The Trendelenberg procedure, combined with long saphenous vein stripping (LSVS), is a well-established technique for treating chronic venous insufficiency (CVI). While endovenous ablation remains the gold standard, open surgery is still a feasible option in resource-limited settings with strong outcomes. Another indication for open surgery over endovenous thermal ablation remains large saphenous vein [1]. Use of surgeon-administered femoral block for open surgery remains a viable option with multiple advantages over alternative forms of anaesthesia. We therefore share our experience with using a femoral block for performing above-knee LSVS.

Methods: Patients presenting with clinical CVI between January 2024 and March 2025 were evaluated through clinical examination, blood biochemistry, and venous duplex ultrasound of the lower limbs. Patients were counselled about the natural history of the disease and the benefits and risks of intervention. All patients over 18 years of age, regardless of systemic comorbidities, were considered for surgery under femoral block anaesthesia. Patients with a history of deep venous thrombosis, those under 18 years of age, or patients who did not consent to femoral block were excluded. Using aseptic technique, a femoral block was performed with 2% lidocaine administered under ultrasound guidance by the operating surgeon. With the patient in a supine position and the surgeon standing on the ipsilateral operative limb, a linear ultrasound transducer was used to delineate standard anatomy. Under ultrasound guidance, 15-20 ml of 2% lidocaine was injected lateral to the femoral artery, between the fascia lata and fascia iliaca [2]. Additional local infiltration of 2% lidocaine was carried out in the groin for the Trendelenburg procedure and in the leg for ligation of incompetent leg perforators as needed. Postoperative intravenous analgesics and intravenous antibiotics were administered as per standard dosage for one day. The intraoperative analgesic effect was assessed using the Numerical Pain Rating Scale (NPRS), where 0 represented no pain and 10 represented the worst imaginable pain. The NPRS was categorised as mild pain, moderate pain, and severe pain for scores of 1-4, 5-6, and 7-10.

Twenty patients underwent LSVS with a femoral block. The mean age was 32.6 years (SD 9.4). Males made up 90% (18/20) of the patients. Presenting symptoms included calf cramps, leg oedema, skin changes secondary to CVI, healed varicose ulcer, and active venous ulcer in 2/20 (10%), 2/20 (10%), 6/20 (30%), 7/20 (35%), and 3/20 (6%), respectively. Intraoperative and immediate postoperative Pain control was adequate, with one patient (5%) experiencing mild pain (mean 0.27, SD 0.88) during LSVS. No patients required conversion to spinal anaesthesia. Oral feeds were allowed on the same day as surgery. The patient was allowed to ambulate on the next day. All patients were discharged on the 2nd postoperative day after dressing removal. There were no complications related to stripping of LSV (paraesthesia, haemorrhage, skin pigmentation, etc.) or femoral block administration (femoral nerve injury, vascular injury), and no mortality was reported.

