The treatment of incompetent small saphenous veins (SSV) is challenging, with a higher complication rate due to diverse SSV anatomical variations and a close relation-ship with nerves along the running course. The relationship between SSV and the sural nerve (SN) showed a wide variation between patients; therefore, a meticulous approach is necessary to prevent nerve injury during the procedure. There are no standard clinical practice guidelines for managing SSV; therefore, various procedures exist, even though the treatment options are the same. However, in the literature, there has been much evidence of a method to minimize recurrence and complication rates in managing incompetent SSV.

This study aimed to explore the current practices of the Korean Society for Phlebology members concerning incom-petent SSV and help the composition of the academic program for the management of SSV given this survey’s result.

This study was approved by the institutional review board of the National Health Insurance Service Ilsan Hos-pital (2021-08-018-001). The questionnaire was sent to 291 Korean Society for Phlebology members between January and March 2022. The questionnaire sought information regarding preoperative investigations, preferred treatment, and preferred techniques during surgery or endovenous thermal ablation (ETA). Forty-seven (16%) replies were received.

Forty-seven (16%) of the 291 Korean Society for Phle-bology members contacted completed the survey. Concerning the classification of medical facilities, 34 (72%), four (9%), and four (9%) respondents practiced in private, general, and tertiary hospitals, respectively. Concerning the regional dist-ribution of respondents, 20 (43%), seven (15%), and four (8.5%) were from Seoul, Busan, and Daegu, respectively (Fig. 1). Regarding the respondents’ medical specializations, 28 (60%), 14 (30%), one, and one surveyees practiced general surgery, cardiothoracic surgery, orthopedics, and plastic sur-gery, respectively, and the remaining three were unspecified.

Fig. 1. Regional distribution of institutes.

1) The age distribution of the respondents

Most respondents (16, 34%) were aged 50∼55 years; six (13%), 15 (32%), and one (2%) respondents were aged 45∼50, 40∼45, and <40 years, respectively.

2) Annual number of surgical cases of the SSV treatment

Twenty-three (49%), 13 (28%), 7 (15%), and four (8%) respondents reported handling >50, 25∼50, 10∼25, and <10 cases of SSV annually, respectively. Among the 36 (77%) respondents who performed more than 25 cases annually, 30 were from clinics, constituting 88% of the members from private clinics, and three were from general hospitals and tertiary hospitals, comprising 75% and 33% from general hospitals and tertiary hospitals, respectively.

3) Duplex ultrasound (DUS) investigation before surgery

The survey showed that 46 respondents, constituting 98% of the total number of respondents, performed DUS before the operation, and only one did not. The individual who did not perform DUS used computed tomography (CT) veno-graphy instead and was a cardiothoracic surgeon aged 50∼55 years practicing in a tertiary hospital. Of these 46 respo-ndents, DUS was conducted by 39 (85%) members who were operating surgeons. For the rest respondents, the sonographer examined the DUS in four cases, a nurse examined the DUS in one case, and either a different surgeon with the same specialty or a radiologist examined the DUS in the other cases. The affiliations of the respondents who did not perform DUS as operating surgeons also varied: four members were affiliated with tertiary hospitals, two with private clinics, and one with a general hospital.

4) Preoperative ultrasound-guided mapping of SSV

Forty-three (92%) respondents answered yes to the ques-tionnaire on whether they marked the treatment segment of the SSV under ultrasound guidance before conducting SSV treatment, and four answered no. Members who excluded preoperative marking procedures were affiliated with tertiary and general hospitals.

5) Complications after SSV treatment

Thirty-six (77%) members responded that they encountered complications after SSV, and the rest (23%) reported no complications.

Of those who reported complications, 31 members were affiliated with a doctor’s office comprising 91%. Two and three members from the general and tertiary hospitals, res-pectively, constituted the rest.

Of those who reported no complications, three surveyees were affiliated with private clinics (9%), two with general hospitals (50%), and 6 with tertiary hospitals (67%). Regarding the age range, 61% of the members who encountered complications were above 50 years, and 64% of those who reported no complications were under 45 years.

Regarding the classification of complications, SN injuries constituted 86% of the cases. Three respondents encountered deep vein thrombosis (DVT), and two encountered hematoma.

Eleven members encountered two kinds of complications. Three patients experienced SN injury and DVT, four expe-rienced SN injury and hematoma, two experienced DVT and hematoma, and the remaining two experienced SN injury, DVT, and hematoma.

6) Considerations on selecting treatment options

When treating SSV, 10 members reported implementing the same treatment regimens for all their patients, and the remaining 37 reported varied treatment regimens. Of the 10 members who reported implementing the same treatment for all patients, six were affiliated with private clinics and four with tertiary hospitals. Concerning the preferred treatment options, seven respondents preferred surgical treatments; however, two of these seven members indicated that they had performed high ligation without stripping. The remai-ning three performed ETA only.

