Recurrent varices after internal saphenectomy. Physiopathological hypothesis and clinical approach.

Background. This paper analyses the causes and describes the best care of recurrent varicose veins after internal saphenectomy. Methods. A series of 19 patients who had previously undergone internal saphenectomy were selected for surgery due to recurrent varices in the lower limbs. Clinical examination and colour duplex sonography were used as the preoperative diagnostic tools in all patients. No patients underwent phlebography. In 17 cases the main source of reflux was an incontinent saphenous stump at the level of the saphenofemoral junction with varicose cross-groin collaterals. In 2 cases recurrence was caused by incontinence of the upper thigh perforating vein. In 1 of these patients the recurrence also involved the district of the small saphenous vein. Groin neovascularisation was detected in 1 patient. Results. All patients underwent groin re-dissections using transversal incisions: in 9 cases, access to the saphenofemoral junction was obtained under or at the same level as the inguinal fold, and in 10 cases using a suprainguinal route. The vertical inguinal incision was never employed. Incompetent perforating veins (thigh or leg) were ligated or sectioned in 11 patients. Ligations and exeresis of communicating veins were executed in all patients. Muller's phlebectomies were performed intra- or postoperatively on collateral varices in practically all cases. Postoperative ambulatory sclerotherapy was necessary in 6 cases. Conclusions. A correct surgical approach is only assured by diagnostic accuracy coupled with a precise hemodynamic evaluation. Correct management of the postoperative follow-up of varicose vein surgery is also important.