1. VARICI RECIDIVE DAL 6% ALL`80% ? REZIDIVVARICOSIS von 6% bis 80% ? RECURRENT VARICOSE VEINS FROM 6% TO 80% ? Ebner H*, JA Ebner** * SVGTCHIR, ** CHIRURGIA VASCOLARE E TORACICA Ospedale Centrale Bolzano

2. authoryearrecurrence rateTime F-up Jones L1996 7 - 65%prolonged Perrin MR200020 - 80%5 – 20y Blomgren L200420 - 60%not mentioned Kostas T200420 - 80%not mentioned Egan B200620 - 70%x – 10y Noppeney T2009 6 - 60%not mentioned Parès JO2010 8 - 80%not mentioned Gad M201220 - 60%5y Recurrence Rates in the Literature Recurrent varicose veins from 6% to 80% ?

3. Recurrence Rates in the Literature Recurrent varicose veins from 6% to 80% ? Jones L 1996

4. Recurrent varicose veins from 6% to 80% ? authoryearpercentageF-up Leu HJ 1968 6,5 % 6,5 % 3y 3y Jeanneret C et al. 1999 24,4 % 6y 6y Fischer R et al. 2000 60,0 % 34y The Incidence depends on Time of F-up

5. Recurrent varicose veins from 6% to 80% ? The Incidence depends on Diagnostic Methods Diagn. Method% Recurrence Questionnaire36% Clinical Examination47% Duplex60% Fischer R et al. Phlebologie 2000;29:17-22 Fischer R: 125 legs after 34 years

6. Recurrent varicose veins from 6% to 80% ? The Incidence depends on Diagnostic Methods Author / / Diagn. Method Years F-up Sympto- matic Clinical examination Duplex Specifi- cations Indication for intervention Jones L 19962y11%43%52% Fischer R 200034y36%47%60%22% Recek C 20004y16%68,5%81,5%GSV stem8,6% Blomgren L 20048y68%86%57%57% groin27% Parès J 20105y?50%65%22,2%

7. Recurrent varicose veins from 6% to 80% ? The Incidence depends on Choosen Parameters: 1) Clinical Examination Hobbs Classification 2: „cure“ :absence of Varicose Veins „improvement“: Varicose Veins < 5mm „failure“: Varicose Veins > 5mm, main trunks or incompetent Perforators Hobbs JT, Arch Surg 1974; 109:793-796, cited by Parès Ann Surg 2010 Hobbs Classification 1: Hobbs JT, Arch Surg 1974 „cure“ :no varices or symptoms „improvement“: minor residual varices ± symptoms „failure“: no improvment or worsening of varices or symptoms compared to preoperative findings

8. Recurrent varicose veins from 6% to 80% ? The Incidence depends on Choosen Parameters: 1) Clinical Examination Hobbs JT, Lancet 1978; 27:1149, cited by Carandina Eur J Vasc Endovasc Surg 2007 Hobbs Classification 3: Class A: no visible and palpable varicose veins Class B: a few visible and palpable v.veins < 5mm Class C: remaining or newly formed VV > 5 mm Class D: incompetent main trunks and perforator

9. Recurrent varicose veins from 6% to 80% ? The Incidence depends on Choosen Parameters: 2) Duplex 1 Edinburgh Classification Blomgren L 2004 Reflux on duplex with escape point and change of Compartment Carandina 2007 Fischer`s Classification Fischer R 2000 No precise indications Jones L 1996, Bountouroglou D 06, Faubel 2010, Obliterated, Competent or Reflux Kalodiki E

10. Recurrent varicose veins from 6% to 80% ? The Incidence depends on Choosen Parameters: 2) Duplex 2 Vvein diameter ≥ 3mm Hartmann 2006, Jones 1996, Faubel 2010, van Rij 2004, 4mm Blomgren 2004, ≥ 5mm Carandina 2007, Frings 1999, Parès 2010, Zamboni 2010 Reflux > 0,5 sec Bountouroglou D 2006, Disselhoff 2011, Escribano 2003, + 7 > 1,0 sec Carradice 2011, no value Fischer 2000, Carandina 2007, Faubel 2010, Parès 2010 Clinical Significance Perrin „Consensus“ 2000,

11. Recurrent varicose veins from 6% to 80% ? The Incidence depends on Performed Treatment Therapy % Recurrence Years of F-up authors No SFJ ligature82%3 Zamboni, SFJ alone43%,36%2,10 Jones,Belcaro, SFJ + stripping AK20%,47%,25%,8%1,5,2,2 Carradice,Faubel,Jones,Mooij, SFJ + stripping BK35%5, Kalodiki, SFJ + strip + perfor.60%,48%,34,5 Fischer,Parès, CHIVA87%,31%,18,5%3, Escribano,Parès,Carandina ASVAL/ESECnot found Not found Sclerotherapy ± Foam35%,65%,39%2,6,5 Shadid,Hobbs,Kalodiki Endovasc. Laser4%,38%,25%,44%1,5,2,10 Carradice,Disselhoff,Mooij,Belcaro Endovasc. Termal49%,5 Disselhoff,

12. Recurrent varicose veins from 6% to 80% ? The Incidence depends on Definition Recurrent Varices = Varici Recidive Residual Varices What is „Recurrence“ in Surgery meaning? Return of the same pathology operated on earlier What is „Recurrence“ in Flebology meaning? Presence of varicose veins in a lower limb previously operated on for varices …… and varicose veins still present after the operation? Residual Varices …… and varicose veins in other sides but the operated one? Recurrent TRUE Perrin M, consensus document 2000

13. Recurrent varicose veins from 6% to 80% ? The Incidence depends on Criterion some authors Only clinical Hobbs, Royle, Parès, Rass Clinical and Duplex Faubel and 12 authors more Clinical or Duplex Carandina, Carradice, Blomgren Duplex Fischer, Hofer, Kostas Duplex and Questionaire Bountouroglou, Darwood, Disselhoff Duplex and amb.ven.press. Belcaro 1, Belcaro 2 Duplex and Symptomatic Shadid Assessment for recurrences

14. Recurrent varicose veins from 6% to 80% ? Indication for Reintervention ? Author / / Diagn. Method Years F-up Sympto- matic Clinical examination Duplex Specifi- cations Indication for intervention Jones L 19962y11%43%52%-- Fischer R 200034y36%47%60%22% Recek C 20004y16%68,5%81,5%GSV stem8,6% Blomgren L 20048y68%86%57%57% groin27% Parès J 20105y?50%65%22,2%

15. Recurrent varicose veins from 6% to 80% ? The Incidence depends on % of Patients Lost Y F-up % patients lost in F-up 0,40 - 10, 0, 15, 45 2 - 59, 10, 10, 39, 9, X, 0, 4, 16, 29, 37, 46, 6 - 100, 60, X, X, 11, 17, 14 - 34X, 87

16. Recurrent varicose veins from 6% to 80% ? SUMMARY Recurrence rates depend on Time of Follow up Diagnostic Methods Choosen Parameters Performed Treatment Type of Recurrence Assessment for Recurrences Percentage of Patients controlled

17. CONCLUSIONS Recurrent varicose veins from 6% to 80% ? Dealing with a bare recurrence rate of varicose veins from 6% to 80% is not correct, neither for papers nor for lectures Every recurrence rate has to be supplemented by clear data concerning at least the mentioned variables