Saphenectomy in the presence of chronic venous obstruction

The results of saphenectomy in patients with morphologic and functional obstruction were compared with those in patients without obstruction. Excision of secondary saphenous varices associated with deep venous obstruction has long been considered contraindicated for fear of compromising its collateral contribution. Recent advances in accurate functional assessment of venous obstruction make it possible to test this concept.

Saphenectomy was carried out in 51 limbs without morphologic or functional obstruction and 64 limbs with varying grades of venous obstruction. Significant deep venous obstruction on ascending venography was present in the latter group. Functional assessment of obstruction was based on the arm/foot venous pressure differential technique, outflow fraction measurements, and outflow resistance calculations. Valve reconstruction was carried out in conjunction with saphenectomy in 81% of cases.

Saphenectomy was clinically well tolerated in both groups, and there was no difference in outcome as measured by objective tests for obstruction; improvement in reflux and calf venous pump function was largely similar. Among seven limbs with severe preoperative venous obstruction (grade III or IV), five (70%) had significantly improved obstructive grading, presumably as a result of elimination of reflux flow.

The traditional admonition against removal of secondary varices should be reexamined. Saphenectomy may be indicated in postthrombotic syndrome with mixed obstruction/reflux. The procedure is clinically well tolerated and without malsequelae. Improvement in reflux parameters without significant worsening of objective measures of obstruction is documented in this group.