Among the respondents who varied treatment methods, 27 (73%) performed ETA and surgical treatments, five performed surgical treatments in combination with VenaSeal^TM, and the other five utilized all three options: ETA, surgical treatments, and VenaSeal^TM.

When deciding on the treatment options, 26 (73%) respo-ndents considered the anatomy of SSV, and seven (19%) considered private health insurance membership. Only one respondent scrutinized both private health insurance mem-bership and the SSV anatomy. The remaining three respondents recommended VenaSealTM treatment for young women and stripping treatment for recurrent cases.

7) Anesthesia methods

Seventeen (40%) members reported spinal anesthesia, 12 (26%) reported both sedation and local anesthesia, five each reported local and spinal anesthesia separately, and three chose both sedation and regional anesthesia. The remaining six reported “one of local, regional, and spinal anesthesia.” Regarding the members from the private clinics, 10 chose local anesthesia and sedation, seven chose spinal anesthesia, and five chose local anesthesia. Regarding members from general and tertiary hospitals, four chose spinal anesthesia, three chose general anesthesia, and two reported both local anesthesia and sedation.

Regarding the types of anesthesia for the ETA procedure, 18 respondents reported local anesthesia and sedation; seven reported local anesthesia, five spinal anesthesia, and four general anesthesia. Regarding members from general and tertiary hospitals, spinal anesthesia, general anesthesia, local anesthesia, and a combination of local anesthesia and sedation were chosen by three, two, two, and two respondents, respe-ctively.

In addition, 20 members indicated their choice of anes-thesia for the ClariVein^TM procedure, including local anesthesia and sedation in 10, local anesthesia in five, general anes-thesia in three, spinal anesthesia in two, and local or spinal anesthesia in one.

8) Patient positioning for surgical procedures

When positioning patients while stripping for SSV, 42 (89%) respondents chose the prone position, and one chose the supine position. When performing the endovenous treat-ment, 38 (81%) respondents chose the prone position, and two chose the supine position.

9) Where to commence treatment whensaphenopopliteal junction (SPJ) present

Twenty-four (57%) respondents predominantly favored “between 1 cm and 3 cm distal to the SPJ as the area for employing high ligation in the presence of SPJ”. Seven opted for “flush ligation at the SPJ.” Six reported ligations at the knee crease level, and five chose ligation between 3 cm and 5 cm distal to the SPJ. The affiliations of members who chose “flush ligation at the SPJ” were three at private clinics, one at a general hospital, and three at tertiary hospitals.

Concerning the catheter tip position when practicing ETA, 28 (74%) members responded that the position should be “between 1 cm and 3 cm distal to the SPJ”, and seven res-ponded, “between 3 cm and 5 cm distal to the SPJ”. Three members placed the tip at the SPJ during the procedure; they were affiliated with private clinics and were over 50 years.

Concerning the positioning of the catheter tip during VenaSeal^TM treatment, the endovenous non-thermal ablation (ENTA), 12 (46%) surveyees reported “between 1 cm and 5 cm distal to the SPJ”, 11 (42%) responded “5 cm distal to the SPJ” and 2 answered, “at knee crease level.” One member from a clinic reported, “at the SPJ.”

10) Where to commence treatment when the SPJ is not present

In the absence of SPJ, 18 (45%) respondents reported that they chose high ligation at the knee crease level, 11 (42.5%) chose high ligation above the knee crease, and five ligated SSV at the highest point of venous reflux.

When performing ETA in the absence of SPJ, 20 (54%) respondents placed the catheter tip above the knee crease, 10 (27%) at the knee crease level, and seven positioned the catheter up to the segment of reflux. Concerning VenaSeal^TM treatment, 15 (71%) members positioned the catheter tip above the knee crease, four placed it at the knee crease level, and two set the catheter up to the segment of reflux.

11) The extent of SSV treatment

The response rate to the range of surgical procedures is in descending order: 15 (37.5%) out of 40 respondents reported “to a mid-calf level” as the extent of the treatment. Eight chose “within 5 cm in length,” another eight “maxi-mum length after reviewing its relation to the SN on DUS,” and two chose high ligation only. The rest reported “to distal 2/3 of a calf,” “to an ankle,” “to an entire section of the dilated segment, “sections where reflux was present,” and “up to where the tributary varicose vein was connected.”

Similarly, when applying ETA, 14 (35%) respondents reported the “mid-calf level” to be the optimum length, and 11 (27.5%) reported that they ablate the “maximum length of incompetent segments after extrapolating its relation to the SN under ultrasound guidance.” The responses from the rest varied; these included “distal calf level,” “to where the diameter of the SSV shrinks,” “the part where SSV split, “until perforating vein,” “segments where reflux was present,” and “segments including where the tributary varicose vein was connected.”

