What is involved in the vein stripping procedure for varicose veins?

Vein Stripping Procedure for Varicose Veins

Vein stripping is a surgical procedure for varicose veins that has largely been replaced by less invasive endovenous techniques such as radiofrequency ablation and laser therapy, which are now recommended as first-line treatments for symptomatic varicose veins with documented valvular reflux. 1

Procedure Components

The traditional vein stripping procedure involves:

• Surgical removal of the affected vein (typically the great saphenous vein)
• General or spinal anesthesia
• Incisions at the groin and ankle/calf
• Insertion of a stripper tool through the vein
• Physical removal (stripping) of the vein from the body
• Possible additional phlebectomies for branch varicosities
• Closure of incisions with sutures

Modern Treatment Context

Current guidelines from the American College of Radiology and American Academy of Family Physicians recommend:

• Endovenous thermal ablation (radiofrequency or laser) as first-line treatment for saphenous vein incompetence, particularly for vein diameters >4.5mm 1
• Sclerotherapy for smaller veins, spider veins (≤1 mm), and reticular veins (1-3 mm) 1
• Surgical stripping reserved for specific cases where endovenous techniques are not suitable

Post-Procedure Care

After vein stripping or any invasive venous procedure:

• Compression therapy is recommended to improve outcomes 2
  • Pressures >20 mmHg with eccentric pads placed directly over the treated vein provide the greatest reduction in postoperative pain 2
  • Duration of compression therapy should be determined by clinical judgment 2
• Follow-up ultrasound within 1-2 weeks to confirm successful vein closure and rule out deep venous thrombosis 1
• Regular monitoring for treatment effectiveness and disease progression 1

Complications

Potential complications of vein stripping include:

• Minor complications (occur in approximately 17% of patients) 3:

  • Wound complications (hematoma, cellulitis, abscess) in 2.8% of cases 3
  • Minor neurological disturbances (numbness or tingling) in 6.6% of cases 3

• Major complications (occur in approximately 0.8% of patients) 3:

  • Deep venous thrombosis (0.5%) 3
  • Pulmonary embolism (rare) 3
  • Nerve injury leading to foot drop (rare) 3
  • Major vascular injury (very rare) 3

Current Treatment Algorithm

1. Initial Assessment: Duplex Doppler ultrasound to evaluate venous reflux (abnormal reflux defined as retrograde flow exceeding 500 milliseconds) 1

2. Treatment Selection Based on Vein Characteristics:

   • For saphenous veins >4.5mm with reflux: Endovenous thermal ablation (radiofrequency or laser) preferred over stripping 1
   • For smaller veins (1-3 mm): Sclerotherapy 1
   • For spider veins (≤1 mm): Sclerotherapy 1

3. Special Considerations:

   • For patients with venous leg ulcers: Compression therapy is strongly recommended to increase healing rate and decrease recurrence risk 2
   • For patients with mixed arterial and venous disease: Limit compression to those with ankle-brachial index >0.5 or absolute ankle pressure >60 mmHg 2

Evidence Quality and Evolution of Treatment

The Society for Vascular Surgery, American Venous Forum, and American Vein and Lymphatic Society have updated their guidelines to reflect the evolution from traditional stripping to endovenous techniques 4. While vein stripping was once considered the "gold standard" for treating primary long saphenous veins 5, current evidence suggests endovenous laser therapy and radiofrequency ablation are as safe and effective as surgery, with shorter recovery times 5, 4.

The choice of procedure should be guided by the specific venous anatomy, extent of disease, and patient factors, with the understanding that no single treatment is universally appropriate for all varicose veins 5.