Open and endovenous treatment of recurrent saphenous vein incompetence

Background: The management of saphenofemoral and saphenopopliteal incompetence is complex. The complication rates are high and redo treatment is often unavoidable. Preventive steps and selection of the best treatment method are also very important. Objective: Are there effective measures for prevention of recurrent saphenofemoral or saphenopopliteal incompetence? What are the advantages and disadvantages for the treatment procedures? Which recommendations are given in current guidelines and clinical trials? Material and methods: This review article is based on a systematic literature search in PubMed and currently available guidelines dealing with the prevention and management of recurrent saphenofemoral or saphenopopliteal incompetence. Results: The preventive measures for saphenofemoral interventions include flush saphenofemoral ligation, preferably combined with a barrier technique for open surgery or laser crossectomy including treatment of an anterior accessory saphenous vein when present, using the endovenous thermal ablation procedure (EVTA). Evidence-based data on preventive measures during saphenopopliteal interventions do not exist. Open surgical treatment and ultrasound-guided foam sclerotherapy (UGSS) are in principal equally suitable for use with all forms of recurrent varicose veins. The EVTA procedures show anatomical limitations in the application. The recommendations of the international guidelines suggest the use of minimally invasive interventions (EVTA, UGSS, phlebectomy) for the treatment of inguinal and popliteal saphenous vein recurrences. Conclusion: Minimally invasive interventions are regarded as being more favorable to treat groin or popliteal fossa recurrence, although evidence from randomized controlled studies is lacking. Therefore, the anatomical conditions, patient preferences and expertise of the surgeon should also be taken into account for selection of the most suitable treatment. No systematic investigations on the effectiveness of popliteal saphenous vein revision are available. More controlled prospective studies are necessary to illuminate this complex topic.