REVAT (Recurrent Varices After Treatment)

Summary

The term “recurrent varicose veins” covers various entities. In the first instance, recurrent varicose veins may be the progression of the underlying disease, as there is a hereditary disposition to the condition, but we also find the phenomenon of neovascularisation, and lastly we repeatedly see recurrent varices as a result of technical or strategic surgical errors and the failure of endovenous procedures. No differentiation between these different types of recurrent varicose veins has previously been made in the literature, so that the numbers given vary between 6% and 60%. Up to the present time, few data on the progression of the underlying disease are to be found in the literature. Our own studies, on average 36 months postoperatively, demonstrated new varicose side branches that could be interpreted as progression of the underlying disease in 56.8% of the patients followed up.

Several recent publications demonstrate neovascularisation as a cause of recurrence. While some authors give a figure of 24% for recurrence due to neovascularisation in patients who have had surgery, other publications regard neovascularisation as the main cause of postoperative recurrence.

The data on technical or strategic surgical errors and recanalisation after endovenous procedures are also very varied. Numbers for technical errors as the cause of recurrent varicose veins following surgery range from 10.7% to more than 70%. Published recanalisation rates after endovenous laser therapy vary between 0% and 36%; the average recanalisation rate in the available prospective randomised studies on radiofrequency obliteration was 12.9%. Foam sclerotherapy has recanalisation rates between 69% and 86%, with a mean follow-up of 32.2 months.

Given the different possible causes, it is extremely important, that recurrent varicose veins should be classified. The authors have developed a simple classification that can be used in routine daily practice. Recurrent varicose veins are given the acronym REVAT (recurrent varices after treatment). Generally speaking, on the one hand there is progression of the underlying disease (progression of disease = PD) and, on the other hand, varicosities after treatment as a result of technical error or failure of the method used (recurrence after treatment = RT). Progression of the underlying disease can be further subdivided into neovascularisation at the saphenofemoral or popliteal junction (progression of disease at the junction = PD-J) and new varices arising in the treated vascular territory (progression of disease at the limb = PD-L).

In the case of recurrent varices after treatment we distinguish between a persisting or a new reflux at the saphenofemoral or the popliteal junction (recurrence after treatment at the junction = RT-J), untreated segments of the great or small saphenous veins or recanalisation of the trunk (recurrence after treatment at the trunk = RT-T) and untreated side branches or perforating veins (recurrence after treatment at side branches = RT-S). With the help of these abbreviations a simple formula can be generated to describe the recurrent varices, e.g. recanalisation of the left great saphenous vein (GSV) after endovenous treatment and a new varicosis in the vascular territory of the left great saphenous vein resulting from progression of the underlying disease: vascular territory left great saphenous vein = GSV-L, technical or tactical error due to recanalisation of the GSV = RT-T, progression of the underlying disease in the vascular territory of the GSV = PD-L. This generates the formula: GSV-L : RT-T, PD-L.

Since there are no exact figures on the incidence of the individual causes of recurrent varicosis, a classification of recurrent varicosis is indispensable to ensure clarity in the future.

Zusammenfassung

Mit Rezidivvarikose werden verschiedene Entitäten bezeichnet: natürliche Progression der Grunderkrankung, Neovaskularisation und technische/taktische Fehler bzw. Versagen einer Maßnahme als Ursache für die Rezidivvarikose. Um exakte Zahlen zur Rezidivhäufigkeit und -ursache festzu stellen, ist eine genaue Definition und Klassifikation notwendig. Eine internationale Expertengruppe prägte 1998 den Begriff REVAS. Diese ausführliche Klassifikation ist in der klinischen Routine nicht anwendbar. Eine einfachere Klassifikation wurde daher unter dem Akronym REVAT (Recurrent Varices After Treatment) entwickelt, die die Rezidivvarikose in zwei Gruppen unterteilt: 1.) Progression der Grunderkrankung (Progression of Disease = PD) und 2.) Varikose nach Behandlung (Recurrence After Treatment = RT). Diese Oberbegriffe werden durch die Lokalisationsbezeichnungen des so genannten Rezidives ergänzt.

Um klare Angaben zur Häufigkeit wieder auftretender Venen zu erhalten, sollte REVAT künftig zur Klassifikation bei jedem Wiederholungseingriff angewendet werden.

