Recurrent varicose veins following surgical treatment in the Maltese population

Abstract

Purpose: Various causes for recurrent varicose veins have been discussed and identified in several peer-reviewed studies. However there has been no consensus on the dominant type that leads to symptomatic recurrence and thus to the need for a second intervention. Locally there are no scientific studies that address the issue of recurrence and thus this study aimed to identify the different types of recurrence of varicose veins in the Maltese population. Method: During June 2014 and October 2014, patients with a history of previous varicose veins surgery and recurrent varicose veins were prospectively assessed at the Vascular unit of a general acute public hospital, in Malta. Data regarding the patients’ past medical history, clinical severity of venous disease, and source and route of incompetency was collected through clinical and ultrasonographic diagnosis. Data collected was recorded in a validated structured data record sheet. Quantitative analysis of the data was performed while recurrent varicose veins were anatomically classified according to the Edinburgh classification. Results: Fifty-three (53) limbs from 46 patients with symptomatic recurrent varicose veins were included. Half of these limbs (52.3%) had skin changes (C4) to the lower limb. The mean time since the initial surgery was 19 years while in 92.3% of patients previous surgery was performed to the groin. The saphenofemoral junction was the most common source of incompetency (69.8%), while the great saphenous vein was the most common route of incompetency (60.4%). A completely intact great saphenous vein (type 1A) was present in 30.2% of limbs while a residual great saphenous vein stump (type1B) was present in 32.1% of limbs. Neovascularisation (type 1C) was identified in 24.5% of limbs. Non-saphenous incompetence (type 2) was identified in 26.4% of limbs mostly due to pelvic incompetence (type 2A). Conclusion: All patients were symptomatic with different severity of venous disease. It was established that in the Maltese sample, technical errors (type 1A and type 1B) were the dominant cause for symptomatic recurrent varicose veins. The high proportion of these types of recurrences emphasizes the importance of meticulous preoperative assessment using duplex ultrasound, and the need of a standardised protocol for the initial treatment of varicose veins. This will eventually reduce the need for re treatment in a substantial amount of patients and thus reduce the high levels of morbidity associated with chronic venous disease.