Neovascularization in the groin: treatment options

Introduction

Neovascularization refers to the formation of new blood vessels, which can occur in abnormal tissue or position. New vessels arise in granulation tissue along previously detached or ligated veins. These are numerous, tortuous, new, sometimes wide, veins with pathological reflux in anatomical proximity to previous interventions in the area of the tibio-femoral junction, the popliteal-tibial junction, treated perforators or venous branches.
Neovascularization may be associated with the presence of an incompetent stump of the vein or in the area of the junction we see only numerous tortuous veins connecting with its incompetent basin – varicose veins on the thigh and calf.
Neovascularization is one of the main causes of recurrent varicose veins [1].
Neovascularization occurs relatively often, even after proper functional ligation. It accounts for 8% to 60% of recurrent varicose veins and is the most common cause. Neovascularization is thought to be pathological angiogenesis. Angiogenesis is the process of forming new blood vessels, most often based on existing ones. Various mediators are involved, including growth factors, matrix metalloproteinases and their tissue inhibitors, hypoxia-induced factors and angiopoietin. Important growth factors include: vascular endothelial growth factor, basic fibroblast growth factors and platelet-derived growth factor. Factors such as hypoxia, mechanical stress and inflammation also stimulate angiogenesis, which can be both physiological and pathological [2].
Neovascularization in the groin typically develops after surgical procedures in the area of the saphenofemoral junction. It forms between the common femoral vein, the remaining portion of the saphenous vein or its branches, in areas where the vein wall is cut and its ends are reconnected by new vessels. This condition most commonly occurs after saphenous vein surgery using the Babcock method, which involves crossectomy. This method includes ligation and transsection of the saphenous vein and all veins draining into its bulb in the area of the saphenofemoral junction [3,4].
Neovascularization can occur after incomplete vein ablations, for example, with an obliterating agent or thermal action. It can also occur in the case of superficial vein thrombosis. Each of the new vessels inside its lumen rebuilds into larger ones with visible venous flow where pathological reflux eventually develops [1].
For patients with chronic venous disease, a complete Doppler ultrasound examination of the lower limb veins is recommended as the primary imaging study for diagnosis and treatment planning [1,5]. Before any intervention, it is crucial to accurately assess and identify the presence and location of reflux to optimize treatment and prevent neovascularization (Figs. 1 and 2).
It is worth paying attention to the issue of the risk of varicose vein recurrence, such as: advanced age, female gender, later behavior, body mass index (BMI) determination or previously recurrent disease. Additionally, pelvic venous reflux has been identified as an important factor causing varicose vein recurrence [6].
In a small proportion of patients, without any history of surgical interventions, tortuous veins may also be observed in the groin area and saphenofemoral junction. Such cases involve an anatomical variant that is not a symptom of the disease and may not require treatment.
Neovascularization is usually not visible on the skin, only on ultrasound, but it can also form a conglomerate of visible varicose veins in the groin (Figs. 3 and 4).

Treatment options

Groin neovascularization is a complex problem that often occurs after surgical interventions in this area. It is characterized by numerous tortuous veins in the area of the saphenofemoral junction. Treatment of neovascularization is challenging due to altered anatomical conditions after previous procedures, scars and adhesions in this area, which can lead to further complications and higher variability of cases, requiring accurate diagnosis and an individual approach.
Planning treatment for a patient with groin neovascularization should begin with Doppler ultrasound examination of the veins in this area and the entire limb. This examination allows for the identification of problematic areas and the determination of which veins require intervention.
Treatment options should be tailored to the width of the groin veins, tortuous course, and presence and length of the incompetent saphenous vein stump. There are no typical solutions here. Attention should also be paid to the presence of an additional anterior saphenous vein.
Treatment options include: classic surgery, mini­phlebectomy; thermal methods (laser or radiofrequency thermoablation); mechanochemical ablation of veins (MOCA); glue; and sclerotherapy under ultrasound guidance, which may involve various modifications (tumescence/narrowing of the saphenofemoral junction, ScleroSafe, i.e. simultaneous emptying of the treated veins). Hybrid tratment may also be necessarry which is based on the various invasive treatment method combination.

Classic surgery

This involves exposing and isolating the remaining stump of the saphenous vein after the previous procedure. The stump remains most often in the cases of improper, too low ligation of the saphenous vein within the oval foramen and failure to ligate important tributaries such as the superficial epigastric vein, the superficial circumflex iliac vein, the external pudendal veins and the additional anterior saphenous vein.
However, re-intervention involving the saphenofemoral junction is often not indicated due to altered anatomical conditions after the first procedure. Secondary operation reduces the possibility of precise intervention in this area. It is laborious due to numerous scar changes and adhesions after the primary procedure. It is a more difficult, longer procedure with a potentially higher number of complications such as lymphatic duct damage or wound infection [4,7].
The European Society for Vascular Surgery (ESVS) 2022 guidelines include recommendation no. 56 that for patients with symptomatic recurrent varicose veins requiring treatment, where endovenous ablation is possible, re-exploration of the groin or popliteal fossa is not recommended [1].