The use of femoral block for LSVS was described as early as 1981 by Taylor et al[3]. They performed the procedure on 21 patients with satisfactory outcomes. Over the years, High Ligation and Stripping was generally carried out under spinal or epidural anaesthesia, with the benefits of femoral block not being fully utilised. With the advent of endovenous ablation for varicose veins and increased comfort with tumescent anaesthesia, surgeons have revisited the use of femoral block with or without tumescent anaesthesia. Chen et al[4] found no difference in operative duration, intraoperative blood loss, or postoperative complications among three groups of 30 patients each, with each group undergoing high ligation and LSVS under either epidural anaesthesia alone, tumescent anaesthesia alone, or a combination of tumescent anaesthesia and femoral block. The group undergoing surgery with femoral block and tumescent anaesthesia experienced the least intraoperative heart rate and blood pressure fluctuations and higher postoperative satisfaction rates. Kaçmaz et al [5] compared femoral block with spinal anaesthesia in 160 patients undergoing endovascular thermal ablation of varicose veins. The group receiving a femoral block was given only saline infiltration around the saphenous vein trunk before ablation and had higher blood pressure, earlier mobilisation, less urinary retention, less shivering, and better post-discharge satisfaction scores compared to the other group. Öztürk et al, in a similar study in 40 patients, found femoral block equally effective as spinal anaesthesia with faster motor function recovery after the procedure [6]. A study was conducted by Vloka et al, where they compared spinal anaesthesia against a combination of femoral block and genitofemoral nerve block in patients undergoing LSVS [7]. They found that nerve block group patients had faster recovery, lower incidences of pain and complications. While all patients with nerve block were satisfied with intraoperative analgesia, 15% of patients who received spinal anaesthesia expressed reservations about undergoing surgery under spinal anaesthesia in future. In our experience, a femoral block is sufficient for LSVS and does not require supplementary tumescent anaesthesia. For endovascular thermal ablation of varicose veins, tumescent anaesthesia is necessary as it also collapses the vein around the heating element, resulting in better ablation and protecting the overlying skin from thermal injury. However, adding a femoral block even in thermal ablation provides better pain relief, as the patient does not feel multiple needle pricks while infiltrating tumescent anaesthesia around the vein. Performing varicose vein surgery under a femoral block helps the patient avoid side effects of spinal anaesthesia, such as hypotension, prolonged immobilisation, urinary retention, post-spinal headache, and backache. It is also cost-effective and leads to quicker mobilisation, shorter hospital stays, and increased patient satisfaction. Administration of a femoral block by a surgeon is easy to learn and safe to perform. Complications of femoral block include nerve injury and muscle weakness, but none were reported in our study. Fiutek et al. reported one patient with self-resolving hyperesthesia in their review of 56 patients undergoing LSVS under femoral block [8]. Limitations of this study include the lack of a multicentre trial, its retrospective record review, and a small patient group. Further trials are suggested to

Femoral block is a safe and effective method for LSVS. It reduces the wait for anaesthesia and avoids the side effects linked to neuroaxial anaesthesia, such as headaches, urinary retention, and back pain. Furthermore, a comparative study is recommended to evaluate the femoral block against neuroaxial anaesthesia in a larger patient group.

1. De Maeseneer MG et al., European Society for Vascular Surgery (ESVS) 2022 Clinical Practice Guidelines on the Management of Chronic Venous Disease of the Lower Limbs, European Journal of Vascular and Endovascular Surgery, https://doi.org/10.1016/j.ejvs.2021.12.024 2. Atchabahian A, Leunen I, Vandepitte C, Lopez AM. Ultrasound-Guided Femoral Nerve Block. NYSORA. 2024 Oct 31 [cited 2025 July 9]. Available from: https://www.nysora.com/techniques/lower-extremity/ultrasound-guided-femoral-nerve-block/ 3. Taylor EW, Fielding JW, Keighley MR, Alexander-Williams J. Long saphenous vein stripping under local anaesthesia. Ann R Coll Surg Engl. 1981 May;63(3):206-7. 4. Chen X, Liu Z, Zhou B, Fan Z, Zhao H, Lin C. Application of femoral nerve block combined with modified swelling anaesthesia in high ligation and stripping of the great saphenous vein. Front Surg. 2023 Jan 6;9:1086735. Doi: 10.3389/fsurg . 2022.1086735. 5. Kaçmaz, M. (2021). Femoral nerve block versus spinal anaesthesia in the treatment of saphenous vein ablation. Turkish Journal of Vascular Surgery, 31(1), 7–14. https://doi.org/10.9739/tjvs.2021.1062 6. Öztürk T, Çevikkalp E, Nizamoglu F, Özbakkaloğlu A, Topcu İ. The Efficacy of Femoral Block and Unilateral Spinal Anaesthesia on Analgesia, Haemodynamics and Mobilization in Patients undergoing Endovenous Ablation in the Lower Extremity. Turk J Anaesthesiol Reanim. 2016 Apr;44(2):91-5. doi: 10.5152/TJAR.2015.66933. 7. Vloka JD, Hadzić A, Mulcare R, Lesser JB, Kitain E, Thys DM. Femoral and genitofemoral nerve blocks versus spinal anaesthesia for outpatients undergoing long saphenous vein stripping surgery. Anesth Analg. 1997 Apr;84(4):749-52. doi: 10.1097/00000539-199704000-00009. 8. Fiutek, E., & Fiutek, Z. (2008). Regional Femoral Nerve Block Combined with Local Anaesthesia in Day Surgery for Varicose Veins. EJVES Extra, 16(3–4), 30–31. https://doi.org/10.1016/j.ejvsextra.2008.08.008