Keywords

Recurrent varicose veins - classification - REVAT

Schlüsselwörter

Rezidivvarikose - Klassifizierung - REVAT

• Literatur

• 1 Fischer R, Chandler NJG, De Maesener MG, Frings N, Lefebvre-Vilardebo M, Earnshaw JJ, Bergan JJ, Duff C, Linde N. Collective review: the unresolved problem of recurrent saphenofemoral reflux. J Am Coll Surg 2002; 195: 71-85.
• 2 Frings N, Nelle A, Tran P, Fischer R, Krug W. Reduction of neoreflux after correctly performed ligation of the saphnofemoral junction. A randomized trial. Eur J Vasc Endovasc Surg 2004; 28: 246-252.
• 3 Kostas T, Ioannou CV, Touloupakis E, Daskalaki E, Giannoukas AD, Tsetis D, Katsamouris AN. Recurrent Varicose Veins after Sugery : A New Appraisal of a Common and Complex Problem in Vascular Surgery. Eur J Vasc Endovasc Surg 2004; 27: 275-282.
• 4 Mumme A, Olbrich S, Babera L, Stücker M. Saphenofemorales Leistenrezidiv der Vena saphena magna : technischer Fehler oder Neorevaskularisation?. Phlebologie 2002; 31: 38-41
• 5 Mumme A, Burger P, Hummel T, Frings N, Hartmann M, Schonath M, Schwahn-Schreiber C. Der lang belassene Saphenastumpf – Implikationen für die endovenöse Therapie der Varikose. Phlebologie 2007; 36: 256-259.
• 6 Noppeney T, Noppeney J, Scheidt A, Kurth I. Indikation und Technik zur Sklerotherapie bei Varikose. Zentralbl Chir 2001; 126: 546-550.
• 7 Noppeney T, Noppeney J, Kurth I. Ergebnisse nach klassischer Varizenchirurgie. Zentralbl Chir 2002; 127: 748-751.
• 8 Noppeney T, Kluess HG, Gerlach H, Braunbeck W, Ehresmann U, Fischer R, Hermanns HJ, Langer C, Nüllen H, Salzmann G, Schimmelpfennig L. Leitlinie zur Diagnostik und Therapie des Krampfaderleidens. Gefäßchirurgie 2004; 9: 290-308.
• 9 Noppeney T, Nüllen H. Die Rezidivvarikose – was ist das. Gefäßchirurgie 2005; 10: 424-427.
• 10 Noppeney T, Noppeney J, Winkler M. Update der Ergebnisse nach Radiofrequenzobliteration zur Ausschaltung der Varikose. Gefäßchirurgie 2008; 13: 258-264.
• 11 Noppeney T, Kluess HG, Nüllen H, Pannier F, Ehresmann U, Hermanns HJ, Schmedt CG, Stenger D, Steckmeier B, Schimmelpfennig L, Salzmann G, Breu FX. Leitlinie zur Diagnostik und Therapie der Krampfadererkrankung der Deutschen Gesell schaft für Phlebologie, der Deutschen Gesellschaft für Gefäßchirurgie, des Berufsverbandes der Phlebologen e.V. und der Arbeitsgemeinschaft der niedergelassenen Gefäßchirurgen Deutschland e.V. Gefäßchirurgie. 2010: 15 zur Publikation akzeptiert.
• 12 Perrin M, Guex JJ, Ruckley CV, de Palma R, Royle J, Eklof B, Nicolini P, Jantet G. Recurrent Varices after Surgery (REVAS), a Consensus Document. Cardiovasc Surg 2000; 8: 233-245.
• 13 Rabe E, Pannier-Fischer E, Bromen K, Schuldt K, Stang A, Poncar C, Wittenhorst M, Bock E, Weber S, Jöckel K. Bonner Venenstudie. Phlebologie 2002; 32: 1-14.
• 14 Rewerk S, Noppeney T, Winkler M, Nüllen H, Duzek C, Meyer A, Grobholz A, Willeke F. Venoneurale De- und Regeneration bei Varikogenese und Neovaskularisation. Phlebologie 2007; 36: 8-16.
• 15 Rewerk S, Noppeney T, Winkler M, Willeke F, Duzek C, Meyer A, Gruber A, Grabholz R, Niedergethmann K, Niedergethmann M. Pathogenese der Primär- und Rezidivvarikose an der Magna-Krosse, die Rolle von VEGF und VEGF-Rezeptor. Phlebologie 2007; 36: 137-142.
• 16 Schmedt CG, Steckmeier BM. Endoluminale Radiofrequenz und Lasertherapie zur Therapie der Stammveneninsuffizienz. In: Marshall Breu. (Hrsg) Handbuch der Angiologie 2006; 15: 12.
• 17 Van Rij AM, Jones GT, Hill GB. Neovascularisation and recurrent varicose veins: More histologic and ultrasound evidence. J Vasc Surg 2004; 40: 296-302.