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Varicose Vein Stripping Slipping In Recommendation

Varicose vein stripping is almost synonymous in people’s minds with treating varicose veins.  For years it has been the mainstay of treatment.  But dedicated follow up revealed it might not have been as effective as was once thought.  Less invasive therapies have superseded it.

Internationally it is now recommended as a third level option.  Coming after number one of endovenous laser treatment with number two, sclerotherapy.

Varicose vein stripping represented by a casual array of surgical instrumentsSymbolic surgical instrument array

Years ago surgeons’ and most peoples’ minds wouldn’t have thought this conceivable.  After all once you cut something out, wasn’t it gone?  For good?

It seems not. 

Varicose Vein Stripping Experience

If you know anyone who has had varicose vein stripping done in the past, they will usually tell you it was not the most comfortable procedure.

Yes, they were usually under a general anaesthetic.  Therefore unaware of the actual treatment at the time.

But it was afterwards that they became acutely conscious something major had been done.  It was sore for many days to weeks following.  
I had seen people still bent over unable to fully straighten up two to three weeks later.

Eventually it settled.  But no one wanted to volunteer for another go.

Even so, you will find people who have had two or three varicose vein stripping surgery sessions done over the years.

Usually not for the same area exactly.  But, as I will relate below, sometimes it was.

Some Causes Of Recurrence

Like any person with varicose veins there is a weakness of the vessels that can produce new varicose veins at other places.  At times though they would occur in the same area.

Some regions especially had that risk with the short saphenous vein in the lower leg being particularly prone.

This was due mainly to its varied anatomy.  Connections to the deeper vein could occur much higher than the textbook knee crease.

In the days before vascular ultrasound was routinely used before an operation, this recurrence was more common.  Imaging with the assessment could reduce the chance.  But not entirely.

The Procedure

Varicose vein stripping will result in post-surgical scars.  Here some larger ones from prior instrumentation.Scars from prior varicose vein surgery

Another challenge with varicose vein surgery including stripping is the scars that would be left. 

Original instrumentation was quite bulky.  Larger incisions were made to cater for these.

Essentially a decent diameter wire was passed up the vein with an end like a half ball bearing.  This sharp-edged end was then dragged along the vein to pull it out in a concertina fashion. 

Attached vessels were ruptured off the saphenous vein as it was yanked out.

A British surgeon's explanation of stripping

As you can imagine these bigger instruments would lead to greater bruising and post-operative discomfort.

Later equipment was based on small hooks and finer wires.  Incisions were smaller.  Scars likewise.

Varicose veins visible on the surface were then extracted piecemeal.

Small nicks or incisions were made at selected points.  Forceps would tease the vein to the surface.  A hook would be used to grab it.

Then with gentle pressure and further teasing as much of the vessel as could be pulled from each direction would be pulled above the skin surface.  Until it tore or at times was tied.

Then another incision was made and the process repeated further down the varicose vein length.  With careful work these veins could be cleared.

Other Consequences

Like any surgery a varicose vein operation where the skin is cut risks cutting local nerves.  Areas of numbness or altered sensation can result.

Associated lymphatic vessels which drain fluid from between cells along channels back into the bloodstream near the heart could be severed.  Local swelling or weeping could occur.

Unexpected Long Term Results

But the real kicker was unexpected results from a long term study published in 2003.  A surgical team in Dunedin (site of the country’s original medical school), New Zealand followed people over five years following surgery.

All subjects had duplex ultrasound imaging done before surgery.

The same surgical team did the operations.  To minimise variation.

The outcome?

An over 50% recurrence of varicose veins by five years!

When the professor of surgery author of the study, Dr Andre van Rij presented his results internationally, there was disbelief.

The predominant explanation was that the varicose vein stripping technique must have been poor.

Andre has carefully explored the recurrences.  With exacting surgery and also latex infusions in some excised tissues.

These revealed interesting evolutions of the surgery.

At times a whole new vessel occurred along the site of the stripped vein.  At other times, multiple narrow, incompetent channels occurred.  Much like a medusa type re-connection strands.


What was happening?

With further evaluation, the cause was determined.

Not only that but as other clinics and researchers studied long term results of their varicose vein stripping they found similar outcomes.

Understanding The Progression

The cause?

Any time tissue is cut, or torn, the body establishes a repair process.  Scar tissue forms.  Tissue factors cause new blood vessels to form across the damaged section.

In doing so whole new vessels, that can be similarly incompetent, will be created.

Further instructional video, a little older

As will the multi-channel fine networks that occur.

Moves To Prevent Recurrence

Much research has gone into attempting to prevent this natural phenomenon. 

One was another study by Andre van Rij using a gortex patch implant.

This produced a 50% reduction in recurrence.  Even with the patch new vessels could track right around it producing the noted failures.

Plus there are ongoing concerns about long term consequences of such material being implanted in human tissue.

Fine Vessel Reaction

Many people had been aware that fine fine spider veins arose around the varicose vein stripping surgical scars. 

These could be a part of that same neo-vascularisation process.  Or indicate an unresolved or missed refluxing branch vein issue. 

Frequently with surgery the attitude had been that these fine spider veins were not symptomatic or problematic long term.  They were therefore often left untreated.

It’s just the patients themselves were often not as happy about the appearance.

Positioning And Choices

With increasing validation of these unexpected results, thinking on what is the most effective treatment for varicose veins has changed.

As I indicated, internationally varicose vein stripping is now felt to be the third best option.

With internal vessel laser treatment at number one.  Sclerotherapy at number two.

When given the full range of options some people will still elect to have surgery. 

In their mind one procedure is better for them than going through two or more.  Plus they are “out” for it.

In spite of expected prolonged post-treatment discomfort.

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