Thermal methods

These include radiofrequency ablation (endovenous radiofrequency – EVRF), laser ablation (endovenous laser treatment – EVLT) and steam vein sclerosis (SVS). They are characterized by the fact that catheters introduced into the veins generate high temperatures to close the vein. Radiofrequency or laser energy is converted into heat, which coagulates the blood and the inner wall of the vein, leading to its closure.
Endovenous thermal ablation or ultrasound-guided foam sclerotherapy with or without phlebectomy should be considered for the treatment of symptomatic recurrent veins – ESVS 2022 recommendation no. 55 [1].
If it is possible to catheterize neovascularization or the saphenofemoral junction stump, laser crossectomy is performed [8,9]. If the stump is very short (less than 1 cm), catheterization is possible by advancing a guidewire into the common femoral vein, but if the veins are numerous and tortuous from the beginning, catheterization may be problematic. In such cases, another treatment method is used, e.g. ultrasound-guided sclerotherapy.

Mechanochemical ablation of veins

Mechanochemical obliteration methods include Flebogrif and ClariVein. Both systems utilize obliterating agents – Flebogrif in the form of foam, ClariVein in the form of liquid. These techniques combine mechanical damage to the vein endothelium using an obliterating agent, facilitating its penetration into deeper layers of the vessel wall. This results in better vessel contraction. Currently, these methods have less application and lower effectiveness in treating groin neovascularization compared to thermal ablation.

Glue

Chemical ablation with glue can be used for major venous trunks or perforating veins. However, for numerous, tortuous, and sometimes wide veins in the groin, the authors of this article advise against using glue from point punctures in this area. Glue is a foreign body that remains in the body for a long time. In the groin area, a large volume of glue might be needed, which could cause discomfort, pressure, or thickening for the patient. After using glue for wide neoangioectasia, there is a risk of its transmission to deep veins (endovenous glue-induced thrombosis – EGIT) due to the proximity of the saphenofemoral junction.

Sclerotherapy

Sclerotherapy involves puncturing the vein and injecting a chemical agent that destroys it into the vein’s lumen. This damages the endothelium, causing inflammation, closure, and fibrosis of the vessel. The sclerosing agent is administered under ultrasound control, ensuring high precision. Sclerotherapy is a universal method, effective and recommended for recurrent, tortuous, and atypical veins. It is repeatable and can be used multiple times [10]. When a short, tortuous course of neovascularization is observed in the groin, sclerotherapy is performed under ultrasound control. Vein narrowing at the junction with a tumescent solution can also be performed to reduce complications.
Sclerotherapy involving the introduction of an obliterating drug under ultrasound control can be done through direct punctures or using a catheter. The catheter can be single lumen or double channel (SceroSafe system), with the ability to withdraw blood from the vein to empty it. Two butterfly needles or Venflon cannulas can also be used to evacuate blood from the vein, but this is more difficult. The drugs currently used for sclerotherapy of neovascularization are polidocanol and tetradecyl sodium sulfate, usually in a high concentration, such as 2 or 3%.
Treatment results are good, with only 20% of patients requiring re-treatment after 4.4 years of sclerotherapy under ultrasound control, which is often used for recurrent varicose veins [11].

Treatment monitoring

After the procedures, ultrasound monitoring is crucial. The authors of this article recommend the following follow-up scheme:
• If open vessels in neoangiectasia are visible after one month, a repeat sclerotherapy procedure is performed.
• After another month, if the closed veins appear hypoechoic on ultrasound, follow-up is recommended after 3 months. If they appear hyperechoic, the next follow-up is recommended after six months to a year. Hypoechoic veins after sclerotherapy are vessels that have not yet fibrosed and have a higher risk of recanalization.
• Earlier follow-up aims to detect recanalization and perform sclerotherapy as soon as possible, leading to better long-term effects.
In summary, treatment of a patient with neoangiectasia in the groin should begin with a comprehensive ultrasound Doppler examination of the veins in this area and the entire limb. A plan for hybrid or staged treatment should then be established and presented to the patient. The patient should be aware that further intervention in this area is associated with a greater possibility of failure or recurrence, and treatment may take place over several sessions.

