IMPLICATIONS MŠDICO-LŠGALES AU COURS DU TRAITEMENT SCLŠROSANT DES VARICES (Medicolegal
Implications of Sclerosing Treatment of Varices)
Natali J, Farman T
J Malaides Vasc 1996; 21(4):227-32
ABSTRACT AND COMMENTARY BY:
J. JÈrome Guex, M.D.
Nice, France
The author has been an expert physician in many trials and has the widest experience
in France in medicolegal affairs. This paper summarizes 20 years of complications
of sclerotherapy. In France, sclerotherapy is the most frequently practiced angiologic technique with hundreds of thousands injections being done per day. Although complications
are likely to occur, they remain very rare. This survey reports 102 accidents -
86 local (40 arterial injections, 46 subcutaneous injections) and 16 general complications.
Intra-arterial injections are the main area of interest of the author. After presenting
an extensive clinical description of the lesions and their evolution (seven major
operations, two above the knee, six peripheral amputations, 27 severe muscular sequelae, mainly gastrocnemius retractions), he reports the available experimental studies
and concludes that all severe necrotic lesions are caused by an inadvertent intra-arterial
injection. The most dangerous area is the popliteal fossa. Some cases are presented and discussed. Echoguided sclerotherapy is not considered as a step forward
in terms of safety by the author.
Other local complications are thought to be caused by subcutaneous injection but have
less severe sequelae. General complications are very rare and seldom considered
the fault of the practitioner as differentiated from local complications. The authors
also emphasize the need for proof of the venous condition prior to treatment, and suggest
that a duplex scan is the most suitable examination for that purpose.
COMMENTARY
The paper summarizes brillantly the experience of the authors and represents an excellent
review of the topics. However, some comments must be added. There is no evidence
that subcutaneous injections are not intra-arterial injections. The clinical evolution described is probably perfectly accurate with sotradecol but it could be different
with other sclerosing agents.1 Pain can be delayed and therefore, treatment may be delayed. The effects of early
medical treatment of extravenous injections are not reported in terms of medical
results or final conclusions. Echosclerotherapy is considered unsafe which is true
if one looks at raw figures but not true from inside knowledge of the problem. Many published
complications are related to unsatisfactory technique and personnel.
In conclusion, this paper provides extremely valuable information about complications
of sclerotherapy. It proves the importance of complete knowledge and good technique,
and actually shows that when well practiced, the complications are rare and possibly less frequent than complications from surgical intervention. 6412b
REFERENCE
1. Guex JJ. Indications for the sclerosing agent polidocanol. J Dermatol Surg Oncol
1993; 19:959-61.
RECURRENT VARICOSE VEINS AFTER SHORT SAPHENOUS VEIN SURGERY: A DUPLEX ULTRASOUND
STUDY
Tong Y, Royle J
Cardiovasc Surg 1996; 4:364-67
ABSTRACT AND COMMENTARY BY:
Sidney Rose, M.D., FRCS
Manchester, England
This paper is another well-presented statistical survey from the Austin Hospital of
Melbourne, Australia. It is an analysis of the causes of recurrence of varicose
veins in the short saphenous distribution.
Recurrent veins in this area have been a problem almost since varicose vein surgery
began. The accepted explanation has always been the anatomical irregularity of the
termination of the short saphenous vein. Many papers have been published on this
subject over the last four decades, and all have agreed that the only solution to the problem
is careful identification of the saphenopopliteal junction at operation. At first,
this involved attempts at preoperative clinical identification. These were largely hit-and-miss mainly because of lack of appreciation of the variation in the level
at which the saphenous vein entered the popliteal vein and the part played by the
vein of Giacomini and the gastrocnemius veins. Lack of preoperative information
had to be overcome by the dissecting skills of the surgeon in what was often a long and tedious
procedure.
During the 1960s, phlebography of this difficult region started to become available.
It became the gold standard for preoperative identification of the saphenopopliteal
junction. So it remained until development of the duplex scanner, and it is safe
to say that this has or will supplant phlebography completely. The advantage of the
duplex scanner is that it provides a physiological assessment of reflux as well as
the anatomic point at which it occurs. This enables marking the reflux point or
points on the surface with reasonable accuracy.
