Long-term efficacy of inguinal reoperation for recurrent saphenofemoral incompetence

Abstract

Objective

Recurrence originating from the saphenofemoral junction (SFJ) after an open surgical approach to or endovenous ablation of the great saphenous vein frequently occurs. The optimal treatment for a saphenofemoral recurrence remains a subject of debate. Currently, open redo surgery is becoming less common. This study analyzes the long-term effectiveness of saphenofemoral redo surgery following the principles of a modern surgical approach.

Methods

Patients who underwent saphenofemoral reoperation in 2015 and 2016 were identified retrospectively and invited to participate in a prospective follow-up examination. Redo surgery was performed under general and additional tumescent local anesthesia as inpatient treatment and included flush religation of the SFJ , stump suture, cauterization of the free endothelium, and removal of neovascularization. The following objectives were analyzed: Duplex ultrasound-detectable recurrent reflux at the SFJ, clinical recurrence according to Recurrent Varices After Surgery classification, disease severity and quality of life using standardized protocols (Revised Venous Clinical Severity Score, Homburg Varicose Vein Severity Score, Chronic Venous Insufficiency Questionnaire), and patient-reported satisfaction.

Results

A total of 84 patients (94 treated legs) were included with a median follow-up of 6.6 years. Five of the 94 legs (5.3%) had a duplex-detected reflux in the groin, with only 1 leg (1.1%) showing grade 2 neovascularization (vessel diameter of ≥4 mm). According to Recurrent Varices After Surgery classification, 2 of the 94 legs (2.1%) revealed clinical recurrence arising from the inguinal region. Disease severity at follow-up was low with a mean Revised Venous Clinical Severity Score_(0-30) of 1.8 ± 1.8 and a mean Homburg Varicose Vein Severity Score _(0-33) of 3.9 ± 3.4. According to the Clinical, Etiological, Anatomical and Pathological classification, the stage of disease improved significantly (P < .001) in 55% of the treated legs. The procedure was well-accepted by patients: 94.1% indicated they would undergo saphenofemoral reoperation again if medically advised.

Conclusions

This study demonstrates that saphenofemoral redo surgery is very effective when certain technical strategies are implemented to prevent neovascularization. Long-term treatment results may be superior to minimally invasive procedures, indicating the need for comparative studies. Until such studies are available, open redo surgery should continue to be considered as an appropriate treatment option for saphenofemoral recurrence.

Article Highlights.

• •Type of Research: Single-center prospective observational cross-sectional (follow-up) study
• •Key Findings: Eighty-four patients (94 legs) treated by open redo surgery for recurrent saphenofemoral incompetence were included in this study. At 6.6 years after surgery, the recurrence rate was 5.3% (duplex recurrence) and 2.1% (clinical groin recurrence), respectively. Overall, 94.1% of the patients indicate they would undergo saphenofemoral reoperation again if medically advised.
• •Take Home Message: Saphenofemoral redo surgery using barrier techniques to avoid neovascularization is an effective treatment option with excellent long-term outcomes and high patient acceptance.

Saphenofemoral recurrence can negatively affect the patient's quality of life (QoL), and redo surgery may offer improvement, at least in the short term.¹ Despite of its clinical importance, there is poor evidence on the long-term outcome of various treatments for recurrent varicose veins and comparative studies are largely missing. Provided that endovenous therapy is possible, current guidelines recommend against surgical reoperation of the groin owing to its potentially less favorable side effect profile.² However, randomized controlled trials (RCTs) and meta-analyses suggest that surgical treatment of primary great saphenous vein (GSV) incompetence achieves a better long-term outcome as compared with laser ablation, particularly with regard to duplex and clinical recurrence.^3,4 Thus, the best choice of treatment for saphenofemoral recurrence remains a subject of ongoing debate.⁵

Redo surgery presents specific challenges. Particular importance is attached to the prevention of serious complications, such as lymphatic damage resulting in seroma or edema.⁶ As recently demonstrated, surgical redo treatment of saphenofemoral recurrence according to a modified Junod technique is a safe procedure, when performed by experienced surgeons and using combined tumescent local anesthesia (TLA) and general anesthesia.⁷ Additionally, long-term outcomes are of particular importance; earlier studies suggest that neovascularization may recur in a substantial proportion of patients after open redo surgery at the saphenofemoral junction (SFJ).^8,9