Discussion

The treatment of recurrent varicose veins, including neoangiectasia, is problematic and poses a considerable challenge. Versteeg et al. drew attention to the fact in their publication that the recurrence of varicose veins after venous intervention is a frequent phenomenon that is more apparent with additional years of follow-up. Early ultrasound recurrence is predominantly evidence of neovascularization and some small-vessel remodeling at the site of treatment. When it occurs, some visible varicose veins are inevitable. Initially, the cause of recurrence was attributed to the complexity and variability of the saphenofemoral confluence combined with inadequate surgical technique. However, with the advent of high-resolution duplex ultrasound (DUS), it was found that even in limbs in which surgical success was proven postoperatively, recurrent varicose veins (RVVs) still developed, suggesting that the recurrent vessels were the result of a neovascular process or the enlargement of very small, undetectable, pre-existing vessels [12].
Doppler ultrasound examination of the lower limbs is important when planning procedures and monitoring the effectiveness. Geier et al. conducted a prospective study in which ultrasound scan assessment of groin recurrences was compared to the histological classification of the recurrent groin veins. In summary, they concluded that duplex ultrasound is a reliable tool for diagnosing groin recurrence after varicose vein surgery, but its reliability in classifying different types of recurrent groin vessels is limited. They proposed that histologic examination should be the method of choice for the classification of groin recurrences, especially in a scientific setting comparing the incidence of neovascularization after different forms of treatment [13]. Currently, histological examinations are not the method of choice in the diagnosis of recurrence. The ESVS 2022 guidelines emphasize that Doppler ultrasound is the preferred diagnostic approach for the examination of clinically obvious recurrent varicose veins [1]. It also applies to monitoring after interventions to check for recurrent reflux.
Neoreflux at the sapheno-femoral junction (SFJ) is an important cause of recurrent great saphenous varicose veins. Neovascularization at the SFJ ligation site in the groin may occur within one year after great saphenous vein (GSV) surgery. To reduce the incidence of neovascularization, researchers have proposed various solutions. Frings et al. investigated whether the ligation method or suture material used influences the occurrence of inguinal neoreflux [14].
Postoperative neovascularization at the level of the ligated saphenous stump is now recognized as one of the important pathophysiological mechanisms leading to recurrence of varicose veins after saphenofemoral junction ligation. To contain such neovascularization and thus prevent recurrence from the groin, De Maeseneer et al. proposed the use of a prosthesis or anatomical barrier to cover the ligated saphenous vein stump. They stated that in primary varicose vein surgery, the use of the anatomical barrier technique is an alternative option to prevent postoperative neovascularization [15]. Freis et al. presented an analysis of the effectiveness of additional barrier patch implantation in reducing the number of recurrences of varicose veins in the groin [16].
Re-intervention surgery involving the saphenofemoral junction is difficult due to altered anatomical conditions. Numerous scars and adhesions make it laborious and also hinder precise action in this area. Conventional treatment of recurrent varicose veins of the GSV usually involves surgical re-ligation of the saphenofemoral junction, often combined with multiple phlebectomies. Unfortunately, this-treatment is associated with a higher recurrence rate than primary varicose vein treatment. Currently, the role of endovascular techniques such as thermal ablation or sclerotherapy under ultrasound control is increasing. The study by van Groenendael et al. highlights the use of laser ablation in patients with neovascularization. The authors point out lower complication rates, the minimally invasive nature of the procedure and socio-economic benefits, which are better compared to surgical re-intervention [17]. Also, a review by Bontinis et al. concluded that endovenous thermal ablation (EVTA) was more effective than surgical treatment in the treatment of recurrent varicose vein disease, which supports its use as the preferred treatment when possible [18]. These methods have been included in the ESVS recommendations for the treatment of neoangiectasia [1].
Neoangiectasia in the groin can involve numerous twisted veins of varying size. In such cases, it is worth suggesting sclerotherapy under ultrasound guidance to the patient. This procedure is very effective in treating recurrent varicose veins caused by neovascularization. Pavei et al. published 5-year observations of patients after neovascularization treatment using sclerotherapy under ultrasound guidance. Their data showed that this method is effective, well-tolerated, safe, and easily repeatable [11].

Conclusions

Neovascularization of the groin veins after previous interventions is a costly and complex problem. Treatment of groin neoangioectasia is difficult due to altered anatomical conditions, scars, and adhesions in this area.
It is very important to perform a thorough Doppler ultrasound examination of the veins before and after procedures to achieve optimal treatment outcomes. Re-operation in the groin is not recommended. In most cases, thermoablation is used if possible, or sclerotherapy under ultrasound guidance. These are often hybrid techniques, and sometimes staged treatment is necessary.
Researchers are constantly seeking new solutions to reduce neovascularization after vein procedures. Properly diagnosed and treated intravascular neoangioectasia yields good results. Further research in this area is very important and necessary.

Disclosures

1. Institutional review board statement: Not applicable.
2. Financial support and sponsorship: None.
3. Conflicts of interest: None.

References