Of the perioperative complications, the patient with recurrent deep venous thrombosis, in spite of peri-operative heparin prophylaxis, deserves a comment. The overall risk of DVT following SEPS is low and none was reported following 148 procedures in the NASEPS (North American Subfascial Endoscopic Perforator Surgery) registry.3 However, as experience accumulates further, we are seeing an increasing number of high-risk patients with coagulation abnormalities and a history of recurrent deep venous thrombosis who are on chronic oral anticoagulation and, of course, have the most advanced postthrombotic disease. Similar to Dr. O'Donnell's group, the NASEPS registry also observed one early DVT following 52 SEPS procedures. A prospective duplex screening of all patients was initiated following the procedure to diagnose clinically silent DVT. Late results will determine if it is worthwhile to take the low but definite risk of perioperative DVT in such patients.
Data in this paper support the role of perforators in the pathogenesis of venous ulcers. Nine limbs were treated with SEPS because of failure of previous ablation of incompetent superficial veins. In addition, missed perforators resulted in failure of ulcer healing in four patients. These results are similar to those published recently.4-6
The issue of cost is important but the present data are insufficient for comparison. Endoscopic operations have higher operating room costs than the limited-incision, open ligation of perforating veins. However, SEPS is now performed regularly on an outpatient basis and hospital costs should be minimal. Costs to treat perioperative complications, failure of ulcer healing, and treatment of early recurrence should all be part of a cost analysis before meaningful conclusions can be reached.
Like most studies dealing with endovascular or endoscopic operations, this paper also
lacks sufficient followup and does not answer the question of ulcer recurrence and
late effectiveness. There is no question that there is need for long-term, controlled
studies to confirm late efficacy. The addition of SEPS to ablation of superficial
veins also needs justification for those who question the value of this procedure.
This series, like other reports on SEPS, indicates that there is a substantial number
of patients who fail conservative management or have ulcer recurrence after ablation
of superficial reflux. Good early results combined with a low complication rate
in these patients are eminent reasons to continue to offer SEPS for treatment of
advanced venous insufficiency. 6973b
EDITORIAL COMMENT:
This article is of such importance that it also appeared in the October 1997 issue
of Venous Digest
with a slightly different point of view. JJ Bergan
TECHNICAL OPTIONS IN VENOUS VALVE RECONSTRUCTION
Raju S, Hardy JD
Am J Surg 1997; 173:301-307
ABSTRACT AND COMMENTARY BY:
Robert L. Kistner, M.D.
Straub Clinic and Hospital
Honolulu, Hawaii
This article is a "how-to" for the surgeon who wants to undertake reconstructive surgery
of the deep venous system. It is a compilation from the wide experience of Dr. Raju.
He reviews methodology obtained from experience with 582 valve segment reconstructions in 347 limbs - a truly massive experience!
The techniques vary from the original technique of internal valvuloplasty through
most of the published variations on this original theme with some alternative approaches
to restoring valve competence in the deep venous system. Also included are descriptions of reconstructions unique to Dr. Raju's experience. These are thought provoking
for anyone who would undertake deep vein reconstruction. Specifically, he describes
de novo
valve reconstruction and venoplastic procedures that are imaginative even if they
have not been subjected to scientific study, either for validity or long-term function.
COMMENTARY
This paper states that "regardless of pathology, a functional venous valve can be
constructed in most patients utilizing one of the described techniques." This statement
is a very personal opinion of Dr. Raju who has reported an amazing ability to operate in the postthrombotic vein. He reports total intraoperative competence was achieved
in 86% of cases and in an additional 10% there was a residual reflux which was less
than the patient presented originally.
Postoperative thrombosis of the valve repair occurred in less than 1%. Deep venous
thrombosis, either in the distal veins or in the unoperated limb, was found in 3.5%.
Hematoma and seroma formation was seen in 5% and wound infection was found in 2%.
These are magnificent results in such varied cases of severe venous insufficiency and
present a challenge for other surgeons to equal.
Dr. Raju states that the internal valvuloplasty is an effective repair for a single
valve but it is time consuming and, when multiple repairs are needed, he prefers
to use one of the external techniques. In spite of the fact that he repaired multiple
valves in many cases, he did not present data to show that correction of multiple valves
gave better results than repair of a single valve at the femoral level.
The description of technique in this paper is particularly valuable and begins with
a discussion of internal valvuloplasty in which the author states his preference
for a transverse venotomy to expose the valve. He discusses some of the technical
problems encountered with this approach and he provides valuable clues on how to locate the
valve and how to identify the attachments of the valve cusp from the outside of the
vein.