According to the UIP Consensus, “neovascularization” describes the presence of new vessels at the site of the previous saphenofemoral or saphenopopliteal junction ligation without residual stump neither terminal valve.¹⁰ Major microscopic criteria of neovascularization—the presence of scar tissue associated with an irregular vascular network, lack of vein valves, and absence of intramural nerve fibers—have been described in several publications.11, 12, 13 A key factor in the pathogenesis of neovascularization appears to be the exposure of free endothelium to the wound environment.¹⁴ Therefore, various barrier techniques have been proposed to reduce the risk of saphenofemoral re-recurrence, such as silicone or polytetrafluoroethylene (PTFE) patch saphenoplasty, leading to inconsistent results.^9,15,16 Neovascularization may still develop despite technically adequate barrier surgery, as shown by van Rij et al,¹⁷ who demonstrated, by duplex ultrasound and histological examination, that neovascular channels can bypass a PTFE patch. An effective and technically straightforward barrier method introduced by our group for saphenofemoral redo surgery involves the stump suture technique described by Frings et al^18,19 combined with electrocauterization of free endothelium and the use of TLA. Short-term outcomes of this approach were reported recently, showing a neovascularization rate of 5% on duplex ultrasound examination after a median follow-up of 18 months.¹⁹ Because the long-term results of this surgical strategy have not yet been examined, this study aimed to evaluate its effect on duplex and clinical re-recurrence after reoperation for recurrent saphenofemoral incompetence.

Methods

This study was conducted in adherence to national guidelines and to the current Declaration of Helsinki. Before commencing the clinical examinations, the research team obtained approval from the local ethics committee (Ärztekammer Nordrhein, ID 2,022,139).

Patients who underwent groin reoperation for saphenofemoral recurrence between January 2015 and December 2016 were identified by an operation report registry of our clinic. An indication for redo surgery was given, if the following findings were present: clinically relevant recurrent varicose veins (Clinical, Etiological, Anatomical, and Pathological [CEAP] C2s), the source of recurrence at the SFJ with a detectable, incompetent connection with the common femoral vein (CFV), and a recurrent vessel diameter of ≥4 mm at the SFJ. The study protocol stipulated that all patients who underwent surgery during this period should be contacted prospectively by phone call and invited to attend a follow-up examination with clinical investigation and duplex ultrasound examination. The following data were gathered from the medical records: age, gender, side of the procedure, CEAP classification for chronic venous disorders,²⁰ number of preceding surgical interventions for saphenofemoral incompetence or recurrence, and duration of the whole surgical intervention.

Surgical procedure

Before surgery, duplex ultrasound examination and mapping of clinically visible and palpable varicose veins, as well as residual segments of persisting great and anterior saphenous veins, were performed by the surgeon.

Patients were operated under general anesthesia combined with additional TLA as inpatient treatment. The TLA solution consisted of sodium bicarbonate-buffered (0.084%) prilocaine (0.07%) and epinephrine (0.0001%) in isotonic saline. All patients received a single-dose intravenous antibiotic prophylaxis with either cefazolin (2000 mg) or, in case of ß-lactam allergy, clindamycin (600 mg).

The surgical technique has been recently described in detail by our group.¹⁹ In short, reoperations were performed following the modified Junod technique⁷ with a groin incision made roughly 1 cm above and parallel to the previous scar. Dissection proceeded through subcutaneous tissue toward the medial side of the common femoral artery so that the scar tissue and the superficial varicosities within it can be bypassed. After longitudinal incision the fascia lata, preparation continued over the ventral aspect of the CFV in direction to the saphenofemoral stump. Once the periadvential tissue was dissected from the SFJ, the saphenofemoral stump could be looped with an Overholt clamp and flush ligated twofold with a braided nonabsorbable polyester suture (thread thickness 0). When cicatrization was less intensive, a more ventral approach directly to the SFJ was chosen. The flush ligation of the SFJ was followed by dissection of the stump distally, making an invaginating stump suture possible. This barrier technique was performed using a braided polyglactin 910 suture (thread thickness 3-0) whenever possible.¹⁹

After religation of the SFJ, overlying varicosities were removed as far as possible apart from the stump and, to prevent neovascularization, free endothelium was coagulated using bipolar electrocautery, according to the concept of an “extensive crossectomy” (Fig 1).²¹ Remaining saphenous and/or accessory vein segments were extracted via vein stripping or small stab incisions. Finally, the groin incision was closed, multiple phlebectomies of recurrent varicose veins and ligation or dissection of incompetent perforators were performed if applicable.

