1. Lowest traumatism Binocular loupes  3.5 Without electric scalpel Surgicalprinciples Horizontal incision Skin - Aponevrosis

2. ANAESTHESIA 1.General 2.Spinal (homolateral) 3.Sciatic bloc P <.001 Ambulatory VLOKA JD et al. J Clin Anesth 1997;9:618-22 VasoplegiaNeurologique risk +

3. ANAESTHESIA Local Neurological risks

4. Un-crossing under the sciatic nerve Extraction of the vein

5. Inverseintra-dermicsutureBiosyn® Residual stump

6. Double elastic stocking Classe II Cotton wool dressing Biflex bandage n°16 Great saphenous Short saphenous

7. Creton D presented at EVF 2001 Roma Phlebology 2002 ;16 : 93-7 Creton D Phlebology 2002 ;16 : 93-7 Surgery for recurrent saphenofemoral incompetence using ePTFE patch « long-term outcome » 100 patients -119 legs Follow up  5 ans

8. No varices Diffuse varices : no reflux Varices : Varices :Perforators Popliteal fossa ThighCalf Newneovascularization in the groin New neovascularization in the groin 28% 45% 23%4% B1 B2 B0 A Failure

9. Refluxing inguinal vein without connection to the femoral vein Near the femoral vein

10. EARNSHAW n =15 1 an 40 % CRETON n =119 5-6 ans 4.2 % Re-surgery for recurrence without patch Re-surgery for recurrence with patch DE MAESSNER n=14 1 an 21 % DE MAESSNER n=11 4.6 ans 63 % ???? Frequency of re-neovascularization after re-do for recurrence No dissection No resection in the groin

11. ! Echosclerosis Suppress the tank Minimal dissection Stop the leak Complete ablation of varicose veins Ablation of insufficient trunk Conclusion GSV: 1 3 2

12. Randomized studies with and without patch must be done to separate the role of : must be done to separate the role of : 1) No dissection/resection in the groin 2) Patch 3) Complete ablation of varicose veins In this good results In this good results

13. 24 Legs CRETON D. Phlébologie 2000;53:419-24 Surgical treatment of the recurrence in popliteal fossa « Short term results » « Short term results » Premedication 0 Local anaesthesia Lilocaïn 1% 35 ml Midazolan - Hypnovel ® 2 ml Alfentanyl - Rapifen ® 0.5 ml

14. Hospitalisation Day surgery……….19 24 hours…………...5 Distance of their home to the center

15. 138212016151312 Days Sick leave 44%

16. Complication and morbidity (24) § failure in ablation 1 (double Perf Popl Fossa) (double Perf Popl Fossa) § neurologic injury 1 (posterior cutaneous nerve) (posterior cutaneous nerve)

17. Suture of the posterior cutaneous nerve Tinel (new growth) J + 6 months good result Patient’s acute pain during the dissection ! = accidental section of the posterior cutaneous nerve

18. Complications and bad results (15) Œdemas 7 Injury of fibular sciatic nerve 1 Hypertrophic vertical scars 4 LUCERTINI G et al. Minerva Cardioangiol 1998;46:91-5 « General Anaesthesia »

19. Conclusion SSV: Anatomical situation of the incompetent SPJ is favourable to surgery Provided that!!! Provided that !!! Impossible to avoid x% of recurrences PoplitealFossaVein Preoperative duplex US Specific problem of the deep vein pressures between calf and thigh Systolic reflux !!!!! 23% Local Anesthesia Atraumatic

20. Conclusions Local Anesth (Re-do SSV) 100% Loco-regional Anesth (Re-do GSV) 100% Ambulatory 90% Complications  0

21. Conclusion : which treatment ? Surgery can do everything ! Atraumatic Local anaesthesia Echo-guided failures GSV 4% SSV ?% Perf popliteal fossa ?%

22. Perforator Popliteal fossaPerforator Popliteal fossa InguinalInguinalneovascularization LymphoganglionicLymphoganglionicveins Echo-guided sclerotherapyWhich treatment ?

23. Conclusions Recurrence risks SPJ less controled than SFJ Recurrence SPJ Major role of the Deep Vein Pressures ? Recurrence SFJ Major role of the Residual Varicose Veins ? ?