Chapter 22: Ambulatory Phlebectomy

INTRODUCTION AND HISTORY

This safe, aesthetic, and effective operative technique developed by dermatologists enables the physician to remove nearly any incompetent vein after saphenofemoral and saphenopopliteal reflux has been eliminated by endovenous ablation. The saphenofemoral junction (SFJ) and saphenopopliteal junction (SPJ) should never be treated by simple phlebectomy but require endovenous ablation. Large truncal veins can be removed by this method, together with their major tributaries, perforators, and reticular veins, including small reticular veins that supply annoying telangiectasias. A sharp phlebectomy hook enables the extraction of veins through skin incisions or needle punctures as small as 1 mm. A vein that has been removed by this method is gone permanently. The small size of the skin punctures usually results in minimal or no scar. In comparison with sclerotherapy, surgical extraction avoids the risks of intra-arterial injection, extravasation skin necrosis, and residual hyperpigmentation.

The discovery of foam sclerotherapy, however, has greatly reduced the need for ambulatory phlebectomy (AP).

Phlebectomy, first described by Cornelius Celsus (25 BC–45 AD), has been performed since ancient times. Phlebectomy hooks were in regular use as early as 1545, as illustrated in the Textbook of Surgery of W.H. Ryff, published in that year.¹ Phlebectomy was forgotten during the Middle Ages, but the technique was later reinvented and (with later research) rediscovered in 1956 by Dr. Robert Muller, a Swiss dermatologic surgeon in private practice in Neuchâtel, Switzerland. Dr. Muller developed his method following modern surgical principles^2,3 and taught it to a great number of disciples.^4–6 A modest man, Muller always attributed the technique to his historic predecessor, calling his operation Celsus’ phlebectomy. In recent years, Muller’s technique has been further refined by a Swiss dermatologist, Dr. Albert-Adrien Ramelet.⁷

INDICATIONS

The goals of AP depend on a patient’s particular clinical situation. Phlebectomy is rarely a definitive treatment that addresses both the root source of reflux and its visible expression, as endovenous ablation by radiofrequency (RF) and laser is required. Often used in conjunction with a definitive method to resolve saphenous reflux, phlebectomy can also be used when a painful varicose vein is removed in a patient unwilling or unable to consider a more extensive treatment. Sometimes, phlebectomy may be used to eradicate a short varicose segment or feeding vein that is responsible for a leg ulcer.^4–8

Most types of primary and secondary varicose veins (truncal, reticular, and perforating) may be removed by AP, except when junctional saphenous incompetence is present. Veins most readily treated by phlebectomy include accessory saphenous veins of the thigh, pudendal veins, reticular varices in the popliteal fold or on the lateral thigh or leg, veins of the ankles, and the dorsal venous network of the foot. When patients do not want to wait for sclerotherapy results after endovenous ablation, AP may be performed on branch varicosities on the same day as endovenous ablation.