Let's talk about saphenous incontinence: when and how do you opt for saphenoustomy?

By Cristiano Antonino On May 9, 2023

Saphenectomy literally means the removal of the saphenous vein. The internal and external saphenous are important collectors of the superficial venous system of the lower limbs

In particular conditions, generally in the presence of a more generalized venous insufficiency condition, they undergo dilatation and incontinence of their valvular mechanisms, with the benefit of their elimination with one of the various techniques currently used, in order to obtain a reduction in the venous pressures of the affected limb and a condition of improved efficiency of the entire venous system of the limb.

The venous system of the lower limbs consists of three districts

The deep venous system (the most important, as it drains 80-90% of the waste blood from the lower limb), protected by muscle bands and not visible from the outside.
The superficial venous system (consisting of veins located in the subcutaneous tissue, visible from the outside); it is the district in which the varicose veins develop.
The system of perforating veins (consisting of veins that connect the two systems mentioned above).

In particular, in the saphenous axes the blood is conveyed by numerous superficial venous collectors, to then flow into the deep venous system. Each limb has an internal saphenous axis and an external saphenous axis.

The internal saphenous (also called “great saphenous”), originates from the internal marginal vein of the foot, runs along the medial surface of the leg and thigh to flow into the femoral vein at the root of the limb; the external saphenous (also called “small saphenous” due to its smaller caliber and shorter length than the previous one), originates from the external marginal vein of the foot, from the lateral region it moves to the posterior median line of the leg and flows into the popliteal vein at the level of the popliteal fold.

The venous return from the lower limbs towards the heart, in an anti-gravity direction, takes place by means of the propulsive action of the venous walls and the musculo-plantar pump mechanisms activated during walking; the veins are equipped with valve mechanisms able to prevent the return of blood downwards due to the force of gravity.

When, following a condition of venous insufficiency, venous hypertension in the superficial circulation, in this case in the saphenous axes, leads to dilatation of the venous walls and to a consequential insufficiency of the valve mechanisms as well, we speak of saphenous insufficiency.

It is important to underline that saphenous insufficiency per se is not necessarily directly related to the presence or absence of varices in the affected lower limb, it being possible to observe saphenous insufficiency in the absence of varices as well as the presence of varices in the absence of insufficiency. saphenous; this by virtue of the complexity of venous hemodynamics, its compensation mechanisms and the possibility that varicose veins can also develop from the insufficiency of one or more perforating veins, of the leg or thigh (the so-called “brief refluxes”, to distinguish them from so-called “long reflux”, of saphenous origin).

The causes of saphenous saphenous insufficiency fall within the great chapter of venous insufficiency, a chronic, degenerative and evolutionary pathology that is very frequent in the Western world.

It can be said that in the context of a constitutional meiopragy of the venous system, environmental factors and incorrect lifestyle habits are introduced which lead to the weakening of the venous walls.

Among these, the following are of particular importance:

Excess weight
Sedentary lifestyle
Work activity in static orthostatism (many hours standing still)
Excessive ambient temperatures
Excessive sun exposure
Taking oral estrogens
Hormonal imbalances
Pregnancy
Unbalanced diets
Alterations of plantar support with insufficiency of the musculo-plantar pump
Footwear that prevents the correct functionality of the muscle-plantar pump (very high heels)
Inappropriate sports activities (muscle strengthening activities in static orthostatism)
Among the most typical symptoms of saphenous insufficiency are mentioned
Edema of the lower limbs
Tired and heavy legs
Paresthesias of the lower limbs (feeling of diffused or localized heat)
Night cramps
Restlessness in the limbs, especially in bed (so-called “restless legs syndrome”)
Orthostatic phlebodynia (intolerance to prolonged standing)
Phlebostatic cruralgia (pain along the medial surface of the thigh when standing)
Troncular varices
Telangiectatic varicose (the so-called “capillaries”)
Skin ulcers on a phlebostatic basis

Diagnosis of saphenous insufficiency

The complexity of venous hemodynamics and the need for a full knowledge of the anatomical and physiopathological mechanisms that regulate it mean that in the face of a picture of venous insufficiency complicated by varicose veins one should contact a phlebologist specialist, able, following a precise anamnesis general and phlebological as well as following an accurate objective examination, to better frame the patient’s venous pathology.

With the aid of the color Doppler ultrasound, which is an indispensable and irreplaceable tool in first level vascular diagnostics, the phlebologist will carry out a precise haemodynamic mapping of the subject’s varicose veins, with the identification of both the so-called “vanishing points” at the origin of the varicose veins, whether they are long refluxes from the saphenous axes or short refluxes from the perforating veins, or the so-called “return points” of the refluxes in the deep circulation.

All in order to be able to carry out targeted and more stable interventions over time and avoid the execution of less specific, more random and less effective interventions over time in terms of stability of results.

In addition to color Doppler ultrasound, valuable diagnostic information comes from venous photoplethysmography with reflected light, a simple and non-invasive method that allows you to study the dynamic emptying of the veins of the lower limbs and the post-exercise venous filling times, in basic conditions and after tests functional.