COMMENTARY
This paper from Royle and Tong concentrates on the identification of causes of recurrence
as identified by duplex scanning. They examined 70 limbs, and their findings accord
well with those found in other centers. Causes are roughly two-thirds due to reflux at the saphenopopliteal junction and one-third to incompetence of a gastrocnemius
vein.
The main contribution of this paper was an analysis of the anatomy of recurrent short
saphenous incompetence. This was divided into four groups: an intact short saphenous
junction (20/43), a residual short saphenous stump which communicated with the recurrent varices (11/43), the segment of the saphenous vein removed was too short leaving
a residual communication with the popliteal vein, and an isolated segment of the
short saphenous vein left unconnected with any deep vein (4/43). From a viewpoint
of further treatment, it would have been interesting to identify the anatomical distribution
in the 24 cases of recurrence due to incompetence of a gastrocnemius vein.
It is interesting to note that the vein of Giacomini, which figures so prominently
in the literature, does not appear to be a common etiologic factor in this series,
nor does the presence of isolated incompetent deep perforators. Also, communucations
with the long saphenous vein were found only twice. It would have also been helpful to
have more information about length of followup from the time of the original operation.
Of course, it is accepted that this is a small series.
Considering the number of cases involved, the small subgroup of 12 which were fortuitously
scanned pre- and postoperatively merits individual attention. Here we are told that
the mean interval between scans was 11 months. In seven of these cases, the short saphenous vein was still patent. In all of these, there was no preoperative skin
marking. Therefore, one must deduce that accurate duplex scanning alone is not enough.
One might also be permitted to observe that there is no substitute for careful preoperative clinical assessment and preparation. Certainly, there is no substitute
for skillful and careful surgery. 5841b
CONTRIBUTORS TO VENOUS DIGEST 1996
The phenomenal success of the Venous Digest
during 1996 is largely due to the excellent abstracts and commentary prepared by
this list of individuals. A glance will show that the names are truly a "Who's Who"
of physicians interested in venous disease. The Venous Digest
is enormously grateful for their good work.
Jeffrey L. Ballard, MD,
Loma Linda, California
David Bergqvist, MD, PhD,
Uppsala, Sweden
David Brewster, MD,
Boston, Massachusetts
Warner P. Bundens, MD,
La Jolla, California
Keven Burnand, MS,
FRCS,
London, England
Joseph A. Caprini, MD,
Evanston, Illinois
Philip Coleridge Smith, MD,
London, England
Anthony J. Comerota, MD,
Philadelphia, Pennsylvania
Simon Darke, MS, FRCS,
Poole Dorset, England
Ralph DePalma, MD,
Reno, Nevada
Csaba Dzsinich, MD,
Budapest, Hungary
Reinhard H. Fischer, MD,
St. Gallen, Switzerland
Helane Fronek, MD,
La Jolla, California
Max Gaspar, MD,
Long Beach, California
Mitchel P. Goldman, MD,
La Jolla, California
Wayne S. Gradman, MD,
Los Angeles, California
Jean-Jerome Guex, MD,
Nice, France
Douglas Harper, MD, FRCS,
Falkirk, Scotland
Robert J. Hye, MD,
San Diego, California
George Johnson, Jr., MD,
Chapel Hill, North Carolina
Lois A. Killewich, MD, PhD,
Baltimore, Maryland
Stephen G. Lalka, MD,
Indianapolis, Indiana
Herbert Machleder, MD,
Los Angeles, California
Elna Masuda, MD,
Honolulu, Hawaii
Frank T. Padberg, MD,
East Orange, New Jersey
Peter J. Pappas, MD,
Newark, New Jersey
John R. Pfeifer, MD,
Detroit, Michigan
Michael J. Rohrer, MD,
Worcester, Massachusetts
Sidney Rose, MD, FRCS,
Manchester, England
C. Vaughan Ruckley, MB, ChM,
Edinburgh, Scotland
Neil Sadick, MD,
Great Neck, New York
Clifford M. Sales, MD,
Livingston, New Jersey
Richard J. Sanders, MD,
Denver, Colorado
Steven R. Shackford, MD,
Burlington, Vermont
George Somjen, MD,
Victoria, Australia
Steven Sparks, MD,
San Diego, California
Richard K. Spence, MD,
Staten Island, New York
Lloyd Taylor, MD,
Portland, Oregon
Lawrence L. Tretbar, MD,
Shawnee Mission, Kansas
Fred Weaver, MD,
Los Angeles, California
Paul L. van Bemmelen, MD, PhD,
Port Jefferson, New York
Hendrik Van Damme MD,
Liege, Belgium
Robert Weiss, MD,
Baltimore, Maryland
Harold J. Welch, MD,
Boston, Massachusetts
Christopher Zarins, MD,
Stanford, California
VIDEOENDOSCOPY-ASSISTED SAPHENA OCCLUSION (VASO): A MINIMALLY INVASIVE CONCEPT FOR
THE TREATMENT OF VARICOSIS
Klose G, Weber K
Langenbecks Arch Chir 1996; Suppl II:899-902
ABSTRACT AND COMMENTARY BY:
Matthias Widmer, M.D.