Of the 27 respondents that answered the question on the VenaSeal^TM treatment lengths, 10 chose “to a mid-calf level,” and five chose “maximum length after assessing its relation to SN employing DUS.” Additionally, the predo-minant treatment length chosen for the ClariVein^TM proce-dure favored by eight respondents was at the mid-calf level.

12) Indication criteria of the diameter of the SSV for ETA

Concerning the indication criteria of diameters for applying ETA, eight (21%) members reported “SSV with a diameter ≥2 mm,” and another eight (21%) reported a diameter “>2.5 mm,” both of which were the most pre-dominant responses. One member responded that “diameter <2 mm” was also applicable, and the other person ans-wered “≥5 mm”. Nineteen members, constituting 50% of the respondents, reported that they also treated SSV with a diameter of >15 mm by ETA. Seventeen (45%) responded that they utilized ETA for SSV with a diameter of <15 mm.

13) Implementing tumescent solution injection during ETA

Thirty-eight (93%) respondents reported using tumescent solution injections in the ETA. Among them, 35 (85%) responded that they injected tumescent solution with ultra-sound guidance, and three responded that they did not inject tumescent solution during the procedure. Of the six respon-dents who neither injected the solution nor injected it under ultrasound guidance, five were from private clinics, and one was a surgeon from a tertiary hospital.

Concerning the tumescent solution injection methods, 24 (63%) respondents said that manual injection was applied, and 14 (37%) responded that they used a tumescent pump for injection.

14) Imposition of high ligation during endovenous thermal ablation

Of the 41 respondents who responded, 29 (71%) stated that they did not perform high ligation during ETA, and 12 (29%) conducted high ligation during the ETA. Of the 12 members who performed high ligation during ETA, nine respondents were affiliated with private clinics, one with a general hospital, and two with tertiary hospitals.

15) Wavelength for endovenous laser ablation (EVLA)

Thirty-eight members responded. The most favored wavelengths were 1,940 nm and 1,470 nm by 16 (42%) and 15 (40%) respondents, respectively. Six (16%) respondents used below 980 nm, and one used 1319 nm.

In total, 47 members of the Korean Society for Phlebology responded to the survey. Since the mean number of full members who registered in the conference (spring or autumn) of the Korean Society for Phlebology was 48 from 2019 to 2021, it is reasonable to imply that most of the active full members participated in the survey. The respondents comprised 16% of the 291 full members as of 2021. Thus, it may be inappropriate to generalize the distri-bution of responses. Nevertheless, the author elaborated on the survey results to acknowledge the diverse opinions of members affiliated with private clinics, general hospitals, and tertiary hospitals.

In response to a survey question concerning the assess-ment used to diagnose incompetent SSV, 98% of the res-pondents reported that they executed DUS, except for one respondent from the tertiary hospital who reported CT venography instead of DUS.

CT venography provides information about the diameter of the saphenous vein. However, it does not provide the functional disturbance of the venous valve or the anatomic information around the saphenous vein necessary for forming treatment plans. DUS has been used as a universal diagnostic tool for setting up treatment plans targeted at chronic venous insufficiency owing to its ability to under-stand the patient’s venous hemodynamics, including the relationship between the saphenous vein and the saphenous fascia, the location of the saphenous vein from the skin, tortuosity, the relationship between the saphenous vein and nerve, deep venous insufficiency, and the segmental valvular insufficiency of the target saphenous vein. Therefore, edu-cation on DUS’s role as an investigation method in managing chronic venous diseases is still indispensable.

Regarding the examiner of DUS, DUS is recommended to be performed by the operating surgeon or another member of the team in the procedure (1). According to the International Union of Phlebology consensus document, several countries allow radiologic technologists or radiolo-gists to run the DUS. However, DUS performed directly by the operating surgeon is universalized and beneficial for setting up treatment plans using clinical experience and knowledge of the pathological conditions of chronic venous diseases (2). Nonetheless, some respondents reported empo-wering a radiologist, another physician of the same specialty, a sonographer, or a nurse to perform diagnostic DUS on their behalf. Allowing nurses to run such tests violates me-dical law; therefore, the Korean Society for Phlebology must enlighten members on DUS.

Concerning the treatment options for incompetent SSV, 79% of the respondents reported varying the options depen-ding on the patient. However, one study considered the anatomic characteristics of the SSV and the availability of private insurance, and 19% considered only the availability of private insurance. Many surgeons favor ETA or ENTA as alternatives to surgical treatments covered by national health insurance services for scarring, complications, and pain. However, there are reports on minimizing the preva-lence of hematoma at the stripping site or recurrence caused by neovascularization at the SPJ by employing a modified surgical treatment instead of a conventional surgical treatment (3). Furthermore, the risk of SN injury will likely be minimized when determining the extent of stripping after examining the relationship between the SSV and SN under ultrasound guidance. Therefore, assimilation and experience in a modified surgical treatment covered by national health insurance services, other than non-benefit treatment, are necessary for treating patients without private health insurance.