Other higher level diagnostic methods (angioCT scan, MRI, phleboscintigraphy, etc.), are rarely used, and only in highly selected cases.

Risks related to saphenous incontinence and evaluation of saphenectomy

The possible complications of venous insufficiency not adequately treated, while not wanting to cause sterile alarmism, are numerous and some are potentially fatal.

It should be emphasized that the numerous possible and serious complications mean that venous insufficiency cannot be considered a simple ailment or a purely aesthetic problem, but deserves periodic specialist checks and more or less invasive treatments over time.

In particular, the possible complications include:

Edema of the lower limbs
Superficial venous thrombosis (varicophlebitis)
Deep vein thrombosis
Pulmonary embolisms
Worsening varicose veins
Cutaneous dystrophies and dyschromias
Skin ulcers on a phlebostatic basis

Treatments and cures for saphenous incontinence

In the initial stages of venous insufficiency, in the absence of indications for invasive treatments, conservative treatment generally allows good control of the symptoms and slows down the evolution of the pathology.

In particular, conservative treatment is based on a few simple but rigorous rules, such as:

Wear adequate compression stockings, strictly prescribed by the treating phlebologist specialist.
Take phlebotropic, profibrinolytic drugs and/or specific food supplements, on specialist prescription.
Avoid being overweight.
Follow a specific diet, rich in fresh fruit and vegetables, preferably following a prescription from the nutritionist.
Regularly practice aerobic physical activity (especially swimming, walking, Nordic walking, running, cycling).
Avoid inappropriate sports (especially muscle strengthening activities in static orthostatism).
Avoid estrogens and oral contraceptives.
Avoid work activities in static orthostatism (many hours of standing).
Avoid tight-fitting and/or elasticated pants.
Preferably wear comfortable shoes, with 3-4cm. of heel.
Correct the alterations of plantar support with impairment of the musculo-plantar pump.

If the specialist tests have indicated the elimination of one or more saphenous axes of sure utility in improving the symptoms and slowing down the evolution of the venous disease, the current techniques can be divided into two groups:

Ablative techniques
Endovascular occlusion techniques

The ablative techniques involve surgery sensu stricto: the saphenous vein is surgically prepared at the inguinal or popliteal level, and then, guided by a specific vascular probe or a sturdy wire which runs along the lumen up to the chosen distal level, it is removed in a bloody way (“stripping”).

This technique, widely used in the past, is currently used less and less in the specialist field, in favor of less bloody techniques and without the side effects and complications typical of stripping (hematomas, alterations in skin sensitivity, residual pigmentation, prolonged convalescence times, longer surgical and anesthesiological times compared to endovascular techniques, etc.)

Endovascular occlusion techniques do not involve the bloody removal of the saphenous vein.

But its occlusion by endovascular route following an endothelial damage of a chemical or thermal type which is followed by the transformation of the vessel into a fibrous cord which is progressively reabsorbed.

These are outpatient techniques which generally do not involve surgical incisions (unless otherwise preferred by the operator) but only the catheterization of the vessel under ultrasound control

In this context, the techniques currently used are represented by:

Ultrasound-guided scleromousse: a sclerosing agent is injected in the form of a foam to increase its contact time with the vessel wall and therefore its effectiveness. The injection of the sclerosing foam is carried out through a vascular catheter, under strict ultrasound control in order to be able to evaluate its progression up to the saphenofemoral (or saphenopopliteal) junction, and to be sure of a complete sclerosis of the vessel
Occlusion with cyanoacrylate (Super Glue): a cyanoacrylate-based glue, a powerful adhesive that has long been used in the medical-surgical field, is injected into the lumen through the vascular catheter, which immediately closes the lumen of the vessel; it is a technique of Anglo-Saxon origin, still little used in Italy and not yet introduced in the Italian Guidelines, but approved by the American FDA, of which a wider diffusion is expected in the future
Laser photothermosclerosis (EVLT): a laser fiber is introduced into the vessel lumen which, by generating heat, causes physical damage to the vessel wall, causing its occlusion
Endovascular thermoablation with radiofrequency (Closure): as in the use of the laser, a probe is introduced into the lumen of the vessel, which in this case generates heat using radiofrequencies, with physical damage to the vessel wall, causing its occlusion

Regarding the intrinsic characteristics of endovascular treatments, in expert hands all superimposable in terms of effectiveness, it is considered necessary to specify the following:

the scleromousse is simple to perform, quick and cheap, can be performed in the clinic without the use of anesthesia, easily repeatable;
occlusion with cyanoacrylate requires a particularly expensive kit, can be performed in the clinic, is quick and easy to perform, does not require anesthesia and is not yet present in the Italian Guidelines, even if approved by the American FDA;
occlusion with laser or radiofrequency requires expensive disposable kits, is to be performed preferably in the operating room, requires more complex preparation and local anesthesia.

All techniques involve the use of an elastic restraint after the treatment and the rapid resumption of usual occupational activities; being of almost comparable efficacy, the phlebologist specialist will be able to recommend the most appropriate treatment in consideration of his own experience and the individual characteristics of the patient.

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