Liestal, Switzerland
Greater saphenous vein stripping has some morbidity due to wound hematoma and peripheral
nerve irritation. The objective of this study was to combine classical proximal
saphenofemoral junction ligation with proximal saphenofemoral junction ligation after
saphenous vein sclerotherapy using videoendoscopic control. All patients were studied
preoperatively by phlebography except for those with a contrast media allergy. These
were studied by ultrasound. The objective of preoperative evaluation was to exclude previous deep venous thrombosis. Perforating veins were treated either with conventional
therapy or using a subfascial endoscopic perforator vein approach.
For lesser saphenous venous insufficiency, the saphenofemoral junction was ligated
and divided, and a small endoscope was introduced. While the lower leg was compressed,
0.1 ml of 3% aethoxysclerol was introduced at 5 cm intervals using the endoscope
as a control.
For greater saphenous insufficiency after ligation and division of the saphenofemoral
junction and compression of the entire lower extremity, the endoscope was introduced
to examine the vein down to the distal point of the insufficiency. That was identified as the first valve which was competent on distal installation of physiologic saline.
Using a peridural spinal catheter, 0.1 ml of 3% aethoxysclerol was injected every
5 cm. Special attention was paid to areas of vein bifurcation.
In both the greater and lesser saphenous procedures, the vein was ligated proximally
after removal of the endoscope. Compression stockings were used for three weeks,
24 hours a day, and during the subsequent three weeks, only during the day.
Results: From 1993 to 1996, 282 patients were operated upon. A total of 103 were
excluded from the study - 127 were treated conventionally and 71 were treated with
the videoendoscopy approach. Sixty-four patients could be followed. Among the early
results, one hematoma (1.6%) was encountered and no wound infections were seen in the videoendoscopy
group. In the conventional operation group, seven hematomas (6%) were encountered
and wound infection was encountered in three (2.6%). Nerve damage was encountered in one patient in the endoscopy group and four in the surgical group. The endoscopic
(sclerosant) group had three limbs with aseptic inflammation but there were no allergic
reactions. After vein stripping, more patients complained of painful scarring, and induration along hematoma tracks were more common. In both groups, patients
with swelling of the nontreated perforating veins were found. This was encountered
in 9.4% of the endoscopy group and 9.6% of the limbs with saphenous stripping. In
both groups, side-branch varicosities needed postoperative sclerotherapy but deep venous
thrombosis was absent.
The authors conclude that mobilization of the endoscopy group is quicker because of
less pain, less nerve irritation, wound irritation, and hematoma. However, the technique
is more time consuming and, although not encountered in this experience, there is
a risk of allergic reaction. As well, the long-term results have yet to be evaluated.
COMMENTARY
The concept of using an endoscope to inspect saphenous valves is a good one. This
could be used in surgical stripping procedures because it could identify the segment
of saphenous vein with valvular insufficiency and define the first competent valve.1 A surprising number of incompetent and damaged valves has been seen by endoscopic
inspection of the greater saphenous vein in patients requiring surgery.2,3 There has been a considerable experience with operative sclerotherapy of the greater
saphenous vein. Rose has pointed out that the ultimate fate of the operatively sclerosed
saphenous vein is recanalization.4
The concept of limited stripping of the greater saphenous vein from groin to knee
is illustrated by this experience. In the surgical group, 85% of the limbs had a
partial stripping with 67% in the endoscopic sclerosis group. It is apparent that
wound infection, hematoma, and nerve dysthesias can be reduced by this form of intervention.