Fig 1.

Situs at the end of saphenofemoral reoperation. The stump was ligated twice and flushed at the level of the common femoral vein (CFV) using a braided nonabsorbable polyester suture (thread thickness 0). Free endothelium of the stump was sewn over with a braided polyglactin 910 suture (thread thickness 3-0). Additionally, the free endothelium of the stump and in the wound was destroyed by bipolar electrocautery. After transection of the stump, all neovascular tissue was resected.

Follow-up examination

At follow-up, patients were issued with a questionnaire consisting of questions about satisfaction with the surgical and cosmetic outcome, current disease-specific complaints according to a specific venous severity score (Homburg Varicose Vein Severity Score [HVVSS]),²² and with a disease-specific QoL questionnaire (Chronic Venous Insufficiency Questionnaire [CIVIQ-2]).²³ Subsequently, patients were examined by standard clinical and duplex procedures according to the International Union of Phlebology consensus document²³ using Siemens Acuson X600, VF 10-5 (Siemens Healthcare), and digital photoplethysmography (Vasolab 5000, ELCAT).

The following main study objectives were recorded.

• •Duplex recurrence, defined as the reappearance of reflux in the groin lasting >0.5 second, detected in vessels with a diameter of ≥2.0 mm. Duplex recurrence was further characterized in terms of its source specifically whether it was connected to the CFV;
• •Clinical recurrence and disease severity, classified according to Recurrent Varices After Surgery (REVAS)²⁴ classification and Revised Venous Clinical Severity Score (rVCSS, Score 0-30)²⁵;
• •Clinical and functional outcome: HVVSS (score 0-33); and
• •Disease-specific QoL: CIVIQ-2 (score 0-100).

All scores used in this analysis (rVCSS, HVVSS, CIVIQ-2, and visual analog scales [VAS]) increase with disease severity or a worse outcome.

Statistical methods

We performed a descriptive analysis of the data by standard measures (mean, standard deviation, median, range). Preoperative and postoperative CEAP-C distribution was compared by χ²e test. Differences of quantitative variables were analysed using Mann-Whitney U test. P values of <.05 were considered significant. Statistical analyses were performed with IBM SPSS Statistics Version 29.0.2.0 (IBM Corporation).

Results

A total of 177 patients underwent an inguinal reoperation for recurrent saphenofemoral incompetence over the study 2 years (2015 and 2016). At the time of follow-up, seven patients had died, with no deaths attributable to the surgical procedure. Despite repeated attempts, 32 patients could not be contacted, leaving 138 eligible for follow-up. Of these, 84 patients (94 legs) agreed to participate, corresponding with a participation rate of 60.9%. Among the 54 patients who declined participation, 4 (7.4%) reported dissatisfaction with the previous operation as their reason. Other reasons provided included comorbid disease (n = 9), considerable distance from the venous center (n = 5), adverse weather conditions (n = 1), and absence of symptoms (n = 1). The remainder (n = 34) did not state any specific reason for refusal.

Before these 94 redo procedures, high ligation and GSV stripping were performed in 79 cases (84.0%), reoperation for saphenofemoral recurrence in 14 cases (14.9%), and endovenous laser ablation in a single case (1.1%). Where documented in the records, the reoperation was performed following the modified Junod technique⁷ in 76% and in 24% a more ventral approach was chosen. The SFJ recurrent vessel had a mean diameter of 7.75 ± 2.45 mm. The median operative time was 70 minutes (range, 40-150 minutes). The median follow-up time was 6.6 years (79 months; range, 67-100 months). Demographic and clinical patient characteristics are summarized in Table I.

Table I.

Patient demographics and clinical characteristics

Characteristic
No. of patients (legs)	84 (94)
Median age preoperative, years (range)	61 (37-77)
Gender (female), n (%)	68 (81)
Side (right), n (%)	53 (56.4)
CEAP, n (%)
C2	83 (88.3)
C3	7 (7.5)
C4	3 (3.2)
C5	1 (1.1)
Recurrence, n (%) first	80 (85.1)
Second	13 (13.8)
Third	1 (1.1)

CEAP, Clinical, Etiological, Anatomical, and Pathological.

Duplex-detected recurrent reflux at the SFJ

A duplex-detected recurrent reflux at the SFJ was identified in 5 of 94 legs (5.3%). A connection to the CFV with reflux arising from the deep vein was found in three legs (3.2%), with a mean vessel diameter of 3.42 ± 0.45 mm (range, 2.90-4.00 mm). In the remaining two cases, refluxing vessels were not connected to the CFV and measured 3.0 mm and 3.6 mm. A residual or recurrent postoperative saphenofemoral stump was not detected in any of the legs.

