Ambulatory Phlebectomy vs. Stripping of Varicose Veins

Ambulatory Phlebectomy vs. Stripping of Varicose Veins

A New Spin on an Outdated Varicose Vein Technique

The Truth about Phlebectomy – Is It Good or Bad?

Let’s be brutally honest.

Ambulatory phlebectomy (heavy on the ambulatory) is also commonly known as microphlebectomy, stab phlebectomy, or stab avulsion. Ambulatory means that you are able to walk normally right after the procedure.

Walking right away decreases the pressure in your veins. It also increases the flow in the leg veins and reduces the risk of you forming a blood clot.

Phlebectomy is an elegant technique to permanently remove varicose veins.

Varicose veins are similar to a tree and its branches. The varicose veins that are visible are the branches that come from a vein trunk. The saphenous vein is not usually visible. Ablation treats the trunk of the tree and the phlebectomy treats the branches (the visible varicose veins.)

Phlebectomy is unlike the traditional stripping of varicose veins where the patient often was not ambulatory. That is because of the pain caused from trying to walk after the stripping procedure.

Modern minimally invasive phlebectomy is highly effective and safe with little or no pain involved. Sometimes people take an anti-inflammatory medication but narcotics are not required.

Here is an actual phlebectomy performed by a British doctor, Mark Whitely.

Viewer discretion is advised.

It is an adjunctive procedure that is required after the saphenous vein has been removed from the circulation by ablation. Ablation of the saphenous vein can be performed with laser, radiofrequency, foam sclerotherapy or with glue.

These techniques or vein stripping are usually required in order to close down or remove the saphenous vein. It is often (but not always) the underlying source of the varicose veins.

If the varicose veins are not treated and only allowed to decompress after a saphenous vein procedure, they will recur in time.

What is Stripping of Varicose Veins?

Stripping and ligation was the crude ripping out of the saphenous vein. It was done in the operating room in the hospital. Often a long stiff wire was inserted into the saphenous vein after it was tied off at its origin. This vein was ripped out of your body while you were asleep.

When stripping of the saphenous vein was performed in an operating room under general anesthesia, incisions also were made over the varicose veins which were one to several inches long.

Those long phlebectomy incisions over the varicose veins were the trademark of the old stripping operation. The micro incisions are the “bespoke version” of the old traditional technique.

These crude techniques of removing the veins through such large incisions was associated with significant bleeding, bruising and post-operative pain.

Sutures were required to close the incisions resulting in the railroad track scars. The healing of these wounds and nerve damage was often a problem.

I wouldn’t be thrilled about that either.

Advantages of Modern Phlebectomy

A big advantage of today’s minimally invasive micro incision phlebectomy is that the veins cannot recur unlike after injections or sclerotherapy. That is because the varicose veins are completely removed from your body.

People are often concerned and ask about the removal of these large veins.

A common question is where will the blood go? Although these large veins are removed, there are no adverse effects on your circulation. The blood is simply rerouted through other normal veins that are located nearby and deep in the leg.

The final result is that your circulation is improved.

Injections of special medication into the varicose veins are the only other alternative to remove the varicose veins themselves. This is done after the ablation of the saphenous veins has been performed. However, sclerotherapy can leave a partially damaged varicose vein that can open up with time.

Other advantages of phlebectomy are:

  1. Phlebectomy is permanent. The veins that are removed can’t come back. However, depending on factors such as family history of varicose veins, new varicose veins could develop as time passes. Varicose vein disease is progressive. Treatment is palliative but long lasting.
  2. Phlebectomy is indicated for medium sized to large varicose veins over sclerotherapy.
  3. It is minimally invasive and well tolerated. With tumescent anesthesia, the area around the target veins is entirely numbed. Occasionally, people feel a tugging sensation while the veins are being avulsed. However, most people do not complain of pain while it is being done.
  4. From a cosmetic standpoint, it is superior to sclerotherapy which often leaves tender or painful veins with trapped blood that needs to be drained later.
  5. Phlebectomy does not require the drainage of trapped blood. The trapped blood after sclerotherapy often results in significant ugly hyperpigmentation (dark brown lines in the skin over the veins.) That takes months or years to resolve.

The mini incisions are so small that no stitches are required at all. No stitches are needed because the varicose veins are removed through very tiny mini incisions or through needle holes. Therefore, there is no scarring.

Afterwards, the leg is wrapped with a compressive bandage and a support stocking which is worn for 24 hours. The next day you can shower. Subsequently, the stocking is worn for one week during waking hours only.

Disadvantages of Phlebectomy

The main disadvantage is that the procedure is tedious. When there are lots of big varicose veins, their removal through tiny incisions can take up to an hour to perform.

For that reason, surgeons have attempted to remove extensive varicose veins with a new technique called Trivex. With Trivex, a roto-rooter type device is inserted under the skin. A rotating tip grinds up the varicose veins and sucks the ground up pieces through a second tube. It is more destructive than the traditional more elegant but slower phlebectomy technique. For that reason, Trivex is rarely performed.

Another disadvantage is that phlebectomy is a skill that needs to be learned through training. Grasping the varicose veins with the tiny hook and exteriorizing them so that they can be removed requires experience.

However, with the proper training and practice, the results are worth it!

Make sure that you research your vein specialist before going for your initial consultation. Your results will be directly correlated to your vein doctor’s training and experience.


Phlebectomy should not be confused with stripping.

The truth is this: phlebectomy is the modern alternative to vein stripping. It was not widely in the United States until around 2000.

That is when a billing code was approved by Medicare. Other insurance companies began covering it soon afterwards.

Ambulatory phlebectomy differs dramatically and is far less invasive compared to vein stripping. It is a proven technique that has been around for over fifty years. No likes to eat the first oyster.

Stripping of the great or small saphenous vein was a painful surgical procedure. It usually left patients debilitated for many weeks.

The great difference is that modern micro phlebectomy is minimally invasive.

There is little or no pain. There is no scarring. Risks are small. Relief from the symptoms of fatigue, pain, ache, heaviness and swelling from varicose veins is rapid.

This procedure is well tolerated. Phlebectomy also produces excellent cosmetic results.


Insurance covers this technique when it is determined to be medically necessary.

Seek out a qualified, well trained and experienced vein specialist when considering this procedure for your varicose veins.

Call us today at 724-969-0600 to learn more about this great advance in the treatment of varicose veins.

About The Author

Dr. John Happel

Dr. John Happel has been in practice as a surgeon since 1986 in the Pittsburgh region. He specializes in vascular surgery and has subspecialized in the treatment of varicose and spider veins since 1999. Dr. Happel is board certified in vascular surgery and recertified in vascular surgery in 2012. He was chosen in 1985 to fulfill the position for the vascular surgical fellowship at the world renowned Mayo Clinic.