According to our experience there is not any significant difference in outcomes (rate of complications, rate of recurrence, level of patient satisfaction, QoL) between surgery for uncomplicated varicose veins and superficial thrombophlebitis. Moreover, this approach seems to be more cost-effective comparing with one month anticoagulation with LMWH or fondaparinux, followed by elective surgery or saphenous ablation.
High ligation and stripping of Superficial veins is an option in those patients only who are not having associated deep vein thromboses( either masked or overt). However results of surgical intervention ain acute setting are not superior to medical management.Besides there are chances of inducing deep veinous thromboses by the surgicalcintervention.
Thank you Dr. Mohd Akbar Bhat! Of course my question refers to the cases NOT associated with DVT. I don't know any contemporary controlled studies comparing medical treatment with surgery in case of SVT. I'm agree, that theoretically patients with SVT are in increased risk of postoperative DVT (although not proven scientifically), but this problem can be solved by prophylactic administration of LMWH - a standard approach in our clinic. The problem is (to my opinion) that after medical treatment of SVT patient still remain with varicose veins and require (at lest in a part of cases) further treatment, most typically - invasive (surgery, thermal/chemical ablation, phlebectomy ect). Why do not to solve both problems - SVT and varicose veins simultaneously?
There are indeed no studies to answer your question. However, I would rather be in favour of initial conservative treatment with LMWH or Fondaparinux for at least 4 weeks and mobilisation. In a second stage you can evaluate what you still need to do (sometimes the saphenous trunk remains obliterated and the varicose veins are 'gone' as if you would have treated the patient with an endovenous ablation). Operating in the acute setting may result in more morbidity, in particular in case of important inflammatory reaction around the superficial vein thrombosis (SVT), and postoperative LMWH prophylaxis is mandatory.
Some colleagues also propose to endovenously treat the trunk at the moment of SVT. I personally have no experience with this.
Of utmost importance, in case of SVT, is to exclude concommitant DVT, which may be present in as much as 25 % of cases. So duplex ultrasound evaluation is mandatory to evaluate the real extent of the SVT and to exclude DVT.
Thank you Dr. De Maeseneer for your answer! Your expert opinion is very important! I'm completely agree with your approach, because it is less invasive and with proven efficacy. Unfortunately, our patients usually prefer to be supposed to surgery because it is completely covered by medical insurance but medical treatment - is not. If surgery is performed during the first week of SVT, the stripping of GSV is technically not difficult and stab thrombectomy from tributaries results in fast decrease of inflammatory reaction.
Dear Dr.Casian, first of all, it is hardly possible to diagnose venous insufficiency in thrombophlebitic veins, as the lumen is filled with the inflammation! An obliterated lumen is unable to be evaluated for sufficiency! Apart from this, thrombophlebitis is an inflammation having systemic extend as well as local effects. An operation over an inflammation (or rarely a possible superposed infection) is meaningless. As Dr.De Maeseneer explained in details, medical therapy should be conducted first. A need for operation should be re-evaluated after the recovery. Besides, it can also be impossible for you to push the stripper forward through the thrombophlebitic saphenous vein!
I want to thank all colleagues for their high-quality answers. I completely support the "conservative first" approach for SVT. I'm just looking for more additional opinions and arguments to use these in discussion with proponents of more aggressive "emergency surgery" approach which still dramatically dominate in my country.