Primary varicose veins: hemodynamic principles of surgical care. The case for the ambulatory stab evulsion technique

The recently accumulated hemodynamic and anatomic data on primary varicose disease, coupled with concomitant quest for maximal efficiency, cosmesis and saphenous vein preservation, is changing the surgical approach to the classical stripping operation. The long convalescence, with possible loss of income, the possible permanent nerve injury, and the possibility of removing normal truncular veins, makes the stripping operation, in many cases, an overkill. In contrast, the ambulatory stab evulsion phlebectomy (truncal and tributary), performed with the specially designed hooks and, performed in conjunction with ligation of the most proximal source of reflux (escape point), will effectively abolish the regurgitant flow and lower the existing increased ambulatory venous pressure. It will remove the tributary varicosities and thus disconnect all possible (distal) perforators, while undamaged veins, potential graft materials, are left in situ. The incisions of 1.5-3 mm, will guarantee excellent cosmesis, and due to minimal trauma, saphenous and sural nerve injury can be avoided as well. Performed in an ambulatory setting, under loco-regional anesthesia, which permits immediate resumption of the normal daly activities, makes the method appealing from the cost efficient point of view too. This hemodynamically and anatomically sound technique is however dependent on precise clinical as well as non invasive (Doppler ultrasound, air-plethysmography, and in certain cases duplex imaging) evaluation of each case, permitting the tailoring of an individualized treatment protocol for each patient.