Treatment of venous insufficiency: developments and new paradigms in the 21st century

The so-called ‘radical’ treatment of varicose veins which remained the gold-standard for 100 years, known as ‘crossectomy-stripping’, was developed at the very beginning of the 20th century on the principle of removal of the saphenous vein. It is based on the descending physiopathological theory described by Trendelenburg in 1890, which states that reflux begins at the level of the ostial valve of the saphenous vein, then progresses retrograde to the peripheral tributaries. At the dawn of the 21st century, following the general trend in vascular surgical techniques towards percutaneous endovascular techniques (widely developed in arterial pathology), ‘endovenous’ techniques appeared (laser, radiofrequency, steam, glue) which proved to be as effective and less aggressive than stripping. These minimally invasive techniques have unintentionally led to the cornerstones of the dogma of radical treatment of the saphenous vein being called into question. This has led to a paradigm shift that calls into question the central role of the saphenous vein in the treatment of varicose disease and, conversely, reveals the importance of the treatment of varicose tributaries (ASVAL method), on which treatment must focus today and probably even more so in the future.