Histomorphologic classification of recurrent saphenofemoral reflux

AbstractObjectiveThe purpose of this study was to determine the apparent mechanisms of recurrent saphenofemoral junction (SFJ) reflux on the basis of the histologic features of intentionally sampled specimens from repeat operations in groins with symptomatic reflux after SFJ ligation and great saphenous vein (GSV) stripping.Patients and methodsNinety-one samples obtained at repeat operation in patients with symptomatic recurrent groin reflux were evaluated histologically, including the number of venous lumens, the structure of the venous wall, and the surrounding tissue. All repeat operation specimens were obtained in our Department of Vascular Surgery; the original operations in our patients (age 56 ± 11 years) had been performed in different centers and private practices 12.1 ± 8.1 years previously.ResultsSingle-channel recurrence was observed in 63 groins. In 62 the vein wall structure was complex; and 18 demonstrated venous valves. These vessels could be classified as residual stumps of the GSV. Just one single-channel recurrent vessel lined with endothelium and surrounded by scar tissue was detected, and was judged to be neovascular. Multichannel recurrent vessels were found in 28 groins. Twenty-three of these were thin-walled tortuous vessels embedded in scar tissue, and were interpreted as neovascular; 4 were multiple vessels surrounded by fatty tissue and were classified as venule hypertrophy; and 1 was a lymph node that contained numerous channels, and was attributed to lymphovenous connections.ConclusionOriginal misidentification of the SFJ, as evidenced by an identifiable GSV stump with appropriate histologic features, characterized 68% (62 of 91) of these symptomatic groins. Neovascularity, marked by multiple irregular channels with an incomplete wall structure, was observed in 26% of the groins (24 of 91), accounting for 94% of the recurrent vessels. The findings at repeat operation, supported by analysis of histologic tissue sections, imply that better supervision and training or case concentration in centers of excellence should be more effective in decreasing the incidence of recurrent SFJ reflux after SFJ ligation and GSV stripping than putative operative maneuvers directed at reducing neovascularization