There is a considerable literature on the subject of proximal saphenofemoral ligation
and distal sclerotherapy. Uniformly, those patients with proximal ligation and sclerotherapy
experience persistent reflux in the sclerosed saphenous vein ranging from 46 to 74%. Control groups in those series experienced 10 and 15% greater saphenous
territory reflux after stripping of the thigh portion of the saphenous vein. While
nerve damage is decreased by the sclerotherapy approach, it is clear that the risk
of recanalization is quite great. Further, there is the theoretical prospect of damage to
the deep venous system by the sclerosant. Perhaps a prospective study with strict
adherence to protocol would resolve the questions which are raised by the present
report. 6496b
REFERENCES
1. Gradman WS, Segalowitz J, Grundfest W. Venoscopy in varicose vein surgery: Initial
experience. Phlebology 1993; 8:124-50.
2. Van Cleef JF, Hugentobler JP, Desvaux P, et al. Vues endoscopiques de reflux valvulaires
saphÈniens. PhlÈbologie 1991; 4:623-27.
3. Chleir F, Van Cleef JF. Examen simultanÈ Èchographique et endoscopique des anomalies
morphologiques des valvules de la saphene interne. J des Maladies Vasculaires 1997;
1:18-23.
4. Rose SS. Historical development of varicose vein surgery. In: Bergan JJ, Goldman
MP. Varicose Veins & Telangiectasias: Diagnosis and Management.
Quality Medical Publishing, St. Louis 1993; Chapter 8, pg 126.
MORBIDITY OF VARICOSE VEIN SURGERY: AUDITING THE BENEFITS OF CHANGING CLINICAL PRACTICE
Miller GV, et al
Ann R Coll Surg Engl 1996; 78:345-49
ABSTRACT AND COMMENTARY BY:
Travis J. Phifer, M.D.
Associate Professor
Chief, Division of Vascular Surgery
Louisiana State University Medical Center
Shreveport, Louisiana
This study examines morbidity related to varicose vein surgery in 997 patients (1322
legs) (mean age 47.6 years) divided into two study periods over a 40-month interval.
The study groups are similar in bilaterality of surgery (32% total), length of hospital stay (average 1.5 days), nature of operative procedure, and experience of the operators.
In-hospital complications occurred in seven patients (0.7%) in the first study period
and included major complications of groin wound bleeding (2) and a femoral vein injury (1). Sixteen patients (1.6%) (8 from each study period) developed complications
requiring readmission to the hospital within 30 days. Six of these readmissions (five
from the first group) were for major complications. Four of these were thromboembolic in nature as confirmed by radiologic investigation. Five of the eight readmitted
during the first study period also underwent bilateral procedures with no readmissions
in the second study period after bilateral surgery.
The authors attribute the improvement in thromboembolic complication (0.7% to 0.2%)
and rate of readmission after bilateral surgery (0.8% to 0) to changes in clinical
practice during the second period of study. These changes included a different policy
with regard to the type of postoperative bandaging as well as utilization of postoperative
embolic stockings and encouragement of vigorous mobilization after surgery.
COMMENTARY
This is a contemporary study of a large number of consecutive cases of varicose vein
surgery performed by a mixed group of operators at varied levels of experience.
Although not randomized and without controls, the study provides interesting and
valuable information showing significant morbidity associated with this surgical procedure.
The 0.1% incidence of femoral vein injury and 0.2% deep venous thrombosis (in the
second period) are comparable to data reported from other series. There was a significant reduction in thromboembolic complications and rate of readmission following bilateral
surgery in the second phase of study. This is likely related, as suggested by the
authors, to changes in technique of bandaging. Also contributing was utilization
of compressive stockings and vigorous efforts at mobilization.
Unfortunately, the study design seriously limits the strength of these conclusions.
Rather than as a comparison between two forms of management, the real value of this
study rests in the display of significant morbidity (and potential mortality) associated with a procedure which is generally considered relatively minor. Also, the authors
stress need for proper training and adequate experience by operators who do the surgery.