The discussion of external valvuloplasty is short and touches upon Dr. Raju's approach
to the external valve repair as a means to narrow the "commissural valve angle,"
the angle which forms where the two valve cusps meet. He recommends use of a prosthetic sleeve to maintain the size of those valves which become competent at the time of
surgical exposure even though they showed severe reflux on preoperative studies.
The section on axillary vein transfer is useful and addresses the site of harvest
of graft in the upper arm and the need for meticulous suture technique in placing
the valve and vein segment into the transplanted position. In subsequent paragraphs,
he describes the need to be sure that the profunda femoris system has a competent valve
at its upper end and how a valve repair can be performed in the proximal profunda
femoris vein.
Dr. Raju describes a transcommissural external repair in which the needle is placed
deeper than in the conventional external repair. This suture is placed through and
through the vein, entering on one side of the valve commissure and exiting on the
other in order to shorten the valve cusp and produce a result similar to that achieved by
internal valve repair or conventional angioscopic repair. He states that he has
learned to do the operation without introducing the angioscope except to check the
pre-repair and post-repair status of the valve. The method seems simple but there is not
enough convincing data that this produces an effective repair. However, this data
is found in the summary of his experience with his very low postoperative persistence
of reflux in the total valve repair series.
The description of the de novo
valve reconstruction is one in which a segment of vein is harvested, the adventitia
and part of the media is removed surgically, and the remnant tissue is trimmed to
create a semilunar cusp. The non-intimal surface is oriented into the flowing stream
rather than toward the sinus side of the valve cusp. Two such cusps are then sewn into
the vein to create a new valve. This is highly experimental and has not been studied
enough to recommend it for use. The description of plastic procedures to alter the
position of the valve cusps so that the two cusps meet in proper apposition is another
useful section of the paper.
In several single-paragraph commentaries, the author describes valve reconstruction
distal to a proximal obstruction, portions of his technique for multiple valve reconstructions,
and reoperative valve reconstruction. Specific details are provided about each approach and each adds an interesting note for those interested.
In summary, many tips are given in this article from Dr. Raju's extensive experience
in reconstruction of the deep veins of the patient with chronic venous insufficiency.
Some are very useful and others are experimental but all are of interest to anyone
with an interest in venous disorders. 6974b
THE COST AND BENEFIT OF PROPHYLAXIS AGAINST DEEP VENOUS THROMBOSIS IN ELECTIVE HIP
REPLACEMENT: DVT/PE PROPHYLAXIS CONSENSUS FORUM
Abdool-Carim T, Adler H, Becker P, et al.
South African Med J 1997; 87(5):594-600
ABSTRACT AND COMMENTARY BY:
Anthony Comerota, M.D.
Temple University Hospital
Philadelphia, Pennsylvania
A consensus forum was convened to evaluate the economic considerations associated
with prophylaxis against venous thromboembolic complications in patients undergoing
hip replacement in South Africa. Included in the forum were orthopedic surgeons,
vascular surgeons, and a statistician.
The forum evaluated the economic costs of the commonly used forms of thromboembolic
prophylaxis in patients undergoing total hip replacement in South Africa. However,
only short-term events were included. The cost of mortality and the cost of the
postthrombotic syndrome were not included. The particular methods of prophylaxis of venous
thromboembolism in South Africa were determined by a mail survey. A previously validated
decision tree was constructed to determine the events that would occur after a clinical decision not to use prophylaxis. The probabilities of these events were then
determined. Protocols for, and the costs of, prophylaxis and treatment were established.
With the decision tree and these costs, the costs of various modalities of prophylaxis were then determined.
The forum determined that the probability of developing deep venous thrombosis when
no prophylaxis is used was 50% with a mortality rate of 2.1%. The cost of this
decision was R875 (five rands is roughly the equivalent of one U.S. dollar). When
no prophylaxis was given but a venogram was performed on day seven, the mortality rate decreased
to 0.7%. However, the cost rose to R3017. The cost of low-molecular-weight heparin
was R1233 and was associated with a mortality rate of 1.1%. Unfractionated heparin with a graduated compression stocking cost R1351 and was associated with a mortality
rate of 1%. Aspirin along with a graduated compression stocking cost R777 but was
associated with a mortality rate of 1.5%.
The forum concluded that the use of prophylaxis against deep venous thrombosis in
patients undergoing elective hip replacement is mandatory. All of the commonly used
methods of prophylaxis reduced mortality. No prophylaxis with screening for deep
venous thrombosis at day seven is not justified and is very expensive. Aspirin, in combination
with external compression stockings, was the least expensive form of prophylaxis
but did not reduce the prevalence of deep venous thrombosis and did not reduce mortality sufficiently to be clinically effective. The heparins appear to be the most cost
effective but cost between R350 and R500 more per patient than when no prophylaxis
is used.
