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original article

nous ablation, meaning that the sufficient AASV in the SFJ
area is ablated endovenously (surgically the AASV is liga-
ted and cut), even lower recurrence rates can be achieved
compared to surgical crossectomy, since there is no neo-
angiogenesis after laser therapy! This procedure is called
endovenous crossectomy (7, 8). As mentioned above,
Pröbstle demonstrated that AASV was detectable by du-
plex sonography in 46% of cases before VSM treatment.
In 55% of these patients, the disease recurred after four
years via the AASV (14)!
fig. 5 > The anatomical diversity in the area of the SFJ of In conclusion, a prophylactic closure of the AASV in
the great saphenous vein (VSM), e.g. SFJ of the VSM with the SFJ area is to be demanded, as it has always been
proximal junction of the V. circumflexa ileum, V. epigast- standard in surgical crossectomy. There are no data on
rica inferior und V. pudenda externa and separate junc- this, a first study on this topic is currently being launched
tions of Vena saphena accesoria anterior and posterior by the „Endovenous Therapy Working Group“ of the Ger-
with percentages of how frequently the side branches man Society of Phlebology. An exact analysis of the side
are present and at what distance (in mm) they join the branches in the SFJ area before endovenous therapy is es-
VSM on average from the SFJ (mod. after Hartmann M, © Dr. Karsten Hartmann sential to achieve an optimal result and requires great ex-
De Gruyter 1991 (9) and Mühlberger D et al. J Vasc Surg. perience, because inaccurate vein mapping and incorrect
2009;49(6):1562-9 (11)) placement of the endovenous catheter in the SFJ area

leads to a loss of quality of the endovenous techniques.
Therefore, endovenous procedures have to be laid into
There are many anatomical variants of the confluence of the hands of experienced phlebologists and/or physicians
various side branches, for example, the AASV can often with in-depth knowledge of the anatomy who regularly
also enter the epigastric vein into the VSM via the epi- undergo continuing education in phlebology. Endovenous
gastrical junction or, rarely, directly into the femoral vein. crossectomy should be the standard of treatment.
Positioning of the RFA catheter was a similar dis-
tance away from the SFJ, as the manufacturer‘s protocol The article is based on a presentation at the 27th Bonn Vein Days dated
requires. 30th April – 1st May 2021 and was published in vasomed 2021; 33(2):
2. Use of radial fibers as opposed to barefibers. Radial 40-42.
fibers allow the catheter to be advanced flat to the SFJ, Compliance with ethical guidelines
because the laser energy is delivered laterally rather than Conflict of interest: K. Hartmann declares no conflict of interest.
anteriorly. This contribution does not include any studies on humans or animals
performed by the author.
3. Accurate DUS vein mapping especially of the AASV
before the endovenous procedure. If this is not done, an
initially very small but insufficient AASV could be missed
before ablation of the VSM. This could be an explanation
why recurrence may become visible via an AASV after
only a very short time after an endovenous procedure.
If all three points are taken into account, meaning the
EVLA radial fiber (no use of barefibers!) or the RFA cathe-
ter is placed flat at the SFJ and a precise focus is placed
especially on an existing insufficient AASV, then very low
recurrence rates similar to the surgical operation can be
achieved in the long-term analysis. If even an existing suf-
ficient AASV is treated in a second step during endove-

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