Clinical recurrence according to REVAS, rVCSS, and therapeutic consideration

Upon clinical examination, varicose veins were observed in 46 of 94 legs, indicating an overall recurrence and disease progression rate of 48.9%. According to the REVAS classification, 4.4% (n = 2) of clinically recurrent varicose veins originated in the groin (nature of source: “same site”), representing 2.1% of all operated legs. Most of the postoperatively developed new varicose veins (n = 44 [95.7%]) were attributed to disease progression resulting from incompetent leg perforators or side branches (nature of source: “different site” accounting for 47.9% of all operated legs. The detailed REVAS data are summarized in Table II.

Table II.

Clinical repeat recurrence characterized by Recurrent Varices After Surgery (REVAS) classification (n = 94 legs)²⁰

Characteristic	No. (%)
Overall REVAS	46 (48.9)
Topography
Groin	1 (2.2)
Thigh	16 (34.8)
Popliteal fossa	10 (21.7)
Lower leg	38 (82.6)
Source of re-recurrence
Not detectable	28 (60.9)
Pelvic	2 (4.4)
SFJ	1 (2.2)
Thigh perforator	2 (4.4)
Saphenopopliteal junction	1 (2.2)
Lower leg perforator	11 (23.9)
Gastrocnemius vein	1 (2.2)
Nature of source
Same site	2 (4.4)
Neovascularization	2 (4.4)
Different site	44 (95.7)
Persistent	2 (4.4)
New	38 (82.6)
Uncertain	4 (8.7)
Contribution from persistent GSV
Not detectable	44 (95.7)
Below knee	1 (2.2)
Small saphenous vein	1 (2.2)
Management of REVAS
Wait-and-see approach	35 (76.1)
Sclerotherapy and/or phlebectomy	10 (21.7)
SSV- surgery	1 (2.2)

GSV, Great saphenous vein; SFJ, saphenofemoral junction; SSV, small saphenous vein.

Multiple selections were applicable for the topic topography resulting in possible percentages of >100%. Nonapplicable items of REVAS were left out.

The mean rVCSS (maximum score severity, 30 points) of the entire cohort (treated legs) was 1.8 ± 1.8, whereas that of patients with clinical recurrence was 2.8 ± 1.9, consistent with the absence of venous ulceration in all patients. The difference between patients with or without clinical recurrence was statistically significant, even when the varicose vein topic was excluded from the score analysis (P = .012).

The mean severity score of recurrent varicose veins, assessed by VAS (on a scale of 1-5, from 1 [minor] to 5 [major]), was 1.26 ± 0.44. Most legs with a clinical recurrence (n = 34 [73.2%]) showed only minor signs of varicose veins (VAS_1-5 = 1), although 12 legs (26.1%) were moderately (VAS_1-5 = 2) affected.

In 23.2% of clinical recurrence (11/46 legs) an additional treatment was advised. This included sclerotherapy in 1 leg (2.2% of all patients with overall REVAS), multiple phlebectomies in 9 cases (19.6%) and surgical treatment of small saphenous vein incompetence in 1 leg (2.2%). No patient required an inguinal reoperation.

Clinical and functional outcome (HVVSS, D-PPG, and CEAP) and QoL (CIVIQ)

We evaluated postoperative signs and symptoms of chronic venous insufficiency using the HVVSS (range, 0 [best] to 33 [worst]). The mean postoperative HVVSS was 3.9 ± 3.4. The mean HVVSS subscore for objective clinical findings was 1.2 ± 1.4, for symptoms (pain, heaviness, swelling and itching) was 1.3 ± 2.2, and for hemodynamic function based on venous refilling time measured by digital photoplethysmography was 1.3 ± 1.1. Normal venous function (t₀ > 25 seconds) was observed in 32 legs (34.0%). The mean postoperative venous refilling time (t₀) was 21.7 ± 11.8 seconds.

The clinical stage of disease (CEAP-C) decreased significantly (P < .001) (Fig 2). Improvement in CEAP-C was observed in 55% of legs (n = 52), 44% (n = 41) remained unchanged, and 1% (n = 1) worsened.

Fig 2.

Distribution of clinical CEAP classes before and after surgery. The improvement of clinical CEAP was significant (P < .001). CEAP, Clinical, Etiological, Anatomical, Pathological.

