Long-term efficacy of inguinal reoperation for recurrent saphenofemoral incompetence

Abstract

Objective: Recurrence originating from the saphenofemoral junction (SFJ) after an open surgical approach to or endovenous ablation of the great saphenous vein frequently occurs. The optimal treatment for a saphenofemoral recurrence remains a subject of debate. Currently, open redo surgery is becoming less common. This study analyzes the long-term effectiveness of saphenofemoral redo surgery following the principles of a modern surgical approach.

Methods: Patients who underwent saphenofemoral reoperation in 2015 and 2016 were identified retrospectively and invited to participate in a prospective follow-up examination. Redo surgery was performed under general and additional tumescent local anesthesia as inpatient treatment and included flush religation of the SFJ , stump suture, cauterization of the free endothelium, and removal of neovascularization. The following objectives were analyzed: Duplex ultrasound-detectable recurrent reflux at the SFJ, clinical recurrence according to Recurrent Varices After Surgery classification, disease severity and quality of life using standardized protocols (Revised Venous Clinical Severity Score, Homburg Varicose Vein Severity Score, Chronic Venous Insufficiency Questionnaire), and patient-reported satisfaction.

Results: A total of 84 patients (94 treated legs) were included with a median follow-up of 6.6 years. Five of the 94 legs (5.3%) had a duplex-detected reflux in the groin, with only 1 leg (1.1%) showing grade 2 neovascularization (vessel diameter of ≥4 mm). According to Recurrent Varices After Surgery classification, 2 of the 94 legs (2.1%) revealed clinical recurrence arising from the inguinal region. Disease severity at follow-up was low with a mean Revised Venous Clinical Severity Score_(0-30) of 1.8 ± 1.8 and a mean Homburg Varicose Vein Severity Score _(0-33) of 3.9 ± 3.4. According to the Clinical, Etiological, Anatomical and Pathological classification, the stage of disease improved significantly (P < .001) in 55% of the treated legs. The procedure was well-accepted by patients: 94.1% indicated they would undergo saphenofemoral reoperation again if medically advised.

Conclusions: This study demonstrates that saphenofemoral redo surgery is very effective when certain technical strategies are implemented to prevent neovascularization. Long-term treatment results may be superior to minimally invasive procedures, indicating the need for comparative studies. Until such studies are available, open redo surgery should continue to be considered as an appropriate treatment option for saphenofemoral recurrence.

Keywords: Barrier technique; Neovascularization; Recurrent saphenofemoral incompetence; Saphenofemoral reoperation; Varicose veins.