUS closure) does not cause neo-vascularisation at the groin at one year: results of a case controlled study. Surgeon 2006; 4: 71-74.
• 40 Lurie F, Creton D, Eklof B, Kabnick Ls, Kistner Rl, Pichot O, Sessa C, Schuller-Petrovic S. Prospective Randomized Study of EndoVenous radiofrequency Obliteration (Closure) versus Ligation and Vein Stripping (EVOLVeS): two-year followup. Eur J Vasc Endovasc Surg 2005; 29: 67-73.
• 41 De Maeseneer MG, Vandenbroeck CP, Van Schil PE. Silicone patch saphenoplasty to prevent repeat recurrence after surgery to treat recurrent saphenofemoral incompetence: long-term followup study. J Vasc Surg 2004; 40: 98-105.
• 42 Winterborn RJ, Earnshaw JJ. Randomised trial of PTFE patch insertion for recurrent great saphenous varicose veins. Eur J Vasc Endovasc Surg 2007; 34: 367-373.
• 43 Creton D. Surgery for recurrent saphenofemoral incompetence using expanded polytetrafluoroethylene patch interposition in front of the femoral vein: long-term outcome in 119 extremities. Phlebology 2002; 16: 93-97.
• 44 De Maesseneer MG, Vandenbroeck CP, Lauwers PR, Hendricks JM, De Hert SG, Van Schil PE. Early and late complications of silicone patch saphenoplasty at the saphenofemoral junction. J Vasc Surg 2006; 44: 1285-1290.
• 45 Tessari L, Cavezzi A, Frullini A. Preliminary experience with a new sclerosing foam in the treatment of varicose veins. Dermatol Surg 2001; 27: 58-60.