The treatment of venous disease has changed dramatically in recent years with the advent of duplex ultrasound evaluation, minimally invasive treatments, and new thrombolytic drugs. For more than 100 years, the treatment of superficial disease had been limited to high ligation and stripping with limited innovation. Attempts at chemical ablation (sclerotherapy) had, historically, been hampered by serious complications and a high rate of recurrence. Deep venous treatment had been largely limited to the use of compression stockings, with occasional attempts to perform venous bypasses, valve reconstruction, or the radical Linton procedure (subfascial ligation of perforator veins), but all of these interventions had high rates of morbidity and low rates of success.
The first big step was the duplex evaluation, which greatly improved the sensitivity and specificity for the diagnosis of deep vein thrombosis (DVT),1 as well as reduced costs. The progress continued with improved diagnosis of superficial reflux and the mapping of incompetent veins. This greatly improved the results of high ligations and stripping and helped considerably with the results of ultrasound-guided sclerotherapy for the chemical ablation of incompetent superficial veins. Newer techniques that use thermal ablation and improved methods of chemical ablation have furthered the improvement.
Deep venous disease treatment has also undergone a renaissance with the use of similar minimally invasive techniques, such as angioplasty, stenting, and intravascular ultrasound (IVUS).
The prevalence of varicose veins in the Western population is greater than 20%, with about 5% of patients having the sequelae of venous edema, skin changes, or ulceration. Approximately 0.5% of patients have active ulceration. The incidence is higher in women than in men.
The superficial system is defined as the portion of veins that lie between the skin and deep fascia that covers the muscles. The main veins of the superficial system are the great saphenous vein (GSV) and the small saphenous vein (SSV) (Figs. 55-1 and 55-2). The GSV starts in the foot, anterior to the medial malleolus, and courses up the medial leg to the saphenofemoral junction in the groin. The GSV runs in the saphenous sheath, which is formed from the deep fascia. In the calf, major tributaries of the GSV are the anterior and posterior arch veins. In the thigh, major tributaries of the GSV are the anterior and posterior accessory saphenous veins. The anterior accessory saphenous vein (AASV) typically joins the GSV at the saphenofemoral junction (SFJ). The SSV starts posterior to the lateral malleolus and runs in the saphenous sheath to the popliteal fossa. The termination point for the SSV is highly variable. It sometimes ends in the popliteal fossa joining the popliteal vein, or through thigh extensions ending in the thigh underneath the gluteus maximus muscle, or it courses medially and ...