Short saphenous vein surgery in local anaesthesia: four years personal experience
A.Cavezzi * °, C.Tarabini *, M.G.Barboni *, V.Carigi *°, M.Collura *
*Villa Erbosa Clinic, Via Arcoveggio 50/2, Bologna;
°Vascular Unit Stella Maris Clinic, Via Murri 1, S.Benedetto del Tronto. ITALY, www.cavezzi.it
SUMMARY
Aim: since 1990 we have performed surgery of varicose veins (VV) on an outpatient basis ("day-surgery"); the purpose of this study is to review the authors' last four years experience of short saphenous vein (SSV) surgery, managed in local anaesthesia (LA) and with color-duplex (CD) guide
Patients and Methods: from January 1996 to December 1999 92 limbs (78 patients, 61 F and 17 M, mean age 55,4) were operated for VV in LA, with pre-operative CD investigation and CD guided skin marking. As far as LA is concerned, buffered mepivacaine 0.4-0.25% was used; SSV inverted segmental stripping was performed, together with mini-incisions (1-2 mm) phlebectomy of the varicose veins. All the patients had an elastic bandage, or elastic stocking (35 mmHg) as post-operative elastic compression.
Results: 100-160 cc of LA was the amount per intervention and no patient required additional anaesthesiologic procedure; deambulation was possible after 30-60 minutes in all the cases, and all the patients were dischargable after 3-6 hours. CD pre-operative mapping permitted to avoid venography in all the cases and it allowed also a tailored surgical procedure (no complete SSV stripping and no ligation of perforators were necessary). As far complications are concerned there were 1 slight lymphedema, 2 sensitive neurologic troubles, 1 gastrocnemius vein limited thrombosis.
Conclusion: SSV surgery is a demanding and complex procedure, but the usage of CD and LA may help minimizing complications, recurrences and excessive venous avulsion, maintaining a radical excision. Our experience demonstrates that remarkable cosmetic and functional outcomes are possible, thus avoiding old "blind " and invasive surgery, finally decreasing costs of the operation.
Introduction
The therapeutic approach for SSV insufficiency is quite demanding, requiring a careful diagnostic and surgical (or sclerotherapic) management in order to limit recurrences (even if they are unavoidable in a few cases of obstructed drainage of deep venous system) and to achieve a safe and effective treatment. The fundamental role of Color-flow duplex imaging (CD) in SSV therapy is widely accepted, even more when performing a conservative surgery, or duplex guided sclerotherapy . Since 1990 the authors have been performing varicose vein surgery on an outpatient basis, mainly thanks to the use of LA. Here is reported a review of the authors' last 48 months experience of surgery in local anesthesia ("day-surgery"), for varicose veins (VV) due to SSV incompetence. The diagnostic approach, based on the single CD, allowed to obtain a greater accuracy in the understanding of the morpho-functional SSV pathological pattern (which is often complex), and consequently it has permitted to tailor the proper treatment in every single case. CD guided pre-operative mapping and marking resulted in a facilitation for the local anesthesia (LA) guidance, for the intra-operative procedure and for the post-operative follow-up.
As matter of fact the popliteal crease has been always regarded as a difficult territory both from the diagnostic and from the therapeutic point of view, and this may explain the high degree of misdiagnoses, recurrences and complications of SSV management.
Surgery of SSV may comprehend different options: a) crossectomy (flush ligation of SSV at popliteal or at gastrocnemius vein level, with disconnection of possible SSV branches) and b) stripping/phlebectomy represent the most common procedures.
Patients and methods
From January 1996 to December 1999, 92 limbs (78 patients, 61 F and 17 M, mean age 55,4) underwent an intervention for the presence of VV due to SSV insufficiency. The patients were pre-operatively investigated by means of color-flow duplex imaging, in order to achieve a proper map of their venous morphologic and haemodynamic condition. All the patients were operated on with LA, with pre-operative CD guided skin marking. As far as LA is concerned, buffered mepivacaine 0.4-0.25% was used; a popliteal (or slightly higher) 2-3 cm incision was performed to allow a correct ligation of SSV at its junction with deep venous system; when facing a common junction with gastrocnemius venous trunk (GVT), the flush ligation was put at the confluence with the GVT, as in our experience GVT was very rarely incontinent. SSV stem was avulsed by means of inverted segmental stripping, according to the extension of the reflux, by means of a plastic disposable stripper. Mini-incisions (1-2 mm) phlebectomy of the varicose veins (e.g.the tributaries) completed the procedure. All the patients had an eccentric positive multi-layer compression by means of elastic bandage, or elastic stocking (35 mmHg, STRUVA ® system by MEDI) for 7 days. Antibiotic or heparin drugs were peri-operatively administered only in selective cases (less than 10%). 7 and 30 days after operation, the patients were reviewed clinically and by CD surveillance.