Disease-specific postoperative QoL was measured using CIVIQ-2, which includes physical, psychological, social, and pain dimensions. Scores range from 0 (best) to 100 (worst). The mean overall postoperative score was 16.4 ± 18.3. The mean subscores were 3.7 ± 4.6 (physical QoL; range, 0-20), 6.7 ± 8.2 (psychological QoL; range, 0-45), 2.3 ± 3.0 (social QoL; range, 0-15), and 3.6 ± 4.3 (pain dimensions; range, 0-20).

Overall satisfaction with the treatment outcome was rated 2.0 ± 1.0 on a VAS of 1 to 6. The cosmetic outcome (VAS of 1-6) was rated 2.2 ± 1.1. Finally, 79 of the 84 patients (94.1%) stated that they would undergo inguinal reoperation for recurrent saphenofemoral incompetence again if medically indicated. Three of the five patients who declined the third operation explained their decision by expressing fear that the varicose veins would always reoccur. Only one of them (1.2% of the 84 patients) mentioned concerns related to the complexity of the procedure and the hospital stay.

Discussion

Recurrent varicose veins are a common problem with both medical and health-economic implications after varicose vein treatment. Reoperation for recurring saphenofemoral incompetence remains a complex but feasible intervention for managing persistent varicose veins.⁷ Despite advances in noninvasive techniques, such as radial laser ablation of stump recurrence, redo surgery is still considered a relevant treatment approach owing to its potential long-term efficacy and ability to address anatomical challenges comprehensively.26, 27, 28

To decrease the risk of recurrence after saphenofemoral surgery, various barrier techniques, considered as critical element of surgical strategy, have been introduced over the past two decades.²⁸ Although studies on primary surgery with inguinal crossectomy demonstrate the effectiveness of certain techniques, such as oversewing the saphenofemoral stump and closure of the cribriform fascia, evidence in the context of redo procedures remains limited and heterogeneous. In a RCT with a small number of patients (n = 34), Gibbs et al⁸ used a reflected flap of the pectineus fascia. At 28 months after surgery, duplex ultrasound examination revealed repeat recurrence from CFV in ≤71% of patients, with no significant difference observed between those with or without a barrier flap.⁸ Similarly, another RCT involving 40 legs found no difference in recurrence rates between patients with and without PTFE patch saphenoplasty.⁹ However, this study reported a notably lower neovascularization rate of 31% after 24 months compared with the aforementioned study. In a prospective, nonrandomized study by de Maeseneer et al,¹⁵ the use of silicone patch saphenoplasty in 68 limbs demonstrated significantly lower duplex and clinical recurrence rates. At 1 and 5 years, grade 2 neovascularization (defined as vessels ≥4 mm in diameter) was observed in just 6% and 9% of the barrier group, respectively, compared with 27% and 45% without the patch.¹⁵ The divergence of these results indicates that the individual surgical technique might have a strong influence on the outcome, with the latter study demonstrating that a duplex recurrence rate of <10% at 5 years after treatment is achievable with redo surgery.

The use of prosthetic barriers may carry an increased risk of infection, sometimes requiring patch removal through a secondary surgical procedure.¹⁵ To mitigate this risk, we used a simpler technique: suturing and cauterizing the GSV stump to avoid contact and interaction of exposed endothelium with the wound environment combined with an extensive re-crossectomy, both methods originally described by Frings et al for primary saphenofemoral surgery.^18,19,21 In a previous study we reported neovascularization in 5% of treated limbs 16.8 months after saphenofemoral redo surgery, with just one case (1%) involving a vessel diameter of ≥4 mm, classified as grade 2 neovascularization.¹⁹ This rate is comparable with or even lower than the outcomes reported by de Maeseneer et al¹⁵ using silicone patch saphenoplasty. In our current study using the same surgical strategy in a subsequent patient cohort, we could demonstrate durable results even after a significantly longer follow-up period of 6.6 years: 5.3% of the treated legs revealed duplex ultrasound-detected saphenofemoral re-recurrence with only one leg (1.1%) showing grade 2 neovascularization.

