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original article

The status of branchvaricosis after

great saphenous vein ablation

BY KARSTEN HARTMANN,

Vein Center Freiburg, Freiburg im Breisgau, Germany

Summary ing the saphenous-stump of the SFJ too long, for exam-
Thermal ablation of saphenous veins has become a stand- ple, with unligated/untreated side branches opening into
ard procedure in the treatment of varicose vein disease. it, promotes recurrence (5, 12).
Much is said about „occlusion rates,“ recurrence rates,“ and
„recanalizations,“ but little attention is paid to the medi- Current data and discussion
cal status of the side branches that open in the sapheno- What happens to side branches after endovenous
femoral-junction (SFJ) area. Yet we know from surgical thermal therapy?
crossectomy that recurrences via side branches in the SFJ After one year, the sufficient side branches left seem
area are not uncommon, and a correct surgical crossec- to have no influence on the success or recurrence rate of
tomy therefore includes the ligation of all side branches endovenous ablation (17). In 2007, Theivacumar et al.
opening in the junction area. However, endovenous showed that in 59% of 81 treated legs, one or more
thermal treatment is predominantly performed only on sufficient side branches were visible in the SFJ area after
the saphenous (truncal) vein, and the side branches are one year.
left untouched. In recent medical publications, untreated However, long-term data such as that of Pröbstle
side branches in the SFJ area are considered the most fre- et al. 2015 documented that after four years, 32% of 93
quent cause of recurrence after endovenous thermal ab- treated legs had recurrence via an anterior accessory sa-
lation (between 8% and 32%). Therefore, it is important phenous vein (AASV) (14). Interestingly, Pröbstle was also
to perform a precise vein mapping prior to endovenous able to show that a AASV was detectable by duplex so-
ablation and to plan the ablation of the saphenous vein nography in 46% of cases before treatment of the great
and, if necessary, relevant side branches precisely. saphenous vein; after four years, an AASV could then be
detected in as many as 71% of treated legs. Of these pa-
Introduction tients, in whom an AASV was already visible from duplex
Endoluminal procedures, especially endovenous thermal sonography before endovenous treatment, varicose vein
vein ablation, have become an integral part of the treat- disease recurred in 55% after four years via this very vein!
ment spectrum for varicose veins in Germany. The most A recurrence incidence of 8% via AASV two years af-
common procedures are radiofrequency ablation (RFA) ter EVLA was shown by Rasmussen et al. in their 2010
and laser ablation (EVLA). In endovenous procedures, the study; overall, recurrence after EVLA occurred in 22% of
focus is on the treatment of the saphenous truncal vein; cases (n=137) (16).
sufficient side branches are usually not treated. In sur- Disselhoff et al. compared „EVLA alone“ with surgi-
gical crossectomy, however, each side branch (which, by cal crossectomy + EVLA (n=86) and found that after five
the way, are usually all sufficient!) opening in the SFJ area years, recurrences via AASV occurred in 14% of cases in
is carefully dissected, ligated, and transected; the goal is the group of legs treated with EVLA alone versus 0% in
the flush closure of the SFJ (9). the group that also underwent surgical crossectomy. Ho-
Few studies have shed light on the medical status of wever, 33% neovascularization also occurred in the cros-
branchvaricosis after endovenous treatment, and little sectomy group (0% in the „EVLA alone“ group), and 9%
is reported on the precise placement of the endovenous recanalizations occurred in the „EVLA alone“ group (2).
catheter in the SFJ area. However, we now know that leav-

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