Aggressive thromboembolic prophylaxis during the perioperative period may be required by some programs of management. 6501b
PROGRESSION OF SUPERFICIAL VENOUS THROMBOSIS TO DEEP VEIN THROMBOSIS
Chengelis DL, Bendick PJ, Glover JL, et al
J Vasc Surg 1996; 24:745-49
ABSTRACT AND COMMENTARY BY:
Robert M. Blumenberg, M.D.
Division of Vascular Surgery
Ellis Hospital, Schenectady, New York
Albany Medical College, Albany, New York
This is a retrospective review from the vascular laboratory at William Beaumont Hospital
in Royal Oak, Michigan and included a total of 9,286 patients who had undergone venous
duplex ultrasound examinations from January 1992 to January 1996. Although the main focus of the study were the 263 patients found to have isolated superficial thrombophlebitis
without deep venous thrombosis, they also reported that 1,489 (16%) had deep venous
thrombosis, 287 (19%) of which had concurrent superficial thrombophlebitis. Of the entire group studied, 263 (2.5%) had isolated superficial thrombophlebiitis.
Of these, 58 (62%) were located at the saphenofemoral junction. A total of 67 patients
had above-knee greater saphenous vein involvement and 138 were located in the below-knee greater saphenous vein or varicosities.
Of those with superficial thrombophlebitis, 30 (11.4%) progressed into the deep venous
system with a mean time of progression of 6.3 days from the initial duplex diagnosis
(range 2 to 10 days). Extension from the above-knee greater saphenous vein or saphenofemoral junction occurred in 21 patients, 18 of whom had nonocclusive thrombi which
did not cause hemodynamic change. Twelve of these 18 were free-floating clots which
had migrated into the common femoral vein. There were three occurrences of extension from the above-knee greater saphenous vein into the superficial femoral vein via
perforating veins, below-knee greater saphenous vein into the popliteal vein, and
below-knee greater saphenous or lesser saphenous vein into the tibial peroneal veins
via perforating veins.
Risk factors were not unusual. No patient had been anticoagulated at the time of
ultrasound examination, 25 were treated by anticoagulation, and two were treated
by saphenofemoral junction ligation with no subsequent pulmonary embolism.
The authors state that physical examination is unreliable in determining the proximal
extent of superficial thrombophlebitis especially in the upper thigh. Duplex ultrasonography
is reliable, defines clearly the proximal effect of thrombus, and can be used for serial studies which they recommend routinely from two to ten days.
Of the 1,489 patients with deep venous thrombosis, 287 (19%) had associated superficial
thrombophlebitis. Although this study was confined to isolated superficial thrombophlebitis,
the authors refer to studies demonstrating a 20 to 40% incidence of concurrent deep venous thrombosis in patients with superficial thrombophlebitis and contiguous
deep venous thrombosis and superficial thrombophlebitis in 7 to 25%. They state
that it is not possible to determine whether the origin is in the superficial or
deep system. In their study group, progression was most commonly seen extending from the
proximal greater saphenous vein or saphenofemoral junction into the common femoral
vein. All six with thrombi at the saphenofemoral junction (which were not anticoagulated) migrated into the common femoral vein. Of the 67 patients with proximal greater
saphenous vein superficial thrombophlebitis, 18 (27%) extended to femoropopliteal
involvement. Only 20% of those which progressed to the deep venous system did so
from lower leg superficial thrombophlebitis.
Conservative treatment is recommended for superficial thrombophlebitis involving
below-knee superficial veins or varicosities but the more proximal thrombophlebitis
should be treated with anticoagulation. If not anticoagulated, serial duplex examinations should be performed. The authors state that anticoagulation may permit recanalization
which would permit future use of the involved vein in bypass grafting.
COMMENTARY
This paper emphasizes that superficial thrombophlebitis is not always a benign condition
and, in the above-knee greater saphenous vein segment, extension into the common
femoral vein is not rare. For this reason, this is an important study and is in
general agreement with a similar study that we have just concluded.