Results
In our experience of SSV treatment, CD exploration has been able to identify the main sources of reflux, depicting correctly the morphological patterns, having a good correlation with intra-operative findings.
The ultrasonographic evaluation of SSV pathologic conditions has revealed several anatomic and hemodynamic data concerning different pre-post-therapy aspects.
From the diagnostic point of view we have found a few differentiated patterns, each of them having a specific meaning.
SSV incontinence was characterized typically by a reflux from the sapheno-popliteal junction (mostly located between the popliteal crease and 4 cm above, very rarely in different position), but in a few cases the terminal valve of SSV was competent, otherwise the source of the reflux was a popliteal perforator (in this case it was mainly a systolic reflux, that is during the calf compression manoeuvre ), or differently the retrograde flow came from long saphenous vein (LSV) via Giacomini or via other tributaries. The extension of the reflux along the SSV stem was found down to the ankle only in 6% of the cases, as in the remaining 94% of the limbs the reflux moved from SSV to one or more tributary of the leg. The reflux mainly ended into re-entry perforators along the SSV stem or outside the SSV trunk (gastrocnemius perforator etc.); more rarely the reflux re-entered into the LSV stem at the leg level.
The most interesting hemodynamic pattern we have found (due to its negative therapeutic implications) is the functionally obstructed drainage of deep venous system (mainly the popliteal-femoral vein), which is able to generate a systolic reflux (sometimes it is diastolic too) towards the superficial venous system (SVS). In these cases, SSV junction, or popliteal perforator may represent a kind of bypass conduit to permit the ascension of the flow to the common or superficial femoral vein (mainly via Giacomini's vein). This hemodynamic condition has mainly resulted as an expression of the postural compression on the deep venous axis by muscle-ligament-nerve structures. These complex patients have been treated in the most conservative way as possible in order to prevent from unavoidable recurrences, especially if the natural by pass (SSV junction for example) is avulsed.
The role of the perforating veins (PVs)in the leg has largely been debated, yet we may underline that they mainly behave, also for SSV disease, as re-entry points into the deep venous system (DVS), with a very poor pathogenic role. The inward and outward flow has been studied during extremity compression and release, highlighting a main (or unique) re-entry function (as far quantification of the flows concerns) for these terminal PVs.
Most patients with SSV incompetence had a retrograde flow in the femoro-popliteal axis. In our experience this reverse flow has disappeared after SSV crossectomy and stripping in the vast majority of the cases: this remark is a sign of the functional (not post-thrombotic) nature of the incompetence of the DVS, due to the "steal" of the blood from the DVS to the incontinent SSV system.
From the anaesthesiologic and surgical point of view the results of these 4 years personal experience may be summarized as follows.
100-160 cc of LA was the dosage used per intervention and no patient required additional anaesthesiologic (i.e. propofol) procedure; deambulation was possible after 30-60 minutes in all the cases, and all the patients were dischargable after 3-6 hours. The correlation between CD pre-operative mapping and the intraoperative findings was very good, permitting to avoid venography in all the cases and it allowed also a tailored surgical procedure (no complete SSV stripping and no ligation of perforators were necessary) No reflux from residual GVT caused post-surgical recurrence (short-medium term follow-up). As far complications are concerned there were 1 slight lymphedema, 2 sensitive neurologic troubles, 1 GTV limited thrombosis. Costs of this kind of operation were very low, as well as the patients' compliance was very good (i.e. all the patients with bilateral disease accepted the contralateral operation)
Conclusions
CD is a mandatory tool to guide surgery in cases of SSV insufficiency, as it allows to achieve: a) specific reliable diagnosis, b) safe treatment, c) conservative therapy (made-to-measure) when indicated, avoiding blind, anachronistic and generalized treatments, d) good functional and cosmetic outcomes, e) lower costs.
SSV surgery is a demanding and complex procedure, potentially leading to serious complications , especially when operating in the popliteal fold; the usage of CD mapping and of LA may help minimizing complications, recurrences and excessive venous avulsion, maintaining a radical excision. Our experience demonstrates that remarkable cosmetic and functional outcomes are possible when operating on for SSV incompetence, thus avoiding invasive surgery or, on the opposite, partial minimal surgical procedures.
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