Phlebectomy Techniques for Varicose Veins Daniel F. Geersen, MPAP, PA-C*, Cynthia E.K. Shortell, MD KEYWORDS Ambulatory phlebectomy Stab phlebectomy Microphlebectomy Microextraction Stab avulsion Removal varicose veins KEY POINTS Ambulatory phlebectomy is the gold standard for removal of symptomatic residual veins after truncal reflux has been treated. This can be staged or performed concomitantly. Phlebectomy can be performed in a clinical or operative setting with local tumescent anesthesia to augment dissection and provides adequate pain management and hemostasis. Complications of phlebectomy are rare and can be minimized with appropriate risk man- agement and proper patient selection. Although ambulatory phlebectomy is well known and the adopted preference of most practitioners, there are other options and new emerging techniques, such as transillumi- nated powered phlebectomy and cyanoacrylate closure. HISTORY Gaius Marius, Roman statesman, general, and 7-time consul, gained an unprece- dented control of the Roman Army throughout the Mediterranean. He was passion- ately respected by his troops, often eating with them and sharing in their labors. He marched with them through the empire, through North Africa, into the Alps, and against the Germanic tribes and the Gauls of northern and western Europe. His recurrent rise and falls from power were renowned throughout the “modern world.” Less famous is his development of severe venous disease as a result of his campaigns and refusal to undergo treatment of his contralateral leg, once completing a phlebectomy without anesthesia. He is quoted as saying that “the cure is not worth the pain.” The description of venous disease and treatment is well documented. In 400 BC, Hippocrates was the first to conceptualize phlebectomy. He described several The authors have nothing to disclose. Department of Surgery, Division of Vascular and Endovascular Surgery, Duke University Medical Center, Box: DUMC 3538, Durham, NC 27710, USA * Corresponding author. Clinic: 10207 Cerny Street, Suite 312, Raleigh, NC 27617. E-mail address: [email protected] Surg Clin N Am 98 (2018) 401–414 https://doi.org/10.1016/j.suc.2017.11.008 surgical.theclinics.com 0039-6109/18/ª 2017 Elsevier Inc. All rights reserved. 402 Geersen & Shortell sequential punctures in the vein could be used to get rid of the “bad blood” that fed a venous ulcer. The Ebers Papyrus warned against treating the “Leg Serpents,” describing death from presumed hemorrhage and/or infection. Aulus Cornelius Celsus was the first surgeon to perform a phlebectomy by taking a blunt hook or cautery to destroy the veins and made large incisions with compressive bandages.1 Unfortunately, much of his writings were lost or destroyed, and the art of phlebectomy was lost for more than 5000 years until Robert Muller, a dermatology-trained phlebologist from Switzerland, rediscovered it. He was growing frustrated by the poor results of sclerotherapy on larger veins, and he began using small hooks from broken hemostats to remove the veins via small holes. By 1956, Muller had refined his procedure and presented it to the French Society of Phlebology in 1967 and the International Congress of Phlebology in 1968. These presentations were not well received. He described them as “a total fiasco. Everybody agreed that it was a ridiculous method, after which I could have buried myself together with the invention.”2 It was a slow and steady group of disciples that continued the procedure and adopted it across the world and now the United States as the procedure of choice to remove these veins.3 Today, these in- terventions are performed regularly on a growing population of venous disease sufferers. AMBULATORY PHLEBECTOMY Ambulatory phlebectomy, stab avulsion/phlebectomy, microphlebectomy, and microextraction are all interchangeable terms to describe this technique. It con- sists of a method by which the larger varicose veins are removed through small skin punctures and hooks specifically designed for this purpose. It is often performed in the outpatient setting using local anesthetic and tumescent anesthesia. Tumescent anesthesia was originally developed by Klein4 in 1987 for liposuction and was adopted by Cohn and colleagues5 in 1995 to avoid the painful and time- consuming infiltration of local anesthetic and to reduce the risk of lidocaine overdose. This commonly contains saline, epinephrine, and lidocaine. The authors commonly use the term stab phlebectomy and always use a tumescent anesthesia for these patients, often under general anesthesia. The goals of therapy are to remove the residual or remaining large refluxing veins of the limb after ligation or ablation of the source of reflux. This provides an effective and economical way to provide