We reviewed the results of venous duplex imaging in 6,148 limbs referred to our vascular
laboratory "to rule out phlebitis" over a two-year period. Of these, 1,756 (22.2%)
were positive for deep venous thrombosis which is comparable to the 16% reported
by Chengelis, et al. Superficial thrombophlebitis was noted in 232 limbs (13%), 20
(8.6%) of which had extended into the deep venous system. Of these, 14 (70%) had
extended into the deep venous system on the initial ultrasound duplex study and six
were noted to have migrated into the deep venous system on serial studies. A total of 18
(90%) originated in the proximal greater saphenous vein and extended into the common
femoral vein. Nine were free-floating thrombi with a tongue noted on duplex to extend
into the common femoral vein. In our patient cohort, 2.5% were found to have isolated
superficial thrombophlebitis and the remainder had superficial thrombophlebitis associated
with deep venous thrombosis.
Our data corroborates the authors' data that a majority of superficial thrombophlebitis
migrating into the deep venous system are located in the greater saphenous vein in
the proximal above-knee position. When it involves the below-knee superficial veins, direct extension into the deep venous system or via perforating veins is much less
common. It should be emphasized that clot arising in the superficial venous system
and migrating into the deep venous system behaves as deep venous thrombosis. Ten
percent of our cases experienced pulmonary embolism prior to or at ultrasound examination.
In our experience, anticoagulation was the primary therapy used without any subsequent
pulmonary embolism.
The authors state that in cases of concurrent superficial thrombophlebitis and deep
venous thrombosis it is not possible to determine if the origin of the thrombus is
in the superficial or deep system. We have looked for thrombus in the deep system
below the point of extension of clot from the superficial into the deep vein in question.
The absence of clot in the deep vein below the site of extension from the superficial
vein suggests that the process arose in the superficial vein.
In conclusion, we also recommend conservative management of superficial thrombophlebitis
below the knee and in the distal greater saphenous vein. More frequent serial venous
duplex studies are indicated as the clot progresses closer to the saphenofemoral
junction. Anticoagulation is is instituted when the clot extends within 1 to 2 cm
of the saphenofemoral junction. Serial studies were also indicated to monitor superficial
thrombophlebitis involving the lesser saphenous vein, and extension to within 1 cm of the popliteal veins should be treated with anticoagulation. 6502b
A CORRELATION OF AIR PLETHYSMOGRAPHY AND COLOR FLOW-ASSISTED DUPLEX SCANNING IN THE
QUANTIFICATION OF CHRONIC VENOUS INSUFFICIENCY
Weingarten MS, Czeredarczuk M, Scovell S, et al.
J Vasc Surg 1996; 24:750-54
ABSTRACT AND COMMENTARY BY:
Paul S. van Bemmelen, MD, PhD
Port Jefferson, New York
Air plethysmography (APG) and standing duplex studies were compared in 122 legs (59
with ulceration). Reflux times (normal < 0.5 seconds) were added for all segments
(total limb reflux time), all superficial segments (total limb superficial reflux
time), and all deep segments (total limb deep reflux time). Reflux times were averaged:
Mean total limb reflux time, mean total limb deep segment reflux time, and mean
total limb superficial segment segment reflux time. In an earlier paper by these
authors describing the addition of reflux time, a total limb reflux time < 9.66 seconds had been
found predictive of ulceration.
APG data used in this study were venous filling index (VFI), ejection fraction (EF),
and residual volume fraction (RVF). VFI was the only APG parameter that correlated
with all color duplex parameters. The Pearson correlation coefficients were 0.43
for total limb reflux time with VFI and 0.43 for mean total limb reflux time versus VFI.
COMMENTARY
Several authors have tried to assess the respective roles of available noninvasive
venous studies in the workup of patients with chronic venous insufficiency. In a
similar study, van Bemmelen, et al. compared the diameter of incompetent veins in
the calf to APG venous volume and found a correlation of r = 0.75. The VFI correlated with
the diameter of incompetent veins in the calf (r = 0.55).
When proximal and distal reflux times are simply added up, information about the site
of incompetence tends to get lost. One would not expect duplex-derived reflux time
measurements to correspond perfectly to volume rate measurements because different
properties are being compared. A large volume of blood could reflux in a short amount
of time if valves are absent and vein diameters are large.
Clinicians do not need a test to predict venous ulceration as this is the presenting
complaint of these patients. The question is whether one modality (duplex or APG)
is less cumbersome to use on a regular basis and whether it will provide sufficient
information to make therapeutic decisions. For most limbs without postthrombotic damage,
a standing duplex examination may be sufficient for the workup and lead to removal
of incompetent greater or lesser saphenous veins. 6505b