In addition to our surgical barrier approach, the use of TLA as an essential component of the so-called modern crossectomy,²⁹ may have further contributed to the low neovascularization rates. TLA may facilitate a gentler dissection and a cleaner surgical field in the groin, thereby potentially minimizing the trauma that has been identified as a risk factor for neovascularization.¹⁴

According to the REVAS classification, 46 legs (48.9%) showed minimal to moderate clinical recurrence including disease progression, and only 4.4% of them had a detectable origin in the groin. This outcome is similar to, or even more favorable than, the clinical recurrence rates reported in the before mentioned studies: 12% recurrent thigh varicosities 1 year after silicone patch saphenoplasty¹⁵ and 38% recurrence owing to neovascularization or incompetent superficial upper thigh tributaries 2 years after PTFE patch saphenoplasty.⁹ Therefore it seems that, in a small subset of patients undergoing reoperation for recurrent saphenofemoral incompetence, the development of a clinically relevant neovascularization has to be taken into account. However, in our patient group, subsequent interventions were limited to sclerotherapy and miniphlebectomy, with only one case requiring surgery for small saphenous vein incompetence.

Physician- and patient-reported outcomes, including satisfaction and postoperative QoL, are essential parameters in evaluating the severity of chronic venous disease and the overall success of therapeutic interventions.³⁰ In our cohort, a significant clinical improvement was observed according to the CEAP-C classification. Furthermore, postoperative assessments of disease severity using the HVVSS and CIVIQ-2 revealed outcomes only slightly less favorable as compared with those reported 5 years after endovenous laser ablation or high ligation and stripping for primary varicose veins, respectively.³¹ The slightly higher scores can be explained by the significantly older patient population (median baseline 61 years vs 49 years in RELACS [Randomised study comparing endovenous laser ablation with crossectomy and stripping of the great saphenous vein]) and the longer follow-up period in the current study. Of particular note, 94.1% of patients indicated they would choose the same surgical approach again, highlighting both the perceived benefit and high level of acceptance associated with the procedure.

There is an increasing demand for minimally invasive approaches in the treatment of recurrent varicose veins, including recurrences at the SFJ. These include the use of endovenous techniques and hybrid strategies, such as the combination of ultrasound-guided foam sclerotherapy (UGFS) with phlebectomy for the removal of clinically visible varicosities.² However, the current data on the effectiveness of these various treatment modalities is still limited, and the existing recommendations are largely based on expert consensus and not on high-quality comparative studies.

In contrast with surgical treatment of saphenofemoral recurrence, endovenous thermal ablation (ETA) techniques present anatomical limitations, primarily owing to the lack of viable catheter access routes in many cases.^27,32 Technical feasibility and early anatomical success rates of endovenous laser ablation are reported to be high when a residual truncal segment allows catheter access.²⁶ However, long-term efficacy is unknown, and the procedure is not applicable in neovascularization with small diameter vessels. Furthermore, persistent neovascular channels were still identified in ≤79% at 18 months after treatment, even if a hybrid approach with ETA and UGFS has been performed for saphenofemoral recurrence.³² UGFS, in contrast, is more widely applicable, but less effective for treating stump recurrences compared with its use for treating neovascularization.³³ Both ETA and UGFS may offer certain advantages over open surgery, including shorter treatment times, decreased postoperative pain, fewer complications, and faster recovery. However, when a residual venous stump is present, open surgical revision may be particularly effective, offering a low complication risk and potential advantages in terms of long-term recurrence prevention when compared with other treatment modalities.⁷

This study is subject to several limitations. Primarily, it was conducted at a single center and perioperative data were obtained retrospectively from operative records. Although all eligible patients were contacted for a prospective follow-up, a considerable proportion declined participation. This nonresponse may have introduced a selection bias, potentially affecting the results by either overestimating or underestimating the true outcomes of the investigated variables.

Conclusions

Inguinal reoperation for recurrent saphenofemoral incompetence using the aspects of a modern surgical approach to warrant gentle atraumatic preparation and to avoid endothelium-wound interaction represents an effective therapeutic option appreciated by the patients with a small number of saphenofemoral re-recurrences at 6.6 years after surgery. However, to determine whether the advantages of less invasive modalities outweigh the potentially superior durability of surgical reintervention, long-term RCTs directly comparing these approaches are urgently needed.

Author contributions

Conception and design: ED, SG, HJ, KR

Analysis and interpretation: ED, KR

Data collection: ED, CA

Writing the article: ED, KR

Critical revision of the article: ED, SG, CA, HJ, KR

Final approval of the article: ED, SG, CA, HJ, KR

Statistical analysis: ED, KR

Obtained funding: Not applicable

Overall responsibility: KR

Funding

None.

Disclosures

None.