[125 reinterventions for recurrent popliteal varicose veins after excision of the short saphenous vein. Anatomical and physiological hypotheses of the mechanism of recurrence].J Mal Vasc. 1999 Feb; 24(1):30-6.JM
Recurrence of popliteal varicose veins has long been attributed to insufficient excision of an incompetent short saphenous vein. Indeed, recurrence is still frequent after surgery of the short saphenous. In order to assess the risk of insufficient excision and study the mechanism of recurrence, we reviewed 125 popliteal procedures for recurrence after excision of an incompetent short saphenous vein. Among this series, 48 were personal procedures and among these, 43 had been performed without preoperative ultrasound explorations prior to 1991. Recurrences were classified into five categories (table I) according to the anatomic presentation at reoperation. Type 1) 17 patients had an intact short saphenous (13.6%) with either an inadequate incision or a simple recanalized suture. Type 2) 53 patients had a long stump (42.4%) with new superficial varicose communications. Type 3) 4 patients had a small residual and incompetent short saphenous trunk (3.2%), 20 patients had both a long stump and an incompetent residual trunk (16%). Type 4) 29 patients had incompetent popliteal perforating veins (23.2%). Type 5) 2 patients developed recurrence on a new varicose communication which followed the posterior nerves of the thigh. Among our personal series, 43 reoperations for recurrence were performed without preoperative duplex Doppler exploration. Among them, excision was insufficient in 38 (table II). The 5 patients reoperated after preoperative ultrasound exploration had a popliteal perforating vein. Recurrence with a popliteal perforator was significantly more frequent in men than in women (table III). The delay to reoperation for popliteal recurrence after surgery of the short saphenous (50% at 6 years) was significantly shorter than the delay to reoperation for inguinal recurrence after surgery of the greater saphenous (50% at 12 years) (table V). Insufficient excision was observed in 75.2% of the cases, but 23.2% of the recurrences were due to the development of an incompetent popliteal perforating veins. These perforating veins were residual stumps of the short saphenous with complex pathways, unrecognized perforating veins associated with the short saphenous at the first operation, or a new popliteal incompetence. Ces perforantes de la fosse poplitée pourraient être des moignons résiduels de petites saphènes à trajet complexe, des perforantes méconnues associées à la petite saphène developing in several perforating vessels described in the popliteal fossa. The lack of preoperative ultrasound data made it difficult to interpret these recurrences. The development of perforating veins in the popliteal fossa is a type of recurrence which is probably the expression of particular hemodynamic phenomena in the popliteal venous circulation. These phenomena probably involve the flexion of the popliteal vein, the contraction of the calf muscles, and also popliteal valvular incompetence frequently demonstrated in patients who develop short saphenous vein insufficiency.