John J. Bergan

Femoral venous reflux abolished by greater saphenous vein stripping

Preoperative venous duplex scanning has revealed unexpected deep venous incompetence in patients with apparently only varicose veins. Acting on the hypothesis that the deep vein reflux was secondary to deep vein dilation caused by reflux volume, the following was done. Between July 1990 and April 1993, 29 limbs in 21 patients (16 females) were examined by color-flow duplex imaging to determine valve closure by the method of van Bemmelen. Instrumentation included high-resolution ATL-9 venous interrogation using a pneumatic cuff deflation stimulus of reflux in the standing, nonweight-bearing limb. All limbs showed greater saphenous vein reflux. Twenty-nine showed superficial femoral vein reflux and of these three showed popliteal vein reflux. Duplex testing was performed by a certified vascular technologist whose interpretation was blinded as to the results of clinical examination and grading of the severity of venous insufficiency. Surgery was performed on an outpatient basis under general anesthesia using groin-to-knee removal of the greater saphenous vein by the vein inversion technique of Van Der Strict. Stab avulsion of varicose tributary veins was accomplished during the same period of anesthesia. In 27 of 29 limbs with preoperative femoral reflux, that reflux was abolished by greater saphenous stripping. In patients with popliteal reflux both femoral and popliteal reflux was abolished. Improvement of deep venous hemodynamics by ablation of superficial reflux supports the reflux circuit theory of venous overload. Furthermore, preoperative evaluation of venous hemodynamics by duplex scanning appears to provide useful pre- and postoperative information regarding venous insufficiency in individual patients.

Subfascial endoscopic perforator vein surgery: a preliminary report.

Although the open Linton subfascial perforator vein interruption operation succeeded, for the most part, in preventing recurrent venous ulceration, it was associated with morbidity and prolonged hospitalization. We have attempted to obtain the beneficial effects of perforator interruption by the less invasive procedure of subfascial endoscopic perforator vein surgery using laparoscopic instrumentation and limited or no hospitalization. A total of 31 consecutive operations were performed in 30 patients. Sixteen women and 14 men were entered into the study, and all of them had severe chronic venous insufficiency with either open or healed ulcers. Operations were carried out without gas insufflation, in 17 without a hemostatic tourniquet, and in 13 entirely on an outpatient basis. The 18 hospitalizations produced a total of 49 days of inpatient care (mean 2.72 days). One to six perforating veins were encountered in these operations, and veins identified as perforators were electrocoagulated or clipped and sectioned. Sixteen limbs had severe chronic venous insufficiency or healed ulcers, and 15 had open ulcers. In 13 limbs, ulcers were intermittently present for 1 to 5 years. Seven of these healed within 4 weeks of operation and four others within 8 weeks. Two healed more than 8 weeks after surgery. In two limbs with ulcers that were present for 1 to 6 months, healing took place within 4 weeks of the operation in both. Complications included atelectasis in one patient, cellulitis requiring antibiotic therapy in three, wound hematomas not requiring intervention in two, and wound seroma not requiring therapy in one. This preliminary experience suggests that perforator vein interruption can be accomplished using existing instrumentation and a variety of technical modifications to achieve the objectives of the Linton operation without the attendant morbidity. Videoscopic instrumentation obtains benefits of subfascial perforator vein interruption without morbidity of the open operations. This preliminary study suggests that the operative procedure is attended by minimum morbidity without the need for rehospitalization. Long-term observation will be required to assess the procedure definitively, but the short-term objectives can be safely accomplished with minimum use of inpatient facilities.

