Neovascularization and recurrent varicose veins: more histologic and ultrasound evidence

BACKGROUND: The recurrence of varicose veins is a common and costly consequence of varicose vein surgery. Despite the long history and vast experience of varicose vein surgery, the exact cause of recurrence is still unknown. This study aims to investigate the cause of recurrence further by correlating findings from duplex ultrasound scans, resin casts, and histologic investigation at the recurrence of the saphenofemoral junction. In particular, frequency and neovascularization are evaluated. METHOD: Forty-nine saphenofemoral junctions (SFJs) from 42 patients who presented for re-operation on their varicose veins were examined with duplex ultrasound and physiologic air plethysmography tests before surgery. All patients had reflux at the groin for which surgery was carried out. Specimens taken during surgery were sectioned and stained for conventional histology and immunohistology, and 5 specimens were infused with resin to form a cast of the venous vasculature. RESULTS: All but 3 re-operation specimens (94%) showed multiple vessels at the stump site of the previous SFJ ligation. Neovascular channels of variable size, number, and tortuosity accounted for the ultrasound appearances and reflux to recurrent varicosities in the vast majority of specimens. These new vessels connected to the common femoral vein at the site of the previous SFJ. In 2 incompetent junctions without femoral vein involvement, while small vessels were seen surrounding the femoral stump scar, ultrasound and histology confirmed both neovascular and residual (enlarged collateral) connections from epigastric and pudendal vessels into the thigh. CONCLUSION: Neovascularisation is the major cause for ultrasound-confirmed recurrence of reflux in the groin following varicose vein surgery.