COMMENTARY
This is an interesting manuscript which confirms observations in the United States
- that DVT prophylaxis is mandatory in patients undergoing total hip replacement.
The probabilities used in the decision tree analysis are those that were considered
by the forum to reflect most closely the conditions in South Africa. This information is
likely to be inaccurate since no validated survey was performed to confirm those
assumptions.
This study evaluated only the immediately apparent costs of prophylaxis against DVT
and the subsequent management of acute DVT and its short-term sequelae. No long-term
costs, such as cost of the postthrombotic syndrome, chronic pulmonary hypertension,
or the cost to society of mortality was considered. If these variables were included,
substantially greater benefit from prophylaxis would be observed. 6827b
SHORT-STRETCH VERSUS ELASTIC BANDAGES: EFFECTIVE TIME AND WALKING
Veraart JCJM, Daamen E, Neumann HAM
PhlÈbologie 1997; 26:19-24
COMMENTARY BY:
Mitchel P. Goldman, M.D.
La Jolla, California
The authors studied the effect of short-stretch versus elastic bandages on 39 legs
in 35 subjects with known venous insufficiency. The bandages used were a Comprilan
(Beiersdorf, Germany) with 70% elasticity compared to an Elodur (Beiersdorf, Germany)
which maintained 170% elasticity. They used an interface pressure recording device with
an Oxford Pressure Measurement MKII (OPM) machine. This device allowed pressure
to be taken from 12 different areas of the leg while patients were supine and while
walking on a treadmill. The authors found that short-stretch bandages lost upwards of 50%
of their pressure over a three-hour period. This result confirmed results previously
reported by Callam, et al.1 It was also shown that the short-stretch bandages were safer to use than elastic
bandages since they exert the maximal amount of pressure during calf pumping and
have the least amount of pressure when patients are supine. 6504b
REFERENCES
1. Callam MJ, Haiart D, Farouk M, et al. Effective time and posture profiles maintained
by three different types of compression. Phlebology 1991; 6:79-84.
A NEW DEVICE FOR PREVENTION OF POSTOPERATIVE HEMATOMA IN THE SURGERY OF VARICOSE VEINS
Raso AM, Rispoli P, Maggio D, et al.
J Cardiovasc Surg 1997; 38:177-180
ABSTRACT AND COMMENTARY BY:
Clifford M. Sales, MD, FACS
Union Hospital/St. Barnabas Health Care System
Belleville, New Jersey
This article discusses a simple device used to minimize postoperative hematoma following
saphenectomy. It appears that the authors utilized an elastic wrap with an inflatable
pneumatic tube lying along the course of the removed saphenous vein. Insufflation of this tube to 40 to 50 mmHg pressure immediately following saphenectomy reduces
the hematoma that normally occurs along the medial aspect of the leg. The device
is discontinuous at the knee, allowing full movement of this joint. Additionally,
the system can be sterilized so that it can be placed prior
to removing the saphenous vein with insufflation occurring as the stripper proceeds
in a caudal direction. The device is kept in place for 24 hours and then replaced
by a standard compression bandage. The authors note that they have treated a small
number of patients using this device with "good results."
COMMENTARY
This interesting "how-I-do-it" article addresses a minor problem in varicose vein
surgery - postoperative hematoma formation along the course of the removed saphenous
vein. Removal of the greater saphenous vein necessarily requires tributary destruction
with subsequent hemorrhage into the surrounding tissue. Certainly, compression along
this tract could minimize this process. The inversion saphenectomy technique1 serves a similar function, albeit for a shorter time. In that technique, as shown
in the video by Bergan, compression along the path of the removed saphenous vein
is accomplished internally intraoperatively with a gauze packing material. In my
experience, that technique has worked quite well in the majority of cases and significantly
reduces the occurrence of postoperative hematoma formation.
The device described in this article is of passing interest. Unfortunately, the authors
give no objective data to support its use despite having used the equipment for nearly
30 years. A minor concern might be the lack of compression about the knee and the possibility of a tourniquet effect in this region with swelling. The paper proposes
a cognitively interesting tool but with little basis to assess its value in clinical
care. 6921b
REFERENCES
1. van der Strict J. Saphenectomy par invaginationsur fil. Presse Med 1963; 71:1081-82.
CAN THE MAIN TRUNK OF GREATER SAPHENOUS VEIN BE SPARED IN PATIENTS WITH VARICOSE VEINS?
Labropoulos N, Belcaro G, Delis K, et al.
Vasc Surg 1997; 31:531-34
ABSTRACT AND COMMENTARY BY:
Ralph G. DePalma, M.D.
