Unique anatomical characteristics
The GSV is a superficial vein with a thick wall and a double muscle layer, unlike other superficial veins.
It is enclosed in its own fascial compartment (saphenous fascia), which provides protection and support.
Equipped with numerous unidirectional valves (10-20) that facilitate venous return.
Physiological and propulsive role
It actively contributes to venous drainage, particularly during walking.
It can serve as a collateral route in case of deep vein thrombosis (DVT), becoming an alternative drainage pathway.
Use in vascular surgery
It is the vein of choice for coronary and peripheral (especially distal) bypass due to its length, caliber, and resistance.
Risks of GSV elimination (stripping, thermal ablation, obliterative sclerotherapy)
Destroying the GSV eliminates a natural drainage pathway.
Increases the risk of varicose vein recurrence (up to 60-70%) and long-term deterioration of venous drainage (around 40% show objective clinical worsening after 5 years).
Eliminating the vein, which hosts lymphatic collectors in its compartment, can also impair lymphatic drainage, raising the risk of secondary lymphedema, especially in predisposed individuals.
A limb deprived of its main propulsive vein can never be physiologically the same again.
Scientific evidence
Longitudinal studies show that patients who undergo stripping have worse VCSS scores than those treated with less invasive techniques.
The CHIVA approach and non-ablative functional methods show fewer recurrences and better hemodynamic preservation.
Modern clinical perspective
It is no longer enough to compare ablative methods with each other (surgical vs laser), but to assess whether there is a real need to eliminate the GSV.
Even if the GSV is diseased and refluxing, clinical research should focus on therapeutic approaches aiming at its functional recovery rather than its elimination.
This is particularly important in young individuals, where preserving a propulsive vein can positively affect long-term prognosis.
To save the GSV, hemodynamic methods like CHIVA and ASVAL are essential, but not only: today it’s possible to use ablative techniques targeted solely at reflux points.
Particularly relevant is the new HIFU (High-Intensity Focused Ultrasound) method, which can be employed in all these conservative contexts in an absolutely non-invasive and extracorporeal manner.
Even in cases where the GSV is unsalvageable due to anatomical or hemodynamic reasons (excessive dilation, past thrombophlebitis, etc.), HIFU alone or combined with foam sclerotherapy offers a safe, effective, and completely non-invasive treatment-ideal for compromised, elderly, cardiac, nephropathic, or anticoagulated patients.
Whenever possible, preserving the GSV represents a more physiological and sustainable clinical strategy.
Essential references
Casoni P, Nanni E., Pizzamiglio M. High intensity focused ultrasound in treating great saphenous vein incompetence: perioperative and 1-year outcomes. Phlebology. 2024;39(7):448-455.
Casoni P, Nanni E, Pizzamiglio M, Serra L. Action of high intensity focused ultrasound (HIFU) ablation on the venous wall: Histopathological analysis, insights, and perspectives. Phlebology. 2024.
CHIVA – Conservative and Hemodynamic
Franceschi M. CHIVA method: Conservative and hemodynamic approach to vein insufficiency.
Phlebolymphology. 2003;10(1):27-32.
ASVAL – Ambulatory Selective Varicose Ablation
Puggioni A, Lurie F, Kistner RL, Eklof B. ASVAL: Ambulatory selective varicose vein ablation under local anesthesia. J Vasc Surg. 2006;44(3):634-639.