New technology and recurrent varicose veins

New technology and recurrent varicose veins Recent reports of use of colour doppler duplex scanning in the preoperative assessment of varicose veins suggest that almost universal acceptance of this mode of investigation. This attitude raises two questions. Is the technique acceptable when compared with phlebography, a historical gold standard? And what do these investigations teach that allows us to modify our operations to reduce or prevent recurrence of varicose veins? Clinical examination, so important and so accurate in assessing limbs with arterial insufficiency, is notoriously inaccurate in determining saphenofemoral and saphenopopliteal incompetence. Such is also true for the detection of perforating veins. These points of venous dysfunction are the ones most associated with recurrent varices. Addition of the hand-held, continuous-wave doppler examination to the clinical assessment does improve the evaluation but the technique is flawed because of a high likelihood of false-positive findings. The colour-coded duplex ultrasound instrument, however, yields findings that correlate reasonably closely with those of phlebography. This fact and the invasive nature of phlebography, with its potential for reactions to the contrast medium, has led to a near-total acceptance of ultrasound as the single most important preoperative investigation. From these investigations there are at least three lessons that can be learnt to decrease the incidence of was not associated with clinically relevant bleeding, and only one patient had moderate symptomless thrombocytopenia. What is the significance of these findings? First, the overall incidence of contrast-venography-confirmed thrombosis at 3 weeks post-discharge was surprisingly high—ie, 13% compared with 19% in placebo-treated patients—especially since only patients with a normal venogram before randomisation were included in this study. The incidence is even more surprising because of the strict eligibility criteria for this study. Patients were eligible only if they were fully ambulatory (able to walk without assistance other than crutches) and had no disorders known to be associated with an enhanced risk of venous thromboembolism (no history of deep-vein thrombosis or pulmonary embolism or the presence of active malignancy). Three of the patients who developed deep-vein thrombosis had had a history of malignancy, but that still leaves 20 patients without a reason for the complication. Hence, contrast venography—even under the very favourable technical circumstances pertaining in the study—cannot be excluded as being a contributory factor to the thrombosis. In a careful follow-up study in 41 consecutive patients with leg symptoms but without evidence of thrombosis on normal contrast venography, a subsequent I-fibrinogen leg scan revealed thrombosis, which was confirmed by repeat contrast venography in one patient. The frequency of venous thrombosis after venography with non-ionic low-osmolar contrast medium followed by flushing in that study was therefore 2%, with 95% confidence limits of 0 and 13%. Therefore a part of the 19% frequency of thrombosis in placebo-treated patients in the study by Planes et al may be related to the contrast-venography procedure. Second, prophylaxis against thrombosis with LMWH for 3 weeks resulted in an absolute risk reduction of thrombosis of 12·2% (7·1% vs 19·3% in patients receiving placebo). These observations support the antithrombotic efficacy of LMWH revealed by many studies in post-surgical patients at variable risk. However, this risk reduction was not associated with a reduced risk of proximal vein thrombosis (5·9% in the LMWH-treated patients vs 7·9% in the placebo-treated patients). Moreover, 6 out of 85 patients treated with LMWH had deep-vein thrombosis and 5 of those thromboses were proximally located. These findings imply that, even after treatment for 3 weeks after discharge, a subset of patient with proximal deep-vein thrombosis remains. In conclusion, this well-conducted study shows that among patients who have undergone total hipreplacement surgery, followed by venography before discharge, post-discharge deep-vein thrombosis as assessed by repeat venography is common, and LMWH is able to reduce the incidence of post-discharge distal thrombosis. The clinical implications are not immediately clear. Is the risk of post-discharge thrombosis also high when patients do not undergo pre-discharge venography? Is venography-confirmed distal thrombosis a clinically important entity? In follow-up studies examining clinical events the incidence of such events has been low. In the study by Planes, although a third of patients had leg symptoms, they were not subjected to diagnostic tests. Neither was there evidence that LMWH prophylaxis was less likely to be associated with symptoms (14 in the LMWH vs 16 in the placebo group had clinical signs of DVT). There is a clear need for a more definitive randomised clinical trial, in which patients are randomised to shortterm (10 days, followed by placebo) and long-term (3 to 6 weeks active treatment) prophylaxis, with venography only at the end of the study, or for a very large clinical endpoint study with strict rules for outcome detection. Orthopaedic surgeons who prescribe short courses of prophylactic anticoagulants will not find enough evidence to extend this regimen because of the problem of generalisability of Planes and colleagues’ findings, and those who give longer courses (a strategy for which there is not much evidence but that is common practice) will not confidently stop doing so. In summary, the trial highlights the potential importance of post-discharge thrombosis, but will not change current practice.