Concerning the location of high ligation of the SSV for surgical treatment, seven respondents reported implementing flush ligation at the SPJ. Traditionally, optimal management of the incompetent SSV has been achieved by flush ligation at the SPJ (4-6). However, it is challenging to find deeply seated SPJ, and extensive surgical treatment may increase the possibility of injury to the nerves and deep veins. In a United Kingdom vascular surgeons survey, 76% said they did not routinely expose the popliteal vein but ligated the SSV safely from the SPJ (7). It has recently been reported that flush ligation does not affect the surgical result (8) but rather gives rise to significant complications, such as pop-liteal vein injury (9,10). Rashid et al. (10) reported signifi-cant complications, such as DVT and popliteal vein injury, and a 59% low success rate after flush ligation at the SPJ. Therefore, unlike preconception, flush ligation at the SPJ may no longer be considered an ideal treatment for incom-petent SSV, thus requiring a modification in surgical treatment.

Three members reported positioning the terminal end of the radiofrequency ablation (RFA) catheter or laser fiber at the SPJ during the ETA. Regarding ETA, endovenous heat-induced thrombosis (EHIT) can develop by forming a thrombus in front of the terminal end of the catheter or laser fiber, causing severe complications such as pulmonary embo-lism (11). Hence, in RFA, the catheter should be placed 2.0 cm distal from the SPJ (12,13). Similarly, EVLA is recom-mended to position the laser fiber 2 cm distal to the SPJ (13). A report also suggests that changing the treatment distance from 2 cm to ≥2.5 cm distal from the deep venous junction may result in a decreased incidence of EHIT (14).

Regarding the decisions on the extent of the treatment of the SSV, specifically in the case of surgical treatments, 15 respondents responded to the mid-calf level, and eight reported that they examined its relationship to the SN under ultrasound guidance to strip the maximal length of the incompetent segment, minimizing SN injury. According to an ultrasonographic study of the relationship between the SN and SSV (15), the SN pierced the deep fascia at a point more proximal than usual in 26.1% of cases, which does not align with the concept that the SN pierced the deep fascia below the mid-calf level. Therefore, the blind inter-vention of the uppermost segment of the SSV is an unre-liable procedure for preventing SN injury.

Hence, when conducting ETA or surgical treatment, before implementing ETA or stripping, it is recommended to map the relationship between SSV and SN under ultrasound guidance (15).

Three members reported not injecting the tumescent solution when conducting ETA, and the other three reported injecting the solution but not under ultrasound guidance. When performing the ETA, the location of the inserted RFA catheter or laser fiber is at an eccentric position within the saphenous vein. Therefore, allowing the veins to collapse is crucial to increase the occlusion rate by delivering energy to the inner vein wall. Furthermore, ETA requires tumescent solution injection around the target saphenous vein to prevent heat transfer to the surrounding tissue, unlike non- thermal treatments, such as VenaSeal^TM or ClariVein^TM. The solution must be injected under ultrasound guidance to avoid catheter damage by vein puncture or nerve injury caused by the needle and to verify that a tumescent solution appropriately surrounds the target vein.

Twelve members reported using high ligation during ETA. However, several studies comparing EVLA with a combi-nation of EVLA and high ligation have demonstrated that the occlusion rate did not vary regardless of high ligation (16). In addition, after conducting multi-center randomized controlled trials for six years, no dissimilarity in clinical recurrence rate was detected whether EVLA was imple-mented exclusively or in combination with high ligation. The group that did not undergo high ligation also reported that they did not experience endovenous heat-induced thro-mbosis during the study period (17). These studies primarily focused on the great saphenous vein (GSV). Studies inves-tigating a combination of ETA and flush ligation at the SPJ for SSV have not yet been reported. However, similar results can be deduced from the findings of GSV-focused research on SSV. In other words, if the same clinical outcomes are shown, implementing ETA with flush ligation at the SPJ would only lead to the unnecessary addition of invasive dissection, which would eventually lead to a delay in surgery and neovascularization at the SPJ.

The limitation of this study is the small number of respondents; therefore, we cannot say that this study accu-rately represents the current management of SSV among members of the Korean Society for Phlebology. Nevertheless, it offers various opinions demonstrated by members of the Korean Society for Phlebology, affiliated with various me-dical institutions. Therefore, this study provides a rough inspe-ction of the current management of SSV among members of the Korean Society for Phlebology.

We verified various approaches to managing SSV among Korean Society for Phlebology members. Evidence-based practical guidelines and education regarding the management of SSV are necessary for proper management.

None.

Nothing to disclose.