complete treatment of the symptomatic residual veins with a good cosmetic result. PREOPERATIVE ASSESSMENT Upon evaluation of the patient, a complete history, including previous deep vein thrombosis (DVT), chronic edema, family history of venous insufficiency and venous thromboembolic disease, and surgical interventions, should be collected. Each pa- tient’s reflux should be identified with venous duplex, and if unilateral or deep system reflux is noted, consideration of pelvic congestion or May-Thurner should be included. Patients with poorly controlled diabetes, hypercoagulable state, and arterial dis- ease should be considered higher risk. Patients who are pregnant, have infection, or have severe edema should be delayed until these issues have been resolved. Phlebectomy Techniques for Varicose Veins 403 Lipidermatosclerosis should be noted and quality of the skin assessed for potential wound complications. Discontinuation of anticoagulation, if possible, will reduce bruising and hematoma formation. The novel anticoagulants, such as dabigatran, rivaroxaban, and apixaban, are relatively easy to stop and restart. A period of 24 to 48 hours should be allowed between the last doses and intervention. Low- molecular-weight heparin (LMWH) bridging for warfarin should be considered in patients at high risk, previous cerebrovascular accident from atrial fibrillation, recurrent DVT, or pulmonary embolisms (PEs). The authors recommend patients completing anticoagulation for a full 3 months following a DVT or PE before engaging in a phlebectomy and withholding treatment. Anticoagulation can often be restarted 12 hours postoperativelyl. TO STAGE OR NOT TO STAGE There has been debate over concomitant phlebectomy with ligation or ablation, or whether a period of time following ablation of the truncal reflux should be pursued to give the patient an opportunity to avoid the invasive intervention. Mon- ahan6 has presented data demonstrating 13% of limbs treated by radiofrequency ablation alone had complete resolution, and on average, 34.6% of the veins that did not resolve reduced in size by 6 months. The concern with this in today’s market is the need for quicker treatment resolution because insurance carriers are only allowing one treatment per lifetime per limb and limited sessions of sclero- therapy to be completed 6 months from initial ablation.7 It is recommended to pur- sue concomitant treatment when the likelihood of complete resolution of the symptomatic varicosities is not likely, given the disease burden and diameter of the veins. TREATMENT Ambulatory phlebectomy can be performed in a variety of settings, including clinic, operating room (OR), or other ambulatory setting. It can be completed either alone or in conjunction with other procedures. Although it can be done bilaterally, if blood loss is a concern or patient tolerance of the procedure is in question, staged interven- tion is recommended. The patient should have their veins marked in the preoperative area while stand- ing using indelible ink. A nonstaining marker should be used because permanent markers have a risk of tattooing the skin postoperatively. The patient should be involved in the marking to assure all the veins of concern are addressed. Be aware of making sure the markings are not completely washed off with the skin preparation. A near-infrared imaging device or transilluminator can be used intrao- peratively because these veins can shift after surgical positioning.8 Although the authors do not use this device, there is some evidence this can speed up the intervention.9 Prophylactic antibiotics should be given, and the skin should be prepared by sterile technique. There have been case studies of necrotic fasciitis and need for extensive debridement and grafting from tumescent anesthetic administration and skin floral contamination.10 Further thromboprophylaxis should be considered in all patients with a known hypercoagulable condition, or having extensive intervention with liga- tion, ablation, and stab phlebectomy. There is a paucity of literature on thrombopro- phylaxis for stab phlebectomy alone, but data for high ligation and stripping of the great saphenous veins (GSVs) show a benefit. Incidence of PE and DVT were higher in groups that did not receive prophylaxis in a study by Wang and colleagues.11 404 Geersen & Shortell Although bleeding complications were higher in the group receiving LMWH, these complications were short lived. Patients should be counseled as to the risks and ben- efits of anticoagulation, and the authors will often administer prophylactic LMWH postoperatively or prescribe for several days after intervention prophylactic Xa inhib- itors if the patient is at higher risk. INTERVENTION When the patient is brought to