The Traditional Stripping

Truncal Varicose Veins:
Principals of care. (Click to enlarge)

To achieve the  best therapeutic result, any treatment modality for varicose veins has to follow three major steps. Step 1. The method has to completely close/obliterate/stop leakage of blood originating at the level of the escape point/junction usually placed in the groin or behind the knee. Step 2. The method has to also stop (remove or close) the axial vein trunk (located in the inner aspect of the thigh or hind side of the calf)  being the conduit enabling  the downhill/reversed pattern of flow ("reflux"), originated at the level of the escape point, thus permitting large volumes of blood to spill/flood the branches/tributaries of the the axial vein causing them to distend/bulge. Step 3. The method lastly,  should also take care of the distended and bulging tributaries either removing or closing them, if just possible, in the same session. (See drawing).

The over 100 years old traditional and by now outdated traumatic stripping is completely an American procedure unfortunately still practiced by some surgeons who have not kept up with times. Please do not misunderstand, from the results point of view, it  is still a good procedure perfectly controlling  Step 1, Step 2 as well as Step 3 needed for long lasting results. The procedure is outdated  because it was excessive, very traumatic and also not cost efficient. Therefore,  nowadays, in the era of minimally invasive (keyhole) procedures, its place is only in the medical/surgical history books.

The over 100 years old traditional and by now outdated traumatic stripping is completely an American procedure unfortunately still practiced by some surgeons who have not kept up with times. Please do not misunderstand, from the results point of view, it  is still a good procedure perfectly controlling  Step 1Step 2 as well as Step 3 needed for long lasting results. The procedure is outdated  because it was excessive, very traumatic and also not cost efficient. Therefore,  nowadays, in the era of minimally invasive (keyhole) procedures, its place is only in the medical/surgical history books.

The procedure took care of the refluxing incompetent junction, the escape point (in the groin or behind the knee) by ligating it through an open approach (Step 1). The old stripper consisted of a flexible wire was then threaded through the entire length of axial vein trunk from groin to ankle (in case of involvement of the long saphenous vein) or from behind the knee and ankle (in case of short saphenous vein involvement) where - through a second skin opening- the stripper was removed. At this level a thumb size stripper head was attached and the vein tied to it. The wire was pulled upward traveling beneath the skin and towards the groin incision or behind the knee incision bringing with it - all bunched up - the entire length of the vein trunk (Step 2) . This thumb size stripper head traveling form the ankle to groin (or behind the knee) just under the skin, ripped the tissues apart and was the reason for the excessive trauma associated with the procedure (Fig. 7). Insult to injury, the varicose tributaries were removed (Step 3) through generous skin incisions which just enhanced the trauma and were responsible for ugly scars sometimes left for life (Fig. 8).

Since ultrasound examination arrived only in the seventies, up to that point, the whole procedure was done blindly thus the entire length of axial vein was removed. Today’s Doppler ultrasonography / duplex imaging permits to individually tailor the procedure and remove only the segment harboring the reversed pattern of flow existing in the axial vein.

While well performed the results were acceptable, this over-kill traditional and traumatic stripping surgery was  cost inefficient as it had to be performed in a hospital setting under general or spinal/epidural anesthesia followed by weeks of convalescence and loss of income.

Fig. 7 Traumatic stripping (Click to enlarge

Fig 8. Excessive scarring (Click to enlarge)

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What do I do for a skin injury received after Sclerotherapy?

 

            I have seen skin injuries after sclerotherapy but usually, very small ones 2-3 mm in diameter but larger than that should not happen! I do not know what size vein(s) have been injected and where the ”skin burn” is localized, hope not in the ankle area where the healing will be much slower. You must have been possibly injected with a too high concentration and the high volume of the sclerosing agent and also possibly not injected properly into the vein but rater in the skin and tissues along the vein! Occasionally, there are open communications between veins and arteries and the possibility does exist that the sclerosing agent while properly injected in the vein crossed into a small artery and caused severe tissue damage (necrosis) responsible for the damage and thus skin ulceration.

Unfortunately, there is not much one can do as eventually all will heal but it will take a few months. Most probably a scar for life will remind you of the “experience”.

            The injured area should be kept clean and covered with dry gauze to prevent any possibility of infection. If the area is by now clean namely not infected one should discuss with the practitioner the possibility of applying a colloid dressing called Duoderm. Compression stocking the knee is mandatory to prevent swelling which is the biggest enemy of any wound healing. Whenever just possible one should elevate the leg about the level of the heart; this should also reduce swelling by gravitational drainage. Any creams you may want to apply should never cover the ulcerated skin, just beyond its margins. In conclusion, be patient, it will go away but very slowly. How it is in Spanish: “Con paciencia se gana il cielo” or “Heaven is won with patience."