Phlebologie 2014; 43(01): 13-18
DOI: 10.12687/phleb2172-1-2014
Review
Schattauer GmbH

Great uncertainty regarding treatment of varicose vein recurrence

Die große Unsicherheit im Umgang mit wiederkehrender Varikose
O. Nelzén
1   Dept. Surgical Sciences, Uppsala University & Dept. of Vascular Surgery, Skaraborg Hospital Skövde, Sweden
› Author Affiliations
Further Information

Publication History

Received: 27 September 2013

Accepted: 19 November 2013

Publication Date:
04 January 2018 (online)

Summary

Introduction: Although varicose vein recurrence is common and 10–30 % of all varicose vein surgery is done for recurrence of some sort, there are very few studies that can guide us to the best re-treatment option. With the introduction of minimal invasive endovenous treatments there is a variety of possible options besides traditional open surgical techniques.

Method: The Scandinavian Venous Forum held a symposium at the GSP meeting in Lü-beck 2012 and this review article is based on data from the presentations at that symposium. Further data has been added regarding new knowledge that was not available a year ago, from PubMed search and article references.

Results: The most common reasons for recurrence are discussed and also the discrepancy between neovascularization (NV) and recurrence due to technical failures. It is likely that NV is the most commonly duplex detected type of recurrence following open groin surgery, less common early after endovascular techniques. However, technical or tactical failures are the most common reasons for redo surgery because of symptomatic recurrence. NV seldom leads to symptomatic recurrences and thus a need for re- treatment. There is a risk that the stumps left following endovenous treatments will become a source for symptomatic recurrence after 5–10 years and indications of that have been reported in the few available 5 year RCT-reports following laser treatments. Treatment of recurrence due to stumps in the groin can be done safely within a reasonable operating time through a medial approach and the stump itself can generally not be treated with any of the endovenous alternative methods. Foam treatment can be used for most other recurrent veins but the durability is unknown. Endovascular thermal ablation can only be used for reopened or remaining saphenous veins and accessory saphenous veins while tributaries have to be treated by stab excisions or foam.

Conclusion: Long term reports of results of redo surgery are limited but suggest reasonably good results from open surgical intervention and are non-existent for the endovenous techniques. So far groin recurrence seems best treated surgically by an indirect approach, preferably medial. More studies are needed to find the best treatment regime for varicose vein recurrence in general and hybrid procedures might be the way forward by combinations of different techniques.

Zusammenfassung

Einleitung: Obwohl die Rezidivvarikose häufig ist und 10 bis 30 % aller chirurgischer Eingriffe darauf entfallen, gibt es sehr wenige Studien, die dabei zur besten Behandlungsoption raten könnten. Mit der Einführung der minimal-invasiven endovenösen Behandlung gibt es eine Vielzahl möglicher Optionen neben den klassischen offenen chirurgischen Eingriffen.

Methoden: Das Skandinavische Venenforum hielt auf der Tagung der Deutschen Gesellschaft für Phlebologie e.V. 2012 in Lübeck ein Symposium ab. Diese Überblicksarbeit basiert auf Daten der Präsentation, die dort gehalten wurde. Weitere Daten neueren Wissens wurden hinzugefügt, außerdem Informationen aus einer Literaturrecherche bei PubMed und anderen Artikeln.

Ergebnisse: Die häufigsten Ursachen für die Rezidivvarikose werden diskutiert und auch die Diskrepanz zwischen Neovaskularisation (NV) und Rezidivierung infolge technischer Fehler. Es ist wahrscheinlich, dass NV die häufigste durch Duplexsonographie entdeckte Form des Rückfalls ist nach offener Leistenoperation, weniger häufig ist es kurz nach endovenösen Eingriffen. Aber technische oder taktische Fehler sind die häufigsten Gründe für nochmalige Operation wegen eines symptomatischen Rezidivs. NV führt selten zu symptomatischem Wiederauftreten und Bedarf für erneute Behandlung. Es besteht ein Risiko dafür, dass die Stümpfe, die man bei endovenöser Behandlung belässt, Ursache für ein symptomatisches Rezidiv nach 5 bis 10 Jahren werden. Hinweise darauf gibt es in den wenigen 5-Jahres-RCTStudien bezüglich Laserbehandlung. Behandlungen wiederkehrender Varikosen aufgrund von Stümpfen in der Leiste können sicher innerhalb einer überschaubaren Operationszeit vorgenommen werden durch einen medialen Ansatz. Der Stumpf selber kann normalerweise nicht behandelt werden mit einer der alternativen endovenösen Verfahren. Schaumbehandlung kann bei den meisten anderen Rezidivvarikosen eingesetzt werden, aber die Nachhaltigkeit ist hier unbekannt. Die endovaskuläre Thermoablation kann nur für wiedereröffnete oder verbleibende Saphena-Venen und accessorische Saphena-Venen genutzt werden, während Nebengefäße mit Exzision oder Schaum behandelt werden müssen.

Schlussfolgerung: Berichte zu Langzeiter-gebnissen von erneuten Behandlungen sind selten, aber sie deuten auf recht gute Resultate aus der offenen chirurgischen Intervention hin. Keine Daten hierzu gibt es bislangfür endovenöse Techniken. Bislang ist eine Rezidivvarikose in der Leiste am besten operativ zu behandeln durch einen indirekten Ansatz, vorzugsweise medial. Mehr Studien sind notwendig, um die beste Behandlungsoption für Rezidivvarikose zu finden. Hybrid-Techniken könnten ein zukünftiger Weg seindurch Kombination verschiedener Ansätze.

 
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