Associate Dean, Vice Chairman of Surgery
University of Nevada
Reno, Nevada
These authors sought to identify the frequency with which the main trunk of the greater
saphenous vein (GSV) could be spared during varicose vein operations. Subjects included
187 consecutive patients in whom continuous-wave Doppler (CWD) identified reflux. 250 limbs from these individuals were examined by color-flow duplex imaging (CFDI)
to note reflux and varicosities at the saphenofemoral junction (SFJ) thigh, knee,
and below-knee GSV segments. Limbs with previous surgery of the greater saphenous
vein were excluded.
In 50% of patients, reflux throughout the length of the GSV was the most common pattern.
The prevalence of reflux was 78% at the SFJ, 84% at the thigh segment, 92% at the
knee, and 74% at the below-knee segment. In contrast, among the segments with reflux, varicosities were found in 71% at the thigh, 77% at the knee, and in only 28%
at the below-knee segment. "Clinically evident" varicosities involved superficial
tributaries in 93%. No perforating veins were identified in the below-knee segment.
The authors conclude that in approximately 20% of patients, the GSV need not be excised,
particularly in patients at high risk for arterial disease. They also state that
the below-knee GSV is never associated with incompetent perforating veins.
COMMENTARY
This extensive noninvasive study is most important for what it does not say. We know
that 187 consecutive varicose vein patients were screened but were these primary,
secondary, or recurrent varices and what was the severity of chronic venous insufficiency (CVI)? As the title indicates, if these patients had mainly primary varicosities,
one can acknowledge completely that the results were valid for this population.
Of interest, however, is the finding that when the CWD was positive
, CFDI was positive for high incompetence in the SFJ and GSV in only 78% and 84%,
respectively. These numbers agree nicely with findings of positive predictive value
of only 83% for CWD found on our report on primary varicosities.1 Is the continuous-wave Doppler picking up accompanying femoral vein reflux? The
authors imply but do not actually state that varicose vein surgery might be individualized
using CFDI. The idea that the saphenous vein should not be stripped, even when it is refluxing but not varicose, is an interesting one. However, one must not broad-brush
this issue, particularly in severe CVI skin changes of Class 4 or greater. One should
not say 'always' and never say 'never.' The idea that the below-knee GSV should not be stripped because it is "free of varicosities and never associated with
incompetent perforating veins" is not so in approximately 72% of cases.
The below-knee GSV communicates via extrafascial tributaries with the dominant posterior
arcade which is in turn connected to the muscular perforators. Commonly, this occurs
through the Boyd perforator complex located a variable distance below the knee joint and sometimes via a superficial communicating vein between the GSV and the posterior
arcade in the middle of the leg. Inferior to the malleolus, the GSV tributaries
also receive submalleolar perforators from the foot. These may need to be interrupted, particularly in CVI with ulceration.
Thus, I would not go so far as to say never strip the below-knee GSV. With careful
dissection, freeing the nerve under loupe magnification and stripping slowly from
above downward, saphenectomy can almost always be accomplished without nerve injury.
Admittedly, this is currently a minority opinion although Dodd and Cockett2 showed GSV connections in their text. I have difficulty locating interconnections
with the CFDI between the posterior arcade and the course of the below-knee GSV.
I detect superficial communications via lighted fiberoptic probe or on-table phlebography.
Overall, the authors' message is a valid and familiar one. Color-flow duplex imaging
is useful for individualizing varicose vein surgery. Clearly, one should not remove
veins from people who may need them later. Leather has shown that with appropriate
tailoring, varicose veins can be used for in-situ arterial grafts.3
Most of the time, however, the data favoring best long-term results demonstrate the
wisdom of removing incompetent GSV segments. In my experience,1 CFDI was used as a guide in removing incompetent truncal GSV for primary varices
among 80 limbs. A total of 50 limbs had GSV phlebectomy (63%) and the remainder
(37%) were treated by stab avulsion, cluster excision, and sclerotherapy. Results
at 12 to 18 months were similar in the two groups. However, long-term results of this approach
dictated by CFDI require validation. The authors may wish to aim for this in their
well-characterized patient group. 6975b
REFERENCES
1. DePalma RG, Hart MT, Zanin L, Massarin EG. Physical examination, Doppler ultrasound,
and color-flow duplex scanning: Guides to therapy for primary varicose veins. Phlebology
1993; 8:7-11.
2. Dodd H, Cockett FB. Surgical anatomy of the veins of the lower limbs. In: Dodd
H, Cockett FB (eds). The Pathology and Surgery of the Veins of the Lower Limb
. London, Churchill 1976, Chapter 3, pp 18-49.
3. Leather RP, Shah DM. Reoperation after infrapopliteal in-situ saphenous vein bypass.
In: Trout III HH, Giordano JM, DePalma RG (eds). Reoperative Vascular Surgery.
New York, Marcel Dekker 1987; pp 193-207.