Open Surgery: High Tie, Ligation and Stripping
Before the development of minimally invasive treatments such as EVLA and RFA, open surgery was the standard treatment for varicose veins. Although it is performed less frequently today, it remains an effective treatment for selected patients.
The traditional operation is known as high tie, ligation and stripping. It involves tying off the diseased superficial vein where it joins the deep vein (the saphenofemoral junction or saphenopopliteal junction), followed by removal of the faulty vein through small incisions in the leg.
Open surgery removes the diseased vein entirely, eliminating the source of venous reflux. Blood is naturally redirected into the healthy deep veins, which carry the vast majority of blood returning from the leg. Removing the diseased superficial vein therefore does not impair normal circulation.
The procedure is usually performed in an operating theatre under general anaesthesia or spinal anaesthesia. It typically involves marking the diseased veins using duplex ultrasound, making a small incision in the groin or behind the knee to identify the junction, tying and dividing the diseased vein, passing a specialised stripping device through the vein to remove the affected segment, and removing visible varicose veins through several small skin incisions where appropriate. The operation usually takes one to two hours.
Recovery after surgery is generally longer than after modern endovenous procedures. Most patients go home on the same day or after an overnight stay, experience bruising, tenderness and tightness for several weeks, return to office-based work within one to two weeks, and resume strenuous exercise after approximately two to four weeks.
Open surgery has an excellent long-term track record and provides durable relief of symptoms when appropriately performed. However, over the past two decades, multiple clinical trials have shown that endovenous treatments such as EVLA and RFA achieve similar long-term success with less postoperative pain, fewer wound complications, faster recovery and an earlier return to normal activities.
For this reason, current NICE and European Society for Vascular Surgery (ESVS) guidelines recommend endothermal ablation as the preferred first-line treatment for suitable patients. However, surgery continues to play an important role in selected situations, including vein anatomy that is unsuitable for endovenous treatment, certain cases of recurrent varicose veins after previous intervention, very large or tortuous veins that cannot be safely treated using catheter-based techniques, and patients for whom endovenous treatment is not appropriate.
As with any surgical procedure, complications are uncommon but can occur. Potential risks include bruising and postoperative pain, wound infection, bleeding or haematoma, temporary numbness due to irritation of nearby skin nerves, deep vein thrombosis (rare), scarring, and recurrence of varicose veins over time.